Premium Step Therapy. Here s how it works:
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1 Premium 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 prescription Try a Step 1 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 Premium Step Therapy 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. Anti-infectives Oral Brand Tetracyclines doxycycline Otic Agents ofloxacin Cetraxal Cardiovascular Beta Blockers carvedilol Coreg CR Calcium Channel Blockers amlodipine, perindopril Acticlate, Adoxa, Doryx, Monodox, Targadox Prestalia OptumRx optumrx.com
3 Step Therapy Medications Continued 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 Azor, Benicar, Benicar HCT, Edarbi, Edarbyclor, Tekturna, Tekturna HCT, Tribenzor 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 Amturnide, Tekamlo losartan, losartan-hctz, candesartan, candesartan-hctz, irbesartan, irbesartan- HCTZ, telmisartan AND any one of the following Tekturna, Tekturna HCT 3
4 Premium Step Therapy Step Therapy Medications Continued Fibric Acid Derivatives fenofibric cap, fenofibrate tab, fenofibrate micronized cap, fenofibric acid tab Fenoglide, Fibricor, Lofibra, Triglide Antianginals AND any one of the following Lipofen Any one of the following generics or 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, trandolapril-verapamil, verapamil, verapamil ER Ranexa Central Nervous System ADHD Agents Azor, Bystolic, Cardene SR, Dilatrate SR, Inderal XL, Innopran XL, Levatol amphetamine-dextroamphetamine, dexmethylphenidate, dextroamphetamine SR, methylphenidate, methylphenidate ER Vyvanse Adderall XR #, Aptensio XR #, Concerta #, Daytrana #, Desoxyn #, Evekeo #, Focalin XR #, Kapvay, Metadate CD #, Methylin #, Methylin Chew #, Procentra #, Quillivant #, Ritalin LA #, Zenzedi # OptumRx optumrx.com
5 Step Therapy Medications Continued Analgesic Packs ranitidine DermacinRx Inflammatral Pak, Derma SilkRx AND any one of the following generics: diclofenac, diclofenac ER lidocaine patches DermacinRx Analgesic Combopak AND any one of the following generics: diclofenac, diclofenac ER Anticonvulsants* topiramate Qudexy XR, Trokendi XR Antidepressants* bupropion SR Aplenzin # bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, paroxetine ER, sertraline, venlafaxine, venlafaxine ER Pristiq duloxetine, venlafaxine, venlafaxine ER Brintellix #, Viibryd # Fetzima # Pristiq 5
6 Premium Step Therapy Step Therapy Medications Continued Antipsychotics* aripiprazole, olanzapine, quetiapine, risperidone Fanapt #, Geodon #, Invega #, Rexulti #, Latuda # Dementia Agents Saphris, Seroquel XR donepezil AND any one of the following generics or memantine Namzaric # Insomnia Agents Migraine Agents Narcotic Analgesics Neurologic Agents Namenda XR eszopiclone, temazepam, zaleplon, zolpidem, zolpidem CR zolpidem, zolpidem CR rizatriptan, sumatriptan, zolmitriptan tramadol, tramadol-acetaminophen Belsomra # Edluar #, Intermezzo #, Zolpimist # Treximet # Tramadol ER # gabapentin Gralise # Any one of the following generics or Savella # amitriptyline, cyclobenzaprine, duloxetine Lyrica OptumRx optumrx.com
7 Step Therapy Medications Continued Non-Narcotic Analgesics Parkinson s Disease Women s Health Dermatology 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, carbidopa-levodopa CR esterified estrogens-methyltestosterone, estradiol, estradiol-norethindrone, estropipate, paroxetine, fluoxetine Tivorbex Rytary Brisdelle # Miscellaneous triamcinolone cream 0.1% DermacinRx Silapak, Derma SilkRx SDS Pak Skin Cancer Agents Topical Immunomodulators fluorouracil, imiquimod alclometasone, amcinonide, betamethasone, clobetasol, clocortolone, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide, fluticasone, halobetasol, hydrocortisone, mometasone, prednicarbate, triamcinolone, pramoxine-hc, calcipotriene-betamethasone Picato Elidel 7
8 Premium Step Therapy Step Therapy Medications Continued Endocrinology Basal Insulin Lantus Toujeo Diabetic Agents metformin, metformin ER glipizide-metformin, glyburide-metformin pioglitazone, pioglitazone-glimepiride, pioglitazone-metformin metformin, metformin ER chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide pioglitazone Humalog, Humulin, Lantus Bydureon, Byetta, Trulicity, Victoza Actoplus Met XR Glyset OR any one of the following generics: glipizide-metformin, glyburidemetformin, pioglitazone-glimepiride, pioglitazone-metformin Avandamet, Avandaryl, Avandia, Cycloset metformin, metformin ER chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide, pioglitazone Humalog, Humulin, Lantus Bydureon, Byetta, Trulicity, Victoza OptumRx optumrx.com
9 Step Therapy Medications Continued DPP4 Inhibitors GLP-1 Agonists Any one of the following generics or metformin, metformin ER chlorpropamide, glimepiride, glipizide, glipizide-metformin, glyburide, glyburidemetformin, tolazamide, tolbutamide pioglitazone, pioglitazone-glimepiride, pioglitazone-metformin Humalog, Humulin, Lantus Bydureon, Byetta, Trulicity, Victoza Any one of the following generics or metformin, metformin ER chlorpropamide, glimepiride, glipizide, glipizide-metformin, glyburide, glyburidemetformin, tolazamide, tolbutamide pioglitazone, pioglitazone-glimepiride, pioglitazone-metformin Humalog, Humulin, Lantus Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza Bydureon #, Byetta #, Trulicity #, Victoza # 9
10 Premium Step Therapy Step Therapy Medications Continued SGLT2 Inhibitors Gastroenterology Constipation Agents Proton Pump Inhibitors Ulcer Agent Kits Miscellaneous Any one of the following generics or metformin, metformin ER chlorpropamide, glimepiride, glipizide, glipizide-metformin, glyburide, glyburidemetformin, tolazamide, tolbutamide pioglitazone, pioglitazone-glimepiride, pioglitazone-metformin Humalog, Humulin, Lantus Bydureon, Byetta, Trulicity, Victoza Any one of the following preferred brands: Invokamet, Invokana AND any one of the following Jardiance, Synjardy lactulose, polyethylene glycol esomeprazole, omeprazole, lansoprazole, pantoprazole Dexilant Any one of the following preferred brands: Omeclamox-Pak, Pylera Invokamet, Invokana, Jardiance, Synjardy Glyxambi Amitiza #, Linzess # Aciphex #, esomeprazole strontium #, First-Lansoprazole, First-Omeprazole, Prevacid #, Prilosec #, Protonix #, Zegerid # Helidac, Prevpac Antigout Agents Colcrys Mitigare, colchicine allopurinol Uloric OptumRx optumrx.com
11 Step Therapy Medications Continued Ophthalmology Ophthalmic Antihistamines Respiratory Leukotriene Modifiers Long-Acting Bronchodilators Urology BPH Agents Any one of the following generics or azelastine Pataday, Patanol montelukast, zafirlukast Any two of the following preferred brands: Advair, Breo Ellipta, Serevent, Symbicort alfuzosin, doxazosin, tamsulosin, terazosin Bepreve, Lastacaft Zyflo, Zyflo CR Arcapta #, Striverdi Respimat # Cardura XL Urinary Antispasmodics Rapaflo oxybutynin IR/ER, tolterodine IR/ER Myrbetriq Gelnique, Vesicare Step therapy requirements are effective as of July 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. # Quantity limits may also apply. Please refer to the Premium Quantity Limits document. * Applies to new starts only 11
12 optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum company a leading provider of integrated health services. Learn more at optum.com. All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners Optum, Inc. All rights reserved. ORX0785B-CTRX_
Step therapy Premium. Utilization management updates - January 1, Here s how it works:
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ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
If you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card.
Step Therapy The ClearScript Step Therapy program promotes the cost-effective use of clinically appropriate medications when more than one drug is available to treat a medical condition. What is Step Therapy?
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet
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The Step Therapy drug will be dispensed if the drug has been dispensed within 120 days of current fill or if alternative (Step 1) drugs have been used first. If the member s prescription claim fails the
Step Therapy Requirements. Effective: 03/01/2015
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FirstCarolinaCare Insurance Company. Step Therapy Requirements
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Introducing exciting new Rx benefits 2019
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Step Therapy Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
Step Therapy Requirements
Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet
Prescription Step Therapy Program
Prescription Step Therapy Program 04HQ3972 R11/17 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross
ANTICONVULSANT STEP THERAPY
2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: 19391 Last Updated: 2/2019 Effective Date: 03-01-2019 ANTICONVULSANT STEP THERAPY APTIOM 200 MG APTIOM 400 MG APTIOM
Step Therapy Information... 4 Prior Authorization Information ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...
Step Therapy Information... 4 Prior Authorization Information... 27 ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...62 Acne Therapy Topical...64 Alcoholism Treatment Agents... 66 Analgesic
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS. 1 ANTICONVULSANTS
Drug Regimen Optimization
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Excluding Valsartan / Ramipril Prior authorization criteria logic: a description
These medications will require preauthorization (PA) for HMSA Medicare Part D members.
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Step Therapy CareOregon 2018 Last Updated: 07/27/2018 ATYPICAL ANTIPSYCHOTICS Fanapt Fanapt Titration Pack Paliperidone Er Vraylar The following criteria applies to members who newly start on the drug:
2019 Preventive Drug List
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1 of 5 ALLERGY / ASTHMA THERAPIES ANTIHISTAMINES, MINIMALLY SEDATING cetirizine fexofenadine loratadine ANTIHISTAMINE/DECONGESTANT COMBINATIONS cetirizine/pseudoephedrine fexofenadine/pseudoephedrine loratadine/pseudoephedrine
Drugs That Require Step Therapy (ST) Step Therapy Medications
Drugs That Require Step Therapy (ST) In some cases, BlueShield of Northeastern New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that