Updated: 08/2011 1
2011 Medicare National Preferred 4 Tier Step Therapy Criteria
ANTIDEPRESSANTS - SSRI (SARAFEM) ................................................................... 26
fluoxetine.................................................................................................................... 26
SARAFEM® ............................................................................................................... 26
ANTIDEPRESSANTS-BUPROPION ............................................................................. 27
bupropion ................................................................................................................... 27
APLENZIN® ............................................................................................................... 27
WELLBUTRIN SR® ................................................................................................... 27
WELLBUTRIN XL® .................................................................................................... 27
BILE ACID SEQUESTRANTS ....................................................................................... 28
cholestyramine/aspartame ......................................................................................... 28
COLESTID® .............................................................................................................. 28
colestipol .................................................................................................................... 28
QUESTRAN® ............................................................................................................ 28
WELCHOL®............................................................................................................... 28
BRAND NSAIDS ........................................................................................................... 29
diclofenac potassium ................................................................................................. 29
diclofenac sodium ...................................................................................................... 29
etodolac ..................................................................................................................... 29
fenoprofen .................................................................................................................. 29
flurbiprofen ................................................................................................................. 29
ibuprofen .................................................................................................................... 29
indomethacin .............................................................................................................. 29
ketoprofen .................................................................................................................. 29
Updated: 08/2011 2
ketorolac .................................................................................................................... 29
lansoprazole ............................................................................................................... 29
meclofenamate .......................................................................................................... 29
mefenamic acid .......................................................................................................... 29
meloxicam .................................................................................................................. 29
nabumetone ............................................................................................................... 29
naproxen .................................................................................................................... 29
naproxen sodium ....................................................................................................... 29
omeprazole ................................................................................................................ 29
oxaprozin ................................................................................................................... 29
pantoprazole .............................................................................................................. 29
piroxicam.................................................................................................................... 29
sulindac ...................................................................................................................... 29
tolmetin ...................................................................................................................... 29
ANAPROX DS® ......................................................................................................... 29
ANAPROX® ............................................................................................................... 29
ARTHROTEC 50® ..................................................................................................... 29
ARTHROTEC 75® ..................................................................................................... 29
CATAFLAM® ............................................................................................................. 29
CLINORIL® ................................................................................................................ 29
DAYPRO® ................................................................................................................. 29
EC-NAPROSYN® ...................................................................................................... 29
FELDENE® ................................................................................................................ 29
FLECTOR®................................................................................................................ 29
INDOCIN® ................................................................................................................. 29
Updated: 08/2011 3
MOBIC® .................................................................................................................... 29
NALFON® .................................................................................................................. 29
NAPRELAN® ............................................................................................................. 29
NAPROSYN® ............................................................................................................ 29
PENNSAID® .............................................................................................................. 29
PONSTEL® ............................................................................................................... 29
VIMOVO® .................................................................................................................. 29
VOLTAREN® ............................................................................................................. 29
VOLTAREN-XR® ....................................................................................................... 29
ZIPSOR® ................................................................................................................... 29
CCB - DIHYDROPYRIDINES ........................................................................................ 31
amlodipine.................................................................................................................. 31
benazepril/amlodipine besylate .................................................................................. 31
felodipine.................................................................................................................... 31
isradipine.................................................................................................................... 31
nicardipine.................................................................................................................. 31
nifedipine.................................................................................................................... 31
nisoldipine .................................................................................................................. 31
ADALAT CC® ............................................................................................................ 31
DYNACIRC CR® ....................................................................................................... 31
NORVASC®............................................................................................................... 31
PROCARDIA XL® ...................................................................................................... 31
PROCARDIA® ........................................................................................................... 31
SULAR® .................................................................................................................... 31
CCB - VERAPAMIL ....................................................................................................... 32
Updated: 08/2011 4
verapamil ................................................................................................................... 32
CALAN SR® .............................................................................................................. 32
CALAN® .................................................................................................................... 32
COVERA-HS® ........................................................................................................... 32
ISOPTIN SR® ............................................................................................................ 32
VERELAN PM® ......................................................................................................... 32
VERELAN® ............................................................................................................... 32
COX-2 ........................................................................................................................... 33
ANAPROX DS® ......................................................................................................... 34
ANAPROX® ............................................................................................................... 34
CATAFLAM® ............................................................................................................. 34
CLINORIL® ................................................................................................................ 34
DAYPRO® ................................................................................................................. 34
diclofenac potassium ................................................................................................. 34
diclofenac sodium ...................................................................................................... 34
EC-NAPROSYN® ...................................................................................................... 34
etodolac ..................................................................................................................... 34
FELDENE® ................................................................................................................ 34
fenoprofen .................................................................................................................. 34
flurbiprofen ................................................................................................................. 34
ibuprofen .................................................................................................................... 34
INDOCIN® ................................................................................................................. 34
indomethacin .............................................................................................................. 34
ketoprofen .................................................................................................................. 34
ketorolac .................................................................................................................... 34
Updated: 08/2011 5
meclofenamate .......................................................................................................... 34
mefenamic acid .......................................................................................................... 34
meloxicam .................................................................................................................. 34
MOBIC® .................................................................................................................... 34
nabumetone ............................................................................................................... 34
NALFON® .................................................................................................................. 34
NAPRELAN® ............................................................................................................. 34
NAPROSYN® ............................................................................................................ 34
naproxen .................................................................................................................... 34
naproxen sodium ....................................................................................................... 34
oxaprozin ................................................................................................................... 34
piroxicam.................................................................................................................... 34
PONSTEL® ............................................................................................................... 34
sulindac ...................................................................................................................... 34
tolmetin ...................................................................................................................... 34
VOLTAREN® ............................................................................................................. 34
VOLTAREN-XR® ....................................................................................................... 34
ZIPSOR® ................................................................................................................... 34
CELEBREX® ............................................................................................................. 34
ENHANCED ACE-I/ARB ............................................................................................... 36
benazepril .................................................................................................................. 36
benazepril/amlodipine besylate .................................................................................. 36
benazepril/hctz ........................................................................................................... 36
captopril ..................................................................................................................... 36
captopril/hctz .............................................................................................................. 36
Updated: 08/2011 6
enalapril ..................................................................................................................... 36
enalapril maleate/hctz ................................................................................................ 36
fosinopril..................................................................................................................... 36
fosinopril/hctz ............................................................................................................. 36
lisinopril ...................................................................................................................... 36
lisinopril/hctz .............................................................................................................. 36
losartan ...................................................................................................................... 36
losartan /hctz .............................................................................................................. 36
moexipril..................................................................................................................... 36
moexipril/hctz ............................................................................................................. 36
perindopril erbumine .................................................................................................. 36
quinapril ..................................................................................................................... 36
quinapril/hctz .............................................................................................................. 36
ramipril ....................................................................................................................... 36
trandolapril ................................................................................................................. 36
AZOR® ...................................................................................................................... 36
BENICAR HCT® ........................................................................................................ 36
BENICAR® ................................................................................................................ 36
DIOVAN HCT® .......................................................................................................... 36
DIOVAN® .................................................................................................................. 36
EXFORGE HCT® ...................................................................................................... 36
EXFORGE® ............................................................................................................... 36
TRIBENZOR®............................................................................................................ 36
ACCUPRIL® .............................................................................................................. 36
ACCURETIC® ........................................................................................................... 36
Updated: 08/2011 7
ACEON® ................................................................................................................... 36
ALTACE® .................................................................................................................. 36
ATACAND HCT® ....................................................................................................... 36
ATACAND® ............................................................................................................... 36
AVALIDE® ................................................................................................................. 36
AVAPRO® ................................................................................................................. 36
COZAAR® ................................................................................................................. 36
EDARBI® ................................................................................................................... 36
HYZAAR® .................................................................................................................. 36
LOTENSIN HCT® ...................................................................................................... 36
LOTENSIN® .............................................................................................................. 36
LOTREL® .................................................................................................................. 36
MAVIK® ..................................................................................................................... 36
MICARDIS HCT® ...................................................................................................... 36
MICARDIS® ............................................................................................................... 36
MONOPRIL® ............................................................................................................. 36
PRINIVIL® ................................................................................................................. 36
PRINZIDE®................................................................................................................ 36
TARKA® .................................................................................................................... 36
TEVETEN HCT® ....................................................................................................... 36
TEVETEN® ................................................................................................................ 36
TWYNSTA® ............................................................................................................... 36
UNIRETIC® ............................................................................................................... 36
UNIVASC® ................................................................................................................ 36
VASERETIC® ............................................................................................................ 36
Updated: 08/2011 8
VASOTEC® ............................................................................................................... 36
ZESTORETIC® .......................................................................................................... 36
ZESTRIL® ................................................................................................................. 36
ENHANCED ANTIDEPRESSANTS- SNRI .................................................................... 38
citalopram .................................................................................................................. 38
fluoxetine.................................................................................................................... 38
fluvoxamine ................................................................................................................ 38
paroxetine .................................................................................................................. 38
sertraline .................................................................................................................... 38
venlafaxine hcl ........................................................................................................... 38
venlafaxine hcl 100 mg tablet ..................................................................................... 38
venlafaxine hcl 25 mg tablet....................................................................................... 38
venlafaxine hcl 37.5 mg tablet .................................................................................... 38
venlafaxine hcl 50 mg tablet....................................................................................... 38
venlafaxine hcl 75 mg tablet....................................................................................... 38
venlafaxine hcl er 150 mg cap ................................................................................... 38
venlafaxine hcl er 37.5 mg cap .................................................................................. 38
venlafaxine hcl er 75 mg cap ..................................................................................... 38
CYMBALTA® ............................................................................................................. 38
EFFEXOR XR® ......................................................................................................... 38
PRISTIQ® .................................................................................................................. 38
SAVELLA® ................................................................................................................ 38
EFFEXOR® ............................................................................................................... 38
VENLAFAXINE HCL ER 150 mg tab ......................................................................... 38
venlafaxine hcl er 37.5 mg tab ................................................................................... 38
Updated: 08/2011 9
venlafaxine hcl er 75 mg tab ...................................................................................... 38
VENLAFAXINE HCL ER® ......................................................................................... 38
ENHANCED ANTIDEPRESSANTS- SSRI .................................................................... 40
citalopram .................................................................................................................. 40
fluoxetine.................................................................................................................... 40
fluvoxamine ................................................................................................................ 40
paroxetine .................................................................................................................. 40
sertraline .................................................................................................................... 40
LEXAPRO® ............................................................................................................... 40
VIIBRYD® .................................................................................................................. 40
CELEXA® .................................................................................................................. 40
LUVOX CR® .............................................................................................................. 40
PAXIL CR® ................................................................................................................ 40
PAXIL® ...................................................................................................................... 40
PEXEVA® .................................................................................................................. 40
PROZAC WEEKLY® ................................................................................................. 40
PROZAC® ................................................................................................................. 40
ZOLOFT® .................................................................................................................. 40
ENHANCED BISPHOSPHONATES ORAL ................................................................... 41
alendronate ................................................................................................................ 41
ACTONEL® ............................................................................................................... 41
ATELVIA® ................................................................................................................. 41
BONIVA® ................................................................................................................... 41
FOSAMAX PLUS D® ................................................................................................. 41
FOSAMAX® ............................................................................................................... 41
Updated: 08/2011 10
ENHANCED FENOFIBRATE ........................................................................................ 42
fenofibrate .................................................................................................................. 42
TRICOR® .................................................................................................................. 42
TRILIPIX® .................................................................................................................. 42
ANTARA® .................................................................................................................. 42
FENOGLIDE®............................................................................................................ 42
LIPOFEN® ................................................................................................................. 42
LOFIBRA® ................................................................................................................. 42
TRIGLIDE® ................................................................................................................ 42
ENHANCED NON-SEDATING ANTIHISTAMINES ....................................................... 43
cetirizine ..................................................................................................................... 43
fexofenadine .............................................................................................................. 43
levocetirizine dihydrochlor .......................................................................................... 43
ALLEGRA® ................................................................................................................ 43
CLARINEX® .............................................................................................................. 43
CLARINEX-D 12 HOUR® .......................................................................................... 43
CLARINEX-D 24 HOUR® .......................................................................................... 43
XYZAL® ..................................................................................................................... 43
ENHANCED OVERACTIVE BLADDER ........................................................................ 44
oxybutynin .................................................................................................................. 44
trospium chloride ........................................................................................................ 44
ENABLEX® ................................................................................................................ 44
GELNIQUE® .............................................................................................................. 44
SANCTURA XR® ....................................................................................................... 44
DETROL LA® ............................................................................................................ 44
Updated: 08/2011 11
DETROL® .................................................................................................................. 44
DITROPAN XL® ........................................................................................................ 44
OXYTROL® ............................................................................................................... 44
SANCTURA®............................................................................................................. 44
TOVIAZ® ................................................................................................................... 44
VESICARE® .............................................................................................................. 44
ENHANCED SEDATIVE HYPNOTICS .......................................................................... 45
zaleplon ..................................................................................................................... 45
zolpidem..................................................................................................................... 45
AMBIEN CR® ............................................................................................................ 45
LUNESTA® ................................................................................................................ 45
ROZEREM® .............................................................................................................. 45
AMBIEN® .................................................................................................................. 45
EDLUAR® .................................................................................................................. 45
SILENOR® ................................................................................................................ 45
SONATA® ................................................................................................................. 45
ZOLPIMIST® ............................................................................................................. 45
HMG RULE 1 ................................................................................................................ 46
lovastatin .................................................................................................................... 46
pravastatin ................................................................................................................. 46
simvastatin ................................................................................................................. 46
CRESTOR® ............................................................................................................... 46
VYTORIN® ................................................................................................................ 46
HMG RULE 2 ................................................................................................................ 47
CRESTOR® ............................................................................................................... 47
Updated: 08/2011 12
VYTORIN® ................................................................................................................ 47
CADUET® ................................................................................................................. 47
LIPITOR® .................................................................................................................. 47
HMG RULE 3 ................................................................................................................ 48
CRESTOR® ............................................................................................................... 48
lovastatin .................................................................................................................... 48
pravastatin ................................................................................................................. 48
simvastatin ................................................................................................................. 48
VYTORIN® ................................................................................................................ 48
ALTOPREV® ............................................................................................................. 48
CADUET® ................................................................................................................. 48
LESCOL XL® ............................................................................................................. 48
LESCOL® .................................................................................................................. 48
LIPITOR® .................................................................................................................. 48
LIVALO® .................................................................................................................... 48
MEVACOR® .............................................................................................................. 48
PRAVACHOL® .......................................................................................................... 48
ZOCOR® ................................................................................................................... 48
KEPPRA ........................................................................................................................ 49
levetiracetam .............................................................................................................. 49
KEPPRA XR® ............................................................................................................ 49
KEPPRA® .................................................................................................................. 49
LAMICTAL ..................................................................................................................... 50
lamotrigine ................................................................................................................. 50
LAMICTAL (BLUE)® .................................................................................................. 50
Updated: 08/2011 13
LAMICTAL (GREEN)® ............................................................................................... 50
LAMICTAL (ORANGE)® ............................................................................................ 50
LAMICTAL ODT® ...................................................................................................... 50
LAMICTAL XR (BLUE)® ............................................................................................ 50
LAMICTAL XR (GREEN)® ......................................................................................... 50
LAMICTAL XR (ORANGE)® ...................................................................................... 50
LAMICTAL XR® ......................................................................................................... 50
LAMICTAL® ............................................................................................................... 50
LONG ACTING OPIOIDS .............................................................................................. 51
morphine .................................................................................................................... 51
AVINZA® ................................................................................................................... 51
EMBEDA® ................................................................................................................. 51
EXALGO® ................................................................................................................. 51
KADIAN® ................................................................................................................... 51
MS CONTIN® ............................................................................................................ 51
OPANA ER® .............................................................................................................. 51
ORAMORPH SR® ..................................................................................................... 51
OXYCONTIN® ........................................................................................................... 51
LYRICA ......................................................................................................................... 52
gabapentin ................................................................................................................. 52
NEURONTIN® ........................................................................................................... 52
LYRICA® ................................................................................................................... 52
METFORMIN ................................................................................................................ 53
metformin ................................................................................................................... 53
FORTAMET®............................................................................................................. 53
Updated: 08/2011 14
GLUCOPHAGE XR® ................................................................................................. 53
GLUCOPHAGE® ....................................................................................................... 53
GLUMETZA® ............................................................................................................. 53
RIOMET® .................................................................................................................. 53
OPHTHALMIC BETA BLOCKERS ................................................................................ 54
betaxolol..................................................................................................................... 54
carteolol ..................................................................................................................... 54
dorzolamide/timolol .................................................................................................... 54
levobunolol ................................................................................................................. 54
metipranolol ............................................................................................................... 54
timolol ........................................................................................................................ 54
BETAGAN® ............................................................................................................... 54
BETIMOL® ................................................................................................................ 54
BETOPTIC S® ........................................................................................................... 54
COMBIGAN® ............................................................................................................. 54
COSOPT® ................................................................................................................. 54
ISTALOL® ................................................................................................................. 54
OPTIPRANOLOL® .................................................................................................... 54
TIMOPTIC OCUDOSE® ............................................................................................ 54
TIMOPTIC-XE® ......................................................................................................... 54
PPI ENHANCED ........................................................................................................... 55
omeprazole ................................................................................................................ 55
pantoprazole .............................................................................................................. 55
NEXIUM® .................................................................................................................. 55
OMEPRAZOLE/SODIUM bicarbonat ......................................................................... 55
Updated: 08/2011 15
ACIPHEX® ................................................................................................................ 55
DEXILANT® ............................................................................................................... 55
PREVACID® .............................................................................................................. 55
PRILOSEC® .............................................................................................................. 55
PROTONIX®.............................................................................................................. 55
ZEGERID® ................................................................................................................ 55
STAVZOR ..................................................................................................................... 56
divalproex................................................................................................................... 56
valproic acid ............................................................................................................... 56
DEPAKENE® ............................................................................................................. 56
DEPAKOTE ER® ....................................................................................................... 56
DEPAKOTE SPRINKLE® .......................................................................................... 56
DEPAKOTE® ............................................................................................................. 56
STAVZOR® ............................................................................................................... 56
STRATTERA ................................................................................................................. 57
ADDERALL XR® ....................................................................................................... 57
ADDERALL® ............................................................................................................. 57
amphetamine/dextroamphetamine ............................................................................. 57
CONCERTA® ............................................................................................................ 57
d-amphetamine .......................................................................................................... 57
DAYTRANA® ............................................................................................................. 57
DESOXYN® ............................................................................................................... 57
DEXEDRINE® ........................................................................................................... 57
dexmethylphenidate ................................................................................................... 57
FOCALIN XR® ........................................................................................................... 57
Updated: 08/2011 16
FOCALIN® ................................................................................................................. 57
METADATE CD® ....................................................................................................... 57
methamphetamine ..................................................................................................... 57
METHYLIN® .............................................................................................................. 57
methylphenidate ......................................................................................................... 57
RITALIN LA® ............................................................................................................. 57
RITALIN® .................................................................................................................. 57
RITALIN-SR® ............................................................................................................ 57
VYVANSE® ............................................................................................................... 57
INTUNIV® .................................................................................................................. 57
STRATTERA® ........................................................................................................... 57
TEKTURNA ................................................................................................................... 59
ACCUPRIL® .............................................................................................................. 60
ACCURETIC® ........................................................................................................... 60
ACEON® ................................................................................................................... 60
ALTACE® .................................................................................................................. 60
ATACAND HCT® ....................................................................................................... 60
ATACAND® ............................................................................................................... 60
AVALIDE® ................................................................................................................. 60
AVAPRO® ................................................................................................................. 60
AZOR® ...................................................................................................................... 60
benazepril .................................................................................................................. 60
benazepril/amlodipine besylate .................................................................................. 60
benazepril/hctz ........................................................................................................... 60
BENICAR HCT® ........................................................................................................ 60
Updated: 08/2011 17
BENICAR® ................................................................................................................ 60
captopril ..................................................................................................................... 60
captopril/hctz .............................................................................................................. 60
COZAAR® ................................................................................................................. 60
DIOVAN HCT® .......................................................................................................... 60
DIOVAN® .................................................................................................................. 60
EDARBI® ................................................................................................................... 60
enalapril ..................................................................................................................... 60
enalapril maleate/hctz ................................................................................................ 60
EXFORGE HCT® ...................................................................................................... 60
EXFORGE® ............................................................................................................... 60
fosinopril..................................................................................................................... 60
fosinopril/hctz ............................................................................................................. 60
HYZAAR® .................................................................................................................. 60
lisinopril ...................................................................................................................... 60
lisinopril/hctz .............................................................................................................. 60
losartan ...................................................................................................................... 60
losartan /hctz .............................................................................................................. 60
LOTENSIN HCT® ...................................................................................................... 60
LOTENSIN® .............................................................................................................. 60
LOTREL® .................................................................................................................. 60
MAVIK® ..................................................................................................................... 60
MICARDIS HCT® ...................................................................................................... 60
MICARDIS® ............................................................................................................... 60
moexipril..................................................................................................................... 60
Updated: 08/2011 18
moexipril/hctz ............................................................................................................. 61
MONOPRIL® ............................................................................................................. 61
perindopril erbumine .................................................................................................. 61
PRINIVIL® ................................................................................................................. 61
PRINZIDE®................................................................................................................ 61
quinapril ..................................................................................................................... 61
quinapril/hctz .............................................................................................................. 61
ramipril ....................................................................................................................... 61
TARKA® .................................................................................................................... 61
TEVETEN HCT® ....................................................................................................... 61
TEVETEN® ................................................................................................................ 61
trandolapril ................................................................................................................. 61
TRIBENZOR®............................................................................................................ 61
TWYNSTA® ............................................................................................................... 61
UNIRETIC® ............................................................................................................... 61
UNIVASC® ................................................................................................................ 61
VASERETIC® ............................................................................................................ 61
VASOTEC® ............................................................................................................... 61
ZESTORETIC® .......................................................................................................... 61
ZESTRIL® ................................................................................................................. 61
AMTURNIDE® ........................................................................................................... 60
TEKAMLO® ............................................................................................................... 60
TEKTURNA HCT® ..................................................................................................... 60
TEKTURNA® ............................................................................................................. 60
VALTURNA® ............................................................................................................. 60
Updated: 08/2011 19
THIAZOLIDINEDIONE .................................................................................................. 62
FORTAMET®............................................................................................................. 62
glipizide/metformin hcl ............................................................................................... 62
GLUCOPHAGE XR® ................................................................................................. 62
GLUCOPHAGE® ....................................................................................................... 62
GLUCOVANCE® ....................................................................................................... 62
GLUMETZA® ............................................................................................................. 62
glyburide/metformin hcl .............................................................................................. 62
JANUMET® ............................................................................................................... 62
KOMBIGLYZE XR® ................................................................................................... 62
METAGLIP® .............................................................................................................. 62
metformin ................................................................................................................... 62
PRANDIMET® ........................................................................................................... 62
RIOMET® .................................................................................................................. 62
ACTOPLUS MET XR® .............................................................................................. 62
ACTOPLUS MET® .................................................................................................... 62
ACTOS® .................................................................................................................... 62
AVANDAMET® .......................................................................................................... 62
AVANDARYL® ........................................................................................................... 62
AVANDIA® ................................................................................................................ 62
DUETACT® ............................................................................................................... 62
TOPICAL CORTICOSTEROIDS ................................................................................... 63
alclometasone ............................................................................................................ 63
amcinonide ................................................................................................................. 63
betameth/propylene glycol ......................................................................................... 63
Updated: 08/2011 20
betamethasone dipropionate ...................................................................................... 63
betamethasone valerate ............................................................................................ 63
clobetasol propionate ................................................................................................. 63
desonide .................................................................................................................... 63
desoximetasone ......................................................................................................... 63
diflorasone ................................................................................................................. 63
fluocinolone acetonide ............................................................................................... 63
fluocinonide ................................................................................................................ 63
fluticasone propionate ................................................................................................ 63
halobetasol propionate ............................................................................................... 63
hydrocortisone ........................................................................................................... 63
hydrocortisone butyrate ............................................................................................. 63
hydrocortisone valerate .............................................................................................. 63
mometasone .............................................................................................................. 63
prednicarbate ............................................................................................................. 63
triamcinolone acetonide ............................................................................................. 63
ACLOVATE® ............................................................................................................. 63
ALA-CORT® .............................................................................................................. 63
ALA-SCALP HP® ....................................................................................................... 63
CARMOL HC® ........................................................................................................... 63
CLOBEX® .................................................................................................................. 63
CLODERM® .............................................................................................................. 63
CORDRAN SP® ........................................................................................................ 63
CORDRAN® .............................................................................................................. 63
CUTIVATE®............................................................................................................... 63
Updated: 08/2011 21
DERMA-SMOOTHE-FS® .......................................................................................... 63
DERMATOP® ............................................................................................................ 63
DESONATE®............................................................................................................. 63
DESOWEN® .............................................................................................................. 63
DIPROLENE AF® ...................................................................................................... 63
DIPROLENE®............................................................................................................ 63
ELOCON® ................................................................................................................. 63
HALOG® .................................................................................................................... 63
KENALOG® ............................................................................................................... 63
LOCOID LIPOCREAM® ............................................................................................ 63
LOCOID® .................................................................................................................. 63
LOKARA® .................................................................................................................. 63
LUXIQ® ..................................................................................................................... 63
OLUX-E® ................................................................................................................... 63
PANDEL® .................................................................................................................. 63
TEMOVATE®............................................................................................................. 63
TOPICORT LP® ........................................................................................................ 63
TOPICORT® .............................................................................................................. 63
U-CORT® .................................................................................................................. 63
ULTRAVATE® ........................................................................................................... 63
VANOS® .................................................................................................................... 63
VERDESO® ............................................................................................................... 63
WESTCORT® ............................................................................................................ 63
TOPICAL IMMUNOMODULATORS .............................................................................. 65
ACLOVATE® ............................................................................................................. 66
Updated: 08/2011 22
ALA-CORT® .............................................................................................................. 66
ALA-SCALP HP® ....................................................................................................... 66
alclometasone ............................................................................................................ 66
amcinonide ................................................................................................................. 66
betameth/propylene glycol ......................................................................................... 66
betamethasone dipropionate ...................................................................................... 66
betamethasone valerate ............................................................................................ 66
CARMOL HC® ........................................................................................................... 66
clobetasol propionate ................................................................................................. 66
CLOBEX® .................................................................................................................. 66
CLODERM® .............................................................................................................. 66
CORDRAN SP® ........................................................................................................ 66
CORDRAN® .............................................................................................................. 66
CUTIVATE®............................................................................................................... 66
DERMA-SMOOTHE-FS® .......................................................................................... 66
DERMATOP® ............................................................................................................ 66
DESONATE®............................................................................................................. 66
desonide .................................................................................................................... 66
DESOWEN® .............................................................................................................. 66
desoximetasone ......................................................................................................... 66
diflorasone ................................................................................................................. 66
DIPROLENE AF® ...................................................................................................... 66
DIPROLENE®............................................................................................................ 66
ELOCON® ................................................................................................................. 66
fluocinolone acetonide ............................................................................................... 66
Updated: 08/2011 23
fluocinonide ................................................................................................................ 66
fluticasone propionate ................................................................................................ 66
halobetasol propionate ............................................................................................... 66
HALOG® .................................................................................................................... 66
hydrocortisone ........................................................................................................... 66
hydrocortisone butyrate ............................................................................................. 66
hydrocortisone valerate .............................................................................................. 66
KENALOG® ............................................................................................................... 66
LOCOID LIPOCREAM® ............................................................................................ 66
LOCOID® .................................................................................................................. 66
LOKARA® .................................................................................................................. 66
LUXIQ® ..................................................................................................................... 66
mometasone .............................................................................................................. 67
OLUX-E® ................................................................................................................... 67
PANDEL® .................................................................................................................. 67
prednicarbate ............................................................................................................. 67
TEMOVATE®............................................................................................................. 67
TOPICORT LP® ........................................................................................................ 67
TOPICORT® .............................................................................................................. 67
triamcinolone acetonide ............................................................................................. 67
U-CORT® .................................................................................................................. 67
ULTRAVATE® ........................................................................................................... 67
VANOS® .................................................................................................................... 67
VERDESO® ............................................................................................................... 67
WESTCORT® ............................................................................................................ 67
Updated: 08/2011 24
ELIDEL® .................................................................................................................... 66
PROTOPIC®.............................................................................................................. 66
ULORIC ......................................................................................................................... 68
allopurinol................................................................................................................... 68
ZYLOPRIM® .............................................................................................................. 68
ULORIC® ................................................................................................................... 68
ULTRAM ....................................................................................................................... 69
tramadol ..................................................................................................................... 69
tramadol/apap ............................................................................................................ 69
RYZOLT® .................................................................................................................. 69
ULTRACET® ............................................................................................................. 69
ULTRAM ER®............................................................................................................ 69
ULTRAM® ................................................................................................................. 69
ZETIA ............................................................................................................................ 70
ADVICOR® ................................................................................................................ 70
ALTOPREV® ............................................................................................................. 70
CADUET® ................................................................................................................. 70
CRESTOR® ............................................................................................................... 70
LESCOL XL® ............................................................................................................. 70
LESCOL® .................................................................................................................. 70
LIPITOR® .................................................................................................................. 70
LIVALO® .................................................................................................................... 70
lovastatin .................................................................................................................... 70
MEVACOR® .............................................................................................................. 70
PRAVACHOL® .......................................................................................................... 70
Updated: 08/2011 25
pravastatin ................................................................................................................. 70
SIMCOR® .................................................................................................................. 70
simvastatin ................................................................................................................. 70
VYTORIN® ................................................................................................................ 70
ZOCOR® ................................................................................................................... 70
ZETIA® ...................................................................................................................... 70
Index ............................................................................................................................. 72
Updated: 08/2011 26
ANTIDEPRESSANTS - SSRI (SARAFEM)
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
fluoxetine
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: 08/2011 27
ANTIDEPRESSANTS-BUPROPION
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
bupropion
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: 08/2011 28
BILE ACID SEQUESTRANTS
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
cholestyramine/aspartame
COLESTID®
colestipol
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, 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: 08/2011 29
BRAND NSAIDS
Affected Drugs
STEP 1 DRUGS STEP 2 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
ANAPROX DS®
ANAPROX®
ARTHROTEC 50®
ARTHROTEC 75®
CATAFLAM®
CLINORIL®
DAYPRO®
EC-NAPROSYN®
FELDENE®
FLECTOR®
INDOCIN®
MOBIC®
NALFON®
NAPRELAN®
NAPROSYN®
PENNSAID®
PONSTEL®
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, 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. Authorization
may be given for Flector, Pennsaid, or Voltaren Gel for patients with difficulty
Updated: 08/2011 30
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: 08/2011 31
CCB - DIHYDROPYRIDINES
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
amlodipine
benazepril/amlodipine besylate
felodipine
isradipine
nicardipine
nifedipine
nisoldipine
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 Besylate-
benazepril, 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: 08/2011 32
CCB - VERAPAMIL
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
verapamil
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: 08/2011 33
COX-2
Updated: 08/2011 34
Affected Drugs
STEP 1 DRUGS STEP 2 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®
sulindac
tolmetin
VOLTAREN®
VOLTAREN-XR®
ZIPSOR®
CELEBREX®
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
Updated: 08/2011 35
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, 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) 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 cancer-chemotherapy 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 anti-inflammatory drugs]. Authorization for Celebrex
may be given to patients with aspirin-sensitive asthma (also known as aspirin-induced
asthma, aspirin-exacerbated respiratory disease) or NSAID-induced asthma.
Updated: 08/2011 36
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 Hcl-
hctz, Captopril, Captopril-hydrochlorothiazide, Enalapril Maleate, Enalapril Maleate-hctz,
Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Lisinopril, Lisinopril-hctz, Losartan
Potassium, Losartan-Hydrochlorothiazide, Moexipril Hcl, Moexipril-hydrochlorothiazide,
Updated: 08/2011 37
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: 08/2011 38
ENHANCED ANTIDEPRESSANTS- SNRI
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS
citalopram
fluoxetine
fluvoxamine
paroxetine
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®
EFFEXOR XR®
PRISTIQ®
SAVELLA®
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, Effexor Xr, Pristiq,
Savella. Step 3 Drug(s): Effexor, 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
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.
Updated: 08/2011 39
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: 08/2011 40
ENHANCED ANTIDEPRESSANTS- SSRI
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS
citalopram
fluoxetine
fluvoxamine
paroxetine
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. 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: 08/2011 41
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: 08/2011 42
ENHANCED FENOFIBRATE
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS
fenofibrate
TRICOR®
TRILIPIX®
ANTARA®
FENOGLIDE®
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, Lipofen, Lofibra, Triglide.
Updated: 08/2011 43
ENHANCED NON-SEDATING ANTIHISTAMINES
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
cetirizine
fexofenadine
levocetirizine dihydrochlor
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: 08/2011 44
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: 08/2011 45
ENHANCED SEDATIVE HYPNOTICS
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS
zaleplon
zolpidem
AMBIEN CR®
LUNESTA®
ROZEREM®
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): Ambien Cr,
Lunesta, Rozerem. Step 3 Drug(s): Ambien, 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: 08/2011 46
HMG RULE 1
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
lovastatin
pravastatin
simvastatin
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: 08/2011 47
HMG RULE 2
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
CRESTOR®
VYTORIN®
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 ST-
segment elevation] or high-risk unstable angina) and who started therapy with Lipitor 80
mg within 30 days of discharge from the hospital.
Updated: 08/2011 48
HMG RULE 3
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
CRESTOR®
lovastatin
pravastatin
simvastatin
VYTORIN®
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: 08/2011 49
KEPPRA
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
levetiracetam
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: 08/2011 50
LAMICTAL
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
lamotrigine
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: 08/2011 51
LONG ACTING OPIOIDS
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
morphine
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: 08/2011 52
LYRICA
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
gabapentin
NEURONTIN®
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. Participant must
have 60 days of gabapentin therapy in claims history. 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 has used
gabapentin or Neurontin for 60 or more days. Authorization for Lyrica may be given if
the patient has used gabapentin or Neurontin for any length of time at a dose 2400
mg/day or more. 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. This step therapy
program applies to new utilizers only.
Updated: 08/2011 53
METFORMIN
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
metformin
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: 08/2011 54
OPHTHALMIC BETA BLOCKERS
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
betaxolol
carteolol
dorzolamide/timolol
levobunolol
metipranolol
timolol
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: 08/2011 55
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: 08/2011 56
STAVZOR
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
divalproex
valproic acid
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: 08/2011 57
STRATTERA
Affected Drugs
STEP 1 DRUGS STEP 2 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®
INTUNIV®
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, Strattera. Authorization for Strattera or Intuniv 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 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 [Attention Deficit
Updated: 08/2011 58
Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient has hypertension,
heart failure, recent myocardial infarction, or hyperthyroidism.
Updated: 08/2011 59
TEKTURNA
Updated: 08/2011 60
Affected Drugs
STEP 1 DRUGS STEP 2 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®
MICARDIS®
moexipril
AMTURNIDE®
TEKAMLO®
TEKTURNA HCT®
TEKTURNA®
VALTURNA®
Updated: 08/2011 61
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 Besylate-
benazepril, 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, Lisinopril-
hctz, 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: 08/2011 62
THIAZOLIDINEDIONE
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
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®
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: 08/2011 63
TOPICAL CORTICOSTEROIDS
Affected Drugs
STEP 1 DRUGS STEP 2 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
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
Propionate, Cormax, Del-beta, Desonide, Desoximetasone, Diflorasone Diacetate,
Updated: 08/2011 64
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: 08/2011 65
TOPICAL IMMUNOMODULATORS
Updated: 08/2011 66
Affected Drugs
STEP 1 DRUGS STEP 2 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®
LOKARA®
LUXIQ®
ELIDEL®
PROTOPIC®
Updated: 08/2011 67
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: 08/2011 68
ULORIC
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
allopurinol
ZYLOPRIM®
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: 08/2011 69
ULTRAM
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
tramadol
tramadol/apap
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: 08/2011 70
ZETIA
Affected Drugs
STEP 1 DRUGS STEP 2 DRUGS
ADVICOR®
ALTOPREV®
CADUET®
CRESTOR®
LESCOL XL®
LESCOL®
LIPITOR®
LIVALO®
lovastatin
MEVACOR®
PRAVACHOL®
pravastatin
SIMCOR®
simvastatin
VYTORIN®
ZOCOR®
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: 08/2011 71
medication related) OR the patient has an underlying muscle/muscle-metabolism-
related disorder (eg, myositis, McArdle disease).
Updated: 08/2011 72
INDEX
ACCUPRIL®, 36, 60
ACCURETIC®, 36, 60
ACEON®, 36, 60
ACIPHEX®, 55
ACLOVATE®, 63, 66
ACTONEL®, 41
ACTOPLUS MET XR®, 62
ACTOPLUS MET®, 62
ACTOS®, 62
ADALAT CC®, 31
ADDERALL XR®, 57
ADDERALL®, 57
ADVICOR®, 70
ALA-CORT®, 63, 66
ALA-SCALP HP®, 63, 66
alclometasone, 63, 66
alendronate, 41
ALLEGRA®, 43
allopurinol, 68
ALTACE®, 36, 60
ALTOPREV®, 48, 70
AMBIEN CR®, 45
AMBIEN®, 45
amcinonide, 63, 66
amlodipine, 31
amphetamine/dextroamphetamine, 57
AMTURNIDE®, 60
ANAPROX DS®, 29, 34
ANAPROX®, 29, 34
ANTARA®, 42
APLENZIN®, 27
ARTHROTEC 50®, 29
ARTHROTEC 75®, 29
ATACAND HCT®, 36, 60
ATACAND®, 36, 60
ATELVIA®, 41
AVALIDE®, 36, 60
AVANDAMET®, 62
AVANDARYL®, 62
AVANDIA®, 62
AVAPRO®, 36, 60
AVINZA®, 51
AZOR®, 36, 60
benazepril, 36, 60
benazepril/amlodipine besylate, 31, 36,
60
benazepril/hctz, 36, 60
BENICAR HCT®, 36, 60
BENICAR®, 36, 60
BETAGAN®, 54
betameth/propylene glycol, 63, 66
betamethasone dipropionate, 63, 66
betamethasone valerate, 63, 66
betaxolol, 54
BETIMOL®, 54
BETOPTIC S®, 54
BONIVA®, 41
bupropion, 27
CADUET®, 47, 48, 70
CALAN SR®, 32
CALAN®, 32
captopril, 36, 60
captopril/hctz, 36, 60
CARMOL HC®, 63, 66
carteolol, 54
CATAFLAM®, 29, 34
CELEBREX®, 34
CELEXA®, 40
cetirizine, 43
cholestyramine/aspartame, 28
citalopram, 38, 40
CLARINEX®, 43
CLARINEX-D 12 HOUR®, 43
CLARINEX-D 24 HOUR®, 43
CLINORIL®, 29, 34
clobetasol propionate, 63, 66
CLOBEX®, 63, 66
CLODERM®, 63, 66
Updated: 08/2011 73
COLESTID®, 28
colestipol, 28
COMBIGAN®, 54
CONCERTA®, 57
CORDRAN SP®, 63, 66
CORDRAN®, 63, 66
COSOPT®, 54
COVERA-HS®, 32
COZAAR®, 36, 60
CRESTOR®, 46, 47, 48, 70
CUTIVATE®, 63, 66
CYMBALTA®, 38
d-amphetamine, 57
DAYPRO®, 29, 34
DAYTRANA®, 57
DEPAKENE®, 56
DEPAKOTE ER®, 56
DEPAKOTE SPRINKLE®, 56
DEPAKOTE®, 56
DERMA-SMOOTHE-FS®, 63, 66
DERMATOP®, 63, 66
DESONATE®, 63, 66
desonide, 63, 66
DESOWEN®, 63, 66
desoximetasone, 63, 66
DESOXYN®, 57
DETROL LA®, 44
DETROL®, 44
DEXEDRINE®, 57
DEXILANT®, 55
dexmethylphenidate, 57
diclofenac potassium, 29, 34
diclofenac sodium, 29, 34
diflorasone, 63, 66
DIOVAN HCT®, 36, 60
DIOVAN®, 36, 60
DIPROLENE AF®, 63, 66
DIPROLENE®, 63, 66
DITROPAN XL®, 44
divalproex, 56
dorzolamide/timolol, 54
DUETACT®, 62
DYNACIRC CR®, 31
EC-NAPROSYN®, 29, 34
EDARBI®, 36, 60
EDLUAR®, 45
EFFEXOR XR®, 38
EFFEXOR®, 38
ELIDEL®, 66
ELOCON®, 63, 66
EMBEDA®, 51
ENABLEX®, 44
enalapril, 36, 60
enalapril maleate/hctz, 36, 60
etodolac, 29, 34
EXALGO®, 51
EXFORGE HCT®, 36, 60
EXFORGE®, 36, 60
FELDENE®, 29, 34
felodipine, 31
fenofibrate, 42
FENOGLIDE®, 42
fenoprofen, 29, 34
fexofenadine, 43
FLECTOR®, 29
fluocinolone acetonide, 63, 66
fluocinonide, 63, 66
fluoxetine, 26, 38, 40
flurbiprofen, 29, 34
fluticasone propionate, 63, 66
fluvoxamine, 38, 40
FOCALIN XR®, 57
FOCALIN®, 57
FORTAMET®, 53, 62
FOSAMAX PLUS D®, 41
FOSAMAX®, 41
fosinopril, 36, 60
fosinopril/hctz, 36, 60
gabapentin, 52
GELNIQUE®, 44
Updated: 08/2011 74
glipizide/metformin hcl, 62
GLUCOPHAGE XR®, 53, 62
GLUCOPHAGE®, 53, 62
GLUCOVANCE®, 62
GLUMETZA®, 53, 62
glyburide/metformin hcl, 62
halobetasol propionate, 63, 66
HALOG®, 63, 66
hydrocortisone, 63, 66
hydrocortisone butyrate, 63, 66
hydrocortisone valerate, 63, 66
HYZAAR®, 36, 60
ibuprofen, 29, 34
INDOCIN®, 29, 34
indomethacin, 29, 34
INTUNIV®, 57
ISOPTIN SR®, 32
isradipine, 31
ISTALOL®, 54
JANUMET®, 62
KADIAN®, 51
KENALOG®, 63, 66
KEPPRA XR®, 49
KEPPRA®, 49
ketoprofen, 29, 34
ketorolac, 29, 34
KOMBIGLYZE XR®, 62
LAMICTAL (BLUE)®, 50
LAMICTAL (GREEN)®, 50
LAMICTAL (ORANGE)®, 50
LAMICTAL ODT®, 50
LAMICTAL XR (BLUE)®, 50
LAMICTAL XR (GREEN)®, 50
LAMICTAL XR (ORANGE)®, 50
LAMICTAL XR®, 50
LAMICTAL®, 50
lamotrigine, 50
lansoprazole, 29
lansoprazole dr 15 mg capsule, 55
lansoprazole dr 30 mg capsule, 55
lansoprazole odt 15 mg tablet, 55
lansoprazole odt 30 mg tablet, 55
LESCOL XL®, 48, 70
LESCOL®, 48, 70
levetiracetam, 49
levobunolol, 54
levocetirizine dihydrochlor, 43
LEXAPRO®, 40
LIPITOR®, 47, 48, 70
LIPOFEN®, 42
lisinopril, 36, 60
lisinopril/hctz, 36, 60
LIVALO®, 48, 70
LOCOID LIPOCREAM®, 63, 66
LOCOID®, 63, 66
LOFIBRA®, 42
LOKARA®, 63, 66
losartan, 36, 60
losartan /hctz, 36, 60
LOTENSIN HCT®, 36, 60
LOTENSIN®, 36, 60
LOTREL®, 36, 60
lovastatin, 46, 48, 70
LUNESTA®, 45
LUVOX CR®, 40
LUXIQ®, 63, 66
LYRICA®, 52
MAVIK®, 36, 60
meclofenamate, 29, 34
mefenamic acid, 29, 34
meloxicam, 29, 34
METADATE CD®, 57
METAGLIP®, 62
metformin, 53, 62
methamphetamine, 57
METHYLIN®, 57
methylphenidate, 57
metipranolol, 54
MEVACOR®, 48, 70
MICARDIS HCT®, 36, 60
Updated: 08/2011 75
MICARDIS®, 36, 60
MOBIC®, 29, 34
moexipril, 36, 60
moexipril/hctz, 36, 60
mometasone, 63, 66
MONOPRIL®, 36, 60
morphine, 51
MS CONTIN®, 51
nabumetone, 29, 34
NALFON®, 29, 34
NAPRELAN®, 29, 34
NAPROSYN®, 29, 34
naproxen, 29, 34
naproxen sodium, 29, 34
NEURONTIN®, 52
NEXIUM®, 55
nicardipine, 31
nifedipine, 31
nisoldipine, 31
NORVASC®, 31
OLUX-E®, 63, 66
omeprazole, 29, 55
omeprazole/sodium bicarbonat, 55
OPANA ER®, 51
OPTIPRANOLOL®, 54
ORAMORPH SR®, 51
oxaprozin, 29, 34
oxybutynin, 44
OXYCONTIN®, 51
OXYTROL®, 44
PANDEL®, 63, 66
pantoprazole, 29, 55
paroxetine, 38, 40
PAXIL CR®, 40
PAXIL®, 40
PENNSAID®, 29
perindopril erbumine, 36, 60
PEXEVA®, 40
piroxicam, 29, 34
PONSTEL®, 29, 34
PRANDIMET®, 62
PRAVACHOL®, 48, 70
pravastatin, 46, 48, 70
prednicarbate, 63, 66
PREVACID®, 55
PRILOSEC®, 55
PRINIVIL®, 36, 60
PRINZIDE®, 36, 60
PRISTIQ®, 38
PROCARDIA XL®, 31
PROCARDIA®, 31
PROTONIX®, 55
PROTOPIC®, 66
PROZAC WEEKLY®, 40
PROZAC®, 40
QUESTRAN®, 28
quinapril, 36, 60
quinapril/hctz, 36, 60
ramipril, 36, 60
RIOMET®, 53, 62
RITALIN LA®, 57
RITALIN®, 57
RITALIN-SR®, 57
ROZEREM®, 45
RYZOLT®, 69
SANCTURA XR®, 44
SANCTURA®, 44
SARAFEM®, 26
SAVELLA®, 38
sertraline, 38, 40
SILENOR®, 45
SIMCOR®, 70
simvastatin, 46, 48, 70
SONATA®, 45
STAVZOR®, 56
STRATTERA®, 57
SULAR®, 31
sulindac, 29, 34
TARKA®, 36, 60
TEKAMLO®, 60
Updated: 08/2011 76
TEKTURNA HCT®, 60
TEKTURNA®, 60
TEMOVATE®, 63, 66
TEVETEN HCT®, 36, 60
TEVETEN®, 36, 60
timolol, 54
TIMOPTIC OCUDOSE®, 54
TIMOPTIC-XE®, 54
tolmetin, 29, 34
TOPICORT LP®, 63, 66
TOPICORT®, 63, 66
TOVIAZ®, 44
tramadol, 69
tramadol/apap, 69
trandolapril, 36, 60
triamcinolone acetonide, 63, 66
TRIBENZOR®, 36, 60
TRICOR®, 42
TRIGLIDE®, 42
TRILIPIX®, 42
trospium chloride, 44
TWYNSTA®, 36, 60
U-CORT®, 63, 66
ULORIC®, 68
ULTRACET®, 69
ULTRAM ER®, 69
ULTRAM®, 69
ULTRAVATE®, 63, 66
UNIRETIC®, 36, 60
UNIVASC®, 36, 60
valproic acid, 56
VALTURNA®, 60
VANOS®, 63, 66
VASERETIC®, 36, 60
VASOTEC®, 36, 60
venlafaxine hcl, 38
venlafaxine hcl 100 mg tablet, 38
venlafaxine hcl 25 mg tablet, 38
venlafaxine hcl 37.5 mg tablet, 38
venlafaxine hcl 50 mg tablet, 38
venlafaxine hcl 75 mg tablet, 38
venlafaxine hcl er 150 mg cap, 38
venlafaxine hcl er 150 mg tab, 38
venlafaxine hcl er 37.5 mg cap, 38
venlafaxine hcl er 37.5 mg tab, 38
venlafaxine hcl er 75 mg cap, 38
venlafaxine hcl er 75 mg tab, 38
VENLAFAXINE HCL ER®, 38
verapamil, 32
VERDESO®, 63, 66
VERELAN PM®, 32
VERELAN®, 32
VESICARE®, 44
VIIBRYD®, 40
VIMOVO®, 29
VOLTAREN®, 29, 34
VOLTAREN-XR®, 29, 34
VYTORIN®, 46, 47, 48, 70
VYVANSE®, 57
WELCHOL®, 28
WELLBUTRIN SR®, 27
WELLBUTRIN XL®, 27
WESTCORT®, 63, 66
XYZAL®, 43
zaleplon, 45
ZEGERID®, 55
ZESTORETIC®, 36, 60
ZESTRIL®, 36, 60
ZETIA®, 70
ZIPSOR®, 29, 34
ZOCOR®, 48, 70
ZOLOFT®, 40
zolpidem, 45
ZOLPIMIST®, 45
ZYLOPRIM®, 68