Category Second-Line (Targeted) First-Line (Alternative) Most Common Indication
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1 Step therapy requires trial of a step-one drug before a step-two drug will be covered under the plan. If your medical condition warrants, share this list with your doctor and ask her or him to prescribe a step-one drug whenever possible. Contact Express Scripts at with questions about specific drugs. This list is subject to change. Step-one drugs Step-one drugs are less expensive drugs that are known to be safe and effective for most people. Most step-one drugs are generic drugs. (Generic drugs have the lowest copayment.) Step-two drugs Step-two drugs will be denied at your local pharmacy without a claims history of a step-one drug within the past 130 days. In certain situations, your doctor may contact Express Scripts to request authorization of coverage for a step-two drug without use of a step-one drug within the past 130 days. You pay the formulary copayment for formulary steptwo drugs and the non-formulary copayment for non-formulary drugs. New ELCA health plan members Review the step therapy chart below. If you were taking a step-two drug prior to enrolling in the plan, contact an ELCA health care advocate at (800) for help before you use your ELCA benefits to fill a prescription. * Indicates non-formulary drugs. Step Therapy Program Attention Deficit Hyperactivity Disorder (ADHD) Non-Stimulant Most Common Indication Attention Deficit Hyperactivity Disorder (ADHD) Category Second-Line (Targeted) First-Line (Alternative) Generic Strattera, Intuniv, Kapvay* Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Dexedrine, Dexedrine Spansules, Dextroamphetamine IR, Dextroamphetamine SR, dexmethylphenidate IR, Focalin, Focalin XR, Metadate CD, Metadate ER, methamphetamine, Methylin, Methylin ER, methylphenidate ER, methylphenidate immediate release, mixed amphetamine salts IR, Ritalin LA, Ritalin SR, Vyvanse Antiepileptic Drugs (AED) Seizures Generic Rule 1: Stavzor*, Depakote*/ER*/Sprinkle*, Depakene* Rule 2: Lamictal*/XR*/ODT* Rule 3: Keppra*/XR* Rule 4: Trileptal*, Oxtellar XR* Rule 1: valproic acid, divalproic sodium Rule 2: lamotrigine Rule 3: levetiracetam/xr Rule 4: oxcarbazepine This list is subject to change. Page 1 of 5
2 Angiotensin-Receptor Blocker (ARB) Heart and Hypertension Generic Atacand HCT*, Atacand*, Avalide*, Avapro*, Azor, Benicar, Benicar HCT, Cozaar*, Diovan HCT*, Diovan, Exforge, Exforge HCT, Hyzaar*, Twynsta*, Tribenzor benazepril, benazepril/hctz, captopril, captopril/hctz, enalapril, enalapril/hctz, fosinopril, fosinopril/hctz, lisinopril, lisinopril/hctz, ramipril, quinapril, quinapril/hctz, Quinaretic, moexipril, trandolapril, moexipril/hctz, benazepril/amlodipine, perindopril, trandolapril/verapamil, enalapril/felodipine, losartan, losartan/hctz, eprosartan, irbesartan, irbesartan/hctz Avodart Prostate Generic Avodart*, Proscar*, Jalyn* finasteride Conditions Bisphosphonates Osteoporosis Enhanced Fosamax tablets*, Fosamax oral solution*, Fosamax Plus D*, Boniva tablet Step-One: alendronate, ibandronate Step-Two: Actonel, Actonel Plus Calcium, Atelvia, Binosto COX-2 Inhibitors Inflammation Generic Celebrex diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin, diclofenac sodium/misoprostol Fenofibrate High Generic Tricor, Lofibra, Antara, Triglide, Lipofen, Fenoglide, fenofibrate, fenofibric acid Cholesterol Trilipix, Fibricor Gabapentin Inflammation Generic Lyrica, Horizant*, Neurontin*, Gralise gabapentin HMG-CoA Reductase Inhibitor (HMG) High Cholesterol Enhanced Altoprev*, Caduet*, Lescol*/Lescol XL*, Lipitor*, Liptruzet, Livalo*, Mevacor*, Pravachol*, Vytorin, Zocor* Step-One: lovastatin, pravastatin, simvastatin, atorvastatin, fluvastatin, atorvastatin/amlodipine Step-Two: Crestor Before trying a Step-Two drug, please first try a Step-One drug. zolpidem/cr, zaleplon Hypnotics Sleep Disorders Generic Ambien *, Ambien CR*, Lunesta, Rozerem, Sonata*, Edluar*, Silenor*, Zolpimist*, Intermezzo* Long-Acting Opioid Oral Pain Generic MS Contin*, Opana, Opana ER*, OxyContin, Nucynta morphine sustained release, oxymorphone extendedrelease ER Nasal Steroid Allergy Preferred Dymista*, Flonase*, Nasacort AQ* flunisolide, fluticasone, triamcinolone, Nasonex, Qnasl Non-Steroidal Antiinflammatory (NSAID), Inflammation Branded Arthrotec*, Mobic*, Ponstel*, Cataflam*, Voltaren, Voltaren XR, Nalfon*, Motrin, Indocin*, Indocin SR, Naprosyn*, Naprelan*, Anaprox*, Anaprox DS*, Daypro*, Feldene,* Clinoril*, Flector*, Voltaren Gel, Zipsor*, Pennsaid*, Sprix*, Vimovo, Duexis* diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin, diclofenac sodium/misoprostol This list is subject to change. Page 2 of 5
3 Other Antidepressants - Bupropion Other Antidepressants Selective Serotonin Norepinephrine Reuptake Inhibitor (SNRI) Overactive Bladder Proton Pump Inhibitor (PPI) Selective Serotonin Reuptake Inhibitor (SSRI) Depression Generic Wellbutrin SR*/XL*, Aplenzin*, Forfivo XL* bupropion SR, bupropion XL, budeprion SR, budeprion XL Depression Generic Cymbalta, Effexor XR*, Pristiq, Venlafaxine extendedrelease*, Desvenlafaxine ER*, Savella Overactive Bladder Gastrointestinal Conditions fluoxetine, fluvoxamine, paroxetine, citalopram, sertraline, escitalopram, venlafaxine/xr, paroxetine mesylate, vilazodone Preferred Ditropan XL*, Oxytrol, Sanctura*, Sanctura XR* oxybutynin IR/XL, trospium IR/XR, tolterodine IR, Detrol*, Detrol LA, Enablex, Gelnique, Myrbetriq, Toviaz, Vesicare Preferred Rule 1: Aciphex, Dexilant, Esomeprazole Strontium, Rule 1: lansoprazole, omeprazole, omeprazole/sodium Prevacid, Protonix bicarbonate, pantoprazole, Nexium, Prevacid 24HR Rule 2: Prevpac Rule 2: Pylera Within First Line rules, must try a drug included in the previous rule before stepping to the next rule. The same applies with Second Line rules. Depression Generic Brisdelle*, Celexa*, Lexapro*, Luvox CR*, Paxil CR*, Paxil*, Pexeva*, Prozac*, Prozac Weekly*, Sarafem*, Zoloft*, Viibryd fluoxetine/weekly, fluvoxamine, paroxetine, paroxetine CR, citalopram, sertraline, escitalopram Tetracyline Oral Skin Conditions Generic Adoxa*, Monodox*, Avidoxy DK*, Adoxa*, Doryx*, Vibramycin*, Oraxyl, Oracea, Dynacin*, Minocin*/kit*/PAC*, Solodyn, Alodox*, Morgidox* (formulary status varies by product), Ocudox demeclocycline, doxycycline, minocycline, tetracycline Topical Acne Second-Line detail can be found on page 5. Skin Conditions Generic Rule 1 (brand topicals): See full list on page 5. Rule 2 (brand cleansers): Avar*, Benzac*, Desquam X, Lavoclen, Plexion*, Rosanil*, SE BPO, Sumadan*, Sumaxin*, Zencia Rule 3 (brand topical kits): BPO Creamy Wash Complete Pack, Clindacin ETZ, Clindacin PAC*, Rosanil Kit*, Sumadan Kit*, Sumaxin CP Kit*, Zacare* Topical Corticosteroid Skin Conditions Generic Aclovate*, Ala-Scalp*, ApexiCon*, Capex*, Clobex*, Elocon*, Halog*, Kenalog*, Cloderm*, Cordran*, Locoid*, Luxiq*, Olux*, Pandel*, Derma-Smooth/FS*, Dermatop*, Texacort*, Vanos*, Diprolene*/AF*, Rule 1 (generic topicals): azelaic acid, benozyl peroxide, clindamycin, dapsone, erythromycin or sulfacetamide/sulfur-containing products Rule 2 (generic cleansers): benzoyl peroxide, sulfacetamide/sulfur Rule 3: One med from rule 1 AND one med from rule 2 alclometasone, amcinonide, betamethasone dipropionate (augmented), betamethasone dipropionate, fluocinonide, fluticasone, halobetasol, betamethasone valerate, hydrocortisone, clobetasol, hydrocortisone butyrate, This list is subject to change. Page 3 of 5
4 Verdeso*, Desonate*, Olux*, Desowen*, Cutivate*, Nucort*, Ultravate*, Topicort*, Westcort*, Pediaderm*, Triderm, Scalacort, Pramosone* (varies by strength/formulation), Desonil*, Aqua Glycolic HC desonide, desoximetasone, hydrocortisone valerate, mometasone, triamcinolone, diflorasone fluocinolone, pramoxine Topical Immunomodulator Skin Conditions Generic Elidel, Protopic alclometasone, amcinonide, betamethasone dipropionate (augmented), betamethasone dipropionate, clobetasol, clobetasone, fluocinonide, fluticasone, halobetasol, betamethasone valerate, hydrocortisone, hydrocortisone butyrate, hydrocortisone buteprate, hydrocortisone acetate, desonide, desoximetasone, hydrocortisone valerate, mometasone, triamcinolone, diflorasone, fluocinolone, clocortolone, flurandrenolide, halocinonide, prednicarbate Tramadol Pain Generic Ultram*, Ultracet*, Ultram ER*, Ryzolt*, Rybix ODT*, tramadol/er, tramadol/acetaminophen ConZip* Triptan Migraine Generic Amerge*, Axert*, Frova*, Imitrex (oral only)*, Maxalt*/MLT*, Relpax, Treximet, Zomig/ZMT/nasal* naratriptan, rizatriptan, sumatriptan, zolmitriptan This list is subject to change. Page 4 of 5
5 Topical Acne Second-Line Detail Skin Conditions Generic Rule 1 (brand topicals): Benzoyl-Peroxide-containing Products: Creams- Neobenz Micro*, Neobenz Micro SD* Foams- BenzEfoam*, BenzEfoam Ultra*, BenzePrO Gels- Benziq*, Benziq LS*, Desquam X Pads- Inova Easy Pad* Sulfacetamide-containing products- Klaron* Sulfacetamide/sulfur-containing products: Creams- Avar-e*, Avar LS*, Clenia*, Plexion SCT* Suspension- Sumaxin TS* Foam- Clarifoam* Erythromycin products: Solution- Del-Mycin Foam- Emgel* Ointment- Akne-Mycin* Clindamycin-containing products: Pledgets- Cleocin T*, Clindareach* Gel- Cleocin T,* Clindamax*, Clindagel* Foam- Evoclin* Azelalic Acid- Azelex* Dapsone (topical only)- Aczone Other combinations: Acanya, Benzaclin*, Benzamycin*, Benzamycin Pak*, Duac*, Epiduo, Inova Acne Control Therapy*, Nuox*, Veltin, Ziana Rule 1 (generic topicals): azelaic acid benozyl peroxide clindamycin dapsone erythromycin sulfacetamide/sulfur This list is subject to change. Page 5 of 5
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