Medicareassured.com

2012 Medicare Defined Standard Assured® HMO StepTherapy
Last Update: 09/21/2012
Brand Name: ACTOplus Met
Generic Name: Pioglitazone / Metformin
ActoPlus Met(pioglitazone/metformin) Step Therapy Criteria
· Coverage is provided for a diagnosis of type 2 diabetic mellitus in patients whose blood glucose is not adequately controlled on or
had intolerance to metformin or a sulfonyurea (determined by pharmacy claims review or through the exception review process). Brand Name: Actos
Generic Name: Pioglitazone
Actos(pioglitazone)Step Therapy Criteria
· Coverage is provided for a diagnosis of type 2 diabetic mellitus in patients whose blood glucose is not adequately controlled on or
had intolerance to metformin or a sulfonyurea (determined by pharmacy claims review or through the exceptions review process). Brand Name: Avandamet
Generic Name: Rosiglitazone/Metformin HCl
Avandamet (rosiglitazone/metformin) Step Therapy Criteria
· Coverage is provided for a diagnosis of type 2 diabetic mellitus in patients whose blood glucose is not adequately controlled on or
had intolerance to metformin or a sulfonyurea (determined by pharmacy claims review or through the exceptions review process). Brand Name: Avandaryl
Generic Name: Rosiglitazone/Glimepiride
Avandaryl (rosiglitazone/glimepiride) Step Therapy Criteria
· Coverage is provided for a diagnosis of type 2 diabetic mellitus in patients whose blood glucose is not adequately controlled on or
had intolerance to metformin or a sulfonyurea (determined by pharmacy claims review or through the exceptions review process). Brand Name: Avandia
Generic Name: Rosiglitazone Maleate
Avandia (rosiglitazone) Step Therapy Criteria
· Coverage is provided for a diagnosis of type 2 diabetic mellitus in patients whose blood glucose is not adequately controlled on or
had intolerance to metformin or a sulfonyurea (determined by pharmacy claims review or through the exceptions review process). Brand Name: Duetact
Generic Name: Pioglitazone / Glimepiride
Duetact (pioglitazone/glimepiride) Step Therapy Criteria
· Coverage is provided for a diagnosis of type 2 diabetic mellitus in patients whose blood glucose is not adequately controlled on or
had intolerance to metformin or a sulfonyurea (determined by pharmacy claims review or through the exceptions review process). Brand Name: Janumet
Generic Name: Sitagliptin/Metformin
Janumet (sitagliptin/metformin) Step Therapy Criteria

· Coverage is provided for members with a diagnosis of type 2 diabetic mellitus whose blood glucose is not adequately controlled on
metformin or a sulfonyurea (determined by pharmacy claims review or through the exceptions review process).
Brand Name: Janumet XR
Generic Name: Sitagliptin/Metformin ER
Janumet XR (sitagliptin/metformin ER) Step Therapy Criteria
· Coverage is provided for members with a diagnosis of type 2 diabetic mellitus whose blood glucose is not adequately controlled on
metformin or a sulfonyurea (determined by pharmacy claims review or through the exceptions review process).
Brand Name: Januvia
Generic Name: Sitagliptin
Januvia (sitagliptin) Step Therapy Criteria

· Coverage is provided for members with a diagnosis of type 2 diabetic mellitus whose blood glucose is not adequately controlled on
metformin or a sulfonyurea (determined by pharmacy claims review or through the exceptions review process).
Brand Name: Zetia
Generic Name: Ezetimibe
Zetia (ezetimibe) Step Therapy Criteria

· Zetia is provided for the treatment of dyslipidemia if the member had an inadequate response or intolerance to simvastatin (generic
Zocor), lovastatin (generic Mevacor), pravastatin (generic Pravachol) determined by pharmacy claims review or through the exceptions review process.

Source: http://medicareassured.com/sites/default/files/documents/MedicareStepTherapy.pdf

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