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STEP THERAPY PROGRAM FOR ASCENSION HEALTH
JULY 2013
***Most step therapy programs have exception criteria for members taking certain medications and/or medical histories. Depending on a member's specific medical history, a step two medication may be
approved without a trial of a first step medication.***
Step Therapy Program
Targeted drugs
First step drugs
This program looks for
benazepril, benazepril/HCTZ, captopril, captopril/HCTZ, enalapril, enalapril/HCTZ, fosinopril, Benicar, Benicar HCT, Edarbi, Edarbyclor, Exforge, fosinopril/HCTZ, lisinopril, lisinopril/HCTZ, ramipril, Previous rx for ACE inhibitor or ACE combination AND generic
Angiotensin II Receptor Antagonists (ARBs): Exforge HCT, Micardis, Micardis HCT, Teveten, Teveten quinapril, quinapril/HCTZ, moexipril, trandolapril, ARB or generic ARB combination required.
moexipril/HCTZ, candesartan, candesartan/HCTZ, irebsartan, irebsartan/HCTZ, losartan, losartan/HCTZ, valsartan/HCTZ cambamzepine, divalproex, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, topiramate, Prior use of generics as 1st line agentsvalproate, valproic acid, zonisamide Prior use of 1 first line generic medication: Aplenzin requires Aplenzin, Desvenlafaxine ER tabs, Luvox CR, Oleptro, generic bupropion XL first; Oleptro requires immediate release Pexeva, Pristiq, Prozac/Weekly, Sarafem, Viibryd olanzapine, quetiapine, risperidone or ziprasidone alfuzosin, doxazosin, finasteride, tamsulosin or Advicor, Altoprev, Crestor, Lescol, Lescol XL, Livalo, atorvastatin, atorvastatin/amlodipine, lovastatin, Prior use of two generic statins; Zetia concurrent use of any 2 of any of the following; diclofenac, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, COX-2 Inhibitors; naproxen + esomeprazole indomethacin, ketoprofen, ketorolac, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, salsalate or sulindac Actosplus Met XR, Avandamet, Avandaryl, Avandia, Cycloset, Duetact, Invokana, Janumet, Janumet XR, metformin, metformin-glyburide, metformin-glipizide, Januvia, Jentadueto, Juvisync, Kazano, Kombiglyze XR, or sulfonylureaNesina, Oseni, Onglyza, Tradjenta Edluar, Intermezzo, Lunesta, Rozerem, Silenor, Sonata, Alsuma, Axert, Frova, Imitrex, Maxalt/MLT, Relpax, naratriptan, rizatriptan, sumatriptan or zolmitriptan Prior use of vancomycin AND oral metronidazole Avonex, Betaseron, Copaxone, Rebif, Extavia Concurrent use of 1 first line medication STEP THERAPY PROGRAM FOR ASCENSION HEALTH
JULY 2013
***Most step therapy programs have exception criteria for members taking certain medications and/or medical histories. Depending on a member's specific medical history, a step two medication may be
approved without a trial of a first step medication.***
Step Therapy Program
Targeted drugs
First step drugs
This program looks for
Detrol LA, Ditropan XL, Enablex, Gelnique, Myrbetriq, oxybutynin immediate release, oxybutynin extended Immediate release gabapentin for Gralise Generic ropinerole or pramipexole for Horizant Betamethasone dipropionate, desoximetasone, Prior use of generic oral diclofenac for Pennsaid; any generic

Source: https://mp.medimpact.com/brandcontentprovider/ASC/MP/current_step_therapy.pdf