HMG

Step Therapy

The step therapy program allows for payment of Crestor or Vytorin if the MAHP plan participant has had trial with generic cholesterol lowering medication.

# Days for claims review for select or first line drugs: 130 days

# Different generics from select or first line drugs: 1 generic code

History effective date: 130 days prior to effective date

Grandfathering: No grandfathering

On-line Pharmacy Message: “Use lovastatin or simvastatin 1^st”

Override allowed: Yes

Override NCPCP #: 75

Override Criteria: Standard. If not, provide Client-specific criteria

If the step therapy rule is not met at the point of service (when the prescription is processed at the pharmacy), the pharmacy will be directed, via electronic messaging from the PBM, to contact the practitioner for an alternative HMG. Should the practitioner choose to use the second line HMGs without meeting the step therapy criteria, and the participant wants the prescription given special consideration for payment from their prescription drug benefit, the practitioner must contact Health Care Services at MAHP and provide additional clinical/medical information. If the medical/clinical information meets criteria for a medical exception to this step therapy, a prior authorization may be granted.

	Other HMGs	PA REQUIRED
Medications	First Line Lovastatin Simvastatin	Second Line Crestor Vytorin
CRITERIA FOR USE	Driven by formulary status of drug and MAC policies. **Processing of brand name first-line drug will cause ancillary charges to participant	Participants who have failed the first line medications will be given a prior authorization.