Step Therapy Guidelines

Step therapy is in place for the drugs listed below. Step Therapy is the practice of beginning drug therapy for a medical condition with the most cost-effective and safest drug and progressing to other more costly or risky therapy, only if necessary (i.e., you must try drug "A" before you can get drug "B"). The goal is to control costs and minimize risks. Step therapy is an automated process. If a prescription is presented for a "step therapy" drug (i.e., "B") to a pharmacy, an automated check of the member's prescription history will occur. If the system finds that the member has received the qualifying drug(s) (i.e., "A"), the prescription will be processed. If the system does not find the qualifying drug (i.e., "A") in the member's recent history, a prior authorization will be necessary. The step therapy guidelines are developed and reviewed by a panel of practicing physicians and pharmacists.

Click on the drug name below to view the specific step therapy guidelines

Commercial Guidelines:

ARB and ARB Combo 

Abilfy Seroquel 

ADOXA (doxycycline monohydrate) 

Amerge (Nartriptan HCL)

Anora Ellipta ST 

Atypical Antipsychotics ST and QL  

Atypical Antipsychotics for Major Depressive Disorder ST 

ARAVA (leflunomide) 

Aromatase Inhibitors 

ASTAGRAF XL (tacrolimus) 

Avandia Products

Axert (Almotriptan Malate)) 

BELBUCA (buprenorphine 

Brintellix (vortioxetine) 

CAVERJECT EDEX (alprostadil) 

CELEBREX (celecoxib)

CLARINEX (desloratadine) 

CLARINEX-D (desloratadine/pse levocetirizine)CONCERTA (methylphenidate hcl) 

Conzip ST and QL 

Crestor ST 

DALIRESP (roflumilast) 

DPP4 Inhibitors 

DESOXYN (methamphetamine hcl) 

Desvenlafaxine 

Diclofenac 

DIFICID (fidaxomicin) 

DORYX (doxycycline hyclate) 

FARXIGA (dapagliflozin propanediol) 

FETZIMA (levomilnacipran) 

Forfivo XL ST 

Frova (Frovatriptan Succinate)

Fycompa (perampanel) ST 

GLP-1 Analogs ST 

Glaucoma 

GLYXAMBi (empagliflozin/linagliptin) 

Gralise ST 

Hep B Agents 

Horizant ST 

Hypnotics

Imitrex, Alsuma, Sumavel Dosepro, Imitrex Nasal Spray, Zecuity, Zembrace Symtouch Onzetra Xsail (Sumatriptan Succinate)

Imitrex Nasal Spray (Sumatriptan)

INCRUSE ELLIPTA (umeclidinium) 

INVOKAMET (canagliflozin/metformin hcl) 

INVOKANA (canagliflozin) 

INSPRA (eplerenone) 

JARDIANCE (empagliflozin) 

Liptruzet ST 

Luzu (luliconazole) 

Nasal Steriods 

Neupro ST and QL 

Onzetra Xsail (Sumtriptan)

ORACEA (doxycycline monohydrate) 

Oral Proton Pump Inhibitors 

Potiga PA and ST 

Pristiq ST and QL 

Qudexy XR ST 

RASUVO (methotrexate SQ) 

Relpax (Eletriptan HCL) 

Rexulti ST and QL 

SEEBRI NEOHALER (glycoprrolate) 

Sernivo (betametasone) 

Simcor 

SOLODYN (minocycline hcl) 

SYNJARDY (empagliflozin/metformin hcl) 

TREXIMET (naproxen-sumatriptan) 

TUDORZA PRESSAIR (aclidinium bromide) 

Uloric ST and QL 

UTIBRON NEOHALER (indacaterol/glycopyrrolate) 

VIBERZI (eluxadoline) 

VIMOVO (naproxen-esomeprazole) 

VYTORIN 

XIGDUO XR (dapagliflozin/metformin hcl) 

XOPENEX (levalbuterol) 

XYZAL (levocetirizine) 

ZIPSOR (diclofenac) 

Zomig, Zomig Spray, Zomig ZMT (Zolmitriptan) 



Last Updated: 08/2016