Step Therapy Requirements, Effective June 1, 2017
ALOGLIPTIN STEP
Products Affected
Step 2:
 alogliptin 12.5 mg tablet
 alogliptin 12.5 mg-metformin 1,000 mg
tablet
 alogliptin 12.5 mg-metformin 500 mg
tablet
 alogliptin 12.5 mg-pioglitazone 15 mg
tablet
 alogliptin 12.5 mg-pioglitazone 30 mg
tablet
 alogliptin 12.5 mg-pioglitazone 45 mg
tablet
 alogliptin 25 mg tablet
 alogliptin 25 mg-pioglitazone 15 mg
tablet
 alogliptin 25 mg-pioglitazone 30 mg
tablet
 alogliptin 25 mg-pioglitazone 45 mg
tablet
 alogliptin 6.25 mg tablet
 Kazano 12.5 mg-1,000 mg tablet
 Kazano 12.5 mg-500 mg tablet
 Nesina 12.5 mg tablet
 Nesina 25 mg tablet
 Nesina 6.25 mg tablet
 Oseni 12.5 mg-15 mg tablet
 Oseni 12.5 mg-30 mg tablet
 Oseni 12.5 mg-45 mg tablet
 Oseni 25 mg-15 mg tablet
 Oseni 25 mg-30 mg tablet
 Oseni 25 mg-45 mg tablet
Details
Criteria
COVERAGE OF ALOGLIPTIN CONTAINING PRODUCTS
REQUIRES DOCUMENTATION OF SIGNIFICANT
INTOLERANCE OR THERAPEUTIC FAILURE OF EITHER A
SAXAGLIPTIN OR SITAGLIPTIN PRODUCT. IF THE REQUIRED
DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST
365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT
REQUIRED.
1
ANTIDEPRESSANT STEP
Products Affected
Step 2:
 Aplenzin 174 mg tablet,extended release
 Aplenzin 348 mg tablet,extended release
 Aplenzin 522 mg tablet,extended release
 desvenlafaxine ER 100 mg
tablet,extended release 24 hr
 desvenlafaxine ER 50 mg
tablet,extended release 24 hr
 Emsam 12 mg/24 hr transdermal 24 hour
patch
 Emsam 6 mg/24 hr transdermal 24 hour
patch
 Emsam 9 mg/24 hr transdermal 24 hour
patch
 Paxil 10 mg/5 mL oral suspension
 Pexeva 10 mg tablet
 Pexeva 20 mg tablet
 Pexeva 30 mg tablet
 Pexeva 40 mg tablet
 Pristiq 100 mg tablet,extended release
 Pristiq 25 mg tablet,extended release
 Pristiq 50 mg tablet,extended release
 Sarafem 10 mg tablet
 Sarafem 20 mg tablet
 Viibryd 10 mg (7)-20 mg (23) tablets in
a dose pack
 Viibryd 10 mg tablet
 Viibryd 20 mg tablet
 Viibryd 40 mg tablet
Details
Criteria
COVERAGE OF CERTAIN BRAND NAME ANTIDEPRESSANTS
AND DESVENLAFAXINE EXTENDED-RELEASE (ER) REQUIRES
DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR
THERAPEUTIC FAILURE OF AT LEAST TWO DIFFERENT
GENERIC ANTIDEPRESSANTS. IF THE REQUIRED DRUGS
APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365
DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT
REQUIRED.
2
Step Therapy Requirements, Effective June 1, 2017
ANTIEMETICS STEP
Products Affected
Step 2:
 Sancuso 3.1 mg/24 hour transdermal
patch
 Zuplenz 4 mg oral soluble film
 Zuplenz 8 mg oral soluble film
Details
Criteria
COVERAGE OF CERTAIN BRAND NAME ANTI-EMETIC
MEDICATIONS REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF
GENERIC ONDANSETRON AND GENERIC GRANISETRON. IF
THE REQUIRED DRUGS APPEAR IN THE PRESCRIPTION
PROFILE IN THE LAST 365 DAYS, THEN ADDITIONAL
DOCUMENTATION IS NOT REQUIRED.
3
ARB STEP
Products Affected
Step 2:
 Edarbi 40 mg tablet
 Edarbi 80 mg tablet
 Edarbyclor 40 mg-12.5 mg tablet
 Edarbyclor 40 mg-25 mg tablet
Details
Criteria
COVERAGE OF CERTAIN BRANDED ARBS AND ARB COMBOS
REQUIRES DOCUMENTATION OF SIGNIFICANT
INTOLERANCE OR THERAPEUTIC FAILURE OF TWO GENERIC
ARB OR ARB COMBINATIONS. IF THE REQUIRED DRUGS
APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST 365
DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT
REQUIRED.
4
Step Therapy Requirements, Effective June 1, 2017
BRAND HMG STEP
Products Affected
Step 2:




 Vytorin 10 mg-20 mg tablet
 Vytorin 10 mg-40 mg tablet
 Vytorin 10 mg-80 mg tablet
Altoprev 20 mg tablet,extended release
Altoprev 40 mg tablet,extended release
Altoprev 60 mg tablet,extended release
Vytorin 10 mg-10 mg tablet
Details
Criteria
COVERAGE OF BRAND NAME STATINS (HMGS) REQUIRES
DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR
THERAPEUTIC FAILURE OF TWO GENERIC STATIN
MEDICATIONS. IF THE REQUIRED DRUGS APPEAR IN THE
PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED.
5
BRAND TOPICAL ANTIFUNGALS STEP
Products Affected
Step 2:








Ertaczo 2 % topical cream
Exelderm 1 % topical cream
Exelderm 1 % topical solution
Luzu 1 % topical cream
Mentax 1 % topical cream
Naftin 1 % topical gel
Naftin 2 % topical gel
Oxistat 1 % lotion
Details
Criteria
COVERAGE OF BRAND NAME TOPICAL ANTIFUNGALS
REQUIRES DOCUMENTATION OF SIGNIFICANT
INTOLERANCE OR THERAPEUTIC FAILURE TO TWO GENERIC
TOPICAL ANTIFUNGAL MEDICATIONS. IF THE REQUIRED
DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST
365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT
REQUIRED.
6
Step Therapy Requirements, Effective June 1, 2017
BRAND TOPICAL STEROIDS STEP
Products Affected
Step 2:








 Locoid 0.1 % lotion
 Pandel 0.1 % topical cream
 Taclonex 0.005 %-0.064 % topical
ointment
 Taclonex 0.005 %-0.064 % topical
suspension
 Topicort 0.25 % topical spray
Ala-Scalp 2 % lotion
Capex 0.01 % shampoo
Cordran Tape Large Roll 4 mcg/cm2
Desonate 0.05 % topical gel
Enstilar 0.005 %-0.064 % topical foam
Halog 0.1 % topical cream
Halog 0.1 % topical ointment
Kenalog 0.147 mg/gram topical aerosol
Details
Criteria
COVERAGE OF BRAND NAME TOPICAL STEROIDS REQUIRES
DOCUMENTATION OF A TRIAL OF AT LEAST TWO
DIFFERENT GENERIC TOPICAL STEROID MEDICATIONS. IF
THERE LACKS TWO DIFFERENT GENERIC TOPICAL STEROID
MEDICATIONS INDICATED TO TREAT A SPECIFIC DIAGNOSIS,
THEN A TRIAL OF ONE GENERIC TOPICAL STEROID
MEDICATION SATISFIES THIS REQUIREMENT. IF THE
REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE
IN THE LAST 365 DAYS, THEN ADDITIONAL
DOCUMENTATION IS NOT REQUIRED.
7
CAMBIA POWDER STEP
Products Affected
Step 2:
 Cambia 50 mg oral powder packet
Details
Criteria
COVERAGE OF CAMBIA POWDER PACKETS REQUIRES
DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR
THERAPEUTIC FAILURE OF ONE NON-STEROIDAL ANTIINFLAMMATORY DRUG (SUCH AS IBUPROFEN OR
NAPROXEN) AND ONE TRIPTAN DRUG (SUCH AS
SUMATRIPTAN OR RIZATRIPTAN). IF THE REQUIRED
DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST
365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT
REQUIRED.
8
Step Therapy Requirements, Effective June 1, 2017
COREG CR STEP
Products Affected
Step 2:
 Coreg CR 10 mg capsule, extended
release
 Coreg CR 20 mg capsule, extended
release
 Coreg CR 40 mg capsule, extended
release
 Coreg CR 80 mg capsule, extended
release
Details
Criteria
COVERAGE OF COREG CR REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF
GENERIC CARVEDILOL. IF THE REQUIRED DRUG APPEARS IN
THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED.
9
CUPRIMINE
Products Affected
Step 2:
 Cuprimine 250 mg capsule
Details
Criteria
COVERAGE OF CUPRIMINE REQUIRES DOCUMENTATION OF
PRIOR USE OF DEPEN. IF THE REQUIRED DRUG APPEARS IN
THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED.
10
Step Therapy Requirements, Effective June 1, 2017
FENTANYL TRANSDERMAL PATCH
Products Affected
Step 2:








Duragesic 100 mcg/hr transdermal patch
Duragesic 12 mcg/hr transdermal patch
Duragesic 25 mcg/hr transdermal patch
Duragesic 50 mcg/hr transdermal patch
Duragesic 75 mcg/hr transdermal patch
fentanyl 100 mcg/hr transdermal patch
fentanyl 12 mcg/hr transdermal patch
fentanyl 25 mcg/hr transdermal patch
 fentanyl 37.5 mcg/hour transdermal
patch
 fentanyl 50 mcg/hr transdermal patch
 fentanyl 62.5 mcg/hour transdermal
patch
 fentanyl 75 mcg/hr transdermal patch
 fentanyl 87.5 mcg/hour transdermal
patch
Details
Criteria
DUE TO SAFETY CONCERNS REGARDING THE USE OF
FENTANYL PATCHES IN PATIENTS WITHOUT PRIOR OPIATE
USE, COVERAGE OF FENTANYL PATCH REQUIRES
DOCUMENTATION OF PRIOR USE OF ONE OPIATE
ANALGESIC (SUCH AS HYDROCODONE/APAP, OXYCODONE,
MORPHINE) DURING THE PREVIOUS 60 DAYS. IF A
REQUIRED DRUG APPEAR IN THE PRESCRIPTION PROFILE IN
THE LAST 60 DAYS, THEN ADDITIONAL DOCUMENTATION IS
NOT REQUIRED.
11
INVEGA
Products Affected
Step 2:
 Invega Sustenna 117 mg/0.75 mL
intramuscular syringe
 Invega Sustenna 156 mg/mL
intramuscular syringe
 Invega Sustenna 234 mg/1.5 mL
intramuscular syringe
 Invega Sustenna 39 mg/0.25 mL
intramuscular syringe
 Invega Sustenna 78 mg/0.5 mL
intramuscular syringe
 Invega Trinza 273 mg/0.875 mL
intramuscular syringe
 Invega Trinza 410 mg/1.315 mL
intramuscular syringe
 Invega Trinza 546 mg/1.75 mL
intramuscular syringe
 Invega Trinza 819 mg/2.625 mL
intramuscular syringe
Details
Criteria
COVERAGE OF INVEGA REQUIRES DOCUMENTATION OF A
TRIAL OF RISPERIDONE AND AT LEAST ONE OTHER
ANTIPSYCHOTIC MEDICATION OR MOOD STABILIZER. IF THE
REQUIRED DRUGS APPEAR IN THE PRESCRIPTION PROFILE
IN THE LAST 365 DAYS, THEN ADDITIONAL
DOCUMENTATION IS NOT REQUIRED.
12
Step Therapy Requirements, Effective June 1, 2017
ONMEL
Products Affected
Step 2:
 Onmel 200 mg tablet
Details
Criteria
COVERAGE OF ONMEL REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF
ORAL ITRACONAZOLE. IF THE REQUIRED DRUG APPEARS IN
THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED.
13
PHOSPHATE BINDERS
Products Affected
Step 2:
 Auryxia 210 mg iron tablet
 Fosrenol 1,000 mg chewable tablet
 Fosrenol 1,000 mg oral powder packet
 Fosrenol 500 mg chewable tablet
 Fosrenol 750 mg chewable tablet
 Fosrenol 750 mg oral powder packet
Details
Criteria
COVERAGE OF CERTAIN PHOSPHATE BINDERS REQUIRES
DOCUMENTATION OF PRIOR USE OF RENVELA TABLETS OR
PACKETS. IF THE REQUIRED DRUG APPEARS IN THE
PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED.
14
Step Therapy Requirements, Effective June 1, 2017
SAVELLA STEP
Products Affected
Step 2:
 Savella 100 mg tablet
 Savella 12.5 mg (5)-25 mg(8)-50mg(42)
tablets in a dose pack
 Savella 12.5 mg tablet
 Savella 25 mg tablet
 Savella 50 mg tablet
Details
Criteria
COVERAGE OF SAVELLA REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF
ORAL DULOXETINE. IF THE REQUIRED DRUG APPEARS IN
THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED.
15
SOOLANTRA
Products Affected
Step 2:
 Soolantra 1 % topical cream
Details
Criteria
COVERAGE OF SOOLANTRA REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE TO
ONE GENERIC TOPICAL METRONIDAZOLE PRODUCT. IF THE
REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE
IN THE LAST 365 DAYS, THEN ADDITIONAL
DOCUMENTATION IS NOT REQUIRED.
16
Step Therapy Requirements, Effective June 1, 2017
SPORANOX
Products Affected
Step 2:
 Sporanox 10 mg/mL oral solution
 Sporanox 100 mg capsule
Details
Criteria
COVERAGE OF SPORANOX REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF
ORAL ITRACONAZOLE. IF THE REQUIRED DRUG APPEARS IN
THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED. AS ORAL
ITRACONAZOLE CAPSULES ARE NOT FDA-APPROVED FOR
TREATMENT OF OROPHARYNGEAL AND ESOPHAGHEAL
CANDIDIASIS, THE COVERAGE OF SPORANOX ORAL
SOLUTION WILL BE COVERED FOR THESE DIAGNOSES
WITHOUT THE STEP THERAPY REQUIREMENT.
17
TRIPTAN INJECTABLE STEP
Products Affected
Step 2:
 Sumavel DosePro 4 mg/0.5 mL
subcutaneous needle-free injector
 Sumavel DosePro 6 mg/0.5 mL
subcutaneous needle-free injector
 Zembrace Symtouch 3 mg/0.5 mL
subcutaneous pen injector
Details
Criteria
COVERAGE OF CERTAIN BRAND NAME INJECTABLE
TRIPTAN MEDICATIONS REQUIRES DOCUMENTATION OF A
TRIAL OF GENERIC SUMATRIPTAN INJECTABLE. IF THE
REQUIRED DRUG APPEARS IN THE PRESCRIPTION PROFILE
IN THE LAST 365 DAYS, THEN ADDITIONAL
DOCUMENTATION IS NOT REQUIRED.
18
Step Therapy Requirements, Effective June 1, 2017
TRIPTAN STEP
Products Affected
Step 2:
 Relpax 20 mg tablet
 Relpax 40 mg tablet
 Treximet 10 mg-60 mg tablet
 Treximet 85 mg-500 mg tablet
Details
Criteria
COVERAGE OF CERTAIN BRAND NAME TRIPTAN
MEDICATIONS REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF
TWO GENERIC TRIPTAN MEDICATIONS. IF THE REQUIRED
DRUGS APPEAR IN THE PRESCRIPTION PROFILE IN THE LAST
365 DAYS, THEN ADDITIONAL DOCUMENTATION IS NOT
REQUIRED.
19
ULORIC STEP
Products Affected
Step 2:
 Uloric 40 mg tablet
 Uloric 80 mg tablet
Details
Criteria
COVERAGE OF ULORIC REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF
GENERIC ALLOPURINOL. IF THE REQUIRED DRUG APPEARS
IN THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED.
20
Step Therapy Requirements, Effective June 1, 2017
VFEND
Products Affected
Step 2:
 Vfend 200 mg tablet
 Vfend 200 mg/5 mL (40 mg/mL) oral
suspension
 Vfend 50 mg tablet
Details
Criteria
COVERAGE OF VFEND REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF
ORAL VORICONAZOLE. IF THE REQUIRED DRUG APPEARS IN
THE PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED
21
ZELAPAR STEP
Products Affected
Step 2:
 Zelapar 1.25 mg disintegrating tablet
Details
Criteria
COVERAGE OF ZELAPAR REQUIRES DOCUMENTATION OF
SIGNIFICANT INTOLERANCE OR THERAPEUTIC FAILURE OF
ORAL SELEGILINE. IF THE REQUIRED DRUG APPEARS IN THE
PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED.
22
Step Therapy Requirements, Effective June 1, 2017
ZYFLO, ZYFLO CR
Products Affected
Step 2:
 Zyflo 600 mg tablet
 Zyflo CR 600 mg tablet,extended release
Details
Criteria
COVERAGE OF ZYFLO OR ZYFLO CR REQUIRES
DOCUMENTATION OF SIGNIFICANT INTOLERANCE OR
THERAPEUTIC FAILURE OF ORAL MONTELUKAST AND
ZAFIRLUKAST. IF THE REQUIRED DRUGS APPEAR IN THE
PRESCRIPTION PROFILE IN THE LAST 365 DAYS, THEN
ADDITIONAL DOCUMENTATION IS NOT REQUIRED.
23
Index
Duragesic 75 mcg/hr transdermal patch ... 11
E
Edarbi 40 mg tablet ..................................... 4
Edarbi 80 mg tablet ..................................... 4
Edarbyclor 40 mg-12.5 mg tablet ............... 4
Edarbyclor 40 mg-25 mg tablet .................. 4
Emsam 12 mg/24 hr transdermal 24 hour
patch ........................................................ 2
Emsam 6 mg/24 hr transdermal 24 hour
patch ........................................................ 2
Emsam 9 mg/24 hr transdermal 24 hour
patch ........................................................ 2
Enstilar 0.005 %-0.064 % topical foam ...... 7
Ertaczo 2 % topical cream .......................... 6
Exelderm 1 % topical cream ....................... 6
Exelderm 1 % topical solution .................... 6
F
fentanyl 100 mcg/hr transdermal patch..... 11
fentanyl 12 mcg/hr transdermal patch....... 11
fentanyl 25 mcg/hr transdermal patch....... 11
fentanyl 37.5 mcg/hour transdermal patch 11
fentanyl 50 mcg/hr transdermal patch....... 11
fentanyl 62.5 mcg/hour transdermal patch 11
fentanyl 75 mcg/hr transdermal patch....... 11
fentanyl 87.5 mcg/hour transdermal patch 11
Fosrenol 1,000 mg chewable tablet .......... 14
Fosrenol 1,000 mg oral powder packet ..... 14
Fosrenol 500 mg chewable tablet ............. 14
Fosrenol 750 mg chewable tablet ............. 14
Fosrenol 750 mg oral powder packet ........ 14
H
Halog 0.1 % topical cream .......................... 7
Halog 0.1 % topical ointment ..................... 7
I
Invega Sustenna 117 mg/0.75 mL
intramuscular syringe ............................ 12
Invega Sustenna 156 mg/mL intramuscular
syringe ................................................... 12
Invega Sustenna 234 mg/1.5 mL
intramuscular syringe ............................ 12
Invega Sustenna 39 mg/0.25 mL
intramuscular syringe ............................ 12
Invega Sustenna 78 mg/0.5 mL
intramuscular syringe ............................ 12
A
Ala-Scalp 2 % lotion ................................... 7
alogliptin 12.5 mg tablet ............................. 1
alogliptin 12.5 mg-metformin 1,000 mg
tablet ........................................................ 1
alogliptin 12.5 mg-metformin 500 mg tablet
................................................................. 1
alogliptin 12.5 mg-pioglitazone 15 mg tablet
................................................................. 1
alogliptin 12.5 mg-pioglitazone 30 mg tablet
................................................................. 1
alogliptin 12.5 mg-pioglitazone 45 mg tablet
................................................................. 1
alogliptin 25 mg tablet ................................ 1
alogliptin 25 mg-pioglitazone 15 mg tablet 1
alogliptin 25 mg-pioglitazone 30 mg tablet 1
alogliptin 25 mg-pioglitazone 45 mg tablet 1
alogliptin 6.25 mg tablet ............................. 1
Altoprev 20 mg tablet,extended release ...... 5
Altoprev 40 mg tablet,extended release ...... 5
Altoprev 60 mg tablet,extended release ...... 5
Aplenzin 174 mg tablet,extended release ... 2
Aplenzin 348 mg tablet,extended release ... 2
Aplenzin 522 mg tablet,extended release ... 2
Auryxia 210 mg iron tablet ....................... 14
C
Cambia 50 mg oral powder packet ............. 8
Capex 0.01 % shampoo............................... 7
Cordran Tape Large Roll 4 mcg/cm2 ......... 7
Coreg CR 10 mg capsule, extended release 9
Coreg CR 20 mg capsule, extended release 9
Coreg CR 40 mg capsule, extended release 9
Coreg CR 80 mg capsule, extended release 9
Cuprimine 250 mg capsule ....................... 10
D
Desonate 0.05 % topical gel........................ 7
desvenlafaxine ER 100 mg tablet,extended
release 24 hr ............................................ 2
desvenlafaxine ER 50 mg tablet,extended
release 24 hr ............................................ 2
Duragesic 100 mcg/hr transdermal patch . 11
Duragesic 12 mcg/hr transdermal patch ... 11
Duragesic 25 mcg/hr transdermal patch ... 11
Duragesic 50 mcg/hr transdermal patch ... 11
24
Step Therapy Requirements, Effective June 1, 2017
Invega Trinza 273 mg/0.875 mL
intramuscular syringe ............................ 12
Invega Trinza 410 mg/1.315 mL
intramuscular syringe ............................ 12
Invega Trinza 546 mg/1.75 mL
intramuscular syringe ............................ 12
Invega Trinza 819 mg/2.625 mL
intramuscular syringe ............................ 12
K
Kazano 12.5 mg-1,000 mg tablet ................ 1
Kazano 12.5 mg-500 mg tablet ................... 1
Kenalog 0.147 mg/gram topical aerosol ..... 7
L
Locoid 0.1 % lotion..................................... 7
Luzu 1 % topical cream .............................. 6
M
Mentax 1 % topical cream .......................... 6
N
Naftin 1 % topical gel ................................. 6
Naftin 2 % topical gel ................................. 6
Nesina 12.5 mg tablet ................................. 1
Nesina 25 mg tablet .................................... 1
Nesina 6.25 mg tablet ................................. 1
O
Onmel 200 mg tablet ................................. 13
Oseni 12.5 mg-15 mg tablet ........................ 1
Oseni 12.5 mg-30 mg tablet ........................ 1
Oseni 12.5 mg-45 mg tablet ........................ 1
Oseni 25 mg-15 mg tablet ........................... 1
Oseni 25 mg-30 mg tablet ........................... 1
Oseni 25 mg-45 mg tablet ........................... 1
Oxistat 1 % lotion ....................................... 6
P
Pandel 0.1 % topical cream ......................... 7
Paxil 10 mg/5 mL oral suspension .............. 2
Pexeva 10 mg tablet .................................... 2
Pexeva 20 mg tablet .................................... 2
Pexeva 30 mg tablet .................................... 2
Pexeva 40 mg tablet .................................... 2
Pristiq 100 mg tablet,extended release........ 2
Pristiq 25 mg tablet,extended release.......... 2
Pristiq 50 mg tablet,extended release.......... 2
R
Relpax 20 mg tablet .................................. 19
Relpax 40 mg tablet .................................. 19
S
Sancuso 3.1 mg/24 hour transdermal patch 3
Sarafem 10 mg tablet .................................. 2
Sarafem 20 mg tablet .................................. 2
Savella 100 mg tablet ................................ 15
Savella 12.5 mg (5)-25 mg(8)-50mg(42)
tablets in a dose pack ............................ 15
Savella 12.5 mg tablet ............................... 15
Savella 25 mg tablet .................................. 15
Savella 50 mg tablet .................................. 15
Soolantra 1 % topical cream ..................... 16
Sporanox 10 mg/mL oral solution ............ 17
Sporanox 100 mg capsule ......................... 17
Sumavel DosePro 4 mg/0.5 mL
subcutaneous needle-free injector ......... 18
Sumavel DosePro 6 mg/0.5 mL
subcutaneous needle-free injector ......... 18
T
Taclonex 0.005 %-0.064 % topical ointment
................................................................. 7
Taclonex 0.005 %-0.064 % topical
suspension ............................................... 7
Topicort 0.25 % topical spray ..................... 7
Treximet 10 mg-60 mg tablet ................... 19
Treximet 85 mg-500 mg tablet ................. 19
U
Uloric 40 mg tablet ................................... 20
Uloric 80 mg tablet ................................... 20
V
Vfend 200 mg tablet.................................. 21
Vfend 200 mg/5 mL (40 mg/mL) oral
suspension ............................................. 21
Vfend 50 mg tablet.................................... 21
Viibryd 10 mg (7)-20 mg (23) tablets in a
dose pack ................................................. 2
Viibryd 10 mg tablet ................................... 2
Viibryd 20 mg tablet ................................... 2
Viibryd 40 mg tablet ................................... 2
Vytorin 10 mg-10 mg tablet ........................ 5
Vytorin 10 mg-20 mg tablet ........................ 5
Vytorin 10 mg-40 mg tablet ........................ 5
Vytorin 10 mg-80 mg tablet ........................ 5
Z
Zelapar 1.25 mg disintegrating tablet ....... 22
Zembrace Symtouch 3 mg/0.5 mL
subcutaneous pen injector ..................... 18
25
Zuplenz 4 mg oral soluble film ................... 3
Zuplenz 8 mg oral soluble film ................... 3
Zyflo 600 mg tablet ................................... 23
Zyflo CR 600 mg tablet,extended release . 23
26