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Individual step therapy criteria-2014

Health Insurance Exchanges Essential Drug List Individual (Public ) Drugs that Require Step Therapy
LABEL NAME
CRITERIA
A documented trial of one month of one of the covered alternatives: ADAPALENE, BENZOYL PEROXIDE/ERYTHROMYCIN, BENZOYL PEROXIDE/CLINDAMYCIN, TRETINOIN A documented trial of one month of one of the covered alternatives: ADAPALENE, BENZOYL PEROXIDE/ERYTHROMYCIN, BENZOYL PEROXIDE/CLINDAMYCIN, TRETINOIN A documented trial of one month of the covered alternative: OXANDROLONE A documented trial of one month of one of the covered alternatives: EPROSARTAN, IRBESARTAN, LOSARTAN, IRBESARTAN/HCTZ, LOSARTAN/HCTZ, VALSARTAN/HCTZ, CANDESARTAN, CANDESARTAN/HCTZ A documented trial of one month of one of the covered alternatives: ENOXAPARIN, FONDAPARINUX A documented trial of one month of one of the covered alternatives: buproprion/ SR/ XL, citalopram, escitalopram, fluvoxamine, fluoxetine, mirtazapine/ ODT, paroxetine/ CR, sertraline, venlafaxine, or venlafaxine SR A documented trial of one month of one of the covered alternatives: buproprion/ SR/ XL, citalopram, escitalopram, fluvoxamine, fluoxetine, mirtazapine/ ODT, paroxetine/ CR, sertraline, venlafaxine, or venlafaxine SR A documented trial of one month of one of the covered alternatives: buproprion/ SR/ XL, citalopram, escitalopram, fluvoxamine, fluoxetine, mirtazapine/ ODT, paroxetine/ CR, sertraline, venlafaxine, or venlafaxine SR A documented trial of one month of one of the covered alternatives: MONTELUKAST, ZAFIRLUKAST A documented trial of one month of one of the covered alternative: ATORVASATATIN, FLUVASTATIN, LOVASTATIN, SIMVASTATIN, PRAVASTATIN A documented trial of one month of one of the covered alternative: ATORVASATATIN, FLUVASTATIN, LOVASTATIN, SIMVASTATIN, PRAVASTATIN A documented trial of one month of one of the covered alternative: ATORVASATATIN, FLUVASTATIN, LOVASTATIN, SIMVASTATIN, PRAVASTATIN A documented trial of one month of one of the covered alternative: ATORVASATATIN, FLUVASTATIN, LOVASTATIN, SIMVASTATIN, PRAVASTATIN A documented trial of one month of one of the covered alternatives: HALOPERIDOL, LOXAPINE, CHLORPROMAZINE, FLUPHENAZINE, PERPHENAZINE,PROCHLORPERAZINE, THIORIDAZINE HCL, TRIFLUOPERAZINE HCL, A documented trial of one day or one course of one of the covered alternatives: GRANISETRON, ONDANSETRON A documented trial of one day or one course of one of the covered alternatives: GRANISETRON, ONDANSETRON A documented trial of one month of one of the covered alternatives: CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN MESYLATE, IRBESARTAN, LOSARTAN POTASSIUM, IRBESARTAN/HCTZ, LOSARTAN A documented trial of one month of one of the covered alternatives: CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN MESYLATE, IRBESARTAN, LOSARTAN POTASSIUM, IRBESARTAN/HCTZ, LOSARTAN A documented trial of one month of one of the covered alternatives: CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN MESYLATE, IRBESARTAN, LOSARTAN POTASSIUM, IRBESARTAN/HCTZ, LOSARTAN A documented trial of one month of one of the covered alternatives: CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN MESYLATE, IRBESARTAN, LOSARTAN POTASSIUM, IRBESARTAN/HCTZ, LOSARTAN A documented trial of one month of one of the covered alternatives: CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN MESYLATE, IRBESARTAN, LOSARTAN POTASSIUM, IRBESARTAN/HCTZ, LOSARTAN A documented trial of one month of one of the covered alternatives: CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN MESYLATE, IRBESARTAN, LOSARTAN POTASSIUM, IRBESARTAN/HCTZ, LOSARTAN A documented trial of one month of one of the covered alternatives: CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN MESYLATE, IRBESARTAN, LOSARTAN POTASSIUM, IRBESARTAN/HCTZ, LOSARTAN A documented trial of one month of one of the covered alternatives: CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN MESYLATE, IRBESARTAN, LOSARTAN POTASSIUM, IRBESARTAN/HCTZ, LOSARTAN A documented trial of one month of one of the covered alternatives: AMPHETAMINE/DEXTROAMPHETAMINE, DEXTROAMPHETAMINE, DEXMETHYLPHENIDATE, METHYLPHENIDATE, METHAMPHETAMINE A documented trial of one month of one of the covered alternatives: RISPERIDONE, QUETIAPINE, OLANZAPINE, ZIPRASIDONE,OLANZAPINE/FLUOXETINE A documented trial of one month of one of the covered alternatives: RISPERIDONE, QUETIAPINE, OLANZAPINE, ZIPRASIDONE,OLANZAPINE/FLUOXETINE A documented trial of one month of one of the covered alternatives: RISPERIDONE, QUETIAPINE, OLANZAPINE, ZIPRASIDONE,OLANZAPINE/FLUOXETINE A documented trial of one month of one of the covered alternatives: RISPERIDONE, QUETIAPINE, OLANZAPINE, ZIPRASIDONE,OLANZAPINE/FLUOXETINE A documented trial of one month of one of the covered alternatives: RISPERIDONE, QUETIAPINE, OLANZAPINE, ZIPRASIDONE,OLANZAPINE/FLUOXETINE A documented trial of one month of one of the covered alternatives: RISPERIDONE, QUETIAPINE, OLANZAPINE, ZIPRASIDONE,OLANZAPINE/FLUOXETINE A documented trial of one month of one of the covered alternatives: RISPERIDONE, QUETIAPINE, OLANZAPINE, ZIPRASIDONE,OLANZAPINE/FLUOXETINE A documented trial of one month of one of the covered alternatives: RISPERIDONE, QUETIAPINE, OLANZAPINE, ZIPRASIDONE,OLANZAPINE/FLUOXETINE A documented trial of one month of one of the covered alternatives: RISPERIDONE, QUETIAPINE, OLANZAPINE, ZIPRASIDONE,OLANZAPINE/FLUOXETINE A documented trial of one month of the covered alternative: PIOGLITAZONE A documented trial of one month of the covered alternative: SELEGILINE HCL A documented trial of one month of one of the covered alternatives: ALFUZOSIN, TAMSULOSIN, FINASTERIDE, DOXAZOSIN A documented trial of one month of one of the covered alternatives: ALFUZOSIN, TAMSULOSIN, FINASTERIDE, DOXAZOSIN A documented trial of one month of one of the covered alternatives: ALFUZOSIN, TAMSULOSIN, FINASTERIDE, DOXAZOSIN A documented trial of one month of one of the covered alternatives: ALFUZOSIN, TAMSULOSIN, FINASTERIDE, DOXAZOSIN A documented trial of one month of the covered alternative: ZOLEDRONIC ACID MONOHYDRATE A documented trial of one month of the covered alternative: ZOLEDRONIC ACID MONOHYDRATE A documented trial of one month of one of the covered alternatives: ALENDRONATE SODIUM, ETIDRONATE DISODIUM, IBANDRONATE A documented trial of one month of one of the covered alternatives: ALENDRONATE SODIUM, ETIDRONATE DISODIUM, IBANDRONATE A documented trial of one month of one of the covered alternatives: ALENDRONATE SODIUM, ETIDRONATE DISODIUM, IBANDRONATE A documented trial of one month of the covered alternative : CALCIPOTRIENE A documented trial of one month of the covered alternative : CALCIPOTRIENE A documented trial of one month of the covered alternative : CALCIPOTRIENE A documented trial of one month of the covered alternative : CALCIPOTRIENE A documented trial of one month of the covered alternative : CALCIPOTRIENE A documented trial of one week or one course of the covered alternatives: HYDROCORTISONE ACETATE and UREA A documented trial of one month of one of the covered alternatives: ETHOSUXIMIDE, ZONISAMIDE A documented trial of one day or one course of one of the covered alternatives: GRANISETRON, ONDANSETRON A documented trial of one month of the covered alternative: CHOLESTYRAMINE A documented trial of one month of the covered alternative: CHOLESTYRAMINE A documented trial of one month of one of the covered alternatives: CIDOFOVIR, GANCICLOVIR A documented trial of one month of each of the covered alternatives: TIMOLOL and BRIMONIDINE A documented trial of one month of the covered alternative:ENTACAPONE A documented trial of one month of the covered alternative:ENTACAPONE A documented trial of one month of one of the covered alternatives: IPRATROPIUM/ SOL ALBUTEROL, IPRATROPIUM, ALBUTEROL A documented trial of one month of one of the covered alternatives: CALCIPOTRIENE, TOPICAL CORTICOSTEROIDS A documented trial of one month of one of the covered alternatives: CALCIPOTRIENE, TOPICAL CORTICOSTEROIDS A documented trial of one month of one of the covered alternatives: CALCIPOTRIENE, TOPICAL CORTICOSTEROIDS A documented trial of one month of one of the covered alternatives: CALCIPOTRIENE, TOPICAL CORTICOSTEROIDS A documented trial of one week of the covered alternative: VANCOMYCIN Health Insurance Exchanges Essential Drug List Individual (Public ) Drugs that Require Step Therapy
LABEL NAME
CRITERIA
A documented trial of one month of one of the covered alternatives: APRISO A documented trial of one day or one course of one of the covered alternatives: GRANISETRON, ONDANSETRON A documented trial of one day or one course of one of the covered alternatives: GRANISETRON, ONDANSETRON A documented trial of one day or one course of one of the covered alternatives: GRANISETRON, ONDANSETRON A documented trial of one day or one course of one of the covered alternatives: GRANISETRON, ONDANSETRON A documented trial of one application (1 day) of the covered alternative: LIDOCAINE-PRILOCAINE A documented trial of one month of one of the covered alternatives: phenelzine, tranylcypromine A documented trial of one month of the covered alternative: ESTRADIOL A documented trial of one month of the covered alternative: ESTRADIOL A documented trial of one month of the covered alternative: ESTRADIOL A documented trial of one month of each of the covered alternatives: ESTRADIOL, PROGESTERONE MICRONIZED CAP A documented trial of one month of each of the covered alternatives: ESTRADIOL, PROGESTERONE MICRONIZED CAP A documented trial of one month of one of the covered alternatives: ALENDRONATE SODIUM, ETIDRONATE DISODIUM, IBANDRONATE A documented trial of one month of one of the covered alternatives: APRACLONIDINE, BRIMONIDINE, DORZOLAMIDE A documented trial of one month of one of the covered alternatives: LATANOPROST, TRAVOPROST A documented trial of one month of one of the covered alternatives: LATANOPROST, TRAVOPROST A documented trial of one month of one of the covered alternatives: ALLOPURINOL, PROBENECID, PROBENECID-COLCHICINE A documented trial of one month of one of the covered alternatives: ALLOPURINOL, PROBENECID, PROBENECID-COLCHICINE A documented trial of one month of one of the covered alternatives: VICTRELIS A documented trial of one month of one of the covered alternatives: PEG-INTRON A documented trial of one month of the covered alternative: BUDESONIDE SUSP A documented trial of one month of the covered alternative: BUDESONIDE SUSP A documented trial of one course (1 day) of one of the covered alternatives: LACTULOSE, PEG 3350 A documented trial of one month of one of the covered alternatives: AMPHETAMINE/DEXTROAMPHETAMINE, DEXMETHYLPHENIDATE, METHYLPHENIDATE, METHAMPHETAMINE, AND CLONIDINE, OR GUANFACINE A documented trial of one month of one of the covered alternatives: AMPHETAMINE/DEXTROAMPHETAMINE, DEXMETHYLPHENIDATE, METHYLPHENIDATE, METHAMPHETAMINE, AND CLONIDINE, OR GUANFACINE A documented trial of one month of one of the covered alternatives: AMPHETAMINE/DEXTROAMPHETAMINE, DEXMETHYLPHENIDATE, METHYLPHENIDATE, METHAMPHETAMINE, AND CLONIDINE, OR GUANFACINE A documented trial of one month of the covered alternative: LACTULOSE A documented trial of one month of one of the covered alternatives: LEVIMIR A documented trial of one month of one of the covered alternatives: LEVIMIR A documented trial of 14 days of one of the covered alternative(s) : NARATRIPTAN, SUMATRIPTAN, RIZATRIPTAN /RIZATRIPTAN ODT, ZOLMITRIPTAN / ZOLMITRIPTAN ODT A documented trial of 14 days of one of the covered alternative(s) : NARATRIPTAN, SUMATRIPTAN, RIZATRIPTAN /RIZATRIPTAN ODT, ZOLMITRIPTAN / ZOLMITRIPTAN ODT A documented trial of 14 days of one of the covered alternative(s) : NARATRIPTAN, SUMATRIPTAN, RIZATRIPTAN /RIZATRIPTAN ODT, ZOLMITRIPTAN / ZOLMITRIPTAN ODT A documented trial of 14 days of one of the covered alternative(s) : NARATRIPTAN, SUMATRIPTAN, RIZATRIPTAN /RIZATRIPTAN ODT, ZOLMITRIPTAN / ZOLMITRIPTAN ODT A documented trial of 14 days of one of the covered alternative(s) : NARATRIPTAN, SUMATRIPTAN, RIZATRIPTAN /RIZATRIPTAN ODT, ZOLMITRIPTAN / ZOLMITRIPTAN ODT A documented trial of 14 days of one of the covered alternative(s) : NARATRIPTAN, SUMATRIPTAN, RIZATRIPTAN /RIZATRIPTAN ODT, ZOLMITRIPTAN / ZOLMITRIPTAN ODT A documented trial of 14 days of one of the covered alternative(s) : NARATRIPTAN, SUMATRIPTAN, RIZATRIPTAN /RIZATRIPTAN ODT, ZOLMITRIPTAN / ZOLMITRIPTAN ODT A documented trial of 14 days of one of the covered alternative(s) : NARATRIPTAN, SUMATRIPTAN, RIZATRIPTAN /RIZATRIPTAN ODT, DIHYDROERGOTAMINE NASAL SPRAY, ZOLMITRIPTAN / ZOLMITRIPTAN ODT A documented trial of two days of the preferred generic: morphine sr 24hr A documented trial of two days of the preferred generic: morphine sr 24hr A documented trial of one course (1 day) of the covered alternative: DIPHENOXYLATE/ATROPINE TAB A documented trial of one month of one of the covered alternative: EXTAVIA A documented trial of one month of one of the covered alternative: EXTAVIA A documented trial of one month of one of the covered alternative: EXTAVIA A documented trial of one month of one of the covered alternative: EXTAVIA A documented trial of one month of one of the covered alternative: EXTAVIA A documented trial of one month of one of the covered alternative: EXTAVIA A documented trial of one month of one of the covered alternatives: AMIODARONE, DISOPYRAMIDE, FLECAINIDE, MEXILETINE, PROCAINAMIDE, PROPAFENONE, QUINIDINE GL, QUINIDINE SU, SORINE, SOTALOL AF, A documented trial of one month of one of the covered alternatives: pramipexole, ropinirole / ER A documented trial of two weeks of one of the covered alternatives: DESLORATADINE, LEVOCETIRIZINE A documented trial of one month of one of the covered alternatives: LEVIMIR A documented trial of one month of one of the covered alternatives: Humalog/Humalog Kwik/Humalog Mix, Humulin R U-100/N/Mix A documented trial of one month of one of the covered alternatives: Humalog/Humalog Kwik/Humalog Mix, Humulin R U-100/N/Mix A documented trial of one month of one of the covered alternatives: Humalog/Humalog Kwik/Humalog Mix, Humulin R U-100/N/Mix A documented trial of one month of one of the covered alternatives: Humalog/Humalog Kwik/Humalog Mix, Humulin R U-100/N/Mix A documented trial of one month of one of the covered alternatives: Humalog/Humalog Kwik/Humalog Mix, Humulin R U-100/N/Mix A documented trial of one month of one of the covered alternatives: Humalog/Humalog Kwik/Humalog Mix, Humulin R U-100/N/Mix A documented trial of one month of one of the covered alternatives: Humalog/Humalog Kwik/Humalog Mix, Humulin R U-100/N/Mix A documented trial of one month of one of the covered alternatives: Humalog/Humalog Kwik/Humalog Mix, Humulin R U-100/N/Mix NOVOLOG MIX INJ FLEXPEN A documented trial of one month of one of the covered alternatives: Humalog/Humalog Kwik/Humalog Mix, Humulin R U-100/N/Mix A documented trial of two weeks each of two preferred generic nonsteroidal anti-inflammatory agents: DICLOFENAC, ETODOLAC, FENOPROFEN, IBUPROFEN, INDOMETHACIN, KETOROLAC, MEFANAMIC ACID, A documented trial of two weeks each of two preferred generic nonsteroidal anti-inflammatory agents: DICLOFENAC, ETODOLAC, FENOPROFEN, IBUPROFEN, INDOMETHACIN, KETOROLAC, MEFANAMIC ACID, A documented trial of one month of the covered alternative: MODAFINIL A documented trial of one month of the covered alternative: MODAFINIL A documented trial of one month of one of the covered alternatives: AZELASTINE, CROMOLYN, EPINASTINE A documented trial of one month of one of the covered alternatives: AZELASTINE, CROMOLYN, EPINASTINE Health Insurance Exchanges Essential Drug List Individual (Public ) Drugs that Require Step Therapy
LABEL NAME
CRITERIA
A documented trial of one month of one of the covered alternatives: AZELASTINE, CROMOLYN, EPINASTINE A documented trial of one month of one of the covered alternatives: AZELASTINE, CROMOLYN, EPINASTINE A documented trial of one month of one of the covered alternatives: AZELASTINE, CROMOLYN, EPINASTINE A documented trial of one month of one of the covered alternatives: AZELASTINE, CROMOLYN, EPINASTINE A documented trial of one month of one of the covered alternatives: AZELASTINE, CROMOLYN, EPINASTINE A documented trial of 3 DAYS of one of the covered alternatives: BROMFENAC, DICLOFENAC, FLURBIPROFEN, KETOROLAC A documented trial of one month of one of the covered alternatives: DEXAMETHASONE OP, FLUOROMETHOLONE, PREDNISOLONE ACETATE, PREDNISOLONE SOD PHOS A documented trial of one month of one of the covered alternatives: DEXAMETHASONE OP, FLUOROMETHOLONE, PREDNISOLONE ACETATE, PREDNISOLONE SOD PHOS A documented trial of one month of one of the covered alternatives: DEXAMETHASONE OP, FLUOROMETHOLONE, PREDNISOLONE ACETATE, PREDNISOLONE SOD PHOS A documented trial of one month of one of the covered alternatives: DEXAMETHASONE OP, FLUOROMETHOLONE, PREDNISOLONE ACETATE, PREDNISOLONE SOD PHOS A documented trial of one month of one of the covered alternatives: DEXAMETHASONE OP, FLUOROMETHOLONE, PREDNISOLONE ACETATE, PREDNISOLONE SOD PHOS A documented trial of two days of one of the covered alternatives: FENTANYL PATCH, OXYCODONE, OXYMORPHONE, METHADONE, MORPHINE SULFATE SR, TRAMADOL ER A documented trial of two days of one of the covered alternatives: FENTANYL PATCH, OXYCODONE, OXYMORPHONE, METHADONE, MORPHINE SULFATE SR, TRAMADOL ER A documented trial of one month of one of the covered alternatives: Tradjenta.
A documented trial of one month of one of the covered alternatives: Tradjenta.
A documented trial of one day or one course of one of the covered alternatives: LINDANE, MALATHION, PERMETHRIN A documented trial of one day or one course of one of the covered alternatives: LINDANE, MALATHION, PERMETHRIN A documented trial of one day or one course of one of the covered alternatives: LINDANE, MALATHION, PERMETHRIN A documented trial of one course of the covered alternative: PEG-3350 A documented trial of one month of one of the covered alternatives: PEG-INTRON A documented trial of one month of one of the covered alternatives: PEG-INTRON A documented trial of one month of one of the covered alternatives: PEG-INTRON A documented trial of one month of one of the covered alternatives: ZENPEP A documented trial of one month of the covered alternative :PODOFILOX A documented trial of one month of one of the covered alternatives: gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate,zonisamide ORAPRED SOL 15MG/5ML A documented adeqiate trial of up to a month of of the covered alternative: PREDNISOLONE SODIUM PHOSPHATE A documented trial of one month of one of the covered alternatives: AMPHETAMINE/DEXTROAMPHETAMINE, DEXTROAMPHETAMINE, DEXMETHYLPHENIDATE, METHYLPHENIDATE, METHAMPHETAMINE A documented trial of one month of one of the covered alternatives: LANSOPRAZOLE, OMEPRAZOLE, PANTOPRAZOLE A documented trial of one month of one of the covered alternatives: LANSOPRAZOLE, OMEPRAZOLE, PANTOPRAZOLE A documented trial of one month of one of the covered alternatives: LANSOPRAZOLE, OMEPRAZOLE, PANTOPRAZOLE A documented trial of one month of one of the covered alternatives: LANSOPRAZOLE, OMEPRAZOLE, PANTOPRAZOLE A documented trial of one month of one of the covered alternatives: LANSOPRAZOLE, OMEPRAZOLE, PANTOPRAZOLE A documented trial of one month of the covered alternative: SILDENAFIL A documented trial of one month of the covered alternative: SILDENAFIL A documented trial of one month of the covered alternative: SILDENAFIL A documented trial of one month of the covered alternative: SILDENAFIL A documented trial of one month of the covered alternative: SILDENAFIL A documented trial of one month of one of the covered alternatives: FOSRENOL A documented trial of one month of one of the covered alternatives: RILUZOLE A documented trial of two days of one of the covered alternatives: ZALEPLON, ZOLPIDEM A documented trial of two days of one of the covered alternatives: ZALEPLON, ZOLPIDEM A documented trial of one month of one of the covered alternatives: CARISOPRODOL, CHLORZOXAZONE, CYCLOBENZAPRINE, METAXALONE, METHOCARBAMOL, ORPHENADRINE, TIZANIDINE A documented trial of one month of the covered alternative: BUPRENORPHINE/NALOXONE SL A documented trial of one month of the covered alternative: BUPRENORPHINE/NALOXONE SL A documented trial of one month of one of the covered alternatives: DANAZOL, METHITEST, TESTOSTERONE CYPIONATE, TESTOSTERONE ENANTHATE A documented trial of one week or one course of one of the covered alternatives: AMCINONIDE, BETAMETHASONE, DESONIDE, FLUTICASONE, ALCLOMETASONE A documented trial of one week or one course of one of the covered alternatives: AMCINONIDE, BETAMETHASONE, DESONIDE, FLUTICASONE, ALCLOMETASONE A documented trial of one week or one course of one of the covered alternatives: FLUCONAZOLE, ITRACONAZOLE, KETOCONAZOLE, VORICONAZOLE A documented trial of one month of one of the covered alternatives: OXYBUTYNIN, TOLTERODINE, TROSPIUM A documented trial of one month of one of the covered alternatives: OXYBUTYNIN, TOLTERODINE, TROSPIUM A documented trial of one month of one of the covered alternatives: OXYBUTYNIN, TOLTERODINE, TROSPIUM A documented trial of one month of one of the covered alternatives: CIDOFOVIR, GANCICLOVIR A documented trial of one month of one of the covered alternatives: CIDOFOVIR, GANCICLOVIR A documented trial of one month of the covered alternative: CALCITRIOL A documented trial of one month of one of the covered alternatives: CARBAMAZEPINE, DIVALPROEX SODIUM, ETHOSUXAMIDE, FOSPHENYTOIN, GABAPENTIN, LAMOTRIGINE, LEVTIRACETAM, OXCARBAZEPINE, A documented trial of two weeks of one covered alternative indicated for the member's condition: LACTULOSE,AZITHROMYCIN, CIPROFLOXACIN A documented trial of one week of the covered alternative: ACYCLOVIR OINTMENT A documented trial of one week of the covered alternative: ACYCLOVIR OINTMENT A documented trial of one month of the covered alternative: BUPROPION HCL A documented trial of one month of the covered alternative: BUPROPION HCL A documented trial of one month of the covered alternative: BUPROPION HCL

Source: http://aetnafamilyplan.net/healthcare-professionals/documents-forms/exchanges/Individual-Step-Therapy-Criteria-2014.pdf