summary review | 2021

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Summary Review | 2021 THERAPEUTIC CATEGORY CRITERIA STEP ONE AGENTS STEP TWO AGENTS STEP THREE AGENTS ACE Inhibitors (ACEi) New utilizer of step two agents with trial of step one agents amlodipine besylate- benazepril hcl, benazepril & hydrochlorothiazide, benazepril hcl, captopril, captopril & hydrochlorothiazide, enalapril maleate, enalapril maleate & hydrochlorothiazide, fosinopril sodium, fosinopril sodium & hydrochlorothiazide, lisinopril, lisinopril & hydrochlorothiazide, moexipril hcl, moexipril- hydrochlorothiazide, perindopril erbumine, quinapril hcl, quinapril- hydrochlorothiazide, ramipril, trandolapril trandolapril-verapamil hcl ADHD (ER only) amphetamine- dextroamphetamine, dexmethylphenidate hcl, dextroamphetamine sulfate, Metadate ER, methylphenidate hcl Adhansia XR, Adzenys XR- ODT, Cotempla XR-ODT, Daytrana, Dyanavel XR, methylphenidate hcl, Mydayis, QuilliChew ER, Relexxii, Vyvanse Azstarys, Concerta, Focalin XR ADHD (IR only) amphetamine- dextroamphetamine, Dexedrine, dexmethylphenidate hcl, dextroamphetamine sulfate, methylphenidate hcl, Zenzedi amphetamine sulfate, dextroamphetamine sulfate, Evekeo, Evekeo ODT, methamphetamine hcl, methylphenidate hcl, ProCentra, Zenzedi WellManaged Generics: Summary Review 2021 | Page 1

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Summary Review | 2021

THERAPEUTICCATEGORY CRITERIA STEP ONE AGENTS STEP TWO AGENTS STEP THREE

AGENTS

ACE Inhibitors(ACEi)

New utilizer of steptwo agents with trialof step one agents

amlodipine besylate-benazepril hcl, benazepril &hydrochlorothiazide,benazepril hcl, captopril,captopril &hydrochlorothiazide,enalapril maleate, enalaprilmaleate &hydrochlorothiazide,fosinopril sodium, fosinoprilsodium &hydrochlorothiazide,lisinopril, lisinopril &hydrochlorothiazide,moexipril hcl, moexipril-hydrochlorothiazide,perindopril erbumine,quinapril hcl, quinapril-hydrochlorothiazide,ramipril, trandolapril

trandolapril-verapamil hcl

ADHD (ER only)

amphetamine-dextroamphetamine,dexmethylphenidate hcl,dextroamphetamine sulfate,Metadate ER,methylphenidate hcl

Adhansia XR, Adzenys XR-ODT, Cotempla XR-ODT,Daytrana, Dyanavel XR,methylphenidate hcl,Mydayis, QuilliChew ER,Relexxii, Vyvanse

Azstarys, Concerta,Focalin XR

ADHD (IR only)

amphetamine-dextroamphetamine,Dexedrine,dexmethylphenidate hcl,dextroamphetamine sulfate,methylphenidate hcl,Zenzedi

amphetamine sulfate,dextroamphetamine sulfate,Evekeo, Evekeo ODT,methamphetamine hcl,methylphenidate hcl,ProCentra, Zenzedi

WellManaged Generics: Summary Review 2021 | Page 1

Summary Review | 2021

THERAPEUTICCATEGORY CRITERIA STEP ONE AGENTS STEP TWO AGENTS STEP THREE

AGENTS

AngiotensinReceptor Blockers(ARBs)

New utilizer of stepthree agents withtrial of step one andtwo agents

amlodipine besylate-olmesartan medoxomil,amlodipine besylate-valsartan, candesartancilexetil, candesartancilexetil-hydrochlorothiazide,eprosartan mesylate,irbesartan, irbesartan-hydrochlorothiazide,losartan potassium,losartan potassium &hydrochlorothiazide,olmesartan medoxomil,olmesartan medoxomil-amlodipine-hydrochlorothiazide,olmesartan medoxomil-hydrochlorothiazide,telmisartan, valsartan,valsartan-hydrochlorothiazide

amlodipine-valsartan-hydrochlorothiazide,telmisartan-amlodipine,telmisartan-hydrochlorothiazide

aliskiren fumarate,Byvalson, Edarbi,Edarbyclor,Tekturna, TekturnaHCT

AntidepressantsSSRI/SNRI

New utilizer of stepthree agents withtrial of step one andtwo agents

bupropion hcl, citalopramhydrobromide,desvenlafaxine succinate,duloxetine hcl, escitalopramoxalate, fluoxetine hcl,fluvoxamine maleate,paroxetine hcl, sertralinehcl, venlafaxine hcl

fluoxetine hcl, fluvoxaminemaleate, paroxetine hcl,venlafaxine hcl

desvenlafaxine,Drizalma Sprinkle,Khedezla, Pexeva,Trintellix, Viibryd,Viibryd Starter Pack

Benign Prostatichyperplasia (BPH)

alfuzosin hcl, doxazosinmesylate, dutasteride,finasteride, tamsulosin hcl,terazosin hcl

dutasteride-tamsulosin hcl,silodosin Cardura XL

WellManaged Generics: Summary Review 2021 | Page 2

Summary Review | 2021

THERAPEUTICCATEGORY CRITERIA STEP ONE AGENTS STEP TWO AGENTS STEP THREE

AGENTS

Beta Blockers (BB)New utilizer of steptwo agents with trialof step one agents

acebutolol hcl, atenolol,atenolol & chlorthalidone,betaxolol hcl, bisoprolol &hydrochlorothiazide,bisoprolol fumarate,carvedilol, labetalol hcl,metoprolol &hydrochlorothiazide,metoprolol succinate,metoprolol tartrate,pindolol, propranolol &hydrochlorothiazide,propranolol hcl, Sorine,sotalol hcl, Sotalol HCl (AF),sotalol hcl (afib/afl), timololmaleate

Bystolic, carvedilolphosphate, Corzide, InderalXL, InnoPran XL, metoprololtartrate, nadolol, nadolol &bendroflumethiazide,nebivolol hcl

BisphosphonatesNew utilizer of steptwo agents with trialof step one agents

alendronate sodium,ibandronate sodium risedronate sodium

Calcium ChannelBlockers (CCBs)

New utilizer of steptwo agents with trialof step one agents

Afeditab CR, amlodipinebesylate, Cartia XT, Dilt-XR,diltiazem hcl, diltiazem hclcoated beads, diltiazem hclextended release beads,felodipine, isradipine,Matzim LA, nicardipine hcl,nifedipine, Taztia XT, TiadyltER, verapamil hcl, VerelanPM

Cardizem LA, diltiazem hclcoated beads, Katerzia,nimodipine, nisoldipine

Cholesterol Agents -Fibrates

New utilizer of steptwo agents with trialof step one agents

choline fenofibrate,fenofibrate, fenofibratemicronized, fenofibric acid,Fibricor, gemfibrozil,Lipofen, Triglide

Antara, fenofibrate,fenofibrate micronized

Cholesterol Agents -Statins

New utilizer of stepthree agents withtrial of step one andtwo agents

atorvastatin calcium,lovastatin, pravastatinsodium, rosuvastatincalcium, simvastatin

amlodipine besylate-atorvastatin calcium,ezetimibe, ezetimibe-simvastatin, fluvastatinsodium

Altoprev, EzallorSprinkle, FloLipid,Livalo, Roszet,Zypitamag

COX-2Inhibitors/NSAIDs

New utilizer of stepthree agents withtrial of step one andtwo agents

Cataflam, celecoxib,diclofenac potassium,diclofenac sodium,etodolac, fenoprofencalcium, flurbiprofen, IBU,ibuprofen, indomethacin,ketoprofen, ketorolactromethamine, meloxicam,nabumetone, naproxen,piroxicam, ProFeno,Relafen, sulindac

celecoxib, fenoprofencalcium, Fenortho,indomethacin, ketoprofen,meclofenamate sodium,Nalfon, oxaprozin, tolmetinsodium

Relafen DS

DementiaNew utilizer of steptwo agents with trialof step one agents

donepezil hydrochloride,galantamine hydrobromide,memantine hcl, rivastigminetartrate

memantine hcl, Namzaric,rivastigmine

Erectile DysfunctionNew utilizer of steptwo agents with trialof step one agents

sildenafil citrate, vardenafilhcl tadalafil

WellManaged Generics: Summary Review 2021 | Page 3

Summary Review | 2021

THERAPEUTICCATEGORY CRITERIA STEP ONE AGENTS STEP TWO AGENTS STEP THREE

AGENTS

high potency topicalsteroids

betamethasonedipropionate augmented,desoximetasone,fluocinonide, triamcinoloneacetonide (topical)

amcinonide, betamethasonedipropionate (topical),clocortolone pivalate,Cloderm, Cloderm Pump,desoximetasone,fluocinonide, halcinonide,Impoyz, Triderm

ApexiCon E,diflorasonediacetate, Psorcon

inflammatory boweldisease (IBD)

balsalazide disodium,mesalamine

Dipentum, mesalamine,Pentasa

WellManaged Generics: Summary Review 2021 | Page 4

Summary Review | 2021

THERAPEUTICCATEGORY CRITERIA STEP ONE AGENTS STEP TWO AGENTS STEP THREE

AGENTS

LOW POTENCYtopical STEROIDS

Ala-Cort, alclometasonedipropionate, Anti-ItchMaximum Strength, AveenoAnti-Itch Max St, CVS Anti-Itch Maximum Strength,CVS Cortisone IntenseHealing, CVS CortisoneMaximum Strength, CVSEczema Anti-Itch, EQHydrocortisone Plus, EQLAnti-Itch Intensive Heal,EQL Anti-Itch MaximumStrength, fluocinoloneacetonide, hydrocortisone(rectal), hydrocortisone(topical), hydrocortisoneacetate (topical),HydroSKIN, Noble FormulaHC, Preparation H, Procto-Pak, PX Hydrocream, RAAnti-Itch MaximumStrength, Recort Plus, TGTAnti-Itch MaximumStrength, TGT Anti-Itch PlusOatmeal, TGT Anti-Itch/Aloe/Vit E

desonide, fluocinoloneacetonide

Ala Scalp, Capex,Dermasorb TA,Desonate,hydrocortisone(topical), MiCort-HC,Texacort, Verdeso

Medium POTENCYTOPICAL STEROIDS

betamethasone valerate,fluticasone propionate,hydrocortisone butyrate,mometasone furoate,triamcinolone acetonide(topical)

betamethasone valerate,desoximetasone,fluocinolone acetonide,fluocinonide emulsifiedbase, hydrocortisonebutyrate, hydrocortisonevalerate, prednicarbate

Beser,desoximetasone,flurandrenolide,fluticasonepropionate,hydrocortisonebutyrate,hydrocortisonebutyrate hydrophiliclipo base, Nolix,Sernivo,triamcinoloneacetonide (topical),Trianex, Triderm,Tritocin

Muscle relaxants

baclofen, carisoprodol,cyclobenzaprine hcl,methocarbamol,orphenadrine citrate,tizanidine hcl, Vanadom

carisoprodol, Metaxall,metaxalone, tizanidine hcl Skelaxin

Neuropathic PainNew utilizer of steptwo agents with trialof step one agents

gabapentin, pregabalin Lyrica CR, pregabalin,pregabalin (once-daily)

OphthlamicProstaglandins

New utilizer of stepthree agents withtrial of step one andtwo agents

latanoprost bimatoprost, bimatoprost(topical), Lumigan Travatan Z, Vyzulta

OphthlamicQuinoloneAntibiotics

New utilizer of stepthree agents withtrial of step one andtwo agents

ciprofloxacin hcl (ophth),ofloxacin (ophth) moxifloxacin hcl (ophth)

Besivance,moxifloxacin hcl(ophth)

Overactive BladderAntimuscarinics

New utilizer of stepthree agents withtrial of step one andtwo agents

oxybutynin chloride,tolterodine tartrate,trospium chloride

tolterodine tartrate,trospium chloride

darifenacinhydrobromide,Gemtesa, Myrbetriq,solifenacinsuccinate, Toviaz

WellManaged Generics: Summary Review 2021 | Page 5

Summary Review | 2021

THERAPEUTICCATEGORY CRITERIA STEP ONE AGENTS STEP TWO AGENTS STEP THREE

AGENTS

parkinson's disease

carbidopa-levodopa,pramipexoledihydrochloride, ropinirolehydrochloride, selegiline hcl

carbidopa-levodopa-entacapone, pramipexoledihydrochloride, rasagilinemesylate, ropinirolehydrochloride, Rytary,Stalevo 100, Stalevo 200,Stalevo 75, Xadago

Neupro

Proton PumpInhibitors

New utilizer of stepthree agents withtrial of step one andtwo agents

lansoprazole, omeprazole,pantoprazole sodium

esomeprazole magnesium,esomeprazole strontium

AcipHex Sprinkle,Dexilant,esomeprazolemagnesium,NexIUM,pantoprazolesodium, PriLOSEC,rabeprazole sodium

Second GenerationAntipsychotics

aripiprazole, quetiapinefumarate, risperidone,ziprasidone hcl, ZyPREXA,ZyPREXA Zydis

aripiprazole, asenapinemaleate, Fanapt, Latuda,paliperidone, quetiapinefumarate, Rexulti, Vraylar

Invega, SEROquelXR

Sedative Hypnotics:Insomnia

New utilizer of stepthree agents withtrial of step one andtwo agents

estazolam, eszopiclone,flurazepam hcl, temazepam,triazolam, zaleplon,zolpidem tartrate

Edluar

very HIGH POTENCYTOPICAL STEROIDS

betamethasonedipropionate (topical),betamethasonedipropionate augmented,clobetasol propionate,Cormax Scalp Application,halobetasol propionate

clobetasol propionate,clobetasol propionateemollient base, Clodan,desoximetasone,fluocinonide

clobetasolpropionate,clobetasolpropionate emulsion,diflorasonediacetate,halobetasolpropionate, Lexette,Tovet, Ultravate

WellManaged Generics: Summary Review 2021 | Page 6