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Express Scripts, Inc.
Step Therapy
Alternative (Step 2)
Primary (Step 1) Medications
Indication
Medications
Angiotensin II Receptor Atacand HCT, Atacand, Avalide, Avapro, Azor, benazepril, benazepril/HCTZ, captopril, Benicar, Benicar HCT,Cozaar, Diovan HCT, captopril/HCTZ, enalapril, enalapril/HCTZ, Diovan, Edarbi, Edarbyclor, Exforge, Exforge fosinopril, fosinopril/HCTZ, lisinopril, HCT, Hyzaar, Micardis, Micardis HCT, Teveten, lisinopril/HCTZ, ramipril, quinapril, quinapril/HCTZ, Teveten HCT, Twynsta, Tribenzor Quinaretic, moexipril, trandolapril, moexipril/HCTZ, benazepril/amlodipine, perindopril, trandolapril/verapamil, enalapril/felodipine, losartan, losartan/HCTZ, eprosartan, irbesartan, irbesartan/HCTZ bupropion SR, bupropion XL, budeprion SR, Celexa, Lexapro, Luvox CR, Paxil CR, Paxil, fluoxetine/weekly, fluvoxamine, paroxetine, paroxetine CR, citalopram, sertraline, escitalopram fluoxetine, fluvoxamine, paroxetine, citalopram, Norepinephrine Reuptake Inhibitors (SNRI)Avodart Step-One: alendronate, ibandronate
Step-Two: Actonel, Actonel Plus Calcium, Atelvia
Arthrotec, Mobic, Ponstel, Cataflam, Voltaren, diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, Ansaid, Motrin, Indocin, Indocin SR, Orudis, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, Clinoril, Flector, Voltaren Gel, IC 400, IC 800, Zipsor, Pennsaid, Cambia, Sprix, Vimovo, Duexis FOR INTERNAL USE ONLY
Express Scripts, Inc.
Step Therapy
Alternative (Step 2)
Primary (Step 1) Medications
Indication
Medications
diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin Tricor, Lofibra, Antara, Triglide, Lipofen, Ambien CR, Lunesta, Rozerem, Sonata, Ambien, Accolate, Singulair, Zyflo/CR - (generic For non-asthma conditions:
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*^,
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
Rhinocort Aqua, Beconase AQ, Nasacort AQ, fluticasone propionate, flunisolide, triamcinolone Nasonex, Flonase, Veramyst, Omnaris, Qnasl, Zetonna, Dymista loratadine^, loratadine-D^, fexofenadine^, fexofenadine- D^, cetirizine syrup, cetirizine^, cetirizine-D^, levocetirizine ^ these over-the-counter (OTC) products may not be covered under your prescription benefit FOR INTERNAL USE ONLY
Express Scripts, Inc.
Step Therapy
Alternative (Step 2)
Primary (Step 1) Medications
Indication
Medications
Tekturna, Tekturna HCT, Valturna, Amturnide, benazepril, benazepril/HCTZ, benazepril/amlodipine, captopril, captopril/HCTZ, enalapril, enalapril/HCTZ, fosinopril, fosinopril/HCTZ, lisinopril, lisinopril/HCTZ, moexipril, moexipril/HCTZ, perindopril, quinapril, quinapril/HCTZ, trandolapril, trandolapril/verapamil, enalapril/felodipine, benazepril/amlodipine Declomycin, Adoxa, Monodox, Avidoxy/kit, demeclocycline, doxycycline, minocycline, Adoxa/CK/TT/Pak, Doryx, Vibramycin, Vibra- Tabs, Oraxyl, Periostat, Oracea, Dynacin, Minocin/kit/PAC, Solodyn, Sumycin, Alodox/kit, Morgidox, Ocudox Rule 1: Brand topical BPO, antibiotic, etc
Rule 1: Generic topical BPO, antibiotic, etc
containing products Rule 2:
Rule 2: Brand topical cleansers
Rule 3: Brand topical kits
Rule 3: One med from rule 1 AND one med from
rule 2
Aclovate, Ala-Scalp HP, ApexiCon, Capex, alclometasone, amcinonide, betamethasone Clobex, Elocon, Halog, Halonate, Florone, Kenalog, Cloderm, Cordran, Locoid, Luxiq, dipropionate, fluocinonide, fluticasone, halobetasol, Dermatop, Texacort, Vanos, Diprolene/AF, clobetasol, hydrocortisone butyrate, desonide, Verdeso, Desonate, Olux-Olux-E, Desowen, desoximetasone, hydrocortisone valerate, Cutivate, Zytopic, Nucort Lotion, Florone, Ultravate, Topicort/LP, Lidex, Westcort, Momexin, Pediaderm/TA, Triderm, Scalacort, Samol-HC, Pramosone, Pramosone E, Desonil/kit, Aqua Glycolic HC FOR INTERNAL USE ONLY
Express Scripts, Inc.
Step Therapy
Alternative (Step 2)
Primary (Step 1) Medications
Indication
Medications
alclometasone, amcinonide, betamethasone dipropionate (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 Altoprev, Caduet, Lescol, Lescol XL, Mevacor, lovastatin, pravastatin, simvastatin, atorvastatin, Pravachol, Zocor, Vytorin, Livalo, Lipitor fluvastatin, atorvastatin/amlodipineCrestor Aciphex, Dexilant (formerly Kapidex), Prevacid, omeprazole (Rx or OTC), lansoprazole (Rx or OTC), omeprazole-sodium bicarbonate (Rx or OTC), pantoprazole, Nexium Oxybutynin IR/ER (generic only), Enablex, Vesicare, Sanctura (generic only), Detrol/LA, FOR INTERNAL USE ONLY

Source: http://www.lsu-shreveport.com/Documents/Offices%20and%20Services/HR/Step%20Therapy%20Medication%20List.pdf