adapalene/benzoyl peroxide (epiduo forte)

ADAPALENE/BENZOYL PEROXIDE (EPIDUO FORTE)

MEDICATION(S) SUBJECT TO STEP THERAPY

EPIDUO FORTE

CRITERIA

One of the following drugs need to be used first (step 1 drugs): adapalene (generic DIFFERIN),

clindamycin/benzoyl peroxide (generic BENZACLIN, generic DUAC), erythromycin/benzoyl

peroxide (generic BENZAMYCIN).

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ADAPALENE/BENZOYL PEROXIDE (EPIDUO)


ADAPALENE-BENZOYL PEROXIDE

CRITERIA

One of the following drugs need to be used first (step 1 drugs): adapalene (generic DIFFERIN),

clindamycin/benzoyl peroxide (generic BENZACLIN, generic DUAC), erythromycin/benzoyl

peroxide (generic BENZAMYCIN).


ALISKIREN (TEKTURNA)


ALISKIREN

CRITERIA

One of the following ARB’s AND at least one drug in the ACE-inhibitor, beta-blocker, calcium

channel blocker, or thiazide diuretic groups needs to be used first (step 1 drugs):

ARB (candesartan, candesartan hctz, irbesartan, irbesartan hctz, losartan, losartan hctz,

olmesartan, olmesartan hctz, telmisartan, telmisartan/amlodipine, telmisartan hctz, valsartan,

valsartan hctz).

ACE-inhibitor (benazepril, benazepril hctz, captopril, captopril hctz, enalapril, enalapril hctz,

fosinopril, fosinopril hctz, lisinopril, lisinopril hctz, moexipril, perindopril, quinapril, quinapril hctz,

ramipril, trandolapril, trandolapril verapamil er).

Beta-blocker (acebutolol, atenolol, atenolol chlorthalidone, betaxolol, bisoprolol, bisoprolol hctz,

carvedilol, carvedilol er, labetalol, metoprolol er, metoprolol, metoprolol hctz, nadolol, pindolol,

propranolol, propranolol er, propranolol hctz, timolol).

Calcium channel blocker (amlodipine, amlodipine atorvastatin, amlodipine benazepril,

amlodipine olmesartan, amlodipine telmisartan, amlodipine valsartan, diltiazem, diltiazem er,

felodipine er, isradipine, nicardipine, nifedipine er, nisoldipine er, verapamil, verapamil er).

Thiazide diuretic (amiloride hctz, chlorthalidone, hydrochlorothiazide, spironolactone hctz,

triamterene hctz).


ALMOTRIPTAN MALATE (AXERT)


ALMOTRIPTAN MALATE

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): naratriptan, rizatriptan, sumatriptan,

zolmitriptan.


AMCINONIDE


AMCINONIDE

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): betamethasone dipropionate

(cream, ointment), betamethasone dipropionate augmented (cream, gel, lotion, ointment),

betamethasone valerate (cream, ointment), clobetasol (cream, gel, lotion, ointment, shampoo,

solution), clobetasol emollient (cream, foam), clobetasol emulsion foam, desoximetasone (cream,

gel, ointment), fluocinonide (gel, ointment, solution), fluocinonide-e cream, fluticasone

propionate (cream, lotion), mometasone furoate (cream, ointment, solution), triamcinolone

(cream, ointment).


AMPHETAMINE SULFATE (EVEKEO)


AMPHETAMINE SULFATE

CRITERIA

One of the following drugs need to be used first (step 1 drugs): amphetamine/dexamphetamine

(generic ADDERALL), dexmethylphenidate (generic FOCALIN), methylphenidate (generic

METHYLIN), methylphenidate (generic RITALIN).


BIMATOPROST EYE DROPS (BIMATOPROST)


BIMATOPROST 0.03% EYE DROPS

CRITERIA

The following drug needs to be used first (step 1 drug): latanoprost eye drops.


BRIVARACETAM (BRIVIACT)


BRIVIACT 10 MG TABLET, BRIVIACT 10 MG/ML ORAL SOLN, BRIVIACT 100 MG TABLET, BRIVIACT 25

MG TABLET, BRIVIACT 50 MG TABLET, BRIVIACT 75 MG TABLET

CRITERIA

The following drug need to be used first (step 1 drugs): levetiracetam.


BROMOCRIPTINE MESYLATE (CYCLOSET)


CYCLOSET

CRITERIA

One of the following drugs need to be used first (step 1 drugs): metformin ir (GLUCOPHAGE),

metformin er (Glucophage XR).


BUPROPION XL (FORFIVO XL)


BUPROPION HCL XL 450 MG TABLET

CRITERIA

The following drug needs to be used first (step 1 drugs): bupropion xl (generic WELLBUTRIN XL).


CARVEDILOL EXTENDED RELEASE (COREG CR)


CARVEDILOL ER

CRITERIA

The following drug needs to be used first (step 1 drugs): carvedilol immediate release.


CLINDAMYCIN/BENZOYL PEROXIDE GEL WITH PUMP


CLIND PH-BENZOYL PERO 1.2-2.5%, CLINDA-BENZOYL PEROX 1-5% PUMP

CRITERIA

One of the following drugs need to be used first (step 1 drugs): clindamycin 1%/benzoyl peroxide

5% (generic BENZACLIN), clindamycin 1.2%/benzoyl peroxide 5% (generic DUAC).


CLINDAMYCIN/TRETINOIN GEL (VELTIN)


CLINDAMYCIN PHOS-TRETINOIN

CRITERIA

Both of the following drugs need to be used first (step 1 drugs): topical clindamycin, topical

tretinoin.


CLOBETASOL SHAMPOO (CLOBEX)


CLODAN 0.05% SHAMPOO

CRITERIA

One of the following drugs need to be used first (step 1 drugs): clobetasol (cream, gel, ointment,

solution), clobetasol emollient cream.


CLOBETASOL SPRAY (CLOBEX)


CLOBETASOL PROP 0.05% SPRAY

CRITERIA

One of the following drugs need to be used first (step 1 drugs): clobetasol (cream, gel, ointment,

solution), clobetasol emollient cream.


DARIFENACIN EXTENDED RELEASE (ENABLEX)


DARIFENACIN ER

CRITERIA

One of the following drugs need to be used first (step 1 drugs): oxybutynin, trospium.


DESLORATADINE (CLARINEX)


DESLORATADINE

CRITERIA

Allergic rhinitis: one of the following drugs need to be used first (step 1 drugs): azelastine nasal

spray, flunisolide nasal spray, fluticasone nasal spray.

Chronic idiopathic urticaria: step therapy not required.


DESOXIMETASONE (TOPICORT)


DESOXIMETASONE

CRITERIA


(cream, ointment), betamethasone dipropionate augmented (cream, gel, lotion, ointment),

betamethasone valerate (cream, ointment), clobetasol (cream, gel, lotion, ointment, shampoo,

solution), clobetasol emollient (cream), fluocinonide (gel, ointment, solution), fluocinonide-e

cream, fluticasone propionate (cream, lotion), mometasone furoate (cream, ointment, solution),

triamcinolone (cream, ointment).


DESVENLAFAXINE FUMARATE ER (DESVENLAFAXINE FUMARATE ER)


DESVENLAFAXINE ER

CRITERIA

One of the following drugs need to be used first (step 1 drugs): bupropion, citalopram,

desvenlafaxine succinate er (generic Pristiq), duloxetine, escitalopram, fluoxetine, fluvoxamine,

fluvoxamine er, paroxetine, Paxil oral suspension, sertraline, venlafaxine.


DEXLANSOPRAZOLE (DEXILANT)


DEXILANT

CRITERIA

One of the following drugs need to be used first (step 1 drugs): lansoprazole, omeprazole,

pantoprazole, rabeprazole.


DIFLORASONE DIACETATE (APEXICON E)


APEXICON E

CRITERIA


(cream, ointment), betamethasone dipropionate augmented (gel, lotion, ointment),

betamethasone valerate (cream, ointment), clobetasol (cream, gel, ointment, shampoo, solution,

topical lotion), clobetasol emollient (cream, foam), clobetasol emulsion foam, fluocinonide-e

cream, fluticasone propionate (cream, lotion, ointment), mometasone furoate (cream, ointment,

solution).


DONEPEZIL 23MG (ARICEPT)


DONEPEZIL HCL 23 MG TABLET

CRITERIA

One of the following drugs need to be used first (step 1 drugs): donepezil 5mg, donepezil 10mg.


ELETRIPTAN HYDROBROMIDE (RELPAX)


ELETRIPTAN HBR

CRITERIA


zolmitriptan.


EMEDASTINE DIFUMARATE EYE DROPS (EMADINE)


EMADINE

CRITERIA

Both of the following drugs need to be used first (step 1 drugs): azelastine eye drops, olopatadine

eye drops.


ESLICARBAZEPINE ACETATE (APTIOM)


APTIOM

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): carbamazepine, clorazepate,

divalproex, felbamate, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, tiagabine,

topiramate, zonisamide.


FEBUXOSTAT (ULORIC)


FEBUXOSTAT

CRITERIA

The following drug needs to be used first (step 1 drugs): allopurinol.


FENOFIBRATE (TRIGLIDE)


FENOFIBRATE 160 MG TABLET

CRITERIA

One of the following drugs need to be used first (step 1 drugs): fenofibrate nanocrystallized

(generic TRICOR), fenofibric acid (generic FIBRICOR), fenofibrate micronized (generic LOFIBRA).


FENOFIBRATE MICRONIZED (ANTARA)


FENOFIBRATE 130 MG CAPSULE, FENOFIBRATE 43 MG CAPSULE

CRITERIA

One of the following drugs need to be used first (step 1 drugs): fenofibrate, fenofibrate

nanocrystallized, fenofibrate micronized.


FLUNISOLIDE NASAL SPRAY (FLUNISOLIDE)


FLUNISOLIDE

CRITERIA

Following drug needs to be used first (step 1 drugs): fluticasone propionate nasal spray.


FLUOCINOLONE SCALP OIL (DERMA-SMOOTHE-FS)


FLUOCINOLONE 0.01% SCALP OIL

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): alclometasone dipropionate

(cream, ointment), Beser lotion, betamethasone dipropionate (cream, lotion, ointment),

betamethasone dipropionate augmented (cream, gel, lotion, ointment), betamethasone

valerate (cream, lotion, ointment), clobetasol (cream, gel, lotion, ointment, shampoo, solution),

clobetasol emollient (cream, foam) clobetasol emulsion foam, fluocinolone (cream, solution,

ointment), fluocinonide (gel, ointment, solution), fluocinonide-e cream, fluticasone propionate

lotion, hydrocortisone (cream, lotion, ointment), mometasone furoate (cream, ointment, solution),

prednicarbate (cream, ointment), triamcinolone (cream, lotion, ointment), trianex ointment.


FLUTICASONE PROPIONATE LOTION (CUTIVATE)


BESER

CRITERIA


(cream, lotion, ointment), betamethasone dipropionate augmented (cream, gel, lotion,

ointment), betamethasone valerate (cream, lotion, ointment), clobetasol (cream, gel, lotion,

ointment, shampoo, solution), clobetasol emollient cream, fluocinolone (cream, solution,

ointment), fluocinonide (gel, ointment, solution), fluocinonide-e cream, fluticasone propionate

(cream, ointment), hydrocortisone (cream, ointment), mometasone furoate (cream, ointment,

solution), prednicarbate (cream, ointment), triamcinolone (cream, lotion, ointment), trianex

ointment.


FLUVOXAMINE EXTENDED RELEASE


FLUVOXAMINE MALEATE ER

CRITERIA

The following drug needs to be used first (step 1 drugs): fluvoxamine immediate release.


FROVATRIPTAN SUCCINATE (FROVA)


FROVATRIPTAN SUCCINATE

CRITERIA


zolmitriptan.


HYDROCORTISONE BUTYRATE AND VALERATE (LOCOID, WESTCORT)


HYDROCORTISONE BUTY 0.1% CREAM, HYDROCORTISONE BUTYR 0.1% LOTN, HYDROCORTISONE

BUTYR 0.1% OINT, HYDROCORTISONE BUTYR 0.1% SOLN, HYDROCORTISONE VALERATE

CRITERIA


(cream, lotion, ointment), betamethasone valerate (cream, lotion, ointment), fluocinolone

(cream, ointment), fluticasone propionate (cream, ointment), mometasone furoate (cream,

ointment, solution), prednicarbate (cream, ointment), triamcinolone (cream, lotion, ointment).


IMIQUIMOD CREAM (ZYCLARA)


IMIQUIMOD 3.75% CREAM PUMP

CRITERIA

The following drug needs to be used first (step 1 drugs): imiquimod 5% cream packets.


KETOCONAZOLE FOAM (EXTINA)


KETOCONAZOLE 2% FOAM, KETODAN 2% FOAM

CRITERIA

One of the following drugs need to be used first (step 1 drugs): ketoconazole 2% cream,

ketoconazole 2% shampoo.


LACOSAMIDE TABLET (VIMPAT)


VIMPAT 10 MG/ML SOLUTION, VIMPAT 100 MG TABLET, VIMPAT 150 MG TABLET, VIMPAT 200 MG

TABLET, VIMPAT 50 MG TABLET

CRITERIA





LAMOTRIGINE EXTENDED RELEASE (LAMICTAL XR)


LAMOTRIGINE ER

CRITERIA

The following drug needs to be used first (step 1 drugs): lamotrigine immediate release.


LANSOPRAZOLE ODT (PREVACID SOLUTAB)


LANSOPRAZOLE ODT 15 MG TABLET, LANSOPRAZOLE ODT 30 MG TABLET

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): lansoprazole, omeprazole,

pantoprazole, rabeprazole.


LULICONAZOLE CREAM (LUZU)


LULICONAZOLE

CRITERIA

One of the following drugs need to be used first (step 1 drugs): ciclopirox (cream, gel, suspension),

clotrimazole cream, econazole nitrate cream, ketoconazole cream, nystatin ointment.


MESALAMINE (ASACOL HD)


MESALAMINE 800 MG DR TABLET

CRITERIA

The following drugs need to be used first (step 1 drugs): mesalamine dr 1.2-gram tablet and

balsalazide disodium.


MESALAMINE (DELZICOL)


MESALAMINE DR

CRITERIA

The following drugs need to be used first (step 1 drugs): mesalamine dr 1.2-gram tablet and

balsalazide disodium.


MOMETASONE FUROATE NASAL SPRAY (NASONEX)


MOMETASONE FUROATE 50 MCG SPRY

CRITERIA

One of the following drugs need to be used first (step 1 drugs): flunisolide nasal spray, fluticasone

nasal spray.


NAFTIFINE CREAM (NAFTIN)


NAFTIFINE HCL 1% CREAM, NAFTIFINE HCL 2% CREAM

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): ciclopirox (cream, gel, suspension,

shampoo), clotrimazole (cream, solution), clotrimazole/betamethasone (cream, lotion),

econazole nitrate cream, ketoconazole (cream, shampoo), nystatin (cream, ointment, powder,

tablet), nystatin-triamcinolone (cream, ointment).


NAPROXEN SODIUM ER (NAPRELAN CR)


NAPROXEN SODIUM CR, NAPROXEN SODIUM ER

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): diclofenac potassium, diclofenac

sodium, etodolac, flurbiprofen, ibuprofen, indomethacin, ketoprofen, meclofenamate,

meloxicam, nabumetone, naproxen, piroxicam, sulindac.


OLOPATADINE NASAL SPRAY (PATANASE)


OLOPATADINE 665 MCG NASAL SPRY

CRITERIA

The following drugs needs to be used first (step 1 drugs): azelastine nasal spray.


OLSALAZINE SODIUM (DIPENTUM)


DIPENTUM

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): mesalamine dr 1.2-gram tablet,

mesalamine er 0.375-gram capsule, balsalazide disodium.


OXICONAZOLE NITRATE CREAM (OXISTAT)


OXICONAZOLE NITRATE

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): ciclopirox (cream, gel, suspension,

shampoo), clotrimazole (cream, solution), clotrimazole/betamethasone (cream, lotion),

econazole nitrate cream, ketoconazole (cream, shampoo), nystatin (cream, ointment, powder,

tablet, suspension), nystatin/triamcinolone (cream, ointment).


PERAMPANEL (FYCOMPA)


FYCOMPA

CRITERIA





PIMECROLIMUS CREAM (ELIDEL)


PIMECROLIMUS

CRITERIA

One of the following drugs need to be used first (step 1 drugs): betamethasone dipropionate

(cream, lotion, ointment), betamethasone dipropionate augmented (cream, gel, lotion,

ointment), betamethasone valerate (cream, lotion, ointment), clobetasol (cream, gel, ointment,

solution), clobetasol emollient cream, desonide (cream, lotion, ointment), fluocinolone (body oil,

cream, ointment), fluocinonide (cream, gel, ointment, solution), fluticasone (cream, ointment),

halobetasol (cream, ointment), hydrocortisone butyrate (ointment, solution), hydrocortisone

valerate (cream, ointment), mometasone furoate (cream, ointment, solution), prednicarbate

(cream, ointment), triamcinolone (cream, lotion, ointment), trianex ointment, triderm cream.


RISEDRONATE SODIUM (ACTONEL)


RISEDRONATE SODIUM, RISEDRONATE SODIUM DR

CRITERIA

Treatment or prevention of postmenopausal osteoporosis: the following drugs need to be used first

(step 1 drugs): alendronate and ibandronate OR just ibandronate.

All other indications: the following drug needs to be used first (step 1 drugs): alendronate.


RUFINAMIDE (BANZEL)


BANZEL

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): clonazepam, divalproex sodium,

felbamate, lamotrigine, topiramate, valproic acid.


SILODOSIN (RAPAFLO)


SILODOSIN

CRITERIA

The following drug needs to be used first (step 1 drugs): tamsulosin.


TACROLIMUS OINTMENT (PROTOPIC)


TACROLIMUS 0.03% OINTMENT, TACROLIMUS 0.1% OINTMENT

CRITERIA

One of the following drugs need to be used first (step 1 drugs): betamethasone dipropionate

augmented (cream, lotion, ointment), betamethasone valerate (cream, lotion, ointment),

clobetasol (cream, gel, ointment, solution, emollient cream), fluocinolone cream, solution,

ointment), fluocinonide (gel, ointment, solution), fluocinonide-e cream, fluticasone (cream,

ointment), halobetasol (cream, ointment), hydrocortisone butyrate (ointment, solution),

hydrocortisone valerate cream, mometasone furoate (cream, ointment, solution), prednicarbate

(cream, ointment), triamcinolone (cream, lotion, ointment), triderm cream.


TOLCAPONE (TASMAR)


TOLCAPONE

CRITERIA

The following drug needs to be used first (step 1 drugs): entacapone.


TOLTERODINE TARTRATE (DETROL)


TOLTERODINE TARTRATE, TOLTERODINE TARTRATE ER

CRITERIA

One of the following drugs need to be used first (step 1 drugs): oxybutynin, trospium.


TRIAMCINOLONE NASAL SPRAY (KENALOG)


TRIAMCINOLONE 0.147 MG/G SPRAY

CRITERIA


lotion, betamethasone valerate (cream, lotion, ointment), fluticasone (cream, ointment),

mometasone furoate (cream, ointment, solution), prednicarbate (cream, ointment),

triamcinolone (cream, lotion, ointment).


TRIAMTERENE (DYRENIUM)


TRIAMTERENE

CRITERIA

One of the following drugs need to be used first (step 1 drugs): amiloride, amiloride hctz,

spironolactone, spironolactone hctz, or triamterene/hctz.


VILAZODONE (VIIBRYD)


VIIBRYD

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): bupropion, citalopram,

desvenlafaxine er, desvenlafaxine succinate er, duloxetine, escitalopram, fluoxetine, fluvoxamine,

paroxetine, Paxil suspension, sertraline, venlafaxine.


VORTIOXETINE HYDROBROMIDE (TRINTELLIX)


TRINTELLIX

CRITERIA

Two of the following drugs need to be used first (step 1 drugs): bupropion, citalopram,

desvenlafaxine er, desvenlafaxine succinate er, duloxetine, escitalopram, fluoxetine, fluvoxamine,

paroxetine, Paxil suspension, sertraline, venlafaxine.


adapalene/benzoyl peroxide (epiduo forte)

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