GRANDFATHERED DRUGS
GRANDFATHERED DRUGS
Effective January 1, 2016, any NEW prescriptions for the medications in the chart below are subject to the Step Therapy requirements set forth above. If, however, you are currently taking a medication in one of these categories, the Fund will continue to provide benefits for your medication.
GRANDFATHERED DRUGS
Effective January 1, 2016, any NEW prescriptions for the medications in the chart below are subject to the Step Therapy requirements set forth above. If, however, you are currently taking a medication in one of these categories, the Fund will continue to provide benefits for your medication.
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CATEGORY |
STEP I |
STEP II |
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ADD & ADHD |
AMPHETAMINE SALTS D-AMPHETAMINE ER DEXMETHYLPHENIDATE DEXTROAMPHETAMINE METHAMPHETAMINE METHYLPHENIDATE & ALL OTHER GENERICS
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ADDERALL ADHANSIA XR ADZENYS CONCERTA COTEMPLA XR DAYTRANA DESOXYN DEXEDRINE EVEKEO FOCALIN JORNAY METADATE METHYLIN PROCENTRA QUILLIVANT RELEXXII RITALIN VYVANSE ZENZEDI |
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ANTI-MIGRAINE |
DIHYDROERGOTAMINE ERGOTAMINE-CAFFEINE TABLET NARATRIPTAN RIZATRIPTAN SUMATRIPTAN ZOLMITRIPTAN & ALL OTHER GENERICS
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AIMOVIG AJOVY AMERGE CAFERGOT D.H.E.45 EMGALITY ERGOMAR FROVA IMITREX MAXALT MIGERGOT MIGRANAL RELPAX REYVOW SUMAVEL TOSYMRA TREXIMET UBRELVY ZEMBRACE SYMTOUCH ZOMIG |
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ANTI-CONVULSANTS |
CARBAMAZEPINE CLONAZEPAM DIVALPROEX ETHOSUXIMIDE FELBAMATE FOSPHENYTOIN GABAPENTIN LAMOTRIGINE LEVETIRACETAM OXCARBAZEPINE PHENYTOIN PRIMIDONE TIAGABINE TOPIRAMATE VALPROATE VALPROIC ACID ZONISAMIDE & ALL OTHER GENERICS |
APTIOM BANZEL CARBATROL CELONTIN CEREBYX DEPACON DEPAKENE DEPAKOTE DILANTIN EPIDIOLEX FANATREX FELBATOL FYCOMPA GABITRIL KEPPRA KLONOPIN LAMICTAL MYSOLINE NAYZILAM NEURONTIN ONFI OXTELLAR PEGANONE PHENYTEK QUDEXY SYMPAZAN TEGRETOL TOPAMAX TRILEPTAL TROKENDI VALTOCO VIMPAT ZARONTIN ZONEGRAN |
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PROTON PUMP INHIBITORS |
OVER THE COUNTER (“OTC”): LANSOPRAZOLE DR OTC NEXIUM OTC OMEPRAZOLE OTC OMEPRAZOLE-BICARB OTC PREVACID OTC PRILOSEC OTC ZEGERID OTC |
ACIPHEX DEXILANT ESOMEPRAZOLE NEXIUM OMEPRAZOLE-BICARB PANTOPRAZOLE PREVACID PRILOSEC PROTONIX ZEGERID |
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ULCERATIVE COLITIS |
AZULFIDINE BALSALAZIDE MESALAMINE SULFASALAZINE SULFAZINE & ALL OTHER GENERICS
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APRISO ASACOL COLAZAL DELZICOL DIPENTUM ENTYVIC HUMIRA LIALDA PENTASA SIMPONI STELARA |
