2011 Medicare National Preferred 4 Tier Step Therapy Criteria · Updated: 08/2011 27...

Updated: 08/2011 1

2011 Medicare National Preferred 4 Tier Step Therapy Criteria

ANTIDEPRESSANTS - SSRI (SARAFEM) ................................................................... 26

fluoxetine.................................................................................................................... 26

SARAFEM® ............................................................................................................... 26

ANTIDEPRESSANTS-BUPROPION ............................................................................. 27

bupropion ................................................................................................................... 27

APLENZIN® ............................................................................................................... 27

WELLBUTRIN SR® ................................................................................................... 27

WELLBUTRIN XL® .................................................................................................... 27

BILE ACID SEQUESTRANTS ....................................................................................... 28

cholestyramine/aspartame ......................................................................................... 28

COLESTID® .............................................................................................................. 28

colestipol .................................................................................................................... 28

QUESTRAN® ............................................................................................................ 28

WELCHOL®............................................................................................................... 28

BRAND NSAIDS ........................................................................................................... 29

diclofenac potassium ................................................................................................. 29

diclofenac sodium ...................................................................................................... 29

etodolac ..................................................................................................................... 29

fenoprofen .................................................................................................................. 29

flurbiprofen ................................................................................................................. 29

ibuprofen .................................................................................................................... 29

indomethacin .............................................................................................................. 29

ketoprofen .................................................................................................................. 29

Updated: 08/2011 2

ketorolac .................................................................................................................... 29

lansoprazole ............................................................................................................... 29

meclofenamate .......................................................................................................... 29

mefenamic acid .......................................................................................................... 29

meloxicam .................................................................................................................. 29

nabumetone ............................................................................................................... 29

naproxen .................................................................................................................... 29

naproxen sodium ....................................................................................................... 29

omeprazole ................................................................................................................ 29

oxaprozin ................................................................................................................... 29

pantoprazole .............................................................................................................. 29

piroxicam.................................................................................................................... 29

sulindac ...................................................................................................................... 29

tolmetin ...................................................................................................................... 29

ANAPROX DS® ......................................................................................................... 29

ANAPROX® ............................................................................................................... 29

ARTHROTEC 50® ..................................................................................................... 29

ARTHROTEC 75® ..................................................................................................... 29

CATAFLAM® ............................................................................................................. 29

CLINORIL® ................................................................................................................ 29

DAYPRO® ................................................................................................................. 29

EC-NAPROSYN® ...................................................................................................... 29

FELDENE® ................................................................................................................ 29

FLECTOR®................................................................................................................ 29

INDOCIN® ................................................................................................................. 29

Updated: 08/2011 3

MOBIC® .................................................................................................................... 29

NALFON® .................................................................................................................. 29

NAPRELAN® ............................................................................................................. 29

NAPROSYN® ............................................................................................................ 29

PENNSAID® .............................................................................................................. 29

PONSTEL® ............................................................................................................... 29

VIMOVO® .................................................................................................................. 29

VOLTAREN® ............................................................................................................. 29

VOLTAREN-XR® ....................................................................................................... 29

ZIPSOR® ................................................................................................................... 29

CCB - DIHYDROPYRIDINES ........................................................................................ 31

amlodipine.................................................................................................................. 31

benazepril/amlodipine besylate .................................................................................. 31

felodipine.................................................................................................................... 31

isradipine.................................................................................................................... 31

nicardipine.................................................................................................................. 31

nifedipine.................................................................................................................... 31

nisoldipine .................................................................................................................. 31

ADALAT CC® ............................................................................................................ 31

DYNACIRC CR® ....................................................................................................... 31

NORVASC®............................................................................................................... 31

PROCARDIA XL® ...................................................................................................... 31

PROCARDIA® ........................................................................................................... 31

SULAR® .................................................................................................................... 31

CCB - VERAPAMIL ....................................................................................................... 32

Updated: 08/2011 4

verapamil ................................................................................................................... 32

CALAN SR® .............................................................................................................. 32

CALAN® .................................................................................................................... 32

COVERA-HS® ........................................................................................................... 32

ISOPTIN SR® ............................................................................................................ 32

VERELAN PM® ......................................................................................................... 32

VERELAN® ............................................................................................................... 32

COX-2 ........................................................................................................................... 33

ANAPROX DS® ......................................................................................................... 34

ANAPROX® ............................................................................................................... 34

CATAFLAM® ............................................................................................................. 34

CLINORIL® ................................................................................................................ 34

DAYPRO® ................................................................................................................. 34

diclofenac potassium ................................................................................................. 34

diclofenac sodium ...................................................................................................... 34

EC-NAPROSYN® ...................................................................................................... 34

etodolac ..................................................................................................................... 34

FELDENE® ................................................................................................................ 34

fenoprofen .................................................................................................................. 34

flurbiprofen ................................................................................................................. 34

ibuprofen .................................................................................................................... 34

INDOCIN® ................................................................................................................. 34

indomethacin .............................................................................................................. 34

ketoprofen .................................................................................................................. 34

ketorolac .................................................................................................................... 34

Updated: 08/2011 5

meclofenamate .......................................................................................................... 34

mefenamic acid .......................................................................................................... 34

meloxicam .................................................................................................................. 34

MOBIC® .................................................................................................................... 34

nabumetone ............................................................................................................... 34

NALFON® .................................................................................................................. 34

NAPRELAN® ............................................................................................................. 34

NAPROSYN® ............................................................................................................ 34

naproxen .................................................................................................................... 34

naproxen sodium ....................................................................................................... 34

oxaprozin ................................................................................................................... 34

piroxicam.................................................................................................................... 34

PONSTEL® ............................................................................................................... 34

sulindac ...................................................................................................................... 34

tolmetin ...................................................................................................................... 34

VOLTAREN® ............................................................................................................. 34

VOLTAREN-XR® ....................................................................................................... 34

ZIPSOR® ................................................................................................................... 34

CELEBREX® ............................................................................................................. 34

ENHANCED ACE-I/ARB ............................................................................................... 36

benazepril .................................................................................................................. 36


benazepril/hctz ........................................................................................................... 36

captopril ..................................................................................................................... 36

captopril/hctz .............................................................................................................. 36

Updated: 08/2011 6

enalapril ..................................................................................................................... 36

enalapril maleate/hctz ................................................................................................ 36

fosinopril..................................................................................................................... 36

fosinopril/hctz ............................................................................................................. 36

lisinopril ...................................................................................................................... 36

lisinopril/hctz .............................................................................................................. 36

losartan ...................................................................................................................... 36

losartan /hctz .............................................................................................................. 36

moexipril..................................................................................................................... 36

moexipril/hctz ............................................................................................................. 36

perindopril erbumine .................................................................................................. 36

quinapril ..................................................................................................................... 36

quinapril/hctz .............................................................................................................. 36

ramipril ....................................................................................................................... 36

trandolapril ................................................................................................................. 36

AZOR® ...................................................................................................................... 36

BENICAR HCT® ........................................................................................................ 36

BENICAR® ................................................................................................................ 36

DIOVAN HCT® .......................................................................................................... 36

DIOVAN® .................................................................................................................. 36

EXFORGE HCT® ...................................................................................................... 36

EXFORGE® ............................................................................................................... 36

TRIBENZOR®............................................................................................................ 36

ACCUPRIL® .............................................................................................................. 36

ACCURETIC® ........................................................................................................... 36

Updated: 08/2011 7

ACEON® ................................................................................................................... 36

ALTACE® .................................................................................................................. 36

ATACAND HCT® ....................................................................................................... 36

ATACAND® ............................................................................................................... 36

AVALIDE® ................................................................................................................. 36

AVAPRO® ................................................................................................................. 36

COZAAR® ................................................................................................................. 36

EDARBI® ................................................................................................................... 36

HYZAAR® .................................................................................................................. 36

LOTENSIN HCT® ...................................................................................................... 36

LOTENSIN® .............................................................................................................. 36

LOTREL® .................................................................................................................. 36

MAVIK® ..................................................................................................................... 36

MICARDIS HCT® ...................................................................................................... 36

MICARDIS® ............................................................................................................... 36

MONOPRIL® ............................................................................................................. 36

PRINIVIL® ................................................................................................................. 36

PRINZIDE®................................................................................................................ 36

TARKA® .................................................................................................................... 36

TEVETEN HCT® ....................................................................................................... 36

TEVETEN® ................................................................................................................ 36

TWYNSTA® ............................................................................................................... 36

UNIRETIC® ............................................................................................................... 36

UNIVASC® ................................................................................................................ 36

VASERETIC® ............................................................................................................ 36

Updated: 08/2011 8

VASOTEC® ............................................................................................................... 36

ZESTORETIC® .......................................................................................................... 36

ZESTRIL® ................................................................................................................. 36

ENHANCED ANTIDEPRESSANTS- SNRI .................................................................... 38

citalopram .................................................................................................................. 38

fluoxetine.................................................................................................................... 38

fluvoxamine ................................................................................................................ 38

paroxetine .................................................................................................................. 38

sertraline .................................................................................................................... 38

venlafaxine hcl ........................................................................................................... 38

venlafaxine hcl 100 mg tablet ..................................................................................... 38

venlafaxine hcl 25 mg tablet....................................................................................... 38

venlafaxine hcl 37.5 mg tablet .................................................................................... 38



venlafaxine hcl er 150 mg cap ................................................................................... 38

venlafaxine hcl er 37.5 mg cap .................................................................................. 38

venlafaxine hcl er 75 mg cap ..................................................................................... 38

CYMBALTA® ............................................................................................................. 38

EFFEXOR XR® ......................................................................................................... 38

PRISTIQ® .................................................................................................................. 38

SAVELLA® ................................................................................................................ 38

EFFEXOR® ............................................................................................................... 38

VENLAFAXINE HCL ER 150 mg tab ......................................................................... 38

venlafaxine hcl er 37.5 mg tab ................................................................................... 38

Updated: 08/2011 9

venlafaxine hcl er 75 mg tab ...................................................................................... 38

VENLAFAXINE HCL ER® ......................................................................................... 38

ENHANCED ANTIDEPRESSANTS- SSRI .................................................................... 40

citalopram .................................................................................................................. 40

fluoxetine.................................................................................................................... 40

fluvoxamine ................................................................................................................ 40

paroxetine .................................................................................................................. 40

sertraline .................................................................................................................... 40

LEXAPRO® ............................................................................................................... 40

VIIBRYD® .................................................................................................................. 40

CELEXA® .................................................................................................................. 40

LUVOX CR® .............................................................................................................. 40

PAXIL CR® ................................................................................................................ 40

PAXIL® ...................................................................................................................... 40

PEXEVA® .................................................................................................................. 40

PROZAC WEEKLY® ................................................................................................. 40

PROZAC® ................................................................................................................. 40

ZOLOFT® .................................................................................................................. 40

ENHANCED BISPHOSPHONATES ORAL ................................................................... 41

alendronate ................................................................................................................ 41

ACTONEL® ............................................................................................................... 41

ATELVIA® ................................................................................................................. 41

BONIVA® ................................................................................................................... 41

FOSAMAX PLUS D® ................................................................................................. 41

FOSAMAX® ............................................................................................................... 41

Updated: 08/2011 10

ENHANCED FENOFIBRATE ........................................................................................ 42

fenofibrate .................................................................................................................. 42

TRICOR® .................................................................................................................. 42

TRILIPIX® .................................................................................................................. 42

ANTARA® .................................................................................................................. 42

FENOGLIDE®............................................................................................................ 42

LIPOFEN® ................................................................................................................. 42

LOFIBRA® ................................................................................................................. 42

TRIGLIDE® ................................................................................................................ 42

ENHANCED NON-SEDATING ANTIHISTAMINES ....................................................... 43

cetirizine ..................................................................................................................... 43

fexofenadine .............................................................................................................. 43

levocetirizine dihydrochlor .......................................................................................... 43

ALLEGRA® ................................................................................................................ 43

CLARINEX® .............................................................................................................. 43

CLARINEX-D 12 HOUR® .......................................................................................... 43

CLARINEX-D 24 HOUR® .......................................................................................... 43

XYZAL® ..................................................................................................................... 43

ENHANCED OVERACTIVE BLADDER ........................................................................ 44

oxybutynin .................................................................................................................. 44

trospium chloride ........................................................................................................ 44

ENABLEX® ................................................................................................................ 44

GELNIQUE® .............................................................................................................. 44

SANCTURA XR® ....................................................................................................... 44

DETROL LA® ............................................................................................................ 44

Updated: 08/2011 11

DETROL® .................................................................................................................. 44

DITROPAN XL® ........................................................................................................ 44

OXYTROL® ............................................................................................................... 44

SANCTURA®............................................................................................................. 44

TOVIAZ® ................................................................................................................... 44

VESICARE® .............................................................................................................. 44

ENHANCED SEDATIVE HYPNOTICS .......................................................................... 45

zaleplon ..................................................................................................................... 45

zolpidem..................................................................................................................... 45

AMBIEN CR® ............................................................................................................ 45

LUNESTA® ................................................................................................................ 45

ROZEREM® .............................................................................................................. 45

AMBIEN® .................................................................................................................. 45

EDLUAR® .................................................................................................................. 45

SILENOR® ................................................................................................................ 45

SONATA® ................................................................................................................. 45

ZOLPIMIST® ............................................................................................................. 45

HMG RULE 1 ................................................................................................................ 46

lovastatin .................................................................................................................... 46

pravastatin ................................................................................................................. 46

simvastatin ................................................................................................................. 46

CRESTOR® ............................................................................................................... 46

VYTORIN® ................................................................................................................ 46

HMG RULE 2 ................................................................................................................ 47

CRESTOR® ............................................................................................................... 47

Updated: 08/2011 12

VYTORIN® ................................................................................................................ 47

CADUET® ................................................................................................................. 47

LIPITOR® .................................................................................................................. 47

HMG RULE 3 ................................................................................................................ 48

CRESTOR® ............................................................................................................... 48

lovastatin .................................................................................................................... 48

pravastatin ................................................................................................................. 48

simvastatin ................................................................................................................. 48

VYTORIN® ................................................................................................................ 48

ALTOPREV® ............................................................................................................. 48

CADUET® ................................................................................................................. 48

LESCOL XL® ............................................................................................................. 48

LESCOL® .................................................................................................................. 48

LIPITOR® .................................................................................................................. 48

LIVALO® .................................................................................................................... 48

MEVACOR® .............................................................................................................. 48

PRAVACHOL® .......................................................................................................... 48

ZOCOR® ................................................................................................................... 48

KEPPRA ........................................................................................................................ 49

levetiracetam .............................................................................................................. 49

KEPPRA XR® ............................................................................................................ 49

KEPPRA® .................................................................................................................. 49

LAMICTAL ..................................................................................................................... 50

lamotrigine ................................................................................................................. 50

LAMICTAL (BLUE)® .................................................................................................. 50

Updated: 08/2011 13

LAMICTAL (GREEN)® ............................................................................................... 50

LAMICTAL (ORANGE)® ............................................................................................ 50

LAMICTAL ODT® ...................................................................................................... 50

LAMICTAL XR (BLUE)® ............................................................................................ 50

LAMICTAL XR (GREEN)® ......................................................................................... 50

LAMICTAL XR (ORANGE)® ...................................................................................... 50

LAMICTAL XR® ......................................................................................................... 50

LAMICTAL® ............................................................................................................... 50

LONG ACTING OPIOIDS .............................................................................................. 51

morphine .................................................................................................................... 51

AVINZA® ................................................................................................................... 51

EMBEDA® ................................................................................................................. 51

EXALGO® ................................................................................................................. 51

KADIAN® ................................................................................................................... 51

MS CONTIN® ............................................................................................................ 51

OPANA ER® .............................................................................................................. 51

ORAMORPH SR® ..................................................................................................... 51

OXYCONTIN® ........................................................................................................... 51

LYRICA ......................................................................................................................... 52

gabapentin ................................................................................................................. 52

NEURONTIN® ........................................................................................................... 52

LYRICA® ................................................................................................................... 52

METFORMIN ................................................................................................................ 53

metformin ................................................................................................................... 53

FORTAMET®............................................................................................................. 53

Updated: 08/2011 14

GLUCOPHAGE XR® ................................................................................................. 53

GLUCOPHAGE® ....................................................................................................... 53

GLUMETZA® ............................................................................................................. 53

RIOMET® .................................................................................................................. 53

OPHTHALMIC BETA BLOCKERS ................................................................................ 54

betaxolol..................................................................................................................... 54

carteolol ..................................................................................................................... 54

dorzolamide/timolol .................................................................................................... 54

levobunolol ................................................................................................................. 54

metipranolol ............................................................................................................... 54

timolol ........................................................................................................................ 54

BETAGAN® ............................................................................................................... 54

BETIMOL® ................................................................................................................ 54

BETOPTIC S® ........................................................................................................... 54

COMBIGAN® ............................................................................................................. 54

COSOPT® ................................................................................................................. 54

ISTALOL® ................................................................................................................. 54

OPTIPRANOLOL® .................................................................................................... 54

TIMOPTIC OCUDOSE® ............................................................................................ 54

TIMOPTIC-XE® ......................................................................................................... 54

PPI ENHANCED ........................................................................................................... 55

omeprazole ................................................................................................................ 55

pantoprazole .............................................................................................................. 55

NEXIUM® .................................................................................................................. 55

OMEPRAZOLE/SODIUM bicarbonat ......................................................................... 55

Updated: 08/2011 15

ACIPHEX® ................................................................................................................ 55

DEXILANT® ............................................................................................................... 55

PREVACID® .............................................................................................................. 55

PRILOSEC® .............................................................................................................. 55

PROTONIX®.............................................................................................................. 55

ZEGERID® ................................................................................................................ 55

STAVZOR ..................................................................................................................... 56

divalproex................................................................................................................... 56

valproic acid ............................................................................................................... 56

DEPAKENE® ............................................................................................................. 56

DEPAKOTE ER® ....................................................................................................... 56

DEPAKOTE SPRINKLE® .......................................................................................... 56

DEPAKOTE® ............................................................................................................. 56

STAVZOR® ............................................................................................................... 56

STRATTERA ................................................................................................................. 57

ADDERALL XR® ....................................................................................................... 57

ADDERALL® ............................................................................................................. 57

amphetamine/dextroamphetamine ............................................................................. 57

CONCERTA® ............................................................................................................ 57

d-amphetamine .......................................................................................................... 57

DAYTRANA® ............................................................................................................. 57

DESOXYN® ............................................................................................................... 57

DEXEDRINE® ........................................................................................................... 57

dexmethylphenidate ................................................................................................... 57

FOCALIN XR® ........................................................................................................... 57

Updated: 08/2011 16

FOCALIN® ................................................................................................................. 57

METADATE CD® ....................................................................................................... 57

methamphetamine ..................................................................................................... 57

METHYLIN® .............................................................................................................. 57

methylphenidate ......................................................................................................... 57

RITALIN LA® ............................................................................................................. 57

RITALIN® .................................................................................................................. 57

RITALIN-SR® ............................................................................................................ 57

VYVANSE® ............................................................................................................... 57

INTUNIV® .................................................................................................................. 57

STRATTERA® ........................................................................................................... 57

TEKTURNA ................................................................................................................... 59

ACCUPRIL® .............................................................................................................. 60

ACCURETIC® ........................................................................................................... 60

ACEON® ................................................................................................................... 60

ALTACE® .................................................................................................................. 60

ATACAND HCT® ....................................................................................................... 60

ATACAND® ............................................................................................................... 60

AVALIDE® ................................................................................................................. 60

AVAPRO® ................................................................................................................. 60

AZOR® ...................................................................................................................... 60

benazepril .................................................................................................................. 60


benazepril/hctz ........................................................................................................... 60

BENICAR HCT® ........................................................................................................ 60

Updated: 08/2011 17

BENICAR® ................................................................................................................ 60

captopril ..................................................................................................................... 60

captopril/hctz .............................................................................................................. 60

COZAAR® ................................................................................................................. 60

DIOVAN HCT® .......................................................................................................... 60

DIOVAN® .................................................................................................................. 60

EDARBI® ................................................................................................................... 60

enalapril ..................................................................................................................... 60

enalapril maleate/hctz ................................................................................................ 60

EXFORGE HCT® ...................................................................................................... 60

EXFORGE® ............................................................................................................... 60

fosinopril..................................................................................................................... 60

fosinopril/hctz ............................................................................................................. 60

HYZAAR® .................................................................................................................. 60

lisinopril ...................................................................................................................... 60

lisinopril/hctz .............................................................................................................. 60

losartan ...................................................................................................................... 60

losartan /hctz .............................................................................................................. 60

LOTENSIN HCT® ...................................................................................................... 60

LOTENSIN® .............................................................................................................. 60

LOTREL® .................................................................................................................. 60

MAVIK® ..................................................................................................................... 60

MICARDIS HCT® ...................................................................................................... 60

MICARDIS® ............................................................................................................... 60

moexipril..................................................................................................................... 60

Updated: 08/2011 18

moexipril/hctz ............................................................................................................. 61

MONOPRIL® ............................................................................................................. 61

perindopril erbumine .................................................................................................. 61

PRINIVIL® ................................................................................................................. 61

PRINZIDE®................................................................................................................ 61

quinapril ..................................................................................................................... 61

quinapril/hctz .............................................................................................................. 61

ramipril ....................................................................................................................... 61

TARKA® .................................................................................................................... 61

TEVETEN HCT® ....................................................................................................... 61

TEVETEN® ................................................................................................................ 61

trandolapril ................................................................................................................. 61

TRIBENZOR®............................................................................................................ 61

TWYNSTA® ............................................................................................................... 61

UNIRETIC® ............................................................................................................... 61

UNIVASC® ................................................................................................................ 61

VASERETIC® ............................................................................................................ 61

VASOTEC® ............................................................................................................... 61

ZESTORETIC® .......................................................................................................... 61

ZESTRIL® ................................................................................................................. 61

AMTURNIDE® ........................................................................................................... 60

TEKAMLO® ............................................................................................................... 60

TEKTURNA HCT® ..................................................................................................... 60

TEKTURNA® ............................................................................................................. 60

VALTURNA® ............................................................................................................. 60

Updated: 08/2011 19

THIAZOLIDINEDIONE .................................................................................................. 62

FORTAMET®............................................................................................................. 62

glipizide/metformin hcl ............................................................................................... 62

GLUCOPHAGE XR® ................................................................................................. 62

GLUCOPHAGE® ....................................................................................................... 62

GLUCOVANCE® ....................................................................................................... 62

GLUMETZA® ............................................................................................................. 62

glyburide/metformin hcl .............................................................................................. 62

JANUMET® ............................................................................................................... 62

KOMBIGLYZE XR® ................................................................................................... 62

METAGLIP® .............................................................................................................. 62

metformin ................................................................................................................... 62

PRANDIMET® ........................................................................................................... 62

RIOMET® .................................................................................................................. 62

ACTOPLUS MET XR® .............................................................................................. 62

ACTOPLUS MET® .................................................................................................... 62

ACTOS® .................................................................................................................... 62

AVANDAMET® .......................................................................................................... 62

AVANDARYL® ........................................................................................................... 62

AVANDIA® ................................................................................................................ 62

DUETACT® ............................................................................................................... 62

TOPICAL CORTICOSTEROIDS ................................................................................... 63

alclometasone ............................................................................................................ 63

amcinonide ................................................................................................................. 63

betameth/propylene glycol ......................................................................................... 63

Updated: 08/2011 20

betamethasone dipropionate ...................................................................................... 63

betamethasone valerate ............................................................................................ 63

clobetasol propionate ................................................................................................. 63

desonide .................................................................................................................... 63

desoximetasone ......................................................................................................... 63

diflorasone ................................................................................................................. 63

fluocinolone acetonide ............................................................................................... 63

fluocinonide ................................................................................................................ 63

fluticasone propionate ................................................................................................ 63

halobetasol propionate ............................................................................................... 63

hydrocortisone ........................................................................................................... 63

hydrocortisone butyrate ............................................................................................. 63

hydrocortisone valerate .............................................................................................. 63

mometasone .............................................................................................................. 63

prednicarbate ............................................................................................................. 63

triamcinolone acetonide ............................................................................................. 63

ACLOVATE® ............................................................................................................. 63

ALA-CORT® .............................................................................................................. 63

ALA-SCALP HP® ....................................................................................................... 63

CARMOL HC® ........................................................................................................... 63

CLOBEX® .................................................................................................................. 63

CLODERM® .............................................................................................................. 63

CORDRAN SP® ........................................................................................................ 63

CORDRAN® .............................................................................................................. 63

CUTIVATE®............................................................................................................... 63

Updated: 08/2011 21

DERMA-SMOOTHE-FS® .......................................................................................... 63

DERMATOP® ............................................................................................................ 63

DESONATE®............................................................................................................. 63

DESOWEN® .............................................................................................................. 63

DIPROLENE AF® ...................................................................................................... 63

DIPROLENE®............................................................................................................ 63

ELOCON® ................................................................................................................. 63

HALOG® .................................................................................................................... 63

KENALOG® ............................................................................................................... 63

LOCOID LIPOCREAM® ............................................................................................ 63

LOCOID® .................................................................................................................. 63

LOKARA® .................................................................................................................. 63

LUXIQ® ..................................................................................................................... 63

OLUX-E® ................................................................................................................... 63

PANDEL® .................................................................................................................. 63

TEMOVATE®............................................................................................................. 63

TOPICORT LP® ........................................................................................................ 63

TOPICORT® .............................................................................................................. 63

U-CORT® .................................................................................................................. 63

ULTRAVATE® ........................................................................................................... 63

VANOS® .................................................................................................................... 63

VERDESO® ............................................................................................................... 63

WESTCORT® ............................................................................................................ 63

TOPICAL IMMUNOMODULATORS .............................................................................. 65

ACLOVATE® ............................................................................................................. 66

Updated: 08/2011 22

ALA-CORT® .............................................................................................................. 66

ALA-SCALP HP® ....................................................................................................... 66

alclometasone ............................................................................................................ 66

amcinonide ................................................................................................................. 66

betameth/propylene glycol ......................................................................................... 66

betamethasone dipropionate ...................................................................................... 66

betamethasone valerate ............................................................................................ 66

CARMOL HC® ........................................................................................................... 66

clobetasol propionate ................................................................................................. 66

CLOBEX® .................................................................................................................. 66

CLODERM® .............................................................................................................. 66

CORDRAN SP® ........................................................................................................ 66

CORDRAN® .............................................................................................................. 66

CUTIVATE®............................................................................................................... 66

DERMA-SMOOTHE-FS® .......................................................................................... 66

DERMATOP® ............................................................................................................ 66

DESONATE®............................................................................................................. 66

desonide .................................................................................................................... 66

DESOWEN® .............................................................................................................. 66

desoximetasone ......................................................................................................... 66

diflorasone ................................................................................................................. 66

DIPROLENE AF® ...................................................................................................... 66

DIPROLENE®............................................................................................................ 66

ELOCON® ................................................................................................................. 66

fluocinolone acetonide ............................................................................................... 66

Updated: 08/2011 23

fluocinonide ................................................................................................................ 66

fluticasone propionate ................................................................................................ 66

halobetasol propionate ............................................................................................... 66

HALOG® .................................................................................................................... 66

hydrocortisone ........................................................................................................... 66

hydrocortisone butyrate ............................................................................................. 66

hydrocortisone valerate .............................................................................................. 66

KENALOG® ............................................................................................................... 66

LOCOID LIPOCREAM® ............................................................................................ 66

LOCOID® .................................................................................................................. 66

LOKARA® .................................................................................................................. 66

LUXIQ® ..................................................................................................................... 66

mometasone .............................................................................................................. 67

OLUX-E® ................................................................................................................... 67

PANDEL® .................................................................................................................. 67

prednicarbate ............................................................................................................. 67

TEMOVATE®............................................................................................................. 67

TOPICORT LP® ........................................................................................................ 67

TOPICORT® .............................................................................................................. 67

triamcinolone acetonide ............................................................................................. 67

U-CORT® .................................................................................................................. 67

ULTRAVATE® ........................................................................................................... 67

VANOS® .................................................................................................................... 67

VERDESO® ............................................................................................................... 67

WESTCORT® ............................................................................................................ 67

Updated: 08/2011 24

ELIDEL® .................................................................................................................... 66

PROTOPIC®.............................................................................................................. 66

ULORIC ......................................................................................................................... 68

allopurinol................................................................................................................... 68

ZYLOPRIM® .............................................................................................................. 68

ULORIC® ................................................................................................................... 68

ULTRAM ....................................................................................................................... 69

tramadol ..................................................................................................................... 69

tramadol/apap ............................................................................................................ 69

RYZOLT® .................................................................................................................. 69

ULTRACET® ............................................................................................................. 69

ULTRAM ER®............................................................................................................ 69

ULTRAM® ................................................................................................................. 69

ZETIA ............................................................................................................................ 70

ADVICOR® ................................................................................................................ 70

ALTOPREV® ............................................................................................................. 70

CADUET® ................................................................................................................. 70

CRESTOR® ............................................................................................................... 70

LESCOL XL® ............................................................................................................. 70

LESCOL® .................................................................................................................. 70

LIPITOR® .................................................................................................................. 70

LIVALO® .................................................................................................................... 70

lovastatin .................................................................................................................... 70

MEVACOR® .............................................................................................................. 70

PRAVACHOL® .......................................................................................................... 70

Updated: 08/2011 25

pravastatin ................................................................................................................. 70

SIMCOR® .................................................................................................................. 70

simvastatin ................................................................................................................. 70

VYTORIN® ................................................................................................................ 70

ZOCOR® ................................................................................................................... 70

ZETIA® ...................................................................................................................... 70

Index ............................................................................................................................. 72

Updated: 08/2011 26

ANTIDEPRESSANTS - SSRI (SARAFEM)

Affected Drugs

STEP 1 DRUGS STEP 2 DRUGS

fluoxetine

SARAFEM®

If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be

given. Step 1 Drug(s): Fluoxetine Hcl, Rapiflux, Selfemra. Step 2 Drug(s): Sarafem.

Authorization may be given for step 2 Sarafem if the patient is currently taking the

requested agent. This step therapy program applies to new utilizers only.

Updated: 08/2011 27

ANTIDEPRESSANTS-BUPROPION

Affected Drugs


bupropion

APLENZIN®

WELLBUTRIN SR®

WELLBUTRIN XL®


given. Step 1 Drug(s): Budeprion Sr, Budeprion Xl, Bupropion Hcl Sr. Step 2 Drug(s):

Aplenzin, Wellbutrin Sr, Wellbutrin XL. Authorization may be given for a step 2 drug if

the patient is currently taking the requested agent. This step therapy program applies to

new utilizers only.

Updated: 08/2011 28

BILE ACID SEQUESTRANTS

Affected Drugs


cholestyramine/aspartame

COLESTID®

colestipol

QUESTRAN®

WELCHOL®


given. Step 1 Drug(s): Cholestyramine, Cholestyramine Light, Colestid, Colestipol Hcl,

Prevalite, Questran, Questran Light. Step 2 Drug(s): Welchol. Authorization may be

given for Welchol if patients have a drug-drug interaction with cholestyramine or

colestipol. Authorization may be given for Welchol in patients who are pregnant.

Authorization may be given for Welchol in patients with type 2 diabetes who are also

using other antidiabetic agents (eg, insulin, metformin, sulfonylurea).

Updated: 08/2011 29

BRAND NSAIDS

Affected Drugs


diclofenac potassium

diclofenac sodium

etodolac

fenoprofen

flurbiprofen

ibuprofen

indomethacin

ketoprofen

ketorolac

lansoprazole

meclofenamate

mefenamic acid

meloxicam

nabumetone

naproxen

naproxen sodium

omeprazole

oxaprozin

pantoprazole

piroxicam

sulindac

tolmetin

ANAPROX DS®

ANAPROX®

ARTHROTEC 50®

ARTHROTEC 75®

CATAFLAM®

CLINORIL®

DAYPRO®

EC-NAPROSYN®

FELDENE®

FLECTOR®

INDOCIN®

MOBIC®

NALFON®

NAPRELAN®

NAPROSYN®

PENNSAID®

PONSTEL®

VIMOVO®

VOLTAREN®

VOLTAREN-XR®

ZIPSOR®

If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be

given. Step 1 Drug(s): Diclofenac Potassium, Diclofenac Sodium, Etodolac, Fenoprofen

Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine,

Lansoprazole, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Omeprazole,

Nabumetone, Naproxen, Naproxen Sodium, Oxaprozin, Pantoprazole Sodium,

Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Anaprox, Anaprox Ds, Arthrotec

50, Arthrotec 75, Cataflam, Clinoril, Daypro, Ec-naprosyn, Feldene, Flector, Indocin,

Indocin Sr, Mobic, Nalfon, Naprelan, Naprosyn, Pennsaid, Ponstel, Vimovo, Voltaren,

Voltaren-XR, Zipsor. Authorization for Vimovo may be given if the patient has claims

history for both pantoprazole sodium, omeprazole, or lansoprazole and a prescription

naproxen or naproxen sodium product. Authorization for a step 2 drug, other than

Vimovo, may be given if the patient has tried two unique generic prescription strength

non-steroidal anti-inflammatory drugs (NSAIDs) for the current condition. Authorization

may be given for Flector, Pennsaid, or Voltaren Gel for patients with difficulty

Updated: 08/2011 30

swallowing or cannot swallow. Authorization may be given for Pennsaid or Voltaren Gel

for patients with a chronic musculoskeletal pain condition (eg, osteoarthritis) in 3 or

fewer joints/sites (ie, hand, wrist, elbow, knee, ankle, or foot each count as 1 joint/site)

who are at risk of NSAID-associated toxicity (eg, previous gastrointestinal [GI] bleed,

history of peptic ulcer disease, impaired renal function, cardiovascular disease,

hypertension, heart failure, elderly patients with impaired hepatic function, or those

taking concomitant anticoagulants).

Updated: 08/2011 31

CCB - DIHYDROPYRIDINES

Affected Drugs


amlodipine

benazepril/amlodipine besylate

felodipine

isradipine

nicardipine

nifedipine

nisoldipine

ADALAT CC®

DYNACIRC CR®

NORVASC®

PROCARDIA XL®

PROCARDIA®

SULAR®


given. Step 1 Drug(s): Afeditab Cr, Amlodipine Besylate, Amlodipine Besylate-

benazepril, Felodipine Er, Isradipine, Nicardipine Hcl, Nifediac Cc, Nifedical Xl,

Nifedipine, Nifedipine Er, Nisoldipine. Step 2 Drug(s): Adalat Cc, Dynacirc Cr, Norvasc,

Procardia, Procardia XL, Sular.

Updated: 08/2011 32

CCB - VERAPAMIL

Affected Drugs


verapamil

CALAN SR®

CALAN®

COVERA-HS®

ISOPTIN SR®

VERELAN PM®

VERELAN®


given. Step 1 Drug(s): Verapamil Er, Verapamil Hcl. Step 2 Drug(s): Calan, Calan Sr,

Covera-hs, Isoptin Sr, Verelan, Verelan PM.

Updated: 08/2011 33

COX-2

Updated: 08/2011 34

Affected Drugs


ANAPROX DS®

ANAPROX®

CATAFLAM®

CLINORIL®

DAYPRO®

diclofenac potassium

diclofenac sodium

EC-NAPROSYN®

etodolac

FELDENE®

fenoprofen

flurbiprofen

ibuprofen

INDOCIN®

indomethacin

ketoprofen

ketorolac

meclofenamate

mefenamic acid

meloxicam

MOBIC®

nabumetone

NALFON®

NAPRELAN®

NAPROSYN®

naproxen

naproxen sodium

oxaprozin

piroxicam

PONSTEL®

sulindac

tolmetin

VOLTAREN®

VOLTAREN-XR®

ZIPSOR®

CELEBREX®


given. Step 1 Drug(s): Anaprox, Anaprox Ds, Cataflam, Clinoril, Daypro, Diclofenac

Updated: 08/2011 35

Potassium, Diclofenac Sodium, Ec-naprosyn, Etodolac, Feldene, Fenoprofen Calcium,

Flurbiprofen, Ibuprofen, Indocin, Indocin Sr, Indomethacin, Ketoprofen, Ketorolac

Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Mobic,

Nabumetone, Nalfon, Naprelan, Naprosyn, Naproxen, Naproxen Sodium, Oxaprozin,

Piroxicam, Ponstel, Sulindac, Tolmetin Sodium, Voltaren, Voltaren-xr, Zipsor. Step 2

Drug(s): Celebrex. This step therapy program will exclude participants with a claims

history of warfarin (Coumadin) within the last 130 days. Authorization for Celebrex may

be given for patients who are currently taking chronic systemic corticosteroid therapy,

warfarin (Coumadin), clopidogrel (Plavix), prasugrel (Effient), dabigatran (Pradaxa),

chronic aspirin therapy, or low molecular weight heparins. Authorization for Celebrex

may be given for patients with reduced platelet counts or other coagulation disorders.

Authorization for Celebrex may be given for patients with familial adenomatous

polyposis (FAP) or attenuated adenomatous polyposis coli (AAPC) who have

adenomatous colorectal polyps. Authorization for Celebrex may be given if used for the

treatment of cancer as part of a cancer-chemotherapy regimen (e. g. , in combination

with chemotherapeutic agents). Authorization for Celebrex may be given for patients

who have had a documented upper gastrointestinal bleed from a duodenal or gastric

ulcer. Authorization for Celebrex may be given for patients with a past hypersensitivity,

anaphylactic or allergic-type reaction (e. g. , erythema, hives, urticaria, angioedema) to

aspirin or NSAIDs [Non-steroidal anti-inflammatory drugs]. Authorization for Celebrex

may be given to patients with aspirin-sensitive asthma (also known as aspirin-induced

asthma, aspirin-exacerbated respiratory disease) or NSAID-induced asthma.

Updated: 08/2011 36

ENHANCED ACE-I/ARB

Affected Drugs

STEP 1 DRUGS STEP 2 DRUGS STEP 3 DRUGS

benazepril

benazepril/amlodipine

besylate

benazepril/hctz

captopril

captopril/hctz

enalapril

enalapril maleate/hctz

fosinopril

fosinopril/hctz

lisinopril

lisinopril/hctz

losartan

losartan /hctz

moexipril

moexipril/hctz

perindopril erbumine

quinapril

quinapril/hctz

ramipril

trandolapril

AZOR®

BENICAR HCT®

BENICAR®

DIOVAN HCT®

DIOVAN®

EXFORGE HCT®

EXFORGE®

TRIBENZOR®

ACCUPRIL®

ACCURETIC®

ACEON®

ALTACE®

ATACAND HCT®

ATACAND®

AVALIDE®

AVAPRO®

COZAAR®

EDARBI®

HYZAAR®

LOTENSIN HCT®

LOTENSIN®

LOTREL®

MAVIK®

MICARDIS HCT®

MICARDIS®

MONOPRIL®

PRINIVIL®

PRINZIDE®

TARKA®

TEVETEN HCT®

TEVETEN®

TWYNSTA®

UNIRETIC®

UNIVASC®

VASERETIC®

VASOTEC®

ZESTORETIC®

ZESTRIL®


given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be

given. Step 1 Drug(s): Amlodipine Besylate-benazepril, Benazepril Hcl, Benazepril Hcl-

hctz, Captopril, Captopril-hydrochlorothiazide, Enalapril Maleate, Enalapril Maleate-hctz,

Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Lisinopril, Lisinopril-hctz, Losartan

Potassium, Losartan-Hydrochlorothiazide, Moexipril Hcl, Moexipril-hydrochlorothiazide,

Updated: 08/2011 37

Perindopril erbumine, Quinapril Hcl, Quinapril-hydrochlorothiazide, Ramipril,

Trandolapril. Step 2 Drug(s): Azor, Benicar, Benicar Hct, Diovan, Diovan Hct, Exforge,

Exforge Hct, Tribenzor. Step 3 Drug(s): Accupril, Accuretic, Aceon, Altace, Atacand,

Atacand Hct, Avalide, Avapro, Cozaar, Edarbi, Hyzaar, Lotensin, Lotensin Hct, Lotrel,

Mavik, Micardis, Micardis Hct, Monopril, Prinivil, Prinzide, Tarka, Teveten, Teveten Hct,

Twynsta, Uniretic, Univasc, Vaseretic, Vasotec, Zestoretic, Zestril. Authorization may be

given for a step 2 or step 3 angiotensin receptor blocker (ARB) or ARB-containing

combination product, without a trial of a step 1 or 2 agent, if the patient was recently

hospitalized and discharged within the previous 30 days for a cardiovascular event (eg,

myocardial infarction, hypertensive emergency, decompensated heart failure) and has

already been started and stabilized on the requested agent. Authorization may be given

for Atacand in children aged less than 6 years.

Updated: 08/2011 38

ENHANCED ANTIDEPRESSANTS- SNRI

Affected Drugs


citalopram

fluoxetine

fluvoxamine

paroxetine

sertraline

venlafaxine hcl

venlafaxine hcl 100 mg

tablet

venlafaxine hcl 25 mg tablet

venlafaxine hcl 37.5 mg

tablet



venlafaxine hcl er 150 mg

cap

venlafaxine hcl er 37.5 mg

cap


cap

CYMBALTA®

EFFEXOR XR®

PRISTIQ®

SAVELLA®

EFFEXOR®

VENLAFAXINE HCL ER

150 mg tab

venlafaxine hcl er 37.5 mg

tab


tab

VENLAFAXINE HCL ER®

If the patient has tried a Step 1 drug, then authorization for a drug in Step 2 drug

may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug

may be given. Step 1 Drug(s): Citalopram, Citalopram Hbr, Fluoxetine Dr, Fluoxetine

Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Paroxetine ER, Rapiflux, Sertraline Hcl,

Venlafaxine Hcl, Venlafaxine Hcl Er. Step 2 Drug(s): Cymbalta, Effexor Xr, Pristiq,

Savella. Step 3 Drug(s): Effexor, Venlafaxine Hcl ER. Patients who have taken a step 2

SNRI [Selective Norepinephrine Reuptake Inhibitor] at any time in the past and

discontinued its use may receive authorization to restart the step 2 SNRI [Selective

Norepinephrine Reuptake Inhibitor] (whichever they used in the past), without a trial of a

step 1 agent. Authorization may be given for a step 2 or 3 SNRI [Selective

Norepinephrine Reuptake Inhibitor] if the patient is currently taking the requested agent.

Authorization may be given for a step 2 SNRI [Selective Norepinephrine Reuptake

Inhibitor], without a trial of a step 1 agent, if the patient is a child or adolescent aged 18

years or less, or the patient has symptoms of suicidal ideation. Authorization may be

given for Cymbalta, without a trial of a step 1 agent, if the patient (men or women) has

symptoms of stress urinary incontinence. Authorization may be given for Cymbalta or

Savella, without a trial of a step 1 agent, if the patient has symptoms of fibromyalgia.

Updated: 08/2011 39

Authorization may be given for Cymbalta, without a trial of a step 1 agent, if the patient

has symptoms of chronic musculoskeletal pain (eg, chronic low back pain or chronic

pain due to osteoarthritis). This step therapy program applies to new utilizers only.

Updated: 08/2011 40

ENHANCED ANTIDEPRESSANTS- SSRI

Affected Drugs


citalopram

fluoxetine

fluvoxamine

paroxetine

sertraline

LEXAPRO®

VIIBRYD®

CELEXA®

LUVOX CR®

PAXIL CR®

PAXIL®

PEXEVA®

PROZAC WEEKLY®

PROZAC®

ZOLOFT®

If the patient has tried two Step 1 drugs, then authorization for a drug in Step 2 drug

may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug

may be given. Step 1 Drug(s): Citalopram, Citalopram Hbr, Fluoxetine Dr, Fluoxetine

Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Paroxetine ER, Rapiflux, Sertraline Hcl. Step

2 Drug(s): Lexapro. Step 3 Drug(s): Celexa, Luvox Cr, Paxil, Paxil Cr, Pexeva, Prozac,

Prozac Weekly, Zoloft. Patients who have taken a step 2 SSRI [Selective Serotonin

Reuptake Inhibitor], Luvox Cr, or Pexeva at any time in the past and discontinued its

use may receive authorization to restart the step 2 SSRI [Selective Serotonin Reuptake

Inhibitor], Luvox Cr, or Pexeva (whichever they used in the past). Authorization may be

given for a step 2 or 3 SSRI [Selective Serotonin Reuptake Inhibitor] if the patient is

currently taking the requested agent. Authorization may be given for a step 2 or 3 SSRI

[Selective Serotonin Reuptake Inhibitor] if the patient is a child or adolescent aged 18

years or less, or has suicidal ideation. Authorization may be given for Lexapro for use in

the management of generalized anxiety disorder (GAD) for patients who have tried

paroxetine HCl immediate release. Authorization may be given for Lexapro for patients

who have tried citalopram or citalopram hbr and who may have a clinically significant

drug interaction with fluoxetine dr/fluoxetine hcl/Rapiflux, fluvoxamine maleate,

sertraline hcl, or paroxetine hcl. This step therapy program applies to new utilizers only.

Updated: 08/2011 41

ENHANCED BISPHOSPHONATES ORAL

Affected Drugs


alendronate

ACTONEL®

ATELVIA®

BONIVA®

FOSAMAX PLUS D®

FOSAMAX®



given. Step 1 Drug(s): Alendronate Sodium. Step 2 Drug(s): Actonel, Actonel With

Calcium, Atelvia, Boniva. Step 3 Drug(s): Fosamax, Fosamax Plus D. Authorization may

be given for Actonel, Actonel with Calcium tablets, or Boniva, if the patient has an

abnormality of the esophagus that delays esophageal emptying (stricture or achalasia).

Authorization may be given for Actonel for use in the management of Paget's disease if

the patient has already started therapy with Actonel. Authorization may be given for

Fosamax oral solution for adult patients with a gastrostomy tube, who cannot swallow,

or who have difficulty swallowing tablets. Authorization may be given for Fosamax oral

solution for children who require an oral solution.

Updated: 08/2011 42

ENHANCED FENOFIBRATE

Affected Drugs


fenofibrate

TRICOR®

TRILIPIX®

ANTARA®

FENOGLIDE®

LIPOFEN®

LOFIBRA®

TRIGLIDE®



given. Step 1 Drug(s): Fenofibrate. Step 2 Drug(s): Tricor, Trilipix. Step 3 Drug(s):

Antara, Fenoglide, Lipofen, Lofibra, Triglide.

Updated: 08/2011 43

ENHANCED NON-SEDATING ANTIHISTAMINES

Affected Drugs


cetirizine

fexofenadine

levocetirizine dihydrochlor

ALLEGRA®

CLARINEX®

CLARINEX-D 12 HOUR®

CLARINEX-D 24 HOUR®

XYZAL®


given. Step 1 Drug(s): Cetirizine Hcl, Fexofenadine Hcl, Levocetirizine Dihydrochloride.

Step 2 Drug(s): Allegra, Clarinex, Clarinex-d 12 Hour, Clarinex-d 24 Hour, Xyzal.

Authorization may be given for Xyzal if the patient is pregnant. Authorization may be

given for Clarinex syrup, Clarinex Reditabs, Allegra suspension, or Xyzal solution if the

patient has difficulty swallowing or cannot swallow (eg, pediatric patients) and the

patient has tried cetirizine syrup or chewable tablets.

Updated: 08/2011 44

ENHANCED OVERACTIVE BLADDER

Affected Drugs


oxybutynin

trospium chloride

ENABLEX®

GELNIQUE®

SANCTURA XR®

DETROL LA®

DETROL®

DITROPAN XL®

OXYTROL®

SANCTURA®

TOVIAZ®

VESICARE®



given. Step 1 Drug(s): Oxybutynin Chloride, Oxybutynin Chloride Er, Trospium Chloride.

Step 2 Drug(s): Enablex, Gelnique, Sanctura Xr. Step 3 Drug(s): Detrol, Detrol La,

Ditropan Xl, Oxytrol, Sanctura, Toviaz, Vesicare. Authorization for Oxytrol or Gelnique

may be given for patients who cannot swallow or who have difficulty swallowing.

Updated: 08/2011 45

ENHANCED SEDATIVE HYPNOTICS

Affected Drugs


zaleplon

zolpidem

AMBIEN CR®

LUNESTA®

ROZEREM®

AMBIEN®

EDLUAR®

SILENOR®

SONATA®

ZOLPIMIST®



given. Step 1 Drug(s): Zaleplon, Zolpidem Tartrate. Step 2 Drug(s): Ambien Cr,

Lunesta, Rozerem. Step 3 Drug(s): Ambien, Edluar, Silenor, Sonata, Zolpimist.

Rozerem will be covered for members equal to or over the age of 65 years. For those

under 65 years of age, the step therapy will apply. Authorization for Rozerem or Silenor

may be given if the patient has a documented history of addiction to controlled

substances. Authorization for Edluar or Zolpimist may be given if the patient has

difficulty swallowing or cannot swallow tablets.

Updated: 08/2011 46

HMG RULE 1

Affected Drugs


lovastatin

pravastatin

simvastatin

CRESTOR®

VYTORIN®


given. Step 1 Drug(s): Lovastatin, Pravastatin Sodium, Simvastatin. Step 2 Drug(s):

Crestor, Vytorin. Authorization may be given for a step 2 drug, if the patient has tried

one step 1 drug, Advicor, or Simcor. Authorization may be given for a step 2 drug, if the

patient at baseline requires a documented 45% or more reduction in LDL-C to meet

NCEP ATP III LDL-C goals. Authorization for Crestor may be given for patients who are

receiving Crestor doses of 10 mg or more per day. Authorization for Vytorin may be

given for patients who are receiving Vytorin doses of 10 mg/20 mg or more per day.

Authorization for a step 2 drug will given on an individual basis for drug-drug

interactions.

Updated: 08/2011 47

HMG RULE 2

Affected Drugs


CRESTOR®

VYTORIN®

CADUET®

LIPITOR®


given. Step 1 Drug(s): Crestor, Vytorin. Step 2 Drug(s): Caduet, Lipitor. Authorization

may be given for a step 2 drug, if the patient has tried one step 1 drug. Authorization for

a step 2 drug will given on an individual basis for drug-drug interactions. Authorization

for Lipitor 80 mg may be given for patients who have had an acute coronary syndrome

(ACS) (eg, myocardial infarction [with or without electrocardiograph evidence of ST-

segment elevation] or high-risk unstable angina) and who started therapy with Lipitor 80

mg within 30 days of discharge from the hospital.

Updated: 08/2011 48

HMG RULE 3

Affected Drugs


CRESTOR®

lovastatin

pravastatin

simvastatin

VYTORIN®

ALTOPREV®

CADUET®

LESCOL XL®

LESCOL®

LIPITOR®

LIVALO®

MEVACOR®

PRAVACHOL®

ZOCOR®

If the patient has tried a Step 1 Group A and a Step 1 Group B drug, then

authorization for a Step 2 drug may be given. Step 1 Group A Drug(s): Lovastatin,

Pravastatin Sodium, Simvastatin. Step 1 Group B Drug(s): Crestor, Vytorin. Step 2

Drug(s): Altoprev, Caduet, Lescol, Lescol Xl, Lipitor, Livalo, Mevacor, Pravachol, Zocor.

Authorization for a step 2 drug will given on an individual basis for drug-drug

interactions. Authorization for a Step 2 drug may be given if the patient has tried Advicor

or Simcor and a Step 1 Group B drug. Authorization may be given for Lipitor, if the

patient at baseline requires a documented 45% or more reduction in LDL-C to meet

NCEP ATP III LDL-C goals and has tried a Step 1 Group B drug.

Updated: 08/2011 49

KEPPRA

Affected Drugs


levetiracetam

KEPPRA XR®

KEPPRA®


given. Step 1 Drug(s): Levetiracetam. Step 2 Drug(s): Keppra, Keppra XR. Authorization

may be given for a Step 2 drug if the patient is currently taking (or has taken in the past)

the requested agent. This step therapy program applies to new utilizers only.

Updated: 08/2011 50

LAMICTAL

Affected Drugs


lamotrigine

LAMICTAL (BLUE)®

LAMICTAL (GREEN)®

LAMICTAL (ORANGE)®

LAMICTAL ODT®

LAMICTAL XR (BLUE)®

LAMICTAL XR (GREEN)®

LAMICTAL XR (ORANGE)®

LAMICTAL XR®

LAMICTAL®


given. Step 1 Drug(s): Lamotrigine. Step 2 Drug(s): Lamictal, Lamictal (blue), Lamictal

(green), Lamictal (orange), Lamictal ODT, Lamictal XR, Lamictal XR (blue), Lamictal XR

(green), Lamictal XR (orange). Authorization may be given for a Step 2drug if the

patient is currently taking (or has taken in the past) the requested agent. Authorization

may be given for Lamictal ODT if the patient cannot chew and swallow lamotrigine

chewable dispersible tablets. This step therapy program applies to new utilizers only.

Updated: 08/2011 51

LONG ACTING OPIOIDS

Affected Drugs


morphine

AVINZA®

EMBEDA®

EXALGO®

KADIAN®

MS CONTIN®

OPANA ER®

ORAMORPH SR®

OXYCONTIN®


given. Step 1 Drug(s): Morphine sulfate. Step 2 Drug(s): Avinza, Embeda, Exalgo,

Kadian, MS [Multiple Sclerosis] Contin, Opana Er, Oramorph Sr, Oxycontin.

Authorization may be given for Exalgo or OxyContin if the patient is unable to tolerate or

has a drug allergy noted with morphine sulfate. Authorization may be given for Exalgo

or OxyContin if the patient has renal insufficiency. Authorization may be given for

OxyContin if the patient is pregnant. Authorization may be given for Avinza, Kadian, or

Embeda if the patient cannot swallow or has difficulty swallowing. Authorization may be

given for Avinza or Kadian if the patient has a gastrostomy tube (G-tube).

Updated: 08/2011 52

LYRICA

Affected Drugs


gabapentin

NEURONTIN®

LYRICA®


given. Step 1 Drug(s): Gabapentin, Neurontin. Step 2 Drug(s): Lyrica. Participant must

have 60 days of gabapentin therapy in claims history. Members with a history of the

following drugs within the 130 day look back period are excluded from step therapy for

Lyrica. Seizure Medications - Diazepam, Felbamate, Ethotoin, Phenytoin, Succinimides,

Primidone, Phenobarbital, or Diabetic Medications - Antidiabetic Meds. Authorization for

Lyrica, without a trial of a step 1 agent, may be given for patients with symptoms of

seizure disorder. Authorization for Lyrica may be given if the patient has used

gabapentin or Neurontin for 60 or more days. Authorization for Lyrica may be given if

the patient has used gabapentin or Neurontin for any length of time at a dose 2400

mg/day or more. Authorization for Lyrica may be given if the patient cannot tolerate

gabapentin due to adverse events. Authorization for Lyrica may be given, without a trial

of a step 1 agent, if the patient has symptoms of fibromyalgia. This step therapy

program applies to new utilizers only.

Updated: 08/2011 53

METFORMIN

Affected Drugs


metformin

FORTAMET®

GLUCOPHAGE XR®

GLUCOPHAGE®

GLUMETZA®

RIOMET®


given. Step 1 Drug(s): Metformin Hcl, Metformin Hcl Er. Step 2 Drug(s): Fortamet,

Glucophage, Glucophage Xr, Glumetza, Riomet. Participant must have 60 days of

generic metformin or generic metformin ER in claims history. Authorization may be

given for Riomet patients who are unable to swallow or have difficulty swallowing tablets

containing metformin.

Updated: 08/2011 54

OPHTHALMIC BETA BLOCKERS

Affected Drugs


betaxolol

carteolol

dorzolamide/timolol

levobunolol

metipranolol

timolol

BETAGAN®

BETIMOL®

BETOPTIC S®

COMBIGAN®

COSOPT®

ISTALOL®

OPTIPRANOLOL®

TIMOPTIC OCUDOSE®

TIMOPTIC-XE®


given. Step 1 Drug(s): Betaxolol Hcl, Carteolol Hcl, Dorzolamide-timolol, Levobunolol

Hcl, Metipranolol, Timolol Maleate. Step 2 Drug(s): Betagan, Betimol, Betoptic S,

Combigan, Cosopt, Istalol, Optipranolol, Timoptic Ocudose, Timoptic-XE.

Updated: 08/2011 55

PPI ENHANCED

Affected Drugs


lansoprazole dr 15 mg

capsule

lansoprazole dr 30 mg

capsule

omeprazole

pantoprazole

lansoprazole odt 15 mg

tablet

lansoprazole odt 30 mg

tablet

NEXIUM®

OMEPRAZOLE/SODIUM

bicarbonat

ACIPHEX®

DEXILANT®

PREVACID®

PRILOSEC®

PROTONIX®

ZEGERID®



given. Step 1 Drug(s): Lansoprazole (capsules), Omeprazole, Pantoprazole Sodium.

Step 2 Drug(s): Lansoprazole (ODT tablets), Nexium, Omeprazole-Sodium Bicarbonate.

Step 3 Drug(s): Aciphex, Dexilant, Prevacid, Prilosec, Protonix, Zegerid. Authorization

may be given for Lansoprazole (ODT tablets) or Prevacid SoluTabs for patients with a

feeding tube (eg, nasogastric tube, gastric tube). Authorization may be given for a Step

2 or a Step 3 agent for children less than 2 years old. Authorization may be given for a

step 3 agent, except Prilosec or Zegerid, for patients concomitantly receiving clopidogrel

who have tried a step 1 agent (not required to try step 2 Nexium).

Updated: 08/2011 56

STAVZOR

Affected Drugs


divalproex

valproic acid

DEPAKENE®

DEPAKOTE ER®

DEPAKOTE SPRINKLE®

DEPAKOTE®

STAVZOR®


given. Step 1 Drug(s): Divalproex Sodium, Divalproex Sodium Er, Valproic Acid. Step 2

Drug(s): Depakene, Depakote, Depakote Er, Depakote Sprinkle, Stavzor. Authorization

may be given for a Step 2 drug if the patient is currently taking (or has taken in the past)

the requested agent. This step therapy program applies to new utilizers only.

Updated: 08/2011 57

STRATTERA

Affected Drugs


ADDERALL XR®

ADDERALL®

amphetamine/dextroamphetamine

CONCERTA®

d-amphetamine

DAYTRANA®

DESOXYN®

DEXEDRINE®

dexmethylphenidate

FOCALIN XR®

FOCALIN®

METADATE CD®

methamphetamine

METHYLIN®

methylphenidate

RITALIN LA®

RITALIN®

RITALIN-SR®

VYVANSE®

INTUNIV®

STRATTERA®


given. Step 1 Drug(s): Adderall, Adderall Xr, Amphetamine Salt Combo, Concerta,

Daytrana, Desoxyn, Dexedrine, Dexmethylphenidate Hcl, Dextroamphetamine Sulfate,

Focalin, Focalin Xr, Metadate Cd, Metadate Er, Methamphetamine Hcl, Methylin,

Methylin Er, Methylphenidate Hcl, Methylphenidate Sr, Ritalin, Ritalin La, Ritalin-sr,

Vyvanse. Step 2 Drug(s): Intuniv, Strattera. Authorization for Strattera or Intuniv may be

given for the use of attention deficit hyperactivity disorder (ADHD)/attention deficit

disorder (ADD) if the patient has a documented history of addiction to controlled

substances. Authorization for Strattera or Intuniv may be given for the use of ADHD

[Attention Deficit Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient

has a history of seizures. Authorization for Strattera may be given for the use of ADHD


has co-morbid anxiety. Authorization for Strattera may be given for the use of ADHD


has a history of motor tics or a family history or diagnosis of Tourette's syndrome.

Authorization for Strattera may be given for the use of ADHD [Attention Deficit

Updated: 08/2011 58

Hyperactive Disorder]/ADD [Attention Deficit Disorder] if the patient has hypertension,

heart failure, recent myocardial infarction, or hyperthyroidism.

Updated: 08/2011 59

TEKTURNA

Updated: 08/2011 60

Affected Drugs


ACCUPRIL®

ACCURETIC®

ACEON®

ALTACE®

ATACAND HCT®

ATACAND®

AVALIDE®

AVAPRO®

AZOR®

benazepril

benazepril/amlodipine besylate

benazepril/hctz

BENICAR HCT®

BENICAR®

captopril

captopril/hctz

COZAAR®

DIOVAN HCT®

DIOVAN®

EDARBI®

enalapril

enalapril maleate/hctz

EXFORGE HCT®

EXFORGE®

fosinopril

fosinopril/hctz

HYZAAR®

lisinopril

lisinopril/hctz

losartan

losartan /hctz

LOTENSIN HCT®

LOTENSIN®

LOTREL®

MAVIK®

MICARDIS HCT®

MICARDIS®

moexipril

AMTURNIDE®

TEKAMLO®

TEKTURNA HCT®

TEKTURNA®

VALTURNA®

Updated: 08/2011 61

moexipril/hctz

MONOPRIL®

perindopril erbumine

PRINIVIL®

PRINZIDE®

quinapril

quinapril/hctz

ramipril

TARKA®

TEVETEN HCT®

TEVETEN®

trandolapril

TRIBENZOR®

TWYNSTA®

UNIRETIC®

UNIVASC®

VASERETIC®

VASOTEC®

ZESTORETIC®

ZESTRIL®


given. Step 1 Drug(s): Accupril, Accuretic, Aceon, Altace, Amlodipine Besylate-

benazepril, Atacand, Atacand Hct, Avalide, Avapro, Azor, Benazepril Hcl, Benazepril

Hcl-hctz, Benicar, Benicar Hct, Captopril, Captopril-hydrochlorothiazide, Cozaar,

Diovan, Diovan Hct, Edarbi, Enalapril Maleate, Enalapril Maleate-hctz, Exforge, Exforge

Hct, Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Hyzaar, Lisinopril, Lisinopril-

hctz, Losartan Potassium, Losartan-Hydrochlorothiazide, Lotensin, Lotensin Hct, Lotrel,

Mavik, Micardis, Micardis Hct, Moexipril Hcl, Moexipril-hydrochlorothiazide, Monopril,

Perindopril erbumine, Prinivil, Prinzide, Quinapril Hcl, Quinapril-hydrochlorothiazide,

Ramipril, Tarka, Teveten, Teveten Hct, Trandolapril, Tribenzor, Twynsta, Uniretic,

Univasc, Vaseretic, Vasotec, Zestoretic, Zestril. Step 2 Drug(s): Amturnide, Tekamlo,

Tekturna, Tekturna Hct, Valturna. Authorization for a step 2 drug may be given if the

patient tried an angiotensin converting enzyme (ACE) inhibitor or ACE inhibitor

combination product in the past. Authorization for a step 2 drug may be given if the

patient tried an angiotensin receptor blocker (ARB) or ARB combination product in the

past they are not required to have a trial with an ACE inhibitor.

Updated: 08/2011 62

THIAZOLIDINEDIONE

Affected Drugs


FORTAMET®

glipizide/metformin hcl

GLUCOPHAGE XR®

GLUCOPHAGE®

GLUCOVANCE®

GLUMETZA®

glyburide/metformin hcl

JANUMET®

KOMBIGLYZE XR®

METAGLIP®

metformin

PRANDIMET®

RIOMET®

ACTOPLUS MET XR®

ACTOPLUS MET®

ACTOS®

AVANDAMET®

AVANDARYL®

AVANDIA®

DUETACT®


given. Step 1 Drug(s): Fortamet, Glipizide-metformin, Glucophage, Glucophage Xr,

Glucovance, Glumetza, Glyburide-metformin Hcl, Janumet, Kombiglyze Xr, Metaglip,

Metformin Hcl, Metformin Hcl Er, Prandimet, Riomet. Step 2 Drug(s): Actoplus Met,

Actoplus Met Xr, Actos, Avandamet, Avandaryl, Avandia, Duetact. Authorization may be

given for a step 2 drug if the patient has tried metformin or a metformin-containing

combination product in the past. Authorization may be given for a step 2 drug if the

patient is already started on the requested step 2 drug. Authorization may be given for

Actos, Avandia, Duetact or Avandaryl without a trial of metformin in patients with renal

insufficiency or renal disease. Authorization may be given for Actos, Avandia, Duetact

or Avandaryl without a trial of metformin in patients with cardiomyopathy, heart failure,

unstable angina, or who have experienced a myocardial infarction. Authorization may

be given for Actos, Avandia, Duetact or Avandaryl without a trial of metformin in patients

with a condition (not already noted above) that could potentially increase the risk of

hypoperfusion, hypoxemia, or dehydration. Authorization may be given for Actos,

Avandia, Duetact or Avandaryl without a trial of metformin if the patient has hepatic

impairment or is alcohol dependent. Authorization may be given for Actos, Avandia,

Duetact or Avandaryl without a trial of metformin if the patient has chronic metabolic

acidosis.

Updated: 08/2011 63

TOPICAL CORTICOSTEROIDS

Affected Drugs


alclometasone

amcinonide

betameth/propylene glycol

betamethasone dipropionate

betamethasone valerate

clobetasol propionate

desonide

desoximetasone

diflorasone

fluocinolone acetonide

fluocinonide

fluticasone propionate

halobetasol propionate

hydrocortisone

hydrocortisone butyrate

hydrocortisone valerate

mometasone

prednicarbate

triamcinolone acetonide

ACLOVATE®

ALA-CORT®

ALA-SCALP HP®

CARMOL HC®

CLOBEX®

CLODERM®

CORDRAN SP®

CORDRAN®

CUTIVATE®

DERMA-SMOOTHE-FS®

DERMATOP®

DESONATE®

DESOWEN®

DIPROLENE AF®

DIPROLENE®

ELOCON®

HALOG®

KENALOG®

LOCOID LIPOCREAM®

LOCOID®

LOKARA®

LUXIQ®

OLUX-E®

PANDEL®

TEMOVATE®

TOPICORT LP®

TOPICORT®

U-CORT®

ULTRAVATE®

VANOS®

VERDESO®

WESTCORT®


given. Step 1 Drug(s): Alclometasone Dipropionate, Amcinonide, Betamethasone

Dipropionate, Betamethasone Valerate, Beta-val, Clobetasol Emollient, Clobetasol

Propionate, Cormax, Del-beta, Desonide, Desoximetasone, Diflorasone Diacetate,

Updated: 08/2011 64

Fluocinolone Acetonide, Fluocinonide, Fluocinonide Emollient, Fluticasone Propionate,

Halobetasol Propionate, Hydrocortisone, Hydrocortisone Butyrate, Hydrocortisone

Valerate, Mometasone Furoate, Prednicarbate, Triamcinolone Acetonide, Triderm. Step

2 Drug(s): Aclovate, Ala-cort, Ala-scalp Hp, Carmol Hc, Clobex, Cloderm, Cordran,

Cordran Sp, Cutivate, Derma-smoothe-fs, Dermatop, Desonate, Desowen, Diprolene,

Diprolene Af, Elocon, Halog, Kenalog, Locoid, Locoid Lipocream, Lokara, Luxiq, Olux-e,

Pandel, Temovate, Topicort, Topicort Lp, U-cort, Ultravate, Vanos, Verdeso, Westcort.

Authorization for a step 2 drug may be given if the patient has tried two step 1 drugs for

the current condition.

Updated: 08/2011 65

TOPICAL IMMUNOMODULATORS

Updated: 08/2011 66

Affected Drugs


ACLOVATE®

ALA-CORT®

ALA-SCALP HP®

alclometasone

amcinonide

betameth/propylene glycol

betamethasone dipropionate

betamethasone valerate

CARMOL HC®

clobetasol propionate

CLOBEX®

CLODERM®

CORDRAN SP®

CORDRAN®

CUTIVATE®

DERMA-SMOOTHE-FS®

DERMATOP®

DESONATE®

desonide

DESOWEN®

desoximetasone

diflorasone

DIPROLENE AF®

DIPROLENE®

ELOCON®

fluocinolone acetonide

fluocinonide

fluticasone propionate

halobetasol propionate

HALOG®

hydrocortisone

hydrocortisone butyrate

hydrocortisone valerate

KENALOG®

LOCOID LIPOCREAM®

LOCOID®

LOKARA®

LUXIQ®

ELIDEL®

PROTOPIC®

Updated: 08/2011 67

mometasone

OLUX-E®

PANDEL®

prednicarbate

TEMOVATE®

TOPICORT LP®

TOPICORT®

triamcinolone acetonide

U-CORT®

ULTRAVATE®

VANOS®

VERDESO®

WESTCORT®


given. Step 1 Drug(s): Aclovate, Ala-cort, Ala-scalp Hp, Alclometasone Dipropionate,

Amcinonide, Betamethasone Dipropionate, Betamethasone Valerate, Beta-val, Carmol

Hc, Clobetasol Emollient, Clobetasol Propionate, Clobex, Cloderm, Cordran, Cordran

Sp, Cormax, Cutivate, Del-beta, Derma-smoothe-fs, Dermatop, Desonate, Desonide,

Desowen, Desoximetasone, Diflorasone Diacetate, Diprolene, Diprolene Af, Elocon,

Fluocinolone Acetonide, Fluocinonide, Fluocinonide Emollient, Fluticasone Propionate,

Halobetasol Propionate, Halog, Hydrocortisone, Hydrocortisone Butyrate,

Hydrocortisone Valerate, Kenalog, Locoid, Locoid Lipocream, Lokara, Luxiq,

Mometasone Furoate, Olux-e, Pandel, Prednicarbate, Temovate, Topicort, Topicort Lp,

Triamcinolone Acetonide, Triderm, U-cort, Ultravate, Vanos, Verdeso, Westcort. Step 2

Drug(s): Elidel, Protopic. Authorization may be given for Elidel or Protopic, if the patient

has tried one prescription strength topical corticosteroid in the previous 60 days.

Authorization for Protopic or Elidel may be given for patients requiring drug application

on or around the eyes, eyelids or genitalia.

Updated: 08/2011 68

ULORIC

Affected Drugs


allopurinol

ZYLOPRIM®

ULORIC®


given. Step 1 Drug(s): Allopurinol, Zyloprim. Step 2 Drug(s): Uloric. Authorization may

be given for Uloric if the patient has tried allopurinol at any time in the past.

Authorization may be given for Uloric if the patient has renal insufficiency or decreased

renal function. Authorization may be given for Uloric if the patient is receiving

concomitant medications that have significant drug-drug interactions with allopurinol,

which are not noted with Uloric (eg, cyclosporine, chlorpropamide).

Updated: 08/2011 69

ULTRAM

Affected Drugs


tramadol

tramadol/apap

RYZOLT®

ULTRACET®

ULTRAM ER®

ULTRAM®


given. Step 1 Drug(s): Tramadol Hcl, Tramadol Hcl-acetaminophen. Step 2 Drug(s):

Ryzolt, Ultracet, Ultram, Ultram ER.

Updated: 08/2011 70

ZETIA

Affected Drugs


ADVICOR®

ALTOPREV®

CADUET®

CRESTOR®

LESCOL XL®

LESCOL®

LIPITOR®

LIVALO®

lovastatin

MEVACOR®

PRAVACHOL®

pravastatin

SIMCOR®

simvastatin

VYTORIN®

ZOCOR®

ZETIA®


given. Step 1 Drug(s): Advicor, Altoprev, Caduet, Crestor, Lescol, Lescol Xl, Lipitor,

Livalo, Lovastatin, Mevacor, Pravachol, Pravastatin Sodium, Simcor, Simvastatin,

Vytorin, Zocor. Step 2 Drug(s): Zetia. Authorization of Zetia may be given if the patient

has tried one HMG-CoA reductase inhibitor (statin) or HMG-CoA reductase inhibitor

(statin) combination product or if Zetia is being initiated in combination with an HMG-

CoA reductase inhibitor (statin). Authorization for Zetia may be given if the patient is

taking or will be taking a medication that has a significant drug interaction with any of

the HMG-CoA reductase inhibitors [statins] (eg, cyclosporine, fibrates, niacin more than

1 g/day, itraconazole, ketoconazole, erythromycin, clarithromycin, HIV protease

inhibitors, nefazodone, amiodarone, and verapamil). Authorization of Zetia may be

given if the patient has severe renal impairment (creatinine clearance of 30 mL/minute

or less). Authorization of Zetia may be given if for management of homozygous familial

sitosterolemia. Authorization of Zetia may be given for use in pregnant woman.

Authorization of Zetia may be given if the patient has active liver disease or unexplained

persistent elevations of serum transaminases. Exceptions are NOT recommended for

Zetia for use in patients with moderate or severe hepatic insufficiency. As reviewed by a

pharmacist, authorization for Zetia may be given for use in patients who have been

previously diagnosed with myopathy or rhabdomyolysis (either medication-related or not

Updated: 08/2011 71

medication related) OR the patient has an underlying muscle/muscle-metabolism-

related disorder (eg, myositis, McArdle disease).

Updated: 08/2011 72

INDEX

ACCUPRIL®, 36, 60

ACCURETIC®, 36, 60

ACEON®, 36, 60

ACIPHEX®, 55

ACLOVATE®, 63, 66

ACTONEL®, 41

ACTOPLUS MET XR®, 62

ACTOPLUS MET®, 62

ACTOS®, 62

ADALAT CC®, 31

ADDERALL XR®, 57

ADDERALL®, 57

ADVICOR®, 70

ALA-CORT®, 63, 66

ALA-SCALP HP®, 63, 66

alclometasone, 63, 66

alendronate, 41

ALLEGRA®, 43

allopurinol, 68

ALTACE®, 36, 60

ALTOPREV®, 48, 70

AMBIEN CR®, 45

AMBIEN®, 45

amcinonide, 63, 66

amlodipine, 31

amphetamine/dextroamphetamine, 57

AMTURNIDE®, 60

ANAPROX DS®, 29, 34

ANAPROX®, 29, 34

ANTARA®, 42

APLENZIN®, 27

ARTHROTEC 50®, 29

ARTHROTEC 75®, 29

ATACAND HCT®, 36, 60

ATACAND®, 36, 60

ATELVIA®, 41

AVALIDE®, 36, 60

AVANDAMET®, 62

AVANDARYL®, 62

AVANDIA®, 62

AVAPRO®, 36, 60

AVINZA®, 51

AZOR®, 36, 60

benazepril, 36, 60

benazepril/amlodipine besylate, 31, 36,

60

benazepril/hctz, 36, 60

BENICAR HCT®, 36, 60

BENICAR®, 36, 60

BETAGAN®, 54

betameth/propylene glycol, 63, 66

betamethasone dipropionate, 63, 66

betamethasone valerate, 63, 66

betaxolol, 54

BETIMOL®, 54

BETOPTIC S®, 54

BONIVA®, 41

bupropion, 27

CADUET®, 47, 48, 70

CALAN SR®, 32

CALAN®, 32

captopril, 36, 60

captopril/hctz, 36, 60

CARMOL HC®, 63, 66

carteolol, 54

CATAFLAM®, 29, 34

CELEBREX®, 34

CELEXA®, 40

cetirizine, 43

cholestyramine/aspartame, 28

citalopram, 38, 40

CLARINEX®, 43

CLARINEX-D 12 HOUR®, 43

CLARINEX-D 24 HOUR®, 43

CLINORIL®, 29, 34

clobetasol propionate, 63, 66

CLOBEX®, 63, 66

CLODERM®, 63, 66

Updated: 08/2011 73

COLESTID®, 28

colestipol, 28

COMBIGAN®, 54

CONCERTA®, 57

CORDRAN SP®, 63, 66

CORDRAN®, 63, 66

COSOPT®, 54

COVERA-HS®, 32

COZAAR®, 36, 60

CRESTOR®, 46, 47, 48, 70

CUTIVATE®, 63, 66

CYMBALTA®, 38

d-amphetamine, 57

DAYPRO®, 29, 34

DAYTRANA®, 57

DEPAKENE®, 56

DEPAKOTE ER®, 56

DEPAKOTE SPRINKLE®, 56

DEPAKOTE®, 56

DERMA-SMOOTHE-FS®, 63, 66

DERMATOP®, 63, 66

DESONATE®, 63, 66

desonide, 63, 66

DESOWEN®, 63, 66

desoximetasone, 63, 66

DESOXYN®, 57

DETROL LA®, 44

DETROL®, 44

DEXEDRINE®, 57

DEXILANT®, 55

dexmethylphenidate, 57

diclofenac potassium, 29, 34

diclofenac sodium, 29, 34

diflorasone, 63, 66

DIOVAN HCT®, 36, 60

DIOVAN®, 36, 60

DIPROLENE AF®, 63, 66

DIPROLENE®, 63, 66

DITROPAN XL®, 44

divalproex, 56

dorzolamide/timolol, 54

DUETACT®, 62

DYNACIRC CR®, 31

EC-NAPROSYN®, 29, 34

EDARBI®, 36, 60

EDLUAR®, 45

EFFEXOR XR®, 38

EFFEXOR®, 38

ELIDEL®, 66

ELOCON®, 63, 66

EMBEDA®, 51

ENABLEX®, 44

enalapril, 36, 60

enalapril maleate/hctz, 36, 60

etodolac, 29, 34

EXALGO®, 51

EXFORGE HCT®, 36, 60

EXFORGE®, 36, 60

FELDENE®, 29, 34

felodipine, 31

fenofibrate, 42

FENOGLIDE®, 42

fenoprofen, 29, 34

fexofenadine, 43

FLECTOR®, 29

fluocinolone acetonide, 63, 66

fluocinonide, 63, 66

fluoxetine, 26, 38, 40

flurbiprofen, 29, 34

fluticasone propionate, 63, 66

fluvoxamine, 38, 40

FOCALIN XR®, 57

FOCALIN®, 57

FORTAMET®, 53, 62

FOSAMAX PLUS D®, 41

FOSAMAX®, 41

fosinopril, 36, 60

fosinopril/hctz, 36, 60

gabapentin, 52

GELNIQUE®, 44

Updated: 08/2011 74

glipizide/metformin hcl, 62

GLUCOPHAGE XR®, 53, 62

GLUCOPHAGE®, 53, 62

GLUCOVANCE®, 62

GLUMETZA®, 53, 62

glyburide/metformin hcl, 62

halobetasol propionate, 63, 66

HALOG®, 63, 66

hydrocortisone, 63, 66

hydrocortisone butyrate, 63, 66

hydrocortisone valerate, 63, 66

HYZAAR®, 36, 60

ibuprofen, 29, 34

INDOCIN®, 29, 34

indomethacin, 29, 34

INTUNIV®, 57

ISOPTIN SR®, 32

isradipine, 31

ISTALOL®, 54

JANUMET®, 62

KADIAN®, 51

KENALOG®, 63, 66

KEPPRA XR®, 49

KEPPRA®, 49

ketoprofen, 29, 34

ketorolac, 29, 34

KOMBIGLYZE XR®, 62

LAMICTAL (BLUE)®, 50

LAMICTAL (GREEN)®, 50

LAMICTAL (ORANGE)®, 50

LAMICTAL ODT®, 50

LAMICTAL XR (BLUE)®, 50

LAMICTAL XR (GREEN)®, 50

LAMICTAL XR (ORANGE)®, 50

LAMICTAL XR®, 50

LAMICTAL®, 50

lamotrigine, 50

lansoprazole, 29

lansoprazole dr 15 mg capsule, 55

lansoprazole dr 30 mg capsule, 55

lansoprazole odt 15 mg tablet, 55

lansoprazole odt 30 mg tablet, 55

LESCOL XL®, 48, 70

LESCOL®, 48, 70

levetiracetam, 49

levobunolol, 54

levocetirizine dihydrochlor, 43

LEXAPRO®, 40

LIPITOR®, 47, 48, 70

LIPOFEN®, 42

lisinopril, 36, 60

lisinopril/hctz, 36, 60

LIVALO®, 48, 70

LOCOID LIPOCREAM®, 63, 66

LOCOID®, 63, 66

LOFIBRA®, 42

LOKARA®, 63, 66

losartan, 36, 60

losartan /hctz, 36, 60

LOTENSIN HCT®, 36, 60

LOTENSIN®, 36, 60

LOTREL®, 36, 60

lovastatin, 46, 48, 70

LUNESTA®, 45

LUVOX CR®, 40

LUXIQ®, 63, 66

LYRICA®, 52

MAVIK®, 36, 60

meclofenamate, 29, 34

mefenamic acid, 29, 34

meloxicam, 29, 34

METADATE CD®, 57

METAGLIP®, 62

metformin, 53, 62

methamphetamine, 57

METHYLIN®, 57

methylphenidate, 57

metipranolol, 54

MEVACOR®, 48, 70

MICARDIS HCT®, 36, 60

Updated: 08/2011 75

MICARDIS®, 36, 60

MOBIC®, 29, 34

moexipril, 36, 60

moexipril/hctz, 36, 60

mometasone, 63, 66

MONOPRIL®, 36, 60

morphine, 51

MS CONTIN®, 51

nabumetone, 29, 34

NALFON®, 29, 34

NAPRELAN®, 29, 34

NAPROSYN®, 29, 34

naproxen, 29, 34

naproxen sodium, 29, 34

NEURONTIN®, 52

NEXIUM®, 55

nicardipine, 31

nifedipine, 31

nisoldipine, 31

NORVASC®, 31

OLUX-E®, 63, 66

omeprazole, 29, 55

omeprazole/sodium bicarbonat, 55

OPANA ER®, 51

OPTIPRANOLOL®, 54

ORAMORPH SR®, 51

oxaprozin, 29, 34

oxybutynin, 44

OXYCONTIN®, 51

OXYTROL®, 44

PANDEL®, 63, 66

pantoprazole, 29, 55

paroxetine, 38, 40

PAXIL CR®, 40

PAXIL®, 40

PENNSAID®, 29

perindopril erbumine, 36, 60

PEXEVA®, 40

piroxicam, 29, 34

PONSTEL®, 29, 34

PRANDIMET®, 62

PRAVACHOL®, 48, 70

pravastatin, 46, 48, 70

prednicarbate, 63, 66

PREVACID®, 55

PRILOSEC®, 55

PRINIVIL®, 36, 60

PRINZIDE®, 36, 60

PRISTIQ®, 38

PROCARDIA XL®, 31

PROCARDIA®, 31

PROTONIX®, 55

PROTOPIC®, 66

PROZAC WEEKLY®, 40

PROZAC®, 40

QUESTRAN®, 28

quinapril, 36, 60

quinapril/hctz, 36, 60

ramipril, 36, 60

RIOMET®, 53, 62

RITALIN LA®, 57

RITALIN®, 57

RITALIN-SR®, 57

ROZEREM®, 45

RYZOLT®, 69

SANCTURA XR®, 44

SANCTURA®, 44

SARAFEM®, 26

SAVELLA®, 38

sertraline, 38, 40

SILENOR®, 45

SIMCOR®, 70

simvastatin, 46, 48, 70

SONATA®, 45

STAVZOR®, 56

STRATTERA®, 57

SULAR®, 31

sulindac, 29, 34

TARKA®, 36, 60

TEKAMLO®, 60

Updated: 08/2011 76

TEKTURNA HCT®, 60

TEKTURNA®, 60

TEMOVATE®, 63, 66

TEVETEN HCT®, 36, 60

TEVETEN®, 36, 60

timolol, 54

TIMOPTIC OCUDOSE®, 54

TIMOPTIC-XE®, 54

tolmetin, 29, 34

TOPICORT LP®, 63, 66

TOPICORT®, 63, 66

TOVIAZ®, 44

tramadol, 69

tramadol/apap, 69

trandolapril, 36, 60

triamcinolone acetonide, 63, 66

TRIBENZOR®, 36, 60

TRICOR®, 42

TRIGLIDE®, 42

TRILIPIX®, 42

trospium chloride, 44

TWYNSTA®, 36, 60

U-CORT®, 63, 66

ULORIC®, 68

ULTRACET®, 69

ULTRAM ER®, 69

ULTRAM®, 69

ULTRAVATE®, 63, 66

UNIRETIC®, 36, 60

UNIVASC®, 36, 60

valproic acid, 56

VALTURNA®, 60

VANOS®, 63, 66

VASERETIC®, 36, 60

VASOTEC®, 36, 60

venlafaxine hcl, 38

venlafaxine hcl 100 mg tablet, 38


venlafaxine hcl 37.5 mg tablet, 38



venlafaxine hcl er 150 mg cap, 38

venlafaxine hcl er 150 mg tab, 38

venlafaxine hcl er 37.5 mg cap, 38

venlafaxine hcl er 37.5 mg tab, 38

venlafaxine hcl er 75 mg cap, 38

venlafaxine hcl er 75 mg tab, 38

VENLAFAXINE HCL ER®, 38

verapamil, 32

VERDESO®, 63, 66

VERELAN PM®, 32

VERELAN®, 32

VESICARE®, 44

VIIBRYD®, 40

VIMOVO®, 29

VOLTAREN®, 29, 34

VOLTAREN-XR®, 29, 34

VYTORIN®, 46, 47, 48, 70

VYVANSE®, 57

WELCHOL®, 28

WELLBUTRIN SR®, 27

WELLBUTRIN XL®, 27

WESTCORT®, 63, 66

XYZAL®, 43

zaleplon, 45

ZEGERID®, 55

ZESTORETIC®, 36, 60

ZESTRIL®, 36, 60

ZETIA®, 70

ZIPSOR®, 29, 34

ZOCOR®, 48, 70

ZOLOFT®, 40

zolpidem, 45

ZOLPIMIST®, 45

ZYLOPRIM®, 68

2011 Medicare National Preferred 4 Tier Step Therapy Criteria · Updated: 08/2011 27...

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