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The Step Therapy drug will be dispensed if the drug has been dispensed within 120 days of current fill or if alternative (Step 1) drugs have been used first. If the member’s prescription claim fails the Step Therapy edit, a prior authorization will be needed. Prior Authorization phone lines provide quicker decisions: 1-800-711-4555 (Physician) or 1-866-815-5332 (Member) STEP THERAPY ALGORITHMS – Golden State Health Plan Platinum Formulary
Treatment Group
Description
Step 1: One Tier 1 or Tier 2 Proton Pump Inhibitor

Step 2: Aciphex
Step 1: One of the following: metformin or thiazolidinedione

Step 2: Actoplus Met
Step 1: One of the following: metformin or thiazolidinedione

Step 2: Actoplus Met XR
Step 1: One of the following:
a. metformin b. sulfonylurea c. insulin d. Byetta
Step 2: Actos
Step 1: One of the following:
b. Long-acting beta agonist c. Inhaled anticholinergic agent d. theophylline
Step 2: Advair Diskus or Advair HFA
Step 1: cetirizine syrup

Step 2 Allegra suspension
Treatment Group
Description
Step 1: fexofenadine

Step 2: Allegra-D
Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,

Step 2: Glyset or Precose (including acarbose)
Step 1: zolpidem

Step 2: Ambien CR
Step 1: One of the following:

Step 2
: Amitiza
Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination Step 2: Micardis or Micardis HCT
Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination Step 2: Benicar or Benicar HCT or Diovan or Diovan HCT or Losartan or Losartan/HCTZ
Step 3: Atacand or Atacand HCT or Avapro or Avalide or Teveten or Teveten HCT
Step 1: One of the following Tier 1 or Tier 2 antidepressants:
a. SSRI b. SNRI c. bupropion d. mirtazapine Step 2: Emsam or Pexeva
Treatment Group
Description
Step 1: One of the following:

Step 2: Actos
Step 3: Avandamet
Step 1: One of the following:

Step 2: Actos
Step 3: Avandaryl
Step 1: One of the following:

Step 2: Actos
Step 3: Avandia
Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination Step 2: Azor
Step 1: Beta blocker (generic) or Beta blocker/Diuretic combination product

Step 2: Bystolic
Treatment Group
Description
Step 1: ofloxacin otic

Step 2: Cetraxal
Step 1: pilocarpine

Step 2: Evoxac
Step 1: cetirizine syrup

Step 2 Clarinex Syrup
Step 1: fexofenadine
Step 2: Clarinex tablets or Clarinex RDT or Clarinex-D tablets
Step 1: One of the following:
b. dextroamphetamine c. dexmethylphenidate d. methylphenidate
Step 2: Strattera
Step 1: carvedilol

Step 2: Coreg CR
Dipeptidyl Peptidase 4 Inhibitor Therapy Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,

Step 2: Januvia or Onglyza
Dipeptidyl Peptidase 4 Inhibitor/ Metformin Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,

Step 2: Janumet
Step 1: sulfonylurea or thiazolidinedione

Step 2: Duetact
Treatment Group
Description
Step 1: One of the following
a. Inhaled corticosteroid b. Long-acting beta agonist c. Inhaled anticholinergic agent d. Theophylline.
Step 2: Dulera
Step 1: calcium acetate 667mg
Step 2: Eliphos
Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination Step 2: Exforge or Exforge HCT
Step 1: One of the following atypical antipsychotics:
Step 2: Fanapt
Genitourinary Smooth Muscle Relaxant Therapy Step 1: Oxybutynin or Oxybutynin ER
One of the following: Detrol, Detrol LA, Enablex, or Oxytrol
Step 2: Vesicare or Toviaz
Step 1: One of the following:
b. sulfonylurea c. insulin d. thiazolidinedione
Step 2: Byetta
Step 3: Victoza
Treatment Group
Description
Step 1: One tier 1 or tier 2 inhaled corticosteroid
Step 2: Aerobid/Aerobid-M or Asmanex or Azmacort or Alvesco or Flovent Diskus
Step 1: Any one formulary ADHD stimulant
Step 2: Intuniv
Step 1: Avodart or tamsulosin
Step 2: Jalyn
Step 1: One of the following:
c. Formulary Inhaled Beta-agonist/Corticosteroid combination d. Formulary Oral Corticosteroid
Step 2
: Singulair
Step 3: Accolate or Zyflo CR
Step 1: Intranasal Steroid or Prescription Second-Generation Antihistamine

Step 2: Singulair
Step 1: zolpidem

Step 2: Lunesta
Step 1: One of the following:
a. fluvoxamine b. paroxetine c. sertraline Step 2: Luvox CR
Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,

Step 2: Prandin or Starlix
Treatment Group
Description
Step 1: metoclopramide
Step 2: Metozolv
Step 1: Ropinorole or Pramipexole
Step 2: Mirapex ER
Step 1: One of the following:

Step 2: Bepreve, Elestat, or Emadine
Step 1: One of the following:

Step 2: Xalatan
Step 1: Ophthalmic prednisolone acetate
Step 2: FML Forte or Vexol
Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,

Step 2: Prandimet
Step 1: One of the following:
b. Beta-blocker c. Calcium-channel blocker
Step 2: Ranexa
Step 1: ropinorole or Mirapex
Step 2: Requip XL
Treatment Group
Description
Step 1: tramadol or tramadol/acetaminophen
Step 2: Ryzolt
Step 1: One of the following:

Step 2: Sarafem or Selfemra
Step 1: One of the following:
a. Advicor b. Vytorin c. Any formulary statin
Step 2
: Simcor
Step 1: cyclobenzaprine (immediate-release)

Step 2: Amrix or Fexmid
Step 1: carbidopa/levodopa AND Comtan
Step 2: Stalevo
Step 1: One of the following:
a. simvastatin b. lovastatin c. pravastatin d. Lipitor
Step 2: Altoprev or Lescol or Lescol XL
Step 1: Lipitor or Crestor

Step 2: Vytorin
Treatment Group
Description
Step 1: Two of the following:
a. simvastatin b. lovastatin c. pravastatin d. Lipitor
Step 2: Livalo
Step 1: sumatriptan injection
Step 2
: Sumavel
Step 1: One of the following:
b. Long-acting beta agonist c. Inhaled anticholinergic agent d. theophylline
Step 2: Symbicort
Step 1: One of the following:
c. Angiotensin II receptor blocker d. Angiotensin II receptor blocker combination
Step 2: Tekturna or Tekturna HCT
Step 1: Topical Corticosteroid

Step 2: Elidel or Protopic
Step 1: One of the following:
a. naratriptan b. sumatriptan c. Maxalt d. Maxalt MLT
Step 2: Treximet
Treatment Group
Description
Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination Step 2: Tribenzor
Step 1: naratriptan or sumatriptan

Step 2: Axert or Frova or Relpax
Step 1: ACEI, ACEI containing product, Azor, Exforge, Exforge HCT, or Tribenzor
Step 2:
Twynsta
Step 1: allopurinol

Step 2: Uloric
Step 1: One of the following:
c. Angiotensin II receptor blocker d. Angiotensin II receptor blocker combination
Step 2: Valturna
Step 1: Both of the following:
a. One oral NSAID b. One Tier 1 or Tier 2 PPI Step 2: Vimovo
Step 1: albuterol (nebulizer)

Step 2: Xopenex Nebulizer
Step 1: cetirizine syrup

Step 2 Xyzal Syrup
Step 1: fexofenadine

Step 2: Xyzal Tablets
Treatment Group
Description
Step 1: selegiline

Step 2: Zelapar

*Step therapy applies to new starts only

Source: http://www.goldenstatemhp.com/documents/2011/2011_StepTherapy.pdf

Http://www.nimh.nih.gov/science-news/2008/maintenance-treatment

NIMH · Science News from 2008 · Maintenance Treatment Crucial for Teens’ Recovery from De. Page 1 of 2Back to: NIMH Home » Science News » 2008 Maintenance Treatment Crucial for Teens’ NIMH Press Office 301-443-4536 NIMHPress@nih.gov Long-term maintenance treatment is likely to sustain improvement and prevent recurrence amo

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