Microsoft word - gd_st_tip sheet_final_3-26-2013.docx

Step Therapy
Program Information

Step Therapy
The step therapy program helps promote safe, quality and affordable pharmacy care. This
program requires you to try a more cost-effective Step 1 drug before a less cost-effective
Step 2 drug will be covered.
If you have already taken the Step 1 drug, or if there is a medical reason why you cannot
do so, your physician can submit a Step Therapy prior authorization request form to
Prime Therapeutics. This form can be found on the MyPrimeTools website (located on the
same page where this form is found).
Step Therapy
Step 1 alternatives to
Step 2 drugs
program name
Step 2 drugs in program
included in program
(Unless otherwise noted one
prerequisite must be tried
prior to a Step 2 drug)
ARTHRITIS / PAIN
For Humira:
If used for arthritis – methotrexate,
leflunomide, minocycline, sulfasalazine,
hydroxychloroquine
If used for psoriasis – methotrexate, topical
corticosteroids, coal tar products, anthralin,
calcipotriene, calcitriol, acitretin, tazarotene,
cyclosporine, methoxsalen, tacrolimus,
pimecrolimus, PUVA
If used for Crohn’s/Ulcerative Colitis -
aminosalicylates, methotrexate, corticosteroids,
metronidazole, ciprofloxacin, cyclosporine,
azathioprine, 6-mercaptopurine
If used for Ankylosing spondylitis - none
For all other agents:
If used for arthritis – methotrexate,
leflunomide, minocycline, sulfasalazine,
hydroxychloroquine PLUS Humira
If used for psoriasis – methotrexate, topical
corticosteroids, coal tar products, anthralin,
calcipotriene, calcitriol, acitretin, tazarotene,
cyclosporine, methoxsalen, tacrolimus,
pimecrolimus, PUVA PLUS Humira
If used for Crohn’s/Ulcerative Colitis -
methotrexate, aminosalicylates, corticosteroids,
cyclosporine, azathioprine, 6-mercaptopurine,
metronidazole, ciprofloxacin PLUS Humira
If used for Ankylosing spondylitis - Humira
generic oral nonselective NSAID plus generic
proton pump inhibitor (PPI)
OR
generic oral nonselective NSAID plus generic
misoprostol OR generic oral nonselective NSAID/misoprostol combination Prime Therapeutics LLC (Prime), the independent pharmacy benefit management company selected by your employer, is dedicated to providing innovative, clinically based, cost-effective pharmacy solutions. Step Therapy
Step 1 alternatives to
Step 2 drugs
program name
Step 2 drugs in program
included in program
(Unless otherwise noted one
prerequisite must be tried
prior to a Step 2 drug)
DEPRESSION
For all Step 2 drugs: bupropion, bupropion
ER, citalopram, escitalopram, fluoxetine, fluoxetine DR, fluvoxamine, mirtazapine, Additional Step 1 alternatives for Cymbalta
only: amitriptyline, cyclobenzaprine,
DERMATOLOGY
DIABETES
metformin, a sulfonylurea (e.g., glimepiride, glipizide, glyburide), a combination product containing metformin and/or a sulfonylurea, Lantus, Levemir GASTROINTESTINAL
oral formulations of omeprazole, lansoprazole, pantoprazole, omeprazole-sodium bicarbonate Nexium, Prevacid, Prilosec, Protonix, Zegerid HIGH CHOLESTEROL
atorvastatin, fluvastatin, lovastatin, pravastatin, Livalo, Pravachol, Simcor, Vytorin, Zocor HYPERTENSION (HIGH BLOOD PRESSURE)
ARB Comminations: Atacand, Atacand HCT, Avalide, Avapro, Azor, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, A generic ACE Inhibitor (e.g. enalapril, lisinopril, combination, candesartan/HCTZ*, eprosartan, Renin Inhibitor Combinations: Amturnide, Tekamlo, Tekturna, Tekturna HCT, Valturna MULTIPLE SCLEROSIS
SLEEP DISORDERS
Intermezzo, Lunesta, Rozerem, Silenor, Sonata, Zolpimist Brand names are the property of their respective owners. DR: delayed-release ER: extended-release SR: sustained-release This program is subject to change without notice. Prime Therapeutics LLC (Prime), the independent pharmacy benefit management company selected by your employer, is dedicated to providing innovative, clinically based, cost-effective pharmacy solutions.

Source: https://primetherapeutics.com/pdf/General%20Dynamics%20Step%20Therapy%20Programs.pdf