STEP THERAPY
STEP THERAPY
NOTE: The medications in each category are subject to change. Please make sure to check with the Fund (Phone: Toll Free in PA: 1-800-422-8330; Toll Free in USA: 1-800-331-0420) or on the Fund’s website (www.centralpateamsters.com) for updates to this chart before beginning a course of medication.
STEP THERAPY
NOTE: The medications in each category are subject to change. Please make sure to check with the Fund (Phone: Toll Free in PA: 1-800-422-8330; Toll Free in USA: 1-800-331-0420) or on the Fund’s website (www.centralpateamsters.com) for updates to this chart before beginning a course of medication.
STEP THERAPY CATEGORIES NOT SUBJECT TO GRANDFATHERING:
Effective January 1, 2016, the Fund will NOT provide benefits for medications in Step II unless you have documented that you have tried and failed on a Step I medication and your physician has submitted documentation demonstrating that the Step II medications are “medically necessary” under the Fund’s criteria.
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CATEGORY |
STEP I |
STEP II |
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ALZHEIMER’S DISEASE |
DONEPEZIL GALANTAMINE RIVASTIGMINE & ALL OTHER GENERICS
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ARICEPT EXELON NAMENDA RAZADYNE |
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ANGIOTENSIN RECEPTOR BLOCKERS (ANTIHYPERTENSIVES) |
CANDESARTAN EPROSARTAN IRBESARTAN LOSARTAN TELMISARTAN VALSARTAN & ALL OTHER GENERICS |
ATACAND AVAPRO BENICAR BYVALSON COZAAR DIOVAN EDARBI MICARDIS
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ANTI-DEPRESSANTS |
BUPROPION HCL CITALOPRAM DESVENLAFAXINE DULOXETINE ESCITALOPRAM FLUOXETINE NEFAZODONE SERTRALINE TRAZODONE VENLAFAXINE & ALL OTHER GENERICS |
APLENZIN BRINTELLIX CYMBALTA EFFEXOR FETZIMA FORFIVO XL KHEDEZLA LEXAPRO PRISTIQ PROZAC SPRAVATO TRINTELLIX VllBRYD WELLBUTRIN ZOLOFT |
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ANTI-GLAUCOMA EYE PREPARATIONS |
APRACLONIDINE HCL BETAXOLOL BRIMONIDINE CARTEOLOL DORZOLAMIDE LATANOPROST LEVOBUNOLOL METIPRANOLOL PILOCARPINE TIMOLOL & ALL OTHER GENERICS |
ALPHAGAN AZOPT BETIMOL BETOPTIC COMBIGAN COSOPT IOPIDINE ISTALOL LUMIGAN PHOSPHOLINE SIMBRINZA TIMOPTIC TRAVATAN TRUSOPT XALATAN XELPROS ZIOPTAN |
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ANTIPSYCHOTICS |
CLOZAPINE OLANZAPINE QUETIAPINE RISPERIDONE ZIPRASIDONE & ALL OTHER GENERICS |
ABILIFY – Evidence of “medical necessity” must include documentation of failure of all other therapies, including non-drug intervention |
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BETA-ADRENERGIC BLOCKERS (ANTIHYPERTENSIVES) |
ACEBUTOLOL ATENOLOL BETAXOLOL BISOPROLOL NADOLOL PINDOLOL PROPRANONOL SOTALOL TIMOLOL & ALL OTHER GENERICS |
BYSTOLIC |
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CALCIUM CHANNEL BLOCKERS (ANTIHYPERTENSIVES) |
AMLODIPINE ATORVASTATIN AMLODIPINE BESYLATE AMLODIPINE VALSARTAN DILTIAZEM FELODIPINE ISRADIPINE NICARDIPINE NIFEDIPINE NISOLDIPINE VERPAMIL & ALL OTHER GENERICS
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ADALAT CADUET CALAN CARDENE CARDIZEM CARTIA XT EFIDITAB EXFORGE NORVASC PROCARDIA XL SULAR TIAZAC ER VERELAN |
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CONTRACEPTIVES |
All Generic Contraceptives |
All Brand Contraceptives |
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DIABETES |
ACARBOSE GLIMEPIRIDE GLIPIZIDE GLYBURIDE JANUMET JANUVIA METFORMIN PIOGLITAZONE REPAGLINIDE & ALL OTHER GENERICS |
INVOKANA JARDIANCE JENTADUETO KAZANO QTERN SEGLUROMET STEGLATRO STEGLUJAN TRADJENTA |
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NARCOTIC ANALGESICS
NOTE: BENEFITS WILL BE PROVIDED ONLY FOR NARCOTIC ANALGESICS PRESCRIBED AT THE MANUFACTURERS RECOMMENDED SCRIPT LEVEL.
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ACETAM INOPHEN-CODEINE HYDROCODONE-ACETAMINOPHEN HYDROMORPHONE MEPERIDINE METHADONE MORPHINE SULFATE OXYCODONE OXYCODONE-ACETAMINOPHEN OXYCODONE-ASPIRIN OXYMORPHONE TRAMADOL & ALL OTHER GENERICS |
APADAZ ARYMO DEMEROL DOLOPHINE LORTAB NORCO NUCYNTA OPANA OXYCONTIN PERCOCET PERCODAN TYLENOL WITH CODEINE ULTRACET ULTRAM VICODIN XTAMPZA |
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OSTEOPOROSIS |
ALENDRONATE CALCITONIN-SALMON IBANDRONATE RALOXIFENE RISEDRONATE & ALL OTHER GENERICS
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ACTONEL ATELVIA BINOSTO BONIVA EVENITY EVISTA FOSAMAX MIACALCIN PROLIA |
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RHEUMATOID ARTHRITIS |
HIGH DOSE IBUPROFEN AND NAPROXEN (PRESCRIPTION STRENGTH) CELECOXIB NABUMETONE PIROXICAM DICLOFENAC DIFLUNISAL INDOMETHACIN KETOPROFEN ETODOLAC PREDNISONE CYCLOPHOSPHAMIDE CYCLOSPORINE AZATHIOPRINE METHOTREXATE XELJANZ & ALL OTHER GENERICS |
ACTEMRA CIMZIA ENBREL HUMIRA INFLECTRA KEVZARA KINERET OLUMIANT ORENCIA RENFLEXIS SIMPONI STELARA TALTZ |
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URINARY AGENTS |
TOVIAZ FLAVOXATE OXYBUTYNIN TOLTERODINE TROSPIUM & ALL OTHER GENERICS |
ENABLEX GELNIQUE MYRBETRIQ OXYTROL VESICARE |
