ARBS MEDICATION(S) SUBJECT TO STEP THERAPY DIOVAN HCT MG TAB, DIOVAN HCT MG TABLET
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1 ARBS DIOVAN HCT MG TAB, DIOVAN HCT MG TABLET 30-day trial of a Step 1 drug in the previous 120 days is required. Step 1 Drugs: Losartan, Losartan/HCTZ PAGE 1 LAST UPDATED 05/2016
2 BILE SEQUESTRANTS COLESTID, COLESTIPOL HCL 1 GM TABLET, COLESTIPOL HCL GRANULES PACKET, COLESTIPOL MICRONIZED 1 GM TAB, WELCHOL 625 MG TABLET 30-day trial required of a Step 1 drug in the previous 120 days. Step 1: Cholestyramine PAGE 2 LAST UPDATED 05/2016
3 BPH AGENTS UROXATRAL 30-day trial of Step 1 drug in the previous 120 days Step 1: Doxazosin, Terazosin PAGE 3 LAST UPDATED 05/2016
4 CELECOXIB CELECOXIB 100 MG CAPSULE, CELECOXIB 200 MG CAPSULE, CELECOXIB 400 MG CAPSULE, CELECOXIB 50 MG CAPSULE Minimum 30-day trial of at least one formulary NSAID with omeprazole in the previous 120 days. Formulary Alternatives: Naproxen plus Omeprazole or Ibuprofen plus Omeprazole PAGE 4 LAST UPDATED 05/2016
5 CEPHALOSPORINS CEFPROZIL 250 MG/5 ML SUSP 5-day supply of a Step 1 drug in the previous 120 days Step 1: Amoxicillin, Cephalexin, Penicillin PAGE 5 LAST UPDATED 05/2016
6 CLONIDINE TRANSDERMAL CLONIDINE 30-day trial of Step 1 drug in the previous 120 days. Step 1: Clonidine (oral) PAGE 6 LAST UPDATED 05/2016
7 DIABETES MEDICATION - 2ND LINE FARXIGA, INVOKANA, ONGLYZA, TRADJENTA Step 1: Trial and failure of Metformin + formulary sulfonyurea, TZD or DPP-4 agent in the past 120 days. Form Alt: Chlorpropamide, Glyburide, Glipizide, Pioglitazone, Janumet, Januvia or Tolazamide PAGE 7 LAST UPDATED 05/2016
8 INHALED CORTICOSTEROIDS - 1 ALVESCO, ASMANEX TWISTHALER 110 MCG #30, ASMANEX TWISTHALER 110 MCG #7, PULMICORT 180 MCG FLEXHALER 30-day trial of Step 1 drug in the previous 120 days. Step 1: Qvar, Flovent Diskus 50, 100, Flovent HFA 44, 110 PAGE 8 LAST UPDATED 05/2016
9 INHALED CORTICOSTEROIDS - 2 FLOVENT 250 MCG DISKUS, FLOVENT HFA 220 MCG INHALER 30-day trial of Step 1 drug in the previous 120 days is required. Step 1: Qvar, Flovent Diskus 50, 100, Flovent HFA 44, 110 PAGE 9 LAST UPDATED 05/2016
10 LIVALO ATORVASTATIN CALCIUM, LIVALO 1. Trial and failure of a minimum 30 day supply of Simvastatin. 2. Trial and failure of a minimum 30 day supply of Atorvastatin in the previous 120 days. PAGE 10 LAST UPDATED 05/2016
11 NASAL INHALED STEROIDS ZETONNA 30-day trial of Step 1 drug in the previous 120 days. Step 1: Fluticasone Prop., Flunisolide PAGE 11 LAST UPDATED 05/2016
12 NIASPAN NIASPAN ER 500 MG TABLET 30-day trial of Step 1 drug and atorvastatin in the previous 120 days required. Step 1: Niacin, Niacin SR PAGE 12 LAST UPDATED 05/2016
13 OPHTHALMIC ANTI-ALLERGY AZELASTINE HCL 0.05% DROPS Minimum 30-eday trial of a Step 1 drug in the previous 120 days. Step-1 Drug: Ketotifen 5ml per 30 days PAGE 13 LAST UPDATED 05/2016
14 PROTON PUMP INHIBITORS LANSOPRAZOLE DR 30 MG CAPSULE, PANTOPRAZOLE SOD DR 40 MG TAB 30 day trial and documented failure of omeprazole in the previous 120 days PAGE 14 LAST UPDATED 05/2016
15 RENAGEL RENAGEL 30-day trial of calcium acetate 667mg in the previous 120 days required. PAGE 15 LAST UPDATED 05/2016
16 STATINS CRESTOR, ZETIA 30-day trial of atorvastatin in the previous 120 days is required PAGE 16 LAST UPDATED 05/2016
17 TECFIDERA TECFIDERA Trial and failure of at least 1 formulary agent in the past 120 days. Form ALt: Avonex, Betaseron, Copaxone, Extavia, Rebif PAGE 17 LAST UPDATED 05/2016
18 TIZANIDINE TIZANIDINE HCL 2 MG TABLET, TIZANIDINE HCL 4 MG TABLET 30-day trial of Step 1 drug in the previous 120 days is required. Step 1: Baclofen, Cyclobenzaprine PAGE 18 LAST UPDATED 05/2016
19 PAGE 19 LAST UPDATED 05/2016
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