PEEHIP Step Therapy List
he following Step Therapy programs to ensure that prescription use by PEEHIP members is safe and affordable. As a PEEHIP member, you
should be aware of the following Step Therapy programs when considering new prescription therapy for any of the conditions listed below. PEEHIP members are required to try
a 1st Step Drug before PEEHIP will pay for a 2nd Step Drug. If after trying a 1st Step Drug your physician decides to prescribe a different
HIP will cover the 2nd Step Drug listed below. A Prior Authorization (PA) is not needed as long as there is a presence of the 1st Step Drug in
your claims history within the past 130 days. If your doctor by-passes the 1st Step Drug and prescribes a 2nd Step Drug, a Prior Authorization (PA) must be completed and s
ubmitted by your doctor’s office. MedImpact, administrator of PEEHIP’s prescription drug benefit, may approve the PA if your doctor provides
on that warrants the use of the 2nd Step Drug. Without an approved PA, the claim will be rejected and the member will be required to pay the
full price of the medication. Your doctor can call MedImpact at the PEEHIP-exclusive Prior Authorization Department at 1-800-347-5841 to complete the PA review by phone,
or to request a PA form. The completed PA form can be faxed to MedImpact at 1-877-606-0728. MedImpact will automatically notify the
PEEHIP members who are currently taking a 2nd step drug, and have had a prescription claim processed for that 2nd Step Drug through the PEEHIP prescription dr
ug benefit within the prior 130 days, will not be subject to Step Therapy for that 2nd Step Drug, i.e. can be grandfathered in from the Step
Therapy requirem ents. NOTE: Samples are not considered processed claims for purposes of Step Therapy. You can ask your doctor if a generic
medication is appropriate for you, and share the PEEHIP Formulary (Preferred Drugs) List with your doctor. Keep the prescription drug program safe and affordable by bei
ng familiar with the Step Therapy programs.
Please Note: Thi s list is subject to change. Generics may be subject to step therapy. In addition, select brands may move to tier 3 status if a generic
equivalent becomes available. KEY: Generics ar
e listed in bold lower case; Formulary Brands are listed in bold upper case; Nonformulary brands are listed in regular upper case; Multi-
source brands (M SBs) with an exact generic equivalent are listed in italics (MSBs are not covered unless the physician indicates in longhand writing on the
prescription “medically necessary” or “dispense as written” or “do not substitute”).
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug montelukast zafirlukast flunisolide fluticasone NASACORT, NASACORT AQ triamcinolone acetonide
- AND- Brand or Generic Antihistamine or Antihistamine/Decongestant tablets or nasal sprays: ALLEGRA, ALLEGRA DASTELIN ASTEPRO CLARINEX, CLARINEX D PATANASE XYZALflunisolide fluticasone triamcinolone acetonide NASAREL OMNARIS RHINOCORT AQ VERAMYST
PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug
(Members must have tried a generic within the
past 365 days before a 2nd step drug will be
flunisolide fluticasone levocetirizine desloratadine donepezil galantamine, galantamine er rivastigmine cap EXELON cap EXELON soln, patch RAZADYNE, RAZADYNE ER
(Members must try two first-line generics before a
diclofenac potassium diclofenac sodium etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketoralac meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium
(Members must try two first-line generics before a
diclofenac potassium diclofenac sodium etodolac EC naproxen fenoprofen flurbiprofen ibuprofen Indomethacin ketoprofen ketoralac meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium RELAFEN TORADOL VOLTAREN, VOLTAREN XR, VOLTAREN GEL ZIPSOR
PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug diclofenac etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meclofenamate meloxicam nabumetone naproxen oxaprozin piroxicam sulindac tolmetin tramadol extended release
doxycycline
Requires a trial of any two generics shown below.
olanzapine quetiapine IR risperidone risperidone ODT ziprasidone
Requires a trial of any two generics shown below.
olanzapine quetiapine IR risperidone risperidone ODT ziprasidone venlafaxine citalopram fluoxetine paroxetine sertraline
SEROQUEL XR
Requires a trial of any two generics shown below. olanzapine quetiapine IR risperidone risperidone ODT ziprasidone venlafaxine citalopram fluoxetine paroxetine sertraline
PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug alfuzosin doxazosin prazosin tamsulosin terazosin finasteride alfuzosin doxazosin prazosin tamsulosin terazosin
Brands: RAPAFLO finasteride alfuzosin doxazosin prazosin tamsulosin terazosin Brands: AVODART RAPAFLO alendronate ACTONEL, ACTONEL W/CALCIUM ibandronate
Authorization will be required for a 2nd step drug.
alendronate ibandronate methylphenidate CD methylphenidate LA lamotrigine topiramate valproic acid lamotrigine immediate release divalproex valproic acid PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug ondansetron tablet or ODT carbamazepine gabapentin lamotrigine levetiracetam oxcarbazepine topiramate zonisamide valproic acid divalproex COMBIVENT DALIRESP
(Must try one first line generic or brand
citalopram escitalopram fluoxetine fluvoxamine CYMBALTA paroxetine sertraline venlafaxine PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug budeprion, budeprion sr, budeprion xl bupropion, bupropion sr, bupropion xl bupropion citalopram escitalopram CYMBALTA fluoxetine fluvoxamine paroxetine sertraline venlafaxine PRISTIQ PROZAC SARAFEM VENLAFAXINE ER ZOLOFT
citalopram escitalopram DESVENLAFAXINE fluoxetine paroxetine sertraline mirtazapine bupropion ir bupropion sr bupropion xl citalopram escitalopram fluoxetine fluvoxamine paroxetine sertraline paroxetine trazodone PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drug 2nd Step Drug h-cortisone-iodoquinol hydrocortisone h-cortisone-iodoquinol PROTOPIC hydrocortisone alclometasone amcinonide lidazone betamethasone betanate lidocaine-hc beta-val clobetasol mometasone del-beta dermazene prednicarbate desonide desoximetasone diflorasone triamcinolone embeline fluocinolone fluocinonide fluticasone halobetasol h-cortisone-iodoquinol PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drugs 2nd Step Drugs 3rd Step Drugs DRITHOCREME HP clobetasol fluticasone fluocinonide triamcinolone VECTICAL metformin er metformin, metformin er metformin/glipizide metformin/glyburide JUVISYNC TRADJENTA JENTADUETO BYDUREON metformin, metformin er metformin/glipizide metformin/glyburide chlorpropamide glimepiride glipizide glyburide tolazamide tolbutamide
BYDUREON AND One of the following generics: metformin, metformin er metformin/glipizide metformin/glyburide chlorpropamide glimepiride glipizide glyburide tolazamide tolbutamide
metformin, metformin er metformin/glipizide metformin/glyburide chlorpropamide glimepiride glipizide glyburide tolazamide tolbutamide pioglitazone prednisone balsalazide PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug dorzolamide/timolol
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug benazepril captopri lenalapril fosinopril lisinopril moexipril perindopril quinapril ramipril trandolapril benazepril/amlodipine benazepril/hctz captopril/hctz enalapril/hctz fosinopril/hctz lisinopril/hctz moexipril/hctz quinapril/hctz losartan +/- hctz valsartan hctz irbesartan +/- hctz EXFORGE, HCT acebutolol BYSTOLIC atenolol atenolol- chlorthalidone betaxolol bisoprolol, -hctz carvedilol, er labetalol metoprolol, -hctz metoprolol succinate er nadolol, bendroflumethiazide pindolol propranolol, LA, -hctz PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug verapamil er verapamil ir verapamil sr COVERA-HS ISOPTIN SR VERELAN, PM amlodipine amlodipine/benazepril felodipine DYNACIRC CR isradipine nicardipine ir nifedipine nisoldipine
Must try a generic ACE, ACE combination product,
lovastatin CRESTOR* pravastatin simvastatin fenofibrate
FENOGLIDE LIPOFEN LOFIBRA TRICOR (fenofibrate) TRIGLIDE TRILIPIX
Requires a trial of any two generics below.
atorvastatin lovastatin pravastatin simvastatin
the past 365 days or a Prior Authorization will be required.
Requires a trial of any two generics below.
atorvastatin lovastatin pravastatin simvastatin
Requires a trial of any two generics below.
atorvastatin lovastatin pravastatin simvastatin atorvastatin 40mg or 80mg PEEHIP Step Therapy List – October 1, 2013
Condition Drug Category 1st Step Drug 2nd Step Drug 3rd Step Drug zaleplon zolpidem AMBIEN CR EDLUAR INTERMEZZO LUNESTA ROZEREM SONATA ZOLPIMIST
Members must try both first line agents before a
COPAXONE entacapone ropinirole pramipexole NEUPRO REQUIP, XL gabapentin pramipexole ropinirole IR gabapentin IR gabapentin oxybutynin ir, xl
GELNIQUE OXYTROL SANCTURA SANCTURA XR TOVIAZ VESICARE
Associates in Gastroenterology, P.C. FLEXIBLE SIGMOIDOSCOPY INSTRUCTIONS Your SIGMOIDOSCOPY is scheduled at: ___________ on ________________ (mo/d/yr). Please arrive at the Endoscopy Center at __________. The Endoscopy Center is located at: POTOMAC CENTER, 2296 Opitz Blvd, 1st Floor, Suite 130, Woodbridge PRINCE WILLIAM AMBULATORY SURGICAL CENTER, 8644 Sudley Rd., Suite 201,
PEEHIP Step Therapy List