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:
ACIPHEX (rabeprazole sodium)
ACIPHEX SPRINKLE (rabeprazole sodium)
ADLYXIN (lixisenatide)
ADOXA (doxycycline monohydrate)
AMBIEN CR (zolpidem tartrate er)
Amerge (Nartriptan HCL)
ANORO ELLIPTA (umeclidinium brm/vilanterol tr)
APTIOM (esliocarbazepine)
ARAVA (leflunomide)
ARCAPTA NEOHALER (indacaterol)
ARNUITY ELLIPTA (fluticasone furoate)
AROMASIN (exemestane)
Asacol (Mesalamine)
Asacol-HD (Mesalamine)
ASTAGRAF XL (tacrolimus)
ATACAND (candesartan cilexetil)
ATACAND HCT (candesartan/hydrochlorothiazide)
Atypical Antipsychotics ST and QL
Atypical Antipsychotics for Major Depressive Disorder ST
AUVI Q (epinephrine)
AVALIDE (irbesartan/hydrochlorothiazide)
Avandia Products
AVAPRO (irbesartan)
Axert (Almotriptan Malate)
AZOR (amlodipine/olmesartan)
BASAGLAR (insulin glargine)
BECONASE AQ (beclomethasone dipropionate)
BELBUCA (buprenorphine)
BELSOMRA (suvorexant)
BENICAR (olmesartan medoxomil)
BENICAR HCT (olmesartan/hydrochlorothiazide)
BEVESPI (glycopyrrolate/formoterol)
Brintellix (vortioxetine)
BYDUREON (exenatide microspheres)
BYETTA (exenatide)
CAMBIA (diclofenac)
CAVERJECT EDEX (alprostadil) 
CELEBREX (celecoxib)
CHILDREN’S QNASL (beclomethasone dipropionate)
CLARINEX (desloratadine) 
CLARINEX-D (desloratadine/pse levocetirizine)
CONZIP (tramadol)
COZAAR (lorsartan potassium)
DALIRESP (roflumilast) 
DPP4 Inhibitors
Delzicol (Mesalamine)
Desvenlafaxine
Detrol (Tolterodine)
Detrol LA (Tolterodine)
DEXILANT (dexlansoprazole)
Diclofenac 
DIFICID (fidaxomicin)
Dipentum (Olsalazine Sodium)
DIOVAN (valsartan)
DIOVAN HCT (valsartan/hydrochlorothiazide)
DORYX (doxycycline hyclate)
DUEXIS (ibuprofen/famotidine)
DYMISTA (azelastine/fluticasone)
EDARBI (azilsartan medoxomil)
EDARBYCLOR (azilsartan/chlorthalidone)
EDLUAR (zolpidem tartrate sl)
Elidel (pimecrolimus)
Enablex (Darifenacin Hydrobromide)
ESOMEPRAZOLE STRONTIUM
EUCRISA (crisaborole)
EXFORGE (amlodipine/valsartan)
EXFORGE HCT (amlodipine/valsartan/hydrochlorothiazide)
FARXIGA (dapagliflozin propanediol)
FETZIMA (levomilnacipran) 
FORADIL AEROLIZER (formoterol fumarate)
Forfivo XL ST 
Frova (Frovatriptan Succinate)
Fycompa (perampanel) ST
Gelnique – gel pump/packets (Oxybutynin)
Giazo (Balsalazide Disodium)
Glaucoma
GLUMETZA (metformin)
GLYXAMBi (empagliflozin/linagliptin) 
GRALISE (gabapentin) 
Hep B Agents 
HORIZANT (gabapentin) 
HYZAAR (lorsartan/hydrochlorothiazide)
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 
LUNESTA (eszopiclone)
Luzu (luliconazole)
MICARDIS (telmisartan)
MICARDIS HCT (telmisartan/hydrochlorothiazide)
NAMZARIC (memantine/donepezil)
NeoSynalar (neomycin sulfate/fluocinolone)
Neupro ST and QL
NEXIUM (esomprazole magnesium)
OMNARIS (ciclesonide)
Onzetra Xsail (Sumtriptan)
ORACEA (doxycycline monohydrate) 
Oral Proton Pump Inhibitors
OXTELLAR XR (oxcarbazepine)
Oxytrol – gel pump (Oxybutynin)
Pentasa (Mesalamine)
POTIGA (EZOGABINE)
PREVACID (lansoprazole)
PRILOSEC (omeprazole)
PRILOSEC (omeprazole magnesium)
Pristiq ST and QL
PROTONIX (pantoprazole sodium) 
QNASL (beclomethasone dipropionate)
QUDEXY XR (topiramate) 
RANEXA (ranolazine)
RASUVO (methotrexate SQ) 
Relpax (Eletriptan HCL) 
Rexulti ST and QL 
RHINOCORT AQUA (budesonide)
RYTARY (carbidopa/levodopa)
SAVELLA (milnacipran)
SEEBRI NEOHALER (glycoprrolate) 
Sernivo (betametasone) 
Simcor
SOLIQUA (insulin glargine/lixisenatide)
SOLODYN (minocycline hcl)
SONATA (zaleplon)
SYNJARDY (empagliflozin/metformin hcl)
TANZEUM (albiglutide)
TEVETEN (eprosartan mesylate)
TEVETEN HCT (eprosartan/hydrochlorothiazide)
TIVORBEX (indomethacin submicron)
Toviaz (Fesoterodine Fumarate)
Tresiba, Tresiba Flextouch (Insulin Degludec)
TREXIMET (naproxen-sumatriptan)
TRIBENZOR (amlodipine/olmesartan/hydrochlorothiazide)
TRULICITY (dulaglutide)
TUDORZA PRESSAIR (aclidinium bromide) 
TWYNSTA (amlodipine/telmisartan)
TYZEKA (telebivudine)
ULORIC (febuxostat) 
UTIBRON NEOHALER (indacaterol/glycopyrrolate) 
VERAMYST (fluticasone furoate)
VIBERZI (eluxadoline)
VICTOZA 2-PAK (liraglutide)
VICTOZA 3-PAK (liraglutide)
VIMOVO (naproxen-esomeprazole)
VIVLODEX (meloxicam)  
VYTORIN 
XIGDUO XR (dapagliflozin/metformin hcl) 
XOPENEX (levalbuterol) 
XULTOPHY (insulin degludec and liraglutide)
XYZAL (levocetirizine)
ZEGERID (omeprazole/sodium bicarbonate)
ZETONNA (ciclesonide)
ZIPSOR (diclofenac)
ZITHRANOL (anthralin)
ZITHRANOL-RR (anthralin)
ZOLPIMIST (zolpidem tartrate)
Zomig, Zomig Spray, Zomig ZMT (Zolmitriptan)
ZUPLENZ (ondansetron)
ZYZAL (levocetirizine)

Last Updated: 04/2017