2011 Medicare National Preferred 4 Tier Step Therapy Criteria ANTIDEPRESSANTS - SSRI (SARAFEM) fluoxetine RAPIFLUX SARAFEM ANT

Transcription

1 2011 Medicare National Preferred 4 Tier Step Therapy Criteria ANTIDEPRESSANTS - SSRI (SARAFEM) fluoxetine RAPIFLUX SARAFEM ANTIDEPRESSANTS-BUPROPION bupropion APLENZIN WELLBUTRIN SR WELLBUTRIN XL BILE ACID SEQUESTRANTS cholestyramine/aspartame COLESTID colestipol QUESTRAN WELCHOL BRAND NSAIDS diclofenac potassium diclofenac sodium etodolac fenoprofen flurbiprofen ibuprofen indomethacin Updated: 11/2011 1

2 ketoprofen ketorolac lansoprazole meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium omeprazole oxaprozin pantoprazole piroxicam sulindac tolmetin ANAPROX DS ANAPROX ARTHROTEC ARTHROTEC CATAFLAM CLINORIL DAYPRO EC-NAPROSYN FELDENE FLECTOR Updated: 11/2011 2

3 INDOCIN MOBIC NALFON NAPRELAN NAPROSYN PENNSAID PONSTEL SPRIX VIMOVO VOLTAREN VOLTAREN-XR ZIPSOR CCB - DIHYDROPYRIDINES amlodipine benazepril/amlodipine besylate felodipine isradipine nicardipine nifedipine nisoldipine ADALAT CC DYNACIRC CR NORVASC PROCARDIA XL PROCARDIA Updated: 11/2011 3

4 SULAR CCB - VERAPAMIL verapamil CALAN SR CALAN COVERA-HS ISOPTIN SR VERELAN PM VERELAN COX ANAPROX DS ANAPROX CATAFLAM CLINORIL DAYPRO diclofenac potassium diclofenac sodium EC-NAPROSYN etodolac FELDENE fenoprofen flurbiprofen ibuprofen INDOCIN indomethacin Updated: 11/2011 4

5 ketoprofen ketorolac meclofenamate mefenamic acid meloxicam MOBIC nabumetone NALFON NAPRELAN NAPROSYN naproxen naproxen sodium oxaprozin piroxicam PONSTEL SPRIX sulindac tolmetin VOLTAREN VOLTAREN-XR ZIPSOR CELEBREX ENHANCED ACE-I/ARB benazepril benazepril/amlodipine besylate Updated: 11/2011 5

6 benazepril/hctz captopril captopril/hctz enalapril enalapril maleate/hctz fosinopril fosinopril/hctz lisinopril lisinopril/hctz losartan losartan /hctz moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril AZOR BENICAR HCT BENICAR DIOVAN HCT DIOVAN EXFORGE HCT EXFORGE Updated: 11/2011 6

7 TRIBENZOR ACCUPRIL ACCURETIC ACEON ALTACE ATACAND HCT ATACAND AVALIDE AVAPRO COZAAR EDARBI HYZAAR LOTENSIN HCT LOTENSIN LOTREL MAVIK MICARDIS HCT MICARDIS MONOPRIL PRINIVIL PRINZIDE TARKA TEVETEN HCT TEVETEN TWYNSTA Updated: 11/2011 7

8 UNIRETIC UNIVASC VASERETIC VASOTEC ZESTORETIC ZESTRIL ENHANCED ANTIDEPRESSANTS- SNRI citalopram fluoxetine fluvoxamine paroxetine RAPIFLUX sertraline venlafaxine hcl venlafaxine hcl 100 mg tablet venlafaxine hcl 25 mg tablet venlafaxine hcl 37.5 mg tablet venlafaxine hcl 50 mg tablet venlafaxine hcl 75 mg tablet venlafaxine hcl er 150 mg cap venlafaxine hcl er 37.5 mg cap venlafaxine hcl er 75 mg cap CYMBALTA PRISTIQ SAVELLA Updated: 11/2011 8

9 EFFEXOR XR EFFEXOR VENLAFAXINE HCL ER 150 mg tab venlafaxine hcl er 37.5 mg tab venlafaxine hcl er 75 mg tab VENLAFAXINE HCL ER ENHANCED ANTIDEPRESSANTS- SSRI citalopram fluoxetine fluvoxamine paroxetine RAPIFLUX sertraline LEXAPRO VIIBRYD CELEXA LUVOX CR PAXIL CR PAXIL PEXEVA PROZAC WEEKLY PROZAC ZOLOFT ENHANCED BISPHOSPHONATES ORAL alendronate Updated: 11/2011 9

10 ACTONEL ATELVIA BONIVA FOSAMAX PLUS D FOSAMAX ENHANCED FENOFIBRATE fenofibrate TRICOR TRILIPIX ANTARA FIBRICOR LIPOFEN LOFIBRA TRIGLIDE ENHANCED NON-SEDATING ANTIHISTAMINES cetirizine fexofenadine levocetirizine dihydrochlor ALLEGRA CLARINEX CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR XYZAL ENHANCED OVERACTIVE BLADDER oxybutynin Updated: 11/

11 trospium chloride ENABLEX GELNIQUE SANCTURA XR DETROL LA DETROL DITROPAN XL OXYTROL SANCTURA TOVIAZ VESICARE ENHANCED SEDATIVE HYPNOTICS zaleplon zolpidem LUNESTA ROZEREM AMBIEN CR AMBIEN EDLUAR SILENOR SONATA ZOLPIMIST HMG RULE lovastatin pravastatin Updated: 11/

12 simvastatin CRESTOR VYTORIN HMG RULE CRESTOR VYTORIN CADUET LIPITOR HMG RULE CRESTOR lovastatin pravastatin simvastatin VYTORIN ALTOPREV CADUET LESCOL XL LESCOL LIPITOR LIVALO MEVACOR PRAVACHOL ZOCOR KEPPRA levetiracetam Updated: 11/

13 KEPPRA XR KEPPRA LAMICTAL lamotrigine LAMICTAL (BLUE) LAMICTAL (GREEN) LAMICTAL (ORANGE) LAMICTAL ODT LAMICTAL XR (BLUE) LAMICTAL XR (GREEN) LAMICTAL XR (ORANGE) LAMICTAL XR LAMICTAL LONG ACTING OPIOIDS morphine AVINZA EMBEDA EXALGO KADIAN MS CONTIN OPANA ER ORAMORPH SR OXYCONTIN LYRICA gabapentin Updated: 11/

14 NEURONTIN GRALISE HORIZANT LYRICA METFORMIN metformin FORTAMET GLUCOPHAGE XR GLUCOPHAGE GLUMETZA RIOMET OPHTHALMIC BETA BLOCKERS betaxolol carteolol dorzolamide/timolol levobunolol metipranolol timolol BETAGAN BETIMOL BETOPTIC S COMBIGAN COSOPT ISTALOL OPTIPRANOLOL Updated: 11/

15 TIMOPTIC OCUDOSE TIMOPTIC-XE PPI ENHANCED omeprazole pantoprazole NEXIUM OMEPRAZOLE/SODIUM bicarbonat ACIPHEX DEXILANT PREVACID PRILOSEC PROTONIX ZEGERID STAVZOR divalproex valproic acid DEPAKENE DEPAKOTE ER DEPAKOTE SPRINKLE DEPAKOTE STAVZOR STRATTERA ADDERALL XR ADDERALL amphetamine/dextroamphetamine Updated: 11/

16 CONCERTA d-amphetamine DAYTRANA DESOXYN DEXEDRINE dexmethylphenidate FOCALIN XR FOCALIN METADATE CD methamphetamine METHYLIN methylphenidate RITALIN LA RITALIN RITALIN-SR VYVANSE INTUNIV KAPVAY STRATTERA TEKTURNA ACCUPRIL ACCURETIC ACEON ALTACE ATACAND HCT Updated: 11/

17 ATACAND AVALIDE AVAPRO AZOR benazepril benazepril/amlodipine besylate benazepril/hctz BENICAR HCT BENICAR captopril captopril/hctz COZAAR DIOVAN HCT DIOVAN EDARBI enalapril enalapril maleate/hctz EXFORGE HCT EXFORGE fosinopril fosinopril/hctz HYZAAR lisinopril lisinopril/hctz losartan Updated: 11/

18 losartan /hctz LOTENSIN HCT LOTENSIN LOTREL MAVIK MICARDIS HCT MICARDIS moexipril moexipril/hctz MONOPRIL perindopril erbumine PRINIVIL PRINZIDE quinapril quinapril/hctz ramipril TARKA TEVETEN HCT TEVETEN trandolapril TRIBENZOR TWYNSTA UNIRETIC UNIVASC VASERETIC Updated: 11/

19 VASOTEC ZESTORETIC ZESTRIL AMTURNIDE TEKAMLO TEKTURNA HCT TEKTURNA VALTURNA THIAZOLIDINEDIONE FORTAMET glipizide/metformin hcl GLUCOPHAGE XR GLUCOPHAGE GLUCOVANCE GLUMETZA glyburide/metformin hcl JANUMET KOMBIGLYZE XR METAGLIP metformin PRANDIMET RIOMET ACTOPLUS MET XR ACTOPLUS MET ACTOS Updated: 11/

20 AVANDAMET AVANDARYL AVANDIA DUETACT TOPICAL CORTICOSTEROIDS alclometasone amcinonide betameth/propylene glycol betamethasone dipropionate betamethasone valerate clobetasol propionate desonide desoximetasone diflorasone fluocinolone acetonide fluocinonide fluticasone propionate halobetasol propionate hydrocortisone hydrocortisone butyrate hydrocortisone valerate mometasone prednicarbate triamcinolone acetonide ACLOVATE Updated: 11/

21 ALA-CORT ALA-SCALP HP CARMOL HC CLOBEX CLODERM CORDRAN SP CORDRAN CUTIVATE DERMA-SMOOTHE-FS DERMATOP DESONATE DESOWEN DIPROLENE AF DIPROLENE ELOCON HALOG KENALOG LOCOID LIPOCREAM LOCOID LOKARA LUXIQ OLUX-E PANDEL TEMOVATE TOPICORT LP Updated: 11/

22 TOPICORT U-CORT ULTRAVATE VANOS VERDESO WESTCORT TOPICAL IMMUNOMODULATORS ACLOVATE ALA-CORT ALA-SCALP HP alclometasone amcinonide betameth/propylene glycol betamethasone dipropionate betamethasone valerate CARMOL HC clobetasol propionate CLOBEX CLODERM CORDRAN SP CORDRAN CUTIVATE DERMA-SMOOTHE-FS DERMATOP DESONATE Updated: 11/

23 desonide DESOWEN desoximetasone diflorasone DIPROLENE AF DIPROLENE ELOCON fluocinolone acetonide fluocinonide fluticasone propionate halobetasol propionate HALOG hydrocortisone hydrocortisone butyrate hydrocortisone valerate KENALOG LOCOID LIPOCREAM LOCOID LOKARA LUXIQ mometasone OLUX-E PANDEL prednicarbate TEMOVATE Updated: 11/

24 TOPICORT LP TOPICORT triamcinolone acetonide U-CORT ULTRAVATE VANOS VERDESO WESTCORT ELIDEL PROTOPIC ULORIC allopurinol ZYLOPRIM ULORIC ULTRAM tramadol tramadol/apap RYZOLT ULTRACET ULTRAM ER ULTRAM ZETIA ADVICOR ALTOPREV CADUET Updated: 11/

25 CRESTOR LESCOL XL LESCOL LIPITOR LIVALO lovastatin MEVACOR PRAVACHOL pravastatin SIMCOR simvastatin VYTORIN ZOCOR ZETIA Index Updated: 11/

26 ANTIDEPRESSANTS - SSRI (SARAFEM) Affected Drugs STEP 1 DRUGS fluoxetine RAPIFLUX STEP 2 DRUGS SARAFEM If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Fluoxetine Hcl, Rapiflux, Selfemra. Step 2 Drug(s): Sarafem. Authorization may be given for step 2 Sarafem if the patient is currently taking the requested agent. This step therapy program applies to new utilizers only. Updated: 11/

27 ANTIDEPRESSANTS-BUPROPION Affected Drugs STEP 1 DRUGS bupropion STEP 2 DRUGS APLENZIN WELLBUTRIN SR WELLBUTRIN XL If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Budeprion Sr, Budeprion Xl, Bupropion Hcl Sr. Step 2 Drug(s): Aplenzin, Wellbutrin Sr, Wellbutrin XL. Authorization may be given for a step 2 drug if the patient is currently taking the requested agent. This step therapy program applies to new utilizers only. Updated: 11/

28 BILE ACID SEQUESTRANTS Affected Drugs STEP 1 DRUGS cholestyramine/aspartame COLESTID colestipol QUESTRAN STEP 2 DRUGS WELCHOL If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Cholestyramine, Cholestyramine Light, Colestid, Colestipol Hcl, Prevalite, Questran, Questran Light. Step 2 Drug(s): Welchol. Authorization may be given for Welchol if patients have a drug-drug interaction with cholestyramine or colestipol. Authorization may be given for Welchol in patients who are pregnant. Authorization may be given for Welchol in patients with type 2 diabetes who are also using other antidiabetic agents (eg, insulin, metformin, sulfonylurea). Updated: 11/

29 BRAND NSAIDS Affected Drugs STEP 1 DRUGS diclofenac potassium diclofenac sodium etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac lansoprazole meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium omeprazole oxaprozin pantoprazole piroxicam sulindac tolmetin STEP 2 DRUGS ANAPROX DS ANAPROX ARTHROTEC 50 ARTHROTEC 75 CATAFLAM CLINORIL DAYPRO EC-NAPROSYN FELDENE FLECTOR INDOCIN MOBIC NALFON NAPRELAN NAPROSYN PENNSAID PONSTEL SPRIX VIMOVO VOLTAREN VOLTAREN-XR ZIPSOR If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Diclofenac Potassium, Diclofenac Sodium, Etodolac, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Lansoprazole, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Omeprazole, Nabumetone, Naproxen, Naproxen Sodium, Oxaprozin, Pantoprazole Sodium, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Anaprox, Anaprox Ds, Arthrotec 50, Arthrotec 75, Cataflam, Clinoril, Daypro, Ec-naprosyn, Feldene, Flector, Indocin, Indocin Sr, Mobic, Nalfon, Naprelan, Naprosyn, Pennsaid, Ponstel, Sprix, Vimovo, Voltaren, Voltaren-XR, Zipsor. Authorization for Vimovo may be given if the patient has claims history for both pantoprazole sodium, omeprazole, or lansoprazole and a prescription naproxen or naproxen sodium product. Authorization for a step 2 drug, other than Vimovo, may be given if the patient has tried two unique generic prescription strength non-steroidal anti-inflammatory drugs (NSAIDs) for the current condition. Updated: 11/

30 Authorization may be given for Flector, Pennsaid, Sprix, or Voltaren Gel for patients with difficulty swallowing or cannot swallow. Authorization may be given for Pennsaid or Voltaren Gel for patients with a chronic musculoskeletal pain condition (eg, osteoarthritis) in 3 or fewer joints/sites (ie, hand, wrist, elbow, knee, ankle, or foot each count as 1 joint/site) who are at risk of NSAID-associated toxicity (eg, previous gastrointestinal [GI] bleed, history of peptic ulcer disease, impaired renal function, cardiovascular disease, hypertension, heart failure, elderly patients with impaired hepatic function, or those taking concomitant anticoagulants). Updated: 11/

31 CCB - DIHYDROPYRIDINES Affected Drugs STEP 1 DRUGS amlodipine benazepril/amlodipine besylate felodipine isradipine nicardipine nifedipine nisoldipine STEP 2 DRUGS ADALAT CC DYNACIRC CR NORVASC PROCARDIA XL PROCARDIA SULAR If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Afeditab Cr, Amlodipine Besylate, Amlodipine Besylatebenazepril, Felodipine Er, Isradipine, Nicardipine Hcl, Nifediac Cc, Nifedical Xl, Nifedipine, Nifedipine Er, Nisoldipine. Step 2 Drug(s): Adalat Cc, Dynacirc Cr, Norvasc, Procardia, Procardia XL, Sular. Updated: 11/

32 CCB - VERAPAMIL Affected Drugs STEP 1 DRUGS verapamil STEP 2 DRUGS CALAN SR CALAN COVERA-HS ISOPTIN SR VERELAN PM VERELAN If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Verapamil Er, Verapamil Hcl. Step 2 Drug(s): Calan, Calan Sr, Covera-hs, Isoptin Sr, Verelan, Verelan PM. Updated: 11/

33 COX-2 Affected Drugs STEP 1 DRUGS ANAPROX DS ANAPROX CATAFLAM CLINORIL DAYPRO diclofenac potassium diclofenac sodium EC-NAPROSYN etodolac FELDENE fenoprofen flurbiprofen ibuprofen INDOCIN indomethacin ketoprofen ketorolac meclofenamate mefenamic acid meloxicam MOBIC nabumetone NALFON NAPRELAN NAPROSYN naproxen naproxen sodium oxaprozin piroxicam PONSTEL SPRIX sulindac tolmetin VOLTAREN VOLTAREN-XR ZIPSOR STEP 2 DRUGS CELEBREX Updated: 11/

34 If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Anaprox, Anaprox Ds, Cataflam, Clinoril, Daypro, Diclofenac Potassium, Diclofenac Sodium, Ec-naprosyn, Etodolac, Feldene, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indocin, Indocin Sr, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Mobic, Nabumetone, Nalfon, Naprelan, Naprosyn, Naproxen, Naproxen Sodium, Oxaprozin, Piroxicam, Ponstel, Sprix, Sulindac, Tolmetin Sodium, Voltaren, Voltaren-xr, Zipsor. Step 2 Drug(s): Celebrex. This step therapy program will exclude participants with a claims history of warfarin (Coumadin) or dabigatran (Pradaxa) within the last 130 days. Authorization for Celebrex may be given for patients who are currently taking chronic systemic corticosteroid therapy, warfarin (Coumadin), clopidogrel (Plavix), prasugrel (Effient), dabigatran (Pradaxa), chronic aspirin therapy, or low molecular weight heparins. Authorization for Celebrex may be given for patients with reduced platelet counts or other coagulation disorders. Authorization for Celebrex may be given for patients with familial adenomatous polyposis (FAP) or attenuated adenomatous polyposis coli (AAPC) who have adenomatous colorectal polyps. Authorization for Celebrex may be given if used for the treatment of cancer as part of a cancerchemotherapy regimen (e. g., in combination with chemotherapeutic agents). Authorization for Celebrex may be given for patients who have had a documented upper gastrointestinal bleed from a duodenal or gastric ulcer. Authorization for Celebrex may be given for patients with a past hypersensitivity, anaphylactic or allergic-type reaction (e. g., erythema, hives, urticaria, angioedema) to aspirin or NSAIDs [Non-steroidal antiinflammatory drugs]. Authorization for Celebrex may be given to patients with aspirinsensitive asthma (also known as aspirin-induced asthma, aspirin-exacerbated respiratory disease) or NSAID-induced asthma. Updated: 11/

35 ENHANCED ACE-I/ARB Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS benazepril benazepril/amlodipine besylate benazepril/hctz captopril captopril/hctz enalapril enalapril maleate/hctz fosinopril fosinopril/hctz lisinopril lisinopril/hctz losartan losartan /hctz moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril AZOR BENICAR HCT BENICAR DIOVAN HCT DIOVAN EXFORGE HCT EXFORGE TRIBENZOR ACCUPRIL ACCURETIC ACEON ALTACE ATACAND HCT ATACAND AVALIDE AVAPRO COZAAR EDARBI HYZAAR LOTENSIN HCT LOTENSIN LOTREL MAVIK MICARDIS HCT MICARDIS MONOPRIL PRINIVIL PRINZIDE TARKA TEVETEN HCT TEVETEN TWYNSTA UNIRETIC UNIVASC VASERETIC VASOTEC ZESTORETIC ZESTRIL If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Amlodipine Besylate-benazepril, Benazepril Hcl, Benazepril Hclhctz, Captopril, Captopril-hydrochlorothiazide, Enalapril Maleate, Enalapril Maleate-hctz, Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Lisinopril, Lisinopril-hctz, Losartan Updated: 11/

36 Potassium, Losartan-Hydrochlorothiazide, Moexipril Hcl, Moexipril-hydrochlorothiazide, Perindopril erbumine, Quinapril Hcl, Quinapril-hydrochlorothiazide, Ramipril, Trandolapril. Step 2 Drug(s): Azor, Benicar, Benicar Hct, Diovan, Diovan Hct, Exforge, Exforge Hct, Tribenzor. Step 3 Drug(s): Accupril, Accuretic, Aceon, Altace, Atacand, Atacand Hct, Avalide, Avapro, Cozaar, Edarbi, Hyzaar, Lotensin, Lotensin Hct, Lotrel, Mavik, Micardis, Micardis Hct, Monopril, Prinivil, Prinzide, Tarka, Teveten, Teveten Hct, Twynsta, Uniretic, Univasc, Vaseretic, Vasotec, Zestoretic, Zestril. Authorization may be given for a step 2 or step 3 angiotensin receptor blocker (ARB) or ARB-containing combination product, without a trial of a step 1 or 2 agent, if the patient was recently hospitalized and discharged within the previous 30 days for a cardiovascular event (eg, myocardial infarction, hypertensive emergency, decompensated heart failure) and has already been started and stabilized on the requested agent. Authorization may be given for Atacand in children aged less than 6 years. Updated: 11/

37 ENHANCED ANTIDEPRESSANTS- SNRI Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS citalopram fluoxetine fluvoxamine paroxetine RAPIFLUX sertraline venlafaxine hcl venlafaxine hcl 100 mg tablet venlafaxine hcl 25 mg tablet venlafaxine hcl 37.5 mg tablet venlafaxine hcl 50 mg tablet venlafaxine hcl 75 mg tablet venlafaxine hcl er 150 mg cap venlafaxine hcl er 37.5 mg cap venlafaxine hcl er 75 mg cap CYMBALTA PRISTIQ SAVELLA EFFEXOR XR EFFEXOR VENLAFAXINE HCL ER 150 mg tab venlafaxine hcl er 37.5 mg tab venlafaxine hcl er 75 mg tab VENLAFAXINE HCL ER If the patient has tried a Step 1 drug, then authorization for a drug in Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Citalopram, Citalopram Hbr, Fluoxetine Dr, Fluoxetine Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Paroxetine ER, Rapiflux, Sertraline Hcl, Venlafaxine Hcl, Venlafaxine Hcl Er. Step 2 Drug(s): Cymbalta, Pristiq, Savella. Step 3 Drug(s): Effexor, Effexor XR, Venlafaxine Hcl ER. Patients who have taken a step 2 SNRI [Selective Norepinephrine Reuptake Inhibitor] at any time in the past and discontinued its use may receive authorization to restart the step 2 SNRI [Selective Norepinephrine Reuptake Inhibitor] (whichever they used in the past), without a trial of a step 1 agent. Authorization may be given for a step 2 or 3 SNRI [Selective Norepinephrine Reuptake Inhibitor] if the patient is currently taking the requested agent. Authorization may be given for a step 2 SNRI [Selective Norepinephrine Reuptake Inhibitor], without a trial of a step 1 agent, if the patient is a child or adolescent aged 18 years or less, or the patient has symptoms of suicidal ideation. Authorization may be given for Cymbalta, without a trial of a step 1 agent, if the patient (men or women) has Updated: 11/

38 symptoms of stress urinary incontinence. Authorization may be given for Cymbalta or Savella, without a trial of a step 1 agent, if the patient has symptoms of fibromyalgia. Authorization may be given for Cymbalta, without a trial of a step 1 agent, if the patient has symptoms of chronic musculoskeletal pain (eg, chronic low back pain or chronic pain due to osteoarthritis). This step therapy program applies to new utilizers only. Updated: 11/

39 ENHANCED ANTIDEPRESSANTS- SSRI Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS citalopram fluoxetine fluvoxamine paroxetine RAPIFLUX sertraline LEXAPRO VIIBRYD CELEXA LUVOX CR PAXIL CR PAXIL PEXEVA PROZAC WEEKLY PROZAC ZOLOFT If the patient has tried two Step 1 drugs, then authorization for a drug in Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Citalopram, Citalopram Hbr, Fluoxetine Dr, Fluoxetine Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Paroxetine ER, Rapiflux, Sertraline Hcl. Step 2 Drug(s): Lexapro, Viibryd. Step 3 Drug(s): Celexa, Luvox Cr, Paxil, Paxil Cr, Pexeva, Prozac, Prozac Weekly, Zoloft. Patients who have taken a step 2 SSRI [Selective Serotonin Reuptake Inhibitor], Luvox Cr, or Pexeva at any time in the past and discontinued its use may receive authorization to restart the step 2 SSRI [Selective Serotonin Reuptake Inhibitor], Luvox Cr, or Pexeva (whichever they used in the past). Authorization may be given for a step 2 or 3 SSRI [Selective Serotonin Reuptake Inhibitor] if the patient is currently taking the requested agent. Authorization may be given for a step 2 or 3 SSRI [Selective Serotonin Reuptake Inhibitor] if the patient is a child or adolescent aged 18 years or less, or has suicidal ideation. Authorization may be given for Lexapro for use in the management of generalized anxiety disorder (GAD) for patients who have tried paroxetine HCl immediate release. Authorization may be given for Lexapro for patients who have tried citalopram or citalopram hbr and who may have a clinically significant drug interaction with fluoxetine dr/fluoxetine hcl/rapiflux, fluvoxamine maleate, sertraline hcl, or paroxetine hcl. This step therapy program applies to new utilizers only. Updated: 11/

40 ENHANCED BISPHOSPHONATES ORAL Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS alendronate ACTONEL ATELVIA BONIVA FOSAMAX PLUS D FOSAMAX If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Alendronate Sodium. Step 2 Drug(s): Actonel, Actonel With Calcium, Atelvia, Boniva. Step 3 Drug(s): Fosamax, Fosamax Plus D. Authorization may be given for Actonel, Actonel with Calcium tablets, or Boniva, if the patient has an abnormality of the esophagus that delays esophageal emptying (stricture or achalasia). Authorization may be given for Actonel for use in the management of Paget's disease if the patient has already started therapy with Actonel. Authorization may be given for Fosamax oral solution for adult patients with a gastrostomy tube, who cannot swallow, or who have difficulty swallowing tablets. Authorization may be given for Fosamax oral solution for children who require an oral solution. Updated: 11/

41 ENHANCED FENOFIBRATE Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS fenofibrate TRICOR TRILIPIX ANTARA FIBRICOR LIPOFEN LOFIBRA TRIGLIDE If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Fenofibrate. Step 2 Drug(s): Tricor, Trilipix. Step 3 Drug(s): Antara, Fibricor, Lipofen, Lofibra, Triglide. Updated: 11/

42 ENHANCED NON-SEDATING ANTIHISTAMINES Affected Drugs STEP 1 DRUGS cetirizine fexofenadine levocetirizine dihydrochlor STEP 2 DRUGS ALLEGRA CLARINEX CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR XYZAL If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Cetirizine Hcl, Fexofenadine Hcl, Levocetirizine Dihydrochloride. Step 2 Drug(s): Allegra, Clarinex, Clarinex-d 12 Hour, Clarinex-d 24 Hour, Xyzal. Authorization may be given for Xyzal if the patient is pregnant. Authorization may be given for Clarinex syrup, Clarinex Reditabs, Allegra suspension, or Xyzal solution if the patient has difficulty swallowing or cannot swallow (eg, pediatric patients) and the patient has tried cetirizine syrup or chewable tablets. Updated: 11/

43 ENHANCED OVERACTIVE BLADDER Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS oxybutynin trospium chloride ENABLEX GELNIQUE SANCTURA XR DETROL LA DETROL DITROPAN XL OXYTROL SANCTURA TOVIAZ VESICARE If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Oxybutynin Chloride, Oxybutynin Chloride Er, Trospium Chloride. Step 2 Drug(s): Enablex, Gelnique, Sanctura Xr. Step 3 Drug(s): Detrol, Detrol La, Ditropan Xl, Oxytrol, Sanctura, Toviaz, Vesicare. Authorization for Oxytrol or Gelnique may be given for patients who cannot swallow or who have difficulty swallowing. Updated: 11/

44 ENHANCED SEDATIVE HYPNOTICS Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS zaleplon zolpidem LUNESTA ROZEREM AMBIEN CR AMBIEN EDLUAR SILENOR SONATA ZOLPIMIST If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Zaleplon, Zolpidem Tartrate. Step 2 Drug(s): Lunesta, Rozerem. Step 3 Drug(s): Ambien, Ambien CR, Edluar, Silenor, Sonata, Zolpimist. Rozerem will be covered for members equal to or over the age of 65 years. For those under 65 years of age, the step therapy will apply. Authorization for Rozerem or Silenor may be given if the patient has a documented history of addiction to controlled substances. Authorization for Edluar or Zolpimist may be given if the patient has difficulty swallowing or cannot swallow tablets. Updated: 11/

45 HMG RULE 1 Affected Drugs STEP 1 DRUGS lovastatin pravastatin simvastatin STEP 2 DRUGS CRESTOR VYTORIN If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Lovastatin, Pravastatin Sodium, Simvastatin. Step 2 Drug(s): Crestor, Vytorin. Authorization may be given for a step 2 drug, if the patient has tried one step 1 drug, Advicor, or Simcor. Authorization may be given for a step 2 drug, if the patient at baseline requires a documented 45% or more reduction in LDL-C to meet NCEP ATP III LDL-C goals. Authorization for Crestor may be given for patients who are receiving Crestor doses of 10 mg or more per day. Authorization for Vytorin may be given for patients who are receiving Vytorin doses of 10 mg/20 mg or more per day. Authorization for a step 2 drug will given on an individual basis for drug-drug interactions. Updated: 11/

46 HMG RULE 2 Affected Drugs STEP 1 DRUGS CRESTOR VYTORIN STEP 2 DRUGS CADUET LIPITOR If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Crestor, Vytorin. Step 2 Drug(s): Caduet, Lipitor. Authorization may be given for a step 2 drug, if the patient has tried one step 1 drug. Authorization for a step 2 drug will given on an individual basis for drug-drug interactions. Authorization for Lipitor 80 mg may be given for patients who have had an acute coronary syndrome (ACS) (eg, myocardial infarction [with or without electrocardiograph evidence of STsegment elevation] or high-risk unstable angina) and who started therapy with Lipitor 80 mg within 30 days of discharge from the hospital. Updated: 11/

47 HMG RULE 3 Affected Drugs STEP 1 DRUGS CRESTOR lovastatin pravastatin simvastatin VYTORIN STEP 2 DRUGS ALTOPREV CADUET LESCOL XL LESCOL LIPITOR LIVALO MEVACOR PRAVACHOL ZOCOR If the patient has tried a Step 1 Group A and a Step 1 Group B drug, then authorization for a Step 2 drug may be given. Step 1 Group A Drug(s): Lovastatin, Pravastatin Sodium, Simvastatin. Step 1 Group B Drug(s): Crestor, Vytorin. Step 2 Drug(s): Altoprev, Caduet, Lescol, Lescol Xl, Lipitor, Livalo, Mevacor, Pravachol, Zocor. Authorization for a step 2 drug will given on an individual basis for drug-drug interactions. Authorization for a Step 2 drug may be given if the patient has tried Advicor or Simcor and a Step 1 Group B drug. Authorization may be given for Lipitor, if the patient at baseline requires a documented 45% or more reduction in LDL-C to meet NCEP ATP III LDL-C goals and has tried a Step 1 Group B drug. Updated: 11/

48 KEPPRA Affected Drugs STEP 1 DRUGS levetiracetam STEP 2 DRUGS KEPPRA XR KEPPRA If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Levetiracetam. Step 2 Drug(s): Keppra, Keppra XR. Authorization may be given for a Step 2 drug if the patient is currently taking (or has taken in the past) the requested agent. This step therapy program applies to new utilizers only. Updated: 11/

49 LAMICTAL Affected Drugs STEP 1 DRUGS lamotrigine STEP 2 DRUGS LAMICTAL (BLUE) LAMICTAL (GREEN) LAMICTAL (ORANGE) LAMICTAL ODT LAMICTAL XR (BLUE) LAMICTAL XR (GREEN) LAMICTAL XR (ORANGE) LAMICTAL XR LAMICTAL If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Lamotrigine. Step 2 Drug(s): Lamictal, Lamictal (blue), Lamictal (green), Lamictal (orange), Lamictal ODT, Lamictal XR, Lamictal XR (blue), Lamictal XR (green), Lamictal XR (orange). Authorization may be given for a Step 2drug if the patient is currently taking (or has taken in the past) the requested agent. Authorization may be given for Lamictal ODT if the patient cannot chew and swallow lamotrigine chewable dispersible tablets. This step therapy program applies to new utilizers only. Updated: 11/

50 LONG ACTING OPIOIDS Affected Drugs STEP 1 DRUGS morphine STEP 2 DRUGS AVINZA EMBEDA EXALGO KADIAN MS CONTIN OPANA ER ORAMORPH SR OXYCONTIN If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Morphine sulfate. Step 2 Drug(s): Avinza, Embeda, Exalgo, Kadian, MS [Multiple Sclerosis] Contin, Opana Er, Oramorph Sr, Oxycontin. Authorization may be given for Exalgo or OxyContin if the patient is unable to tolerate or has a drug allergy noted with morphine sulfate. Authorization may be given for Exalgo or OxyContin if the patient has renal insufficiency. Authorization may be given for OxyContin if the patient is pregnant. Authorization may be given for Avinza, Kadian, or Embeda if the patient cannot swallow or has difficulty swallowing. Authorization may be given for Avinza or Kadian if the patient has a gastrostomy tube (G-tube). Updated: 11/

51 LYRICA Affected Drugs STEP 1 DRUGS gabapentin NEURONTIN STEP 2 DRUGS GRALISE HORIZANT LYRICA If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Gabapentin, Neurontin. Step 2 Drug(s): Lyrica, Gralise, Horizant. Members with a history of the following drugs within the 130 day look back period are excluded from step therapy for Lyrica. Seizure Medications - Diazepam, Felbamate, Ethotoin, Phenytoin, Succinimides, Primidone, Phenobarbital, or Diabetic Medications - Antidiabetic Meds. Authorization for Lyrica, without a trial of a step 1 agent, may be given for patients with symptoms of seizure disorder. Authorization for Lyrica may be given if the patient cannot tolerate gabapentin due to adverse events. Authorization for Lyrica may be given, without a trial of a step 1 agent, if the patient has symptoms of fibromyalgia. Authorization may be given for Lyrica may be given if the patient has tried Gralise or Horizant. This step therapy program applies to new utilizers only. Updated: 11/

52 METFORMIN Affected Drugs STEP 1 DRUGS metformin STEP 2 DRUGS FORTAMET GLUCOPHAGE XR GLUCOPHAGE GLUMETZA RIOMET If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Metformin Hcl, Metformin Hcl Er. Step 2 Drug(s): Fortamet, Glucophage, Glucophage Xr, Glumetza, Riomet. Participant must have 60 days of generic metformin or generic metformin ER in claims history. Authorization may be given for Riomet patients who are unable to swallow or have difficulty swallowing tablets containing metformin. Updated: 11/

53 OPHTHALMIC BETA BLOCKERS Affected Drugs STEP 1 DRUGS betaxolol carteolol dorzolamide/timolol levobunolol metipranolol timolol STEP 2 DRUGS BETAGAN BETIMOL BETOPTIC S COMBIGAN COSOPT ISTALOL OPTIPRANOLOL TIMOPTIC OCUDOSE TIMOPTIC-XE If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Betaxolol Hcl, Carteolol Hcl, Dorzolamide-timolol, Levobunolol Hcl, Metipranolol, Timolol Maleate. Step 2 Drug(s): Betagan, Betimol, Betoptic S, Combigan, Cosopt, Istalol, Optipranolol, Timoptic Ocudose, Timoptic-XE. Updated: 11/

54 PPI ENHANCED Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS lansoprazole dr 15 mg capsule lansoprazole dr 30 mg capsule omeprazole pantoprazole lansoprazole odt 15 mg tablet lansoprazole odt 30 mg tablet NEXIUM OMEPRAZOLE/SODIUM bicarbonat ACIPHEX DEXILANT PREVACID PRILOSEC PROTONIX ZEGERID If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Lansoprazole (capsules), Omeprazole, Pantoprazole Sodium. Step 2 Drug(s): Lansoprazole (ODT tablets), Nexium, Omeprazole-Sodium Bicarbonate. Step 3 Drug(s): Aciphex, Dexilant, Prevacid, Prilosec, Protonix, Zegerid. Authorization may be given for Lansoprazole (ODT tablets) or Prevacid SoluTabs for patients with a feeding tube (eg, nasogastric tube, gastric tube). Authorization may be given for a Step 2 or a Step 3 agent for children less than 2 years old. Authorization may be given for a step 3 agent, except Prilosec or Zegerid, for patients concomitantly receiving clopidogrel who have tried a step 1 agent (not required to try step 2 Nexium). Updated: 11/

55 STAVZOR Affected Drugs STEP 1 DRUGS divalproex valproic acid STEP 2 DRUGS DEPAKENE DEPAKOTE ER DEPAKOTE SPRINKLE DEPAKOTE STAVZOR If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Divalproex Sodium, Divalproex Sodium Er, Valproic Acid. Step 2 Drug(s): Depakene, Depakote, Depakote Er, Depakote Sprinkle, Stavzor. Authorization may be given for a Step 2 drug if the patient is currently taking (or has taken in the past) the requested agent. This step therapy program applies to new utilizers only. Updated: 11/

56 STRATTERA Affected Drugs STEP 1 DRUGS ADDERALL XR ADDERALL amphetamine/dextroamphetamine CONCERTA d-amphetamine DAYTRANA DESOXYN DEXEDRINE dexmethylphenidate FOCALIN XR FOCALIN METADATE CD methamphetamine METHYLIN methylphenidate RITALIN LA RITALIN RITALIN-SR VYVANSE STEP 2 DRUGS INTUNIV KAPVAY STRATTERA If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Adderall, Adderall Xr, Amphetamine Salt Combo, Concerta, Daytrana, Desoxyn, Dexedrine, Dexmethylphenidate Hcl, Dextroamphetamine Sulfate, Focalin, Focalin Xr, Metadate Cd, Metadate Er, Methamphetamine Hcl, Methylin, Methylin Er, Methylphenidate Hcl, Methylphenidate Sr, Ritalin, Ritalin La, Ritalin-sr, Vyvanse. Step 2 Drug(s): Intuniv, Kapvay, Strattera. Authorization for Strattera, or Intuniv, or Kapvay may be given for the use of attention deficit hyperactivity disorder (ADHD)/attention deficit disorder (ADD) if the patient has a documented history of addiction to controlled substances. Authorization for Strattera, or Intuniv, or Kapvay may be given for the use of ADHD [Attention Deficit Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient has a history of seizures. Authorization for Strattera may be given for the use of ADHD [Attention Deficit Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient has co-morbid anxiety. Authorization for Strattera may be given for the use of ADHD [Attention Deficit Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient has a history of motor tics or a family history or diagnosis of Tourette's syndrome. Authorization for Strattera may be given for the use of ADHD Updated: 11/

57 [Attention Deficit Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient has hypertension, heart failure, recent myocardial infarction, or hyperthyroidism. Updated: 11/

58 TEKTURNA Affected Drugs STEP 1 DRUGS ACCUPRIL ACCURETIC ACEON ALTACE ATACAND HCT ATACAND AVALIDE AVAPRO AZOR benazepril benazepril/amlodipine besylate benazepril/hctz BENICAR HCT BENICAR captopril captopril/hctz COZAAR DIOVAN HCT DIOVAN EDARBI enalapril enalapril maleate/hctz EXFORGE HCT EXFORGE fosinopril fosinopril/hctz HYZAAR lisinopril lisinopril/hctz losartan losartan /hctz LOTENSIN HCT LOTENSIN LOTREL MAVIK MICARDIS HCT STEP 2 DRUGS AMTURNIDE TEKAMLO TEKTURNA HCT TEKTURNA VALTURNA Updated: 11/

59 MICARDIS moexipril moexipril/hctz MONOPRIL perindopril erbumine PRINIVIL PRINZIDE quinapril quinapril/hctz ramipril TARKA TEVETEN HCT TEVETEN trandolapril TRIBENZOR TWYNSTA UNIRETIC UNIVASC VASERETIC VASOTEC ZESTORETIC ZESTRIL If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Accupril, Accuretic, Aceon, Altace, Amlodipine Besylatebenazepril, Atacand, Atacand Hct, Avalide, Avapro, Azor, Benazepril Hcl, Benazepril Hcl-hctz, Benicar, Benicar Hct, Captopril, Captopril-hydrochlorothiazide, Cozaar, Diovan, Diovan Hct, Edarbi, Enalapril Maleate, Enalapril Maleate-hctz, Exforge, Exforge Hct, Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Hyzaar, Lisinopril, Lisinoprilhctz, Losartan Potassium, Losartan-Hydrochlorothiazide, Lotensin, Lotensin Hct, Lotrel, Mavik, Micardis, Micardis Hct, Moexipril Hcl, Moexipril-hydrochlorothiazide, Monopril, Perindopril erbumine, Prinivil, Prinzide, Quinapril Hcl, Quinapril-hydrochlorothiazide, Ramipril, Tarka, Teveten, Teveten Hct, Trandolapril, Tribenzor, Twynsta, Uniretic, Univasc, Vaseretic, Vasotec, Zestoretic, Zestril. Step 2 Drug(s): Amturnide, Tekamlo, Tekturna, Tekturna Hct, Valturna. Authorization for a step 2 drug may be given if the patient tried an angiotensin converting enzyme (ACE) inhibitor or ACE inhibitor combination product in the past. Authorization for a step 2 drug may be given if the patient tried an angiotensin receptor blocker (ARB) or ARB combination product in the past they are not required to have a trial with an ACE inhibitor. Updated: 11/

60 THIAZOLIDINEDIONE Affected Drugs STEP 1 DRUGS FORTAMET glipizide/metformin hcl GLUCOPHAGE XR GLUCOPHAGE GLUCOVANCE GLUMETZA glyburide/metformin hcl JANUMET KOMBIGLYZE XR METAGLIP metformin PRANDIMET RIOMET STEP 2 DRUGS ACTOPLUS MET XR ACTOPLUS MET ACTOS AVANDAMET AVANDARYL AVANDIA DUETACT If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Fortamet, Glipizide-metformin, Glucophage, Glucophage Xr, Glucovance, Glumetza, Glyburide-metformin Hcl, Janumet, Kombiglyze Xr, Metaglip, Metformin Hcl, Metformin Hcl Er, Prandimet, Riomet. Step 2 Drug(s): Actoplus Met, Actoplus Met Xr, Actos, Avandamet, Avandaryl, Avandia, Duetact. Authorization may be given for a step 2 drug if the patient has tried metformin or a metformin-containing combination product in the past. Authorization may be given for a step 2 drug if the patient is already started on the requested step 2 drug. Authorization may be given for Actos, Avandia, Duetact or Avandaryl without a trial of metformin in patients with renal insufficiency or renal disease. Authorization may be given for Actos, Avandia, Duetact or Avandaryl without a trial of metformin in patients with cardiomyopathy, heart failure, unstable angina, or who have experienced a myocardial infarction. Authorization may be given for Actos, Avandia, Duetact or Avandaryl without a trial of metformin in patients with a condition (not already noted above) that could potentially increase the risk of hypoperfusion, hypoxemia, or dehydration. Authorization may be given for Actos, Avandia, Duetact or Avandaryl without a trial of metformin if the patient has hepatic impairment or is alcohol dependent. Authorization may be given for Actos, Avandia, Duetact or Avandaryl without a trial of metformin if the patient has chronic metabolic acidosis. Updated: 11/

61 TOPICAL CORTICOSTEROIDS Affected Drugs STEP 1 DRUGS alclometasone amcinonide betameth/propylene glycol betamethasone dipropionate betamethasone valerate clobetasol propionate desonide desoximetasone diflorasone fluocinolone acetonide fluocinonide fluticasone propionate halobetasol propionate hydrocortisone hydrocortisone butyrate hydrocortisone valerate mometasone prednicarbate triamcinolone acetonide STEP 2 DRUGS ACLOVATE ALA-CORT ALA-SCALP HP CARMOL HC CLOBEX CLODERM CORDRAN SP CORDRAN CUTIVATE DERMA-SMOOTHE-FS DERMATOP DESONATE DESOWEN DIPROLENE AF DIPROLENE ELOCON HALOG KENALOG LOCOID LIPOCREAM LOCOID LOKARA LUXIQ OLUX-E PANDEL TEMOVATE TOPICORT LP TOPICORT U-CORT ULTRAVATE VANOS VERDESO WESTCORT If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Alclometasone Dipropionate, Amcinonide, Betamethasone Dipropionate, Betamethasone Valerate, Beta-val, Clobetasol Emollient, Clobetasol Updated: 11/

62 Propionate, Cormax, Del-beta, Desonide, Desoximetasone, Diflorasone Diacetate, Fluocinolone Acetonide, Fluocinonide, Fluocinonide Emollient, Fluticasone Propionate, Halobetasol Propionate, Hydrocortisone, Hydrocortisone Butyrate, Hydrocortisone Valerate, Mometasone Furoate, Prednicarbate, Triamcinolone Acetonide, Triderm. Step 2 Drug(s): Aclovate, Ala-cort, Ala-scalp Hp, Carmol Hc, Clobex, Cloderm, Cordran, Cordran Sp, Cutivate, Derma-smoothe-fs, Dermatop, Desonate, Desowen, Diprolene, Diprolene Af, Elocon, Halog, Kenalog, Locoid, Locoid Lipocream, Lokara, Luxiq, Olux-e, Pandel, Temovate, Topicort, Topicort Lp, U-cort, Ultravate, Vanos, Verdeso, Westcort. Authorization for a step 2 drug may be given if the patient has tried two step 1 drugs for the current condition. Updated: 11/

63 TOPICAL IMMUNOMODULATORS Affected Drugs STEP 1 DRUGS ACLOVATE ALA-CORT ALA-SCALP HP alclometasone amcinonide betameth/propylene glycol betamethasone dipropionate betamethasone valerate CARMOL HC clobetasol propionate CLOBEX CLODERM CORDRAN SP CORDRAN CUTIVATE DERMA-SMOOTHE-FS DERMATOP DESONATE desonide DESOWEN desoximetasone diflorasone DIPROLENE AF DIPROLENE ELOCON fluocinolone acetonide fluocinonide fluticasone propionate halobetasol propionate HALOG hydrocortisone hydrocortisone butyrate hydrocortisone valerate KENALOG LOCOID LIPOCREAM LOCOID STEP 2 DRUGS ELIDEL PROTOPIC Updated: 11/

64 LOKARA LUXIQ mometasone OLUX-E PANDEL prednicarbate TEMOVATE TOPICORT LP TOPICORT triamcinolone acetonide U-CORT ULTRAVATE VANOS VERDESO WESTCORT If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Aclovate, Ala-cort, Ala-scalp Hp, Alclometasone Dipropionate, Amcinonide, Betamethasone Dipropionate, Betamethasone Valerate, Beta-val, Carmol Hc, Clobetasol Emollient, Clobetasol Propionate, Clobex, Cloderm, Cordran, Cordran Sp, Cormax, Cutivate, Del-beta, Derma-smoothe-fs, Dermatop, Desonate, Desonide, Desowen, Desoximetasone, Diflorasone Diacetate, Diprolene, Diprolene Af, Elocon, Fluocinolone Acetonide, Fluocinonide, Fluocinonide Emollient, Fluticasone Propionate, Halobetasol Propionate, Halog, Hydrocortisone, Hydrocortisone Butyrate, Hydrocortisone Valerate, Kenalog, Locoid, Locoid Lipocream, Lokara, Luxiq, Mometasone Furoate, Olux-e, Pandel, Prednicarbate, Temovate, Topicort, Topicort Lp, Triamcinolone Acetonide, Triderm, U-cort, Ultravate, Vanos, Verdeso, Westcort. Step 2 Drug(s): Elidel, Protopic. Authorization may be given for Elidel or Protopic, if the patient has tried one prescription strength topical corticosteroid in the previous 60 days. Authorization for Protopic or Elidel may be given for patients requiring drug application on or around the eyes, eyelids or genitalia. Updated: 11/

65 ULORIC Affected Drugs STEP 1 DRUGS allopurinol ZYLOPRIM STEP 2 DRUGS ULORIC If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Allopurinol, Zyloprim. Step 2 Drug(s): Uloric. Authorization may be given for Uloric if the patient has tried allopurinol at any time in the past. Authorization may be given for Uloric if the patient has renal insufficiency or decreased renal function. Authorization may be given for Uloric if the patient is receiving concomitant medications that have significant drug-drug interactions with allopurinol, which are not noted with Uloric (eg, cyclosporine, chlorpropamide). Updated: 11/

66 ULTRAM Affected Drugs STEP 1 DRUGS tramadol tramadol/apap STEP 2 DRUGS RYZOLT ULTRACET ULTRAM ER ULTRAM If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Tramadol Hcl, Tramadol Hcl-acetaminophen. Step 2 Drug(s): Ryzolt, Ultracet, Ultram, Ultram ER. Updated: 11/

67 ZETIA Affected Drugs STEP 1 DRUGS ADVICOR ALTOPREV CADUET CRESTOR LESCOL XL LESCOL LIPITOR LIVALO lovastatin MEVACOR PRAVACHOL pravastatin SIMCOR simvastatin VYTORIN ZOCOR STEP 2 DRUGS ZETIA If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Advicor, Altoprev, Caduet, Crestor, Lescol, Lescol Xl, Lipitor, Livalo, Lovastatin, Mevacor, Pravachol, Pravastatin Sodium, Simcor, Simvastatin, Vytorin, Zocor. Step 2 Drug(s): Zetia. Authorization of Zetia may be given if the patient has tried one HMG-CoA reductase inhibitor (statin) or HMG-CoA reductase inhibitor (statin) combination product or if Zetia is being initiated in combination with an HMG- CoA reductase inhibitor (statin). Authorization for Zetia may be given if the patient is taking or will be taking a medication that has a significant drug interaction with any of the HMG-CoA reductase inhibitors [statins] (eg, cyclosporine, fibrates, niacin more than 1 g/day, itraconazole, ketoconazole, erythromycin, clarithromycin, HIV protease inhibitors, nefazodone, amiodarone, and verapamil). Authorization of Zetia may be given if the patient has severe renal impairment (creatinine clearance of 30 ml/minute or less). Authorization of Zetia may be given if for management of homozygous familial sitosterolemia. Authorization of Zetia may be given for use in pregnant woman. Authorization of Zetia may be given if the patient has active liver disease or unexplained persistent elevations of serum transaminases. Exceptions are NOT recommended for Zetia for use in patients with moderate or severe hepatic insufficiency. As reviewed by a pharmacist, authorization for Zetia may be given for use in patients who have been previously diagnosed with myopathy or rhabdomyolysis (either medication-related or not Updated: 11/