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? If you are taking a medication in the Step Therapy program, you are required to try one or more first step drugs before a second step drug is considered for coverage. Talk with your physician about which first step medication might be a good choice for you. A clinical review may be required before a second step drug is covered. If you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card. Important Note: The drugs included on this list may not be covered by all benefit plans. Your benefit plan determines coverage for all medications. Additional coverage restrictions may apply for the medications included on this list. This list is subject to change throughout the year. (INTERIM: Effective Any ONE of the following generics: doxycycline or SEYSARA 3/15/19-7/1/19) minocycline Doxycycline - SEYSARA Allergy Eyedrops Anti-Inflammatory Eyedrops History of ONE of the following: azelastine, olopatadine, PATADAY. History of ONE of the following generic, single ingredient, ophthalmic NSAID solutions: diclofenac, flurbiprofen, ketorolac PROLENSA BEPREVE LASTACAFT BROMSITE ILEVRO NEVANAC Antibiotics - Eardrops History of ofloxacin otic solution. CETRAXAL ciprofloxacin hcl Antibiotics - Oral Brand Tetracyclines Asthma/COPD - Long- Acting Combo Inhalers Asthma/COPD - Long- Acting Inhalers History of ONE of the following: generic doxycycline History of TWO of the following: ADVAIR DISKUS/HFA, SYMBICORT, BREO ELLIPTA OR fluticasone-salmeterol. History of TWO of the following: ADVAIR DISKUS/HFA, BREO ELLIPTA, SEREVENT OR SYMBICORT. ACTICLATE ADOXA DORYX DORYX MPC MONODOX TARGADOX AIRDUO RESPICLICK DULERA ARCAPTA NEOHALER STRIVERDI RESPIMAT CAPITAL LETTERS = BR MEDICATIONS 1
Asthma/COPD - Short- Acting Inhalers Asthma/COPD - Steroid Inhalers Asthma/COPD Oral Asthma Medications Attention Disorder - Stimulants Blood Pressure - Renin Inhibitors History of both of the following: Anoro Ellipta and Stiolto Respimat History of BOTH of the following: INCRUSE ELLIPTA SPIRIVA. History of VENTOLIN HFA ONE of the following preferred brands: PROAIR HFA OR PROAIR RESPICLICK. 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: amphetaminedextroamphetamine, dexmethylphenidate, dextroamphetamine, methylphenidate, OR VYVANSE. History of ONE of the following: amphetaminedextroamphetamine, dexmethylphenidate, dextroamphetamine, methylphenidate, OR VYVANSE. 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, trandolaprilverapamil, candesartan, Irbesartan, losartan, olmesartan, Telmisartan, amlodipine-olmesartan, candesartan-hctz, irbesartan-hctz, losartan- HCTZ, olmesartan-hctz, telmisartan-hctz OR olmesartan-amlodipine-hctz BEVESPI AEROSPHERE UTIBRON NEOHALER SEEBRI NEOHALER TUDORZA PRESSAIR levalbuterol tartrate hfa PROVENTIL HFA XOPENEX HFA ALVESCO ARMONAIR RESPICLICK ASMANEX ASMANEX HFA zileuton er ZYFLO ZYFLO CR ADDERALL XR ADZENYS ER APTENSIO XR CONCERTA DAYTRANA DESOXYN DYANAVEL XR EVEKEO FOCALIN XR KAPVAY METADATE CD METHYLIN MYDAYIS procentra QUILLICHEW ER QUILLIVANT XR RITALIN LA ZENZEDI zenzedi ADZENYS XR-ODT COTEMPLA XR-ODT aliskiren EDARBI EDARBYCLOR TEKTURNA TEKTURNA HCT CAPITAL LETTERS = BR MEDICATIONS 2
Cholesterol Medications - Fenofibrates Cholesterol Medications - Statins Cystic Fibrosis - Inhaled Tobramycin Diabetes - Blood Glucose Meters Diabetes - Blood Glucose Test Strips Diabetic Medications History of LIPOFEN ONE of the following generics: fenofibrate micronized capsule, fenofibrate tablet, fenofibric capsule OR fenofibric acid tablet. History of ONE of the following: atorvastatin, fluvastatin, fluvastatin ER, lovastatin, pravastatin, rosuvastatin, simvastatin. History of ONE of the following: atorvastatin, fluvastatin, fluvastatin ER, lovastatin, pravastatin, rosuvastatin, simvastatin LIVALO History of Bethkis. History of BOTH of the following preferred brands of blood glucose meters: ACCU-CHEK ONE TOUCH. History of BOTH of the following preferred brands of blood glucose test strips: ACCU-CHEK ONE TOUCH. or pioglitazone-metformin ONE of the following: BYETTA, BYDUREON OR BYDUREON BCISE ONE of the following: OZEMPIC, TRULICITY OR VICTOZA History of ONE of the following: HUMALOG (insulin lispro) OR NOVOLOG (insulin aspart). pioglitazone-metformin ONE of the following: JANUMET, JANUMET XR, JANUVIA ONE of the following preferred brands: JENTADUETO, JENTADUETO XR, OR TRADJENTA. History of TWO of the following: LANTUS, LEVEMIR, TRESIBA TOUJEO. FENOGLIDE FIBRICOR lofibra TRIGLIDE ALTOPREV FLOLIPID LIPITOR LIVALO ZYPITAMAG KITABIS PAK TOBI tobramycin All non-preferred brands and generics of blood glucose meters. All non-preferred brands and generics of blood glucose test strips. ACTOPLUS MET XR AVIA CYCLOSET ADLYXIN TANZEUM ADMELOG ADMELOG SOLOSTAR APIDRA APIDRA SOLOSTAR FIASP FIASP FLEXTOUCH alogliptin alogliptin-metformin alogliptin-pioglitazone KAZANO KOMBIGLYZE XR NESINA ONGLYZA OSENI BASAGLAR KWIKPEN U-100 CAPITAL LETTERS = BR MEDICATIONS 3
Epinephrine Auto- Injectors OR pioglitazone-metformin ONE of the following: INVOKANA, INVOKAMET OR INVOKAMET XR ONE of the following: GLYXAMBI, SYNJARDY, SYNJARDY XR, OR JARDIANCE. History of ONE of the following: ADYLYXIN, BYETTA, BYDUREON, BYDUREON BCISE, OZEMPIC, TANZEUM, TRULICITY, VICTOZA, BASAGLAR, LANTUS, LEVEMIR, TRESIBA, OR TOUJEO History of ONE of the following: BYETTA, BYDUREON, BYDUREON BCISE, OZEMPIC, TRULICITY, VICTOZA, LANTUS, LEVEMIR, TOUJEO, OR TRESIBA. History of epinephrine (generic EPIPEN or generic EPIPEN JR. manufacturer: Mylan and Impax) ONE of the following : epinephrine 0.3 mg (manufacturer: Mylan or Impax) or EPIPEN 0.3 mg (manufacturer: Mylan) BYDUREON BYDUREON BCISE BYDUREON PEN BYETTA TRULICITY VICTOZA 2-PAK VICTOZA 3-PAK FARXIGA QTERN SEGLUROMET STEGLATRO STEGLUJAN XIGDUO XR GLYXAMBI JARDIANCE SYNJARDY SYNJARDY XR INVOKAMET INVOKAMET XR INVOKANA JANUMET JANUMET XR JANUVIA JENTADUETO JENTADUETO XR TRADJENTA OZEMPIC SOLIQUA 100-33 XULTOPHY 100-3.6 AUVI-Q EPIPEN JR 2-PAK AUVI-Q SYMJEPI Gout Medications History of COLCRYS (colchicine). colchicine MITIGARE History of generic allopurinol. DUZALLO ULORIC ZURAMPIC CAPITAL LETTERS = BR MEDICATIONS 4
Heart Medications - Chest Pain HIV INVELTYS History of ONE of the following: acebutolol, amlodipine, amlodipine-benazepril, amlodipinetelmisartan, 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, trandolaprilverapamil, verapamil, verapamil ER, AZOR, BYSTOLIC, DILATRATE SR, INDERAL XL, INNOPRAN XL OR LEVATOL History of ONE of the following: SYMFI, SYMFI LO, TRIUMEQ, JULUCA, CIMDUO ONE of the following: ISENTRESS, TIVICAY Requires trial of any ONE of the following generics: prednisolone acetate, prednisolone sodium phosphate, dexamethasone any ONE of the following preferred brands: FML FORTE or PRED MILD RANEXA ranolazine er ATRIPLA INVELTYS KHAPZORY Any ONE of the following generics: levoleucovorin KHAPZORY LUCEMYRA Any ONE of the following generics: clonidine LUCEMYRA Mental Health - Depression Mental Health - Mood Stabilizers Migraine Medications Narcotic Overdose Rescue Medications Opthalmic - Xelpros Pain Management - Fibromyalgia History of a generic bupropion SR product. 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. History of ONE of the following: aripiprazole, olanzapine, quetiapine, risperidone OR SAPHRIS History of TWO of the following: naratriptan, rizatriptan tablet/rizatriptan ODT, sumatriptan tablets/nasal spray, or zolmitriptan tablet/zolmitriptan ODT History of ONE of the following: naratriptan, rizatriptan tablet/rizatriptan ODT, sumatriptan tablets/nasal spray, or zolmitriptan tablet/zolmitriptan ODT History of NARCAN nasal spray. History of ALL of the following generics latanoprost the following Brands Lumigan Travatan Z History of ONE of the following: amitriptyline, cyclobenzaprine, duloxetine, OR LYRICA APLENZIN BRINTELLIX TRINTELLIX FETZIMA FANAPT VRAYLAR ONZETRA XSAIL TREXIMET EVZIO XELPROS LYRICA CR CAPITAL LETTERS = BR MEDICATIONS 5
History of ONE of the following: amitriptyline, cyclobenzaprine, duloxetine, gabapentin OR LYRICA SAVELLA Pain Management - Non- Narcotic Parkinson's Disease Prostate Medications History of any TWO of the following: diclofenac, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, OR tolmetin History of gabapentin. History of any ONE of the following: Tramadol or Tramadol/APAP. History of ONE of the following: carbidopa-levodopa OR carbidopa-levodopa ER. History of BOTH of the following: rasagiline tablets selegiline. History of TWO of the following: alfuzosin, doxazosin, tamsulosin, terazosin, OR RAPAFLO. CAMBIA TIVORBEX GRALISE tramadol hcl er RYTARY XADAGO CARDURA XL Seizure Medications History of ONE of the following: oxcarbazepine IR OXTELLAR XR Sleep Aids Stomach Medications - IBS Constipation Stomach Medications - IBS/IBD Stomach Medications - Pancreatic Enzymes History of topiramate IR. History of ONE of the following: eszopiclone, temazepam, zaleplon, zolpidem, OR zolpidem ER. History of ONE of the following: zolpidem OR zolpidem ER. Requires any ONE of the following generics: lactulose, polyethylene glycol any ONE of the following preferred brands: Linzess, Movantik, or Symproic History of ONE of the following: lactulose OR polyethylene glycol (PEG) History of ONE of the following generics: lactulose, polyethylene glycol History of ONE of the following generics: lactulose, polyethylene glycol History of ONE of the following: lactulose OR polyethylene glycol (PEG) LINZESS. History of the following: APRISO ER. History of BOTH of the following: CREON ZENPEP. QUDEXY XR topiramate er TROKENDI XR BELSOMRA EDLUAR ZOLPIMIST AMITIZA LINZESS MOVANTIK SYMPROIC TRULANCE ASACOL HD DELZICOL LIALDA PANCREAZE PERTZYE VIOKACE CAPITAL LETTERS = BR MEDICATIONS 6
Stomach Medications - Ulcer Topical - Acne Topical - Acne Combinations Topical - Atopic Dermatitis Topical - Cancer Agents History of TWO of the following: DEXILANT, esomeprazole, lansoprazole (capsules), omeprazole, rabeprazole OR pantoprazole. History of TWO of the following generic, single ingredient, generic topical clindamycin products History of ONE of the following: EPIDUO/EPIDUO FORTE OR ONEXTON History of one prescription strength topical corticosteroid. History of one of the following topical generics: fluorouracil or imiquimod. ACIPHEX ACIPHEX SPRINKLE esomeprazole strontium PREVACID PRILOSEC PROTONIX ZEGERID CLEOCIN T CLINDAGEL clindamycin phosphate ACANYA AKTIPAK BENZACLIN BENZAMYCIN DUAC VELTIN ZIANA ELIDEL EUCRISA diclofenac sodium PICATO SOLARAZE TOLAK Topical - Rosacea History of SOOLANTRA. FINACEA History of MIRVASO. RHOFADE CAPITAL LETTERS = BR MEDICATIONS 7
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 59212 Minneapolis, MN 55459-0212 Phone: 1.800.940.5049 (TTY: 763.847.4013) Fax: 763.847.4010 Email: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or email. 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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, 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. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. NDR PIC LV (1/18)
PreferredOne Community Health Plan Nondiscrimination Notice PreferredOne Community Health Plan ( PCHP ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PCHP: 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 PCHP 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 Community Health Plan PO Box 59052 Minneapolis, MN 55459-0052 Phone: 1.800.940.5049 (TTY: 763.847.4013) Fax: 763.847.4010 customerservice@preferredone.com You can file a grievance in person or by mail, fax, or email. 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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, 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. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. NDR PCHP LV (1/18)