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 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

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.

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

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