Step Therapy Drug List

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1 Step Therapy Drug List The Step Therapy Program requires a trial of one or more "first step" drugs before a "second step" or "target" drug is covered. For example, if two drugs are used to treat the same medical condition, you may be required to first try one drug before the second drug is covered. Some drugs require trials of more than one drug before the target drug is covered. The length of the trial period may vary for prerequisite step drugs. The goal of the Step Therapy Program is to promote the cost-effective use of medications based on clinically accepted treatment guidelines, the medical literature and other factors. This list is subject to change throughout the year. The presence of a drug on this list does not guarantee coverage and not all drugs included on this list may be covered by your pharmacy benefit plan. Coverage of medications is determined your benefit plan. Condition / Drug Class First Step Drugs Second Step Drugs Anticonvulsants A Anticonvulsants B Antidepressants C Antidepressants D GRALISE TROKENDI XR BRINTELLIX TRINTELLIX FETZIMA History of gabapentin. History of topiramate IR. History of any TWO of the following: bupropion, citalopram, desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, paroxetine ER, sertraline, venlafaxine, OR venlafaxine ER. History of any TWO of the following: desvenlafaxine succinate ER, duloxetine, venlafaxine, OR venlafaxine ER. Antihypertensive - Renin Inhibitors EDARBI EDARBYCLOR TEKTURNA TEKTURNA HCT History of ONE of the following: 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, candesartan, Irbesartan, losartan, olmesartan, Telmisartan, amlodipine-olmesartan, candesartan- HCTZ, irbesartan-hctz, losartan-hctz, olmesartan- HCTZ, telmisartan-hctz OR olmesartan-amlodipine- HCTZ

2 Condition / Drug Class First Step Drugs Second Step Drugs Antiparkinson Agents B XADAGO Antipsychotics - Atypicals FANAPT LATUDA VRAYLAR BPH Agents CARDURA XL Cardiovascular - Antianginals RANEXA CNS Stimulants ADDERALL XR ADZENYS ER ADZENYS XR-ODT APTENSIO XR CONCERTA COTEMPLA XR-ODT DAYTRANA DESOXYN DYANAVEL XR EVEKEO FOCALIN XR KAPVAY METADATE CD METHYLIN MYDAYIS PROCENTRA QUILLICHEW ER QUILLIVANT XR History of BOTH of the following: rasagiline tablets AND selegiline. History of TWO of the following: aripiprazole, olanzapine, quetiapine, risperidone/risperidone ODT, SAPHRIS, OR SEROQUEL XR. History of TWO of the following: alfuzosin, doxazosin, tamsulosin, terazosin, OR RAPAFLO. History of ONE of the following: acebutolol, amlodipine, amlodipine-benazepril, amlodipine-telmisartan, amlodipine-valsartan, atenolol, betaxolol, 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, trandolapril-verapamil, verapamil, verapamil ER, AZOR, BYSTOLIC, DILATRATE SR, INDERAL XL, INNOPRAN XL OR LEVATOL History of TWO of the following: amphetaminedextroamphetamine, dexmethylphenidate, dextroamphetamine, methylphenidate, OR VYVANSE.

3 Diabetes - Blood Glucose Meters RITALIN LA ZENZEDI ZENZEDI ADVANCED GLUCOSE METER ADVOCATE BLOOD GLUCOSE MONITOR ADVOCATE REDI- CODE ADVOCATE REDI- CODE PLUS AGAMATRIX AMP ASSURE PLATINUM ASSURE PRISM MULTI BLOOD GLUCOSE METER BLOOD GLUCOSE MONITOR BLOOD GLUCOSE MONITORING BLOOD-GLUCOSE METER CARESENS N CARESENS N VOICE CARETOUCH GLUCOSE MONITORING CHOICEDM CLARUS CLEVER CHEK BLOOD GLUCOSE SYST CLEVER CHOICE CLEVER CHOICE BLOOD GLUC SYS CLEVER CHOICE HD GLUCOSE SYST CLEVER CHOICE MICRO CLEVER CHOICE PRO CLEVER CHOICE TALK CONTOUR CONTOUR LINK CONTOUR NEXT CONTOUR NEXT EZ CONTOUR NEXT LINK History of BOTH of the following preferred brands of blood glucose meters: ACCU-CHEK AND ONE TOUCH.

4 CONTOUR NEXT LINK 2.4 CONTOUR NEXT ONE CONTROL AST COOL BLOOD GLUCOSE COOL BLOOD GLUCOSE METER EASY PLUS EASY PLUS II EASY STEP EASY TALK EASY TOUCH GLUCOSE MONITOR EASY TRAK EASYGLUCO EASYGLUCO METER EASYGLUCO METER STARTER KIT EASYGLUCO PLUS EASYMAX L EASYMAX NG EASYMAX V SPEAKING EASYMAX V2 ELEMENT COMPACT ELEMENT COMPACT V ELEMENT PLUS EMBRACE EMBRACE EVO EMBRACE PRO EVENCARE EVENCARE G2 EVENCARE G3 EVENCARE MINI MONITOR SYSTEM EVOLUTION BLOOD GLUCOSE METER EZ SMART EZ SMART PLUS FORA D20 FORA G20 FORA G30A FORA GD50

5 FORA PREMIUM V10 FORA TEST N'GO VOICE FORA TN'G VOICE FORA V10 FORA V12 FORA V20 FORA V30A FORACARE GD20 FORACARE GD40A FORACARE GD40B FORTISCARE BLOOD GLUCOSE SYST FREESTYLE FLASH SYSTEM FREESTYLE FREEDOM FREESTYLE FREEDOM LITE FREESTYLE INSULINX FREESTYLE LITE METER FREESTYLE PRECISION NEO METER FREESTYLE SIDEKICK II FREESTYLE SYSTEM GDRIVE GE100 BLOOD GLUCOSE SYSTEM GLUCO NAVII GLUCOCARD 01 GLUCOCARD EXPRESSION GLUCOCARD SHINE GLUCOCARD SHINE XL GLUCOCARD VITAL GLUCOCOM BLOOD GLUCOSE GMATE VOICE METER GMATE VOICE STARTER GOODLIFE AC-302 GLUCOSE METER

6 HEALTHPRO GLUCOSE MONITOR IGLUCOSE BLOOD GLUCOSE MONITOR INFINITY INFINITY VOICE GLUCOSE MONITOR JAZZ WIRELESS 2 LIBERTY MONITOR MICRODOT MYGLUCOHEALTH NOVA MAX BLOOD GLUCOSE METER ON CALL EXPRESS METER ON CALL PLUS METER ON CALL VIVID METER ON CALL VIVID PAL OPTUMRX PHARMACIST CHOICE PRECISION PRECISION XTRA PREMIER BLU PREMIER VOICE PREMIUM BLOOD GLUCOSE PREMIUM V10 PRESTO PRO PRODIGY PRODIGY AUTOCODE PRODIGY POCKET PRODIGY VOICE QUINTET QUINTET AC REFUAH PLUS RELION ALL-IN-ONE RELION CONFIRM RELION MICRO RELION PRIME REVEAL BLOOD GLUCOSE METER RIGHTEST GM100 SYSTEM

7 RIGHTEST GM250S METER RIGHTEST GM260 METER RIGHTEST GM300 SYSTEM RIGHTEST GM550 SYSTEM SIDEKICK SMART CARESENS N SMARTEST EJECT SMARTEST PERSONA SMARTEST PRONTO SMARTEST PROTEGE SMARTEST SMART CODE SMARTEST TALKING SOLUS V2 SURE-TEST EASYPLUS MINI TELCARE TELCARE BGM TEST N'GO TRUE METRIX AIR GLUCOSE METER TRUE METRIX BLOOD GLUCOSE MTR TRUE METRIX GO TRUE2GO BLOOD GLUCOSE SYSTEM TRUERESULT BLOOD GLUCOSE METER TRUERESULT BLOOD GLUCOSE SYSTM TRUETRACK BLOOD GLUCOSE SYSTEM TRUETRACK SMART SYSTEM ULTIMA ULTRATRAK ULTRATRAK PRO ULTRATRAK ULTIMATE VERASENS BLOOD GLUCOSE METER VERASENS METER STARTER KIT

8 Diabetes - Blood Glucose Test Strips WAVESENSE AMP WAVESENSE PRESTO ACCUTREND GLUCOSE ADVANCED GLUCOSE TEST ADVOCATE REDI- CODE ADVOCATE REDI- CODE+ ADVOCATE TEST AGAMATRIX AMP ASSURE 4 ASSURE PLATINUM ASSURE PRISM MULTI BG-STAR BLOOD GLUCOSE TEST BREEZE 2 CARESENS N CARETOUCH TEST CHOICEDM CLARUS TEST CLEVER CHOICE MICRO TEST CLEVER CHOICE PRO CLEVER CHOICE TALK CLEVER CHOICE TEST CLEVER CHOICE VOICE+ TST CONTOUR NEXT TEST CONTOUR TEST CONTROL AST TEST COOL GLUCOSE TEST DARIO BLOOD GLUCOSE TEST EASY GLUCO G2 EASY PLUS History of BOTH of the following preferred brands of blood glucose test strips: ACCU-CHEK AND ONE TOUCH.

9 EASY PLUS II EASY STEP EASY TALK EASY TOUCH TEST EASY TRAK EASYGLUCO PLUS EASYGLUCO TEST EASYMAX EASYMAX 15 ELEMENT COMPACT ELEMENT TEST EMBRACE EMBRACE EVO EMBRACE PRO EVENCARE EVENCARE G2 EVENCARE G3 EVENCARE MINI GLUCOSE TEST STR EVENCARE PROVIEW TEST EVOLUTION TEST EZ SMART EZ SMART PLUS FIFTY50 TEST FORA D15G FORA D20 FORA D40-G31 TEST FORA G20 FORA G30-PREMIUM V10 TEST STRP FORA GD50 TEST FORA TEST FORA TN'G VOICE TEST FORA V10 FORA V10-V12-D10-D20 FORA V12

10 FORA V20 FORA V30A FORACARE GD20 FORACARE GD40 FORTISCARE GLUCOSE TEST FREESTYLE INSULINX FREESTYLE INSULINX TEST FREESTYLE LITE FREESTYLE LITE TEST FREESTYLE PRECISION NEO FREESTYLE TEST GE100 BLOOD GLUCOSE TEST GEN GENULTIMATE TEST GLUCO NAVII GLUCOCARD 01 SENSOR PLUS GLUCOCARD EXPRESSION GLUCOCARD SHINE GLUCOCARD VITAL GLUCOCARD VITAL SENSOR GLUCOCOM GLUCOSE GLUCOSE TEST GMATE TEST GOODLIFE AC-302 TEST HARMONY GLUCOSE TEST HEALTHPRO TEST IGLUCOSE TEST INFINITY TEST INFINITY VOICE TEST LIBERTY TEST

11 MICRO MICRODOT MICRODOT XTRA MYGLUCOHEALTH NEUTEK 2TEK TEST NOVA MAX GLUCOSE TEST ON CALL EXPRESS TEST ON CALL PLUS TEST ON CALL VIVID TEST OPTIUM OPTIUM EZ OPTUMRX PHARMACIST CHOICE PRECISION PCX PRECISION PCX PLUS PRECISION POINT OF CARE PRECISION Q-I-D PRECISION XTRA PREMIER TEST PREMIUM BLOOD GLUCOSE TEST PREMIUM V10 PRODIGY NO CODING QUINTET QUINTET AC REFUAH PLUS RELION CONFIRM- MICRO RELION PRIME TEST REVEAL TEST RIGHTEST GS100 TEST RIGHTEST GS300 TEST RIGHTEST GS550 TEST SMARTEST TEST

12 Diabetes - DPP-4 A Diabetes - DPP-4 B SOLUS V2 TEST SURE-TEST EASYPLUS MINI TELCARE TEST N'GO TEST TRUE METRIX GLUCOSE TEST TRUE METRIX PRO TEST TRUETEST TEST TRUETRACK TEST ULTIMA ULTRATRAK ULTRATRAK ULTIMATE UNI1 VERASENS TEST WAVESENSE JAZZ WAVESENSE PRESTO JANUMET JANUMET XR JANUVIA JENTADUETO JENTADUETO XR TRADJENTA ALOGLIPTIN ALOGLIPTIN- METFORMIN KAZANO KOMBIGLYZE XR NESINA History of ONE of the following: metformin, metformin ER, glipizide-metformin, glyburide-metformin, OR pioglitazone-metformin. History of ONE of the following: metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin AND ONE of the following: JANUMET, JANUMET XR, JANUVIA AND ONE of the following preferred brands: JENTADUETO, JENTADUETO XR, OR TRADJENTA.

13 ONGLYZA Diabetes - GLP-1 A Diabetes - GLP-1 B Diabetes - Insulin Glargine Diabetes - Insulin Lispro BYDUREON BYDUREON BCISE BYDUREON PEN BYETTA TRULICITY VICTOZA 2-PAK VICTOZA 3-PAK ADLYXIN OZEMPIC TANZEUM BASAGLAR KWIKPEN U-100 ADMELOG ADMELOG SOLOSTAR APIDRA APIDRA SOLOSTAR FIASP FIASP FLEXTOUCH Diabetes - Insulin/GLP-1 Combination A SOLIQUA Diabetes - Insulin/GLP-1 Combination B Diabetes - SGLT2 A XULTOPHY INVOKAMET INVOKAMET XR INVOKANA History of ONE of the following: metformin, metformin ER, glipizide-metformin, glyburide-metformin, OR pioglitazone-metformin. History of ONE of the following: metformin, metformin ER, glipizide-metformin, glyburide-metformin, or pioglitazone-metformin AND ONE of the following: BYETTA, BYDUREON OR BYDUREON BCISE AND ONE of the following: TRULICITY OR VICTOZA History of ALL of the following: LANTUS, LEVEMIR AND TOUJEO. History of ONE of the following: HUMALOG (insulin lispro) OR NOVOLOG (insulin aspart). History of ONE of the following: ADYLYXIN, BYETTA, BYDUREON, BYDUREON BCISE, TANZEUM, TRULICITY, VICTOZA, BASAGLAR, LANTUS, LEVEMIR, TRESIBA, OR TOUJEO. History of ONE of the following: BYETTA, BYDUREON, BYDUREON BCISE, TRULICITY, VICTOZA, LANTUS, LEVEMIR, OR TOUJEO. History of ONE of the following: metformin, metformin ER, glipizide-metformin, glyburide-metformin, OR pioglitazone-metformin.

14 Condition / Drug Class First Step Drugs Second Step Drugs Diabetes - SGLT2 B FARXIGA GLYXAMBI QTERN SEGLUROMET STEGLATRO STEGLUJAN XIGDUO XR Diabetes - SGLT2 C JARDIANCE SYNJARDY SYNJARDY XR Diabetes - TZD/Bromocriptine ACTOPLUS MET XR AVANDIA CYCLOSET Doxycycline ADOXA MONODOX Dsylipidemia - Statins ALTOPREV FLOLIPID LIPITOR LIVALO ZYPITAMAG History of ONE of the following: metformin, metformin ER, glipizide-metformin, glyburide-metformin, OR pioglitazone-metformin AND ONE of the following: INVOKANA, INVOKAMET OR INVOKAMET XR AND ONE of the following: SYNJARDY, SYNJARDY XR, OR JARDIANCE. History of ONE of the following: metformin, metformin ER, glipizide-metformin, glyburide-metformin, OR pioglitazone-metformin. History of ONE of the following: metformin, metformin ER, glipizide-metformin, glyburide-metformin, OR pioglitazone-metformin. History of BOTH of the following: generic doxycycline AND DORYX MPC. History of ONE of the following: atorvastatin, fluvastatin, fluvastatin ER, lovastatin, pravastatin, rosuvastatin, simvastatin.

15 Condition / Drug Class First Step Drugs Second Step Drugs Dyslipidemia - Fibric Acid FENOGLIDE FIBRICOR LOFIBRA TRIGLIDE Epinephrine Auto-Injectors EPINEPHRINE Gastrointestinal - H. Pylori PREVPAC Gastrointestinal - Pancreatic Enzymes PANCREAZE PERTZYE VIOKACE Gastrointestinal - PPIs ACIPHEX ACIPHEX SPRINKLE PREVACID PRILOSEC PROTONIX Gout Agents A COLCHICINE MITIGARE Gout Agents B DUZALLO ULORIC ZURAMPIC IBS Constipation A AMITIZA LINZESS History of LIPOFEN AND ONE of the following generics: fenofibrate micronized capsule, fenofibrate tablet, fenofibric capsule OR fenofibric acid tablet. History of epinephrine (generic EPIPEN or generic EPIPEN JR. manufacturer: Mylan) History of ONE of the following: OMECLAMOX-PAK OR PYLERA. History of BOTH of the following: CREON AND ZENPEP. History of TWO of the following: DEXILANT, esomeprazole, lansoprazole (capsules), omeprazole, OR pantoprazole. History of COLCRYS (colchicine). History of generic allopurinol. History of ONE of the following: lactulose OR polyethylene glycol (PEG)

16 Condition / Drug Class First Step Drugs Second Step Drugs IBS Constipation B TRULANCE IBS/IBD - Aminosalicylates ASACOL HD DELZICOL LIALDA Insomnia A BELSOMRA Migraine - 5HT-1 B ONZETRA XSAIL Ophthalmic - Allergy LASTACAFT Opioid Induced Constipation A MOVANTIK Opioid Induced Constipation B SYMPROIC Opioid Overdose EVZIO Otic - Antibiotics CETRAXAL CIPROFLOXACIN HCL Pain Management - Fibromyalgia SAVELLA Pain Management - Neuropathic LYRICA CR Pain Management - Tramadol Agents TRAMADOL HCL ER History of ONE of the following: lactulose OR polyethylene glycol (PEG) AND ONE of the following: AMITIZA OR LINZESS. History of the following: APRISO ER. History of ONE of the following: eszopiclone, temazepam, zaleplon, zolpidem, OR zolpidem ER. History of TWO of the following: rizatriptan tablet/rizatriptan ODT, sumatriptan tablets/nasal spray, or zolmitriptan tablet/zolmitriptan ODT History of ONE of the following: azelastine, olopatadine, PATADAY. History of Amitiza AND any one of the following generics: lactulose, polyethylene glycol. History of AMITIZA AND ONE of the following: lactulose OR polyethylene glycol (PEG). History of NARCAN nasal spray. HISTORY OF OFLOXACIN OTIC SOLUTION History of ONE of the following: amitriptyline, cyclobenzaprine, duloxetine, gabapentin OR LYRICA History of ONE of the following: amitriptyline, cyclobenzaprine, duloxetine, OR LYRICA History of any ONE of the following: Tramadol or Tramadol/APAP.

17 Condition / Drug Class First Step Drugs Second Step Drugs Respiratory - Inhaled Corticosteroids ALVESCO ARMONAIR RESPICLICK ASMANEX Respiratory - Leukotriene Modifiers ASMANEX HFA ZILEUTON ER ZYFLO ZYFLO CR Respiratory - Long-Acting Bronchodilator Combinations A AIRDUO RESPICLICK DULERA Respiratory - Long-Acting Bronchodilator Combinations B BEVESPI AEROSPHERE UTIBRON NEOHALER Respiratory - Long-Acting Bronchodilators A ARCAPTA NEOHALER STRIVERDI RESPIMAT Respiratory - Long-Acting Bronchodilators B SEEBRI NEOHALER TUDORZA PRESSAIR Respiratory - Short-Acting Bronchodilators LEVALBUTEROL TARTRATE HFA PROVENTIL HFA XOPENEX HFA History of TWO of the following: ARNUITY ELLIPTA, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR, OR QVAR REDIHALER History of ONE of the following: montelukast OR zafirlukast. History of TWO of the following: ADVAIR DISKUS/HFA, SYMBICORT, BREO ELLIPTA OR fluticasonesalmeterol. History of ONE of the following: ADVAIR DISKUS/HFA, ANORO ELLIPTA, BREO ELLIPTA, SEREVENT, STIOLTO RESPIMAR, OR SYMBICORT AND ONE of the following: SPIRIVA OR SPIRIVA RESPIMAT. History of TWO of the following: ADVAIR DISKUS/HFA, BREO ELLIPTA, SEREVENT OR SYMBICORT. History of BOTH of the following: INCRUSE ELLIPTA AND SPIRIVA. History of VENTOLIN HFA AND ONE of the following preferred brands: PROAIR HFA OR PROAIR RESPICLICK.

18 Condition / Drug Class First Step Drugs Second Step Drugs Respiratory - Tobramycin Inhaled Products KITABIS PAK TOBI TOBI PODHALER TOBRAMYCIN Topical - Acne AKTIPAK BENZACLIN BENZAMYCIN DUAC Topical - Antineoplastics PICATO TOLAK Topical - Atopic Dermatitis EUCRISA Topical - Rosacea A FINACEA Topical - Rosacea B RHOFADE History of Bethkis. History of ONE of the following: EPIDUO/EPIDUO FORTE OR ONEXTON History of one of the following topical generics: fluorouracil or imiquimod. History of one prescription strength topical corticosteroid. History of SOOLANTRA. History of MIRVASO.

19 PreferredOne Insurance Company Nondiscrimination Notice PreferredOne Insurance Company ( PIC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PIC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Insurance Company PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at NDR PIC LV (1/18)

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