Step Therapy - Woodgrain

Step Therapy

Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment you need, usually at a lower cost.

Here’s how it works:

With this program, you need to try a Step 1 medication first, before a Step 2 medication may be covered. When you bring a prescription to the pharmacy, our system will automatically screen the medication for step therapy requirements. If your prior pharmacy claims show you have tried a Step 1 medication in the recent past, the Step 2 medication may be processed. If not, the pharmacist will contact your doctor for further explanation.

There are some drugs that require three steps before a medication is covered. You must try Step 1 and Step 2 medications before receiving benefit coverage for a Step 3 medication.

We encourage you to discuss your treatment and medication options with your doctor. If you have questions about the Step Therapy program, call the toll-free member phone number on the back of your ID card.

You get a prescription

Try a Step 1 medication first

Before a Step 2 medication is covered

Step Therapy Program

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Step Therapy Medications (2 steps)*

If you have a prescription for any of the following Step 2 medications, you will be required to first try a Step 1 medication(s) for benefit coverage.

Condition Step 1 Step 2

Attention Deficit Disorder

Any two of the following: Dextroamphetamine, Amphetamine-dextroamphetamine, Methylphenidate, Dexmethylphenidate, Vyvanse

Procentra/Dextroamphetamine, Desoxyn/Methamphetamine, Adderall XR/Amphetamine ER, Kapvay/Clonidine ER, Focalin XR/Dexmethylphenidate ER, Metadate CD/Methylphenidate ER, Ritalin SR/Concerta/Methylphenidate ER, Methylin/Methylphenidate Solution, Ritalin LA/Methylphenidate ER, Daytrana, Methylin, Quillivant

Antibiotics Doxycycline Acticlate, Adoxa, Doryx

Bethkis Tobi Neb/Tobramycin Neb

Antipsychotics Any two of the following: Olanzapine, Risperidone, Risperidone ODT, Quetiapine, Seroquel XR, Saphris, Abilify

Geodon/Ziprasidone, Fanapt, Invega, Latuda

Asthma/COPD Any one of the following: Symbicort, Advair Diskus, Foradil, Serevent

Striverdi

Any one of the following: Advair Diskus, Advair HFA, Symbicort

Dulera

Any one of the following: Symbicort, Advair Diskus, Foradil, Serevent, Spiriva, Breo Ellipta

Anoro Ellipta

Montelukast and any one of the following: Methylprednisolone, Prednisolone, Prednisone, Ventolin HFA,Proair HFA, Foradil, Serevent, Qvar, Pulmicort, Flovent Diskus, Flovent HFA, Asmanex, Advair Diskus, Advair HFA, Symbicort

Zyflo, Zyflo CR

Bold type = Brand-name drug Plain type = Generic drug

3


Cardiovascular Carvedilol Coreg CR

Any one of the following: Benazepril, Candesartan, Captopril, Enalopril, Fosinopril, Irbesartan, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Telmisartan, Trandolapril, Benazepril-amlodipine, Trandolapril-verapamil, Benazepril-HCTZ, Captopril-HCTZ, Enalapril-HCTZ, Fosinopril-HCTZ, Irbesartan-HCTZ, Lisinopril-HCTZ, Moexipril-HCTZ, Quinapril-HCTZ, Losartan, Losartan-HCTZ

Edarbi, Edarbyclor, Azor, Exforge, Exforge HCT, Tribenzor

Amlodipine and any one of the following: Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Crestor, Vytorin

Caduet/Amlodipine-atorvastatin

Cholesterol Lowering Agents

Lipofen and any one of the following: Fenofibric Acid, Fenofibrate

Fibricor, Fenoglide, Triglide

Any one of the following: Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Crestor

Lipitor, Lescol/Fluvastatin, Lescol XL, Mevacor, Altroprev, Livalo, Pravachol, Zocor

Any one of the following: Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Crestor, Vytorin

Liptruzet

Depression Any two of the following: Citalopram, Escitalopram, Fluoxetine, Paroxetine, Paroxetine ER, Sertraline, Venlafaxine, Venlafaxine ER, Bupropion SR, Mirtazapine, Mirtazapine ODT, Duloxetine, Pristiq

Viibryd, Brintellix

Paroxetine or Sertraline Luvox CR/Fluvoxamine ER

Any two of the following: Venlafaxine, Venlafaxine ER, Duloxetine, Pristiq

Fetzima

Bupropion SR Aplenzin


Step Therapy Medications (2 steps)* Continued




Diabetes Humalog or Novolog Apidra

Metformin or Metformin ER Amaryl, Diabeta, Duetact, Glucotrol, Glucotrol XR, Glucovance, Glynase, Metaglip, Prandimet, Prandin, Precose, Starlix

Any one of the following: Metformin, Metformin ER

Actoplus Met XR, Actos

Any two of the following: Metformin, Metformin ER, Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta

Glyset

Any one of the following: Metformin, Metformin ER, Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta

Riomet

Ear Condition Ofloxacin Cetraxal/Ciprofloxacin

Gastrointestinal (Miscellaneous)

Creon and Zenpep Viokace, Pancreaze, Pertzye, Ultresa

Polyethylene Glycol or Lactulose Amitiza, Linzess

Gout Allopurinol Uloric

Insomnia Zolpidem or Zolpidem CR Intermezzo, Edluar, Zolpimist



5


Migraine Rizatriptan (tablet)/Rizatriptan RDT, Sumatriptan (tablet), Zolmitriptan (tablet)/Zolmitriptan ODT

Treximet

Skin Conditions (Miscellaneous)

Any one of the following topical corticosteroids: Alclometasone, Betamethasone Dipropionate (augmented), Betamethasone Dipropionate, Clobetasol, Desonide, Desoximetasone, Diflorasone, Fluocinolone, Fluocinonide, Fluticasone, Hydrocortisone, Mometasone, Triamcinolone, Pramosone

Elidel, Protopic

Narcotic Analgesics

Any one of the following: Morphine Sulfate CR, Morphine Sulfate SR, Oxycontin

Exalgo

Tramadol or Tramadol-acetaminophen

Tramadol ER

Nausea/Vomiting

Metoclopramide Metozolv ODT

Neurologic Any one of the following: Amitriptyline, Cyclobenzaprine, Duloxetine, Lyrica

Savella

Gabapentin Gralise

Non-Narcotic Analgesics

Any one of the following: Diclofenac, Etodolac, Fenoprofen, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac, Meloxicam, Nabumetone, Naproxen, Oxaprozin, Piroxicam, Sulindac, Tolmetin

Duexis

Oncology Fluorouracil or Imiquimod Picato

Opthalamic Agents

Any one of the following: Azelastine, Patanol, Pataday

Bepreve, Lastacaft

Osteoporosis Alendronate Atelvia






Overactive Bladder

Any two of the following: Oxybutynin, Vesicare, Oxytrol, Gelnique

Detrol/Tolterodine, Sanctura/Trospium, Sanctura XR/Trospium ER, Detrol LA/Tolterodine SR, Myrbetriq

Parkinson's Disease

Ropinorole or Pramipexole Requip XL/Ropinirole ER, Mirapex ER

Prostatic Hypertrophy

Any two of the following: Alfuzosin, Doxazosin, Terazosin, Tamsulosin, Rapaflo

Cardura XL

Severe Allergic Reaction

Epipen, Epipen Jr Epinephrine, Auvi-Q, Adrenaclick

Ulcer/Acid Reflux

Any two of the following: Omeprazole, Lansoprazole (capsule), Pantoprazole, Nexium, Dexilant

Esomeprazole Strontium, Lansoprazole Suspension, Prevacid, Prevacid ODT/Lanosprazole ODT, First-Omeprazole Suspension, Aciphex/Rabeprazole, Zegerid/ Omeprazole-sodium Bicarbonate, Prilosec, Protonix

Omeclamox or Pylera Prevpac/Lansoprazole-amoxicillin-clarithromycin, Helidac


Step Therapy Medications (3 steps)*

If you have a prescription for any of the following Step 3 medications, you must first try Step 1 and Step 2 medications for benefit coverage.

Condition Step 1 Step 2 Step 3

Asthma /COPD Any one of the following: Theophylline, Qvar, Pulmicort, Flovent Diskus, Flovent HFA, Asmanex, Tudorza, Atrovent HFA, Spiriva, Advair Diskus, Advair HFA, Symbicort, Theo-24

Foradil and Serevent

Arcapta



7


Cardiovascular Any one of the following: Benazepril, Candesartan, Captopril, Enalopril, Fosinopril, Irbesartan, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Telmisartan, Trandolapril, Benazepril-amlodipine, Trandolapril-verapamil, Benazepril-HCTZ, Captopril-HCTZ, Enalapril-HCTZ, Fosinopril-HCTZ, Irbesartan-HCTZ, Lisinopril-HCTZ, Moexipril-HCTZ, Quinapril-HCTZ, Losartan, Losartan-HCTZ

Any one of the following: Azor, Exforge, Exforge HCT

Twynsta/ Telmisartan-amlopidine

Any one of the following: Benazepril, Candesartan, Captopril, Enalopril, Fosinopril, Irbesartan, Irbesartan HCTZ, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril, Benazepril-amlodipine, Trandolapril-verapamil, Telmisartan, Benazepril-HCTZ, Captopril-HCTZ, Enalapril-HCTZ, Fosinopril-HCTZ, Lisinopril-HCTZ, Moexipril-HCTZ, Quinapril-HCTZ, Losartan, Losartan-HCTZ

Tekturna or Tekturna HCT

Tekamlo, Amturnide

Any two of the following: Benicar, Benicar HCT, Diovan, Micardis HCT

Atacand, Atacand HCT/Candesartan-HCTZ, Teveten/Eprosartan, Teveten HCT, Avapro, Avalide, Cozaar, Hyzaar, Diovan HCT, Micardis

Diabetes Any one of the following: Metformin, Metformin ER, Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta

Any one of the following: Tradjenta, Onglyza, Januvia, Jentadueto, Kombiglyze, Janumet

Nesina, Kazano, Oseni



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Diabetes Continued


Janumet Janumet XR

Any one of the following: Metformin, Metformin ER, Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin

Byetta, Victoza Bydureon, Tanzeum


Invokamet, Invokana

Fargixa, Jardiance



* Step therapy requirements are effective as of January 1, 2015. The list of step therapy medications is subject to change without notice. Step therapy requirements may vary by benefit plan. Additional clinical programs, including quantity limits and prior authorization, may exist for the above medications which may affect your prescription drug coverage.

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Step Therapy - Woodgrain