Step Therapy Requirements Effective June 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone 15 mg tablet alogliptin 12.5 mg-pioglitazone 30 mg tablet alogliptin 12.5 mg-pioglitazone 45 mg tablet alogliptin 25 mg tablet alogliptin 25 mg-pioglitazone 15 mg tablet alogliptin 25 mg-pioglitazone 30 mg tablet alogliptin 25 mg-pioglitazone 45 mg tablet alogliptin 6.25 mg tablet Kazano 12.5 mg-1,000 mg tablet Kazano 12.5 mg-500 mg tablet Nesina 12.5 mg tablet Nesina 25 mg tablet Nesina 6.25 mg tablet Oseni 12.5 mg-15 mg tablet Oseni 12.5 mg-30 mg tablet Oseni 12.5 mg-45 mg tablet Oseni 25 mg-15 mg tablet Oseni 25 mg-30 mg tablet Oseni 25 mg-45 mg tablet COVERAGE OF ALOGLIPTIN-CONTAINING PRODUCTS REQUIRES A TRIAL OF EITHER A SAXAGLIPTIN OR SITAGLIPTIN PRODUCT. IF THE REQUIRED DRUGS APPEAR IN THE 1
ANTIEMETICS STEP Sancuso 3.1 mg/24 hour transdermal patch Zuplenz 4 mg oral soluble film Zuplenz 8 mg oral soluble film COVERAGE OF CERTAIN BRAND NAME ANTI-EMETIC MEDICATIONS REQUIRES A TRIAL OF BOTH GENERIC ONDANSETRON AND GENERIC GRANISETRON. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 2
ARB STEP Edarbi 40 mg tablet Edarbi 80 mg tablet Edarbyclor 40 mg-12.5 mg tablet Edarbyclor 40 mg-25 mg tablet COVERAGE OF CERTAIN BRANDED ARBS AND ARB COMBOS REQUIRES A TRIAL OF TWO GENERIC ARB OR ARB COMBINATIONS. IF THE REQUIRED DRUGS APPEAR IN THE 3
BRAND HMG STEP Altoprev 20 mg tablet,extended release Altoprev 40 mg tablet,extended release Altoprev 60 mg tablet,extended release COVERAGE OF BRAND NAME STATINS (HMGS) REQUIRES A TRIAL OF TWO GENERIC STATIN MEDICATIONS. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 4
BRAND TOPICAL ANTIFUNGALS STEP Ertaczo 2 % topical cream Exelderm 1 % topical cream Exelderm 1 % topical solution Luzu 1 % topical cream Mentax 1 % topical cream Naftin 1 % topical gel Naftin 2 % topical gel Oxistat 1 % lotion COVERAGE OF BRAND NAME TOPICAL ANTIFUNGALS REQUIRES A TRIAL OF TWO GENERIC TOPICAL ANTIFUNGAL MEDICATIONS. IF THE REQUIRED DRUGS APPEAR IN THE 5
BRAND TOPICAL STEROIDS STEP Capex 0.01 % shampoo Cordran Tape Large Roll 4 mcg/cm2 Desonate 0.05 % topical gel Enstilar 0.005 %-0.064 % topical foam Halog 0.1 % topical cream Halog 0.1 % topical ointment Locoid 0.1 % lotion Pandel 0.1 % topical cream Taclonex 0.005 %-0.064 % topical suspension Topicort 0.25 % topical spray COVERAGE OF BRAND NAME TOPICAL STEROIDS REQUIRES A TRIAL OF TWO DIFFERENT GENERIC TOPICAL STEROID MEDICATIONS. IF TWO DIFFERENT GENERIC TOPICAL STEROID MEDICATIONS ARE NOT AVAILABLE TO TREAT A SPECIFIC DIAGNOSIS, THEN A TRIAL OF ONE GENERIC TOPICAL STEROID MEDICATION SATISFIES THIS REQUIREMENT. IF THE REQUIRED DRUGS APPEAR IN THE 6
COREG CR STEP Coreg CR 10 mg capsule, extended release Coreg CR 20 mg capsule, extended release Coreg CR 40 mg capsule, extended release Coreg CR 80 mg capsule, extended release COVERAGE OF COREG CR REQUIRES A TRIAL OF GENERIC CARVEDILOL. IF THE REQUIRED DRUG APPEARS IN THE 7
CUPRIMINE Cuprimine 250 mg capsule COVERAGE OF CUPRIMINE REQUIRES A TRIAL OF DEPEN. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 8
INVEGA Invega Sustenna 117 mg/0.75 ml intramuscular syringe Invega Sustenna 156 mg/ml intramuscular syringe Invega Sustenna 234 mg/1.5 ml intramuscular syringe Invega Sustenna 39 mg/0.25 ml intramuscular syringe Invega Sustenna 78 mg/0.5 ml intramuscular syringe Invega Trinza 273 mg/0.875 ml intramuscular syringe Invega Trinza 410 mg/1.315 ml intramuscular syringe Invega Trinza 546 mg/1.75 ml intramuscular syringe Invega Trinza 819 mg/2.625 ml intramuscular syringe COVERAGE OF INVEGA REQUIRES A TRIAL OF RISPERIDONE AND AT LEAST ONE OTHER ANTIPSYCHOTIC MEDICATION OR MOOD STABILIZER. IF THE REQUIRED DRUGS APPEAR IN THE 9
NAMENDA XR Namenda XR 14 mg capsule sprinkle,extended release Namenda XR 21 mg capsule sprinkle,extended release Namenda XR 28 mg capsule sprinkle,extended release Namenda XR 7 mg capsule sprinkle,extended release Namenda XR 7 mg-14 mg-21 mg-28 mg capsule,sprinkle,er 24hr,dose pack COVERAGE OF NAMENDA XR REQUIRES A TRIAL OF MEMANTINE IMMEDIATE-RELEASE TABLETS. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 10
ONMEL Onmel 200 mg tablet COVERAGE OF ONMEL REQUIRES A TRIAL OF ORAL ITRACONAZOLE. IF THE REQUIRED DRUG APPEARS IN THE 11
PHOSPHATE BINDERS Auryxia 210 mg iron tablet Fosrenol 1,000 mg chewable tablet Fosrenol 1,000 mg oral powder packet Fosrenol 500 mg chewable tablet Fosrenol 750 mg chewable tablet Fosrenol 750 mg oral powder packet COVERAGE OF CERTAIN PHOSPHATE BINDERS REQUIRES DOCUMENTATION OF PRIOR USE OF SEVELAMER TABLETS, SEVELAMER PACKETS, RENVELA TABLETS, OR RENVELA PACKETS. IF THE REQUIRED DRUG APPEARS IN THE 12
SAVELLA STEP Savella 100 mg tablet Savella 12.5 mg (5)-25 mg(8)-50mg(42) tablets in a dose pack Savella 12.5 mg tablet Savella 25 mg tablet Savella 50 mg tablet COVERAGE OF SAVELLA REQUIRES A TRIAL OF DULOXETINE. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 13
SOOLANTRA Soolantra 1 % topical cream COVERAGE OF SOOLANTRA REQUIRES A TRIAL OF ONE GENERIC TOPICAL METRONIDAZOLE PRODUCT. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 14
SPORANOX Sporanox 10 mg/ml oral solution Sporanox 100 mg capsule COVERAGE OF SPORANOX REQUIRES A TRIAL OF ORAL ITRACONAZOLE. IF THE REQUIRED DRUG APPEARS IN THE AS ORAL ITRACONAZOLE CAPSULES ARE NOT FDA-APPROVED FOR TREATMENT OF OROPHARYNGEAL AND ESOPHAGHEAL CANDIDIASIS, THE COVERAGE OF SPORANOX ORAL SOLUTION WILL BE COVERED FOR THESE DIAGNOSES WITHOUT THE STEP THERAPY REQUIREMENT. 15
SYPRINE Syprine 250 mg capsule trientine 250 mg capsule COVERAGE OF TRIENTINE OR SYPRINE REQUIRES A TRIAL OF DEPEN. IF THE REQUIRED DRUG APPEARS IN THE 16
TRIPTAN INJECTABLE STEP Sumavel DosePro 6 mg/0.5 ml subcutaneous needle-free injector Zembrace Symtouch 3 mg/0.5 ml subcutaneous pen injector COVERAGE OF CERTAIN BRAND NAME INJECTABLE TRIPTAN MEDICATIONS REQUIRES A TRIAL OF A GENERIC SUMATRIPTAN INJECTABLE. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 17
TRIPTAN STEP Onzetra Xsail 11 mg powder for nasal inhalation Relpax 20 mg tablet Relpax 40 mg tablet Treximet 10 mg-60 mg tablet Treximet 85 mg-500 mg tablet COVERAGE OF CERTAIN BRAND NAME TRIPTAN MEDICATIONS REQUIRES A TRIAL OF TWO GENERIC TRIPTAN MEDICATIONS. IF THE REQUIRED DRUGS APPEAR IN THE 18
ULORIC STEP Uloric 40 mg tablet Uloric 80 mg tablet COVERAGE OF ULORIC REQUIRES A TRIAL OF GENERIC ALLOPURINOL. IF THE REQUIRED DRUG APPEARS IN THE 19
ZELAPAR STEP Zelapar 1.25 mg disintegrating tablet COVERAGE OF ZELAPAR REQUIRES A TRIAL OF ORAL SELEGILINE. IF THE REQUIRED DRUG APPEARS IN THE 20
ZYFLO, ZYFLO CR zileuton ER 600 mg tablet,extended release 12hr mphase Zyflo 600 mg tablet Zyflo CR 600 mg tablet,extended release COVERAGE OF ZILEUTON, ZYFLO, OR ZYFLO CR REQUIRES TRIALS OF BOTH ORAL MONTELUKAST AND ZAFIRLUKAST. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 21
Index A alogliptin 12.5 mg tablet... 1 alogliptin 12.5 mg-metformin 1,000 mg tablet... 1 alogliptin 12.5 mg-metformin 500 mg tablet... 1 alogliptin 12.5 mg-pioglitazone 15 mg tablet... 1 alogliptin 12.5 mg-pioglitazone 30 mg tablet... 1 alogliptin 12.5 mg-pioglitazone 45 mg tablet... 1 alogliptin 25 mg tablet... 1 alogliptin 25 mg-pioglitazone 15 mg tablet 1 alogliptin 25 mg-pioglitazone 30 mg tablet 1 alogliptin 25 mg-pioglitazone 45 mg tablet 1 alogliptin 6.25 mg tablet... 1 Altoprev 20 mg tablet,extended release... 4 Altoprev 40 mg tablet,extended release... 4 Altoprev 60 mg tablet,extended release... 4 Auryxia 210 mg iron tablet... 12 C Capex 0.01 % shampoo... 6 Cordran Tape Large Roll 4 mcg/cm2... 6 Coreg CR 10 mg capsule, extended release 7 Coreg CR 20 mg capsule, extended release 7 Coreg CR 40 mg capsule, extended release 7 Coreg CR 80 mg capsule, extended release 7 Cuprimine 250 mg capsule... 8 D Desonate 0.05 % topical gel... 6 E Edarbi 40 mg tablet... 3 Edarbi 80 mg tablet... 3 Edarbyclor 40 mg-12.5 mg tablet... 3 Edarbyclor 40 mg-25 mg tablet... 3 Enstilar 0.005 %-0.064 % topical foam... 6 Ertaczo 2 % topical cream... 5 Exelderm 1 % topical cream... 5 Exelderm 1 % topical solution... 5 F Fosrenol 1,000 mg chewable tablet... 12 Fosrenol 1,000 mg oral powder packet... 12 Fosrenol 500 mg chewable tablet... 12 Fosrenol 750 mg chewable tablet... 12 Fosrenol 750 mg oral powder packet... 12 H Halog 0.1 % topical cream... 6 Halog 0.1 % topical ointment... 6 I Invega Sustenna 117 mg/0.75 ml intramuscular syringe... 9 Invega Sustenna 156 mg/ml intramuscular syringe... 9 Invega Sustenna 234 mg/1.5 ml intramuscular syringe... 9 Invega Sustenna 39 mg/0.25 ml intramuscular syringe... 9 Invega Sustenna 78 mg/0.5 ml intramuscular syringe... 9 Invega Trinza 273 mg/0.875 ml intramuscular syringe... 9 Invega Trinza 410 mg/1.315 ml intramuscular syringe... 9 Invega Trinza 546 mg/1.75 ml intramuscular syringe... 9 Invega Trinza 819 mg/2.625 ml intramuscular syringe... 9 K Kazano 12.5 mg-1,000 mg tablet... 1 Kazano 12.5 mg-500 mg tablet... 1 L Locoid 0.1 % lotion... 6 Luzu 1 % topical cream... 5 M Mentax 1 % topical cream... 5 N Naftin 1 % topical gel... 5 Naftin 2 % topical gel... 5 Namenda XR 14 mg capsule sprinkle,extended release... 10 Namenda XR 21 mg capsule sprinkle,extended release... 10 Namenda XR 28 mg capsule sprinkle,extended release... 10 Namenda XR 7 mg capsule sprinkle,extended release... 10 Namenda XR 7 mg-14 mg-21 mg-28 mg capsule,sprinkle,er 24hr,dose pack... 10 Nesina 12.5 mg tablet... 1 22
Nesina 25 mg tablet... 1 Nesina 6.25 mg tablet... 1 O Onmel 200 mg tablet... 11 Onzetra Xsail 11 mg powder for nasal inhalation... 18 Oseni 12.5 mg-15 mg tablet... 1 Oseni 12.5 mg-30 mg tablet... 1 Oseni 12.5 mg-45 mg tablet... 1 Oseni 25 mg-15 mg tablet... 1 Oseni 25 mg-30 mg tablet... 1 Oseni 25 mg-45 mg tablet... 1 Oxistat 1 % lotion... 5 P Pandel 0.1 % topical cream... 6 R Relpax 20 mg tablet... 18 Relpax 40 mg tablet... 18 S Sancuso 3.1 mg/24 hour transdermal patch 2 Savella 100 mg tablet... 13 Savella 12.5 mg (5)-25 mg(8)-50mg(42) tablets in a dose pack... 13 Savella 12.5 mg tablet... 13 Savella 25 mg tablet... 13 Savella 50 mg tablet... 13 Soolantra 1 % topical cream... 14 Sporanox 10 mg/ml oral solution... 15 Sporanox 100 mg capsule... 15 Sumavel DosePro 6 mg/0.5 ml subcutaneous needle-free injector... 17 Syprine 250 mg capsule... 16 T Taclonex 0.005 %-0.064 % topical suspension... 6 Topicort 0.25 % topical spray... 6 Treximet 10 mg-60 mg tablet... 18 Treximet 85 mg-500 mg tablet... 18 trientine 250 mg capsule... 16 U Uloric 40 mg tablet... 19 Uloric 80 mg tablet... 19 Z Zelapar 1.25 mg disintegrating tablet... 20 Zembrace Symtouch 3 mg/0.5 ml subcutaneous pen injector... 17 zileuton ER 600 mg tablet,extended release 12hr mphase... 21 Zuplenz 4 mg oral soluble film... 2 Zuplenz 8 mg oral soluble film... 2 Zyflo 600 mg tablet... 21 Zyflo CR 600 mg tablet,extended release. 21 23