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 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 BlueShield of Northeastern New York before filling prescriptions for the Step-2 drugs shown in the chart below. BlueShield of Northeastern New York 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 1-800-329-2792 (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, www.bsneny.com/medicare Step Therapy ALPHA BLOCKERS Step Therapy Medications 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 0.4 MG CAPSULE 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 COLCRYS-PST Step-1: MITIGARE 0.6 MG CAPSULE Step-2: COLCRYS 0.6 MG TABLET If the patient has tried one Step 1 product, authorization for a Step 2 product Exceptions can be made for a step 2 drug (without a trial of a step 1 drug) for the treatment of Familial Mediterranean Fever and for the treatment of gout flares (i.e, prophylaxis of gout flares requires a trial of a step 1 drug). Last Updated: 11/1/17 Page 1
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 DPP-4 INHIBITORS-PST 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 JENTADUETO XR 2.5 MG-1,000 MG TABLET, EXTENDED RELEASE or JENTADUETO XR 5 MG-1,000 MG TABLET, EXTENDED RELEASE 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 Last Updated: 11/1/17 Page 2
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 patients greater than 64 years of age only.authorization for a step 2 drug may be given in patients aged less than 65 years. Prior to approval of a step 2 drug, the physician must have assessed risk versus benefit in prescribing the requested HRM for the patient and must confirm that he/she would still like to initiate/continue therapy. OPHTHALMIC PROSTAGLANDI NS-PST Step-1: BIMATOPROST 0.03 % EYE DROPS or LATANOPROST 0.005 % EYE DROPS or LUMIGAN 0.01 % EYE DROPS or TRAVATAN Z 0.004 % EYE DROPS Step-2: ZIOPTAN (PF) 0.0015 % 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. Last Updated: 11/1/17 Page 3
ORAL BISPHOSPHONA TES 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 (4 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 Step-1: HUMALOG 100 UNIT/ML SUBCUTANEOUS CARTRIDGE or HUMALOG 100 UNIT/ML SUBCUTANEOUS SOLUTION or HUMALOG KWIKPEN 100 UNIT/ML SUBCUTANEOUS or HUMALOG KWIKPEN 200 UNIT/ML (3 ML) SUBCUTANEOUS or HUMALOG MIX 50-50 100 UNIT/ML SUBCUTANEOUS SUSPENSION or HUMALOG MIX 50-50 KWIKPEN 100 UNIT/ML SUBCUTANEOUS PEN or HUMALOG MIX 75-25 100 UNIT/ML SUBCUTANEOUS SUSPENSION or HUMALOG MIX 75-25 KWIKPEN 100 UNIT/ML SUBCUTANEOUS INSULIN PEN Step-2: APIDRA 100 UNIT/ML SUBCUTANEOUS SOLUTION or APIDRA SOLOSTAR 100 UNIT/ML SUBCUTANEOUS INSULIN PEN or NOVOLOG 100 UNIT/ML SUBCUTANEOUS SOLUTION or NOVOLOG FLEXPEN 100 UNIT/ML SUBCUTANEOUS or NOVOLOG MIX 70-30 100 UNIT/ML SUBCUTANEOUS SOLUTION or NOVOLOG MIX 70-30 FLEXPEN 100 UNIT/ML SUBCUTANEOUS PEN or NOVOLOG PENFILL 100 UNIT/ML SUBCUTANEOUS CARTRIDGE Last Updated: 11/1/17 Page 4
TOPICAL ACTINIC KERATOSIS-PST 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 or PICATO 0.015 % TOPICAL GEL or PICATO 0.05 % TOPICAL GEL Step-2: FLUOROURACIL 0.5 % TOPICAL CREAM or ZYCLARA 2.5 % TOPICAL CREAM PUMP or ZYCLARA 3.75 % TOPICAL CREAM PACKET 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). Last Updated: 11/1/17 Page 5