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2012 Step Therapy Program Drug List
Condition/
Second Line (Step Two)
First Line (Step One) Products
Drug Classification
Products
High Blood Pressure
benazepril, benazepril/HCTZ, captopril, captopril/HCTZ, Brand name ACE inhibitors (including but not ACE Inhibitors
enalapril, enalapril/HCTZ, fosinopril, fosinopril/HCTZ, lisinopril, limited to): Accupril, Accuretic, Aceon, Altace, lisinopril/HCTZ, ramipril, quinapril, quinapril/HCTZ, moexipril, Capoten, Capozide, Lexxel, Lotensin HCT, trandolapril, moexipril/HCTZ, benazepril/amlodipine, Lotensin, Lotrel, Mavik, Monopril HCT, Monopril, Prinivil, Prinzide, Tarka, Uniretic, Univasc, Vaseretic, Vasotec, Zestoretic, Zestril High Blood Pressure
benazepril, benazepril/HCTZ, captopril, captopril/HCTZ, Atacand HCT, Atacand, Avalide, Avapro, Azor, Angiotensin-2 Receptor
enalapril, enalapril/HCTZ, fosinopril, fosinopril/HCTZ, lisinopril, Benicar, Benicar HCT,Cozaar, Diovan HCT, Blockers (ARBs or A2s)
lisinopril/HCTZ, ramipril, quinapril, quinapril/HCTZ, moexipril, Diovan, Exforge, Exforge HCT, Hyzaar, Micardis, trandolapril, moexipril/HCTZ, benazepril/amlodipine, Micardis HCT, Teveten, Teveten HCT, Twynsta, perindopril, trandolapril/verapamil, enalapril/felodipine Note: Members that have used second line medications from the ACE inhibitors step therapy program wil be able to move to second line medications within this program. High Blood Cholesterol
HMG (Statins)
Step Three: Altoprev, Caduet, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Zocor, Vytorin High Blood Cholesterol
Tricor, Lofibra, Antara, Triglide, Lipofen, Fenoglide, Fenofibrates
Stomach Acid Reduction
Step Two: Nexium, pantoprazole, omeprazole- Proton Pump Inhibitors (PPIs)
sodium bicarbonate, lansoprazole orally disintegrating tab Step Three: Aciphex, (formerly Kapidex), Prilosec, Protonix, Zegerid, Prevacid Diabetes
metformin, metformin extended-release, metformin/glyburide, Januvia, Janumet, Onglyza, Kombiglyze, Tradjenta DPP-4 Inhinitors
Pain and Inflammation
diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, Arthrotec, Mobic, Ponstel, Cataflam, Voltaren,
Non-steroidal Anti-inflammatory
indomethacin, ketoprofen, ketorolac, meclofenamate, Voltaren XR, Lodine, Lodine XL, Nalfon,
drugs (NSAIDs)
mefenamic acid, meloxicam, nabumetone, naproxen, Ansaid, Motrin, Indocin, Indocin SR, Orudis,
oxaprozin, piroxicam, sulindac, tolmetin Toradol, Relafen, Naprosyn, Naprelan,
Cox-2 Inhibitors (COX-2s)
Anaprox, Anaprox DS, Daypro, Feldene,
Clinoril, Flector, Voltaren Gel, IC 400, IC 800,
Celebrex, Zipsor, Pennsaid, Cambia
Depression
fluoxetine, fluvoxamine, paroxetine, paroxetine CR, citalopram, Celexa, Lexapro, Luvox CR, Paxil CR, Paxil, Selective Serotonin Reuptake
Pexeva, Prozac, Prozac Weekly, Sarafem, Viibryd, Other Antidepressants
fluoxetine, fluvoxamine, paroxetine/CR, citalopram, sertraline, Other Antidepressants
bupropion SR, bupropion XL, budeprion SR, budeprion XL Cymbalta, Effexor, Effexor XR, Pristiq, Venlafaxine Bupropion
Condition/
Second Line (Step Two)
Drug Classification
First Line (Step One) Products
Products
Skin Inflammation
alclometasone, amcinonide, betamethasone dipropionate Topical Immunomodulators
(augmented), betamethasone dipropionate, clobetasol, clobetasone, fluocinonide, fluticasone, halobetasol, betamethasone valerate, hydrocortisone, hydrocortisone butyrate, hydrocortisone buteprate, hydrocortisone acetate, desonide, desoximetasone, hydrocortisone valerate, mometasone, triamcinolone, diflorasone, fluocinolone, clocortolone, flurandrenolide, halocinonide, prednicarbate Skin Conditions
alclometasone, amcinonide, betamethasone dipropionate Aclovate, Ala-Scalp HP, ApexiCon, Capex, Topical Corticosteroids
(augmented), betamethasone dipropionate, fluocinonide, Clobex, Elocon, Halog, Halonate, Florone, fluticasone, halobetasol, betamethasone valerate, Kenalog, Cloderm, Cordran, Locoid, Luxiq, hydrocortisone, clobetasol, hydrocortisone butyrate, desonide, desoximetasone, hydrocortisone valerate, mometasone, triamcinolone, diflorasone fluocinolone, pramoxine Diprolene/AF, Verdeso, Desonate, Olux-Olux-E, Desowen, Cutivate, Zytopic, Nucort Lotion, Florone, Ultravate, Topicort/LP, Lidex, Westcort, Momexin, Pediaderm, Triderm, Scalacort, Samol-HC, Pramosone, Pramosone E, Desonil/kit Skin Conditions
demeclocycline, doxycycline, minocycline, tetracycline Declomycin, Adoxa, Monodox, Avidoxy/kit, Tetracyclines-Oral
Adoxa/CK/TT/Pak, Doryx, Vibramycin, Vibra-Tabs, Oraxyl, Periostat, Oracea, Dynacin, Minocin/kit/PAC, Solodyn, Sumycin, Alodox/kit, Morgidox, Ocudox Allergies (non-asthma)
For non-asthma conditions:
Leukotriene Pathway Inhibitors
Category 1:fluticasone propionate*, Beconase AQ,
Flonase, flunisolide*, Nasacort, Nasarel, Veramyst,
Nasonex, Rhinocort AQ, Omnaris
Category 2: fexofenadine*, Allegra, Allegra-D,
Clarinex,Clarinex-D, loratadine*^,
try two First Line medications, one from loratadine/pseudoephedrine*^, Claritin, Claritin-D,
cetirizine*^, cetirizine-pseudoephedrine*^, Zyrtec, Zyrtec
D, Xyzal, Astelin/Astepro, Patanase
*try these generics first to avoid being targeted by another step
therapy program;^ these over-the-counter (OTC) products may
not be covered under your prescription benefit
Allergies
loratadine^, loratadine-D^, fexofenadine, fexofenadine-D, Non-Sedating Antihistamines
cetirizine syrup, cetirizine^, cetirizine-D^, levocetirizine ^ these over-the-counter (OTC) products may not be covered under your prescription benefit Allergies
Generics: fluticasone propionate, flunisolide Nasal Steroids
Nasacort AQ, Nasarel, Nasonex, Flonase, Veramyst, Omnaris Sleep Disorders
Sedative Hypnotics
Overactive Bladder (OAB)
Detrol, Detrol LA, Sanctura, Vesicare, Enablex, Oxytrol, Ditropan, Ditropan XL, Toviaz, Gelnique Hypertension
benazepril, benazepril/HCTZ, benazepril/amlodipine, captopril, Tekturna, Tekturna HCT, Valturna, captopril/HCTZ, enalapril, enalapril/HCTZ, fosinopril, Tekturna
fosinopril/HCTZ, lisinopril, lisinopril/HCTZ, moexipril, moexipril/HCTZ, perindopril, quinapril, quinapril/HCTZ, trandolapril, trandolapril/verapamil, enalapril/felodipine, benazepril/amlodipine Neuropathic pain
Osteoporosis
Step-Two: Actonel, Actonel Plus Calcium, Boniva, Atelvia Bisphosphonates Enhanced
Restless Leg
Syndrome/Parkinson’s Disease
Mirapex/Requip
Adderall, Adderall XR, Concerta, Daytrana, Desoxyn, Strattera
Dexedrine, Dexedrine Spansules, Dextroamphetamine IR, Dextroamphetamine SR, dexmethylphenidate IR, Focalin, Focalin XR, Metadate CD, Metadate ER, methamphetamine, Methylin, Methylin ER, methylphenidate ER, methylphenidate immediate release, mixed amphetamine salts IR, Ritalin LA, Ritalin SR, Vyvanse
Notes: For the drug classifications listed in the table above, members must have tried one First-Line medication within the past
130 days before a Second-Line medication will be covered unless otherwise indicated.
Product lists may not be all inclusive and are subject to change. For the most up-to-date information, it is suggested that you
visiand look up your medication with the price check feature. Vislearn more about the program.

Within all step therapy programs, all brand drugs that have a generic equivalent are non-formulary.
Members may call Express Scripts with any questions.

Source: http://www.rewardsat3ds.com/FormsAndDocs/ESI_KC9StepTherapyTrendPackage.pdf