Step therapy_rev 10-20.xlsx

To help make the use of prescription drugs safer and more affordable, NHP/SHP is using a Step Therapy program
Medications are grouped into two categories:
First Step Medications: These are the drugs recommended to take first — usually generic medications, which have been proven safe and effective.
Targeted Step Medications: These are brand-name medications, recommended for patients only if a first step medication doesn’t work.
Step Therapy
Your prescription is for one of
The program points to one of these
This program looks for
Indication
these Targeted Step
First Step Medications
Medications
Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Prior use of 1 first line medication in the Dexedrine, Dexedrine Spansules, Dextroamphetamine IR, Dextroamphetamine SR, dexmethylphenidate IR, Focalin, Focalin XR, Metadate CD, Metadate ER, methamphetamine, Methylin, Methylin ER, methylphenidate ER, methylphenidate immediate release, mixed amphetamine salts IR, Ritalin LA, Ritalin SR, Vyvanse Angiotensin II Receptor Diovan HCT, Diovan, Exforge, Exforge benazepril, benazepril/HCTZ, captopril, captopril/HCTZ, Prior use of 1 first line medication in the enalapril, enalapril/HCTZ, fosinopril, fosinopril/HCTZ, lisinopril, lisinopril/HCTZ, ramipril, quinapril, quinapril/HCTZ, Quinaretic, moexipril, trandolapril, moexipril/HCTZ, benazepril/amlodipine, perindopril, trandolapril/verapamil, enalapril/felodipine, losartan, losartan/HCTZ Prior use of 1 first line medication in the fluoxetine, fluvoxamine, paroxetine, citalopram, sertraline, Prior use of 1 first line medication in the last 130 days; for Savella prior use of 2 medication (SSRI and/or SNRI) in the last PLEASE NOTE - Members who were
taking one of the Targeted Step
Medications prior to 10/1/2011 will be
able to continue taking the medication.
diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, Prior use of 2 first line medications in the Arthritis/Pain indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin Januvia, Janumet, Onglyza, Kombiglyze XR, Prior use of 1 first line medication in the Step Therapy
Your prescription is for one of
The program points to one of these
This program looks for
Indication
these Targeted Step
First Step Medications
Medications
Altoprev, Caduet, Lescol, Lescol XL, Mevacor, Step-One: lovastatin, pravastatin, simvastatin
Step-Two: Crestor, Lipitor
of a Step-Two medication in the last 130 days for a targeted product. Prior use of a Step-One and a Step-Two medication in the last 180 days for a targeted product. Grandfathering is not required Prior use of 1 first line medication in the For asthma conditions:
Prior use of 1 first line medication from Antiasthmatic and Bronchodilator Agents will be used to identify members who likely have asthma. These claims will automatically pay. Accuneb Inh Soln ,Advair Diskus , Advair HFA Mcg Inhaler , Aerobid-M Aerosol , Albuterol Inhal Soln, Albuterol Sulf Syrup, Albuterol Sulfate Tab, Alvesco Inhaler, Aminophylline Tablet, Asmanex Twisthalr, Atrovent Hfa Inhaler, Azmacort Inhaler , Brethine Tablet, Brovana Solution, Budesonide Susp , Combivent Inhaler, Cromolyn NebulizerSolution , Cromolyn Sodium Powder, Daliresp Tablet, Difil-G Tablet, Difil-G Forte Liquid, Dilex-G Tablet, Dilex-G Liquid, Dilex-G Tablet, Dulera Inhalet, Duoneb Soln, Elixophyllin Elix , Flovent Diskus , Flovent HFA Inhaler , Foradil Aerolizer Cap ,Intal Inhaler, Ipratropium Br Soln, Ipratropium Bromide , Isoproterenol Sulfate Powdr, Levalbuterol Conc , Maxair Autohaler Aero, Metaproterenol Tablet, Metaproterenol Syr , Metaproterenol Sulfate Pwdr , Perforom For non-asthma conditions: Category Prior use of 1 first line medication from
1:Fluticasone propionate* , Beconase AQ, Flonase,
Flunisolide*, Nasacort, Nasarel, Veramyst, Nasonex,
Rhinocort AQ, Omnaris
Category 2: Fexofenadine*^ , Allegra^, Allegra-D^,
Clarinex,Clarinex-D, loratadine*^,
loratadine/pseudoephedrine*^, Claritin^, Claritin-D^,
cetirizine*^, cetirizine-pseudoephedrine*^, Zyrtec^, Zyrtec
D^, Xyzal, Astelin/Astepro, Patanase
*try these generics first to avoid being targeted by another step therapy
program;^ these over-the-counter (OTC) products may not be covered
under your prescription benefit
Long-Acting Opioid-Oral Opana ER, OxyContin Morphine sustained release, oxymorphone extended- Prior use of 1 first line medication in the Prior use of 1 first line medication in the Prior use of 90 days of therapy of first line Diabetesmedication in the last 130 days Proton Pump Inhibitors Aciphex®, Nexium®, Prevacid®, Prilosec®, Category 1:cimetidine, famotidine, nizatidine, ranitidine History of 1 first line medication in the last
Category 2: omeprazole
Step Therapy
Your prescription is for one of
The program points to one of these
This program looks for
Indication
these Targeted Step
First Step Medications
Medications
Thiazolidinediones (TZD) Actos, Actoplus Met/XR, Duetact Prior use of 1 first line medication in the metformin/glyburide, metformin, glipizide, alclometasone, amcinonide, betamethasone dipropionate Prior use of 1 first line medication in the (augmented), betamethasone dipropionate, clobetasol, clobetasone, fluocinonide, fluticasone, halobetasol, betamethasone valerate, hydrocortisone, hydrocortisone butyrate, hydrocortisone buteprate, hydrocortisone acetate, desonide, desoximetasone, hydrocortisone valerate, mometasone, triamcinolone, diflorasone, fluocinolone, clocortolone, flurandrenolide, halocinonide, prednicarbate Imitrex, Sumavel DosePro, Alsuma, Treximet, Prior use of 1 first line medication in the Amerge, Zomig/ZMT, Maxalt/MLT, Axert, Frova, Prior use of 1 first line medication in the Lipitor, Lescol, Prior use of 1 first line medication in the Lescol XL, Altoprev, Pravachol, Crestor, Mevacor, Zocor, last 130 daysCaduet, *try one of these generics first to avoid being targeted by another steptherapy program.

Source: http://nhptest.royaldc.com/PDFs/ProviderPDF/Provider_Manual.old/Appendix/Tab%2003%20step%20therapy_rev%2010-20.pdf