Hospitality Rx Step Therapy

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1 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 + 1 st Line ERYTHROMYCIN/BENZOYL PERO Benzoyl Peroxide ACANYA Acne 1 st Line BP 10 1 CERISA WASH HYDROCORTISONE SALACYN SALICYLIC ACID SCALACORT SE 10 5 SS SEB PREV WASH SODIUM SULFACETAMIDE WASH SS 10 2 SSS 10% 5% SSS 10 5 SULFACETAMIDE SODIUM/SULF SULFACLEANSE 8/4 AVAR CLEANSER AVAR E EMOLLIENT AVAR E GREEN BP CLEANSING WASH PRASCION PRASCION FC PRASCION RA WITH SUNSCREE ROSANIL ROSANIL CLEANSER ROSULA WASH ROSULA PAD SULFACETAMIDE SODIUM/SULF WASH & SUNSCREEN KIT SUMADAN XLT

2 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. SUMAXIN CP KIT TRISEON ZENCIA Antidepressants 1st line BUPROPION HCL BUPROPION HCL ER BUPROPION HCL SR BUPROPION HCL XL CITALOPRAM HYDROBROMIDE DESVENLAFAXINE ER DULOXETINE HCL ESCITALOPRAM OXALATE FLUOXETINE DR FLUOXETINE HCL FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE ER KHEDEZLA MIRTAZAPINE MIRTAZAPINE ODT NEFAZODONE HCL PAROXETINE HCL PAROXETINE HCL ER PHENELZINE SULFATE SERTRALINE HCL TRANYLCYPROMINE SULFATE TRAZODONE HCL VENLAFAXINE HCL VENLAFAXINE HCL ER APLENZIN BRINTELLIX EMSAM FETZIMA

3 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. FORFIVO XL IRENKA LEXAPRO MAPROTILINE HCL MARPLAN NEFAZODONE HCL OLEPTRO PAXIL PEXEVA PRISTIQ VIIBRYD Hypertension Angiotensin Receptor Blocker AMLODIPINE BESYLATE/VALSARTAN AMLODIPINE/VALSARTAN/HCTZ AZOR BENICAR BENICAR HCT CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL/HCTZ IRBESARTAN IRBESARTAN/HYDROCHLOROTHI LOSARTAN POTASSIUM LOSARTAN POTASSIUM/HCTZ TELMISARTAN TELMISARTAN/AMLODIPINE TELMISARTAN/HCTZ TRIBENZOR VALSARTAN VALSARTAN/HCTZ AMTURNIDE DIOVAN

4 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. EDARBI DUTOPROL EDARBYCLOR EPROSARTAN MESYLATE EXFORGE EXFORGE HCT PRESTALIA TEKTURNA HCT Asthma Inhaled Corticosteriod BUDESONIDE ASMANEX HFA ASMANEX METERED DOSES ASMANEX TWISTHALER PULMICORT PULMICORT FLEXHALER PULMICORT FLEXHALER QVAR AEROSPAN ALVESCO ARNUITY ELLIPTA FLOVENT HFA FLOVENT DISKUS ARIPIPRAZOLE CHLORPROMAZINE HCL CLOZAPINE CLOZAPINE ODT OLANZAPINE OLANZAPINE ODT PALIPERIDONE ER QUETIAPINE FUMARATE

5 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. Atypical Antipsychotic RISPERIDONE RISPERIDONE M TAB RISPERIDONE ODT ZIPRASIDONE HCL ABILIFY ADASUVE ARIPIPRAZOLE ODT ARISTADA FANAPT FAZACLO GEODON INVEGA INVEGA SUSTENNA INVEGA TRINZA LATUDA SAPHRIS SEROQUEL SEROQUEL XR VERSACLOZ ZYPREXA Over Active Bladder GELNIQUE MYRBETRIQ OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE ER TOLTERODINE TARTRATE TOLTERODINE TARTRATE ER TOVIAZ TROSPIUM CHLORIDE TROSPIUM CHLORIDE ER VESICARE ENABLEX

6 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. OXYTROL Regular Insulin NOVOLIN R NOVOLIN N NOVOLIN 70/30 INSULIN REG/NPH HUMAN HUMULIN 70/30 HUMULIN N HUMULIN R RELION 70/30 RELION N RELION R Topical Estrogen EVAMIST ESTRADIOL ALORA BIEST/PROGESTERONE CLIMARA PRO ELESTRIN ESTROGEL MENOSTAR MINIVELLE VIVELLE DOT Rapid Acting Insulin NOVOLOG NOVOLOG MIX 70/30 APIDRA HUMALOG HUMALOG MIX Long Acting Insulin LANTUS

7 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. Long Acting Insulin LEVEMIR Diabetes DPP4 Inhibitor JANUVIA JANUMET JANUMET XR JENTADUETO JUVISYNC TRADJENTA KAZANO KOMBIGLYZE XR NESINA ONGLYZA OSENI Osteoporosis Bisphosphonate ALENDRONATE SODIUM RISEDRONATE SODIUM DR ACTONEL ALENDRONATE SODIUM ATELVIA BINOSTO ETIDRONATE DISODIUM FOSAMAX FOSAMAX PLUS D Choleterol Agent Fibric Acid FENOFIBRATE FENOFIBRATE MICRONIZED FENOFIBRIC ACID DR LIPOFEN ANTARA FENOFIBRIC ACID FENOGLIDE

8 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. FIBRICOR TRIGLIDE Allergy Nasal Steriods BUDESONIDE DYMISTA FLUNISOLIDE FLUTICASONE PROPIONATE NASAL ALLERGY 24 HOUR NASONEX TRIAMCINOLONE ACETONIDE BECONASE AQ DERMACINRX RHINOCORT AQUA Asthma Bronchodilator PROAIR HFA PROAIR RESPICLICK VENTOLIN HFA PROVENTIL HFA XOPENEX HFA Asthma/COPD combo B2 agonist + steriod DULERA SYMBICORT ADVAIR DISKUS ADVAIR HFA ANORO ELLIPTA BREO ELLIPTA STIOLTO RESPIMAT STRIVERDI RESPIMAT CREON PANCRELIPASE

9 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. Pancreatic Enzyme ZENPEP PANCREAZE PERTZYE SUCRAID VIOKACE Inflammatory Bowel Agents BALSALAZIDE DISODIUM LIALDA MESALAMINE PENTASA SULFASALAZINE SULFAZINE SULFAZINE EC ASACOL CANASA SFROWASA Sleep Agents ESZOPICLONE ZALEPLON ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ER BELSOMRA EDLUAR HETLIOZ INTERMEZZO LUNESTA ROZEREM SILENOR ZOLPIMIST ALMOTRIPTAN MALATE

10 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. Migraine Agents Triptans NARATRIPTAN HCL RELPAX RIZATRIPTAN BENZOATE RIZATRIPTAN BENZOATE ODT SUMATRIPTAN SUCCINATE ZOLMITRIPTAN ZOLMITRIPTAN ODT ALSUMA AXERT FROVA IMITREX SUMATRIPTAN NASAL SPRAY SUMAVEL DOSEPRO TREXIMET ZOMIG ZOMIG NASAL SPRAY ZOMIG ZMT Opthalmic Agent Prostaglandins LUMIGAN LATANOPROST TRAVATAN Z TRAVOPROST BIMATOPROST RESCULA ZIOPTAN Opthalmic Agent Alpha adrenergic receptor agonist ALPHAGAN P APRACLONIDINE BRIMONIDINE TARTRATE IOPIDINE SIMBRINZA

11 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. Antibiotic Drops Ear CIPROFLOXACIN CIPRODEX OFLOXACIN CETRAXAL CIPRO HC Diabetes GLP1 BYDUREON TRULICITY BYETTA TANZEUM VICTOZA

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