2014 Assurant Health Step Therapy Edits Created 11/04/2013; Effective 01/01/2014
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1 2014 Assurant Health Step Therapy Edits Created 11/04/2013; Effective 01/01/2014 Drug Class Restricted Drug Pre-requisite Drugs (Try First) Acne Products Tretin-X topical tretinoin- must try Veltin AND 1 of: Atralin adapalene (Differin) Retin-A clindamycin/benzoyl peroxide gel 1-5% Fabior foam clindamycin/benzoyl peroxide gel 1.2-5% Retin-A Micro/tretinoin micro gel Ziana benzoyl peroxide topical clindamycin topical erythromycin erythromycin/benzoyl peroxide sulfacetamide sulfacetamide/sulfur Benzefoam Ultra 9.8% benzoyl peroxide foam 9.8% Riax 5.5% aerosol foam benzoyl peroxide foam (any strength) Riax 9.5% aerosol foam Acanya % clindamycin/benzoyl peroxide OR Benzaclin 1-5% erythromycin/benzoyl peroxide Benzamycin 5-3% Benzamycin pak 5-3% Duac 1-5% Differin Cream adapalene cream/gel Differin Lotion Differin 0.1% gel Mirvaso 0.33% gel sulfacetamide/sulfur AND metronidazole topical gel, cream, lotion ADHD-Stimulant Adderall, Adderall XR Any 3 of: Concerta amphetamine/dextroamphetamine, Desoxyn amphetamine/dextroamphetamine SR Dexedrine CR dexmethylphenidate, dextroamphetamine, Focalin, Focalin XR methamphetamine, methylphenidate, Metadate CD methylphenidate ER, methylphenidtate SR, Methylin chew, Methylin soln Daytrana, Strattera, Vyvanse ProCentra soln Quillivant XR 25mg/5ml Ritalin, Ritalin LA, Ritalin SR Zenzedi 2.5mg, 7.5mg ADHD-Nonstimulant Intuniv Any 3 of: Kapvay, Kapvay Dose Pack clonidine/er, guanfacine, amphetamine/dextroamphetamine, amphetamine/dextroamphetamine SR dexmethylphenidate, dextroamphetamine, methamphetamine, methylphenidate, methylphenidate ER, methylphenidtate SR, Daytrana, Strattera, Vyvanse
2 Analgesic-NSAID Duexis Try 1 generic NSAID Pennsaid 1.5% soln examples: naproxen, ibuprofen (400mg, 600mg, 800mg), meloxicam, diclofenac, nabumetone, Vimovo etodolac, indomethacin, sulindac Voltaren 1% gel Analgesic-Opioid Exalgo morphine sulfate CR Anaphylaxis Auvi-Q EpiPen or EpiPen JR. Androgens Androderm AndroGel OR Testim Axiron Fortesta Striant Angiotensin II Receptor Blocker Diovan 2 preferred generics AND Micardis/Micardis HCT Anticoagulant Eliquis 2.5mg tab Xarelto AND Pradaxa Eliquis 5mg tab (preferred generics = candesartan, candesartan/hctz, eprosartan, irbesartan, losartan, losartan/hctz, valsartan/hctz) Anticonvulsant Trokendi XR topiramate Lyrica duloxetine- must try AND any 2 of: gabapentin, tramadol, citalopram, escitalopram, fluoxetine, fluvoxamine/sr, paroxetine/er, sertraline, venlafaxine/er,sr, amitriptyline, nortriptyline, cyclobenzaprine/er, carisoprodol, chlozoxazone, metaxolone, orphenadrine, tizanidine, baclofen, methocarbamol, Savella Antidepressant Brintellix Any 3 of: Desvenlafaxine ER tablet budeprion SR, bupropion, bupropion SR/XL, citalopram, escitalopram, Khedezla fluoxetine, fluoxetine weekly, fluoxetine (PMDD), Pristiq Viibryd, Viibryd Kit Aplenzin Forfivo XL Fluoxetine 60mg tablet Pexeva Venlafaxine ER tablet fluvoxamine, fluovoxamine SR, paroxetine, paroxetine ER, mirtazepine, sertraline, venlafaxine, venlafaxine ER (cap), venlafaxine SR (tab) Any 1 of: budeprion SR, bupropion, buproion SR/XL, citalopram, escitalopram, fluoxetine, fluoxetine weekly, fluoxetine (PMDD), fluvoxamine, fluovoxamine SR, paroxetine, paroxetine ER, mirtazepine, sertraline, venlafaxine, venlafaxine ER (cap), venlafaxine SR (tab)
3 Cymbalta duloxetine- must try AND any 2 of: budeprion SR, bupropion, buproion SR/XL, citalopram, escitalopram, fluoxetine, fluoxetine weekly, fluoxetine (PMDD), fluvoxamine, fluovoxamine SR, paroxetine, paroxetine ER, mirtazepine, sertraline, venlafaxine, venlafaxine ER (cap), venlafaxine SR (tab) gabapentin, tramadol, amitriptyline, nortriptyline, cyclobenzaprine/er, carisoprodol, chlozoxazone, metaxolone, orphenadrine, tizanidine, baclofen, methocarbamol, naproxen,nabumetone, ibuprofen (400mg, 600mg, 800mg), meloxicam, diclofenac, etodolac, indomethacin, sulindac Oleptro trazodone Antiparkinson's Mirapex ER pramipexole Antipsychotic Fanapt Try 1 of: olanzapine/odt, quietiapine, risperidone/odt, ziprasidone Invega risperidone OR risperidone ODT Asthma/COPD Advair Diskus, Advair HFA Dulera AND Symbicort Breo Ellipta Advair OR Symbicort Daliresp Try 1 of: albuterol/ipratropium, ipratropium inhalation soluation, Combivent Respimat AND Spiriva AND Symbicort Maxair Autohaler 200 mcg/act ProAir HFA OR Proventil HFA Ventolin HFA Xopenex HFA Xopenex Neb 0.31mg albuterol nebules OR Xopenex Neb 0.63mg albuterol concentrate Xopenex Neb 1.25mg/3ml Xopenex Neb 1.25mg Xopenex Conc Neb 1.25mg/ 0.5ml Bisphosphonate Binostro alendronate AND either Actonel or Atelvia Fosamax +D Boniva tablet ibandronate AND either Actonel or Atelvia Diabetes-oral Invokana tab 100mg Invokana tab 300mg Preferred generic metformin (single or combo) AND preferred generic sulfonylurea (single or combo) AND preferred DPP4 (single or combo) AND one additional TZD, alpha-glucosidase inhibitor or glinide Kazano 12.5mg-500mg Kazano 12.5mg-1000mg Jentadueto AND Kombiglyze AND either Janumet or Janumet XR
4 Diagnostic Tests-BGTS Nesina 6.25mg tab Nesina 12.5mg tab Nesina 25mg tab Oseni 12.5mg-15mg tab Oseni 12.5mg-30mg tab Oseni 12.5mg-45mg tab Oseni 25mg-15mg tab Oseni 25mg-30mg tab Oseni 25mg-45mg tab All non-preferred blood glucose test strips Preferred generic metformin (single or combo) AND Januvia AND Onglyza AND Tradjenta Preferred generic metformin (single or combo) AND pioglitazone in combination with one month Januvia AND Onglyza AND Tradjenta Preferred blood glucose test strip by Johnson & Johnson OR Abbott Laboratories Enzyme Replacement Pertzye Ultresa Creon, Ultrase, Ultrase MT, Zenpep Viokace Fibric Acid Derivatives Antara Any 1 of: Fenoglide tab fenofibrate capsule Fibricor fenofibrate micronized capsule Lipofen fenofibrate tablet Lofibra cap gemfibrozil Lofibra tab choline fenofibrate Lopid fenofibric acid Tricor Triglide Trilipix Gastrointestinal Glycate 1.5mg tablet glycopyrrolate Linzess 1 prescription laxative (example lactulose, PEG 3350) AND Amitiza Glaucoma Zioptan latanaprost Glucocorticoid Rayos prednisone Gout Uloric allopurinol HMG CoA Reductase Inhibitors Altoprev lovastatin Lipitor atorvastatin AND simvastatin AND either Crestor or Liptruzet Lescol XL 80mg tablet atorvastatin AND simvastatin AND fluvastatin AND either Crestor or Liptruzet HMG and Calcium Channel Blocker Combinations Caduet amlodipine/atorvastatin
5 Hyperlipidemia Hypertension Juxtapid 5mg cap Juxtapid 10mg cap Juxtapid 20mg cap Vecamyl 10mg tab atorvastatin AND Crestor AND one of: Zetia, bile sequestrant or niacin Triple drug combination from the preferred alternatives from these drug classes: Azor Twynsta Benicar Edarbi Benicar HCT Diovan HCT Edarbyclor Tribenzor Nexiclon XR diuretics, angiotensin converting enzyme (ACE) inhibitor, angiotensin II receptor antagonist (ARB), beta-blocker (BB) or calcium channel blocker (CaB) candesartan, eprosartan, irbesartan, losartan in combination with amlodipine or Exforge as a single entity or hydrochlorothiazide combination product candesartan, eprosartan, irbesartan, losartan AND either: Micardis or Micardis HCT candesartan/hctz, eprosartan/hctz, irbesartan/hctz, losartan/hctz, valsartan/hctz AND Micardis HCT candesartan/hctz, eprosartan/hctz, irbesartan/hctz, losartan/hctz, valsartan/hctz in combination with amlodipine, Exforge HCT clonidine Insulin Novolin 70/30 Humulin 70/30 Relion 70/30 Novolin R Humulin R Relion R Novolin N Humulin N Relion N Migraine Axert Any 3 of: Frova naratriptan, rizatriptan/mlt, Relpax sumatriptan, zolmitriptan/odt Sumavel
6 Treximet naproxen- must try AND any 3 of: naratriptan, rizatriptan/mlt, sumatriptan, zolmitriptan/odt Muscle Relaxant Amrix cyclobenzaprine or cyclobenzaprine ER- must try Fexmid AND any 1 of: baclofen, carisoprodol, carisoprodol w/asa, carisoprodol w/codeine, chlorzoxazone, methocarbamol, orphenadrine ER, orphenadrine cpd, tizanidine Nasal Steroids Rhinocort Flonase (fluticasone) Nasacort Nasonex Zetonna Veramyst Narcotic Partial Opioid Suboxone sublingual film buprenorphine/naloxone sublingual tablet Zubsolv sublingual tablet Nephrotic Cystinosis Procysbi Cystagon Ophthalmics-miscellaneous Patanol Pataday Phosphate Binder Renagel Renvela Pulmonary Arterial Hypertension Adempas Try 1 of: (PAH) sildenafil, Revatio, Adcirca AND either Letairis or Tracleer Opsumit Letairis OR Tracleer Proton Pump Inhibitors Prilosec 10mg Must try all 5: Prilosec 20mg Rx Nexium AND Dexilant AND lansoprazole AND Prilosec 40mg pantoprazole AND Prilosec powder 2.5mg either omeprazole/sodium or omeprazole Prilosec powder 10mg Zegerid AcipHex Protonix 20mg Protonix 40mg Protonix pack Prevacid 30mg Prevacid SoluTab Esomeprazole strontium capsule Sedative/Hypnotic Edluar zolpidem OR zolpidem ER Intermezzo Rozerem Sonata Zolpimist spray Silenor doxepin AND either zolpidem or zolpidem ER Urinary Antispasmodics Detrol LA Try 1 of: Myrbetriq oxybutynin/er, tolteridine/er, trospium/er Oxytrol 3.9mg/24hr patch (male AND either Enablex or Vesicare only) Female coverage excludedavailable OTC Toviaz Detrol tolterodine
7 Ditropan XL Sanctura Sanctura XR oxybutynin ER trospium trospium ER
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