Transcription
Step Therapy MedicationsStep therapy is a limitation that requires you to try preferred medications before the plan will pay foranother medication for the same medical condition that the doctor may have originally prescribed. Anautomated, electronic review of your medication history is performed to determine whether othermedications have been tried first for your condition. This ensures clinically sound and cost-effectivetreatment options are tried. If a prescribed medication does not meet the step therapy criteria, it maynot be covered. You should consult with your doctor about alternative therapy. If a medication does notmeet the step therapy criteria for automatic approval, it will reject at the pharmacy; your provider mayrequest prior authorization.Questions?Log in to MyBlueSM to find participating retail pharmacies, review your specific benefit information, andcompare medication pricing and options. If you have questions, please call us.Member ServicesPhone NumberStandard Hours of OperationPharmacy Benefits1 (866) 325-179424/7/365BCBSAZCall the number on your ID card8:30 a.m. to 4:30 p.m.Monday - Friday
Step Therapy Drug ListTable of ants*.4*Analgesics - Opioid*. 4*Antiasthmatic And Bronchodilator Agents*.4*Anticonvulsants*. 6*Antidepressants*. 8*Antidiabetics*. 8*Antidotes And Specific Antagonists*. 13*Antiemetics*. idemics* . 14*Antimalarials*. 14*Antipsychotics/Antimanic Agents*. 14*Antivirals*. 14*Beta Blockers*. 15*Calcium Channel Blockers*. 15*Cardiovascular Agents - Misc.*. 15*Contraceptives*. 15*Corticosteroids*. 15*Cough/Cold/Allergy* . 16*Dermatologicals*. 16*Diagnostic Products* . 18*Digestive Aids*.30*Gastrointestinal Agents - Misc.*.30*Gout Agents*. 30*Hematopoietic Agents* . 31*Hypnotics/Sedatives/Sleep Disorder Agents*.31*Medical Devices And Supplies*.31*Migraine Products*. 32*Musculoskeletal Therapy Agents*. 32*Ophthalmic Agents*. 33*Psychotherapeutic And Neurological Agents - Misc.*. 33*Ulcer Drugs/Antispasmodics/Anticholinergics*. 332
3
Step 2 ProductStep 1 nts**Adhd Agent - Selective Norepinephrine Reuptake Inhibitor***QELBREEQL (1 capsule per day); Step TherapyRequired (EST as follows:ST throughatomoxetine (generic for Strattera) for atleast 3 months in the last 12 months.)*Amphetamine Mixtures***MYDAYISQL (1 capsule per day); Step TherapyRequired (Trial of the following for 3months in last 12 months: ADDERALL XRor amphetamine/dextroamphetamine ER);AL (Min 6 Years)*Amphetamines***VYVANSE ORAL CAPSULEQL (1 capsule per day); Step TherapyRequired (Trial of brand OR genericAdderall XR for 1 fill in the last 3 MO.); AL(Min 6 Years)VYVANSE ORAL TABLET CHEWABLEQL (1 tablet per day); Step TherapyRequired (Trial of brand OR genericAdderall XR for 1 fill in the last 3 MO.); AL(Min 6 Years)*Analgesics - Opioid**Opioid Agonists***tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200mg, 300 mgQL (1 tablet per day); Step TherapyRequired (Trial of Non ER Tramadol tabletsin last 3 months); AL (Min 16 Years)*Antiasthmatic And Bronchodilator Agents**5-Lipoxygenase Inhibitors***zileuton erQL (2 tablets per day); Step TherapyRequired (Trial of both of the following forat least 3 months each in last 12 months:montelukast, zafirlukast); AL (Min 12Years)ZYFLOQL (4 tablets per day); Step TherapyRequired (Trial of both of the following forat least 3 months each in last 12 months:montelukast, zafirlukast); AL (Min 12Years)*Adrenergic Combinations***AIRDUO DIGIHALERLast revision date:08/25/2022 To search for a drug use control f4QL (1 inhaler per month); Step TherapyRequired (Trial of two of the following for 3months each in the last 12 months:ADVAIR (DISKUS or HFA), BREOELLIPTA, fluticasonepropionate/salmeterol, SYMBICORT); AL(Min 12 Years)
Step 2 ProductStep 1 ProductAIRDUO RESPICLICK 113/14QL (1 inhaler per month); Step TherapyRequired (Trial of two the following for 3months in the last 12 months: ADVAIR(DISKUS or HFA), BREO ELLIPTA,fluticasone propionate/salmeterol,SYMBICORT); AL (Min 12 Years)AIRDUO RESPICLICK 232/14QL (1 inhaler per month); Step TherapyRequired (Trial of two the following for 3months in the last 12 months: ADVAIR(DISKUS or HFA), BREO ELLIPTA,fluticasone propionate/salmeterol,SYMBICORT); AL (Min 12 Years)AIRDUO RESPICLICK 55/14QL (1 inhaler per month); Step TherapyRequired (Trial of two the following for 3months in the last 12 months: ADVAIR(DISKUS or HFA), BREO ELLIPTA,fluticasone propionate/salmeterol,SYMBICORT); AL (Min 12 Years)BEVESPI AEROSPHEREQL (1x 5.9gm or 1x 10.7gm inhaler permonth); Step Therapy Required (Trial ofboth of the following in the last 12 months:ANORO ELLIPTA, STIOLTO RESPIMAT);AL (Min 15 Years)BREZTRI AEROSPHEREQL (Max one 10.7gm inhaler per month);Step Therapy Required (Trial of two of thefollowing for 3 months each in the last 12months: Bevespi, Duaklir Pressair, LonhalaMagnair); AL (Min 18 Years)budesonide-formoterol fumarate inhalation aerosol 80-4.5 mcg/actStep Therapy Required (TRIAL OF 2 OFTHE FOLOWING FOR 3 MO IN LAST 12MO: Advair diskus or HFA, Breo Ellipta,Wixela, fluticasone propionate/salmaterolOR brand Symbicort.)DUAKLIR PRESSAIRQL (1 inhaler per month); Step TherapyRequired (Trial of both of the following inthe last 6 months: ANORO ELLIPTA,SYMBICORT); AL (Min 18 Years)DULERAQL (1x 8.8gm or 1x 13gm inhaler permonth); Step Therapy Required (Trial oftwo the following for 3 months in the last 12months: ADVAIR (DISKUS or HFA), BREOELLIPTA, fluticasonepropionate/salmeterol, SYMBICORT)*Beta Adrenergics***levalbuterol tartrateQL (1gm per day); Step Therapy Required(Trial of the following in the last 1 month:Albuterol HFA)Last revision date:08/25/2022 To search for a drug use control f5
Step 2 ProductStep 1 ProductSTRIVERDI RESPIMATQL (4 inhalers per month); Step TherapyRequired (Trial of three of the following for3 months each In the last 12 months:ANORO ELLIPTA, ARCAPTA NEOHALER,SEREVENT DISKUS, simultaneous use ofSPIRIVA with SEREVENT DISKUS,simultaneous use of SPIRIVA withARCAPTA NEOHALER); AL (Min 18Years)XOPENEX HFAQL (1gm per day); Step Therapy Required(Trial of the following in the last 1 month:Albuterol HFA)*Bronchodilators - Anticholinergics***LONHALA MAGNAIR REFILL KITQL (2ml per day); DS (30); Step TherapyRequired (Trial of two of the following for 3months each in the last 12 months:INCRUSE ELLIPTA, SEEBRI NEOHALER,SPIRIVA (HANDIHALER or RESPIMAT),TUDORZA PRESSAIR); AL (Min 18 Years)LONHALA MAGNAIR STARTER KITQL (2ml per day); DS (30); Step TherapyRequired (Trial of two of the following for 3months each in the last 12 months:INCRUSE ELLIPTA, SEEBRI NEOHALER,SPIRIVA (HANDIHALER or RESPIMAT),TUDORZA PRESSAIR); AL (Min 18 Years)*Steroid Inhalants***ARMONAIR DIGIHALERQL (1 inhaler per month); Step TherapyRequired (Trial of the following in the last 3months: Flovent); AL (Min 12 Years)*Anticonvulsants**Anticonvulsants - Benzodiazepines***SYMPAZANQL (2 films per day); Step TherapyRequired (Trial of the following in the last 3months: ONFI)*Anticonvulsants - Misc.***APTIOM ORAL TABLET 200 MG, 400 MGQL (1 tablet per day); Step TherapyRequired (Trial of three of the following inthe last 12 months: gabapentin,lamotrigine, levetiracetam, oxcarbazepine,pregabalin, topiramate, zonisamide)APTIOM ORAL TABLET 600 MG, 800 MGQL (2 tablets per day); Step TherapyRequired (Trial of three of the following inthe last 12 months: gabapentin,lamotrigine, levetiracetam, oxcarbazepine,pregabalin, topiramate, zonisamide)BRIVIACT ORAL SOLUTIONQL (20ml per day); Step Therapy Required(Trial of the following for 2 months in thelast 12 months: levetiracetam (generic forKEPPRA)); AL (Min 4 Years)Last revision date:08/25/2022 To search for a drug use control f6
Step 2 ProductStep 1 ProductBRIVIACT ORAL TABLETQL (2 tablets per day); Step TherapyRequired (Trial of the following for 2months in the last 12 months: levetiracetam(generic for KEPPRA)); AL (Min 4 Years)ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MGQL (3 tablets per day); Step TherapyRequired (EST as follows: ST throughlevetircetam 24hr tablet (generic forKEPPRA ) for at least 3 months in the last12 months.); AL (Min 12 Years)ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 1500 MGQL (2 tablets per day); Step TherapyRequired (EST as follows: ST throughlevetircetam 24hr tablet (generic forKEPPRA ) for at least 3 months in the last12 months.); AL (Min 12 Years)QUDEXY XRQL (1 capsule per day); Step TherapyRequired (Trial of the following for 3months in the last 12 months: topiramate(generic for TOPAMAX)); AL (Min 3 Years)topiramate erQL (1 capsule per day); Step TherapyRequired (Trial of the following for 3months in the last 12 months: topiramate(generic for TOPAMAX)); AL (Min 3 Years)TROKENDI XRQL (1 capsule per day); Step TherapyRequired (Trial of both of the following for 3months each in the last 12 months:topiramate (generic for TOPAMAX) andtopiramate ER capsule (generic forQUDEXY XR)); AL (Min 6 Years)*Carbamates***XCOPRIQL (1 tablet per day); Step TherapyRequired (Trial of at least 3 of the followingin the last 12 months: carbamazepine,lacosamide (generic for VIMPAT),lamotrigine, levetiracetam IR,oxcarbazepine, topiramate, valproic acid &derivatives); AL (Min 18 Years)XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 100 &150 MGQL (2 tablets per day); Step TherapyRequired (Trial of at least 3 of the followingin the last 12 months: carbamazepine,lacosamide (generic for VIMPAT),lamotrigine, levetiracetam IR,oxcarbazepine, topiramate, valproic acid &derivatives); AL (Min 18 Years)XCOPRI (350 MG DAILY DOSE)QL (2 tablets per day); Step TherapyRequired (Trial of at least 3 of the followingin the last 12 months: carbamazepine,lacosamide (generic for VIMPAT),lamotrigine, levetiracetam IR,oxcarbazepine, topiramate, valproic acid &derivatives); AL (Min 18 Years)Last revision date:08/25/2022 To search for a drug use control f7
Step 2 ProductStep 1 Product*Antidepressants**Serotonin Modulators***TRINTELLIX ORAL TABLET 10 MGQL (2 tablets per day); Step TherapyRequired ( Trial of one drug from selectiveserotonin reuptake inhibitors for 60 days inthe last 12 months AND a trial of one drugfrom serotonin norepinephrine reuptakeinhibitors for 60 days in the last 12 months.); AL (Min 18 Years)TRINTELLIX ORAL TABLET 20 MG, 5 MGQL (1 tablet per day); Step TherapyRequired ( Trial of one drug from selectiveserotonin reuptake inhibitors for 60 days inthe last 12 months AND a trial of one drugfrom serotonin norepinephrine reuptakeinhibitors for 60 days in the last 12 months.); AL (Min 18 Years)*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***DRIZALMA SPRINKLEQL (1 capsule per day); Step TherapyRequired (Trial of the following for 3 monthin the last 6 months: CYMBALTA,duloxetine); AL (Min 7 Years)FETZIMAQL (1 capsule per day); Step TherapyRequired ( Trial of one drug from selectiveserotonin reuptake inhibitors for 60 days inthe last 12 months AND a trial of one drugfrom serotonin norepinephrine reuptakeinhibitors for 60 days in the last 12 months.)FETZIMA TITRATIONQL (1 capsule per day); Step TherapyRequired ( Trial of one drug from selectiveserotonin reuptake inhibitors for 60 days inthe last 12 months AND a trial of one drugfrom serotonin norepinephrine reuptakeinhibitors for 60 days in the last 12 months.)*Antidiabetics**Biguanides***metformin hcl er (osm) oral tablet extended release 24 hour 1000 mgQL (2 tablets per day); Step TherapyRequired (Trial of the following for 3months in the last 12 months: genericGLUCOPHAGE XR)metformin hcl er (osm) oral tablet extended release 24 hour 500 mgQL (4 tablets per day); Step TherapyRequired (Trial of the following for 3months in the last 12 months: genericGLUCOPHAGE XR)*Diabetic Other***ZEGALOGUELast revision date:08/25/2022 To search for a drug use control f8QL (0.6ml/day with fill limit of 2 fills/month);DS (2); Step Therapy Required (EST: Stepthrough generic Glucagon (NDC00548585000) for at least 1 month in thelast 12 months); AL (Min 6 Years)
Step 2 ProductStep 1 Product*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***alogliptin benzoateQL (1 tablet per day); Step TherapyRequired (Trial of 2 the following for 3months in the last 12 months: Janumet/XRor Januvia AND Jentadueto/XR orTradjenta.); AL (Min 18 Years)NESINAQL (1 tablet per day); Step TherapyRequired (Trial of 2 the following for 3months in the last 12 months: Janumet/XRor Januvia AND Jentadueto/XR orTradjenta.); AL (Min 18 Years)ONGLYZAQL (1 tablet per day); Step TherapyRequired (Jamumet/XR or Janvuvia ANDJentadueto/XR or Tradjenta for 3MO); AL(Min 16 Years)*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations***alogliptin-metformin hclStep Therapy Required (Trial of 2 thefollowing for 3 months in the last 12months: Janumet/XR or Januvia ANDJentadueto/XR or Tradjenta.)KAZANOStep Therapy Required (Trial of 2 thefollowing for 3 months in the last 12months: Janumet/XR or Januvia ANDJentadueto/XR or Tradjenta.)KOMBIGLYZE XRStep Therapy Required (Jamumet/XR orJanvuvia AND Jentadueto/XR or Tradjentafor 3MO)*Dpp-4 Inhibitor-Thiazolidinedione Combinations***alogliptin-pioglitazone oral tablet 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30mg, 25-45 mgStep Therapy Required (Trial of 2 thefollowing for 3 months in the last 12months: Janumet/XR or Januvia ANDJentadueto/XR or Tradjenta)OSENIStep Therapy Required (Trial of 2 thefollowing for 3 months in the last 12months: Janumet/XR or Januvia ANDJentadueto/XR or Tradjenta)*Human Insulin***ADMELOG INJECTIONQL (60ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)ADMELOG SOLOSTARQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)APIDRAQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTORQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)BASAGLAR KWIKPENQL (2ml per day); Step Therapy Required(Trial history of LANTUS)Last revision date:08/25/2022 To search for a drug use control f9
Step 2 ProductStep 1 ProductFIASP FLEXTOUCHQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)FIASP INJECTIONQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)FIASP PENFILLQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)insulin asp prot & asp flexpenQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG MIX 75/25)insulin aspart flexpenQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)insulin aspart injectionQL (2ML per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)insulin aspart penfillQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)insulin aspart prot & aspartQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG MIX 75/25)insulin glargineQL (2ml per day); Step Therapy Required(Trial history of LANTUS)insulin glargine solostarQL (2ml per day); Step Therapy Required(Trial history of LANTUS)insulin glargine-yfgnQL (2ml per day); Step Therapy Required(Trial history of LANTUS)insulin lispro (1 unit dial)QL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)insulin lispro injectionQL (60ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)insulin lispro junior kwikpenQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)insulin lispro prot & lisproQL (2 ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)LEVEMIRQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:LANTUS)LEVEMIR FLEXTOUCHQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:LANTUS)NOVOLIN 70/30QL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN 70/30)Last revision date:08/25/2022 To search for a drug use control f10
Step 2 ProductStep 1 ProductNOVOLIN 70/30 FLEXPENQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN 70/30)NOVOLIN 70/30 FLEXPEN RELIONQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN 70/30)NOVOLIN 70/30 RELIONQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN 70/30)NOVOLIN NQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN N)NOVOLIN N FLEXPENQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN N)NOVOLIN N FLEXPEN RELIONQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN N)NOVOLIN N RELIONQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN N)NOVOLIN RQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN R)NOVOLIN R FLEXPENQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN R)NOVOLIN R FLEXPEN RELIONQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN R)NOVOLIN R RELIONQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMULIN R)NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTORQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)NOVOLOG INJECTIONQL (2ML per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)NOVOLOG MIX 70/30QL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG MIX 75/25)NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PENINJECTORQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG MIX 75/25)NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGEQL (2ml per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)NOVOLOG RELION INJECTIONQL (2ML per day); Step Therapy Required(Trial of the following in the last 12 months:HUMALOG)Last revision date:08/25/2022 To search for a drug use control f11
Step 2 ProductStep 1 ProductSEMGLEE (YFGN) SUBCUTANEOUS SOLUTIONQL (2ml per day); Step Therapy Required(Trial history of LANTUS)SEMGLEE (YFGN) SUBCUTANEOUS SOLUTION PEN-INJECTORQL (2 ml per day); Step Therapy Required(Trial history of LANTUS)TRESIBAQL (2 ml per day); Step Therapy Required(Trial of the following in the last 12 months:LANTUS); AL (Min 1 Years)TRESIBA FLEXTOUCHQL (2 ml per day); Step Therapy Required(Trial of the following in the last 12 months:LANTUS); AL (Min 1 Years)*Incretin Mimetic Agents (Glp-1 Receptor Agonists)***ADLYXINQL (2 pens (6ml) per month); Step TherapyRequired (Trial of either Byetta orBydureon/Bydureon Bisce AND one of 4following drugs-Victoza, Rybelsus,Ozempic or Trulicity.); AL (Min 18 Years)ADLYXIN STARTER PACKQL (2 pens per lifetime); Step TherapyRequired (Trial of either Byetta orBydureon/Bydureon Bisce AND one of 4following drugs-Victoza, Rybelsus,Ozempic or Trulicity.); AL (Min 18 Years)*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***QTERNQL (1 tablet per day); Step TherapyRequired (Trial of one drug in eachcategory for at least 3 months: FARXIGA orXIGDUO XR and GLYXAMBI,JARDIANCE, SYNJARDY, SYNJARDYXR, or TRIJARDY); AL (Min 18 Years)STEGLUJANQL (1 tablet per day); Step TherapyRequired (Trial of one drug in eachcategory for at least 3 months: FARXIGA orXIGDUO XR and GLYXAMBI,JARDIANCE, SYNJARDY, SYNJARDYXR, or TRIJARDY); AL (Min 18 Years)*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors***INVOKANAQL (1 tablet per day); Step TherapyRequired (EST: DSE requiring at leastthree (3) month trial/failure of one (1) ofFarxiga or Xigduo XR AND one (1) ofGlyxambi, Jardiance, Synjardy/XR, orTrijardy. ); AL (Min 18 Years)STEGLATROQL (1ml per day); Step Therapy Required(Trial of one drug in each category for atleast 3 months: FARXIGA or XIGDUO XRand GLYXAMBI, JARDIANCE,SYNJARDY, SYNJARDY XR, orTRIJARDY)Last revision date:08/25/2022 To search for a drug use control f12
Step 2 ProductStep 1 Product*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***INVOKAMETQL (2 tablets per day); Step TherapyRequired (Trial of one drug in eachcategory for at least 3 months: FARXIGA orXIGDUO XR and GLYXAMBI,JARDIANCE, SYNJARDY, SYNJARDYXR, or TRIJARDY); AL (Min 18 Years)INVOKAMET XRQL (2 tablets per day); Step TherapyRequired (Trial of one drug in eachcategory for at least 3 months: FARXIGA orXIGDUO XR and GLYXAMBI,JARDIANCE, SYNJARDY, SYNJARDYXR, or TRIJARDY); AL (Min 18 Years)SEGLUROMETQL (2 tablets per day); Step TherapyRequired (Trial of one drug in eachcategory for at least 3 months: FARXIGA orXIGDUO XR and GLYXAMBI,JARDIANCE, SYNJARDY, SYNJARDYXR, or TRIJARDY); AL (Min 18 Years)*Antidotes And Specific Antagonists**Opioid Antagonists***ZIMHIQL (.034ml per day); DS (1ml per 30 days);Step Therapy Required (Trial of genericnaloxone prefilled syringe in last 3 months);AL (Min 12 Years)*Antiemetics**Antiemetic Combinations***AKYNZEO ORALQL (One capsule); Step Therapy Required(Trial of the following in the last 3 months:simultaneous use of ondansetron withaprepitant); AL (Min 18 Years)*Antifungals**Antifungal - Glucan Synthesis Inhibitors (Triterpenoids)***BREXAFEMMEQL (4 tablets per day, 1 fill per month); DS(30); Step Therapy Required (EST asfollows:ST through Fluconazole for 1 fill inthe last 3 months.)*Triazoles***tolsuraQL (4 capsules per day); Step TherapyRequired (Trial of the following in the last 6months: itraconazole 100mg capsule); AL(Min 18 Years)*Antihistamines**Antihistamines - Ethanolamines***KARBINAL ER ORAL SUSPENSION EXTENDED RELEASEQL (4ml per day); DS (30); Step TherapyRequired (Trial through the following for atleast one month in the last 60 days:carbinoxamine 4 mg tablet); AL (Min 2Years)Last revision date:08/25/2022 To search for a drug use control f13
Step 2 ProductStep 1 Product*Antihyperlipidemics**Acl Inhib-Intestinal Cholesterol Absorption Inhib Comb***NEXLIZETQL (1 tablet per day); Step TherapyRequired (Trial of the following for at least2 months each in last 12 months: twostatins plus ezetimbe (generic for ZETIA));AL (Min 18 Years)*Adenosine Triphosphate-Citrate Lyase (Acl) Inhibitors***NEXLETOLQL (1 tablet per day); Step TherapyRequired (Trial of the following for at least2 months each in last 12 months: twostatins plus ezetimibe (generic for ZETIA));AL (Min 18 Years)*Hmg Coa Reductase Inhibitors***LIVALOQL (1 tablet per day); Step TherapyRequired (Trial of two of the following in thelast 12 months: atorvastatin, simvastatin,rosuvastatin); AL (Min 8 Years)ZYPITAMAG ORAL TABLET 2 MG, 4 MGQL (1 tablet per day); Step TherapyRequired (Trial of two of the following in thelast 12 months: atorvastatin, simvastatin,rosuvastatin); AL (Min 8 Years)*Antimalarials**Antimalarials***chloroquine phosphate oralQL (2 tablets per day); DS (30)*Antipsychotics/Antimanic Agents**Antipsychotics - Misc.***VRAYLAR ORAL CAPSULEQL (1 capsule per day); Step TherapyRequired (Trial of at least 2 of the followingin the last 12 months: aripiprazole,quetiapine, risperidone, Saphris,ziprasidone.); AL (Min 18 Years)VRAYLAR ORAL CAPSULE THERAPY PACKQL (1 box per 7 days); Step TherapyRequired (Trial of at least 2 of the followingin the last 12 months: aripiprazole,quetiapine, risperidone, Saphris,ziprasidone.); AL (Min 18 Years)*Antivirals**Antiretroviral Combinations***DELSTRIGOQL (1 tablet per day); Step TherapyRequired (Reject if any history within last180 days of antiretroviral therapy); AL (Min12 Years)DESCOVYQL (1 tablet per day); Step TherapyRequired (Trial through the following for atleast two months in the last 90 days:generic Truvada (emtricitabine-tenofovirdisoproxil fumarate))Last revision date:08/25/2022 To search for a drug use control f14
Step 2 ProductStep 1 Product*Antiretrovirals - Rti-Non-Nucleoside Analogues***PIFELTROQL (1 tablet per day); Step TherapyRequired (Reject if any history within last180 days of antiretroviral therapy); AL (Min12 Years)*Beta Blockers**Beta Blockers Cardio-Selective***KAPSPARGO SPRINKLEQL (1 capsule per day); Step TherapyRequired (Trial of the following for at least3 months in the last 12 months: MetoprololSuccinate Er Oral Tablet ExtendedRelease 24 Hour or Toprol Xl Oral TabletExtended Release 24 Hour); AL (Min 6Years)*Calcium Channel Blockers**Calcium Channel Blockers***CONJUPRIQL (1 tablet per day); Step TherapyRequired (Trial of the following in the last 3months: amlodipine)levamlodipine maleateQL (1 tablet per day); Step TherapyRequired (Trial of the following in the last 3months: amlodipine)*Cardiovascular Agents - Misc.**Selective Cgmp Phosphodiesterase Type 5 Inhibitors***CIALIS ORAL TABLET 2.5 MG, 5 MGQL (1 tablet per day); Step TherapyRequired (ST: thru 3 meds x
budesonide-formoterol fumarate inhalation aerosol 80-4.5 mcg/act: Step Therapy Required (TRIAL OF 2 OF THE FOLOWING FOR 3 MO IN LAST 12 MO: Advair diskus or HFA, Breo Ellipta, . DULERA: QL (1x 8.8gm or 1x 13gm inhaler per month); Step Therapy Required (Trial of . APTIOM ORAL TABLET 200 MG, 400 MG. QL (1 tablet per day); Step Therapy
