2013 Aetna Medicare Prescription Drugs that Require Step Therapy ...

ATYPICAL ANTIPSYCHOTICProducts AffectedFanaptFanapt Titration PackFazacloGeodon CAPSDetailsCriteriaA documented trial of one month of one of the following alternativesclozapine, risperidone, quetiapine, ziprasodone, Seroquel XR, Seroquel,Zyprexa Zydis or olanzapine.4

RANEXAProducts AffectedRanexaDetailsCriteriaA documented trial of one month of one drug from any of the following, abeta-blocker or a nitrate or amlodipine6

LIDODERMProducts Affected Lidocaine PTCH LidodermDetailsCriteriaA documented trial of one month of generic gabapentin7

ELIDELProducts AffectedElidelDetailsCriteriaA documented trial of two weeks (14 days) of one alternative generictopical corticosteroid8

SOMATOSTATIN ANALOGSProducts AffectedSandostatin Lar DepotSomatuline DepotSomavertDetailsCriteriaA documented trial of one month of generic octreotide9

DIABETIC SUPPLIESProducts AffectedBd Insulin SyringeSafetyglide/1ml/29g X 1/2"Bd Insulin SyringeUltrafine/0.3ml/31g X 5/16"Bd Insulin SyringeUltrafine/0.5ml/30g X 1/2"Bd Insulin Syringe Ultrafine/1ml/31gX 5/16" Bd Pen Needle/ultrafine/29g X12.7mm V-go 20 V-go 30 V-go 40DetailsCriteriaA documented concurrent use of an insulin product or Byetta or Bydureonor Symlin or Victoza within the past 120 days10

SMOKING CESSATIONProducts AffectedChantixChantix Continuing Month PakChantix Starting Month PakDetailsCriteriaA documented trial of 6 weeks of Buproban (bupropion SR)11

FORTEOProducts AffectedForteo INJ 600MCG/2.4ML,750MCG/3MLDetailsCriteriaA documented trial of one month of generic alendronate or ibandronate12

INDEXBBd Insulin Syringe Safetyglide/1ml/29g X 1/2 ... 10Bd Insulin Syringe Ultrafine/0.3ml/31g X 5/16 .. 10Bd Insulin Syringe Ultrafine/0.5ml/30g X 1/2 .... 10Bd Insulin Syringe Ultrafine/1ml/31g X 5/16 ..... 10Bd Pen Needle/ultrafine/29g X 12.7mm ............. 10Brintellix ............................................................... 3CChantix ................................................................ 11Chantix Continuing Month Pak .......................... 11Chantix Starting Month Pak ................................ 11EElidel ..................................................................... 8FFanapt .................................................................... 4Fanapt Titration Pack ............................................ 4Fazaclo .................................................................. 4Forteo .................................................................. 12GGabitril .................................................................. 1Geodon .................................................................. 4LLamictal Odt .......................................................... 2Lidocaine................................................................ 7Lidoderm ................................................................ 7NNucynta .................................................................. 5RRanexa.................................................................... 6SSabril ...................................................................... 1Sandostatin Lar Depot ............................................ 9Somatuline Depot................................................... 9Somavert ................................................................ 9VV-go 20 ................................................................ 10V-go 30 ................................................................ 10V-go 40 ................................................................ 10Vimpat.................................................................... 113