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 DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF EITHER A SAXAGLIPTIN OR SITAGLIPTIN PRODUCT. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 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 DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF 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 DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF TWO GENERIC ARB OR ARB COMBINATIONS. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 3
BRAND HMG STEP Altoprev 20 mg tablet,extended release Altoprev 40 mg tablet,extended release Altoprev 60 mg tablet,extended release Vytorin 10 mg-10 mg tablet Vytorin 10 mg-20 mg tablet Vytorin 10 mg-40 mg tablet Vytorin 10 mg-80 mg tablet COVERAGE OF BRAND NAME STATINS (HMGS) REQUIRES DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF TWO GENERIC STATIN MEDICATIONS. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 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 DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE TO TWO GENERIC TOPICAL ANTIFUNGAL MEDICATIONS. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 5
BRAND TOPICAL STEROIDS STEP Ala-Scalp 2 % lotion 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 Kenalog 0.147 mg/gram topical aerosol Locoid 0.1 % lotion Pandel 0.1 % topical cream Taclonex 0.005 %-0.064 % topical ointment Taclonex 0.005 %-0.064 % topical suspension Topicort 0.25 % topical spray COVERAGE OF BRAND NAME TOPICAL STEROIDS REQUIRES DOCUMENTATION OF A TRIAL OF AT LEAST TWO DIFFERENT GENERIC TOPICAL STEROID MEDICATIONS. IF THERE LACKS TWO DIFFERENT GENERIC TOPICAL STEROID MEDICATIONS INDICATED TO TREAT A SPECIFIC DIAGNOSIS, THEN A TRIAL OF ONE GENERIC TOPICAL STEROID MEDICATION SATISFIES THIS REQUIREMENT. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 6
CAMBIA POWDER STEP Cambia 50 mg oral powder packet COVERAGE OF CAMBIA POWDER PACKETS REQUIRES DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF ONE NON-STEROIDAL ANTI- INFLAMMATORY DRUG (SUCH AS IBUPROFEN OR NAPROXEN) AND ONE TRIPTAN DRUG (SUCH AS SUMATRIPTAN OR RIZATRIPTAN). IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 7
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 DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF GENERIC CARVEDILOL. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 8
CUPRIMINE Cuprimine 250 mg capsule COVERAGE OF CUPRIMINE REQUIRES DOCUMENTATION OF PRIOR USE OF DEPEN. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 9
FENTANYL TRANSDERMAL PATCH Duragesic 100 mcg/hr transdermal patch Duragesic 12 mcg/hr transdermal patch Duragesic 25 mcg/hr transdermal patch Duragesic 50 mcg/hr transdermal patch Duragesic 75 mcg/hr transdermal patch fentanyl 100 mcg/hr transdermal patch fentanyl 12 mcg/hr transdermal patch fentanyl 25 mcg/hr transdermal patch fentanyl 37.5 mcg/hour transdermal patch fentanyl 50 mcg/hr transdermal patch fentanyl 62.5 mcg/hour transdermal patch fentanyl 75 mcg/hr transdermal patch fentanyl 87.5 mcg/hour transdermal patch DUE TO SAFETY CONCERNS REGARDING THE USE OF FENTANYL PATCHES IN PATIENTS WITHOUT PRIOR OPIATE USE, COVERAGE OF FENTANYL PATCH REQUIRES DOCUMENTATION OF PRIOR USE OF ONE OPIATE ANALGESIC (SUCH AS HYDROCODONE/APAP, OXYCODONE, MORPHINE) DURING THE PREVIOUS 60 DAYS. IF A REQUIRED DRUG APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 60 DAYS, THEN 10
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 DOCUMENTATION OF A TRIAL OF RISPERIDONE AND AT LEAST ONE OTHER ANTIPSYCHOTIC MEDICATION OR MOOD STABILIZER. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED. 11
ONMEL Onmel 200 mg tablet COVERAGE OF ONMEL REQUIRES DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF ORAL ITRACONAZOLE. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 12
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 PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 13
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 DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF ORAL DULOXETINE. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 14
SOOLANTRA Soolantra 1 % topical cream COVERAGE OF SOOLANTRA REQUIRES DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE TO 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. 15
SPORANOX Sporanox 10 mg/ml oral solution Sporanox 100 mg capsule COVERAGE OF SPORANOX REQUIRES DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF ORAL ITRACONAZOLE. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 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. 16
TRIPTAN INJECTABLE STEP Sumavel DosePro 4 mg/0.5 ml subcutaneous needle-free injector 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 DOCUMENTATION OF A TRIAL OF 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 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 DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF TWO GENERIC TRIPTAN MEDICATIONS. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 18
ULORIC STEP Uloric 40 mg tablet Uloric 80 mg tablet COVERAGE OF ULORIC REQUIRES DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF GENERIC ALLOPURINOL. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 19
VFEND Vfend 200 mg tablet Vfend 200 mg/5 ml (40 mg/ml) oral suspension Vfend 50 mg tablet COVERAGE OF VFEND REQUIRES DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF ORAL VORICONAZOLE. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT REQUIRED 20
XADAGO Xadago 100 mg tablet Xadago 50 mg tablet COVERAGE OF XADAGO REQUIRES A TRIAL OF ORAL SELEGILINE. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 21
ZELAPAR STEP Zelapar 1.25 mg disintegrating tablet COVERAGE OF ZELAPAR REQUIRES DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF ORAL SELEGILINE. IF THE REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 22
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 ZYFLO, ZYFLO CR, OR ZILEUTON ER REQUIRES DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF ORAL MONTELUKAST AND ZAFIRLUKAST. IF THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN 23
Index A Ala-Scalp 2 % lotion... 6 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... 13 C Cambia 50 mg oral powder packet... 7 Capex 0.01 % shampoo... 6 Cordran Tape Large Roll 4 mcg/cm2... 6 Coreg CR 10 mg capsule, extended release 8 Coreg CR 20 mg capsule, extended release 8 Coreg CR 40 mg capsule, extended release 8 Coreg CR 80 mg capsule, extended release 8 Cuprimine 250 mg capsule... 9 D Desonate 0.05 % topical gel... 6 Duragesic 100 mcg/hr transdermal patch. 10 Duragesic 12 mcg/hr transdermal patch... 10 Duragesic 25 mcg/hr transdermal patch... 10 Duragesic 50 mcg/hr transdermal patch... 10 Duragesic 75 mcg/hr transdermal patch... 10 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 fentanyl 100 mcg/hr transdermal patch... 10 fentanyl 12 mcg/hr transdermal patch... 10 fentanyl 25 mcg/hr transdermal patch... 10 fentanyl 37.5 mcg/hour transdermal patch 10 fentanyl 50 mcg/hr transdermal patch... 10 fentanyl 62.5 mcg/hour transdermal patch 10 fentanyl 75 mcg/hr transdermal patch... 10 fentanyl 87.5 mcg/hour transdermal patch 10 Fosrenol 1,000 mg chewable tablet... 13 Fosrenol 1,000 mg oral powder packet... 13 Fosrenol 500 mg chewable tablet... 13 Fosrenol 750 mg chewable tablet... 13 Fosrenol 750 mg oral powder packet... 13 H Halog 0.1 % topical cream... 6 Halog 0.1 % topical ointment... 6 I Invega Sustenna 117 mg/0.75 ml intramuscular syringe... 11 Invega Sustenna 156 mg/ml intramuscular syringe... 11 Invega Sustenna 234 mg/1.5 ml intramuscular syringe... 11 Invega Sustenna 39 mg/0.25 ml intramuscular syringe... 11 Invega Sustenna 78 mg/0.5 ml intramuscular syringe... 11 Invega Trinza 273 mg/0.875 ml intramuscular syringe... 11 Invega Trinza 410 mg/1.315 ml intramuscular syringe... 11 Invega Trinza 546 mg/1.75 ml intramuscular syringe... 11 Invega Trinza 819 mg/2.625 ml intramuscular syringe... 11 K Kazano 12.5 mg-1,000 mg tablet... 1 Kazano 12.5 mg-500 mg tablet... 1 Kenalog 0.147 mg/gram topical aerosol... 6 L Locoid 0.1 % lotion... 6 Luzu 1 % topical cream... 5 24
M Mentax 1 % topical cream... 5 N Naftin 1 % topical gel... 5 Naftin 2 % topical gel... 5 Nesina 12.5 mg tablet... 1 Nesina 25 mg tablet... 1 Nesina 6.25 mg tablet... 1 O Onmel 200 mg tablet... 12 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... 14 Savella 12.5 mg (5)-25 mg(8)-50mg(42) tablets in a dose pack... 14 Savella 12.5 mg tablet... 14 Savella 25 mg tablet... 14 Savella 50 mg tablet... 14 Soolantra 1 % topical cream... 15 Sporanox 10 mg/ml oral solution... 16 Sporanox 100 mg capsule... 16 Sumavel DosePro 4 mg/0.5 ml subcutaneous needle-free injector... 17 Sumavel DosePro 6 mg/0.5 ml subcutaneous needle-free injector... 17 T Taclonex 0.005 %-0.064 % topical ointment... 6 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 U Uloric 40 mg tablet... 19 Uloric 80 mg tablet... 19 V Vfend 200 mg tablet... 20 Vfend 200 mg/5 ml (40 mg/ml) oral suspension... 20 Vfend 50 mg tablet... 20 Vytorin 10 mg-10 mg tablet... 4 Vytorin 10 mg-20 mg tablet... 4 Vytorin 10 mg-40 mg tablet... 4 Vytorin 10 mg-80 mg tablet... 4 X Xadago 100 mg tablet... 21 Xadago 50 mg tablet... 21 Z Zelapar 1.25 mg disintegrating tablet... 22 Zembrace Symtouch 3 mg/0.5 ml subcutaneous pen injector... 17 zileuton ER 600 mg tablet,extended release 12hr mphase... 23 Zuplenz 4 mg oral soluble film... 2 Zuplenz 8 mg oral soluble film... 2 Zyflo 600 mg tablet... 23 Zyflo CR 600 mg tablet,extended release. 23 25