2019 Step Therapy Drugs · meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen (ir and er), oxaprozin, piroxicam, sulindac, tolmetin, diclofenac sodium/misoprostol antara

2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVEACANYA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,

ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS

ACIPHEXULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR

OTC), PANTOPRAZOLE, RABEPRAZOLE

ACIPHEX SPRINKLEULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR

OTC), PANTOPRAZOLE, RABEPRAZOLEACTEMRA SC INFLAMMATORY CONDITIONS JUVENILE IDIOPATHIC ARTHRITIS: HUMIRA

ACTICLATEANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,

DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE

ACTONELBONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE

STEP 2: ATELVIA

ACTONEL PLUS CALCIUMBONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE

STEP 2: ATELVIA

ACTOPLUS METDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

ACTOPLUS MET XRDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

ACTOSDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

ACZONESKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


ADALAT CC

HIGH BLOOD PRESSURE RULE 1: GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER

ADAPALENESKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


ADCIRCA PULMONARY HYPERTENSION SILDENAFIL 20MG TABLETS, TADALAFIL 20MG TABLETS

ADDERALL XR

ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONSFOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

ADOXAANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


ADZENXS XR ODT


AEROSPANASTHMA/COPD ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS,

FLOVENT HFA, PULMICORT FLEXHALER, QVAR

AKTIPAKSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


ALA-SCALP HP

SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

ALCORTIN A SKIN INFECTIONS RULE 1: TOPICAL STEROID+MUPIROCIN

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MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVEALLZITAL PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITALALOCRIL EYE CONDITIONS CROMOLYN

ALOGLIPTINDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

ALOGLIPTIN/METFORMINDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

ALOGLIPTIN/PIOGLITAZONEDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)ALOMIDE EYE CONDITIONS CROMOLYNALREX EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE

ALSUMA INJECTIONMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,

SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN

ALTOPREV

HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATINSTEP 2: LIVALO

ALVESCOASTHMA/COPD ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS,

FLOVENT HFA, PULMICORT FLEXHALER, QVARAMBIEN SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ERAMBIEN CR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER

AMERGEMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


AMPYRA MULTIPLE SCLEROSIS RULE 2: DALFAMPRIDINEAMRIX ER MUSCLE RELAXANT RULE 3: GENERIC CYCLOBENZAPRINE

ANAPROX

PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL

ANAPROX DS


ANDROID HORMONAL SUPPLEMENTATION RULE 4: GENERIC OR METHITEST

ANSAID


ANTARA HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID

ANUSOL HC SUPPOSITORYINFLAMMATORY CONDITIONS GENERIC HYDROCORTISONE ACETATE SUPPOSITORY (25 MG OR 30 MG),

ANUCORT-HC (25 MG), GRX HICORT (25 MG), HEMMOREX-HC (25 MG OR 30 MG), RECTACORT-HC (25 MG)

APLENZIN DEPRESSION BUPROPION SR, BUPROPION ER

APTENSIO XR


2 HCR-0764-013019


MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE

AQUA GLYCOLIC HC


ARANESP BLOOD DISORDERS PROCRITARBINOXA 4 MG TABLET ALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUIDARBINOXA 4 MG/5 ML LIQUID ALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUID

ARCALYSTMETABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE

ILARIS

ARICEPT 10MG TABLETMENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES

NOT INCLUDE DONEPEZIL 23 MG TABLETS)

ARICEPT 23MG TABLET (BRAND OR GENMENTAL/NEUROLOGICAL DISORDERS RULE 2: ARICEPT 10 MG TABLETS (BRAND OR GENERIC) OR ARICEPT ODT 10 MG

(BRAND OR GENERIC)

ARICEPT 5MG TABLETMENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES


ARICEPT ODTMENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES


ARTHROTEC


ASTAGRAF XL TRANSPLANT RULE 5: GENERIC TACROLIMUS

ATACAND

HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE

ATACAND HCT


ATELVIABONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE

STEP 2: ATELVIAAUBAGIO MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG

AVALIDE


AVANDAMETDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

AVANDARYLDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

AVANDIADIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

AVAPRO


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AVAR CLEANSERSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL

PEROXIDE OR SULFACETAMIDE/SULFUR

AVAR LS CLEANSERSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


AVAR-E CREAMSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


AVAR-E LS CREAMSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


AVIDOXY DK KITANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


AVINZA PAIN - NARCOTIC N/AAVODART BPH FINASTERIDE 5 MGAVONEX MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG

AXERTMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


AZELEXSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


AZILECT MENTAL/NEUROLOGICAL DISORDERS RASAGILINE, SELEGILINE

AZOR


BECONASE AQ

ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY

BELBUCA PAIN - NARCOTIC N/ABELSOMRA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER

BENICAR


BENICAR HCT


BENZAC ACSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


BENZAC WSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


BENZACLINSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


BENZAMYCINSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


BENZAMYCIN PAKSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


BENZEFOAMSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


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BENZEFOAM ULTRASKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


BEPREVE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINEBERINERT HEREDITARY ANGIOEDEMA RUCONESTBETAPACE HIGH BLOOD PRESSURE RULE 2: GENERIC ORAL SOTALOL BETAPACE AF HIGH BLOOD PRESSURE RULE 2: GENERIC ORAL SOTALOL BETASERON MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG

BINOSTOBONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE

STEP 2: ATELVIA

BONIVABONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE

STEP 2: ATELVIA

BRINTELLIXDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:

CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE

BRISDELLEDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


BRIVIACT MENTAL/NEUROLOGICAL DISORDERS RULE 3: LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRABUPAP PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITALBUTRANS PAIN - NARCOTIC N/A

BYSTOLIC

HIGH BLOOD PRESSURE RULE 1: GENERIC BETA-BLOCKERS (I.E., ACEBUTOLOL, ATENOLOL, BETAXOLOL, BISOPROLOL, CARVEDILOL, LABETALOL, METOPROLOL SUCCINATE ER, METOPROLOL TARTRATE, NADOLOL, PINDOLOL, PROPRANOLOL, PROPRANOLOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

BYVALSON


CADUET


CALAN HIGH BLOOD PRESSURE RULE 3: VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ERCALAN SR HIGH BLOOD PRESSURE RULE 3: VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER

CAMBIA


CAPEX


CARBINOXAMINE MALEATE 6 MG TABLEALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUID

CARDENE SR


CARDURA BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSINCARDURA XL BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSINCAROSPIR HIGH BLOOD PRESSURE RULE 22: SPIRONOLACTONE

5 HCR-0764-013019



CATAFLAM


CELEBREX

PAIN STEP 1: BRAND OR GENERIC ORAL NSAIDS (MUST USE 2)FOR EXAMPLE: DICLOFENAC (IR AND ER), ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC, MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOLSTEP 2: CELECOXIB

CELECOXIB

PAIN BRAND OR GENERIC ORAL NSAIDS (MUST USE 2)FOR EXAMPLE: DICLOFENAC (IR AND ER), ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC, MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL

CELEXADEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


CICLODAN 8% KITANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%,

CICLOPIROX 8% TREATMENT KIT

CIMZIA

INFLAMMATORY CONDITIONS RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR (TRY 2)ANKYLOSING SPONDYLITIS: COSENTYX, ENBREL, HUMIRA (TRY 2)PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC, XELJANZ/XR (TRY 2) PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC (TRY 2)CROHN'S DISEASE: HUMIRA, STELARA SC (TRY 1)

CINQAIR ASTHMA SPECIALTY FASENRA, NUCALA

CLARIFOAM EFSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


CLEOCIN TSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


CLINDACIN ETZ 1% KITSKIN CONDITIONS ONE BRAND OR GENERIC PRESCRIPTION TOPICAL ACNE PRODUCT AND ONE

BRAND OR GENERIC PRESCRIPTION TOPICAL ACNE CLEANSER

CLINDACIN PACSKIN CONDITIONS ONE BRAND OR GENERIC PRESCRIPTION TOPICAL ACNE PRODUCT AND ONE

BRAND OR GENERIC PRESCRIPTION TOPICAL ACNE CLEANSER

CLINDAGELSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


CLOBEX


CLODAN


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CLODERM


CNL 8 NAIL KITANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%,

CICLOPIROX 8% TREATMENT KITCOLCHICINE CAPSULES GOUT COLCRYS, MITIGARECOLCHICINE TABLETS GOUT COLCRYS, MITIGARECOLESTID HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE

CONCERTA


CONZIP PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN

CORDRAN


COREG


COREG CR


CORGARD


CORZIDE


COZAAR


7 HCR-0764-013019



CRESTOR


CUPRIMINEWILSON'S DISEASE STEP 1: GALZIN (WITH EXCEPTIONS)

STEP 2: DEPEN

CUTIVATE


CYMBALTA

DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI)SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYDSNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS

DAKLINZA HEPATITIS C HARVONI, EPCLUSA, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER

DAYPRO


DAYTRANA


DEMSERPHEOCHROMOCYTOMA STEP 1: ALPHA BLOCKERS (DOXAZOSIN, PRAZOSIN, TERAZOSIN)

STEP 2: DIBENZYLINE

DEPAKENEMENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID

DEPAKOTEMENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID

DEPAKOTE ER/EC/DRMENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID

DEPAKOTE SPRINKLEMENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID

DEPENWILSON'S DISEASE STEP 1: GALZIN (WITH EXCEPTIONS)

STEP 2: DEPEN

DERMA-SMOOTH FS


DERMASORB HC


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DERMASORB TA


DERMATOP


DESONATE


DESOWEN


DESVENLAFAXINE ER (BRAND)


DESVENLAFAXINE FUMARATE ER (BRAND


DETROLOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE

ER, TROSPIUM, TROSPIUM ER

DETROL LAOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE

ER, TROSPIUM, TROSPIUM ERDEXAMETHASONE 1.5 MG TABLET (6 DAY/10 DAY/13 DAY DOSE PACKS)

INFLAMMATORY CONDITIONS RULE 19: GENERIC DEXAMETHASON TABLETS

DEXEDRINE


DEXILANTULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR

OTC), PANTOPRAZOLE, RABEPRAZOLEDEXPAK 6 DAY/10 DAY/13 DAY INFLAMMATORY CONDITIONS RULE 19: GENERIC DEXAMETHASON TABLETS

DIBENZYLINEPHEOCHROMOCYTOMA STEP 1: ALPHA BLOCKERS (DOXAZOSIN, PRAZOSIN, TERAZOSIN)

STEP 2: DIBENZYLINE

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DICLOFENAC SODIUM 1% GEL


DIFFERINSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


DIOVAN


DIOVAN HCT


DIPROLENE


DIPROLENE/AF


DISKETS PAIN - NARCOTIC N/A

DITROPAN XLOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE

ER, TROSPIUM, TROSPIUM ERDOLOPHINE PAIN - NARCOTIC N/A

DORYXANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


DORYX MPCANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


DOXEPIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CORTICOSTEROIDS (MUST TRY 2)

DOXYCYCLINE 40MG CAPSULES (IR/DR) (ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


DUACSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


DUETACTDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)DURAGESIC PAIN - NARCOTIC N/ADURLAZA BLOOD MODIFYING RULE 7: TWO OTHER ASPIRIN PRODUCTSDUTASTERIDE BPH FINASTERIDE 5 MGDUTASTERIDE/TAMSULOSIN BPH FINASTERIDE 5 MG

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DUTOPROL


DUZALLO GOUT ALLOPURINOL

DYMISTA


DYNAVEL XR


EC-NAPROSYN


EDARBI


EDARBYCLOR


EDLUAR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER

EFFEXOR


EFFEXOR XR


ELDEPRYL MENTAL/NEUROLOGICAL DISORDERS RASAGILINE, SELEGILINE

ELELYSOMETABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE

RULE 1: CEREZYME

ELESTAT EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE

ELIDEL

SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): FOR EXAMPLE:ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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ELOCON


EMADINE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINEEMBEDA PAIN - NARCOTIC N/A

ENABLEXOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE

ER, TROSPIUM, TROSPIUM ERENVARSUS XR TRANSPLANT RULE 5: GENERIC TACROLIMUS

EPIDUOSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


EPIDUO FORTESKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


EPOGEN BLOOD DISORDERS PROCRITESGIC PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITAL

ESOMEPRAZOLE STRONTIUMULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR


EUCRISA


EVOCLINSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


EVZIOPAIN - NARCOTIC NALOXONE 0.4 MG/ML VIAL, NALOXONE 0.4 MG/ML SYRINGE, NALOXONE 2 MG/2

ML SYRINGEEXALGO PAIN - NARCOTIC N/A

EXELON PATCHMENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES


EXELON TABLETMENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES


EXFORGE


EXFORGE HCT


EXTAVIA MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG

FARXIGADIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

FELDENE


12 HCR-0764-013019


MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVEFENOFIBRATE CAPSULES (BRAND) HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACIDFENOGLIDE HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID

FENOPROFEN (BRAND)


FETZIMA


FEXMID MUSCLE RELAXANT RULE 3: GENERIC CYCLOBENZAPRINEFIBRICOR HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID

FINACEA FOAMSKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%,

METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL

FINACEA GELSKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%,

METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GELFIORICET PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITALFIORINAL PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITALFIRMAGON ONCOLOGY ELIGARD

FLECTOR PATCH


FLOMAX BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN

FLONASE


FLOWTUSS COUGH AND COLD RULE 8: GENERIC COUGH/COLD LIQUID

FLUOXETINE 60MG TABLETSDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


FOCALIN XR


FORFIVO XL DEPRESSION BUPROPION SR, BUPROPION ERFORTAMET (BRAND AND GENERIC) DIABETES METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY

FOSAMAX PLUS DBONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE

STEP 2: ATELVIA

FOSAMAX TABLETSBONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE

STEP 2: ATELVIA

FROVAMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


GELNIQUEOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE

ER, TROSPIUM, TROSPIUM ERGILENYA MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MGGLATOPA 20 MG MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MGGLUCOPHAGE DIABETES METFORMIN IRGLUCOPHAGE XR (BRAND) DIABETES METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY

GLUMETZA (BRAND AND GENERIC)DIABETES STEP 1: METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY)

STEP 2: GLUCOPHAGE XR (BRAND), FORTAMET (BRAND AND GENERIC)

GLYXAMBIDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

13 HCR-0764-013019


MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVEGRALISE MENTAL/NEUROLOGICAL DISORDERS GABAPENTIN

HALOG


HECTOROL CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION HORIZANT MENTAL/NEUROLOGICAL DISORDERS GABAPENTINHYCOFENIX COUGH AND COLD RULE 8: GENERIC COUGH/COLD LIQUIDHYDROMORPHONE ER PAIN - NARCOTIC N/AHYSINGLA ER PAIN - NARCOTIC N/AHYTRIN BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN

HYZAAR


IMITREX (ORAL)MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


IMITREX INJECTIONMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


IMITREX NASAL SPRAYMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


INDERAL LA


INDERAL XL


INDOCIN


INGREZZA MENTAL/NEUROLOGICAL DISORDERS TETRABENAZINE

INNOPRAN XL


INOVA 4-1 EASY PADSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


INOVA 8-2 EASY PADSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


14 HCR-0764-013019



INOVA EASY PADSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


INTERMEZZO SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER

INTUNIV

ATTENTION DISORDERS BRAND AND GENERIC STIMULANT MEDICATIONSFOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, DEXMETHYLPHENIDATE IR, DYNAVEL XR, FOCALIN, FOCALIN XR, METADATE CD, METADATE ER, METHAMPHETAMINE, METHYLIN, METHYLIN ER, METHYLPHENIDATE ER, METHYLPHENIDATE IMMEDIATE RELEASE, MIXED AMPHETAMINE SALTS IR, QUILLICHEW ER, RITALIN LA, RITALIN SR, VYVANSE

INVOKAMETDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

INVOKAMET XRDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

INVOKANADIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

IRENKA


JALYN BPH FINASTERIDE 5 MG

JANUMETDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

JANUMET XRDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

JANUVIADIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

JARDIANCEDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

JENTADUETODIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

JENTADUETO XRDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

JUBLIAANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%,


JUVISYNCDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)KADIAN PAIN - NARCOTIC N/A

KAPVAY


KARBINAL ER 4 MG/5 ML SUSPENSION ALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUID

KAZANODIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

KENALOG


KEPPRA MENTAL/NEUROLOGICAL DISORDERS RULE 3: LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRAKEPPRA XR MENTAL/NEUROLOGICAL DISORDERS RULE 3: LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA

KERYDINANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%,


15 HCR-0764-013019



KHEDEZLA


KLARONSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


KLOFENSAID II


KOMBIGLYZE XRDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)LAMICTAL MENTAL/NEUROLOGICAL DISORDERS RULE 2: LAMOTRIGINE, LAMOTRIGINE XR LAMICTAL XR MENTAL/NEUROLOGICAL DISORDERS RULE 2: LAMOTRIGINE, LAMOTRIGINE XR LASTACAFT EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE

LESCOL


LESCOL XL


LETAIRIS PULMONARY HYPERTENSION TRACLEER, OPSUMIT

LEVATOL


LEXAPRODEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


LIDOCAINE-TETRACAINE 7%-7% CREAM SKIN CONDITIONS RULE 9: LIDOCAINE/PRILOCAINE CREAM

LIPITOR


LIPOFEN HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID

LIVALO


LOCOID


LOCORT 7 DAY/11 DAY INFLAMMATORY CONDITIONS RULE 19: GENERIC DEXAMETHASON TABLETSLOFIBRA HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID

16 HCR-0764-013019



LOPRESSOR


LOPRESSOR HCT


LORZONE MUSCLE RELAXANT RULE 10: GENERIC CHLORZOXAZONELUNESTA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER

LUVOX CRDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


LUXIQ


LYRICA CR MENTAL/NEUROLOGICAL DISORDERS N/A (PA RULE WILL STOP ALL CLAIMS)

MARINOLNAUSEA/VOMITING AT LEAST 2 CONVENTIONAL ANTIEMETIC TREATMENT (FOR N/V ASSOCIATED

WITH CANCER CHEMOTHERAPY) OR GENERIC DRONABINOL CAPSULESMAVYRET HEPATITIS C HARVONI, EPCLUSA, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER

MAXALTMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


MAXALT MLTMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


METADATE CD


METHADOSE PAIN - NARCOTIC N/A

METHERGINEMIGRAINE HEADACHES TRIAL OF OTHER SPECIFIC HEADACHE THERAPIES (PRIOR AUTH WITH STEP

THERAPY)

METROCREAMSKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%,


METROGELSKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%,


METROLOTIONSKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%,


MEVACOR


MICARDIS


17 HCR-0764-013019



MICARDIS HCT


MIGRANALMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


MINOCINANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


MINOCIN KITANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


MINOCYCLINE ERANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


MIRCERA BLOOD DISORDERS PROCRIT

MOBIC


MONODOXANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


MORGIDOX KITANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


MORPHINE SULFATE CR/ER PAIN - NARCOTIC N/A

MOTRIN


MS CONTIN PAIN - NARCOTIC N/A

MYRBETRIQOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE


NALFON


NAMENDA ORAL SOLUTION MENTAL/NEUROLOGICAL DISORDERS RULE 3: MEMANTINE TABLETS, MEMANTINE ORAL SOLUTIONNAMENDA TABLETS MENTAL/NEUROLOGICAL DISORDERS RULE 3: MEMANTINE TABLETS, MEMANTINE ORAL SOLUTIONNAMENDA XR MENTAL/NEUROLOGICAL DISORDERS RULE 3: MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION

NAMZARICMENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES


NAPRELAN


18 HCR-0764-013019



NAPROSYN


NASACORT


NASACORT AQ


NASONEX


NESINADIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

NEUACSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


NEURONTIN MENTAL/NEUROLOGICAL DISORDERS GABAPENTIN

NEXIUMULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR

OTC), PANTOPRAZOLE, RABEPRAZOLENOCTIVA OVERACTIVE BLADDER DESMOPRESSIN

NORITATE CREAMSKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%,


NORVASC


NOVACORT 2%-1% GEL SKIN CONDITIONS RULE 11: HYDROCORTISONE-PRAMOXINE CREAMNUCYNTA ER PAIN - NARCOTIC N/A

NUOXSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


OBERDON COUGH AND COLD RULE 8: GENERIC COUGH/COLD LIQUIDOLEPTRO ER SLEEP DISORDERS RULE 12: GENERIC TRAZODONEOLUMIANT INFLAMMATORY CONDITIONS RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR (TRY 2)

OLUX


OLUX-E


OLYSIO HEPATITIS C HARVONI, EPCLUSA, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER

OMNARIS


ONEXTONSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


19 HCR-0764-013019



ONGLYZADIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

ONZETRA XSAILMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


OPANA ER PAIN - NARCOTIC N/AOPTIVAR EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE

ORACEAANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


ORENCIA SC

INFLAMMATORY CONDITIONS RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR (TRY 2)JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA, ACTEMRA SC (TRY 2) PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC, XELJANZ/XR (TRY 2)

ORTHO EVRA AND BRAND ORAL CONTRACONTRACEPTIVES XULANE AND GENERIC ORAL CONTRACEPTIVES

OSENIDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

OTEZLAINFLAMMATORY CONDITIONS PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC, XELJANZ/XR

(TRY 1)OTREXUP INFLAMMATORY CONDITIONS METHOTREXATE INJECTION

OVACE PLUS CREAM & LOTIONSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


OXTELLAR XR MENTAL/NEUROLOGICAL DISORDERS RULE 4: OXCARBAZEPINEOXYCODONE ER (BRAND) PAIN - NARCOTIC N/AOXYCONTIN PAIN - NARCOTIC N/AOXYMORPHONE ER PAIN - NARCOTIC N/A

OXYTROLOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE


PACNEX 7%SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


PACNEX HPSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


PACNEX LPSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


PACNEX MXSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


PANDEL


PATADAY EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINEPATANOL EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE

PAXILDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


PAXIL CRDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


PAZEO EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE

PEDIADERM


20 HCR-0764-013019



PEDIADERM TA


PEDIPIROX-4 NAIL KITANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%,


PENLACANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%,


PENNSAID


PEXEVADEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


PLEXION CLEANSER & CLOTHSSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


PLEXION CREAM & LOTIONSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


PLIAGLIS SKIN CONDITIONS RULE 9: LIDOCAINE/PRILOCAINE CREAM

PONSTEL


PRAVACHOL


PRESTALIAHIGH BLOOD PRESSURE RULE 2: MUST USE ONE GENERIC DHP CCB AND ONE ACE-INHIBITOR (BRAND OR

GENERIC)

PREVACIDULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR


PREVACID SOLUTABULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR


PRILOSECULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR


PRISTIQ


PROCARDIA


PROCARDIA XL


PROCYSBI DR URINARY DISORDERS RULE 13: CYSTAGONPROSCAR BPH FINASTERIDE 5 MG

PROTOCORT SUPPOSITORYINFLAMMATORY CONDITIONS GENERIC HYDROCORTISONE ACETATE SUPPOSITORY (25 MG OR 30 MG),

ANUCORT-HC (25 MG), GRX HICORT (25 MG), HEMMOREX-HC (25 MG OR 30 MG), RECTACORT-HC (25 MG)

21 HCR-0764-013019



PROTONIXULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR


PROTOPIC


PROZACDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


PROZAC WEEKLYDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


PRUDOXIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CORTICOSTEROIDS (MUST TRY 2)

PSORCON


QDEXY XR MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN

QNASAL


QTERNDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)QUESTRAN HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITEQUESTRAN LIGHT HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE

QUILLICHEW ER


QUILLIVANT XR


RAPAFLO BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSINRASUVO INFLAMMATORY CONDITIONS METHOTREXATE INJECTIONRAYALDEE CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION RAYOS DR INFLAMMATION/IMMUNE DISORDERS RULE 14: GENERIC PREDNISONE

RAZADYNEMENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES


RAZADYNE ERMENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES


RECOMBINATEHEMOPHILIA ADVATE, ADYNOVATE, AFSTYLA, HELIXATE, KOGENATE, KOVALTRY, NOVOEIGHT,

NUWIQRELISTOR CONSTIPATION AMITIZA, MOVANTIK, SYMPROIC (MUST TRY TWO)

RELPAXMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


REVATIO ORAL SUSPENSION PULMONARY HYPERTENSION SILDENAFIL 20MG TABLETS, TADALAFIL 20MG TABLETSREVATIO TABLETS PULMONARY HYPERTENSION SILDENAFIL 20MG TABLETS, TADALAFIL 20MG TABLETS

22 HCR-0764-013019



RHINOCORT


RHINOCORT AQUA


RIOMET DIABETES METFORMIN IR

RITALIN LA


RITALIN SR


ROCALTROL CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION ROCALTROL ORAL SOLUTION VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION

ROSADAN CREAM KITSKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%,


ROSADAN GEL KITSKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%,


ROSANILSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


ROSULASKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL

PEROXIDE OR SULFACETAMIDE/SULFURROZEREM SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ERRYVENT 6 MG TABLET ALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUID

SANCTURAOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE


SANCTURA XROVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE


SARAFEMDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


SAVELLA

PAIN/INFLAMMATION REQUIRES USE OF ANY TWO (BRAND OR GENERIC SSRIS) OR (BRAND OR GENERIC SNRIS)SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYDSNRIS: DESVENLAFAXINE ER (BRAND), DESVENLAFAXINE FUMARATE ER (BRAND), FETZIMA, IRENKA, KHEDEZLA, PRISTIQ, VENLAFAXINE IR OR ER (EFFEXOR, EFFEXOR XR), VENLAFAXINE ER (BRAND PRODUCT)

SCALACORT


SECTRAL


23 HCR-0764-013019



SERNIVO


SIKLOS SICKLE CELL DISEASE DROXIASILENOR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ERSITAVIG BUCCAL TABLETS VIRAL INFECTIONS RULE 15: GENERIC ACYCLOVIR

SOLODYNANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


SONATA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER

SOOLANTRASKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%,

METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GELSOVALDI HEPATITIS C HARVONI, EPCLUSA, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIERSPIRITAM MENTAL/NEUROLOGICAL DISORDERS RULE 3: LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA

SPRIX


STAVZORMENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID

STEGLATRODIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

STRATTERA


SULAR


SUMADANSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


SUMADAN XLTSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


SUMAVEL DOSEPROMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


SUMAXINSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


SUMAXIN CPSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL


SYNALAR


24 HCR-0764-013019



SYNALAR TS KIT


SYNDROSNAUSEA/VOMITING AT LEAST 2 CONVENTIONAL ANTIEMETIC TREATMENT (FOR N/V ASSOCIATED

WITH CANCER CHEMOTHERAPY) OR GENERIC DRONABINOL CAPSULES

SYNJARDYDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)

TACROLIMUS OINTMENT(GENERIC)


TALTZINFLAMMATORY CONDITIONS PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC, XELJANZ/XR

(TRY 2)PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC (TRY 2)

TARGADOXANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


TECFIDERA MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG

TEMOVATE


TENORETIC


TENORMIN


TESTRED HORMONAL SUPPLEMENTATION RULE 4: GENERIC OR METHITEST

TEVETEN


TEVETEN HCT


25 HCR-0764-013019



TEXACORT


TIVORBEX


TOPAMAX MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGENTOPAMAX SPRINKLE MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN

TOPICORT


TOPICORT SPRAY


TOPIRAMATE ER MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN

TOPROL XL


TOVIAZOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE


TRADJENTADIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)TRAMADOL EXTENDED RELEASE PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN

TRANDATE


TRELSTAR DEPOT ONCOLOGY ELIGARDTRELSTAR LA ONCOLOGY ELIGARDTREMFYA INFLAMMATORY CONDITIONS PSORIASIS: HUMIRA

TREXIMETMIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN,


TRIBENZOR


26 HCR-0764-013019


MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVETRICOR HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACIDTRIGLIDE HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACIDTRILEPTAL MENTAL/NEUROLOGICAL DISORDERS RULE 4: OXCARBAZEPINETRILIPIX HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACIDTROKENDI XR MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGENTUSSICAPS COUGH AND COLD RULE 16: GENERIC COUGH/COLD LIQUIDTUZISTRA XR COUGH AND COLD RULE 17: GENERIC COUGH/COLD LIQUID

TWYNSTA


ULORIC GOUT ALLOPURINOLULTRACET PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHENULTRAM PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHENULTRAM ER PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN

ULTRAVATE


ULTRAVATE X


UROXATRAL BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSINVANATOL LQ PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITALVANATOL S PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITAL

VANOS


VELTINSKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN,


VENLAFAXINE EXTENDED-RELEASE (BRA


VENTAVIS PULMONARY HYPERTENSION TYVASO

VERAMYST


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VERDESO


VERELAN HIGH BLOOD PRESSURE RULE 3: VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ERVERELAN PM HIGH BLOOD PRESSURE RULE 3: VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER

VESICAREOVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE


VIBRAMYCINANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR,


VIIBRYDDEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI:


VITUZ COUGH AND COLD RULE 17: GENERIC COUGH/COLD LIQUID

VIVLODEX


VOLTAREN GEL


VOLTAREN XR


VYTORIN


VYVANSE


WELCHOL HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITEWELLBUTRIN SR DEPRESSION BUPROPION SR, BUPROPION ERWELLBUTRIN XL DEPRESSION BUPROPION SR, BUPROPION ERXADAGO MENTAL/NEUROLOGICAL DISORDERS RASAGILINE, SELEGILINEXATMEP ONCOLOGY/INFLAMMATORY CONDITIONS RULE 21: METHOTREXATE TABLETS, TREXALLXENAZINE MENTAL/NEUROLOGICAL DISORDERS TETRABENAZINE

XIGDUO XRDIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT

(BRAND OR GENERIC)XTAMPZA ER PAIN - NARCOTIC N/A

XYNTHAHEMOPHILIA ADVATE, ADYNOVATE, AFSTYLA, HELIXATE, KOGENATE, KOVALTRY, NOVOEIGHT,

NUWIQYOSPRALA ULCER RULE 18: ASPIRIN + RX PPI

ZAVESCAMETABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE

RULE 2: CERDELGA, GENERIC MIGLUSTAT

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ZEBETA


ZEGERID (BRAND AND SELECT GENERICS

ULCER RULE 2: ALL CLAIMS ARE STOPPED AND GIVEN THE POS MESSAGING TO TRY 5 OTHER GENERICS. IF A PATIENT HAS TRIED THE FIRST LINE ALTERNATIVES, A COVERAGE REVIEW MUST BE COMPLETED IN ORDER TO GAIN ACCESS TO A STEP 2 DRUG.

ZELAPAR MENTAL/NEUROLOGICAL DISORDERS RASAGILINE, SELEGILINE

ZEMAIRAMETABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE

ARALAST NP, GLASSIA

29 HCR-0764-013019

Documents

2019 Step Therapy Drugs · meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen (ir and er), oxaprozin, piroxicam, sulindac, tolmetin, diclofenac sodium/misoprostol antara