Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment you need, usually at a lower cost. Here s how it works: You get a prescription Try a Step 1 medication first Before a Step 2 medication is covered With this program, you need to try a Step 1 medication first, before a Step 2 medication may be covered. When you bring a prescription to the pharmacy, our system will automatically screen the medication for step therapy requirements. If your prior pharmacy claims show you have tried a Step 1 medication in the recent past, the Step 2 medication may be processed. If not, the pharmacist will contact your doctor for further explanation. There are some drugs that require three steps before a medication is covered. You must try Step 1 and Step 2 medications before receiving benefit coverage for a Step 3 medication. We encourage you to discuss your treatment and medication options with your doctor. If you have questions about the Step Therapy program, call the toll-free member phone number on the back of your ID card.
Step Therapy Program Step Therapy Medications (2 steps)* If you have a prescription for any of the following Step 2 medications, you will be required to first try a Step 1 medication(s) for benefit coverage. Attention Deficit Disorder Dextroamphetamine, Amphetamine-dextroamphetamine, Methylphenidate, Dexmethylphenidate, Vyvanse Procentra/Dextroamphetamine, Desoxyn/Methamphetamine, Adderall XR/Amphetamine ER, Kapvay/Clonidine ER, Focalin XR/ Dexmethylphenidate ER, Metadate CD/Methylphenidate ER, Ritalin SR/Concerta/Methylphenidate ER, Methylin/Methylphenidate Solution, Ritalin LA/Methylphenidate ER, Daytrana, Methylin, Quillivant, Evekeo Antibiotics Doxycycline Acticlate, Adoxa, Doryx Antipsychotics Asthma/COPD Bethkis Olanzapine, Risperidone, Risperidone ODT, Quetiapine, Seroquel XR, Saphris, Abilify Symbicort, Advair Diskus, Foradil, Serevent Advair Diskus, Advair HFA, Symbicort Symbicort, Advair Diskus, Foradil, Serevent, Spiriva, Spiriva Respimat, Breo Ellipta Montelukast and any one of the following: Methylprednisolone, Prednisolone, Prednisone, Ventolin HFA,Proair HFA, Foradil, Serevent, Qvar, Pulmicort, Flovent Diskus, Flovent HFA, Asmanex, Advair Diskus, Advair HFA, Symbicort Kitabis, Tobi Neb/Tobramycin Neb Geodon/Ziprasidone, Fanapt, Invega, Latuda Striverdi Dulera Anoro Ellipta, Incruse Ellipta Zyflo, Zyflo CR OptumRx optumrx.com
Step Therapy Medications (2 steps)* Continued Asthma/COPD continued QVAR, Pulmicort Flexhaler, Flovent Diskus, Flovent HFA, or Asmanex Arnuity Ellipta Cardiovascular Carvedilol Coreg CR Cholesterol Lowering Agents Depression Benazepril, Candesartan, Captopril, Enalopril, Fosinopril, Irbesartan, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Telmisartan, Trandolapril, Benazepril-amlodipine, Trandolapril-verapamil, Benazepril-HCTZ, Captopril-HCTZ, Enalapril-HCTZ, Fosinopril-HCTZ, Irbesartan-HCTZ, Lisinopril-HCTZ, Moexipril-HCTZ, Quinapril-HCTZ, Losartan, Losartan-HCTZ Amlodipine and any one of the following: Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Crestor, Vytorin Lipofen and any one of the following: Fenofibric Acid, Fenofibrate Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Crestor Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Crestor, Vytorin Citalopram, Escitalopram, Fluoxetine, Paroxetine, Paroxetine ER, Sertraline, Venlafaxine, Venlafaxine ER, Bupropion SR, Mirtazapine, Mirtazapine ODT, Duloxetine, Pristiq Paroxetine or Sertraline Edarbi, Edarbyclor, Azor, Exforge, Exforge HCT, Tribenzor Caduet/Amlodipine-atorvastatin Fibricor, Fenoglide, Triglide Lipitor, Lescol/Fluvastatin, Lescol XL, Mevacor, Altroprev, Livalo, Pravachol, Zocor Liptruzet Viibryd, Brintellix Luvox CR/Fluvoxamine ER 3
Step Therapy Program Step Therapy Medications (2 steps)* Continued Depression continued Venlafaxine, Venlafaxine ER, Duloxetine, Pristiq Bupropion SR Fetzima Aplenzin Diabetes Humalog or Novolog Apidra Metformin or Metformin ER Metformin, Metformin ER Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Amaryl, Diabeta, Duetact, Glucotrol, Glucotrol XR, Glucovance, Glynase, Metaglip, Prandimet, Prandin, Precose, Starlix Actoplus Met XR, Actos Glyset Riomet Ear Condition Ofloxacin Cetraxal/Ciprofloxacin Gastrointestinal (Miscellaneous) Creon and Zenpep Polyethylene Glycol or Lactulose Viokace, Pancreaze, Pertzye, Ultresa Amitiza, Linzess OptumRx optumrx.com
Step Therapy Medications (2 steps)* Continued Gout Allopurinol Uloric Colcrys Colchicine Capsule, Mitigare Insomnia Zolpidem or Zolpidem CR Intermezzo, Edluar, Zolpimist Migraine Skin Conditions (Miscellaneous) Narcotic Analgesics Nausea/ Vomiting Neurologic Non-Narcotic Analgesics Eszopiclone, Temazepam, Zaleplon, Zolpidem, Zolpidem ER Rizatriptan (tablet)/rizatriptan RDT, Sumatriptan (tablet), Zolmitriptan (tablet)/zolmitriptan ODT Any one of the following topical corticosteroids: Alclometasone, Betamethasone Dipropionate (augmented), Betamethasone Dipropionate, Clobetasol, Desonide, Desoximetasone, Diflorasone, Fluocinolone, Fluocinonide, Fluticasone, Hydrocortisone, Mometasone, Triamcinolone, Pramosone Morphine Sulfate CR, Morphine Sulfate SR, Oxycontin Tramadol or Tramadol-acetaminophen Metoclopramide Amitriptyline, Cyclobenzaprine, Duloxetine, Lyrica Gabapentin Diclofenac, Etodolac, Fenoprofen, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac, Meloxicam, Nabumetone, Naproxen, Oxaprozin, Piroxicam, Sulindac, Tolmetin Belsomra Treximet Elidel Exalgo Tramadol ER Metozolv ODT Savella Gralise Duexis 5
Step Therapy Program Step Therapy Medications (2 steps)* Continued Oncology Fluorouracil or Imiquimod Picato Opthalamic Agents Azelastine, Patanol, Pataday Osteoporosis Alendronate Atelvia Overactive Bladder Parkinson's Disease Prostatic Hypertrophy Seizure Disorders Severe Allergic Reaction Ulcer/Acid Reflux Women s Health: Miscellaneous Oxybutynin, Vesicare, Oxytrol, Gelnique Ropinorole or Pramipexole Donepezil SR and Namenda or Namenda XR carbidopa-levodopa IR, carbidopa-levodopa ER Alfuzosin, Doxazosin, Terazosin, Tamsulosin, Rapaflo Topiramate IR Epipen, Epipen Jr Omeprazole, Lansoprazole (capsule), Pantoprazole, Nexium, Dexilant Omeclamox or Pylera Estradiol, Fluoxetine, Paroxetine Bepreve, Lastacaft Detrol/Tolterodine, Sanctura/Trospium, Sanctura XR/Trospium ER, Detrol LA/ Tolterodine SR, Myrbetriq Requip XL/Ropinirole ER, Mirapex ER Namzaric Rytary Cardura XL Qudexy XR, Trokendi XR Epinephrine, Auvi-Q, Adrenaclick Esomeprazole Strontium, Lansoprazole Suspension, Prevacid, Prevacid ODT/Lanosprazole ODT, First-Omeprazole Suspension, Aciphex/Rabeprazole, Zegerid/ Omeprazole-sodium Bicarbonate, Prilosec, Protonix Prevpac/Lansoprazole-amoxicillinclarithromycin, Helidac Brisdelle OptumRx optumrx.com
Step Therapy Medications (3 steps)* If you have a prescription for any of the following Step 3 medications, you must first try Step 1 and Step 2 medications for benefit coverage. Step 3 Asthma /COPD Cardiovascular Theophylline, Qvar, Pulmicort, Flovent Diskus, Flovent HFA, Asmanex, Tudorza, Atrovent HFA, Spiriva, Advair Diskus, Advair HFA, Symbicort, Theo-24 Benazepril, Candesartan, Captopril, Enalopril, Fosinopril, Irbesartan, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Telmisartan, Trandolapril, Benazepril-amlodipine, Trandolaprilverapamil, Benazepril-HCTZ, Captopril- HCTZ, Enalapril-HCTZ, Fosinopril-HCTZ, Irbesartan-HCTZ, Lisinopril-HCTZ, Moexipril-HCTZ, Quinapril-HCTZ, Losartan, Losartan-HCTZ Benazepril, Candesartan, Captopril, Enalopril, Fosinopril, Irbesartan, Irbesartan HCTZ, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril, Benazepril-amlodipine, Trandolaprilverapamil, Telmisartan, Benazepril- HCTZ, Captopril-HCTZ, Enalapril-HCTZ, Fosinopril-HCTZ, Lisinopril-HCTZ, Moexipril-HCTZ, Quinapril-HCTZ, Losartan, Losartan-HCTZ Foradil and Serevent Any one of the following: Azor, Exforge, Exforge HCT Tekturna or Tekturna HCT Any two of the following: Benicar, Benicar HCT, Diovan, Micardis HCT Arcapta Twynsta/ Telmisartanamlopidine Tekamlo, Amturnide Atacand, Atacand HCT/ Candesartan- HCTZ, Teveten/ Eprosartan, Teveten HCT, Avapro, Avalide, Cozaar, Hyzaar, Diovan HCT, Micardis 7
Step Therapy Program Step Therapy Medications (3 steps)* Continued Step 3 Diabetes Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin Metformin, Metformin ER, Metformin-glipizide, Metformin-glyburide, Metforminpioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Any one of the following: Tradjenta, Onglyza, Januvia, Jentadueto, Kombiglyze, Janumet Janumet Byetta, Victoza Invokamet or Invokana, and Jardiance Nesina, Kazano, Oseni Janumet XR Bydureon, Tanzeum, Trulicity Fargixa, Glyxambi, Xigduo XR OptumRx optumrx.com
* Step therapy requirements are effective as of July 1, 2015. The list of step therapy medications is subject to change without notice. Step therapy requirements may vary by benefit plan. Additional clinical programs, including quantity limits and prior authorization, may exist for the above medications which may affect your prescription drug coverage. optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum TM company a leading provider of integrated health services. Learn more at optum.com. All Optum TM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. 2015 Optum, Inc. All rights reserved. ORX0785_150701 42207A-062015