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Step Therapy Drug List
Effective: 1/1/18
Date last updated: 1/1/20
Step Therapy is a limitation that requires you to try preferred medications before the plan will pay for another drug for the same medical condition that the doctor may have originally prescribed. An automated, electronic review of the your drug history is performed to determine whether other drugs have been tried first for your condition. This ensures clinically sound and cost-effective treatment options are tried. If a prescribed drug does not meet the step therapy criteria, it may not be covered. You should consult with your doctor about alternative therapy.
The table below lists drugs that are subject to Step Therapy. The drugs listed in the “Step Therapy Criteria (A)” column
must be tried first before drugs listed in the “Step Edit Drug (B)” column will be covered.
Therapeutic Class
Step Edit Drug (B) Step Therapy Criteria (A)
Antiasthmatic and Bronchodilator Agents
Bronchodilators -Anticholinergics
LONHALA MAGNAIR (glycopyrrolate) inhalation
solution 25mcg/ml Trial of two of the following for 3 months each in the last 12 months:
INCRUSE ELLIPTA SEEBRI NEOHALER SPIRIVA (HANDIHALER or RESPIMAT) TUDORZA PRESSAIR
Sympathomimetics generic ADVAIR DISKUS (fluticasone-salmeterol) inhalation aerosol powder-breath
activate 100-50mcg, 250-50mcg, 500-50mcg
generic ADVAIR DISKUS (WIXELA INHUB,
fluticasone-salmeterol) inhalation aerosol powder-breath activate 100-50mcg, 250-50mcg, 500-50mcg
Trial of the following in last 3 months:
ADVAIR DISKUS
AIRDUO RESPICLICK (fluticasone-salmeterol)
inhalation aerosol powder-breath activate 55-14 mcg/act, 113-14mcg/act, 232-14 mcg/act
Trial of two of the following for 3 months each in the last 12 months:
ADVAIR (DISKUS or HFA) BREO ELLIPTA fluticasone propionate/salmeterol SYMBICORT
BEVESPI AEROSPHERE (glycopyrrolate-
formoterol fumarate) inhalation aerosol 9-4.8 mcg/act
Trial of both of the following in the last 12 months:
ANORO ELLIPTA STIOLTO RESPIMAT
DULERA (mometasone furoate-formoterol
fumarate) inhalation aerosol 100-5mcg/act, 200-5mcg/act
Trial of two the following for 3 months in the last 12 months:
ADVAIR (DISKUS or HFA) BREO ELLIPTA fluticasone propionate/salmeterol SYMBICORT
D20110 05/18 Page 1
Step Therapy List
Date last updated: 8/1/19
Therapeutic Class Step Edit Drug (B) Step Therapy Criteria (A)
PROVENTIL HFA (albuterol sulfate) aerosol
solution 108mcg/act
generic PROVENTIL HFA (albuterol sulfate hfa)
aerosol solution 108mcg/act
Trial of both of the following in the last 12 months:
PROAIR (HFA or RESPICLICK) VENTOLIN HFA AER
STRIVERDI RESPIMAT (olodaterol hcl)
inhalation aerosol solution 2.5mcg/act Trial of three of the following for 3 months each Inthe last 12 months:
ANORO ELLIPTA ARCAPTA NEOHALER SEREVENT DISKUS simultaneous use of SPIRIVA with SEREVENT DISKUS simultaneous use of SPIRIVA with ARCAPTA NEOHALER
UTIBRON NEOHALER (indacaterol-
glycopyrrolate) inhalation capsule 27.5-15.6 mcg Trial of both of the following in the last 12 months:
ANORO ELLIPTA STIOLTO RESPIMAT
XOPENEX HFA AER (levalbuterol tartrate)
inhalation nebulization solution 45mcg/act
generic XOPENEX HFA AER (levalbuterol tartrate) inhalation nebulization solution
45mcg/act
Trial of both of the following in the last 12 months:
PROAIR (HFA or RESPICLICK) VENTOLIN HFA
Anticonvulsants
Anticonvulsants -Benzodiazepines
SYMPAZAN (clobazam) oral film 5mg, 10mg,
20mg Trial of the following in the last 3 months:
ONFI
Anticonvulsants -Miscellaneous
APTIOM (eslicarbazepine acetate) tablet 200mg,
400mg, 600mg, 800mg Trial of three of the following in the last 12 months:
gabapentin lamotrigine levetiracetam oxcarbazepine pregabalin topiramate zonisamide
BRIVIACT (brivaracetam) oral solution 10mg/ml
BRIVIACT (brivaracetam) tablet 10mg, 25mg,
50mg, 75mg, 100mg
Trial of the following for 2 months in the last 12 months:
levetiracetam (generic for KEPPRA)
QUDEXY XR (topiramate) capsule 24-hour
sprinkle 25mg, 50mg, 100mg, 150mg, 200mg
generic QUDEXY XR (topiramate ER) capsule
24-hour sprinkle 25mg, 50mg, 100mg, 150mg, 200mg
Trial of the following for 3 months in the last 12 months:
topiramate (generic for TOPAMAX)
D20110 0518 Page 2
Step Therapy List
Date last updated: 8/1/19
Therapeutic Class Step Edit Drug (B) Step Therapy Criteria (A)
TROKENDI XR (topiramate) capsule ER 24-hour
25mg, 50mg, 100mg, 200mg Trial of both of the following for 3 months each In the last 12 months:
topiramate (generic for TOPAMAX) topiramate ER capsule
Antidiabetics
Antidiabetic Combinations QTERN (dapagliflozin-saxagliptin) tablet 10-5mg,
5-5mg Trial of the following in the last 6 months:
simultaneous use of FARXIGA with JANUVIA
STEGLUJAN (ertugliflozin-sitagliptin) tablet 5-
100mg, 15-100mg Trial of the following in the last 6 months:
simultaneous use of FARXIGA with JANUVIA
Biguanides FORTAMET (metformin hcl) tablet ER 24-hour
500mg, 1000mg Trial of both of the following for 3 months each in the last 12 months:
generic GLUCOPHAGE XR generic FORTAMET
generic FORTAMET (metformin hcl) tablet ER
24-hour 500mg, 1000mg Trial of the following for 3 months in the last 12 months:
generic GLUCOPHAGE XR
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
NESINA (alogliptin benzoate) tablet 6.25mg,
12.5mg, 25mg
generic NESINA (alogliptin benzoate) tablet
6.25mg, 12.5mg, 25mg
Trial of one the following for 3 months in the last 12 months:
simultaneous use of metformin with ONGLYZA simultaneous use of metformin with JANUVIA
Incretin Mimetic Agents (GLP-1 Receptor Agonists)
OZEMPIC (semaglutide) subcutaneous solution
pen-injection 2mg/1.5ml Trial of both of the following in the last 12 months:
TRULICITY VICTOZA
Insulin ADMELOG (insulin lispro) subcutaneous solution
vial 100u/ml
ADMELOG SOLOSTAR (insulin lispro)
subcutaneous solution pen-injector 100u/ml
Trial of the following in the last 12 months:
HUMALOG
APIDRA (insulin glulisine) subcutaneous solution
vial 100u/ml
APIDRA SOLOSTAR (insulin glulisine)
subcutaneous solution pen-injector 100u/ml
Trial of the following in the last 12 months:
HUMALOG
BASAGLAR KWIKPEN (insulin glargine)
subcutaneous solution pen-injector 100u/ml Trial of the following in the last 12 months:
LANTUS
FIASP (insulin aspart with niacinamide)
subcutaneous solution vial 100u/ml
FIASP FLEXTOUCH (insulin aspart with
niacinamide) subcutaneous solution pen-injector 100u/ml
Trial of the following in the last 12 months:
HUMALOG
D20110 0518 Page 3
Step Therapy List
Date last updated: 8/1/19
Therapeutic Class Step Edit Drug (B) Step Therapy Criteria (A)
HUMULIN R U 500 Vial (insulin regular) HUMULIN R U 500 Kwikpen (insulin regular)
Trial of the following for 3 months in the last 6 months
HUMULIN R U-100
LEVEMIR (insulin detemir) subcutaneous solution
vial 100u/ml
LEVEMIR FLEXTOUCH (insulin detemir) solution
pen-injection 100u/ml
Trial of the following in the last 12 months:
LANTUS
NOVOLIN 70/30 (insulin NPH isophane & regular
human) subcutaneous suspension vial 100u/ml
NOVOLIN 70/30 FLEXPEN (insulin NPH
isophane & regular human) subcutaneous suspension pen-injector 100u/ml
NOVOLIN 70/30 FLEXPEN RELION (insulin NPH
isophane & regular human) subcutaneous suspension pen-injector 100u/ml
NOVOLIN 70/30 RELION (insulin NPH isophane
& regular human) subcutaneous suspension vial 100u/ml
Trial of the following in the last 12 months:
HUMULIN 70/30
NOVOLIN N (insulin NPH isophane human
injection) subcutaneous suspension vial 100u/ml
NOVOLIN N RELION (insulin NPH isophane
human injection) subcutaneous suspension vial 100u/ml
Trial of the following in the last 12 months:
HUMULIN N
NOVOLIN R (insulin regular (human)) injection
solution vial 100u/ml
NOVOLIN R RELION (insulin regular (human))
injection solution vial 100u/ml
Trial of the following in the last 12 months:
HUMULIN R
NOVOLOG (insulin aspart) subcutaneous
solution vial 100u/ml
NOVOLOG FLEXPEN (insulin aspart)
subcutaneous solution pen-injector 100u/ml
NOVOLOG PENFILL (insulin aspart)
subcutaneous solution cartridge 100u/ml
Trial of the following in the last 12 months:
HUMALOG
NOVOLOG MIX 70/30 (insulin aspart protamine
and insulin aspart) subcutaneous suspension vial 100u/ml
NOVOLOG MIX 70/30 FLEXPEN (insulin aspart
protamine and insulin aspart) subcutaneous suspension pen-injector 100u/ml
Trial of the following in the last 12 months:
HUMALOG MIX 75/25
D20110 0518 Page 4
Step Therapy List
Date last updated: 8/1/19
Therapeutic Class Step Edit Drug (B) Step Therapy Criteria (A)
TRESIBA (insulin degludec) subcutaneous
solution vial 100u/ml
TRESIBA FLEXTOUCH (insulin degludec)
subcantaneous solution pen-injector 100u/ml, 200u/ml
Trial of the following for 3 months in the last 12 months:
LANTUS
Sodium-Glucose Co-Transporter 2 Inhibitors
STEGLATRO (ertugliflozin L-pyroglutamic acid)
tablet 5mg, 15mg Trial of the following in the last 6 months:
FARXIGA
Antidepressants
Serotonin Modulators TRINTELLIX (vortioxetine hbr) tablet 5mg, 10mg, 20mg
Trial of two drugs in either of the following classes for at least 2 months in last 12 months:
Selective Serotonin Reuptake Serotonin Norepinephrine Reuptake
Antifungal
Imidazole-Related Antifungals
TOLSURA (itraconazole) capsule 65mg Trial of the following in the last 6 months:
itraconazole 100mg capsule
Antihyperlipidemics
HMG COA Reductase Inhibitors
LIVALO (pitavastatin calcium) tablet 1mg, 2mg,
4mg Trial of two of the following in the last 12 months:
atorvastatin simvastatin rosuvastatin
ZYPITAMAG (pitavastatin calcium) tablet 1mg,
2mg, 4mg Trial of two of the following in the last 12 months:
atorvastatin simvastatin rosuvastatin
Antimetics
Antiemetics -Miscellaneous
AKYNZEO (netupitant-palonosetron) capsule
300-0.5mg Trial of the following in the last 3 months:
simultaneous use of ondansetron with aprepitant
Antiviral
Antiretrovirals DELSTRIGO (doravirine-lamivudine-tenofovir df )
tablet 100-300-300mg Reject if any history within last 180 days of antiretroviral therapy.
DOVATO (dolutegravir sodium-lamivudine) tablet
50-300mg Reject if any history within last 180 days of antiretroviral therapy.
PIFELTRO (doravirine) tablet 100mg Reject if any history within last 180 days of antiretroviral therapy.
Attention-deficit hyperactivity disorder
Amphetamines MYDAYIS (amphetamine-dextroamphetamine)
capsule ER 24-hour 12.5mg, 25mg, 37.5mg, 50mg
Trial of the following for 3 months in the last 12 months:
ADDERALL XR
Beta Blockers
D20110 0518 Page 5
Step Therapy List
Date last updated: 8/1/19
Therapeutic Class Step Edit Drug (B) Step Therapy Criteria (A)
Beta Blockers Cardio-Selective
KAPSPARGO SPRINKLE (metoprolol succinate)
capsule 24-hour sprinkle 25mg, 50mg, 100mg, 200mg
Trial of the following for 3 months in the last 12 months:
metoprolol succinate ER
Cardiovascular Agents
Impotence Agents CIALIS (tadalafil) tablet 2.5mg, 5mg Trial of three of the following for benign prostatic hyperplasia (BPH) for 3 months each in the last 18 months:
alfuzosin ER tamsulosin silodosin finasteride 5mg dutasteride dutasteride-tamsulosin (generic for JALYN)
Corticosteroids
Topicals DIFLORASONE DIACETATE (diflorasone diacetate) ointment 0.05%
Trial of two of the following in the last three months:
Betamethasone Clobetasol Hydrocortisone Triamcinolone
PSORCON (diflorasone diacetate) cream 0.05%
Trial of two of the following in the last three months:
Betamethasone Clobetasol Hydrocortisone Triamcinolone
Dermatologicals
Antibiotics-Topical XEPI (ozenoxacin) cream 1% Trial of the following for 3 months in the last 12 months:
mupirocin ointment 2%
Digestive Aids
Digestive Enzymes PANCREAZE (pancrelipase) capsule DR particle
2600-6200-10850 unit, 4200-14200-24600 unit, 10500-35500-61500 unit, 16800-56800-98400 unit, 21000-54700-83900 unit
Trial of both of the following in the last 12 months:
CREON ZENPEP
PERTZYE (pancrelipase) capsule DR particule
4000-14375-15125 unit, 8000-28750-30250 unit, 16000-57500-60500 unit, 24000-86250-90750 unit,
Trial of both of the following in the last 12 months:
CREON ZENPEP
VIOKACE (pancrelipase) tablet 10440-39150-
39150 unit, 20880-78300-78300 unit Trial of both of the following in the last 12 months:
CREON ZENPEP
Hematopoietic Agents
D20110 0518 Page 6
Step Therapy List
Date last updated: 8/1/19
Therapeutic Class Step Edit Drug (B) Step Therapy Criteria (A)
Agents For Sickle Cell Anemia
DROXIA (hydroxyurea) capsule 200mg, 300mg,
400mg Trial of both of the following for 3 months each in the last 12 months:
SIKLOS 100mg, 1000mg tablet hydroxyurea 500mg capsule
Gout Agents
Antigout ULORIC (febuxostat) tablet 40mg, 80mg Trial of both of the following for 3 months each in last 12 months:
allopurinal 100mg, 300mg tablet febuxostat 40mg, 80mg tablet
generic ULORIC (febuxostat) tablet 40mg, 80mg Trial of the following for 3 months in last 6 months:
allopurinal 100mg, 300mg tablet
Hypnotics/Sedatives/Sleep Disorder Agents
Hypnotics - Tricyclic Agents
SILENOR (doxepin hydrochloride) tablet 3mg,
6mg Trial of the following for 3 months in the last 12 months:
doxepin hcl 10mg capsule
Non-Barbiturate Hypnotics generic FROVA (frovatriptan succinate) tablet
2.5mg Trial of two of the following in the last 12 months:
almotriptan eletriptan naratriptan rizatriptan sumatriptan zolmitriptan
Medical Devices and Supplies
Diabetic Supplies DEXCOM G6 RECEIVER
DEXCOM G6 SENSOR
DEXCOM G6 TRANSMITTER
Trial of any of the following in last 3 months:
insulins
FREESTYLE LIBRE 14 DAY READER for flash
monitoring system
FREESTYLE LIBRE 14 DAY SENSOR for flash
monitoring system
FREESTYLE LIBRE READER for flash
monitoring system
FREESTYLE LIBRE SENSOR for flash
monitoring system
Trial of any of the following in last 3 months:
insulins amylin analogs incretin mimetic agents (GLP-1) sulfonylureas meglitinide analogues sodium-glucose co-transporter 2 Inhibitors insulin sensitizing agents
Opthalmic Agents
D20110 0518 Page 7
Step Therapy List
Date last updated: 8/1/19
Therapeutic Class Step Edit Drug (B) Step Therapy Criteria (A)
Prostaglandins -Ophthalmic
VYZULTA (latanoprostene bunod) ophthalmic
solution 0.024% Trial of two of the following in the last 12 months:
LUMIGAN XALATAN ZIOPTAN
Psychotherapeutic and Neurological Agents - Misc.
Postherpetic Neuralgia (PHN) / Neuropathic Pain Agents
LYRICA CR (pregabalin) tablet ER 24-hour
82.5mg, 165mg, 330mg Trial of one of the following in the last 6 months:
pregabalin LYRICA
D20110 0518 Page 8
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