ALPHA BLOCKERS
Products Affected
Step 2:
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Cardura 1 mg tablet
Cardura 2 mg tablet
Cardura 4 mg tablet
Cardura 8 mg tablet
Cardura XL 4 mg tablet,extended release
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Cardura XL 8 mg tablet,extended release
Flomax 0.4 mg capsule
Rapaflo 4 mg capsule
Rapaflo 8 mg capsule
Uroxatral 10 mg tablet,extended release
Details
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2
drug may be given.
1
ANTIDEPRESSANTS - SNRI
Products Affected
Step 2:
 Cymbalta 20 mg capsule,delayed release
 Cymbalta 30 mg capsule,delayed release
 Cymbalta 60 mg capsule,delayed release
 desvenlafaxine ER 100 mg
tablet,extended release 24 hr
 desvenlafaxine ER 50 mg
tablet,extended release 24 hr
 Effexor XR 150 mg capsule,extended
release
 Effexor XR 37.5 mg capsule,extended
release
 Effexor XR 75 mg capsule,extended
release
 Fetzima 120 mg capsule,extended
release
 Fetzima 20 mg (2)-40 mg (26)
capsule,extended release,24 hr,dose pack
 Fetzima 20 mg capsule,extended release
 Fetzima 40 mg capsule,extended release
 Fetzima 80 mg capsule,extended release
 Khedezla 100 mg tablet,extended release
 Khedezla 50 mg tablet,extended release
 Pristiq 100 mg tablet,extended release
 Pristiq 50 mg tablet,extended release
Details
Criteria
If the patient has tried a Step 1 drug, then authorization for a drug in
Step 2 drug may be given. Authorization may be given for a step 2 drug
that does not have a generic equivalent included in step 1, without trial
of a step 1 drug, if the patient is currently taking or has taken the drug in
the past. Authorization may be given for a step 2 drug that does not
have a generic equivalent included in step 1, without a trial of a step 1
drug, if the patient has symptoms of suicidal ideation.
2
DPP-4 INHIBITORS-PST
Products Affected
Step 2:
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Jentadueto 2.5 mg-1,000 mg tablet
Jentadueto 2.5 mg-500 mg tablet
Jentadueto 2.5 mg-850 mg tablet
Kazano 12.5 mg-1,000 mg tablet
Kazano 12.5 mg-500 mg tablet
Nesina 12.5 mg tablet
Nesina 25 mg tablet
Nesina 6.25 mg tablet
Tradjenta 5 mg tablet
Details
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2
drug may be given.
3
ENHANCED OVERACTIVE BLADDER
Products Affected
Step 2:
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Enablex 15 mg tablet,extended release
Enablex 7.5 mg tablet,extended release
Myrbetriq 25 mg tablet,extended release
Myrbetriq 50 mg tablet,extended release
Step 3:
 Detrol 1 mg tablet
 Detrol 2 mg tablet
 Detrol LA 2 mg capsule,extended release
 Detrol LA 4 mg capsule,extended release
 Ditropan XL 10 mg tablet,extended
release
 Ditropan XL 15 mg tablet,extended
release
Toviaz 4 mg tablet,extended release
Toviaz 8 mg tablet,extended release
Vesicare 10 mg tablet
Vesicare 5 mg tablet
 Ditropan XL 5 mg tablet,extended
release
 Gelnique 10 % (100 mg/gram)
transdermal gel packet
 Gelnique 28 mg/0.92 gram (3 %)
transdermal gel pump
 Oxytrol 3.9 mg/24 hr transdermal patch
 Sanctura 20 mg tablet
 Sanctura XR 60 mg capsule,extended
release
Details
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2
drug may be given. If the patient has tried a Step 1 and a Step 2 drug,
then authorization for a Step 3 drug may be given. Authorization for
Gelnique or Oxytrol may be given for patients who cannot swallow or
who have difficulty swallowing.
4
OPHTHALMIC PROSTAGLANDINS-PST
Products Affected
Step 2:
 Rescula 0.15 % eye drops
 Xalatan 0.005 % eye drops
 Zioptan (PF) 0.0015 % eye drops in a
dropperette
Details
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2
drug may be given. Authorization for Zioptan may be given if the
patient has a known benzalkonium chloride (BAK) sensitivity and a
known sensitivity to other ophthalmic preservatives.
5
TETRACYCLINES (ORAL)
Products Affected
Step 2:
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Adoxa 150 mg capsule
Doryx 150 mg tablet,delayed release
Doryx 200 mg tablet,delayed release
Oracea 40 mg capsule, extended release
Solodyn 105 mg tablet,extended release
Solodyn 115 mg tablet,extended release
Solodyn 55 mg tablet,extended release
Solodyn 65 mg tablet,extended release
Solodyn 80 mg tablet,extended release
Vibramycin 100 mg capsule
Details
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2
drug may be given. Authorization for Oracea will be given if it is being
used in the treatment of rosacea.
6
TOPICAL CORTICOSTEROIDS
Products Affected
Step 2:
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


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Ala-Scalp 2 % lotion
Capex 0.01 % shampoo
Clobex 0.05 % lotion
Clobex 0.05 % shampoo
Clobex 0.05 % topical spray
Cloderm 0.1 % topical cream
Cordran Tape Large Roll 4 mcg/cm2
Cutivate 0.05 % lotion
Cutivate 0.05 % topical cream
Dermatop 0.1 % topical cream
Dermatop 0.1 % topical ointment
Desonate 0.05 % topical gel
DesOwen 0.05 % lotion
DesOwen 0.05 % topical cream
Diprolene 0.05 % lotion
Diprolene 0.05 % topical ointment
Diprolene AF 0.05 % topical cream
Elocon 0.1 % topical cream
Elocon 0.1 % topical lotion (solution)
Elocon 0.1 % topical ointment
Halog 0.1 % topical cream
Halog 0.1 % topical ointment
Kenalog 0.147 mg/gram topical aerosol
Olux 0.05 % topical foam
Pandel 0.1 % topical cream
Synalar Cream Kit 0.025 % topical
Temovate 0.05 % topical cream
Temovate 0.05 % topical ointment
Topicort 0.05 % topical cream
Topicort 0.05 % topical gel
Topicort 0.05 % topical ointment
Topicort 0.25 % topical cream
Topicort 0.25 % topical ointment
Topicort 0.25 % topical spray
U-Cort 1 %-10 % topical cream
Ultravate 0.05 % topical cream
Ultravate 0.05 % topical ointment
Vanos 0.1 % topical cream
Details
Criteria
If the patient has tried two Step 1 drugs, then authorization for a Step 2
drug may be given. Authorization for a step 2 drug may be given if the
patient has tried two step 1 drugs for the current condition.
Authorization may be given for Capex shampoo without a trial of two
step 1 drugs for the treatment of dermatoses of the scalp. Authorization
may be given for Derma-Smoothe FS scalp oil without a trial of two
step 1 drugs for the treatment of psoriasis of the scalp.
7
TOPICAL NSAIDS-PST
Products Affected
Step 2:
 Pennsaid 1.5 % topical drops
 Pennsaid 20 mg/gram/actuation (2 %)
topical soln in metered-dose pump
Details
Criteria
If the patient has tried one Step 1 drug, then authorization for a Step 2
drug may be given.
8
ULORIC
Products Affected
Step 2:
 Uloric 40 mg tablet
 Uloric 80 mg tablet
Details
Criteria
If the patient has tried a Step 1 drug (brand or generic), then
authorization for a Step 2 drug may be given. Authorization may be
given for Uloric if the patient has renal insufficiency or decreased renal
function. Authorization may be given for Uloric if the patient is
receiving concomitant medications that have significant drug-drug
interactions with allopurinol, which are not noted with Uloric (eg,
cyclosporine, chlorpropamide).
9
Index
A
Adoxa 150 mg capsule ................................ 6
Ala-Scalp 2 % lotion ................................... 7
C
Capex 0.01 % shampoo............................... 7
Cardura 1 mg tablet ..................................... 1
Cardura 2 mg tablet ..................................... 1
Cardura 4 mg tablet ..................................... 1
Cardura 8 mg tablet ..................................... 1
Cardura XL 4 mg tablet,extended release ... 1
Cardura XL 8 mg tablet,extended release ... 1
Clobex 0.05 % lotion .................................. 7
Clobex 0.05 % shampoo ............................. 7
Clobex 0.05 % topical spray ....................... 7
Cloderm 0.1 % topical cream...................... 7
Cordran Tape Large Roll 4 mcg/cm2 ......... 7
Cutivate 0.05 % lotion ................................ 7
Cutivate 0.05 % topical cream .................... 7
Cymbalta 20 mg capsule,delayed release ... 2
Cymbalta 30 mg capsule,delayed release ... 2
Cymbalta 60 mg capsule,delayed release ... 2
D
Dermatop 0.1 % topical cream.................... 7
Dermatop 0.1 % topical ointment ............... 7
Desonate 0.05 % topical gel........................ 7
DesOwen 0.05 % lotion .............................. 7
DesOwen 0.05 % topical cream .................. 7
desvenlafaxine ER 100 mg tablet,extended
release 24 hr ............................................ 2
desvenlafaxine ER 50 mg tablet,extended
release 24 hr ............................................ 2
Detrol 1 mg tablet ....................................... 4
Detrol 2 mg tablet ....................................... 4
Detrol LA 2 mg capsule,extended release .. 4
Detrol LA 4 mg capsule,extended release .. 4
Diprolene 0.05 % lotion .............................. 7
Diprolene 0.05 % topical ointment ............. 7
Diprolene AF 0.05 % topical cream ........... 7
Ditropan XL 10 mg tablet,extended release 4
Ditropan XL 15 mg tablet,extended release 4
Ditropan XL 5 mg tablet,extended release . 4
Doryx 150 mg tablet,delayed release .......... 6
Doryx 200 mg tablet,delayed release .......... 6
E
Effexor XR 150 mg capsule,extended
release ..................................................... 2
Effexor XR 37.5 mg capsule,extended
release ..................................................... 2
Effexor XR 75 mg capsule,extended release
................................................................. 2
Elocon 0.1 % topical cream ........................ 7
Elocon 0.1 % topical lotion (solution) ........ 7
Elocon 0.1 % topical ointment .................... 7
Enablex 15 mg tablet,extended release ....... 4
Enablex 7.5 mg tablet,extended release ...... 4
F
Fetzima 120 mg capsule,extended release .. 2
Fetzima 20 mg (2)-40 mg (26)
capsule,extended release,24 hr,dose pack 2
Fetzima 20 mg capsule,extended release .... 2
Fetzima 40 mg capsule,extended release .... 2
Fetzima 80 mg capsule,extended release .... 2
Flomax 0.4 mg capsule ............................... 1
G
Gelnique 10 % (100 mg/gram) transdermal
gel packet ................................................ 4
Gelnique 28 mg/0.92 gram (3 %)
transdermal gel pump .............................. 4
H
Halog 0.1 % topical cream .......................... 7
Halog 0.1 % topical ointment ..................... 7
J
Jentadueto 2.5 mg-1,000 mg tablet ............. 3
Jentadueto 2.5 mg-500 mg tablet ................ 3
Jentadueto 2.5 mg-850 mg tablet ................ 3
K
Kazano 12.5 mg-1,000 mg tablet ................ 3
Kazano 12.5 mg-500 mg tablet ................... 3
Kenalog 0.147 mg/gram topical aerosol ..... 7
Khedezla 100 mg tablet,extended release ... 2
Khedezla 50 mg tablet,extended release ..... 2
M
Myrbetriq 25 mg tablet,extended release .... 4
Myrbetriq 50 mg tablet,extended release .... 4
N
Nesina 12.5 mg tablet ................................. 3
Nesina 25 mg tablet .................................... 3
10
Nesina 6.25 mg tablet ................................. 3
O
Olux 0.05 % topical foam ........................... 7
Oracea 40 mg capsule, extended release..... 6
Oxytrol 3.9 mg/24 hr transdermal patch ..... 4
P
Pandel 0.1 % topical cream ......................... 7
Pennsaid 1.5 % topical drops ...................... 8
Pennsaid 20 mg/gram/actuation (2 %)
topical soln in metered-dose pump ......... 8
Pristiq 100 mg tablet,extended release........ 2
Pristiq 50 mg tablet,extended release.......... 2
R
Rapaflo 4 mg capsule .................................. 1
Rapaflo 8 mg capsule .................................. 1
Rescula 0.15 % eye drops ........................... 5
S
Sanctura 20 mg tablet.................................. 4
Sanctura XR 60 mg capsule,extended
release ..................................................... 4
Solodyn 105 mg tablet,extended release ..... 6
Solodyn 115 mg tablet,extended release ..... 6
Solodyn 55 mg tablet,extended release ....... 6
Solodyn 65 mg tablet,extended release ....... 6
Solodyn 80 mg tablet,extended release ....... 6
Synalar Cream Kit 0.025 % topical ............ 7
T
Temovate 0.05 % topical cream.................. 7
Temovate 0.05 % topical ointment ............. 7
Topicort 0.05 % topical cream .................... 7
Topicort 0.05 % topical gel ......................... 7
Topicort 0.05 % topical ointment ............... 7
Topicort 0.25 % topical cream .................... 7
Topicort 0.25 % topical ointment ............... 7
Topicort 0.25 % topical spray ..................... 7
Toviaz 4 mg tablet,extended release ........... 4
Toviaz 8 mg tablet,extended release ........... 4
Tradjenta 5 mg tablet .................................. 3
U
U-Cort 1 %-10 % topical cream.................. 7
Uloric 40 mg tablet ..................................... 9
Uloric 80 mg tablet ..................................... 9
Ultravate 0.05 % topical cream ................... 7
Ultravate 0.05 % topical ointment .............. 7
Uroxatral 10 mg tablet,extended release ..... 1
V
Vanos 0.1 % topical cream ......................... 7
Vesicare 10 mg tablet.................................. 4
Vesicare 5 mg tablet.................................... 4
Vibramycin 100 mg capsule ....................... 6
X
Xalatan 0.005 % eye drops ......................... 5
Z
Zioptan (PF) 0.0015 % eye drops in a
dropperette .............................................. 5
11