MEDICARE PART D STEP THERAPY CRITERIA risedronate sodium

MEDICARE PART D STEP THERAPY CRITERIA risedronate sodium

MEDICARE PART D STEP THERAPY CRITERIA
risedronate sodium
Plan Limitations:
 Does not apply to the following Blue Shield of California Medicare Part D
plans:
o Blue Shield Medicare Basic Plan (PDP)
o Blue Shield 65 Plus Riverside (MAPD)
o Blue Shield 65 Plus San Bernardino (MAPD)
o Blue Shield 65 Plus Sacramento (MAPD)
o Blue Shield 65 Plus San Diego (MAPD)
o Blue Shield 65 Plus Ventura (MAPD)
o Blue Shield 65 Plus Contra Costa (MAPD)
o Blue Shield 65 Plus Fresno (MAPD)
o Blue Shield 65 Plus Santa Clara (MAPD)
o Blue Shield 65 Plus Kern (MAPD)
o Blue Shield 65 Plus San Luis Obispo (MAPD)
o Blue Shield Medicare Enhanced Plan (PDP)
o Blue Shield of California Medicare Rx Plan (PDP)
o Blue Shield of California Medicare Rx Plan (MADP)
Step Therapy Criteria:
1) Step One:
 Alendronate sodium tablets or oral solution
2) Step Two:
 Ibandronate sodium tablets
3) Step Three:
 If any claims history for a step one drug (alendronate) AND a step two drug
(ibandronate), OR if any claims history for a step two drug (ibandronate) within
the past 180 days, then risedronate sodium is approved for coverage.
Coverage Duration: Annual
Effective: 03/2016