2014 Step Therapy Programs for Concordia Plan Services Medicare Members 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. BLOOD DISORDERSSP Erythroid Stimulants DEPRESSION Other Antidepressants (bupropion and Selective Serotonin Norepinephrine Reuptake Inhibitors, SNRIs) For Savella, prior use of 2 medications (SSRI and SNRI) in the past 130 days. Selective Serotonin Reuptake Inhibitors (SSRI) DIABETES Thiazolidinediones (TZDs)
metformin, / XR, metformin, glipizide, metformin/glyburide, metformin/repaglinide, pioglitazone, pioglitazone/metformin, pioglitazone/glimepiride, Prandimet, Riomet
GASTROINTESTINAL DISORDERS Proton Pump Inhibitors (PPI)
Does not target patients < 2 years of age.
HIGH BLOOD CHOLESTEROL Statins
Prior use of a first line and a second line
medication in the last 180 days for a non-
formulary brand. HIGH BLOOD PRESSURE AND HEART DISEASE Angiotensin Receptor Blockers
Contact Express Scripts 800-344-3896 with questions about specific drugs. List is subject to change.
Revision Date: 12.17.13 (to include
Page 1 of 3 2014 Step Therapy Programs for Concordia Plan Services Medicare Members 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. Tekturna
fosinopril / HCTZ, irbesartan / HCTZ, lisinopril / HCTZ, losartan / HCTZ, moexipril / HCTZ, perindopril, quinapril / HCTZ, ramipril, trandolapril trandolapril-verapamil
INFLAMMATORY CONDITIONSSP
Prior use of 2 first line medications in the last
180 days; prior use of second line injectable
product before infused medication in last 180 days.
MULTIPLE SCLEROSISSP Injectable
Prior use of ALL first line medications in the
last 180 days. Oral PAIN AND INFLAMMATION Neuropathic (Nerve) Pain
Patient must use step one drug for at least 60
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Patient must try 2 different first line drugs
before a second line agent will be approved. For Duexis, prior use of H2RA AND Rx
strength ibuprofen. For Vimovo, use of generic
omeprazole, lansoprazole or pantoproazole
PROSTATE / URINARY CONDITIONS Overactive Bladder RESPIRATORY Other – Alpha1 InhibitorsSP SKIN CONDITIONS Tetracycline
Contact Express Scripts 800-344-3896 with questions about specific drugs. List is subject to change.
Revision Date: 12.17.13 (to include
Page 2 of 3 2014 Step Therapy Programs for Concordia Plan Services Medicare Members 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. Topical Acne
Rule 1: Brand topical BPO, antibiotic, etc containing
Prior use of first line medication in the last 130
days for Rules 1 and 2; prior use of two products in the last 130 days for Rule 3.Topical Corticosteroids
Prior use of 2 first line medication in the last
hydrocortisone acetate, butyrate, or valerate mometasone, pramoxine, triamcinolone
Topical Immunomodulators
Prior use of 1 first line medication in the last
halobetasol, hydrocortisone, hydrocortisone acetate, butyrate, or valerate, mometasone, triamcinolone hydrocortisone acetate, butyrate, or valerate mometasone, pramoxine, triamcinolone
SLEEP DISORDERS Hypnotics
Contact Express Scripts 800-344-3896 with questions about specific drugs. List is subject to change.
Revision Date: 12.17.13 (to include
Page 3 of 3
Patient Information Last, First MI (Preferred Name) Birth Date: Phone (Home): ____ For your convenience, please provide your E-mail Address:_____________________ for appointment reminders. Reason for this visit: ___________________________ Are you in good health? (Y) (N) If no, please explain:__________________________________________ Has there been any change in you general
Possible Side Effects of Drugs That Lower Blood Pressure Some of the drugs listed below can affect certain functions of the body, resulting in bad side effects. However, drugs that lower blood pressure have proven effective over the years. The benefits of using them far outweigh the risk of side effects. Most people who’ve taken these drugs haven’t had any problems. Diuretics — Some o