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 

 

 

ADOXA (doxycycline monohydrate) 







Amerge (Nartriptan HCL)







Anora Ellipta ST 


Asacol (Mesalamine)


Asacol-HD (Mesalamine)



 



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 


Bevespi Aerosphere (glycopyrrolate/formoterol)



 



Brintellix (vortioxetine) 







CAVERJECT EDEX (alprostadil) 







CELEBREX (celecoxib)







CLARINEX (desloratadine) 







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







Conzip ST and QL 

  

DALIRESP (roflumilast) 







DPP4 Inhibitors 


Delzicol (Mesalamine)



 



DESOXYN (methamphetamine hcl) 







Desvenlafaxine


Detrol (Tolterodine)


Detrol LA (Tolterodine)



 



Diclofenac 







DIFICID (fidaxomicin) 


Dipentum (Olsalazine Sodium)



 



DORYX (doxycycline hyclate) 


Elidel (pimecrolimus)

 

Enablex (Darifenacin Hydrobromide)




FARXIGA (dapagliflozin propanediol) 







FETZIMA (levomilnacipran) 







Forfivo XL ST 







Frova (Frovatriptan Succinate)







Fycompa (perampanel) ST 


Gelnique – gel pump/packets (Oxybutynin)


Giazo (Balsalazide Disodium)



 



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) 


Levemir, Levemir Flextouch (Insulin Detemir)



 



Liptruzet ST 







Luzu (luliconazole) 







Nasal Steriods 


NeoSynalar (neomycin sulfate/fluocinolone)



 



Neupro ST and QL 







Onzetra Xsail (Sumtriptan)







ORACEA (doxycycline monohydrate) 







Oral Proton Pump Inhibitors 




Oxytrol – gel pump (Oxybutynin)


Pentasa (Mesalamine)


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) 


Toviaz (Fesoterodine Fumarate)


Tresiba, Tresiba Flextouch (Insulin Degludec)



 



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