Responsible steps program information

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Effective 10/1/09
Therapeutic
Drugs Included in Program
Prerequisite Drugs
Category
(Target Drug)
Celexa, Effexor, Effexor XR, Lexapro, Luvox CR, Paxil, Paxil CR, Pexeva, Pristiq, Prozac, bupropion, citalopram, fluoxetine, mirtazipine, Venlafaxine ER, Wellbutrin, Wellbutrin SR, Antidepressants
bupropion, citalopram, fluoxetine, mirtazipine, paroxetine, or sertraline OR previous use of gabapentin, amitriptyline, nortriptyline, imipramine, or desipramine Previous use of any brand or generic versions Anti-Inflammatory
diclofenac, etodolac, indomathacin, ketorolac, meclofenamate, mefenamic acid, piroxicam, fenoprofen, flurbiprofen, ibuprofen, ketoprofen, naproxen, or oxaprozin Accupril, Accuretic, Aceon, Altace, Benicar, Previous use of any of the following generic drugs either alone or as an component of a Diovan HCT, Exforge, Exforge HCT, Lexxel, Lotensin, Lotensin HCT, Lotrel, Mavik, Micardis, Micardis HCT, Monopril, Monopril HCT, Prinivil, benazepril, captopril, enalapril, fosinopril, Prinzide, Tarka, Uniretic, Univasc, Vaseretic, lisinopril, moexepril, quinapril, ramipril, or Page 2 of 3
Previous use of any of the following generic Atacand, Atacand HCT, Avapro, Avalide, Azor, drugs either alone or as an component of a benazepril, captopril, enalapril, fosinopril, lisinopril, moexepril, quinapril, ramipril, or Cardiovascular
AND, in addition, previous use of any or the Benicar, Benicar HCT, Diovan, Diovan HCT, Micardis, Micardis HCT, Exforge, Exforge HCT Previous or current use of any of the following drugs alone or as a component of a combination product: Accupril, Accuretic, Aceon, Altace, Atacand, Atacand HCT, Avapro, Avalide, Azor, benazepril, Benicar, Benicar HCT, Capoten, Capozide, captopril, Cozaar, Diovan, Diovan HCT, enalapril, Exforge, Exforge HCT, fosinopril, Hyzaar, Lexxel, lisinopril, Lotensin, Lotensin HCT, Lotrel, Mavik, Micardis, Micardis HCT, moexepril, Monopril, Monopril HCT, Prinivil, Prinzide, quinapril, ramipril, trandolapril, Tarka, Teveten, Teveten HCT, Uniretic, Univasc, Vaseretic, Vasotec, Zestoretic, Zestril, Current use of brand or generic versions of the metformin, chlorpropramide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide, Actos, Actoplus Met, Avandamet, Avandaryl, Endocrine/Metabolic
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Current or previous use of brand or generic versions of at least one of the following (BlueSelect Members Only)
metformin, chlorpropramide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide, or insulin Avandia, Avandamet, Avandaryl Safety Edit
No concurrent use of insulin or nitrates Gastrointestinal
Previous use of omeprazole OR Prilosec OTC Insomnia
Lipid Management
Advicor, Altoprev, Crestor, Lipitor, Mevacor, Previous use of one of the following generics: Previous use of a topical corticosteroid or topical corticosteroid combination product including but not limited to any of the following betamethasone, clobetasol, desonide, desoximetasone, fluocinolone, fluocinonide, hydrocortisone, triamcinolone, diflorasone, or mometasone. *Please check member benefit documentation to determine inclusion in the Responsible Steps program and the member medication guide to determine coverage of drugs

Source: http://www.rogersbenefit.com/forms/2009ResponsibleStepsTable--10-1-09.pdf