SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations are not reflected in this list. Step criteria are listed on pages 2-9 as well as in the SmithRx Clinical Criteria document. ACIPHEX 2 ACTICLATE 2 ADDERALL 2 ADDERALL XR 2 ADOXA 2 ADZENYS XR-ODT 2 AMBIEN 2 AMBIEN CR 2 AMTURNIDE 3 APIDRA 2 APIDRA SOLOSTAR 2 ARCAPTA NEOHALER 2 ARICEPT 2 ATELVIA 2 BELSOMRA 2 BEVESPI AEROSPHERE 2 BRINTELLIX 2 BYVALSON 2 CARDURA XL 2 CONCERTA 2 COREG CR 2 CORLANOR 2 DAYTRANA 2 DESOXYN 2 DEXILANT 2 DORYX 2 DORYX MPC 2 DYANAVEL XR 2 EDARBI 2 EDARBYCLOR 3 EDLUAR 2 ELIDEL 3 EURAX 2 EVEKEO 3 FANAPT 2 FETZIMA 2 FOCALIN XR 2 GEODON 2 GRALISE 2 INDERAL XL 2 INNOPRAN XL 2 INTERMEZZO 2 INVEGA 2 KAPVAY 2 LASTACAFT 2 LINZESS 2 LUNESTA 2 METADATE CD 2 MIRAPEX ER 2 MITIGARE 2 NAMENDA XR 2 NAMZARIC 2 NATROBA 2 ONZETRA XSAIL 2 ORACEA 2 OVIDE 2 PICATO 2 PRESTALIA 2 PREVACID 2 PRILOSEC 2 PROCENTRA 2 PROTONIX 2 PROTOPIC 3 QUILLICHEW ER 2 QUILLIVANT XR 2 RITALIN LA 2 ROZEREM 2 SAPHRIS 2 SAVELLA 2 SKLICE 2 SOLODYN 2 SONATA 2 STRIVERDI RESPIMAT 2 TACROLIMUS 2 TARGADOX 2 TEKTURNA 2 TEKTURNA HCT 2 TOLAK 2 TREXIMET 2 TRINTELLIX 2 ULESFIA 2 ULORIC 2 UTIBRON NEOHALER 2 VIBRAMYCIN 2 VIMOVO 3 ZEGERID 2 ZEMBRACE SYMTOUCH 2 SmithRx Step Therapy List Page 1
ADDERALL, ADDERALL XR STEP 2 At least TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), ADZENYS XR, ADZENYS XR-ODT STEP 2 At least TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine AMBIEN, AMBIEN CR STEP 2 Eszopiclone zolpidem (generic) or zaleplon (generic) AMTURNIDE STEP 3 Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil Step 2: Tekturna or Tekturna HCT ANTIPARASITICS: EURAX, NATROBA, OVIDE, SKLICE, ULESFIA STEP 2 Permethrin APIDRA, APIDRA SOLOSTAR STEP 2 Humalog or Novolog ARCAPTA NEOHALER STEP 2 Any TWO of the following: Advair HFA/ Diskus, Breo Ellipta, Serevent, Symbicort SmithRx Step Therapy List Page 2
ARICEPT 23MG STEP 2 At least 10mg of Aricept/Aricept ODT ATELVIA STEP 2 Alendronate BELSOMRA STEP 2 Zolpidem or zaleplon or eszopiclone BEVESPI AEROSPHERE STEP 2 Any one of the following: Advair HFA/ Diskus, Breo Ellipta, Serevent, Symbicort Spiriva BRINTELLIX, TRINTELLIX STEP 2 Any TWO of the following preferred agents: citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, olanzapine-fluoxetine, paroxetine, sertraline, venlafaxine, bupropion, mirtazapine BYVALSON STEP 2 Must try generic first (nebivolol/valsartan) CARDURA XL STEP 2 Tamsulosin or terazosin Cardura CONCERTA STEP 2 At least TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), SmithRx Step Therapy List Page 3
COREG CR STEP 2 Carvedilol or Coreg CORLANOR STEP 2 Any beta blocker DAYTRANA STEP 2 DESOXYN STEP 2 DYNAVEL XR STEP 2 Any TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine EDARBI STEP 2 Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil EDARBYCLOR STEP 3 Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil Step 2: Edarbi SmithRx Step Therapy List Page 4
EDLUAR STEP 2 Zolpidem or Ambien ELIDEL STEP 3 Topical corticosteroid Step 2: Tacrolimus EVEKEO STEP 3 Any TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine FANAPT STEP 2 Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify FETZIMA STEP 2 Any TWO of the following preferred SNRIs: desvenlafaxine, duloxetine, venlafaxine FOCALIN XR STEP 2 GEODON STEP 2 Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify GRALISE STEP 2 Gabapentin INNOPRAN, INDERAL STEP 2 Must try propranolol ER generics SmithRx Step Therapy List Page 5
INTERMEZZO STEP 2 Zolpidem or Ambien INVEGA STEP 2 Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify KAPVAY STEP 2 LASTACAFT STEP 2 Patanol or Pataday or Optivar LINZESS STEP 2 For patients >18 years old: Polyethylene glycol or lactulose LUNESTA STEP 2 Zolpidem (generic) or zaleplon (generic) METADATE CD STEP 2 MIRAPEX ER STEP 2 Ropinirole or pramipexole MITIGARE STEP 2 Colcrys SmithRx Step Therapy List Page 6
NAMENDA XR STEP 2 Namenda NAMZARIC STEP 2 Generic donepezil and memantine ONZETRA XSAIL STEP 2 Any TWO of the following preferred serotonin 5HT1 agonists: almotriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan PICATO STEP 2 Topical fluorouracil or imiquimod PPIs: ACIPHEX, DEXILANT, PREVACID, PRILOSEC, PROTONIX, ZEGERID STEP 2 Pantoprazole or lansoprazole (rx) omeprazole, OTC Prilosec, OTC Prevacid, or OTC Zegerid PRESTALIA STEP 2 Amlodipine or perindopril Tribenzor or Azor PROCENTRA STEP 2 PROTOPIC STEP 3 Topical corticosteroid Step 2: SmithRx Step Therapy List Page 7
Tacrolimus QUILLICHEW ER STEP 2 Any TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine QUILLIVANT XR STEP 2 RITALIN LA STEP 2 ROZEREM STEP 2 Eszopiclone, zolpidem, or zaleplon SAPHRIS STEP 2 Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify SAVELLA STEP 2 Any ONE of the following: amitriptyline, cyclobenzaprine, Cymbalta SOLODYN STEP 2 Must try 2 minocycline generics SONATA STEP 2 Eszopiclone Zolpidem (generic) or zaleplon (generic) SmithRx Step Therapy List Page 8
STRIVERDI RESPIMAT STEP 2 Any TWO of the following: Advair HFA/Diskus, Breo Ellipta, Serevent, Symbicort TACROLIMUS OINTMENT STEP 2 Topical corticosteroid TEKTURNA, TEKTURNA HCT STEP 2 Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil TETRACYCLINES STEP 2 Must try 2 doxycycline generics TOLAK STEP 2 Any TWO of the following preferred agents: fluorouracil 0.5%, fluorouracil 2%, Carac, or Fluoroplex TREXIMET STEP 2 Sumatriptan Any NSAID (Rx only) ULORIC STEP 2 Allopurinol UTIBRON NEOHALER STEP 2 Any ONE of the following: Advair HFA/Diskus, Breo Ellipta, Serevent, Symbicort Spiriva SmithRx Step Therapy List Page 9
VIMOVO STEP 3 Arthrotec Step 2: Any TWO NSAIDs ZEMBRACE SYMTOUCH STEP 2 Any TWO of the following preferred serotonin 5HT1 agonists: almotriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan SmithRx Step Therapy List Page 10