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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