Step Therapy Requirements

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1 An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1

2 BETA-BLOCKERS BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET DRUG(S): ACEBUTOLOL HCL, ATENOLOL, ATENOLOL- CHLORTHALIDONE, BETAXOLOL HCL, BISOPROLOL FUMARATE, BISOPROLOL-HYDROCHLOROTHIAZIDE, CARVEDILOL, LABETALOL HCL, METOPROLOL SUCCINATE, METOPROLOL TARTRATE, METOPROLOL- HYDROCHLOROTHIAZIDE, NADOLOL, NADOLOL- BENDROFLUMETHIAZIDE, PINDOLOL, PROPRANOLOL HCL, PROPRANOLOL-HYDROCHLOROTHIAZIDE, TIMOLOL MALEATE. STEP 2 DRUG(S): BYSTOLIC 2

3 BILE ACID SEQUESTRANTS WELCHOL 3.75 GRAM ORAL POWDER PACKET WELCHOL 625 MG TABLET DRUG(S): CHOLESTYRAMINE LIGHT, COLESTIPOL HCL, PREVALITE. STEP 2 DRUG(S): WELCHOL. AUTHORIZATION MAY BE GIVEN FOR WELCHOL IF PATIENTS HAVE A DRUG- DRUG INTERACTION WITH CHOLESTYRAMINE OR COLESTIPOL. AUTHORIZATION MAY BE GIVEN FOR WELCHOL IN PATIENTS WHO ARE PREGNANT. AUTHORIZATION MAY BE GIVEN FOR WELCHOL IN PATIENTS WITH TYPE 2 DIABETES WHO ARE ALSO USING OTHER ANTIDIABETIC AGENTS (EG, INSULIN, METFORMIN, SULFONYLUREA). AUTHORIZATION MAY BE GIVEN FOR WELCHOL IN PATIENTS LESS THAN 18 YEARS OF AGE. Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 3

4 DPP4 JANUMET 50 MG-1,000 MG TABLET JANUMET 50 MG-500 MG TABLET JANUMET XR 100 MG-1,000 MG JANUMET XR 50 MG-1,000 MG JANUMET XR 50 MG-500 MG JANUVIA 100 MG TABLET JANUVIA 25 MG TABLET JANUVIA 50 MG TABLET KOMBIGLYZE XR 2.5 MG-1,000 MG KOMBIGLYZE XR 5 MG-1,000 MG KOMBIGLYZE XR 5 MG-500 MG ONGLYZA 2.5 MG TABLET ONGLYZA 5 MG TABLET TRADJENTA 5 MG TABLET DRUG(S): ALOGLIPTIN, ALOGLIPTIN/METFORMIN, ALOGLIPTIN/PIOGLITAZONE. STEP 2 DRUG(S): ONGLYZA, JANUVIA, TRADJENTA, JANUMET, JANUMET XR, KOMBIGLYZE 4

5 LEVEMIR LEVEMIR FLEXTOUCH U-100 INSULIN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN LEVEMIR U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SOLUTION DRUGS: LANTUS, TOUJEO. STEP 2 DRUGS: LEVEMIR Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 5

6 LUMIGAN LUMIGAN 0.01 % EYE DROPS DRUG(S): BIMATOPROST 0.03%, LATANOPROST. STEP 2 DRUG(S): LUMIGAN 6

7 METFORMIN RIOMET 500 MG/5 ML ORAL SOLUTION DRUG(S): METFORMIN HCL, METFORMIN HCL ER. STEP 2 DRUG(S): RIOMET. PARTICIPANT MUST HAVE 30 DAYS OF GENERIC METFORMIN OR GENERIC METFORMIN ER IN CLAIMS HISTORY. AUTHORIZATION MAY BE GIVEN FOR RIOMET PATIENTS WHO ARE UNABLE TO SWALLOW OR HAVE DIFFICULTY SWALLOWING TABLETS CONTAINING METFORMIN. Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 7

8 NAMENDA XR NAMENDA XR 14 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 21 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 7 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 7 MG-14 MG-21 MG-28 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK DRUG(S): MEMANTINE. STEP 2 DRUG(S): NAMENDA XR 8

9 NAMZARIC NAMZARIC 14 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMZARIC 21 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMZARIC 28 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMZARIC 7 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMZARIC 7/14/21/28 MG-10 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK DRUG(S): MEMANTINE. STEP 2 DRUG(S): NAMZARIC. Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 9

10 PPI ENHANCED DEXILANT 30 MG CAPSULE, DELAYED RELEASE DEXILANT 60 MG CAPSULE, DELAYED RELEASE DRUG(S): GENERIC PROTON PUMP INHIBITORS. STEP 2 DRUG(S): DEXILANT. AUTHORIZATION MAY BE GIVEN FOR A STEP 2 AGENT FOR PATIENTS CONCOMITANTLY RECEIVING CLOPIDOGREL WHO HAVE TRIED A STEP 1 AGENT. 10

11 PREFERRED INSULIN HUMALOG KWIKPEN (U-100) INSULIN 100 UNIT/ML SUBCUTANEOUS HUMALOG KWIKPEN U-200 INSULIN 200 UNIT/ML (3 ML) SUBCUTANEOUS HUMALOG MIX (U-100) INSULIN 100 UNIT/ML SUBCUTANEOUS SUSPENSION HUMALOG MIX KWIKPEN U- 100 INSULIN 100 UNIT/ML SUBCUTANEOUS PEN HUMALOG MIX (U-100) INSULIN 100 UNIT/ML SUBCUTANEOUS SUSPENSION HUMALOG MIX KWIKPEN U- 100 INSULIN 100 UNIT/ML SUBCUTANEOUS PEN HUMALOG U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS CARTRIDGE HUMALOG U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SOLUTION HUMULIN 70/30 U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SUSPENSION HUMULIN N NPH U-100 INSULIN (ISOPHANE SUSP) 100 UNIT/ML SUBCUTANEOUS HUMULIN R REGULAR U-100 INSULIN 100 UNIT/ML INJECTION SOLUTION HUMULIN R U-500 (CONCENTRATED) INSULIN 500 UNIT/ML SUBCUTANEOUS SOLN DRUGS: NOVOLIN INSULINS, NOVOLOG INSULINS OR LEVEMIR. STEP 2 DRUGS: HUMULIN INSULINS OR HUMALOG INSULINS. Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/

12 SYMBICORT SYMBICORT 160 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER SYMBICORT 80 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER DRUG(S): ADVAIR. STEP 2 DRUG(S): SYMBICORT 12

13 TETRACYCLINES (ORAL) SOLODYN 105 MG SOLODYN 115 MG SOLODYN 55 MG SOLODYN 65 MG SOLODYN 80 MG VIBRAMYCIN 50 MG/5 ML SYRUP DRUG(S): DEMECLOCYCLINE HCL, DOXYCYCLINE, DOXYCYCLINE HYCLATE, DOXYCYCLINE MONOHYDRATE, MINOCYCLINE HCL, TETRACYCLINE HCL STEP 2 DRUG(S): SOLODYN AND VIBRAMYCIN SYRUP. AUTHORIZATION MAY BE GIVEN FOR A STEP 2 AGENT IF THE PATIENT HAS TRIED A GENERIC ORAL TETRACYCLINE-TYPE PRODUCT (DEMECLOCYCLINE, DOXYCYCLINE, MINOCYCLINE, TETRACYCLINE). Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/

14 TOPICAL STEROIDS clobetasol 0.05 % lotion clobetasol 0.05 % topical cream clobetasol 0.05 % topical gel clobetasol 0.05 % topical ointment clobetasol-emollient 0.05 % topical cream desonide 0.05 % lotion desonide 0.05 % topical cream desonide 0.05 % topical ointment hydrocortisone valerate 0.2 % topical cream hydrocortisone valerate 0.2 % topical ointment DRUG(S): FLUOCINOLONE ACETONIDE, BETAMETHASONE DIPROPIONATE, MOMETASONE FUROATE, STEP 2 DRUG(S): DESONIDE, HYDROCORTISONE VALERATE, CLOBETASOL PROPIONATE 14

15 TRAVATAN Z TRAVATAN Z % EYE DROPS DRUG(S): LATANOPROST. STEP 2 DRUG(S): TRAVATAN Z. Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/

16 TRELEGY TRELEGY ELLIPTA 100 MCG-62.5 MCG-25 MCG POWDER FOR INHALATION DRUG(S): BREO ELLIPTA. STEP 2 DRUG(S): TRELEGY ELLIPTA 16

17 ULORIC ULORIC 40 MG TABLET ULORIC 80 MG TABLET DRUG(S): ALLOPURINOL. STEP 2 DRUG(S): ULORIC. AUTHORIZATION MAY BE GIVEN FOR ULORIC IF THE PATIENT HAS TRIED ALLOPURINOL (BRAND OR GENERIC) AT ANY TIME IN THE PAST. AUTHORIZATION MAY BE GIVEN FOR ULORIC IF THE PATIENT HAS RENAL INSUFFICIENCY OR DECREASED RENAL FUNCTION. AUTHORIZATION MAY BE GIVEN FOR ULORIC IF THE PATIENT IS RECEIVING CONCOMITANT MEDICATIONS THAT HAVE SIGNIFICANT DRUG-DRUG INTERACTIONS WITH ALLOPURINOL, WHICH ARE NOT NOTED WITH ULORIC (EG, CYCLOSPORINE, CHLORPROPAMIDE). Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/

18 XIIDRA XIIDRA 5 % EYE DROPS IN A DROPPERETTE DRUG(S): CYCLOSPORINE OPTHALMIC. STEP 2 DRUG(S): XIIDRA 18

19 INDEX B BYSTOLIC 10 MG TABLET... 1 BYSTOLIC 2.5 MG TABLET... 1 BYSTOLIC 20 MG TABLET... 1 BYSTOLIC 5 MG TABLET... 1 C clobetasol 0.05 % lotion clobetasol 0.05 % topical cream clobetasol 0.05 % topical gel clobetasol 0.05 % topical ointment clobetasol-emollient 0.05 % topical cream 13 D desonide 0.05 % lotion desonide 0.05 % topical cream desonide 0.05 % topical ointment DEXILANT 30 MG CAPSULE, DELAYED RELEASE... 9 DEXILANT 60 MG CAPSULE, DELAYED RELEASE... 9 H HUMALOG KWIKPEN (U-100) INSULIN 100 UNIT/ML SUBCUTANEOUS HUMALOG KWIKPEN U-200 INSULIN 200 UNIT/ML (3 ML) SUBCUTANEOUS HUMALOG MIX (U-100) INSULIN 100 UNIT/ML SUBCUTANEOUS SUSPENSION HUMALOG MIX KWIKPEN U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS PEN HUMALOG MIX (U-100) INSULIN 100 UNIT/ML SUBCUTANEOUS SUSPENSION HUMALOG MIX KWIKPEN U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS PEN HUMALOG U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS CARTRIDGE HUMALOG U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SOLUTION HUMULIN 70/30 U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SUSPENSION HUMULIN N NPH U-100 INSULIN (ISOPHANE SUSP) 100 UNIT/ML SUBCUTANEOUS HUMULIN R REGULAR U-100 INSULIN 100 UNIT/ML INJECTION SOLUTION HUMULIN R U-500 (CONCENTRATED) INSULIN 500 UNIT/ML SUBCUTANEOUS SOLN hydrocortisone valerate 0.2 % topical cream hydrocortisone valerate 0.2 % topical ointment J JANUMET 50 MG-1,000 MG TABLET... 3 JANUMET 50 MG-500 MG TABLET... 3 JANUMET XR 100 MG-1,000 MG... 3 JANUMET XR 50 MG-1,000 MG... 3 JANUMET XR 50 MG-500 MG... 3 JANUVIA 100 MG TABLET... 3 JANUVIA 25 MG TABLET... 3 JANUVIA 50 MG TABLET... 3 K KOMBIGLYZE XR 2.5 MG-1,000 MG... 3 KOMBIGLYZE XR 5 MG-1,000 MG... 3 KOMBIGLYZE XR 5 MG-500 MG... 3 L LEVEMIR FLEXTOUCH U-100 INSULIN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN... 4 LEVEMIR U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SOLUTION... 4 LUMIGAN 0.01 % EYE DROPS

20 N NAMENDA XR 14 MG CAPSULE SPRINKLE,EXTENDED RELEASE... 7 NAMENDA XR 21 MG CAPSULE SPRINKLE,EXTENDED RELEASE... 7 NAMENDA XR 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE... 7 NAMENDA XR 7 MG CAPSULE SPRINKLE,EXTENDED RELEASE... 7 NAMENDA XR 7 MG-14 MG-21 MG-28 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK... 7 NAMZARIC 14 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE... 8 NAMZARIC 21 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE... 8 NAMZARIC 28 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE... 8 NAMZARIC 7 MG-10 MG CAPSULE SPRINKLE,EXTENDED RELEASE... 8 NAMZARIC 7/14/21/28 MG-10 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK... 8 O ONGLYZA 2.5 MG TABLET... 3 ONGLYZA 5 MG TABLET... 3 R RIOMET 500 MG/5 ML ORAL SOLUTION... 6 S SOLODYN 105 MG SOLODYN 115 MG SOLODYN 55 MG TABLET,EXTENDED RELEASE SOLODYN 65 MG TABLET,EXTENDED RELEASE SOLODYN 80 MG TABLET,EXTENDED RELEASE SYMBICORT 160 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER SYMBICORT 80 MCG-4.5 MCG/ACTUATION HFA AEROSOL INHALER T TRADJENTA 5 MG TABLET... 3 TRAVATAN Z % EYE DROPS TRELEGY ELLIPTA 100 MCG-62.5 MCG-25 MCG POWDER FOR INHALATION U ULORIC 40 MG TABLET ULORIC 80 MG TABLET V VIBRAMYCIN 50 MG/5 ML SYRUP W WELCHOL 3.75 GRAM ORAL POWDER PACKET... 2 WELCHOL 625 MG TABLET... 2 X XIIDRA 5 % EYE DROPS IN A DROPPERETTE

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