Step Therapy Program Information - Prime Therapeutics

<strong>Step</strong> <strong>Therapy</strong><strong>Program</strong> <strong>Information</strong><strong>Step</strong> <strong>Therapy</strong>The step therapy program helps promote safe, quality and affordable pharmacy care. Thisprogram requires you to try a more cost-effective <strong>Step</strong> 1 drug before a less cost-effective<strong>Step</strong> 2 drug will be covered.If you have already taken the <strong>Step</strong> 1 drug, or if there is a medical reason why you cannotdo so, your physician can submit a <strong>Step</strong> <strong>Therapy</strong> prior authorization request form to<strong>Prime</strong> <strong>Therapeutics</strong>. This form can be found on the My<strong>Prime</strong>Tools website (located on thesame page where this form is found).<strong>Step</strong> <strong>Therapy</strong>program nameARTHRITIS / PAINBiologicImmunomodulatorsCOX-2 InhibitorsNSAID/Gastrointestinal(GI) Protectants<strong>Step</strong> 1 alternatives to<strong>Step</strong> 2 drugs in programFor Humira:If used for arthritis – methotrexate, leflunomide,minocycline, sulfasalazine, hydroxychloroquineIf used for psoriasis – methotrexate, topicalcorticosteroids, coal tar products, anthralin, calcipotriene,calcitriol, acitretin, tazarotene, cyclosporine, methoxsalen,tacrolimus, pimecrolimus, PUVAIf used for Crohn’s/Ulcerative Colitis -aminosalicylates, methotrexate, corticosteroids,metronidazole, ciprofloxacin, cyclosporine, azathioprine,6-mercaptopurineIf used for Ankylosing spondylitis - noneFor all other agents:If used for arthritis – methotrexate, leflunomide,minocycline, sulfasalazine, hydroxychloroquine PLUSHumiraIf used for psoriasis – methotrexate, topicalcorticosteroids, coal tar products, anthralin, calcipotriene,calcitriol, acitretin, tazarotene, cyclosporine, methoxsalen,tacrolimus, pimecrolimus, PUVA PLUS HumiraIf used for Crohn’s/Ulcerative Colitis -methotrexate, aminosalicylates, corticosteroids,cyclosporine, azathioprine, 6-mercaptopurine,metronidazole, ciprofloxacin PLUS HumiraIf used for Ankylosing spondylitis - Humirageneric oral nonselective NSAID plus generic proton pumpinhibitor (PPI)ORgeneric oral nonselective NSAID plus generic misoprostolORgeneric oral nonselective NSAID/misoprostol combinationgeneric oral nonselective NSAID plus generic proton pumpinhibitor (PPI)ORgeneric oral nonselective NSAID plus generic misoprostolORgeneric oral nonselective NSAID/misoprostol combination<strong>Step</strong> 2 drugsincluded in program(Unless otherwise notedone prerequisite must betried prior to a <strong>Step</strong> 2 drug)Actemra, Amevive, Enbrel,Cimzia, Humira, Kineret,Orencia, Remicade, Rituxan,Simponi, Stelara, XeljanzCelebrexDuexis, Vimovo<strong>Prime</strong> <strong>Therapeutics</strong> LLC (<strong>Prime</strong>), the independent pharmacy benefit management company selected by your employer, is dedicated toproviding innovative, clinically based, cost-effective pharmacy solutions.5483-D Page 1 of 3

<strong>Step</strong> <strong>Therapy</strong>program nameBLOOD DISORDERSHereditary Angioedema(HAE)DEPRESSION<strong>Step</strong> 1 alternatives to<strong>Step</strong> 2 drugs in programFirazyr<strong>Step</strong> 2 drugsincluded in program(Unless otherwise notedone prerequisite must betried prior to a <strong>Step</strong> 2 drug)Berinert, KalbitorAntidepressantDERMATOLOGYAtopic DermatitisGASTROINTESTINALProton Pump Inhibitors(PPI)HIGH CHOLESTEROLStatinFibratesoral formulations of omeprazole, lansoprazole,pantoprazole, omeprazole-sodium bicarbonateatorvastatin, fluvastatin, lovastatin, pravastatin,simvastatina generic fenofibrateHYPERTENSION (HIGH BLOOD PRESSURE)ARB Renin InhibitorFor all <strong>Step</strong> 2 drugs: bupropion, bupropion ER,citalopram, escitalopram, fluoxetine, fluoxetine DR,fluvoxamine, mirtazapine, paroxetine, paroxetine ER,venlafaxine, venlafaxine ERAdditional <strong>Step</strong> 1 alternatives for Cymbalta only:amitriptyline, cyclobenzaprine, desipramine, gabapentin,imipramine, nortriptyline, tramadolA topical corticosteroid or a topical corticosteroidcombination preparationA generic ACE Inhibitor (e.g. enalapril, lisinopril,benazepril), a generic ACE Inhibitor combination,candesartan/HCTZ*, eprosartan, irbesartan,irbesartan/HCTZ*, losartan, losartan/HCTZ*,valsartan/HCTZ*Aplenzin, Celexa, Cymbalta,Effexor, Effexor XR, Fluoxetine60 mg, Forfivo XL, Lexapro,Luvox CR, Maprotiline, Oleptro,Paxil, Paxil CR, Pexeva, Pristiq,Prozac, Prozac Weekly,Remeron, RemeronSolTab,Venlafaxine ER, Viibryd,Wellbutrin, Wellbutrin SR,Wellbutrin XL, ZoloftElidel, ProtopicAciphex, Dexilant, FIRST-Lansoprazole, FIRST-Omeprazole, Nexium, Prevacid,Prilosec, Protonix, ZegeridAdvicor, Altoprev, Mevacor,Crestor, Lescol, Lescol XL,Lipitor, Livalo, Pravachol,Simcor, Vytorin, ZocorAntara, Fenoglide, Fibricor,Lipofen, Lofibra, TriCor,Triglide, Trilipix, fenofibric acid(brand)ARB Comminations: Atacand,Atacand HCT, Avalide, Avapro,Azor, Benicar, Benicar HCT,Cozaar, Diovan, Diovan HCT,Edarbi, Edarbyclor, Exforge,Exforge HCT, Hyzaar, Micardis,Micardis HCT, Teveten, TevetenHCT, Tribenzor, TwynstaRenin Inhibitor Combinations:Amturnide, Tekamlo, Tekturna,Tekturna HCT, Valturna<strong>Prime</strong> <strong>Therapeutics</strong> LLC (<strong>Prime</strong>), the independent pharmacy benefit management company selected by your employer, is dedicated toproviding innovative, clinically based, cost-effective pharmacy solutions.5483-D Page 2 of 3

<strong>Step</strong> <strong>Therapy</strong>program nameMULTIPLE SCLEROSISMultiple SclerosisSLEEP DISORDERSInsomnia Agents<strong>Step</strong> 1 alternatives to<strong>Step</strong> 2 drugs in programBetaseron, Copaxone, Rebifzolpidem, zolpidem ER, zaleplonBrand names are the property of their respective owners.<strong>Step</strong> 2 drugsincluded in program(Unless otherwise noted oneprerequisite must be triedprior to a <strong>Step</strong> 2 drug)Aubagio, Avonex, Extavia,Gilenya, TysabriAmbien, Ambien CR, Edluar,Intermezzo, Lunesta, Rozerem,Silenor, Sonata, Zolpimist*HCTZ: hydrochlorothiazideDR: delayed-releaseER: extended-releaseSR: sustained-release<strong>Program</strong>s subject to change without notice<strong>Prime</strong> <strong>Therapeutics</strong> LLC (<strong>Prime</strong>), the independent pharmacy benefit management company selected by your employer, is dedicated toproviding innovative, clinically based, cost-effective pharmacy solutions.5483-D Page 3 of 3