STEP THERAPY

Jul 25, 2019 | News

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.

 

CATEGORY

STEP I

STEP II

ALZHEIMER’S DISEASE

DONEPEZIL

GALANTAMINE

RIVASTIGMINE

& ALL OTHER GENERICS

 

ARICEPT

EXELON

NAMENDA

RAZADYNE

ANGIOTENSIN RECEPTOR BLOCKERS (ANTIHYPERTENSIVES)

CANDESARTAN

EPROSARTAN

IRBESARTAN

LOSARTAN

TELMISARTAN

VALSARTAN

& ALL OTHER GENERICS

ATACAND

AVAPRO

BENICAR

BYVALSON

COZAAR

DIOVAN

EDARBI

MICARDIS

 

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

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

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

BETA-ADRENERGIC BLOCKERS (ANTIHYPERTENSIVES)

ACEBUTOLOL

ATENOLOL

BETAXOLOL

BISOPROLOL

NADOLOL

PINDOLOL

PROPRANONOL

SOTALOL

TIMOLOL

& ALL OTHER GENERICS

BYSTOLIC

CALCIUM CHANNEL BLOCKERS (ANTIHYPERTENSIVES)

AMLODIPINE ATORVASTATIN

AMLODIPINE BESYLATE

AMLODIPINE VALSARTAN

DILTIAZEM

FELODIPINE

ISRADIPINE

NICARDIPINE

NIFEDIPINE

NISOLDIPINE

VERPAMIL

& ALL OTHER GENERICS

 

ADALAT

CADUET

CALAN

CARDENE

CARDIZEM

CARTIA XT

EFIDITAB

EXFORGE

NORVASC

PROCARDIA XL

SULAR

TIAZAC ER

VERELAN

CONTRACEPTIVES

All Generic Contraceptives

All Brand Contraceptives

DIABETES

ACARBOSE

GLIMEPIRIDE

GLIPIZIDE

GLYBURIDE

JANUMET

JANUVIA

METFORMIN

PIOGLITAZONE

REPAGLINIDE

& ALL OTHER GENERICS

INVOKANA

JARDIANCE

JENTADUETO

KAZANO

QTERN

SEGLUROMET

STEGLATRO

STEGLUJAN

TRADJENTA

NARCOTIC ANALGESICS

 

NOTE:  BENEFITS WILL BE PROVIDED ONLY FOR NARCOTIC ANALGESICS PRESCRIBED AT THE MANUFACTURERS RECOMMENDED SCRIPT LEVEL.

 

 

 

 

 

 

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

OSTEOPOROSIS

ALENDRONATE

CALCITONIN-SALMON

IBANDRONATE

RALOXIFENE

RISEDRONATE

& ALL OTHER GENERICS

 

ACTONEL

ATELVIA

BINOSTO

BONIVA

EVENITY

EVISTA

FOSAMAX

MIACALCIN

PROLIA

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

URINARY AGENTS

TOVIAZ

FLAVOXATE

OXYBUTYNIN

TOLTERODINE

TROSPIUM

& ALL OTHER GENERICS

ENABLEX

GELNIQUE

MYRBETRIQ

OXYTROL

VESICARE