LEUKOTRIENE STEP THERAPY

 

The Leukotriene step therapy allows coverage for leukotriene medications if the participant is using the medication for treatment of asthma.  For leukotriene medications to be covered as a part of the Medical Associates Health Plans Formulary, the participant must be diagnosed with asthma and will be identified from other medications he/she is using---leukotriene pathway inhibitors, inhaled corticosteroids, other inhalations for asthma, and beta-2 adrenergic agonist drugs. 

 

Participants who receive a new prescription for a Leukotriene mediations and who have a drug history of using one of each of the following: one nasal corticosteroid AND either a non-sedating antihistamine or non-sedating antihistamine/decongestant combinations within 130 days (4 months) will be able to have the Leukotriene medication paid through their prescription drug coverage. 

 

When criteria are not met, the pharmacy will receive the electronic message “Nonasthmatic use NSA & nasal steroid 1st”, and will need to call the practitioner to determine if first-line medications may be prescribed.  Should the practitioner choose to use the Leukotriene medications without meeting the step criteria, and the participant wants the prescription given special consideration for coverage, the practitioner must contact Health Care Services at MAHP and provide additional medical/clinical information.  If the medical/clinical information meets criteria for a medical exception to this step therapy, a prior authorization may be granted.

 

*If under 5 years of age, okay, if diagnosis of asthma or allergic rhinitis (seasonal) then okay.

 

 

FIRST-LINE MEDICATIONS

LEUKOTRIENE MEDICATIONS

MEDICATION

NASAL CORTICOSTEROIDS (NSA): 

Generic name

Brands

 

Beclomethasone dipropionate

Beconase® Inhaler, Beconase AQ Spray, Vancenase® Inhaler, Vancenase Pockethaler, Vancenase AQ

Budesonide

Rhinocort®, Rhinocort® AQ nasal spray

Flunisolide

FLUNISOLIDE

Fluticasone propionate

Flonase® nasal spray

Mometasone furoate

Nasonex® nasal spray

Antihistamines and Antihistamine/Decongestant Combinations:

Generic name

Brands

cetirizine

Zyrtec® tablets and syrup

fexofenadine

Allegra® capsules and tablets

cetirizine/pseudoephedrine

ZYRTEC D™ extended release tablets

fexofenadine/pseudoephedrin.

ALLEGRA-D® extended release tablets

ACCOLATE (zafirlukast)

SINGULAIR (montelukast sodium)

 

CRITERIA FOR USE

Driven by formulary status of drug, formulary (open, benefit-driven, closed) and MAC policies.

**Processing of brand name first-line drug will cause ancillary charges to participant

Participant has two, one each of a nasal corticosteroid

AND a non-sedating antihistamine or non-sedating antihistamine/decongestant combination within 130 days of the prescription fill date for the Leukotriene medication

Kt 04/28/05