Select Step Therapy Programs January 2016
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- Howard Sims
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2 Anti-infectives Oral Brand Tetracyclines Acticlate, Adoxa, Doryx, Targadox doxycycline Otic Agents Cetraxal Cardiovascular ofloxacin Beta Blockers Coreg CR Calcium Channel Blockers Prestalia Renin-Angiotensin System Agents Azor, Benicar, Benicar HCT, Edarbi, Edarbyclor, Tekturna, Tekturna HCT, Tribenzor Amturnide, Tekamlo Statins Altoprev, Lescol, Lescol XL, Lipitor, Livalo, Mevacor, Pravachol, Zocor Fibric Acid Derivatives Fenoglide, Fibricor, Lofibra, Triglide carvedilol amlodipine, perindopril benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril, benazepril-hctz, captopril-hctz, enalapril-hctz, fosinopril-hctz, lisinopril-hctz, moexipril-hctz, quinapril-hctz, amlodipine-benazepril, trandolaprilverapamil losartan, losartan-hctz, candesartan, candesartan-hctz, irbesartan, irbesartan-hctz, telmisartan benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril, benazepril-hctz, captopril-hctz, enalapril-hctz, fosinopril-hctz, lisinopril-hctz, moexipril-hctz, quinapril-hctz, amlodipine-benazepril, trandolaprilverapamil losartan, losartan-hctz, candesartan, candesartan-hctz, irbesartan, irbesartan-hctz, telmisartan Tekturna, Tekturna HCT atorvastatin, fluvastatin, fluvastatin ER, lovastatin, pravastatin, simvastatin Crestor, Vytorin fenofibric cap, fenofibrate tab, fenofibrate micronized cap, fenofibric acid tab Lipofen Updated 11/10/2015 Page 1 of 6
3 Antianginals Ranexa Central Nervous System ADHD Agents Adderall XR #, Aptensio XR #, Concerta #, Daytrana #, Desoxyn #, Evekeo #, Focalin XR #, Kapvay, Metadate CD #, Methylin #, Methylin Chew #, Procentra #, Quillivant #, Ritalin LA #, Zenzedi # Analgesic Packs DermacinRx Inflammatral Pak, Derma SilkRx DermacinRx Analgesic Combopak acebutolol, amlodipine, amlodipine-benazepril, amlodipinetelmisartan, amlodipine-valsartan, atenolol, bextaxolol, bisoprolol, carvedilol, diltiazem, diltiazem ER, felodipine ER, isosorbide dinitrate ER, isosorbide mononitrate ER, isradipine, metoprolol, metoprolol ER, nadolol, nicardipine, nifedipine, nisoldipine SR, nitroglycerin ER, pindolol, propranolol, propranolol SR, timolol, trandolapril-verapamil, verapamil, verapamil ER Azor, Bystolic, Cardene SR, Dilatrate SR, Inderal XL, Innopran XL, Levatol amphetamine-dextroamphetamine, dexmethylphenidate, dextroamphetamine SR, methylphenidate, methylphenidate ER Vyvanse ranitidine AND any one of the following generics: diclofenac, diclofenac ER lidocaine patches AND any one of the following generics: diclofenac, diclofenac ER Anticonvulsants* Qudexy XR, Trokendi XR topiramate Antidepressants* Aplenzin # Brintellix #, Viibryd # Fetzima # Antipsychotics* Fanapt #, Geodon #, Invega #, Latuda # bupropion SR bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, paroxetine ER, sertraline, venlafaxine, venlafaxine ER Pristiq duloxetine, venlafaxine, venlafaxine ER Pristiq aripiprazole, olanzapine, quetiapine, risperidone Saphris, Seroquel XR Updated 11/10/2015 Page 2 of 6
4 Dementia Agents Namzaric # donepezil AND any one of the following generics or preferred brands: memantine Namenda XR Insomnia Agents Belsomra # Edluar #, Intermezzo #, Zolpimist # eszopiclone, temazepam, zaleplon, zolpidem, zolpidem CR zolpidem, zolpidem CR Migraine Agents Treximet # rizatriptan, sumatriptan, zolmitriptan Narcotic Analgesics Tramadol ER # tramadol, tramadol-acetaminophen Neurologic Agents Gralise # Savella # gabapentin amitriptyline, cyclobenzaprine, duloxetine Lyrica Non-Narcotic Analgesics Tivorbex Any two of the following generics: diclofenac, diclofenac CR, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin Parkinson s Disease Rytary carbidopa-levodopa, carbidopa-levodopa CR Women s Health Brisdelle # Dermatology Miscellaneous DermacinRx Silapak, Derma SilkRx SDS Pak esterified estrogens-methyltestosterone, estradiol, estradiolnorethindrone, estropipate, paroxetine, fluoxetine triamcinolone cream 0.1% Skin Cancer Agents Picato Topical Immunomodulators Elidel fluorouracil, imiquimod alclometasone, amcinonide, betamethasone, clobetasol, clocortolone, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide, fluticasone, halobetasol, hydrocortisone, mometasone, prednicarbate, triamcinolone, pramoxine-hc, calcipotrienebetamethasone Updated 11/10/2015 Page 3 of 6
5 Endocrinology Basal Insulin Toujeo, Tresiba, Ryzodeg Both of the following preferred brands: Lantus, Levemir Diabetic Agents Actoplus Met XR glipizide-metformin, glyburide-metformin Diabetic Agents Glyset chlorpropamide, glimepiride, glipizide, glyburide, pioglitazone, tolazamide, tolbutamide Bydureon, Byetta, Victoza OR any one of the following generics: glipizide-metformin, glyburide-metformin, pioglitazone-glimepiride, pioglitazone-metformin Diabetic Test Strips Abbott #, Acon #, At Last #, Bayer #, Embrace #, EPS #, Fora Care #, Accu-Check, Onetouch Glucocard #, Gmate #, Liberty #, Neutek #, Quintet #, Relion #, Reveal #, Supreme #, True Metrix #, Truetest #, Truetrack #, Ultima #, Unistrip # DPP4 Inhibitors GLP-1 Agonists Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza Jentadueto, Kazano, Nesina, Oseni, Tradjenta Bydureon, Byetta, Victoza chlorpropamide, glimepiride, glipizide, glipizide-metformin, glyburide, glyburide-metformin, tolazamide, tolbutamide Bydureon, Byetta, Victoza Janumet, Janumet XR, Januvia Kombiglyze XR, Onglyza chlorpropamide, glimepiride, glipizide, glipizide-metformin, glyburide, glyburide-metformin, tolazamide, tolbutamide Updated 11/10/2015 Page 4 of 6
6 GLP-1 Agonists SGLT2 Inhibitors SGLT2 Inhibitors Tanzeum, Trulicity Invokamet, Invokana, Jardiance, Synjardy Bydureon, Byetta Victoza chlorpropamide, glimepiride, glipizide, glipizide-metformin, glyburide, glyburide-metformin, tolazamide, tolbutamide Bydureon, Byetta, Victoza Farxiga, Glyxambi, Xigduo XR Invokamet, Invokana Jardiance, Synjardy Short-Acting Insulin Apidra Gastroenterology Humalog, Novolog Constipation Agents Amitiza #, Linzess # lactulose, polyethylene glycol Gastroprotective Agents Duexis # diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin Irritable Bowel Syndrome Apriso, Asacol HD, Delzicol Pancreatic Enzymes Proton Pump Inhibitors Miscellaneous Pancreaze, Pertzye, Ultresa, Viokace Aciphex #, esomeprazole strontium #, First-Lansoprazole, First-Omeprazole, Prevacid #, Prilosec #, Protonix #, Zegerid # Helidac, Prevpac Lialda Both of the following preferred brands: Creon, Zenpep esomeprazole, omeprazole, lansoprazole, pantoprazole Dexilant Omeclamox-Pak, Pylera Antigout Agents Mitigare Uloric Colcrys allopurinol Updated 11/10/2015 Page 5 of 6
7 Ophthalmology Ophthalmic Antihistamines Bepreve, Lastacaft Respiratory azelastine Pataday, Patanol Epinephrine Auto Injectors Adrenaclick, Auvi-Q, epineprhine Epipen, Epipen-Jr Inhaled Corticosteroids Alvesco #, Asmanex # Any two of the following preferred brands: Inhaled Cystic Fibrosis Agents Kitabis, Tobi, Tobi Podhaler Arnuity Ellipta, Flovent, Pulmicort Flexhaler, QVAR Bethkis Leukotriene Modifiers Zyflo, Zyflo CR Long-Acting Bronchodilators Long-Acting Bronchodilators Long-Acting Bronchodilator Combinations Short-Acting Beta Agonist Inhalers Urology Arcapta # Striverdi Respimat # Dulera # Proventil HFA #, Xopenex HFA # montelukast, zafirlukast Both of the following preferred brands: Foradil, Serevent Advair, Breo Ellipta, Foradil, Serevent, Symbicort Any two of the following preferred brands: Advair, Breo Ellipta, Symbicort Ventolin HFA ProAir BPH Agents Cardura XL Urinary Antispasmodics Detrol, Detrol LA, Myrbetriq, Sanctura, Sanctura XR alfuzosin, doxazosin, tamsulosin, terazosin Rapaflo oxybutynin Gelnique, Oxytrol, Vesicare These agents are also subject to additional step requirements as indicated in table. Quantity limits may also apply. Please refer to the Focused UM document. # Quantity limits may also apply. Please refer to the Select Quantity Limits document. * Applies to new starts only Updated 11/10/2015 Page 6 of 6
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Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
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1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL
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ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
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