ClearScript Step Therapy Drug List
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- Britton Lucas
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1 ClearScript Step Therapy Drug List The ClearScript Step Therapy Program requires a trial of one or more first step drugs before a second step or target drug is covered. For example, if two drugs are used to treat the same medical condition, you may be required to first try one drug before the second drug is covered. Some drugs require trials of more than one drug before the target drug is covered. The length of the trial period may vary for prerequisite step drugs. The goal of the ClearScript Step Therapy Program is to promote the cost-effective use of medications based on clinically accepted treatment guidelines, the medical literature and other factors. This list is subject to change throughout the year. The presence of a drug on this list does not guarantee coverage and not all drugs included on this list may be covered by your pharmacy benefit plan. Coverage of medications is determined your benefit plan. Condition/Drug Class Target Drugs Prerequisite Step Drugs Acid Reflux Actinic Keratosis Allergic Anaphylaxis Anti-Bacterial Anti-Bacterial Ears ACIPHEX ESOMEPRAZOLE CAP FIRST-OMEPRA LANSOPRAZOLE SUS OMEPRAZOLE + SUS SYRSPEND PREVACID PRILOSEC PROTONIX ZEGERID OMEPRA/BICAR POW OMEPRA/BICAR POW PICATO TOLAK AUVI-Q ADRENACLICK INJ EPINEPHRINE INJ ACTICLATE ADOXA ADOXA PAK DORYX MONODOX TARGADOX CIPROFLOXACIN CETRAXAL Step 1: Any two of the following: omeprazole, lansoprazole (capsule), pantoprazole, esomeprazole, Dexilant Step 1: Any two of the following: omeprazole, lansoprazole (capsule), pantoprazole, esomeprazole, Dexilant Step 2: Zegerid Step 1: Any one of the following: 1. generic Fluorouracil, 2. generic Imiquimod Step 1: Any Epipen product Step 1: generic doxycycline Step 1: ofloxacin otic Anti-Convulsants GRALISE Step 1: Gabapentin TROKENDI XR Step 1: Any one generic topiramate IR Anti-Depressants BRINTELLIX TRINTELLIX FETZIMA bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, paroxetine ER, sertraline, venlafaxine, venlafaxine ER, Pristiq Step 1: TWO preferred SNRIs. (Example: duloxetine, venlafaxine, Pristiq)
2 Anti-Depressants Continued VIIBRYD Step 1: TWO preferred drugs from the following: SSRIs or SNRIs or bupropion or mirtazapine APLENZIN Step 1: Any preferred generic bupropion product Anti-Psychotic Asthma Attention Deficit Hyperactivity Disorder (ADHD) Cardiovascular Chronic Obstructive Pulmonary Disease (COPD) Cholesterol Cystic Fibrosis BRISDELLE FANAPT LATUDA VRAYLAR ZYFLO ZYFLO CR DULERA ASMANEX ALVESCO PROVENTIL XOPENEX ADDERALL XR ADZENYS XR APTENSIO XR CONCERTA DAYTRANA DESOXYN DEXTROAMPHET SOL DYANAVEL XR EVEKEO FOCALIN XR KAPVAY METADATE CD METHYLIN PROCENTRA QUILLICHEW QUILLIVANT RITALIN ZENZEDI FENOGLIDE FIBRICOR LOFIBRA FENOFIBRATE CAP 200MG CARDURA XL COREG CR ARCAPTA BEVESPI STRIVERDI TUDORZA PRESSAIR UTIBRON NEOHALER ALTOPREV ER LIPITOR LIVALO TOBI PODHALR TOBI NEB TOBRAMYCIN NEB Step 1: Any one of the following: estradiol, paroxetine, fluoxetine Step 1: Any TWO of the following medications on formulary: 1. olanzapine, 2. quetiapine, 3. risperidone/risperidone ODT, 4. Saphris, 5. Seroquel XR, 6. aripiprazole For management of asthma in patients > 12 years of age with the following: Step 1: Any one generic leukotriene modifier (montelukast, zafirlukast) Step 1: TWO of the following: Advair Diskus or Advair HFA, Symbicort, and Breo Ellipta Step 1: TWO of the following: Pulmicort Flexhaler, Flovent, QVAR, Arnuity Ellipta Step 1: TWO of the following: Pulmicort Flexhaler, Flovent, QVAR, Arnuity Ellipta Step 1: Ventolin HFA and Proair HFA/Proair Respiclick amphetamine-dextroamphetamine, dexmethylphenidate, dextroamphetamine SR, methylphenidate, methylphenidate ER, or Vyvanse Step 1: Any one of the following generics: fenofibric cap, fenofibrate tab, fenofibrate micronized cap, fenofibric acid tab AND Lipofen Step 1: Any TWO: 1. doxazosin, 2. terazosin, 3. tamsulosin, 4. Rapaflo, 5. alfuzosin Step 1: Cavedilol (generic Coreg) Step 1: Any two of the following: Advair (Diskus or HFA), Breo Ellipta, Serevent, Symbicort Step 1: Any one of the following preferred brands: Advair, Breo Ellipta, Serevent, or Symbicort AND Spiriva Step 1: Any two of the following: Advair (Diskus or HFA), Breo Ellipta, Serevent, Symbicort Step 1: Both of the following preferred brands: Spiriva and Incruse Ellipta Step 1: Spiriva/Spiriva Respimat, and any one of the following: Advair, Breo Ellipta, Serevent, Symbicort Step 1: Any two of the following generics: atorvastatin, fluvastatin, fluvastatin ER, lovastatin, pravastatin, rosuvastatin, simvastatin Step 1: Bethkis
3 Diabetes Non-preferred Blood Glucose Test Strips Non-Preferred Blood Glucose Meters and Kits ALOG/PIOGLIP ALOGLIPTIN KAZANO KOMBIGLYZE NESINA ONGLYZA OSENI ACTOPLUS AVANDAMET AVANDARYL AVANDIA BYDUREON BYETTA CYCLOSET INVOKAMET INVOKANA JANUMET JANUVIA JARDIANCE JENTADUETO SYNJARDY TRADJENTA TRULICITY VICTOZA TANZEUM FARXIGA GLYXAMBI XIGDUO XR APIDRA Step 1: Trial of both of the following preferred brands of blood glucose test strips: 1.Accu-Chek test strips, 2. One Touch test strips Step 1: Trial of both of the following; 1. Accu-Chek meters and One Touch meters Step 1: metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin AND 30 day trial of any one of the following preferred brands: Janumet, Janumet XR, Januvia AND any one of the following preferred brands: Jentadueto, Jentadueto XR, Tradjenta Step 1: metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin Step 1: Trial of one of the following generics: metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin AND any one of the following preferred brands: Byetta, Bydureon AND any one of the following preferred brands: Trulicity, Victoza Step 1: Trial of one of the following generics: metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin AND any one of the following preferred brands: Invokana, Invokamet AND any one of the following preferred brands: Jardiance, Synjardy Step 1: Humalog or Novolog Eczema ELIDEL Step 1: Corticosteroid (topical) Fibromyalgia SAVELLA Step 1: Any ONE of the following: 1. Amitriptyline, Gastrointestinal ASACOL HD DELZICOL MESALAMINE PANCREAZE PERTZYE VIOKACE ULTRESA AMITIZA LINZESS MOVANTIK 2. Cyclobenzaprine, 3. Duloxetine, or 4. Lyrica Step 1: Both of the following preferred brands: Apriso and Lialda Step 1: Creon AND Zenpep Gout MITIGARE Step 1: Colcrys COLCHICINE Step 1: Colcrys Step 2: Mitigare ULORIC ZURAMPIC Step 1: allopurinol Step 1: Polyethylene glycol or lactulose Step Therapy For patients > 18 years old: Step 1: Polyethylene glycol or lactulose Trial of Amitiza
4 Hypertension Blood Pressure AZOR BENICAR BENICAR HCT EDARBI EDARBYCLOR TRIBENZOR AMTURNIDE RANEXA TEKAMLO TEKTURNA PRESTALIA 2. captopril, 3. enalapril, 4. fosinopril, 5. lisinopril, 6. moexipril, 7. perindopril, 8. quinapril, 9. ramipril. 10. trandolapril, 14. fosinopril-hctz, 5. lisinopril-hctz, 16. moexpril-hctz, 26. telmisartan 2. captopril, 3. enalapril, 4. fosinopril, 5. lisinopril, 6. moexipril, 7. Perindopril, 8. quinapril, 9. ramipril, 10. trandolapril, 14. fosinopril-hctz, 15. lisinopril-hctz, 16. moexpril-hctz, 17. quinapril-hctz,18. amlodipine-benazepril, 19. trandolaprilverapamil, 23. candesartan-hctz, 24. irbesartan,25. irbesartan-hctz 26, telmisartan AND Step 2: Any one of the following preferred brands: 1. Tekturna, 2. Tekturna HCT Step 1: Any one of the following generics or preferred brands: 1. acebutolol, 2. amlodipine, 3. amlodipine-benazepril, 4. amlodipine telmisartan, 5. amlodipine-valsartan, 6. atenolol, 7. bextaxolol, 8. bisoprolol,9. carvedilol, 10. diltiazem / diltiazem ER, 11. felodipine ER, 12. isosorbide dinitrate ER, 13. isosorbide mononitrate ER, 14. isradipine, 15. metoprolol / metoprolol ER, 16. nadolol,17. nicardipine, 18. nifedipine, 19. nisoldipine SR, 20. nitroglycerin ER, 21. pindolol, 22. propranolol/propranolol SR, 23. timolol, 24. trandolaprilverapamil, 25. verapamil / verapamil ER, 26. Azor, 27. Bystolic, 28. Cardene SR, 29. Dilatrate SR, 30. Inderal XL, 31. Innopran XL, 32. Levatol 2.captopril, 3. enalapril, 4. fosinopril, 5. lisinopril, 6. moexipril, 7. perindopril, 8. quinapril, 9. ramipril, 10. trandolapril, 14. fosinopril-hctz, 15. lisinopril-hctz, 16. moexpril-hctz, 26. telmisartan AND Step 2: Any one of the following preferred brands: 1. Tekturna, 2. Tekturna HCT 2.captopril, 3. enalapril, 4. fosinopril, 5. lisinopril, 6. moexipril, 7. perindopril, 8. quinapril, 9. ramipril, 10. trandolapril, 14. fosinopril-hctz,15. lisinopril-hctz, 16. moexpril-hctz, 26. telmisartan Step 1: amlodipine or perindopril Ophthalmic Drops LASTACAFT SOL 0.25% BEPREVE Pain Management TRAMADOL ER Step 1: Any ONE of the following medications on formulary: Pain Management Long-acting Opioids Pain Management Migraine HYSINGLA KADIAN NUCYNTA ER XTAMPZA ZOHYDRO TREXIMET ONZETRA XSAIL ZECUITY Step 1: Any ONE of the following medications: 1. azelastine, 2. Patanol, 3. Pataday 1. tramadol, 2. tramadol/ APAP hydromorphone ER, morphine sulfate ER, oxymorphone ER, Embeda, Opana ER, Oxycontin Step 1: Any one of the following generics: rizatriptan tablet/odt, sumatriptan tablet/nasal, or zolmitriptan tablet/odt
5 Pain Management NSAIDS DERMA SILKRX PAK ANODYNEX DERMACINRX PAK INFLAMMA DERMAWERX PAK SDS DERMACINRX KIT ANALGESI DUEXIS TIVORBEX Step 1: Diclofenac tablet and ranitidine tablet Step 2: DermacinRx Inflammatral or Derma SilkRx Pak Anodynex Step 1: Diclofenac tablet and lidocaine 5% patch. Step 2: DermacinRx Kit Analgesic Step 1: Any ONE oral generic NSAID Step 1: Any two oral generic formulary NSAIDs Parkinson s Disease RYTARY Step 1: Generic carbidopa-levodopa IR or generic carbidopalevodopa ER Rosacea FINACEA Step 1: Any one of the following preferred brands: Soolantra Sedative/Hypnotic EDLUAR ZOLPIMIST Step 1: Zolpidem (generic Ambien) or zolpidem CR (generic Ambien CR) BELSOMRA Step 1: any one generic: zolpidem, zolpidem ER, eszopiclone, zaleplon, or temazepam Smoking Cessation CHANTIX NICOTROL Topical Acne Topical Steroids ACANYA BENZACLIN DUAC ERYTHROMYCIN GEL /BENZOYL VELTIN ZIANA DERMACINRX KIT SILAPAK DERMA SILKRX KIT SDS PAK NUTRIARX KIT CREAMPAK SANADERMRX KIT SKIN REP SURE RESULT KIT TAC PAK TRI-SILA KIT 0.1-5% WHYTEDERM KIT TRILASIL WHYTEDERM TD KIT PAK Step 1: Both generic Zyban (bupropion SR in GPI 6210*) AND one generic OTC nicotine replacement product (gum, patch, or lozenge). Step 2: Chantix or Nicotrol NS or Nicotrol Inh Step 1: Trial of one of the following preferred brands: Epiduo/Epiduo Forte, Onexton Step 1: Triamcinolone cream 0.1%. Step 2: DermacinRx SilaPak, or Derma SilkRx, or SanadermRx Kit Step 1: Triamcinolone cream 0.1%. Step 2: DermacinRx SilaPak or Derma SilkRx or Whytederm TD kit or Whytederm KIT Trilasil or SanadermRx Kit Urology MYRBETRIQ oxybutynin IR/ER, tolterodine IR/ER, Vesicare
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AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, EXTENDED RELEASE OSMOLEX ER 258 MG TABLET, PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
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Prescription Step Therapy Program 04HQ3972 R11/17 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross
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Effective: 1/1/2019 Updated 1/2019 AMANTADINE ER Sharp Health Plan (HMO) OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE
Lower your costs. Save money with preferred generic and preferred brand-name drugs 2018 Aetna Rx Step Program Medicine List
Call out bold Call out light Contact information, call X-XXX-XXX-XXXX or visit www.aetna.com Call to action small copy (especially related to mobile apps). Hendani adionse rferum faceatis incte voluptassi
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AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, EXTENDED RELEASE OSMOLEX ER 258 MG TABLET, PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
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ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
Step Therapy Information... 4 Prior Authorization Information ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...
Step Therapy Information... 4 Prior Authorization Information... 27 ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...62 Acne Therapy Topical...64 Alcoholism Treatment Agents... 66 Analgesic
Hospitality Rx Step Therapy
agents may not be a generic medication. Second line agent may not be a brand medication. Some Step Therapy category may require trial of more than one medication. CLINDAMYCIN/BENZOYL PEROX Acne Combo Antibiotic
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ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
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Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
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ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET BANZEL 200 MG TABLET BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG TABLET FYCOMPA 0.5 MG/ML ORAL SUSPENSION
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1 of 5 ALLERGY / ASTHMA THERAPIES ANTIHISTAMINES, MINIMALLY SEDATING cetirizine fexofenadine loratadine ANTIHISTAMINE/DECONGESTANT COMBINATIONS cetirizine/pseudoephedrine fexofenadine/pseudoephedrine loratadine/pseudoephedrine
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JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
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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Santa Clara Family Health Plan Cal MediConnect Formulary List of Step Therapy Requirements Effective: 12/01/2018 13027.12E ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET
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Updated 11/1/17 5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda