Core and Select Step Therapy

Transcription

1 Core and Select Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment you need, usually at a lower cost. Here s how it works: You get a Try a Step 1 prescription medication first Before a Step 2 medication is covered With this program, you need to try a Step 1 medication first, before a Step 2 medication may be covered. When you bring a prescription to the pharmacy, our system will automatically screen the medication for step therapy requirements. If your prior pharmacy claims show you have tried a Step 1 medication in the recent past, the Step 2 medication may be processed. If not, the pharmacist will contact your doctor for further explanation. We encourage you to discuss your treatment and medication options with your doctor. If you have questions about the Step Therapy program, call the toll-free member phone number on the back of your ID card.

2 Core and Select Step Therapy Program Core and Select Step Therapy Medications If you have a prescription for any of the following Step 2 medications, you will be required to first try a Step 1 medication(s) for benefit coverage. Condition Step 1 Step 2 Anti-infectives Oral Brand doxycycline Acticlate, Adoxa, Doryx, Monodox, Tetracyclines Targadox Otic Agents ofloxacin Cetraxal, Ciprofloxacin Cardiovascular Beta Blockers carvedilol Coreg CR Calcium Channel Prestalia Blockers amlodipine, perindopril Renin- Angiotensin System Agents benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril, benazepril-hctz, captopril- HCTZ, enalapril-hctz, fosinopril- HCTZ, lisinopril-hctz, moexipril-hctz, quinapril-hctz, amlodipine-benazepril, trandolapril-verapamil losartan, losartan-hctz, candesartan, candesartan-hctz, irbesartan, irbesartan-hctz, telmisartan benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril, benazepril-hctz, captopril-hctz, enalapril-hctz, fosinopril-hctz, lisinopril-hctz, moexipril-hctz, quinapril-hctz, amlodipine-benazepril, trandolaprilverapamil losartan, losartan-hctz, candesartan, candesartan-hctz, irbesartan, irbesartan-hctz, telmisartan preferred Tekturna, Tekturna HCT Azor, Benicar, Benicar HCT, Edarbi, Edarbyclor, Tekturna, Tekturna HCT, Tribenzor Amturnide, Tekamlo

3 Core and Select Step Therapy Medications Continued Condition Step 1 Step 2 Statins Any two of the following generics: Altoprev, Lipitor, Livalo atorvastatin, fluvastatin, fluvastatin ER, lovastatin, pravastatin, rosuvastatin, simvastatin Fibric Acid Fenoglide, Fibricor, Lofibra Derivatives fenofibric cap, fenofibrate tab, fenofibrate micronized cap, fenofibric acid tab (fenofibrate cap), Triglide Antianginals preferred Lipofen Any one of the following generics or preferred acebutolol, amlodipine, amlodipinebenazepril, amlodipine-telmisartan, amlodipine-valsartan, atenolol, bextaxolol, bisoprolol, carvedilol, diltiazem, diltiazem ER, felodipine ER, isosorbide dinitrate ER, isosorbide mononitrate ER, isradipine, metoprolol, metoprolol ER, nadolol, nicardipine, nifedipine, nisoldipine SR, nitroglycerin ER, pindolol, propranolol, propranolol SR, timolol, trandolaprilverapamil, verapamil, verapamil ER Ranexa Azor, Bystolic, Cardene SR, Dilatrate SR, Inderal XL, Innopran XL, Levatol 3

4 Core and Select Step Therapy Program Core and Select Step Therapy Medications Continued Condition Step 1 Central Nervous System ADHD Agents Analgesic Packs Any two of the following generics or preferred amphetamine-dextroamphetamine IR or ER, dexmethylphenidate IR or ER, dextroamphetamine IR or SR, methylphenidate IR or ER, Vyvanse ranitidine generics: diclofenac, diclofenac ER lidocaine patches Step 2 Adderall XR, Adzenys XR ODT, Aptensio XR, Concerta, Daytrana, Desoxyn, Dyanavel XR, Evekeo, Focalin XR, Kapvay, Metadate CD, Methylin Solution, Methylin Chew, Procentra, Quillichew ER, Quillivant, Ritalin LA, Zenzedi DermacinRx Inflammatral Pak, Derma SilkRx DermacinRx Analgesic Combopak generics: diclofenac, diclofenac ER Anticonvulsants* topiramate Trokendi XR Antidepressants* bupropion SR Aplenzin Any two of the following generics or preferred bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, paroxetine ER, sertraline, venlafaxine, venlafaxine ER, Pristiq Any two of the following generics or preferred duloxetine, venlafaxine, venlafaxine ER, Pristiq Antipsychotics* Any two of the following generics or preferred aripiprazole, olanzapine, quetiapine, risperidone, Saphris, Seroquel XR Trintellix, Viibryd Fetzima Fanapt, Latuda, Vraylar

5 Core and Select Step Therapy Medications Continued Condition Insomnia Agents Migraine Agents Narcotic Analgesics Step 1 eszopiclone, temazepam, zaleplon, zolpidem, zolpidem CR zolpidem, zolpidem CR rizatriptan, sumatriptan, zolmitriptan Any two of the following generics: rizatriptan, sumatriptan, zolmitriptan; tramadol, tramadol-acetaminophen Any two of the following generics or preferred Step 2 Belsomra Edluar, Zolpimist Treximet, Zecuity Onzetra Xsail Tramadol ER Hysingla ER, Kadian, Nucynta ER, Zohydro ER, Xtampza ER Neurologic Agents Non-Narcotic Analgesics Parkinson s Disease Women s Health hydromorphone ER, morphine sulfate ER, oxymorphone ER, Embeda, Opana ER, Oxycontin gabapentin Any one of the following generics or preferred amitriptyline, cyclobenzaprine, duloxetine, Lyrica Any two of the following generics: diclofenac, diclofenac CR, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin carbidopa-levodopa, carbidopalevodopa CR esterified estrogensmethyltestosterone, estradiol, estradiol-norethindrone, estropipate, paroxetine, fluoxetine Gralise Savella Cambia, Tivorbex Rytary Brisdelle 5

6 Core and Select Step Therapy Program Core and Select Step Therapy Medications Continued Condition Step 1 Step 2 Dermatology Miscellaneous triamcinolone cream 0.1% DermacinRx Silapak, Derma SilkRx SDS Pak, Dermawerx, NutriaRx, Sanadermrx, Sure Result Kit TAC Pak, Tri-Sila, Whytederm Rosacea Soolantra Finacea Skin Cancer Agents Topical Acne Treatments Topical Immunomodulators Endocrinology Basal Insulin Diabetic Agents fluorouracil, imiquimod Any one of the following preferred Epiduo/Epiduo Forte, Onexton alclometasone, amcinonide, betamethasone, clobetasol, clocortolone, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide, fluticasone, halobetasol, hydrocortisone, mometasone, prednicarbate, triamcinolone, pramoxine-hc, calcipotriene-betamethasone All of the following preferred Lantus, Levemir, and Toujeo metformin, metformin ER glipizide-metformin, glyburidemetformin, pioglitazone-metformin glipizide-metformin, glyburidemetformin, metformin, metformin ER, pioglitazone-metformin Picato Acanya, Benzaclin, Benzamycin, Duac, Veltin, Ziana Elidel Ryzodeg, Basaglar Actoplus Met XR Avandamet, Avandaryl, Avandia, Cycloset

7 Core and Select Step Therapy Medications Continued Condition Step 1 Step 2 Blood Glucose Both of the following preferred Abbott, Acon, At Last, Bayer, Meters and Strips Accu-Check, Onetouch Embrace, EPS, Fora Care, Glucocard, Gmate, Liberty, Neutek, Quintet, Relion, Reveal, Supreme, True Metrix, Truetest, Truetrack, Ultima, Unistrip DPP4 Inhibitors metformin, metformin ER, glipizidemetformin, glyburide-metformin, pioglitazone-metformin Any one of the following preferred Janumet, Janumet XR, Januvia Janumet, Janumet XR, Januvia, Jentadueto, Jentadueto XR, Tradjenta alogliptin, alogliptin-pioglitazone, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni GLP-1 Agonists SGLT2 Inhibitors preferred Jentadueto, Jentadueto XR, Tradjenta metformin, metformin ER, glipizidemetformin, glyburide-metformin, pioglitazone-metformin Any one of the following preferred Bydureon, Byetta preferred Trulicity, Victoza metformin, metformin ER glipizide-metformin, glyburidemetformin, pioglitazone-metformin Any one of the following preferred Invokamet, Invokana Bydureon, Byetta, Trulicity, Victoza Tanzeum Invokamet, Invokana, Jardiance, Synjardy Farxiga, Glyxambi, Xigduo XR preferred Jardiance, Synjardy 7

8 Core and Select Step Therapy Program Core and Select Step Therapy Medications Continued Condition Step 1 Step 2 Short-Acting Any one of the following preferred Apidra Insulin Humalog, Novolog Gastroenterology Constipation Amitiza, Linzess Agents lactulose, polyethylene glycol Gastroprotective Duexis Agents diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin Irritable Bowel Both of the following preferred Asacol HD, Delzicol, mesalamine Syndrome Apriso, Lialda Opioid-Induced Amitiza Movantik Constipation Pancreatic Both of the following preferred Pancreaze, Pertzye, Ultresa, Viokace Enzymes Creon, Zenpep Proton Pump Any two of the following generics Aciphex, esomeprazole strontium, Inhibitors or preferred First-Lansoprazole, Firstesomeprazole, omeprazole, Omeprazole, omeprazole-sodium lansoprazole, pantoprazole bicarbonate, Prevacid, Prilosec, Dexilant Protonix, Zegerid Any one of the following preferred Helidac, Prevpac Omeclamox-Pak, Pylera Miscellaneous Antigout Agents Colcrys Mitigare, colchicine allopurinol Uloric, Zurampic

9 Core and Select Step Therapy Medications Continued Condition Step 1 Step 2 Ophthalmology Ophthalmic Antihistamines Respiratory Epinephrine Auto Injectors* Inhaled Corticosteroids Inhaled Cystic Fibrosis Agents Any one of the following generics or preferred azelastine Pataday, Patanol Any one of the following preferred Epipen, Epipen-Jr Any two of the following preferred Arnuity Ellipta, Flovent, Pulmicort Flexhaler, QVAR Bethkis Bepreve, Lastacaft Adrenaclick, Auvi-Q, epinephrine Alvesco, Asmanex Kitabis, Tobi, Tobi Podhaler, tobramycin nebulizer Leukotriene Zyflo, Zyflo CR Modifiers montelukast, zafirlukast Long-Acting Any two of the following Arcapta, Striverdi Respimat Bronchodilators preferred Advair, Breo Ellipta, Serevent, Symbicort Both of the following preferred Tudorza Pressair Incruse Ellipta, Spiriva

10 Core and Select Step Therapy Program Core and Select Step Therapy Medications Continued Condition Long-Acting Bronchodilator Combinations Step 1 Any two of the following preferred Advair, Breo Ellipta, Symbicort Any one of the following preferred Advair, Breo Ellipta, Serevent, Symbicort Step 2 Dulera Bevespi Aerosphere, Utibron Neohaler preferred Spiriva Short-Acting Beta Any one of the following preferred Proventil HFA, Xopenex HFA Agonist Inhalers Ventolin HFA preferred ProAir HFA, ProAir Respiclick

11 Core and Select Step Therapy Medications Continued Condition Urology BPH Agents Urinary Antispasmodics Step 1 Step 2 Any two of the following generics or preferred alfuzosin, doxazosin, tamsulosin, terazosin Rapaflo Any two of the following generics or preferred oxybutynin IR/ER, tolterodine IR/ER Vesicare Cardura XL Myrbetriq Step therapy requirements are effective as of January 1, The list of step therapy medications is subject to change without notice. Step therapy requirements may vary by benefit plan. Additional clinical programs, including quantity limits and prior authorization, may exist for the above medications which may affect your prescription drug coverage. These agents are also subject to additional step requirements as indicated in table. * Applies to new starts only 11

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