List of Step Therapy Drugs

2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE ACANYA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS ULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR ACIPHEX OTC), PANTOPRAZOLE, RABEPRAZOLE ULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR ACIPHEX SPRINKLE OTC), PANTOPRAZOLE, RABEPRAZOLE ACTEMRA SC INFLAMMATORY CONDITIONS JUVENILE IDIOPATHIC ARTHRITIS: HUMIRA ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, ACTICLATE DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE ACTONEL STEP 2: ATELVIA BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE ACTONEL PLUS CALCIUM STEP 2: ATELVIA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT ACTOPLUS MET (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT ACTOPLUS MET XR (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT ACTOS (BRAND OR GENERIC) SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, ACZONE ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS HIGH BLOOD PRESSURE RULE 1: GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ADALAT CC ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, ADAPALENE ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS ADCIRCA PULMONARY HYPERTENSION SILDENAFIL 20MG TABLETS, TADALAFIL 20MG TABLETS ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, ADDERALL XR DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, ADOXA DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, ADZENXS XR ODT DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

ASTHMA/COPD ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS, AEROSPAN FLOVENT HFA, PULMICORT FLEXHALER, QVAR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, AKTIPAK ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS 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, ALA-SCALP HP DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

ALCORTIN A SKIN INFECTIONS RULE 1: TOPICAL STEROID+MUPIROCIN

1 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE ALLZITAL PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITAL ALOCRIL EYE CONDITIONS CROMOLYN DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT ALOGLIPTIN (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT ALOGLIPTIN/METFORMIN (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT ALOGLIPTIN/PIOGLITAZONE (BRAND OR GENERIC) ALOMIDE EYE CONDITIONS CROMOLYN ALREX EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, ALSUMA INJECTION SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, ALTOPREV ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO ASTHMA/COPD ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS, ALVESCO FLOVENT HFA, PULMICORT FLEXHALER, QVAR AMBIEN SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER AMBIEN CR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, AMERGE SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN AMPYRA MULTIPLE SCLEROSIS RULE 2: DALFAMPRIDINE AMRIX ER MUSCLE RELAXANT RULE 3: GENERIC CYCLOBENZAPRINE PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, ANAPROX 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 PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, ANAPROX DS 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 ANDROID HORMONAL SUPPLEMENTATION RULE 4: GENERIC OR METHITEST PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, ANSAID 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 ANTARA HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID INFLAMMATORY CONDITIONS GENERIC HYDROCORTISONE ACETATE SUPPOSITORY (25 MG OR 30 MG), ANUSOL HC SUPPOSITORY 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 ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, APTENSIO XR DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

2 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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, AQUA GLYCOLIC HC DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

ARANESP BLOOD DISORDERS PROCRIT ARBINOXA 4 MG TABLET ALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUID ARBINOXA 4 MG/5 ML LIQUID ALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUID METABOLIC, IMMUNE DISORDERS OR INHERITED ILARIS ARCALYST RARE DISEASE MENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES ARICEPT 10MG TABLET NOT INCLUDE DONEPEZIL 23 MG TABLETS) MENTAL/NEUROLOGICAL DISORDERS RULE 2: ARICEPT 10 MG TABLETS (BRAND OR GENERIC) OR ARICEPT ODT 10 MG ARICEPT 23MG TABLET (BRAND OR GEN (BRAND OR GENERIC) MENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES ARICEPT 5MG TABLET NOT INCLUDE DONEPEZIL 23 MG TABLETS) MENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES ARICEPT ODT NOT INCLUDE DONEPEZIL 23 MG TABLETS) PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, ARTHROTEC 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 ASTAGRAF XL TRANSPLANT RULE 5: GENERIC TACROLIMUS HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, ATACAND OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, ATACAND HCT OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE ATELVIA STEP 2: ATELVIA AUBAGIO MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, AVALIDE OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT AVANDAMET (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT AVANDARYL (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT AVANDIA (BRAND OR GENERIC) HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, AVAPRO OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE

3 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL AVAR CLEANSER PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL AVAR LS CLEANSER PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, AVAR-E CREAM ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, AVAR-E LS CREAM ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, AVIDOXY DK KIT DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE AVINZA PAIN - NARCOTIC N/A AVODART BPH FINASTERIDE 5 MG AVONEX MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, AXERT SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, AZELEX ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS AZILECT MENTAL/NEUROLOGICAL DISORDERS RASAGILINE, SELEGILINE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, AZOR OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE BECONASE AQ NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY BELBUCA PAIN - NARCOTIC N/A BELSOMRA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, BENICAR OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, BENICAR HCT OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL BENZAC AC PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL BENZAC W PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, BENZACLIN ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, BENZAMYCIN ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, BENZAMYCIN PAK ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, BENZEFOAM ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS

4 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, BENZEFOAM ULTRA ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS BEPREVE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE BERINERT HEREDITARY ANGIOEDEMA RUCONEST BETAPACE 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 BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE BINOSTO STEP 2: ATELVIA BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE BONIVA STEP 2: ATELVIA DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: BRINTELLIX CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: BRISDELLE CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE BRIVIACT MENTAL/NEUROLOGICAL DISORDERS RULE 3: LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA BUPAP PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITAL BUTRANS PAIN - NARCOTIC N/A 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 BYSTOLIC ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

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 BYVALSON ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, CADUET ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO CALAN HIGH BLOOD PRESSURE RULE 3: VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER CALAN SR HIGH BLOOD PRESSURE RULE 3: VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, CAMBIA 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 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, CAPEX DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

CARBINOXAMINE MALEATE 6 MG TABLEALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUID HIGH BLOOD PRESSURE RULE 1: GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, CARDENE SR ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER CARDURA BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN CARDURA XL BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN CAROSPIR HIGH BLOOD PRESSURE RULE 22: SPIRONOLACTONE

5 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, CATAFLAM 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 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 CELEBREX ER), KETOROLAC, MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL STEP 2: 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 CELECOXIB ER), KETOROLAC, MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: CELEXA CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, CICLODAN 8% KIT CICLOPIROX 8% TREATMENT KIT 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 CIMZIA (TRY 2) PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC (TRY 2) CROHN'S DISEASE: HUMIRA, STELARA SC (TRY 1) CINQAIR ASTHMA SPECIALTY FASENRA, NUCALA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, CLARIFOAM EF ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, CLEOCIN T ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS SKIN CONDITIONS ONE BRAND OR GENERIC PRESCRIPTION TOPICAL ACNE PRODUCT AND ONE CLINDACIN ETZ 1% KIT BRAND OR GENERIC PRESCRIPTION TOPICAL ACNE CLEANSER SKIN CONDITIONS ONE BRAND OR GENERIC PRESCRIPTION TOPICAL ACNE PRODUCT AND ONE CLINDACIN PAC BRAND OR GENERIC PRESCRIPTION TOPICAL ACNE CLEANSER SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, CLINDAGEL ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS 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, CLOBEX DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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, CLODAN DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

6 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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, CLODERM DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, CNL 8 NAIL KIT CICLOPIROX 8% TREATMENT KIT COLCHICINE CAPSULES GOUT COLCRYS, MITIGARE COLCHICINE TABLETS GOUT COLCRYS, MITIGARE COLESTID HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, CONCERTA DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

CONZIP PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN 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, CORDRAN DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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 COREG ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

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 COREG CR ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

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 CORGARD ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

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 CORZIDE ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

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

7 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, CRESTOR ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO WILSON'S DISEASE STEP 1: GALZIN (WITH EXCEPTIONS) CUPRIMINE STEP 2: DEPEN 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, CUTIVATE DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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 CYMBALTA CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS DAKLINZA HEPATITIS C HARVONI, EPCLUSA, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, DAYPRO 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 ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DAYTRANA DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

PHEOCHROMOCYTOMA STEP 1: ALPHA BLOCKERS (DOXAZOSIN, PRAZOSIN, TERAZOSIN) DEMSER STEP 2: DIBENZYLINE MENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID DEPAKENE MENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID DEPAKOTE MENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID DEPAKOTE ER/EC/DR MENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID DEPAKOTE SPRINKLE WILSON'S DISEASE STEP 1: GALZIN (WITH EXCEPTIONS) DEPEN STEP 2: DEPEN 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, DERMA-SMOOTH FS DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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, DERMASORB HC DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

8 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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, DERMASORB TA DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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, DERMATOP DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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, DESONATE DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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, DESOWEN DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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 DESVENLAFAXINE ER (BRAND) CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS 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 DESVENLAFAXINE FUMARATE ER (BRAND CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE DETROL ER, TROSPIUM, TROSPIUM ER OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE DETROL LA ER, TROSPIUM, TROSPIUM ER DEXAMETHASONE 1.5 MG TABLET (6 INFLAMMATORY CONDITIONS RULE 19: GENERIC DEXAMETHASON TABLETS DAY/10 DAY/13 DAY DOSE PACKS) ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DEXEDRINE DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

ULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR DEXILANT OTC), PANTOPRAZOLE, RABEPRAZOLE DEXPAK 6 DAY/10 DAY/13 DAY INFLAMMATORY CONDITIONS RULE 19: GENERIC DEXAMETHASON TABLETS PHEOCHROMOCYTOMA STEP 1: ALPHA BLOCKERS (DOXAZOSIN, PRAZOSIN, TERAZOSIN) DIBENZYLINE STEP 2: DIBENZYLINE

9 HCR-0764-013019 2019 Step Therapy Drugs

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, DIPROLENE/AF DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

DISKETS PAIN - NARCOTIC N/A OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE DITROPAN XL ER, TROSPIUM, TROSPIUM ER DOLOPHINE PAIN - NARCOTIC N/A ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, DORYX DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, DORYX MPC DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE DOXEPIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CORTICOSTEROIDS (MUST TRY 2) ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, DOXYCYCLINE 40MG CAPSULES (IR/DR) ( DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, DUAC ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT DUETACT (BRAND OR GENERIC) DURAGESIC PAIN - NARCOTIC N/A DURLAZA BLOOD MODIFYING RULE 7: TWO OTHER ASPIRIN PRODUCTS DUTASTERIDE BPH FINASTERIDE 5 MG DUTASTERIDE/TAMSULOSIN BPH FINASTERIDE 5 MG

10 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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 DUTOPROL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

DUZALLO GOUT ALLOPURINOL ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE DYMISTA NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, DYNAVEL XR DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, EC-NAPROSYN 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 HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, EDARBI OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, EDARBYCLOR OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE EDLUAR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER 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 EFFEXOR CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS 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 EFFEXOR XR CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS ELDEPRYL MENTAL/NEUROLOGICAL DISORDERS RASAGILINE, SELEGILINE METABOLIC, IMMUNE DISORDERS OR INHERITED RULE 1: CEREZYME ELELYSO RARE DISEASE ELESTAT EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE ELIDEL (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

11 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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, ELOCON DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

EMADINE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE EMBEDA PAIN - NARCOTIC N/A OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ENABLEX ER, TROSPIUM, TROSPIUM ER ENVARSUS XR TRANSPLANT RULE 5: GENERIC TACROLIMUS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, EPIDUO ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, EPIDUO FORTE ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS EPOGEN BLOOD DISORDERS PROCRIT ESGIC PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITAL ULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR ESOMEPRAZOLE STRONTIUM OTC), PANTOPRAZOLE, RABEPRAZOLE SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE EUCRISA (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, EVOCLIN ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS PAIN - NARCOTIC NALOXONE 0.4 MG/ML VIAL, NALOXONE 0.4 MG/ML SYRINGE, NALOXONE 2 MG/2 EVZIO ML SYRINGE EXALGO PAIN - NARCOTIC N/A MENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES EXELON PATCH NOT INCLUDE DONEPEZIL 23 MG TABLETS) MENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES EXELON TABLET NOT INCLUDE DONEPEZIL 23 MG TABLETS) HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, EXFORGE OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, EXFORGE HCT OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE EXTAVIA MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT FARXIGA (BRAND OR GENERIC) PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, FELDENE 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

12 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE FENOFIBRATE CAPSULES (BRAND) HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID FENOGLIDE HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, FENOPROFEN (BRAND) 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 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 FETZIMA CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS FEXMID MUSCLE RELAXANT RULE 3: GENERIC CYCLOBENZAPRINE FIBRICOR HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, FINACEA FOAM METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, FINACEA GEL METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL FIORICET PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITAL FIORINAL PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITAL FIRMAGON ONCOLOGY ELIGARD PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, FLECTOR PATCH 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 FLOMAX BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE FLONASE NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY FLOWTUSS COUGH AND COLD RULE 8: GENERIC COUGH/COLD LIQUID DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: FLUOXETINE 60MG TABLETS CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, FOCALIN XR DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

FORFIVO XL DEPRESSION BUPROPION SR, BUPROPION ER FORTAMET (BRAND AND GENERIC) DIABETES METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE FOSAMAX PLUS D STEP 2: ATELVIA BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE FOSAMAX TABLETS STEP 2: ATELVIA MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, FROVA SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE GELNIQUE ER, TROSPIUM, TROSPIUM ER GILENYA MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG GLATOPA 20 MG MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG GLUCOPHAGE DIABETES METFORMIN IR GLUCOPHAGE XR (BRAND) DIABETES METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY DIABETES STEP 1: METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY) GLUMETZA (BRAND AND GENERIC) STEP 2: GLUCOPHAGE XR (BRAND), FORTAMET (BRAND AND GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT GLYXAMBI (BRAND OR GENERIC)

13 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE GRALISE MENTAL/NEUROLOGICAL DISORDERS GABAPENTIN 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, HALOG DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

HECTOROL CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION HORIZANT MENTAL/NEUROLOGICAL DISORDERS GABAPENTIN HYCOFENIX COUGH AND COLD RULE 8: GENERIC COUGH/COLD LIQUID HYDROMORPHONE ER PAIN - NARCOTIC N/A HYSINGLA ER PAIN - NARCOTIC N/A HYTRIN BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, HYZAAR OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, IMITREX (ORAL) SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, IMITREX INJECTION SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, IMITREX NASAL SPRAY SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN 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 INDERAL LA ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

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 INDERAL XL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOCIN 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 INGREZZA MENTAL/NEUROLOGICAL DISORDERS TETRABENAZINE 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 INNOPRAN XL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, INOVA 4-1 EASY PAD ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, INOVA 8-2 EASY PAD ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS

14 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, INOVA EASY PAD ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS INTERMEZZO SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER ATTENTION DISORDERS BRAND AND GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, INTUNIV 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 DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT INVOKAMET (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT INVOKAMET XR (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT INVOKANA (BRAND OR GENERIC) 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 IRENKA CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS JALYN BPH FINASTERIDE 5 MG DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT JANUMET (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT JANUMET XR (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT JANUVIA (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT JARDIANCE (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT JENTADUETO (BRAND OR GENERIC) DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT JENTADUETO XR (BRAND OR GENERIC) ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, JUBLIA CICLOPIROX 8% TREATMENT KIT DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT JUVISYNC (BRAND OR GENERIC) KADIAN PAIN - NARCOTIC N/A ATTENTION DISORDERS BRAND AND GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, KAPVAY 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 KARBINAL ER 4 MG/5 ML SUSPENSION ALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUID DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT KAZANO (BRAND OR GENERIC) 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, KENALOG DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

KEPPRA MENTAL/NEUROLOGICAL DISORDERS RULE 3: LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA KEPPRA XR MENTAL/NEUROLOGICAL DISORDERS RULE 3: LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, KERYDIN CICLOPIROX 8% TREATMENT KIT

15 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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 KHEDEZLA CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, KLARON ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, KLOFENSAID II 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 DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT KOMBIGLYZE XR (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 HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, LESCOL ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, LESCOL XL ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO LETAIRIS PULMONARY HYPERTENSION TRACLEER, OPSUMIT 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 LEVATOL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: LEXAPRO CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE LIDOCAINE-TETRACAINE 7%-7% CREAM SKIN CONDITIONS RULE 9: LIDOCAINE/PRILOCAINE CREAM HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, LIPITOR ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO LIPOFEN HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, LIVALO ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO 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, LOCOID DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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

16 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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 LOPRESSOR ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

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 LOPRESSOR HCT ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

LORZONE MUSCLE RELAXANT RULE 10: GENERIC CHLORZOXAZONE LUNESTA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: LUVOX CR CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE 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, LUXIQ DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

LYRICA CR MENTAL/NEUROLOGICAL DISORDERS N/A (PA RULE WILL STOP ALL CLAIMS) NAUSEA/VOMITING AT LEAST 2 CONVENTIONAL ANTIEMETIC TREATMENT (FOR N/V ASSOCIATED MARINOL WITH CANCER CHEMOTHERAPY) OR GENERIC DRONABINOL CAPSULES MAVYRET HEPATITIS C HARVONI, EPCLUSA, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, MAXALT SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, MAXALT MLT SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE CD DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

METHADOSE PAIN - NARCOTIC N/A MIGRAINE HEADACHES TRIAL OF OTHER SPECIFIC HEADACHE THERAPIES (PRIOR AUTH WITH STEP METHERGINE THERAPY) SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METROCREAM METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METROGEL METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METROLOTION METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, MEVACOR ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, MICARDIS OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE

17 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, MICARDIS HCT OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, MIGRANAL SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, MINOCIN DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, MINOCIN KIT DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, MINOCYCLINE ER DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE MIRCERA BLOOD DISORDERS PROCRIT PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, MOBIC 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 ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, MONODOX DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, MORGIDOX KIT DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE MORPHINE SULFATE CR/ER PAIN - NARCOTIC N/A PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, MOTRIN 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 MS CONTIN PAIN - NARCOTIC N/A OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE MYRBETRIQ ER, TROSPIUM, TROSPIUM ER PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, NALFON 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 NAMENDA ORAL SOLUTION MENTAL/NEUROLOGICAL DISORDERS RULE 3: MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION NAMENDA TABLETS MENTAL/NEUROLOGICAL DISORDERS RULE 3: MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION NAMENDA XR MENTAL/NEUROLOGICAL DISORDERS RULE 3: MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION MENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NAMZARIC NOT INCLUDE DONEPEZIL 23 MG TABLETS) PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, NAPRELAN 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

18 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, NAPROSYN 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 ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASACORT NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASACORT AQ NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE NASONEX NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT NESINA (BRAND OR GENERIC) SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, NEUAC ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS NEURONTIN MENTAL/NEUROLOGICAL DISORDERS GABAPENTIN ULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR NEXIUM OTC), PANTOPRAZOLE, RABEPRAZOLE NOCTIVA OVERACTIVE BLADDER DESMOPRESSIN SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, NORITATE CREAM METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL HIGH BLOOD PRESSURE RULE 1: GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, NORVASC ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER NOVACORT 2%-1% GEL SKIN CONDITIONS RULE 11: HYDROCORTISONE-PRAMOXINE CREAM NUCYNTA ER PAIN - NARCOTIC N/A SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, NUOX ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS OBERDON COUGH AND COLD RULE 8: GENERIC COUGH/COLD LIQUID OLEPTRO ER SLEEP DISORDERS RULE 12: GENERIC TRAZODONE OLUMIANT INFLAMMATORY CONDITIONS RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR (TRY 2) 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, OLUX DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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, OLUX-E DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

OLYSIO HEPATITIS C HARVONI, EPCLUSA, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE OMNARIS NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, ONEXTON ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS

19 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT ONGLYZA (BRAND OR GENERIC) MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, ONZETRA XSAIL SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN OPANA ER PAIN - NARCOTIC N/A OPTIVAR EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, ORACEA DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE INFLAMMATORY CONDITIONS RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR (TRY 2) JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA, ACTEMRA SC (TRY 2) ORENCIA SC PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC, XELJANZ/XR (TRY 2) ORTHO EVRA AND BRAND ORAL CONTRACONTRACEPTIVES XULANE AND GENERIC ORAL CONTRACEPTIVES DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT OSENI (BRAND OR GENERIC) INFLAMMATORY CONDITIONS PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC, XELJANZ/XR OTEZLA (TRY 1) OTREXUP INFLAMMATORY CONDITIONS METHOTREXATE INJECTION SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, OVACE PLUS CREAM & LOTION ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS OXTELLAR XR MENTAL/NEUROLOGICAL DISORDERS RULE 4: OXCARBAZEPINE OXYCODONE ER (BRAND) PAIN - NARCOTIC N/A OXYCONTIN PAIN - NARCOTIC N/A OXYMORPHONE ER PAIN - NARCOTIC N/A OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE OXYTROL ER, TROSPIUM, TROSPIUM ER SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL PACNEX 7% PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL PACNEX HP PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL PACNEX LP PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL PACNEX MX PEROXIDE OR SULFACETAMIDE/SULFUR 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, PANDEL DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

PATADAY EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE PATANOL EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: PAXIL CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: PAXIL CR CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE PAZEO EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE 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, PEDIADERM DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

20 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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, PEDIADERM TA DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, PEDIPIROX-4 NAIL KIT CICLOPIROX 8% TREATMENT KIT ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION , CICLOPIROX TOPICAL SOLUTION 8%, PENLAC CICLOPIROX 8% TREATMENT KIT PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, PENNSAID 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 DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: PEXEVA CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL PLEXION CLEANSER & CLOTHS PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, PLEXION CREAM & LOTION ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS PLIAGLIS SKIN CONDITIONS RULE 9: LIDOCAINE/PRILOCAINE CREAM PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, PONSTEL 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 HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, PRAVACHOL ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO HIGH BLOOD PRESSURE RULE 2: MUST USE ONE GENERIC DHP CCB AND ONE ACE-INHIBITOR (BRAND OR PRESTALIA GENERIC) ULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR PREVACID OTC), PANTOPRAZOLE, RABEPRAZOLE ULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR PREVACID SOLUTAB OTC), PANTOPRAZOLE, RABEPRAZOLE ULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR PRILOSEC OTC), PANTOPRAZOLE, RABEPRAZOLE 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 PRISTIQ CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS HIGH BLOOD PRESSURE RULE 1: GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, PROCARDIA ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER HIGH BLOOD PRESSURE RULE 1: GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, PROCARDIA XL ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER PROCYSBI DR URINARY DISORDERS RULE 13: CYSTAGON PROSCAR BPH FINASTERIDE 5 MG INFLAMMATORY CONDITIONS GENERIC HYDROCORTISONE ACETATE SUPPOSITORY (25 MG OR 30 MG), PROTOCORT SUPPOSITORY ANUCORT-HC (25 MG), GRX HICORT (25 MG), HEMMOREX-HC (25 MG OR 30 MG), RECTACORT-HC (25 MG)

21 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE ULCER RULE 1: ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR PROTONIX OTC), PANTOPRAZOLE, RABEPRAZOLE SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE PROTOPIC (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: PROZAC CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: PROZAC WEEKLY CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE PRUDOXIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CORTICOSTEROIDS (MUST TRY 2) 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, PSORCON DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

QDEXY XR MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE QNASAL NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT QTERN (BRAND OR GENERIC) QUESTRAN HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE QUESTRAN LIGHT HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, QUILLICHEW ER DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

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

RAPAFLO BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN RASUVO INFLAMMATORY CONDITIONS METHOTREXATE INJECTION RAYALDEE CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION RAYOS DR INFLAMMATION/IMMUNE DISORDERS RULE 14: GENERIC PREDNISONE MENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES RAZADYNE NOT INCLUDE DONEPEZIL 23 MG TABLETS) MENTAL/NEUROLOGICAL DISORDERS RULE 1: GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES RAZADYNE ER NOT INCLUDE DONEPEZIL 23 MG TABLETS) HEMOPHILIA ADVATE, ADYNOVATE, AFSTYLA, HELIXATE, KOGENATE, KOVALTRY, NOVOEIGHT, RECOMBINATE NUWIQ RELISTOR CONSTIPATION AMITIZA, MOVANTIK, SYMPROIC (MUST TRY TWO) MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, RELPAX SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN REVATIO ORAL SUSPENSION PULMONARY HYPERTENSION SILDENAFIL 20MG TABLETS, TADALAFIL 20MG TABLETS REVATIO TABLETS PULMONARY HYPERTENSION SILDENAFIL 20MG TABLETS, TADALAFIL 20MG TABLETS

22 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE RHINOCORT NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE RHINOCORT AQUA NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY RIOMET DIABETES METFORMIN IR ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, RITALIN LA DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

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

ROCALTROL CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION ROCALTROL ORAL SOLUTION VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, ROSADAN CREAM KIT METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, ROSADAN GEL KIT METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL ROSANIL PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL ROSULA PEROXIDE OR SULFACETAMIDE/SULFUR ROZEREM SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER RYVENT 6 MG TABLET ALLERGY CARBINOXAMINE 4 MG TABLET, CARBINOXAMINE 4 MG/5 ML LIQUID OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE SANCTURA ER, TROSPIUM, TROSPIUM ER OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE SANCTURA XR ER, TROSPIUM, TROSPIUM ER DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: SARAFEM CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE 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 SAVELLA CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: DESVENLAFAXINE ER (BRAND), DESVENLAFAXINE FUMARATE ER (BRAND), FETZIMA, IRENKA, KHEDEZLA, PRISTIQ, VENLAFAXINE IR OR ER (EFFEXOR, EFFEXOR XR), VENLAFAXINE ER (BRAND PRODUCT) 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, SCALACORT DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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 SECTRAL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

23 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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, SERNIVO DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

SIKLOS SICKLE CELL DISEASE DROXIA SILENOR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER SITAVIG BUCCAL TABLETS VIRAL INFECTIONS RULE 15: GENERIC ACYCLOVIR ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, SOLODYN DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE SONATA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, SOOLANTRA METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL SOVALDI HEPATITIS C HARVONI, EPCLUSA, VIEKIRA PAK, VIEKIRA XR, VOSEVI, ZEPATIER SPIRITAM MENTAL/NEUROLOGICAL DISORDERS RULE 3: LEVETIRACETAM , LEVETIRACETAM XR, ROWEEPRA PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, SPRIX 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 MENTAL/NEUROLOGICAL DISORDERS RULE 1: DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID STAVZOR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT STEGLATRO (BRAND OR GENERIC) ATTENTION DISORDERS BRAND AND GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, STRATTERA 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 HIGH BLOOD PRESSURE RULE 1: GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, SULAR ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL SUMADAN PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL SUMADAN XLT PEROXIDE OR SULFACETAMIDE/SULFUR MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMAVEL DOSEPRO SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL SUMAXIN PEROXIDE OR SULFACETAMIDE/SULFUR SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACNE CLEANSERS CONTAINING BENZOYL SUMAXIN CP PEROXIDE OR SULFACETAMIDE/SULFUR 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, SYNALAR DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

24 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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, SYNALAR TS KIT DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

NAUSEA/VOMITING AT LEAST 2 CONVENTIONAL ANTIEMETIC TREATMENT (FOR N/V ASSOCIATED SYNDROS WITH CANCER CHEMOTHERAPY) OR GENERIC DRONABINOL CAPSULES DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT SYNJARDY (BRAND OR GENERIC) SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE TACROLIMUS OINTMENT(GENERIC) (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

INFLAMMATORY CONDITIONS PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC, XELJANZ/XR TALTZ (TRY 2) PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC (TRY 2) ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, TARGADOX DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE TECFIDERA MULTIPLE SCLEROSIS RULE 1: GENERIC GLATIRAMER 20MG OR 40 MG 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, TEMOVATE DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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 TENORETIC ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

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 TENORMIN ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

TESTRED HORMONAL SUPPLEMENTATION RULE 4: GENERIC OR METHITEST HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, TEVETEN OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, TEVETEN HCT OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE

25 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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, TEXACORT DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, TIVORBEX 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 TOPAMAX MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN TOPAMAX SPRINKLE MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN 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, TOPICORT DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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, TOPICORT SPRAY DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

TOPIRAMATE ER MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN 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 TOPROL XL ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE TOVIAZ ER, TROSPIUM, TROSPIUM ER DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT TRADJENTA (BRAND OR GENERIC) TRAMADOL EXTENDED RELEASE PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN 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 TRANDATE ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

TRELSTAR DEPOT ONCOLOGY ELIGARD TRELSTAR LA ONCOLOGY ELIGARD TREMFYA INFLAMMATORY CONDITIONS PSORIASIS: HUMIRA MIGRAINE HEADACHES ALMOTRIPTAN, ELETRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, TREXIMET SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, TRIBENZOR OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE

26 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE TRICOR HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID TRIGLIDE HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID TRILEPTAL MENTAL/NEUROLOGICAL DISORDERS RULE 4: OXCARBAZEPINE TRILIPIX HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID TROKENDI XR MENTAL/NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN TUSSICAPS COUGH AND COLD RULE 16: GENERIC COUGH/COLD LIQUID TUZISTRA XR COUGH AND COLD RULE 17: GENERIC COUGH/COLD LIQUID HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, TWYNSTA OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, VALSARTAN/AMLODIPINE/HYDROCHLOROTHIAZIDE ULORIC GOUT ALLOPURINOL ULTRACET PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN ULTRAM PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN ULTRAM ER PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN 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, ULTRAVATE DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

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, ULTRAVATE X DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

UROXATRAL BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN VANATOL LQ PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITAL VANATOL S PAIN RULE 6: GENERIC PRODUCT WITH BUTALBITAL 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, VANOS DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE, BENZOYL PEROXIDE, CLINDAMYCIN, VELTIN ERYTHROMYCIN, SODIUM SULFACETAMIDE, OR SODIUM SULFACETAMIDE/SULFUR-CONTAINING PRODUCTS 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 VENLAFAXINE EXTENDED-RELEASE (BRA CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE-RELEASE TABLETS VENTAVIS PULMONARY HYPERTENSION TYVASO ALLERGIES BUDESONIDE NASAL SPRAY, BUDESONIDE NASAL SPRAY (OTC), FLUTICASONE PROPIONATE NASAL SPRAY, FLUNISOLIDE NASAL SPRAY, MOMETASONE FUROATE VERAMYST NASAL SPRAY, TRIAMCINOLONE NASAL SPRAY (OTC), TRIAMCINOLONE ACETONIDE NASAL SPRAY

27 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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, VERDESO DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

VERELAN HIGH BLOOD PRESSURE RULE 3: VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER VERELAN PM HIGH BLOOD PRESSURE RULE 3: VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE VESICARE ER, TROSPIUM, TROSPIUM ER ANTI-INFECTIVE GENERIC SOLID DOSAGE FORMS: AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE IR, VIBRAMYCIN DOXYCYCLINE DR, MINOCYCLINE IR, MONDOXYNE NL, MORGIDOX, OCUDOX CONVENIENCE KIT, TETRACYCLINE DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI: VIIBRYD CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE VITUZ COUGH AND COLD RULE 17: GENERIC COUGH/COLD LIQUID PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, VIVLODEX 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 PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, VOLTAREN GEL 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 PAIN GENERIC NSAIDS (MUST USE TWO) FOR EXAMPLE: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, VOLTAREN XR 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 HIGH BLOOD CHOLESTEROL STEP 1: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, ROSUVASTATIN, VYTORIN ATORVASTATIN/AMLODIPINE, EZETIMIBE/SIMVASTATIN STEP 2: LIVALO ATTENTION DISORDERS GENERIC STIMULANT MEDICATIONS FOR EXAMPLE: AMPHETAMINE/DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED-RELEASE CAPSULES, VYVANSE DEXTROAMPHETAMINE EXTENDED-RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED-RELEASE TABLETS

WELCHOL HIGH BLOOD CHOLESTEROL CHOLESTYRAMINE, COLESTIPOL, PREVALITE WELLBUTRIN SR DEPRESSION BUPROPION SR, BUPROPION ER WELLBUTRIN XL DEPRESSION BUPROPION SR, BUPROPION ER XADAGO MENTAL/NEUROLOGICAL DISORDERS RASAGILINE, SELEGILINE XATMEP ONCOLOGY/INFLAMMATORY CONDITIONS RULE 21: METHOTREXATE TABLETS, TREXALL XENAZINE MENTAL/NEUROLOGICAL DISORDERS TETRABENAZINE DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT XIGDUO XR (BRAND OR GENERIC) XTAMPZA ER PAIN - NARCOTIC N/A HEMOPHILIA ADVATE, ADYNOVATE, AFSTYLA, HELIXATE, KOGENATE, KOVALTRY, NOVOEIGHT, XYNTHA NUWIQ YOSPRALA ULCER RULE 18: ASPIRIN + RX PPI METABOLIC, IMMUNE DISORDERS OR INHERITED RULE 2: CERDELGA, GENERIC MIGLUSTAT ZAVESCA RARE DISEASE

28 HCR-0764-013019 2019 Step Therapy Drugs

MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE 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 ZEBETA ER, TIMOLOL) AND GENERIC BETA-BLOCKER COMBINATION PRODUCTS (I.E., ATENOLOL/CHLORTHALIDONE, BISOPROLOL/HCTZ, METOPROLOL/HCTZ, NADOLOL/BENDROFLUMETHIAZIDE, PROPRANOLOL/HCTZ)

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 ZEGERID (BRAND AND SELECT GENERICS COVERAGE REVIEW MUST BE COMPLETED IN ORDER TO GAIN ACCESS TO A STEP 2 DRUG. ZELAPAR MENTAL/NEUROLOGICAL DISORDERS RASAGILINE, SELEGILINE METABOLIC, IMMUNE DISORDERS OR INHERITED ARALAST NP, GLASSIA ZEMAIRA RARE DISEASE

29 HCR-0764-013019