Rx-esi-step_therapy-drug_list-_2013-amhic-10113.xlsx

Express Scripts, Inc.
***Most step therapy programs have exception criteria for members taking certain medications and/or medical histories.
Depending on a member's specific medical history, a back-up medication may be approved without a trial of a front-line
medication.***
Step Therapy
Your prescription is for one of
Your program points you to one of
This program looks for
Indication
these targeted step drugs
these first step drugs
Cardura IR/XL, Flomax, Hytrin, Rapaflo, UroXatrol alfuzosin, tamsulosin, doxazosin, terazosin Prior use of 1 first line medication in the last BPH130 days Atacand HCT, Atacand, Avalide, Avapro, Azor, Prior use of 1 first line medication in the last Heart and hypertension Benicar, Benicar HCT,Cozaar, Diovan HCT, Diovan, captopril/HCTZ, enalapril, enalapril/HCTZ, fosinopril, Edarbi, Edarbyclor, Exforge, Exforge HCT, Hyzaar, fosinopril/HCTZ, lisinopril, lisinopril/HCTZ, ramipril, Micardis, Micardis HCT, Teveten, Teveten HCT, quinapril, quinapril/HCTZ, Quinaretic, moexipril, trandolapril, moexipril/HCTZ, benazepril/amlodipine, perindopril, trandolapril/verapamil, enalapril/felodipine, losartan, losartan/HCTZ, eprosartan, irbesartan, irbesartan/HCTZ bupropion SR, bupropion XL, budeprion SR, budeprion Prior use of 1 first line medication in the last Depression Celexa, Lexapro, Luvox CR, Paxil CR, Paxil, fluoxetine/weekly, fluvoxamine, paroxetine, paroxetine Prior use of 1 first line medication in the last Depression Pexeva, Prozac, Prozac Weekly, Sarafem, Zoloft, Cymbalta, Effexor, Effexor XR, Pristiq, Venlafaxine fluoxetine, fluvoxamine, paroxetine, citalopram, Prior use of 1 first line medication in the last Depression medication (SSRI and/or SNRI) in the last Prior use of 1 first line medication in the last BPH130 days Welchol, Questran/Light, Prevalite, Colestid Prior use of 1 first line medication in the last Triglycerides130 days Bisphosphonates Enhanced Fosamax tablets, Fosamax oral solution, Fosamax Step-One: alendronate, ibandronate
Step-Two: Actonel, Actonel Plus Calcium, Atelvia,
for a Step-Two Product. Prior use of a Step- Two medication in the last 130 days for a Step-Three product. Arthrotec, Mobic, Ponstel, Cataflam, Voltaren, diclofenac, etodolac, fenoprofen, flurbiprofen, Prior use of 2 first line medications in the last Arthritis/Pain Voltaren XR, Lodine, Lodine XL, Nalfon, Ansaid, ibuprofen, indomethacin, ketoprofen, ketorolac, Motrin, Indocin, Indocin SR, Orudis, Toradol, meclofenamate, mefenamic acid, meloxicam, omeprazole, generic lansoprazole, or generic Relafen, Naprosyn, Naprelan, Anaprox, Anaprox nabumetone, naproxen, oxaprozin, piroxicam, sulindac, pantoprazole AND naproxen (brand or DS, Daypro, Feldene, Clinoril, Flector, Voltaren Gel, tolmetin, diclofenac sodium/misoprostol IC 400, IC 800, Zipsor, Pennsaid, Cambia, Sprix, ranitidine AND prescription strength ibuprofen (brand or generic) diclofenac, etodolac, fenoprofen, flurbiprofen, Prior use of 2 first line medications in the last Arthritis/Pain ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin, diclofenac sodium/misoprostol DPP-4 Inhibitors (formerly Rule 1: Januvia, Janumet/XR, Onglyza,
Rule 1: metformin, metformin extended-release,
Prior use of 1 first line medication in the last Antidiabetic Rule 2: Juvisync
Rule 2: Januvia, Janumet/XR, Onglyza, Kombiglyze,
Tradjenta, Jentadueto
FOR INTERNAL USE ONLY
Express Scripts, Inc.
***Most step therapy programs have exception criteria for members taking certain medications and/or medical histories.
Depending on a member's specific medical history, a back-up medication may be approved without a trial of a front-line
medication.***
Step Therapy
Your prescription is for one of
Your program points you to one of
This program looks for
Indication
these targeted step drugs
these first step drugs
Tricor, Lofibra, Antara, Triglide, Lipofen, Fenoglide, fenofibrate, fenofibric acid Prior use of 1 first line medication in the last Cholesterol HMG - Enhanced National Altoprev, Caduet, Lescol, Lescol XL, Lipitor Step-One: lovastatin, pravastatin, simvastatin,
Prior use of a Step-One in the last 130 days Cholesterol Mevacor, Pravachol, Zocor, Vytorin, Livalo atorvastatin, fluvastatin, atorvastatin/amlodipine for a Step-Two Product. Prior use of a Step- Step-Two: Crestor
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 Ambien CR, Lunesta, Rozerem, Sonata, Ambien, Edluar, zolpidem/CR, zaleplon Prior use of 1 first line medication in the last Insomnia Prior use of 1 first line medication in the last Neuropathic pain Glucophage XR, Glucophage, Fortamet, Riomet, Prior use of 90 days of therapy of first line Rhinocort Aqua, Beconase AQ, Nasacort AQ, Nasonex, fluticasone propionate, flunisolide, triamcinolone Prior use of 1 first line medication in the last Allergies Flonase, Veramyst, Omnaris, Qnasl, Zetonna, Dymista Non-sedating Antihistamines Clarinex, Clarinex-D, Xyzal loratadine^, loratadine-D^, fexofenadine^, fexofenadine-D^, Prior use of 1 first line medication in the last Allergies cetirizine syrup, cetirizine^, cetirizine-D^, levocetirizine ^ these over-the-counter (OTC) products may not be covered under your prescription benefit Detrol, Detrol LA, Sanctura/XR, Vesicare, Enablex, oxybutynin IR, oxybutynin XL, trospium/XR, tolterodine Prior use of 1 first line medication in the last Overactive Bladder Oxytrol, Ditropan, Ditropan XL, Toviaz, Gelnique Step Two: Nexium, omeprazole-sodium bicarbonate,
omeprazole (Rx or OTC), lansoprazole, pantoprazole Prior use of a Step-One in the last 130 days Stomach acid conditions for a Step-Two Product. Prior use of a Step- Step Three: Aciphex, Dexilant (formerly Kapidex),
Two medication in the last 130 days for a Prilosec/OTC, Protonix, Zegerid/OTC, Prevacid/OTC, target kids 2 years of age and younger.
Declomycin, Adoxa, Monodox, Avidoxy/kit, demeclocycline, doxycycline, minocycline, tetracycline Prior use of 1 first line medication in the last Dermatologic Conditions Adoxa/CK/TT/Pak, Doryx, Vibramycin, Vibra-Tabs, Oraxyl, Periostat, Oracea, Dynacin, Minocin/kit/PAC, Solodyn, Sumycin, Alodox/kit, Morgidox, Ocudox Thiazolidinediones (TZD) Actos, Avandia, Actoplus Met/XR, Avandamet, Prior use of 1 first line medication in the last Antidiabetic metformin/glyburide, metformin, glipizide, metformin/repaglinide, pioglitazone, pioglitazone/metformin Rule 1: Brand topical BPO, antibiotic, etc
Rule 1: Generic topical BPO, antibiotic, etc containing Prior use of first line medication in the last
containing products Rule products Rule 2: Generic
130 days for Rules 1 and 2; Prior use of two 2: Brand topical cleansers Rule 3:
topical cleansers Rule 3: One products in the last 130 days for Rule 3.
****Due to the massive list of medications included in this step therapy, the 2nd line ST medications tab is not populated with these meds, please refer to the BAC for the most complete listing of targets and alternatives.*** FOR INTERNAL USE ONLY
Express Scripts, Inc.
***Most step therapy programs have exception criteria for members taking certain medications and/or medical histories.
Depending on a member's specific medical history, a back-up medication may be approved without a trial of a front-line
medication.***
Step Therapy
Your prescription is for one of
Your program points you to one of
This program looks for
Indication
these targeted step drugs
these first step drugs
Aclovate, Ala-Scalp HP, ApexiCon, Capex, Clobex, alclometasone, amcinonide, betamethasone Prior use of 2 first line medication in the last Dermatologic Conditions Elocon, Halog, Halonate, Florone, Kenalog, Cloderm, Cordran, Locoid, Luxiq, Olux, Pandel, dipropionate, fluocinonide, fluticasone, halobetasol, Psorcon, Derma-Smooth/FS, Dermatop, Texacort, betamethasone valerate, hydrocortisone, clobetasol, Vanos, Diprolene/AF, Verdeso, Desonate, Olux- hydrocortisone butyrate, desonide, desoximetasone, Olux-E, Desowen, Cutivate, Zytopic, Nucort Lotion, hydrocortisone valerate, mometasone, triamcinolone, Florone, Ultravate, Topicort/LP, Lidex, Westcort, Momexin, Pediaderm/TA, Triderm, Scalacort, Samol-HC, Pramosone, Pramosone E, Desonil/kit, Aqua Glycolic HC alclometasone, amcinonide, betamethasone Prior use of 1 first line medication in the last Dermatologic Conditions 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 FOR INTERNAL USE ONLY

Source: http://www.amhic.com/PDF/Rx%20-%20ESI%20-%20Step%20Therapy%20-%20Drug%20List%20-%20%202013%20-%20AMHIC%20-%2010.1.13.pdf