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Step Therapy Programs for Board of Pensions, Presbyterian Church 2013
(Medicare)
CONDITION TREATED
STEP ONE DRUGS
STEP TWO DRUGS
Wil deny at pharmacy without trial of step-
Drug Class
one drug within the past 130 days. Prior
authorization is required for use of step-
two drug without use of step-one drug
within past 130 days.
ALLERGIES
Antihistamines/Decongestants
ATTENTION DEFICIT DISORDER
Concerta Daytrana* Desoxyn* Dexedrine* dextroamphetamine-amphetamine Focalin* Metadate CD*/ER* Methylin ER methylphenidate Ritalin*/ SR* Vyvanse DEPRESSION
Other Antidepressants
DEPRESSION
Selective Serotonin Reuptake Inhibitors
(SSRI)
Prozac*/Prozac Weekly* Sarafem* Viibryd Zoloft* Contact Express Scripts (800) 575-8090 with questions about specific drugs. * Indicates non-formulary drugs. List subject to change Step Therapy Programs for Board of Pensions, Presbyterian Church 2013
(Medicare)
CONDITION TREATED
STEP ONE DRUGS
STEP TWO DRUGS
Wil deny at pharmacy without trial of step-one drug
Drug Class
within the past 130 days. Prior authorization is required
for use of step-two drug without use of step-one drug
within past 130 days.
Angiotensin Receptor Blockers

TEKTURNA
fosinopril / fosinopril HCT lisinopril / lisinopril HCT moexipril / moexipril HCT perindopril quinapril / quinapril HCT ramipril trandolapril trandolapril-verapamil (Tarka*) CONDITION TREATED
STEP ONE DRUGS
STEP TWO DRUGS
Wil deny at pharmacy without trial of step-one drug
Drug Class
within the past 130 days. Prior authorization is required
for use of step-two drug without use of step-one drug
within past 130 days.
ENHANCED
PROSTAGLANDIN
HIGH BLOOD
CHOLESTEROL
Statins
Contact Express Scripts (800) 575-8090 with questions about specific drugs. * Indicates non-formulary drugs. List subject to change Step Therapy Programs for Board of Pensions, Presbyterian Church 2013
(Medicare)
CONDITION TREATED
STEP ONE DRUGS
STEP TWO DRUGS
Wil deny at pharmacy without trial of step-one drug
Drug Class
within the past 130 days. Prior authorization is required
for use of step-two drug without use of step-one drug
within past 130 days.
HIGH BLOOD
CHOLESTEROL
Fibrate agents
Lofibra*,Lipofen*Tricor, Triglide*, Trilipix CONDITION TREATED
STEP ONE DRUGS
STEP TWO DRUGS
Wil deny at pharmacy without trial of
Drug Class
step-one drug within the past 130 days.
Prior authorization is required for use of
step-two drug without use of step-one
drug within past 130 days.
OSTEOPOROSIS
Bisphosphonates
PAIN AND INFLAMMATION
Neuropathic (Nerve) Pain
Horizant*
Neurontin*
Gralise
OVERACTIVE BLADDER
Vesicare Sanctura Detrol/LA Toviaz Gelnique PAIN AND INFLAMMATION
Nonsteroidal Anti-Inflammatory
Drugs (NSAIDs)
Patient must try 2 different step-
one drugs before step-two drug
will be approved
RESPIRATORY & ASTHMA
betamethasone benzoate, dipropionate, or valerate DRUGS
SKIN INFLAMMATIONS
Topical Immunomodulators
Contact Express Scripts (800) 575-8090 with questions about specific drugs. * Indicates non-formulary drugs. List subject to change Step Therapy Programs for Board of Pensions, Presbyterian Church 2013
(Medicare)
CONDITION TREATED
STEP ONE DRUGS
STEP TWO DRUGS
Wil deny at pharmacy without trial of step-one drug
Drug Class
within the past 130 days. Prior authorization is required
for use of step-two drug without use of step-one drug
within past 130 days.
Patient must have used step-one
drug during previous 60 days
before step-two drug will be
approved
hydrocortisone acetate, butyrate, or valerate
SKIN INFLAMMATIONS

Betamethasone Dipropionate, Betamethasone Valerate, Beta-val, Clobetasol Emollient, CORTICOSTEROIDS
Clobetasol Propionate, Cormax, Del-beta, Desonide, Desoximetasone, Diflorasone Diacetate, Fluocinonide Emollient, Fluticasone Propionate, Valerate, Mometasone Furoate, Prednicarbate, cort, Ultravate, Vanos, Verdeso, Westcort. SLEEP DISORDERS
Hypnotics
STOMACH ACID REDUCTION lansoprazole
Proton Pump Inhibitors (PPI)
TETRACYCLINE
Morgidox, Nutridox Kit, Ocudox Kit, Oracea, Periostat, Solodyn, Sumycin, Vibramycin, Vibra-tabs. THIAZOLIDINEDIONE
Glipizide-metformin, Glyburide-metformin Hcl, Metformin Hcl, Metformin Hcl Er, metformin- Contact Express Scripts (800) 575-8090 with questions about specific drugs. * Indicates non-formulary drugs. List subject to change

Source: http://web.pensions.org/Publications/pensions/Home/Forms%20%26%20Publications/Booklets%20%26%20Brochures/KF5%20Step%20Therapy%20Grid.pdf

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