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.
CATEGORY |
STEP I |
STEP II |
ALZHEIMER’S DISEASE |
DONEPEZIL GALANTAMINE RIVASTIGMINE & ALL OTHER GNERICS |
ADLARITY ARICEPT EXELON LEQEMBI NAMENDA
|
ANGIOTENSIN RECEPTOR BLOCKERS (ANTIHYPERTENSIVES) |
CANDESARTAN EPROSARTAN IRBESARTAN LOSARTAN TELMISARTAN VALSARTAN & ALL OTHER GENERICS |
ATACAND AVAPRO BENICAR COZAAR DIOVAN EDARBI MICARDIS |
ANTIDEPRESSANTS |
BUPROPION HCL CITALOPRAM DESVENLAFAXINE DULOXETINE ESCITALOPRAM FLUOXETINE NEFAZODONE PAROXETINE SERTRALINE TRAZODONE VENLAFAXINE & ALL OTHER GENERICS |
APLENZIN AUVELITY CYMBALTA EFFEXOR FETZIMA FORFIVO XL LEXAPRO PRISTIQ PROZAC SPRAVATO TRINTELLIX VIIBRYD WELLBUTRIN ZOLOFT |
ANTI-GLAUCOMA EYE PREPARATIONS |
APRACLONIDINE HCL BETAXOLOL BRIMONIDINE CARTEOLOL DORZOLAMDE LATANOPROST LEVOBUNOLOL PILOCARPINE TIMOLOL TRAVOPROST & ALL OTHER GENERICS |
ALPHAGAN AZOPT BETIMOL BETOPTIC COMBIGAN COSOPT ISTALOL LUMIGAN PHOSPHOLINE RHOPRESSA ROCKLATAN SIMBRINZA TIMOPTIC TRAVATAN VYZULTA 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 METOPROLOL NADOLOL PINDOLOL PROPRANONOL SOTALOL TIMOLOL & ALL OTHER GENERICS |
BYSTOLIC KAPSPARGO |
CALCIUM CHANNEL BLOCKERS (ANTIHYPERTENSIVES) |
AMLODIPINE ATORVASTATIN AMLODIPINE BESYLATE AMLODIPINE VALSARTAN DILTIAZEM FELODIPINE ISRADIPINE NICARDIPINE NIFEDIPINE NISOLDIPINE VERPAMIL & ALL OTHER GENERICS |
CADUET CARDIZEM CARTIA XT CONJUPRI EXFORGE NORVASC PROCARDIA XL SULAR TIADYLT TIAZAC ER VERELAN |
CONTRACEPTIVES |
All Generic Contraceptives |
All Brand Contraceptives |
DIABETES |
ACARBOSE GLIMEPIRIDE GLIPIZIDE GLYBURIDE METFORMIN PIOGLITAZONE REPAGLINIDE & ALL OTHER GENERICS
|
INVOKANA INPEFA JANUMET JANUVIA 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 DEMEROL DSUVIA MITIGO NUCYNTA OXYCONTIN PERCOCET PROLATE TYLENOL WITH CODEINE XTAMPZA
|
OSTEOPOROSIS |
ALENDRONATE CALCITONIN-SALMON BANDRONATE RALOXIFENE RISEDRONATE & ALL OTHER GENERICS |
ACTONEL ATELVIA BINOSTO 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 & ALL OTHER GENERICS |
ACTEMRA AMJEVITA CIMZIA CYLTEZO ENBREL ENSPRYNG HADLIMA HULIO HUMIRA HYRIMOZ IDACIO ILUMYA INFLECTRA KEVZARA KINERET OLUMIANT ORENCIA RENFLEXIS RINVOQ SIMPONI SILIQ SKYRIZI STELARA TALTZ XELJANZ YUFLYMA YUSIMRY
|
URINARY AGENTS |
FLAVOXATE OXYBUTYNIN TOLTERODINE TROSPIUM & ALL OTHER GENERICS |
GELNIQUE MYRBETRIQ OXYTROL TOVIAZ 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.
CATEGORY |
STEPI |
STEP II |
|
ADD & ADHD |
ALL GENERICS |
ADDERALL ADZENYS AZSTARYS CONCERTA COTEMPLA XR DAYTRANA DESOXYN DEXEDRINE DYANAVEL EVEKEO FOCALIN JORNAY METHYLIN MYDAYIS PROCENTRA QELBREE QUILLIVANT RELEXXI RITALIN VYVANSE XELSTRY ZENZEDI |
|
ANTIMIGRAINE |
ALL GENERICS |
AIMOVIG AJOVY BRIVIACT ELYXYB EMGALITY ERGOMAR FROVA IMITREX MAXALT MIGERGOT MIGRANAL NURTEC ONZETRA QULIPTA RELPAX REYVOW TOSYMRA TREXIMET TRUDHESA UBRELVY VYEPTI ZAVZPRET ZEMBRACE SYMTOUCH ZOMIG SUMAVEL TREXIMET ZOMIG |
|
ANTICONVULSANTS |
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 DEPAKOTE DIACOMIT DILANTIN ELEPSIA EPIDIOLEX EPRONTIA FELBATOL FINTEPLA FYCOMPA KEPPRA KLONOPIN LAMICTAL 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 |
ACIPHEX DEXILANT ESOMEPRAZOLE KONVOMEP LANSOPRAZOLE NEXIUM OMEPRAZOLE OMEPRAZOLE-BICARB PANTOPRAZOLE PREVACID PRILOSEC PROTONIX ZEGERID |
|
ULCERATIVE COLITIS |
AZULFIDINE BALSALAZIDE MESALAMINE SULFASALAZINE & ALL OTHER GENERICS |
AMJEVITA APRISO COLAZAL DELZICOL DIPENTUM ENTYVIO HUMIRA LIALDA PENTASA SIMPONI STELARA |
|
revised 12.8.23