2012 Medicare National Preferred 4 Tier Step Therapy Criteria ANTIDEPRESSANTS - SSRI citalopram escitalopram oxalate fluoxetine... 2

Transcription

1 2012 Medicare National Preferred 4 Tier Step Therapy Criteria ANTIDEPRESSANTS - SSRI citalopram escitalopram oxalate fluoxetine fluvoxamine paroxetine RAPIFLUX sertraline CELEXA LEXAPRO LUVOX CR PAXIL CR PAXIL PEXEVA PROZAC WEEKLY PROZAC VIIBRYD ZOLOFT ANTIDEPRESSANTS - SSRI (SARAFEM) fluoxetine RAPIFLUX SARAFEM ANTIDEPRESSANTS-BUPROPION Updated: 09/2012 1

2 bupropion APLENZIN WELLBUTRIN SR WELLBUTRIN XL BILE ACID SEQUESTRANTS cholestyramine/aspartame colestipol COLESTID QUESTRAN WELCHOL BRAND NSAIDS diclofenac potassium diclofenac sodium etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac lansoprazole meclofenamate mefenamic acid meloxicam nabumetone Updated: 09/2012 2

3 naproxen naproxen sodium omeprazole oxaprozin pantoprazole piroxicam sulindac tolmetin ANAPROX DS ANAPROX ARTHROTEC ARTHROTEC CAMBIA CATAFLAM CLINORIL DAYPRO DUEXIS EC-NAPROSYN FELDENE FLECTOR INDOCIN MOBIC NALFON NAPRELAN NAPROSYN Updated: 09/2012 3

4 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 SULAR CCB - VERAPAMIL verapamil CALAN SR CALAN COVERA-HS Updated: 09/2012 4

5 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 ketoprofen ketorolac meclofenamate mefenamic acid meloxicam MOBIC Updated: 09/2012 5

6 nabumetone NALFON NAPRELAN NAPROSYN naproxen naproxen sodium oxaprozin piroxicam PONSTEL SPRIX sulindac tolmetin VOLTAREN-XR ZIPSOR CELEBREX ENHANCED ACE-I/ARB benazepril benazepril/amlodipine besylate benazepril/hctz captopril captopril/hctz enalapril enalapril maleate/hctz eprosartan mesylate fosinopril Updated: 09/2012 6

7 fosinopril/hctz irbesartan irbesartan/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 Updated: 09/2012 7

8 ALTACE ATACAND HCT ATACAND AVALIDE AVAPRO COZAAR EDARBI EDARBYCLOR HYZAAR LOTENSIN HCT LOTENSIN LOTREL MAVIK MICARDIS HCT MICARDIS PRINIVIL PRINZIDE TARKA TEVETEN HCT TEVETEN TWYNSTA UNIRETIC UNIVASC VASERETIC VASOTEC Updated: 09/2012 8

9 ZESTORETIC ZESTRIL ENHANCED ANTIDEPRESSANTS- SNRI citalopram escitalopram oxalate 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 ER SAVELLA EFFEXOR XR VENLAFAXINE HCL ER 150 mg tab venlafaxine hcl er 37.5 mg tab Updated: 09/2012 9

10 venlafaxine hcl er 75 mg tab VENLAFAXINE HCL ER ENHANCED BISPHOSPHONATES ORAL alendronate ibandronate ACTONEL ATELVIA BONIVA FOSAMAX PLUS D FOSAMAX ENHANCED FENOFIBRATE fenofibrate TRICOR TRILIPIX ANTARA FENOGLIDE FIBRICOR LIPOFEN LOFIBRA TRIGLIDE ENHANCED OVERACTIVE BLADDER oxybutynin trospium chloride ENABLEX GELNIQUE Updated: 09/

11 SANCTURA XR DETROL LA DETROL DITROPAN XL OXYTROL SANCTURA TOVIAZ VESICARE ENHANCED SEDATIVE HYPNOTICS zaleplon zolpidem LUNESTA ROZEREM AMBIEN CR AMBIEN EDLUAR INTERMEZZO SILENOR SONATA ZOLPIMIST HMG RULE atorvastatin calcium fluvastatin lovastatin pravastatin Updated: 09/

12 simvastatin CRESTOR VYTORIN HMG RULE CRESTOR VYTORIN CADUET LIPITOR HMG RULE atorvastatin calcium CRESTOR fluvastatin lovastatin pravastatin simvastatin VYTORIN ALTOPREV CADUET LESCOL XL LESCOL LIPITOR LIVALO MEVACOR PRAVACHOL ZOCOR Updated: 09/

13 KEPPRA levetiracetam 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 oxymorphone AVINZA EMBEDA EXALGO KADIAN MS CONTIN NUCYNTA ER OPANA ER Updated: 09/

14 ORAMORPH SR OXYCONTIN LYRICA gabapentin NEURONTIN GRALISE HORIZANT LYRICA METFORMIN metformin FORTAMET GLUCOPHAGE XR GLUCOPHAGE GLUMETZA RIOMET MIRAPEX/REQUIP pramipexole ropinirole MIRAPEX ER MIRAPEX REQUIP XL REQUIP NON-SEDATING ANTIHISTAMINES cetirizine levocetirizine dihydrochlor Updated: 09/

15 ALLEGRA CLARINEX CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR XYZAL OPHTHALMIC BETA BLOCKERS betaxolol carteolol dorzolamide/timolol levobunolol metipranolol timolol BETAGAN BETIMOL BETOPTIC S COMBIGAN COSOPT ISTALOL OPTIPRANOLOL TIMOPTIC OCUDOSE TIMOPTIC-XE PPI ENHANCED omeprazole pantoprazole NEXIUM Updated: 09/

16 OMEPRAZOLE/SODIUM bicarbonat ACIPHEX DEXILANT PREVACID PRILOSEC PROTONIX ZEGERID STAVZOR divalproex valproic acid DEPAKENE DEPAKOTE ER DEPAKOTE SPRINKLE DEPAKOTE STAVZOR STRATTERA ADDERALL XR amphetamine/dextroamphetamine CONCERTA d-amphetamine DAYTRANA DESOXYN DEXEDRINE dexmethylphenidate FOCALIN XR Updated: 09/

17 FOCALIN METADATE CD methamphetamine METHYLIN methylphenidate RITALIN LA RITALIN RITALIN-SR VYVANSE INTUNIV KAPVAY STRATTERA TEKTURNA TETRACYCLINES (ORAL) demeclocycline hcl doxycycline hyclate doxycycline monohydrate minocycline tetracycline ADOXA PAK ADOXA DORYX DYNACIN MINOCIN MONODOX Updated: 09/

18 ORACEA PERIOSTAT SOLODYN VIBRAMYCIN THIAZOLIDINEDIONE FORTAMET glipizide/metformin hcl GLUCOPHAGE XR GLUCOPHAGE GLUCOVANCE GLUMETZA glyburide/metformin hcl JANUMET XR JANUMET JENTADUETO KOMBIGLYZE XR METAGLIP metformin PRANDIMET RIOMET ACTOPLUS MET XR ACTOPLUS MET ACTOS AVANDAMET AVANDARYL Updated: 09/

19 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 ALA-CORT ALA-SCALP HP Updated: 09/

20 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 U-CORT ULTRAVATE Updated: 09/

21 VANOS VERDESO WESTCORT TOPICAL IMMUNOMODULATORS ULORIC allopurinol ZYLOPRIM ULORIC ULTRAM tramadol tramadol/apap RYZOLT ULTRACET ULTRAM ER ULTRAM ZETIA ADVICOR ALTOPREV atorvastatin calcium CADUET CRESTOR fluvastatin JUVISYNC LESCOL XL LESCOL Updated: 09/

22 LIPITOR LIVALO lovastatin MEVACOR PRAVACHOL pravastatin SIMCOR simvastatin VYTORIN ZOCOR ZETIA Index ACLOVATE ALA-CORT ALA-SCALP HP alclometasone amcinonide betameth/propylene glycol betamethasone dipropionate betamethasone valerate CARMOL HC clobetasol propionate CLOBEX CLODERM CORDRAN SP Updated: 09/

23 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 LOKARA LUXIQ Updated: 09/

24 mometasone OLUX-E PANDEL prednicarbate TEMOVATE TOPICORT triamcinolone acetonide U-CORT ULTRAVATE VANOS VERDESO WESTCORT ELIDEL PROTOPIC 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, CARMOL HC, CLOBETASOL EMOLLIENT, CLOBETASOL PROPIONATE, CLOBEX, CLODERM, CORDRAN, CORDRAN SP, CUTIVATE, 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 FOR ATOPIC DERMATITIS OR ECZEMA IN THE PREVIOUS Updated: 09/

25 60 DAYS. AUTHORIZATION FOR PROTOPIC OR ELIDEL MAY BE GIVEN FOR PATIENTS WITH A DERMATOLOGIC CONDITION ON OR AROUND THE EYES, EYELIDS OR GENITALIA. AUTHORIZATION FOR PROTOPIC OR ELIDEL MAY BE GIVEN FOR PATIENTS WITH THE FOLLOWING CONDITIONS AFTER A TRIAL OF A PRESCRIPTION STRENGTH TOPICAL CORTICOSTEROID: LICHEN PLANUS, SEBORRHEIC DERMATITIS, CHRONIC HAND DERMATITIS, CUTANEOUS LUPUS ERYTHEMATOSUS OR DERMATOMYOSITIS OR DISCOID LUPUS ERYTHEMATOSUS, PSORIASIS, AND VITILIGO. AUTHORIZATION FOR PROTOPIC MAY BE GIVEN FOR PATIENTS WITH THE FOLLOWING CONDITIONS AFTER A TRIAL OF A PRESCRIPTION STRENGTH TOPICAL CORTICOSTEROID: DYSHIDROTIC PALMAR ECZEMA, PYODERMA GANGRENOSUM, OROFACIAL OR PERINEAL CROHN'S DISEASE, EROSIVE PUSTULAR DERMATOSIS, CHRONIC CUTANEOUS GRAFT-VS-HOST DISEASE (GVHD), CHRONIC ACTINIC DERMATITIS, ALLERGIC CONTACT DERMATITIS, AND BULLOUS PEMPHIGOID. AUTHORIZATION MAY BE GIVEN FOR ELIDEL OR PROTOPIC, FOR STEROID-INDUCED ROSACEA IF THE PATIENT HAS TRIED TWO THERAPIES FOR ROSACEA (E. G., AZELAIC ACID, TOPICAL METRONIDAZOLE, TOPICAL TRETINOIN PRODUCTS, ORAL ANTIBIOTICS [E. G., TETRACYCLINE, METRONIDAZOLE, DOXYCYCLINE, MINOCYCLINE, CLARITHROMYCIN], OR ORAL ISOTRETINOIN). AUTHORIZATION MAY BE GIVEN FOR PROTOPIC, FOR SEVERE UREMIC PRURITUS IF THE PATIENT HAS TRIED TWO OTHER THERAPIES FOR THIS CONDITION (E. G., EMOLLIENTS, CAPSAICIN, TOPICAL CORTICOSTEROIDS, ULTRAVIOLET B IRRADIATION) ACCUPRIL ACCURETIC ACEON ALTACE ATACAND HCT ATACAND AVALIDE AVAPRO AZOR benazepril benazepril/amlodipine besylate Updated: 09/

26 benazepril/hctz BENICAR HCT BENICAR captopril captopril/hctz COZAAR DIOVAN HCT DIOVAN EDARBI EDARBYCLOR enalapril enalapril maleate/hctz eprosartan mesylate EXFORGE HCT EXFORGE fosinopril fosinopril/hctz HYZAAR irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz LOTENSIN HCT Updated: 09/

27 LOTENSIN LOTREL MAVIK MICARDIS HCT MICARDIS moexipril moexipril/hctz perindopril erbumine PRINIVIL PRINZIDE quinapril quinapril/hctz ramipril TARKA TEVETEN HCT TEVETEN trandolapril TRIBENZOR TWYNSTA UNIRETIC UNIVASC VASERETIC VASOTEC ZESTORETIC ZESTRIL Updated: 09/

28 AMTURNIDE TEKAMLO TEKTURNA HCT TEKTURNA VALTURNA 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 BESYLATE-BENAZEPRIL, ATACAND, ATACAND HCT, AVALIDE, AVAPRO, AZOR, BENAZEPRIL HCL, BENAZEPRIL- HYDROCHLOROTHIAZIDE, BENICAR, BENICAR HCT, CAPTOPRIL, CAPTOPRIL- HYDROCHLOROTHIAZIDE, COZAAR, DIOVAN, DIOVAN HCT, EDARBI, EDARBYCLOR, ENALAPRIL MALEATE, ENALAPRIL-HYDROCHLOROTHIAZIDE, EPROSARTAN, EXFORGE, EXFORGE HCT, FOSINOPRIL SODIUM, FOSINOPRIL- HYDROCHLOROTHIAZIDE, HYZAAR, IRBESARTAN, IRBESARTAN- HYDROCHLOROTHIAZIDE, LISINOPRIL, LISINOPRIL-HYDROCHLOROTHIAZIDE, LOSARTAN POTASSIUM, LOSARTAN-HYDROCHLOROTHIAZIDE, LOTENSIN, LOTENSIN HCT, LOTREL, MAVIK, MICARDIS, MICARDIS HCT, MOEXIPRIL HCL, MOEXIPRIL-HYDROCHLOROTHIAZIDE, 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: 09/

29 ANTIDEPRESSANTS - SSRI Affected Drugs STEP 1 DRUGS citalopram escitalopram oxalate fluoxetine fluvoxamine paroxetine RAPIFLUX sertraline STEP 2 DRUGS CELEXA LEXAPRO LUVOX CR PAXIL CR PAXIL PEXEVA PROZAC WEEKLY PROZAC VIIBRYD ZOLOFT If the patient has tried two Step 1 drugs, then authorization for a drug in Step 2 drug may be given. Step 1 Drug(s): Citalopram, Citalopram Hbr, Escitalopram, Fluoxetine Dr, Fluoxetine Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Paroxetine ER, Rapiflux, Sertraline Hcl. Step 2 Drug(s): Celexa, Lexapro, Luvox Cr, Paxil, Paxil Cr, Pexeva, Prozac, Prozac Weekly, Viibryd, Zoloft. Patients who have taken Lexapro, Luvox Cr, Pexeva, or Viibryd at any time in the past and discontinued its use may receive authorization to restart Lexapro, Luvox Cr, Pexeva or Viibryd (whichever they used in the past). Authorization may be given for a step 2 SSRI [Selective Serotonin Reuptake Inhibitor] if the patient is currently taking the requested agent. Authorization may be given for Lexapro, Luvox Cr, Pexeva, or Viibryd 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: 09/

30 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: 09/

31 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: 09/

32 BILE ACID SEQUESTRANTS Affected Drugs STEP 1 DRUGS cholestyramine/aspartame colestipol STEP 2 DRUGS COLESTID QUESTRAN 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 Light, Colestipol Hcl, Prevalite. Step 2 Drug(s): Colestid, Questran, 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). Authorization may be given for Welchol in patients less than 18 years of age. Updated: 09/

33 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 CAMBIA CATAFLAM CLINORIL DAYPRO DUEXIS 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, Cambia, Cataflam, Clinoril, Daypro, Duexis, Ec-naprosyn, Feldene, Flector, Indocin, 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 omeprazole or lansoprazole or pantoprazole sodium and a prescription naproxen or naproxen sodium product. Authorization for a step 2 drug, Updated: 09/

34 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. 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). Authorization for Duexis may be given if there is a claims history for both a generic H2RA (famotidine, cimetidine, nizatidine, ranitidine) and ibuprofen (brand or generic) 1, 200 to 3, 200 mg/day. These must be in the claims history. Coverage of Duexis is not recommended if the patient has only tried OTC ibuprofen, other NSAIDs [Non-steroidal anti-inflammatory drugs] besides ibuprofen, or a COX-2 inhibitor (Celebrex). Updated: 09/

35 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 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 Er, Nisoldipine. Step 2 Drug(s): Adalat Cc, Dynacirc Cr, Norvasc, Procardia XL, Sular. Updated: 09/

36 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 Er Pm, Verapamil Hcl. Step 2 Drug(s): Calan, Calan Sr, Covera-hs, Isoptin Sr, Verelan, Verelan PM. Updated: 09/

37 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-XR ZIPSOR STEP 2 DRUGS CELEBREX Updated: 09/

38 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, 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-xr, Zipsor. Step 2 Drug(s): Celebrex. Authorization for Celebrex may be given if the patient has tried two oral prescription strength NSAIDs [Non-steroidal anti-inflammatory drugs] (brand or generic) for the current condition. This step therapy program will exclude participants with a claims history of warfarin (Coumadin) 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), ticagrelor (Brilinta), rivaroxaban (Xarelto), dabigatran (Pradaxa), chronic aspirin therapy, or low molecular weight heparins. Updated: 09/

39 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 eprosartan mesylate fosinopril fosinopril/hctz irbesartan irbesartan/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 EDARBYCLOR HYZAAR LOTENSIN HCT LOTENSIN LOTREL MAVIK MICARDIS HCT MICARDIS 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, Benazeprilhydrochlorothiazide, Captopril, Captopril-hydrochlorothiazide, Enalapril Maleate, Enalapril-hydrochlorothiazide, eprosartan, Fosinopril Sodium, Fosinopril- Updated: 09/

40 hydrochlorothiazide, Irbesartan, Irbesartan-hydrochlorothiazide, Lisinopril, Lisinoprilhydrochlorothiazide, Losartan Potassium, Losartan-Hydrochlorothiazide, Moexipril Hcl, Moexipril-hydrochlorothiazide, Perindopril erbumine, Quinapril Hcl, Quinaprilhydrochlorothiazide, 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, Edarbyclor, Hyzaar, Lotensin, Lotensin Hct, Lotrel, Mavik, Micardis, Micardis Hct, 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: 09/

41 ENHANCED ANTIDEPRESSANTS- SNRI Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS citalopram escitalopram oxalate 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 ER SAVELLA EFFEXOR XR 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, Escitalopram, Fluoxetine Dr, Fluoxetine Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Rapiflux, Sertraline Hcl, Venlafaxine Hcl, Venlafaxine Hcl Er. Step 2 Drug(s): Cymbalta, Pristiq, Savella. Step 3 Drug(s): Effexor Xr, Venlafaxine Hcl ER. Patients who have taken a step 2 drug at any time in the past may restart. Authorization may be given for a step 2 or 3 drug if the patient is currently taking the requested agent. Patients aged 18 years of less: approve Cymbalta or Pristiq without a trial of a step 1 agent. Symptoms of suicidal ideation: approve Cymbalta or Pristiq without a trial of a step 1 agent. Stress urinary incontinence: approve Cymbalta without a trial of a step 1 agent. Fibromyalgia: approve Cymbalta or Savella without a trial of a step 1 agent. Chronic musculoskeletal pain (eg, low back pain or pain due to osteoarthritis): approve Cymbalta without a trial of a step 1 Updated: 09/

42 agent. Diabetic peripheral neuropathy: approve Cymbalta without a trial of a step 1 agent. This step therapy program applies to new utilizers only. Updated: 09/

43 ENHANCED BISPHOSPHONATES ORAL Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS alendronate ibandronate 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, Ibandronate Sodium. Step 2 Drug(s): Actonel, Atelvia, Boniva. Step 3 Drug(s): Fosamax, Fosamax Plus D. Authorization may be given for a step 2 agent, if the patient has tried alendronate sodium or ibandronate sodium (brand or generic). 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: 09/

44 ENHANCED FENOFIBRATE Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS fenofibrate TRICOR TRILIPIX ANTARA FENOGLIDE 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, Fenoglide, Fibricor, Lipofen, Lofibra, Triglide. Updated: 09/

45 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 Gelnique may be given for patients who cannot swallow or who have difficulty swallowing. Updated: 09/

46 ENHANCED SEDATIVE HYPNOTICS Affected Drugs STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS zaleplon zolpidem LUNESTA ROZEREM AMBIEN CR AMBIEN EDLUAR INTERMEZZO 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, Intermezzo, 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. Authorization for Intermezzo may be given if the patient has middle-of-the-night awakening followed by difficulty returning to sleep. Updated: 09/

47 HMG RULE 1 Affected Drugs STEP 1 DRUGS atorvastatin calcium fluvastatin 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): Atorvastatin, Fluvastatin, Lovastatin, Pravastatin Sodium, Simvastatin. Step 2 Drug(s): Crestor 5 mg, Vytorin 10/10 mg. Authorization may be given for a step 2 drug, if the patient has tried atorvastatin (brand or generic), fluvastatin (brand or generic), lovastatin (brand or generic), pravastatin sodium (brand or generic), or simvastatin (brand or generic). Authorization for a step 2 drug will be given on an individual basis for drug-drug interactions. Updated: 09/

48 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: 09/

49 HMG RULE 3 Affected Drugs STEP 1 DRUGS atorvastatin calcium CRESTOR fluvastatin 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): Atorvastatin, Fluvastatin, Lovastatin, Pravastatin Sodium, Simvastatin. Step 1 Group B Drug(s): Crestor, Vytorin. Step 2 Drug(s): Altoprev, Caduet 2. 5/10, 5/10, 10/10, 2. 5/20, 5/20, 10/20 mg, Lescol, Lescol Xl, Lipitor 10 mg and 20 mg, Livalo, Mevacor, Pravachol, Zocor. Authorization for a step 2 drug will given on an individual basis for drug-drug interactions. Authorization may be given for a step 2 drug, if the patient has tried atorvastatin (brand or generic), fluvastatin (brand or generic), lovastatin (brand or generic), pravastatin sodium (brand or generic), or simvastatin (brand or generic) and a Step 1 Group B drug. Updated: 09/

50 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, levetiracetam ER. Step 2 Drug(s): Keppra, Keppra XR. Authorization may be given for a Step 2 drug if the patient is currently taking the requested agent. Authorization may be given for a Keppra XR if the patient has taken it at any time in the past. This step therapy program applies to new utilizers only. Updated: 09/

51 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 2 drug if the patient is currently taking the requested agent. Authorization may be given for Lamictal XR, Lamictal XR (blue), Lamictal XR (green), Lamictal XR (orange) if the patient has taken it at any time in the past. 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: 09/

52 LONG ACTING OPIOIDS Affected Drugs STEP 1 DRUGS morphine oxymorphone STEP 2 DRUGS AVINZA EMBEDA EXALGO KADIAN MS CONTIN NUCYNTA ER 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, morphine sulfate ER, oxymorphone ER. Step 2 Drug(s): Avinza, Embeda, Exalgo, Kadian, MS [Multiple Sclerosis] Contin, Nucynta ER, Opana Er, Oramorph Sr, Oxycontin. Authorization may be given for Exalgo, OxyContin, or Nucynta ER if the patient is unable to tolerate or has a drug allergy noted with morphine sulfate. Authorization may be given for Exalgo, OxyContin, or Nucynta ER 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: 09/

53 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. Authorization for Lyrica, without a trial of a step 1 agent, may be given for patients with symptoms of seizure disorder. Authorization may be given for Lyrica if the patient has tried Gralise or Horizant. 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 if the patient has symptoms of generalized anxiety disorder (GAD) and has been previously treated with two drugs from the following drug classes - tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), or buspirone. This step therapy program applies to new utilizers only. Updated: 09/

54 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 30 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: 09/

55 MIRAPEX/REQUIP Affected Drugs STEP 1 DRUGS pramipexole ropinirole STEP 2 DRUGS MIRAPEX ER MIRAPEX REQUIP XL REQUIP If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Pramipexole Dihydrochloride, Ropinirole Hcl, Ropinirole Er. Step 2 Drug(s): Mirapex, Mirapex Er, Requip, Requip Xl. Authorization may be given for Mirapex or Requip if the patient has tried a step 1 drug for symptoms of restless leg syndrome (RLS). Authorization may be given for Mirapex ER or Requip XL if the patient has symptoms of Parkinson's disease and is currently taking (or has taken in the past) the requested agent. Updated: 09/

56 NON-SEDATING ANTIHISTAMINES Affected Drugs STEP 1 DRUGS cetirizine 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, Levocetirizine Dihydrochloride. Step 2 Drug(s): Allegra, Clarinex, Clarinex-d 12 Hour, Clarinex-d 24 Hour, Xyzal. 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: 09/

57 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: 09/

58 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 SoluTab for patients with a feeding tube (eg, nasogastric tube, gastric tube) and patients post-bariatric surgery. Authorization may be given for a Step 2 or a Step 3 agent for children less than 2 years old. Authorization for Nexium may be given in patients less than 1 year of age. 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 a step 2). Updated: 09/

59 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 the requested agent. Authorization may be given for Stavzor if the patient has taken it at any time in the past. This step therapy program applies to new utilizers only. Updated: 09/

60 STRATTERA Affected Drugs STEP 1 DRUGS ADDERALL XR 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 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 Er, Methylphenidate Sr, Ritalin, Ritalin La, Ritalin-sr, Vyvanse. Step 2 Drug(s): Intuniv, Kapvay, Strattera. Authorization for a step 2 agent may be given for patients with symptoms of attention deficit hyperactivity disorder (ADHD)/attention deficit disorder (ADD) if they have previously tried a methylphenidate/dexmethylphenidate product (brand or generic) or an amphetamine product (brand or generic). Authorization for Strattera, Kapvay, or Intuniv may be given for symptoms of ADHD [Attention Deficit Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient has a documented history of addiction to controlled substances. Authorization for Strattera, Kapvay, or Intuniv may be given for symptoms 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 symptoms of ADHD [Attention Deficit Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient has co-morbid anxiety. Authorization for Strattera, Intuniv, or Kapvay may be Updated: 09/

61 given for symptoms 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 symptms of ADHD [Attention Deficit Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient has hypertension, heart failure, recent myocardial infarction, or hyperthyroidism. Updated: 09/

62 TEKTURNA Affected Drugs STEP 1 DRUGS STEP 2 DRUGS Updated: 09/

63 TETRACYCLINES (ORAL) Affected Drugs STEP 1 DRUGS demeclocycline hcl doxycycline hyclate doxycycline monohydrate minocycline tetracycline STEP 2 DRUGS ADOXA PAK ADOXA DORYX DYNACIN MINOCIN MONODOX ORACEA PERIOSTAT SOLODYN VIBRAMYCIN If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Demeclocycline Hcl, Doxycycline, Doxycycline Hyclate, Doxycycline Monohydrate, Minocycline Hcl, Tetracycline Hcl. Step 2 Drug(s): Adoxa, Adoxa Pak, Doryx, Dynacin, Minocin, Monodox, Oracea, Periostat, Solodyn, Vibramycin. Authorization may be given for a step 2 agent if the patient has tried a generic oral tetracycline-type product (demeclocycline, doxycycline, minocycline or tetracycline). Authorization may be given for a 3-day supply of a single-entity, step 2 doxycycline agent without a generic equivalent (eg, Doryx, Vibramycin Calcium oral suspension/syrup, Adoxa capsules) for a patient with a systemic infection when the physician or a representative of the physician cannot be contacted. If the patient cannot swallow or has difficulty swallowing tablets or capsules, authorization for Vibramycin oral suspension or syrup may be given. Updated: 09/

64 THIAZOLIDINEDIONE Affected Drugs STEP 1 DRUGS FORTAMET glipizide/metformin hcl GLUCOPHAGE XR GLUCOPHAGE GLUCOVANCE GLUMETZA glyburide/metformin hcl JANUMET XR JANUMET JENTADUETO 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, Janumet XR, Jentadueto, 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: 09/

65 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 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, Clobetasol Emollient, Clobetasol Propionate, Desonide, Desoximetasone, Diflorasone Diacetate, Fluocinolone Acetonide, Updated: 09/

66 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: 09/