STEP THERAPY

Jan 9, 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

 

ARICEPT

EXELON

NAMENDA

RAZADYNE

ANGIOTENSIN RECEPTOR BLOCKERS (ANTIHYPERTENSIVES)

CANDESARTAN

EPROSARTAN

IRBESARTAN

LOSARTAN

TELMISARTAN

VALSARTAN

ATACAND

AVAPRO

BENICAR

COZAAR

DIOVAN

EDARBI

MICARDIS

TEVETEN

ANTI-DEPRESSANTS

BUPROPION HCL DESVENLAFAXINE

DULOXETINE

ESCITALOPRAM

FLUOXETINE

NEFAZODONE

SERTRALINE

TRAZODONE

VENLAFAXINE

APLENZIN

BRINTELLIX

CYMBALTA

EFFEXOR

FETZIMA

FORFIVO XL

KHEDEZLA

LEXAPRO

OLEPTRO

PRISTIQ

PROZAC

VllBRYD

WELLBUTRIN

ZOLOFT

ANTI-GLAUCOMA EYE PREPARATIONS

APRACLONIDINE HCL

BETAXOLOL

BRIMONIDINE

CARTEOLOL

DORZOLAMIDE

LATANOPROST

LEVOBUNOLOL

METIPRANOLOL

PILOCARPINE

TIMOLOL

TRAVOPROST

ALPHAGAN

AZOPT

BETIMOL

BETOPTIC

COMBIGAN

COSOPT

IOPIDINE

ISTALOL

LUMIGAN

PHOSPHOLINE

RESCULA

SIMBRINZA

TIMOPTIC

TRAVATAN

TRUSOPT

XALATAN

ZIOPTAN

ANTIPSYCHOTICS

CLOZAPINE

OLANZAPINE

QUETIAPINE

RISPERIDONE

ZIPRASIDONE

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

BYSTOLIC

CALCIUM CHANNEL BLOCKERS (ANTIHYPERTENSIVES)

AMLODIPINE ATORVASTATIN AMLODIPINE BESYLATE

AMLODIPINE VALSARTAN DILTIAZEM

FELODIPINE

ISRADIPINE

NICARDIPINE

NIFEDIPINE

NISOLDIPINE

VERPAMIL

ADALAT

CADUET

CALAN

CARDENE

CARDIZEM

CARTIA XT

EFIDITAB

EXFORGE

NORVASC

PROCARDIA XL

SULAR

TIAZAC ER

VERELAN

CONTRACEPTIVES

All Generic Contraceptives

BEYAZ

CYCLESSA

DESOGEN

MODICON

NATAZIA

ORTHO MICRONOR

ORTHO TRl-CYCLEN

ORTHO-CEPT

ORTHO-CYCLEN

ORTHO-NOVUM

SAFYRAL

YASMIN

YAZ

DIABETES

ACARBOSE

GLIMEPIRIDE

GLIPIZIDE

GLYBURIDE

JANUMET

JANUVIA

METFORMIN

PIOGLITAZONE

REPAGLINIDE

INVOKANA

JARDIANCE

JENTADUETO

KAZANO

TRADJENTA

NARCOTIC ANALGESICS

 

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

 

 

 

 

 

NARCOTIC ANALGESICS CONTINUED….

ACETAM INOPHEN-CODEINE HYDROCODONE-ACETAMINOPHEN HYDROMORPHONE

MEPERIDINE

METHADONE

MORPHINE  SULFATE

OXYCODONE

OXYCODONE-ACETAMINOPHEN OXYCODONE-ASPIRIN OXYMORPHONE

TRAMADOL

DEMEROL

DOLOPHINE

LORTAB

NORCO

NUCYNTA

OPANA

OXYCONTIN

PERCOCET

PERCODAN

TYLENOL WITH CODEINE ULTRACET

ULTRAM

VICODIN

VICOPROFEN

 

OSTEOPOROSIS

ALENDRONATE

CALCITONIN-SALMON BANDRONATE

RALOXIFENE

RISEDRONATE

ACTONEL

ATELVIA

BINOSTO

BONIVA

EVISTA

FORTICAL

FOSAMAX

MIACALCIN

PROLIA

RHEUMATOID ARTHRITIS

XELJANZ

ACTEMRA

CIMZIA

ENBREL

HUMIRA

KINERET

ORENCIA

SIMPONI

STELARA

URINARY AGENTS

TOVIAZ

FLAVOXATE

OXYBUTYNIN

TOLTERODINE

TROSPIUM

ENABLEX

GELNIQUE

MYRBETRIQ

OXYTROL

VESICARE