Step Therapy Criteria
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
Benicar, Benicar HCT,
DRUGS, 1 DRUG FROM EACH CLASS, IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2:
Diovan, Diovan HCT
ACE-Inhibitor (including combinations with HCTZ) Benazepril Hcl, Benazepril Hcl/Hydrochlorothiazide, Captopril, Captopril /Hydrochlorothiazide, Enalapril Maleate, Enalapril Maleate/Hydrochlorothiazide, Fosinopril Sodium, Fosinopril sodium/Hydrochlorothiazide, Lisinopril, Lisinopril /Hydrochlorothiazide, Quinapril Hcl, Trandolapril, Ramipril. ARB (including combinations with HCTZ), losartan, losartan/HCTZ, irbesartan, irbesartan/Hctz Step 2: Benicar, Benicar Hct, Diovan, Diovan Hct
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY ONE OF THE FOLLOWING
Promethazine, Hydroxyzine,
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Ondansetron, Granisetron. Step 2: Promethagan, Promethazine, Hydroxyzine, Promethagan, Trimethobenzamide Trimethobenzamide Step therapy only applies to members 65 years of age or older
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY ONE OF THE FOLLOWING
Meprobamate, hydroxyzine
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Buspirone. Step 2: Meprobamate, hydroxyzine Step therapy only applies to members 65 years of age or older
Atypicals: Abilify, Fanapt,
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ONE OF THE FOLLOWING DRUGS
Fazaclo, Invega, Latuda,
IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: clozapine, risperidone, olanzapine,
Risperdal Consta, Risperdal
quetiapine, ziprasidone. Step 2: Abilify, Fanapt, Fazaclo, Invega, Latuda, Risperdal Consta, M-Tab, Saphris, Seroquel Risperdal M-Tab, Saphris, Seroquel XR.Step Therapy only applies to new starts only. Enrollees stabilized on medication will not be required to go through step therapy.
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Fortamet, Glimepiride, Glipizide, Glipizide Er, Glipizide Xl, Glipizide/Metformin Hcl, Metformin Hcl, Metformin Hcl Er, Prandin, Precose, Starlix, Tolazamide, Tolbutamide. Step 2: Byetta
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
Seroquel XR
DRUG IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: bupropion, bupropion SR, bupropion XL, citalopram, Cymbalta, mirtazapine, nefazodone, trazodone, escitalopram, fluoxetine, paroxetine, quetiapine, sertraline, venlafaxine, venlafaxine XR Step 2: Seroquel XR Step Therapy only applies to new starts only. Enrollees stabilized on medication will not be required to go through step therapy.
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
Avandamet, Avandamet,
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Fortamet, Glimepiride, Glipizide,
Avandaryl, Avandia
Glipizide Er, Glipizide Xl, Glipizide/Metformin Hcl, Humalog, Humalog Mix 50/50, Humalog Mix 75/25, Humulin 70/30, Humulin N, Humulin R, Lantus, Lantus Solostar, Levemir, Levemir Flexpen, Metformin Hcl, Metformin Hcl Er, Novolog, Novolog Flexpen, Novolog Mix 70/30, Novolin N, Novolin R, Novolin 70/30, Prandin, Precose, Starlix, Tolazamide. Step 2: Avandamet, Avandamet, Avandaryl, Avandia
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY ONE OF THE FOLLOWING
Glyburide
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Glipizide, Glipizide/Metformin, Glimepiride, Metformin. Step 2: Glyburide Step therapy only applies to members 65 years of age or older
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
Janumet, Januvia, Onglyza
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Fortamet, Glipizide/Metformin Hcl, Metformin Hcl, Metformin Hcl ER. Step 2: Janumet, Januvia, Onglyza
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
Celebrex
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Diclofenac Potassium, Diclofenac Sodium, Diclofenac Sodium Dr, Diclofenac Sodium Ec, Diclofenac Sodium Er, Diflunisal, Etodolac, Etodolac Er, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Indomethacin Er, Ketoprofen, Ketoprofen Er, Ketorolac Tromethamine, Meloxicam, Nabumetone, Naproxen, Naproxen Dr, Naproxen Sodium, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2: Celebrex
Step_Therapy_Criteria Step Therapy does not apply to members 65 yrs or older.
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
Desloratadine,
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Allegra OTC, Allegra D OTC,
Levocetirizine, Clarinex D
Loratadine OTC, Loratadine D OTC, Cetirizine OTC, Cetirizine D OTC. Step 2: Desloratadine, Levocetirizine, Clarinex D
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
Prevacid
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: lansoprazole, lansoprazole OTC, Priolosec OTC, Omeprazole OTC, Omeprazole, Pantoprazole, Prevacid OTC, Zegerid OTC. Step 2: Prevacid Pradaxa, Xarelto
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF THE FOLLOWING DRUG IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Warfarin, Jantoven. Step 2: Pradaxa, Xarelto Step Therapy does not apply to Xarelto when being used for Deep Vein Thrombosis or Pulmonary Embolism
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
Tekturna, Tekturna Hct
DRUGS, 1 DRUG FROM EACH CLASS, IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: • ACE-Inhibitors (including combinations with HCTZ) - Benazepril Hcl, Benazepril Hctz, Captopril, Captopril /Hctz, Enalapril Maleate, Enalapril Maleate/Hctz, Fosinopril Sodium, Fosinoprilsodium/Hctz, Lisinopril, Lisinopril /Hctz, Quinapril Hcl, Trandolapril, Ramipril. • ARBs (including combinations with HCTZ) - Benicar, Benicar Hct, Diovan Hct, losartan, losartan/HCT, irbesartan, irbesartan/Hctz. Step 2: Tekturna, Tekturna Hct
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL THE FOLLOWING DRUG IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Gleevec. Step 2: Sprycel Step Therapy only applies to new starts only. Enrollees stabilized on medication will not be required to go through step therapy.
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Atorvastatin, Simvastatin, Pravastatin, Lovastatin. Step 2: Crestor
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Humalog, Humalog Mix 50/50, Humalog Mix 75/25, Humulin 70/30, Humulin N, Humulin R, Lantus, Levemir, Novolog, Novolog Mix 70/30, Novolin R, Novolin N, Novolin 70/30. Step 2: Symlin
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING
Elidel, Protopic
DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Alclometasone Dipropionate, Amcinonide, Augmented Betamethasone Dipropionate, Betamethasone Dipropionate, Betamethasone Valerate, Clobetasol Propionate, Clobetasol Propionate Emollient, Desonide, Desoximetasone, Diflorasone Diacetate, Fluocinolone Acetonide, Fluocinonide, Fluticasone, Halobetasol Propionate, Hydrocortisone Butyrate, Hydrocortisone Valerate, Mometasone Furoate, Prednicarbate, Triamcinolone Acetonide, Triamcinolone Acetonide In Absorbase. Step 2: Elidel, Protopic
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Fortamet, Glimepiride, Glipizide, Glipizide Er, Glipizide Xl, Glipizide/Metformin Hcl, Glycron, Metformin Hcl, Metformin Hcl Er, Prandin, Precose, Starlix, Tolazamide, Tolbutamide. Step 2: Victoza Welchol, diabetes
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Fortamet, Glimepiride, Glipizide, Glipizide Er, Glipizide Xl, Glipizide/Metformin Hcl, Glycron, Humalog, Humalog Mix 50/50, Humalog Mix 75/25, Humulin 70/30, Humulin N, Humulin R, Lantus, Lantus Solostar, Levemir, Levemir Flexpen, Metformin Hcl, Metformin Hcl Er, Novolog, Novolog Flexpen, Novolog Mix 70/30, Novolin N, Novolin R, Novolin 70/30, Prandin, Precose, Starlix, Tolazamide. Step 2: Welcol Welchol, statins first
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Atorvastatin, Simvastatin, Pravastatin, Lovastatin. Step 2: Welchol Xifaxam 550
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY ONE OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Lactulose, Enulose, Constulose, Generalac. Step 2: Xifaxam
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Step Therapy Criteria