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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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