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Step Therapy Criteria

Drug Name
Step Therapy Criteria
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS, 1 DRUG
FROM EACH CLASS, IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: ACE-Inhibitor (including
combinations with HCTZ) Benazepril Hcl, Benazepril Hcl/Hydrochlorothiazide, Captopril, Captopril /Hydrochlorothiazide,
Enalapril Maleate, Enalapril Maleate/Hydrochlorothiazide, Fosinopril Sodium, Fosinopril sodium/Hydrochlorothiazide, Benicar, Benicar Hct, Diovan,
Lisinopril, Lisinopril /Hydrochlorothiazide, Quinapril Hcl, Quinaretic, Trandolapril, Ramipril. ARB (including combinations Diovan Hct, Micardis, Micardis Hct
with HCTZ), losartan, losartan/HCTZ Step 2: Benicar, Benicar Hct, Diovan, Diovan Hct, Micardis, Micardis Hct
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: clozapine, risperidone, olanzapine, Seroquel, Geodon Step 2:
Abilify, Fanapt, Fazaclo, Invega, Latuda, Risperdal Consta, Risperdal M-Tab, Saphris, Seroquel XR, Zyprexa.
Step Therapy only applies to new starts only. Enrollees stabilized on medication will not be required to go
through step therapy.
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Chlorpropamide, Fortamet, Glimepiride, Glipizide, Glipizide Er,
Glipizide Xl, Glipizide/Metformin Hcl, Glyburide, Glyburide Micronized, Glyburide/Metformin Hcl, Glycron, Metformin Hcl, Metformin Hcl Er, Prandin, Precose, Starlix, Tolazamide, Tolbutamide. Step 2: Byetta
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF THE FOLLOWING DRUG IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: bupropion, bupropion SR, mirtazapine, nefazodone, trazodone, fluoxetine, Lexapro, paroxetine, sertraline, venlafaxine, venlafaxine XR, Seroquel Step 2: Abilify, Seroquel XR Step Therapy
Abilify, Seroquel XR
only applies to new starts only. Enrollees stabilized on medication will not be required to go through step
therapy.
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Chlorpropamide, Fortamet, Glimepiride, Glipizide, Glipizide Er,
Glipizide Xl, Glipizide/Metformin Hcl, Glyburide, Glyburide Micronized, Glyburide/Metformin Hcl, Glycron, Humalog,
Humalog Mix 50/50, Humalog Mix 75/25, Humulin 50/50, Humulin 70/30, Humulin N, Humulin R, Lantus, Lantus Actos, Avandamet, Avandamet,
Solostar, Levemir, Metformin Hcl, Metformin Hcl Er, Novolog, Novolog Flexpen, Novolog Mix 70/30, Prandin, Precose, Avandaryl, Avandia, Duetact
Relion 70/30, Relion 70/30 Innolet, Relion N, Relion N Innolet, Relion R, Starlix, Tolazamide. Step 2: Actos,
Avandamet, Avandamet, Avandaryl, Avandia, Duetact
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE Janumet, Januvia, Onglyza
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Fortamet, Glipizide/Metformin Hcl, Glyburide/Metformin Hcl, Metformin Hcl, Metformin Hcl ER. Step 2: Janumet, Januvia, Onglyza
Drug Name
Step Therapy Criteria
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Diclofenac Potassium, Diclofenac Sodium, Diclofenac Sodium
Dr, Diclofenac Sodium Ec, Diclofenac Sodium Er, Diflunisal, Etodolac, Etodolac Er, Fenoprofen Calcium, Flurbiprofen,
Ibuprofen, Indomethacin, Indomethacin Er, Ketoprofen, Ketoprofen Er, Ketorolac Tromethamine, Meloxicam, Celebrex
Nabumetone, Naproxen, Naproxen Dr, Naproxen Sodium, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2:
Celebrex
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE Clarinex, Clarinex D
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Allegra OTC, Allegra D OTC, Loratadine, Loratadine/Pseudoephedrine, Cetirizine, Cetirizine/Pseudoephedrine. Step 2: Clarinex, Clarinex D
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE Prevacid, Nexium, Protonix IV
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: lansoprazole, Priolosec Otc, Omeprazole Otc, Omeprazole, Omeprazole/Sodium Bicarbonate, Pantoprazole, Prevacid OTC, Zegerid OTC. Step 2: Prevacid, Nexium, Protonix IV
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF THE FOLLOWING DRUG IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Warfarin Step 2: Pradaxa
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS, 1 DRUG
FROM EACH CLASS, IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: • ACE-Inhibitors (including
combinations with HCTZ) - Benazepril Hcl, Benazepril Hctz, Captopril, Captopril /Hctz, Enalapril Maleate, Enalapril
Maleate/Hctz, Fosinopril Sodium, Fosinoprilsodium/Hctz, Lisinopril, Lisinopril /Hctz, Quinapril Hcl, Quinaretic,
Trandolapril, Ramipril. • ARBs (including combinations with HCTZ) - Benicar, Benicar Hct, Diovan Hct, losartan, Tekturna, Tekturna Hct
losartan/HCT, Micardis, Micardis Hct. Step 2: Tekturna, Tekturna Hct
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL THE FOLLOWING DRUG IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Gleevec. Step 2: Sprycel Step Therapy only applies to new starts only. Enrollees
stabilized on medication will not be required to go through step therapy. Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Atorvastatin, Simvastatin, Pravastatin, Lovastatin. Step
2:Crestor
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Humalog, Humalog Mix 50/50, Humalog Mix 75/25, Lantus, Levemir, Novolog, Novolog Flexpen, Novolog Mix 70/30, Novolin R, Novolin N, Novolin 70/30. Step 2: Symlin
Drug Name
Step Therapy Criteria
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Alclometasone Dipropionate, Amcinonide, Augmented
Betamethasone Dipropionate, Betamethasone Dipropionate, Betamethasone Valerate, Clobetasol Propionate,
Clobetasol Propionate Emollient, Desonide, Desoximetasone, Diflorasone Diacetate, Fluocinolone Acetonide, Elidel, Protopic
Fluticasone, Halobetasol Propionate, Hydrocortisone Butyrate, Hydrocortisone Valerate, Mometasone Furoate, Prednicarbate, Triamcinolone Acetonide, Triamcinolone Acetonide In Absorbase. Step 2: Elidel, Protopic
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Chlorpropamide, Fortamet, Glimepiride, Glipizide, Glipizide Er, Glipizide Xl, Glipizide/Metformin Hcl, Glyburide, Glyburide Micronized, Glyburide/Metformin Hcl, Glycron, Metformin Hcl, Metformin Hcl Er, Prandin, Precose, Starlix, Tolazamide, Tolbutamide. Step 2:Victoza
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Chlorpropamide, Fortamet, Glimepiride, Glipizide, Glipizide Er,
Glipizide Xl, Glipizide/Metformin Hcl, Glyburide, Glyburide Micronized, Glyburide/Metformin Hcl, Glycron, Humalog,
Humalog Mix 50/50, Humalog Mix 75/25, Humulin 50/50, Humulin 70/30, Humulin N, Humulin R, Metformin Hcl,
Metformin Hcl Er, Novolog, Novolog Mix 70/30, Prandin, Precose, Relion 70/30, Relion 70/30 Innolet, Relion N, Relion
N Innolet, Relion R, Starlix, Tolazamide. Step 2: Welchol
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Atorvastatin, Simvastatin, Pravastatin, Lovastatin. Step 2:
For information on obtaining an updated coverage determination or an exception to a coverage determination please call Member Services at 1-888-300-9320. Hours of operation from October 1, 2012 to February 14, 2013, are 7 days a week from 8:00 AM to 8:00 PM. From February 15, 2013 to October 14, 2013, hours of operation are Monday through Friday from 8:00 AM to 8:00 PM. TTY/TDD users should call 1-800-662-1220.

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