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 GENERICS |
ADLARITY ARICEPT EXELON NAMENDA RAZADYNE |
|
ANGIOTENSIN RECEPTOR BLOCKERS (ANTIHYPERTENSIVES) |
CANDESARTAN EPROSARTAN IRBESARTAN LOSARTAN TELMISARTAN VALSARTAN & ALL GENERICS |
ATACAND AVAPRO BENICAR BYVALSON COZAAR DIOVAN EDARBI MICARDIS |
|
ANTI-DEPRESSANTS |
BUPROPION HCL CITALOPRAM DESVENLAFAXINE DULOXETINE ESCITALOPRAM FLUOXETINE NEFAZODONE SERTRALINE TRAZODONE VENLAFAXINE & ALL GENERICS |
AUVELITY APLENZIN CYMBALTA DRIZALMA EFFEXOR FETZIMA FORFIVO XL KHEDEZLA LEXAPRO PEXEVA PRISTIQ PROZAC SPRAVATO TRINTELLIX VllBRYD WELLBUTRIN ZOLOFT |
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ANTI-GLAUCOMA EYE PREPARATIONS
ANTI-GLAUCOMA EYE PREPARATIONS (continued) |
APRACLONIDINE HCL BETAXOLOL BRIMONIDINE CARTEOLOL DORZOLAMIDE LATANOPROST LEVOBUNOLOL METIPRANOLOL PILOCARPINE TIMOLOL & ALL GENERICS |
ALPHAGAN AZOPT BETIMOL BETOPTIC COMBIGAN COSOPT IOPIDINE ISTALOL LUMIGAN PHOSPHOLINE ROCKLATAN RHOPRESSA SIMBRINZA TIMOPTIC TRAVATAN TRUSOPT VYZULTA XALATAN XELPROS ZIOPTAN |
|
ANTIPSYCHOTICS |
CLOZAPINE OLANZAPINE QUETIAPINE RISPERIDONE ZIPRASIDONE & ALL 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 GENERICS |
BYSTOLIC KAPSPARGO |
|
CALCIUM CHANNEL BLOCKERS (ANTIHYPERTENSIVES) |
AMLODIPINE ATORVASTATIN AMLODIPINE BESYLATE AMLODIPINE VALSARTAN DILTIAZEM FELODIPINE ISRADIPINE NICARDIPINE NIFEDIPINE NISOLDIPINE VERPAMIL & ALL GENERICS |
CADUET CALAN CARDENE CARDIZEM CARTIA XT CONJUPRI EFIDITAB EXFORGE NORVASC PROCARDIA XL SULAR TIADYLT TIAZAC ER VERELAN |
|
CONTRACEPTIVES |
All Generic Contraceptives |
All Brand Contraceptives |
|
DIABETES |
ACARBOSE GLIMEPIRIDE GLIPIZIDE GLYBURIDE JANUMET JANUVIA METFORMIN PIOGLITAZONE REPAGLINIDE & ALL GENERICS |
INVOKANA INPEFA 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.
NARCOTIC ANALGESICS (continued) |
ACETAMINOPHEN-CODEINE HYDROCODONE-ACETAMINOPHEN HYDROMORPHONE MEPERIDINE METHADONE MORPHINE SULFATE OXYCODONE OXYCODONE-ACETAMINOPHEN OXYCODONE-ASPIRIN OXYMORPHONE TRAMADOL & ALL GENERICS |
APADAZ DEMEROL DSUVIA LAZANDA LORTAB MITIGO NUCYNTA OXYCONTIN PERCOCET PROLATE TYLENOL WITH CODEINE ULTRACET ULTRAM XTAMPZA |
|
OSTEOPOROSIS |
ALENDRONATE CALCITONIN-SALMON IBANDRONATE RALOXIFENE RISEDRONATE & ALL GENERICS |
ACTONEL ATELVIA BINOSTO BONIVA EVENITY EVISTA FOSAMAX MIACALCIN PROLIA |
|
RHEUMATOID ARTHRITIS |
HIGH DOSE IBUPROFEN AND NAPROXEN (PRESCRIPTION STRENGTH) CELECOXIB NABUMETONE PIROXICAM DIFLUNISAL INDOMETHACIN KETOPROFEN ETODOLAC PREDNISONE CYCLOPHOSPHAMIDE CYCLOSPORINE AZATHIOPRINE METHOTREXATE XELJANZ & ALL GENERICS
|
ACTEMRA AMJEVITA CIMZIA ENBREL ENSPRING HUMIRA ILUMYA INAVIX INFLECTRA KEVZARA KINERET OLUMIANT ORENCIA RENFLEXIS RINVOQ SIMPONI SILIQ SKYRIZI STELARA TALTZ |
|
URINARY AGENTS |
TOVIAZ FLAVOXATE OXYBUTYNIN TOLTERODINE TROSPIUM & ALL GENERICS |
GELNIQUE GEMTESA MYRBETRIQ OXYTROL VESICARE |
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 |
|
ADD & ADHD
|
ALL GENERICS
|
ADDERALL ADHANSIA XR ADZENYS CONCERTA COTEMPLA XR DAYTRANA DESOXYN DEXEDRINE DYANAVEL EVEKEO FOCALIN JORNAY METADATE METHYLIN MYDAYIS PROCENTRA QUILLIVANT RELEXXII RITALIN VYVANSE XELSTRY ZENZEDI |
|
ANTI-MIGRAINE
|
ALL GENERICS |
AIMOVIG AJOVY AMERGE BRIVIACT CAFERGOT D.H.E.45 EMGALITY ERGOMAR FROVA IMITREX MAXALT MIGERGOT MIGRANAL NURTEC ONZETRA RELPAX REYVOW SUMAVEL TOSYMRA TREXIMET UBELVY VYEPTI ZAVZPRET ZEMBRACE SYMTOUCH ZOMIG |
|
ANTI-CONVULSANTS
ANTI-CONVULSANTS (continued) |
CARBAMAZEPINE CLONAZEPAM DIVALPROEX ETHOSUXIMIDE FELBAMATE FOSPHENYTOIN GABAPENTIN LAMOTRIGINE LEVETIRACETAM OXCARBAZEPINE PHENYTOIN PRIMIDONE TIAGABINE TOPIRAMATE VALPROATE VALPROIC ACID ZONISAMIDE & ALL GENERICS |
APTIOM BANZEL CARBATROL CELONTIN CEREBYX DEPAKOTE DIACOMIT DILANTIN EPEPSIA EPIDIOLEX EPRONTA FELBATOL FINTEPLA FYCOMPA GABITRIL KEPPRA KLONOPIN LAMICTAL LIPRITIN MYSOLINE NAYZILAM NEURONTIN ONFI OXTELLAR PHENYTEK QUDEXY ROWEEPRA SYMPAZAN TEGRETOL TOPAMAX TRILEPTAL TROKENDI VALTOCO VIMPAT XCOPRI ZARONTIN ZONEGRAN |
|
PROTON PUMP INHIBITORS
|
OVER THE COUNTER (“OTC”): LANSOPRAZOLE DR OTC NEXIUM OTC OMEPRAZOLE OTC OMEPRAZOLE-BICARB OTC PREVACID OTC PRILOSEC OTC ZEGERID OTC & ALL GENERICS |
ACIPHEX DEXILANT ESOMEPRAZOLE KONVOMEP NEXIUM OMEPRAZOLE-BICARB PANTOPRAZOLE PREVACID PRILOSEC PROTONIX ZEGERID |
|
ULCERATIVE COLITIS |
AZULFIDINE BALSALAZIDE MESALAMINE SULFASALAZINE & ALL GENERICS |
AMJEVITA APRISO ASACOL COLAZAL DELZICOL DIPENTUM ENTYVIC HUMIRA LIALDA PENTASA SIMPONI STELARA |
Effective 7.1.2023
rev. 6.20.2023
