STEP THERAPY

Jul 25, 2019News

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

 

 

 

Our website is no longer supported by Internet Explorer due to Microsoft changes with the browser. If you continue to use Internet Explorer to access our website some of the features will not function properly. Click here to download a browser that is compatible with our website.
Your browser is out-of-date!

Update your browser to view this website correctly. Update my browser now

×