NON-STEROIDAL
ANTI-INFLAMMATORY DRUGS (NSAIDs)
STEP THERAPY
The NSAID step therapy program supports the coverage of a legend second-line, non-specific NSAID or a COX-II or brand NSAID if the participant has met the following criteria:
1. To obtain coverage for a legend, second-line NSAID, the participant must have used two over-the-counter (OTC), non-specific NSAIDs as first-line therapy for their current condition within 180 days (6 months) of the prescription for second-line NSAID. If the participant meets the criteria for the step therapy rule, the second-line NSAIDs will be covered.
2. To obtain coverage for a COX-II or brand NSAID, the participant must use two second-line NSAIDS for their current condition within 180 days prior to the COX-II or brand NSAID order.
Should the practitioner choose to use the second-line NSAID without meeting the step criteria, or use a third-line NSAID without meeting the criteria, and the participant wants the prescription given special consideration for payment within their prescription drug benefit, the practitioner must contact Health Care Services at MAHP to provide additional medical/clinical information for review. If the medical/clinical information meets criteria for a medical exception to this step therapy, a prior authorization may be granted, allowing payment under the prescription drug benefit. If the medical/clinical information is determined not to meet the criteria for granting a prior authorization for payment after review by MAHP Medical Director, the participant may elect to pay privately for the prescription.
*Fail 2 first line, fail 2 second
line (180 days), OR Have been using
a second line regularly (180 days) OR Medical
exception
|
|
FIRST-LINE (OTC) NSAID |
SECOND-LINE NSAID |
THIRD-LINE NSAID |
|
MEDICATIONS |
ASA Ibuprofen – Advil,Motrin Naproxen - Aleve Naproxen Sodium-Aleve Ketoprofen - Orudis |
Indomethicin - INDOCIN Piroxicam - FELDENE Diclofenac Sodium - VOLTAREN Diclofenac Potassium–CATAFLAM Sulindac
– CLINORIL Tolmetin - TOLECTIN Meclofenamate – MECLOMEN Etodolac
- LODINE Fenoprofen - NALFON Flurbiprofen – ANSAID OCUFEN |
Oxaprozin (DAYPRO) Nabumetone (RELAFEN) Diclofenac
Sodium/misoprostol (ARTHROTEC) CELEBREX |
|
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
different generic NSAIDs in claims history from the first-line NSAID category
within 180 days prior to the prescription date of a second-line NSAID OR
the participant has a claims history of seond-line NSAIDs being filled
regularly prior to the request. |
Participant has two
different second-line NSAIDs in claims history within 180 days prior to the
prescription date of a third-line NSAID OR the participant has a
claims history of second-line NSAIDs being filled regularly prior to the
request |
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