Drugs That Require Step Therapy (ST) Step Therapy Medications

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1 Drugs That Require Step Therapy (ST) In some cases, HealthNow New York Inc. requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Step-1 and Step-2 drugs both treat your medical condition, we may not cover the Step-2 drug unless you try the Step-1 drug first. If the Step-1 drug does not work for you, we will then cover the Step-2 drug. You will need authorization from HealthNow New York Inc. before filling prescriptions for the Step-2 drugs shown in the chart below. HealthNow New York Inc. will only provide coverage after it determines that the drug is being prescribed according to the criteria specified in the chart. You, your appointed representative, or your prescriber can request a review by calling Member Services at (TTY only, call 711). We are open October 1 - February 14 8 a.m. to 8 p.m., 7 days a week and February 15 -September 30 8 a.m. to 8 p.m., Monday - Friday. Calls to these numbers are free. You can also visit our website, Step Therapy Medications Step Therapy alpha blockers Step-1: ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR or DOXAZOSIN 1 MG TABLET or DOXAZOSIN 2 MG TABLET or DOXAZOSIN 4 MG TABLET or DOXAZOSIN 8 MG TABLET or TAMSULOSIN ER 0.4 MG CAPSULE,EXTENDED RELEASE 24 HR or TERAZOSIN 1 MG CAPSULE or TERAZOSIN 10 MG CAPSULE or TERAZOSIN 2 MG CAPSULE or TERAZOSIN 5 MG CAPSULE Step-2: RAPAFLO 4 MG CAPSULE or RAPAFLO 8 MG CAPSULE Page 1

2 antidepressants - snri antidepressants - snri Step-1: CITALOPRAM 10 MG TABLET or CITALOPRAM 10 MG/5 ML ORAL SOLUTION or CITALOPRAM 20 MG TABLET or CITALOPRAM 40 MG TABLET or DULOXETINE 20 MG CAPSULE,DELAYED RELEASE or DULOXETINE 30 MG CAPSULE,DELAYED RELEASE or DULOXETINE 60 MG CAPSULE,DELAYED RELEASE or ESCITALOPRAM 10 MG TABLET or ESCITALOPRAM 20 MG TABLET or ESCITALOPRAM 5 MG TABLET or ESCITALOPRAM 5 MG/5 ML ORAL SOLUTION or FLUOXETINE 10 MG CAPSULE or FLUOXETINE 10 MG TABLET or FLUOXETINE 20 MG CAPSULE or FLUOXETINE 20 MG TABLET or FLUOXETINE 20 MG/5 ML ORAL SOLUTION or FLUOXETINE 40 MG CAPSULE or FLUOXETINE 90 MG CAPSULE,DELAYED RELEASE or FLUVOXAMINE 100 MG TABLET or FLUVOXAMINE 25 MG TABLET or FLUVOXAMINE 50 MG TABLET or FLUVOXAMINE ER 100 MG CAPSULE,EXTENDED RELEASE 24 HR or FLUVOXAMINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR or PAROXETINE 10 MG TABLET or PAROXETINE 20 MG TABLET or PAROXETINE 30 MG TABLET or PAROXETINE 40 MG TABLET or PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR or PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR or PAROXETINE ER 37.5 MG TABLET,EXTENDED RELEASE 24 HR or SERTRALINE 100 MG TABL Step-2: FETZIMA 120 MG CAPSULE,EXTENDED RELEASE or FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK or FETZIMA 20 MG CAPSULE,EXTENDED RELEASE or FETZIMA 40 MG CAPSULE,EXTENDED RELEASE or FETZIMA 80 MG CAPSULE,EXTENDED RELEASE or PRISTIQ 100 MG TABLET,EXTENDED RELEASE or PRISTIQ 25 MG TABLET,EXTENDED RELEASE or PRISTIQ 50 MG TABLET,EXTENDED RELEASE Authorization may be given for a step 2 drug that does not have a generic equivalent included in step 1, without trial of a step 1 drug, if the patient is currently taking or has taken the drug in the past. Authorization may be given for a step 2 drug that does not have a generic equivalent included in step 1, without a trial of a step 1 drug, if the patient has symptoms of suicidal ideation. Page 2

3 dpp-4 inhibitorspst Step-1: JANUMET 50 MG-1,000 MG TABLET or JANUMET 50 MG-500 MG TABLET or JANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASE or JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE or JANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE or JANUVIA 100 MG TABLET or JANUVIA 25 MG TABLET or JANUVIA 50 MG TABLET or KOMBIGLYZE XR 2.5 MG-1,000 MG TABLET,EXTENDED RELEASE or KOMBIGLYZE XR 5 MG-1,000 MG TABLET,EXTENDED RELEASE or KOMBIGLYZE XR 5 MG-500 MG TABLET,EXTENDED RELEASE or ONGLYZA 2.5 MG TABLET or ONGLYZA 5 MG TABLET Step-2: JENTADUETO 2.5 MG-1,000 MG TABLET or JENTADUETO 2.5 MG-500 MG TABLET or JENTADUETO 2.5 MG-850 MG TABLET or KAZANO 12.5 MG- 1,000 MG TABLET or KAZANO 12.5 MG-500 MG TABLET or NESINA 12.5 MG TABLET or NESINA 25 MG TABLET or NESINA 6.25 MG TABLET or TRADJENTA 5 MG TABLET Page 3

4 enhanced arb Step-1: AMLODIPINE 10 MG-VALSARTAN 160 MG TABLET or AMLODIPINE 10 MG-VALSARTAN 160 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET or If the patient has AMLODIPINE 10 MG-VALSARTAN 160 MG-HYDROCHLOROTHIAZIDE 25 MG tried a Step 1 and a Step 2 drug, then TABLET or AMLODIPINE 10 MG-VALSARTAN 320 MG TABLET or authorization for a Step 3 drug may AMLODIPINE 10 MG-VALSARTAN 320 MG-HYDROCHLOROTHIAZIDE 25 MG be given. Authorization may be TABLET or AMLODIPINE 5 MG-VALSARTAN 160 MG TABLET or AMLODIPINE given for a step 2 or step 3 5 MG-VALSARTAN 160 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET or angiotensin receptor blocker (ARB) AMLODIPINE 5 MG-VALSARTAN 160 MG-HYDROCHLOROTHIAZIDE 25 MG or ARB-containing combination TABLET or AMLODIPINE 5 MG-VALSARTAN 320 MG TABLET or product that does not have a generic CANDESARTAN 16 MG TABLET or CANDESARTAN 16 MGequivalent in step 1, without a trial HYDROCHLOROTHIAZIDE 12.5 MG TABLET or CANDESARTAN 32 MG of a step 1 or 2 agent, if the patient TABLET or CANDESARTAN 32 MG-HYDROCHLOROTHIAZIDE 12.5 MG was recently hospitalized and TABLET or CANDESARTAN 32 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET discharged within the previous 30 or CANDESARTAN 4 MG TABLET or CANDESARTAN 8 MG TABLET or days for a cardiovascular event (eg, EPROSARTAN 600 MG TABLET or IRBESARTAN 150 MG TABLET or myocardial infarction, hypertensive IRBESARTAN 150 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET or emergency, decompensated heart IRBESARTAN 300 MG TABLET or IRBESARTAN 300 MGfailure) and has already been started HYDROCHLOROTHIAZIDE 12.5 MG TABLET or IRBESARTAN 75 MG TABLET and stabilized on the requested or LOSARTAN 100 MG TABLET or LOSARTAN 100 MG-HYDROCHLOROTHIAZI agent. or TELMISARTAN 80 MG-AMLODIPINE 5 MG TABLET or TELMISARTAN 80 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET or TELMISARTAN 80 MG- HYDROCHLOROTHIAZIDE 25 MG TABLET or VALSARTAN 160 MG TABLET or VALSARTAN 160 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET or VALSARTAN 160 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET or VALSARTAN 320 MG TABLET or VALSARTAN 320 MG- HYDROCHLOROTHIAZIDE 12.5 MG TABLET or VALSARTAN 320 MG- HYDROCHLOROTHIAZIDE 25 MG TABLET or VALSARTAN 40 MG TABLET or VALSARTAN 80 MG TABLET or VALSARTAN 80 MG- HYDROCHLOROTHIAZIDE 12.5 MG TABLET Page 4

5 enhanced arb Step-2: AZOR 10 MG-20 MG TABLET or AZOR 10 MG-40 MG TABLET or AZOR 5 MG-20 MG TABLET or AZOR 5 MG-40 MG TABLET or BENICAR 20 MG TABLET or BENICAR 40 MG TABLET or BENICAR 5 MG TABLET or BENICAR HCT 20 MG-12.5 MG TABLET or BENICAR HCT 40 MG-12.5 MG TABLET or BENICAR HCT 40 MG-25 MG TABLET or TRIBENZOR 20 MG-5 MG-12.5 MG TABLET or TRIBENZOR 40 MG-10 MG-12.5 MG TABLET or TRIBENZOR 40 MG-10 MG-25 MG TABLET or TRIBENZOR 40 MG-5 MG-12.5 MG TABLET or TRIBENZOR 40 MG-5 MG-25 MG TABLET Step-3: EDARBI 40 MG TABLET or EDARBI 80 MG TABLET or EDARBYCLOR 40 MG-12.5 MG TABLET or EDARBYCLOR 40 MG-25 MG TABLET Page 5

6 high risk medications - sedative hypnotics Step-1: ROZEREM 8 MG TABLET or TRAZODONE 100 MG TABLET or TRAZODONE 150 MG TABLET or TRAZODONE 300 MG TABLET or TRAZODONE 50 MG TABLET Step-2: ESZOPICLONE 1 MG TABLET or ESZOPICLONE 2 MG TABLET or ESZOPICLONE 3 MG TABLET or ZALEPLON 10 MG CAPSULE or ZALEPLON 5 MG CAPSULE or ZOLPIDEM 10 MG TABLET or ZOLPIDEM 5 MG TABLET or ZOLPIDEM ER 12.5 MG TABLET,EXTENDED RELEASE,MULTIPHASE or ZOLPIDEM ER 6.25 MG TABLET,EXTENDED RELEASE,MULTIPHASE This step therapy program applies to chronic utilizers greater than 64 years of age only. Authorization for zolpidem or zolpidem Er (brand or generic) may be given if being used for neuroleptic induced parkinsonism, dystonia, restless leg syndrome, or supranuclear paralysis. Authorization for a step 2 drug may be given in patients aged less than 65 years. ophthalmic prostaglandins-pst Step-1: BIMATOPROST 0.03 % EYE DROPS or LATANOPROST % EYE DROPS or LUMIGAN 0.01 % EYE DROPS or TRAVATAN Z % EYE DROPS or TRAVOPROST (BENZALKONIUM) % EYE DROPS Step-2: ZIOPTAN (PF) % EYE DROPS IN A DROPPERETTE Authorization for Zioptan may be given if the patient has a known benzalkonium chloride (BAK) sensitivity or a known sensitivity to other ophthalmic preservatives. Page 6

7 oral bisphosphonates Step-1: ALENDRONATE 10 MG TABLET or ALENDRONATE 35 MG TABLET or ALENDRONATE 40 MG TABLET or ALENDRONATE 5 MG TABLET or ALENDRONATE 70 MG TABLET or ALENDRONATE 70 MG/75 ML ORAL SOLUTION or IBANDRONATE 150 MG TABLET or RISEDRONATE 150 MG TABLET or RISEDRONATE 30 MG TABLET or RISEDRONATE 35 MG TABLET or RISEDRONATE 35 MG TABLET (12 PACK) or RISEDRONATE 35 MG TABLET,DELAYED RELEASE or RISEDRONATE 5 MG TABLET Step-2: FOSAMAX PLUS D 70 MG-2,800 UNIT TABLET or FOSAMAX PLUS D 70 MG-5,600 UNIT TABLET rapid-acting insulin-pst topical actinic keratosis-pst Step-1: HUMALOG 100 UNIT/ML SUBCUTANEOUS CARTRIDGE or HUMALOG 100 UNIT/ML SUBCUTANEOUS SOLUTION or HUMALOG 100 UNIT/ML SUBCUTANEOUS SOLUTION (PREFILLED SYRINGE) or HUMALOG KWIKPEN 100 UNIT/ML SUBCUTANEOUS or HUMALOG KWIKPEN 200 UNIT/ML (3 ML) SUBCUTANEOUS or HUMALOG MIX UNIT/ML SUBCUTANEOUS SUSPENSION or HUMALOG MIX KWIKPEN 100 UNIT/ML SUBCUTANEOUS PEN or HUMALOG MIX UNIT/ML SUBCUTANEOUS SUSPENSION or HUMALOG MIX KWIKPEN 100 UNIT/ML SUBCUTANEOUS INSULIN PEN Step-2: APIDRA 100 UNIT/ML SUBCUTANEOUS SOLUTION or APIDRA SOLOSTAR 100 UNIT/ML SUBCUTANEOUS INSULIN PEN Step-1: CARAC 0.5 % TOPICAL CREAM or DICLOFENAC 3 % TOPICAL GEL or FLUOROURACIL 2 % TOPICAL SOLUTION or FLUOROURACIL 5 % TOPICAL CREAM or FLUOROURACIL 5 % TOPICAL SOLUTION or IMIQUIMOD 5 % TOPICAL CREAM PACKET Step-2: FLUOROURACIL 0.5 % TOPICAL CREAM Page 7

8 uloric Step-1: ALLOPURINOL 100 MG TABLET or ALLOPURINOL 300 MG TABLET Step-2: ULORIC 40 MG TABLET or ULORIC 80 MG TABLET 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). Page 8