Priority Health Medicare step therapy

Priority Health Medicare step therapy requirements

Priority Health Medicare plans at times require use of first-line agents or classes of products before certain drugs or classes of drugs may be approved. The process is commonly referred to as step therapy.

Considerations in this process may include clinical effectiveness, potential for adverse events, and total overall cost of therapy. This is especially important since many new drugs do not offer significant clinical advantages, but come with a much higher cost. 

Documenting therapeutic trial and clinical failure
The Pharmacy and Therapeutics Committee has approved the requirement for a physician to show documented evidence of therapeutic trial and clinical failure of a drug or drug class before PriorityMedicare plans will authorize the use of specific agents.

Exceptions may be granted on a case-by-case basis taking individual information into consideration.

Classes with step therapy requirements
Click on any class to jump to the protocol for that class.

Allergic rhinitis therapy

Anti-depressant therapy

Angiotensin receptor blocker (ARB) therapy

Non-sedating antihistamine (NSA) therapy

NSA-decongestant therapy

Asthma therapy

Proton pump inhibitor (PPI) therapy

 

Allergic rhinitis step therapy

Criteria for use of Singulair: The purpose of this step therapy protocol is to confirm that a patient using Singulair is using it for the treatment of an asthmatic condition rather than as a first line agent for allergic rhinitis.  If a patient has a history of using any of the following drugs a claim for Singulair will process.  If there is no history of using any of the following drugs, the claim will not process.

• H1 blocking agents
• Glucocorticoids
• Antihistamines
• Bronchodilators, Anti-Inflammatories
• Mast Cell Stabilizers

Anti-depressant therapy
New prescriptions only

• Tricyclic antidepressants
• Selective Serotonin Reuptake Inhibitors (SSRI)
• Selective Serotonin & Norepinephrine Reuptake Inhibitors (SNRI)
• Sulfonylureas
• Biguanides
• Insulins
• Thiazolidinediones
• Alpha-Glucosidase Inhibitors
• Meglitinides

There are multiple purposes for this step therapy protocol for new prescriptions only. Meeting the step therapy requirements for a new prescription will automatically allow a member to receive future prescriptions.

1. The protocol confirms that a patient has had a documented therapeutic trial and clinical failure of a generic SSRI, SNRI, or tricyclic before being able to receive a new prescription for Cymbalta.
2. The protocol confirms the diagnosis of diabetes by confirming utilization of a drug for diabetes and before allowing the use of a new prescription for Cymbalta for the treatment of peripheral neuropathy.
3. The protocol confirms previous use of generic gabapentin before allowing the use of a new prescription for Cymbalta for the treatment of peripheral neuropathy.

Angiotensin receptor blocker (ARB) therapy

• Angiotensin-Converting Enzyme (ACE) Inhibitors

The purpose of this step therapy protocol is to confirm a documented therapeutic trial and clinical failure of an ACE Inhibitor before allowing the use of an ARB.


Non-sedating antihistamine (NSA) therapy

• H1 blocking agents

Over-the-counter (OTC) loratadine and OTC cetirizine are covered benefits.  The purpose of this step therapy protocol is to confirm the use of OTC loratadine or OTC cetirizine before allowing a claim for a formulary NSA.
 

Non-sedating antihistimine (NSA) decongestant therapy

• H1 blocking agents

Over-the-counter (OTC) loratadine and OTC cetirizine are covered benefits.  The purpose of this step therapy protocol is to confirm the use of OTC loratadine or OTC cetirizine before allowing a claim for a formulary NSA-decongestant.


Asthma therapy

• Albuterol
• Xopenex
  

The purpose of this step therapy protocol is to confirm the use of albuterol before allowing a claim for Xopenex to process.

 
Proton pump inhibitor (PPI) therapy

• Prilosec OTC
• Omeprazole
• Pantoprazole
• Aciphex
• Nexium
  

Prilosec OTC, omeprazole, and pantoprazole are covered benefits.  The purpose of this step therapy protocol is to confirm the use of Prilosec OTC, omeprazole or pantoprazole before allowing a claim for  Aciphex, and to confirm the use of Prilosec OTC, omeprazole, or pantoprazole and Aciphex before allowing a claim for Nexium.