SmithRx Step Therapy List | Page 1

SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017

The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations are not reflected in this list. Step criteria are listed on pages 2-9 as well as in the SmithRx Clinical Criteria document. ACIPHEX | 2 ACTICLATE | 2 ADDERALL | 2 ADDERALL XR | 2 ADOXA | 2 ADZENYS XR-ODT | 2 AMBIEN | 2 AMBIEN CR | 2 AMTURNIDE | 3 APIDRA | 2 APIDRA SOLOSTAR | 2 ARCAPTA NEOHALER | 2 ARICEPT | 2 ATELVIA | 2 BELSOMRA | 2 BEVESPI AEROSPHERE | 2 BRINTELLIX | 2 BYVALSON | 2 CARDURA XL | 2 CONCERTA | 2 COREG CR | 2 CORLANOR | 2 DAYTRANA | 2 DESOXYN | 2 DEXILANT | 2 DORYX | 2 DORYX MPC | 2 DYANAVEL XR | 2 EDARBI | 2 EDARBYCLOR | 3

EDLUAR | 2 ELIDEL | 3 EURAX | 2 EVEKEO | 3 FANAPT | 2 FETZIMA | 2 FOCALIN XR | 2 GEODON | 2 GRALISE | 2 INDERAL XL | 2 INNOPRAN XL | 2 INTERMEZZO | 2 INVEGA | 2 KAPVAY | 2 LASTACAFT | 2 LINZESS | 2 LUNESTA | 2 METADATE CD | 2 MIRAPEX ER | 2 MITIGARE | 2 NAMENDA XR | 2 NAMZARIC | 2 NATROBA | 2 ONZETRA XSAIL | 2 ORACEA | 2 OVIDE | 2 PICATO | 2 PRESTALIA | 2 PREVACID | 2 PRILOSEC | 2

PROCENTRA | 2 PROTONIX | 2 PROTOPIC | 3 QUILLICHEW ER | 2 QUILLIVANT XR | 2 RITALIN LA | 2 ROZEREM | 2 SAPHRIS | 2 SAVELLA | 2 SKLICE | 2 SOLODYN | 2 SONATA | 2 STRIVERDI RESPIMAT | 2 TACROLIMUS | 2 TARGADOX | 2 TEKTURNA | 2 TEKTURNA HCT | 2 TOLAK | 2 TREXIMET | 2 TRINTELLIX | 2 ULESFIA | 2 ULORIC | 2 UTIBRON NEOHALER | 2 VIBRAMYCIN | 2 VIMOVO | 3 ZEGERID | 2 ZEMBRACE SYMTOUCH | 2

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ADDERALL, ADDERALL XR | STEP 2 Step 1: At least TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

ADZENYS XR, ADZENYS XR-ODT | STEP 2 Step 1: At least TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine

AMBIEN, AMBIEN CR | STEP 2 Step 1: Eszopiclone --AND-- zolpidem (generic) or zaleplon (generic)

AMTURNIDE | STEP 3 Step 1: Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil Step 2: Tekturna or Tekturna HCT

ANTIPARASITICS: EURAX, NATROBA, OVIDE, SKLICE, ULESFIA | STEP 2 Step 1: Permethrin

APIDRA, APIDRA SOLOSTAR | STEP 2 Step 1: Humalog or Novolog

ARCAPTA NEOHALER | STEP 2 Step 1: Any TWO of the following: Advair HFA/ Diskus, Breo Ellipta, Serevent, Symbicort

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ARICEPT 23MG | STEP 2 Step 1: At least 10mg of Aricept/Aricept ODT

ATELVIA | STEP 2 Step 1: Alendronate

BELSOMRA | STEP 2 Step 1: Zolpidem or zaleplon or eszopiclone

BEVESPI AEROSPHERE | STEP 2 Step 1: Any one of the following: Advair HFA/ Diskus, Breo Ellipta, Serevent, Symbicort --AND-- Spiriva

BRINTELLIX, TRINTELLIX | STEP 2 Step 1: Any TWO of the following preferred agents: citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, olanzapine-fluoxetine, paroxetine, sertraline, venlafaxine, bupropion, mirtazapine

BYVALSON | STEP 2 Step 1: Must try generic first (nebivolol/valsartan)

CARDURA XL | STEP 2 Step 1: Tamsulosin or terazosin --AND-- Cardura

CONCERTA | STEP 2 Step 1: At least TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

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COREG CR | STEP 2 Step 1: Carvedilol or Coreg

CORLANOR | STEP 2 Step 1: Any beta blocker

DAYTRANA | STEP 2 Step 1: Any TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

DESOXYN | STEP 2 Step 1: Any TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

DYNAVEL XR | STEP 2 Step 1: Any TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine

EDARBI | STEP 2 Step 1: Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil

EDARBYCLOR | STEP 3 Step 1: Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil Step 2: Edarbi

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EDLUAR | STEP 2 Step 1: Zolpidem or Ambien

ELIDEL | STEP 3 Step 1: Topical corticosteroid Step 2: Tacrolimus

EVEKEO | STEP 3 Step 1: Any TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine

FANAPT | STEP 2 Step 1: Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify

FETZIMA | STEP 2 Step 1: Any TWO of the following preferred SNRIs: desvenlafaxine, duloxetine, venlafaxine

FOCALIN XR | STEP 2 Step 1: Any TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

GEODON | STEP 2 Step 1: Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify

GRALISE | STEP 2 Step 1: Gabapentin

INNOPRAN, INDERAL | STEP 2 Step 1: Must try propranolol ER generics

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INTERMEZZO | STEP 2 Step 1: Zolpidem or Ambien

INVEGA | STEP 2 Step 1: Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify

KAPVAY | STEP 2 Step 1: Any TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

LASTACAFT | STEP 2 Step 1: Patanol or Pataday or Optivar

LINZESS | STEP 2 Step 1: For patients >18 years old: Polyethylene glycol or lactulose

LUNESTA | STEP 2 Step 1: Zolpidem (generic) or zaleplon (generic)

METADATE CD | STEP 2 Step 1: Any TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

MIRAPEX ER | STEP 2 Step 1: Ropinirole or pramipexole

MITIGARE | STEP 2 Step 1: Colcrys

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NAMENDA XR | STEP 2 Step 1: Namenda

NAMZARIC | STEP 2 Step 1: Generic donepezil and memantine

ONZETRA XSAIL | STEP 2 Step 1: Any TWO of the following preferred serotonin 5HT1 agonists: almotriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan

PICATO | STEP 2 Step 1: Topical fluorouracil or imiquimod

PPIs: ACIPHEX, DEXILANT, PREVACID, PRILOSEC, PROTONIX, ZEGERID | STEP 2 Step 1: Pantoprazole or lansoprazole (rx) --AND-- omeprazole, OTC Prilosec, OTC Prevacid, or OTC Zegerid

PRESTALIA | STEP 2 Step 1: Amlodipine or perindopril --AND-- Tribenzor or Azor

PROCENTRA | STEP 2 Step 1: Any TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

PROTOPIC | STEP 3 Step 1: Topical corticosteroid Step 2:

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Tacrolimus

QUILLICHEW ER | STEP 2 Step 1: Any TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine

QUILLIVANT XR | STEP 2 Step 1: Any TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

RITALIN LA | STEP 2 Step 1: Any TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), methylphenidate (generic), dextroamphetamine (generic), modafinil, Vyvanse, guanfacine (generic), or Strattera

ROZEREM | STEP 2 Step 1: Eszopiclone, zolpidem, or zaleplon

SAPHRIS | STEP 2 Step 1: Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify

SAVELLA | STEP 2 Step 1: Any ONE of the following: amitriptyline, cyclobenzaprine, Cymbalta

SOLODYN | STEP 2 Step 1: Must try 2 minocycline generics

SONATA | STEP 2 Step 1: Eszopiclone --AND-- Zolpidem (generic) or zaleplon (generic)

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STRIVERDI RESPIMAT | STEP 2 Step 1: Any TWO of the following: Advair HFA/Diskus, Breo Ellipta, Serevent, Symbicort

TACROLIMUS OINTMENT | STEP 2 Step 1: Topical corticosteroid

TEKTURNA, TEKTURNA HCT | STEP 2 Step 1: Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil

TETRACYCLINES | STEP 2 Step 1: Must try 2 doxycycline generics

TOLAK | STEP 2 Step 1: Any TWO of the following preferred agents: fluorouracil 0.5%, fluorouracil 2%, Carac, or Fluoroplex

TREXIMET | STEP 2 Step 1: Sumatriptan --AND-- Any NSAID (Rx only)

ULORIC | STEP 2 Step 1: Allopurinol

UTIBRON NEOHALER | STEP 2 Step 1: Any ONE of the following: Advair HFA/Diskus, Breo Ellipta, Serevent, Symbicort --AND-- Spiriva

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VIMOVO | STEP 3 Step 1: Arthrotec Step 2: Any TWO NSAIDs

ZEMBRACE SYMTOUCH | STEP 2 Step 1: Any TWO of the following preferred serotonin 5HT1 agonists: almotriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan