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*Antiasthmatic And Bronchodilator Agents*.4*Anticonvulsants*. 6*Antidepressants*. 7*Antidiabetics*. 8*Antiemetics*. idemics* . 12*Antimalarials*. 13*Antipsychotics/Antimanic Agents*. 13*Antivirals*. 13*Beta Blockers*. 14*Calcium Channel Blockers*. 14*Cardiovascular Agents - Misc.*. 14*Corticosteroids*. 14*Dermatologicals*. 14*Diagnostic Products* . 16*Digestive Aids*.29*Gastrointestinal Agents - Misc.*.29*Gout Agents*. 30*Hematopoietic Agents* . 30*Hypnotics/Sedatives/Sleep Disorder Agents*.30*Medical Devices And Supplies*.31*Migraine Products*. 32*Musculoskeletal Therapy Agents*. 32*Ophthalmic Agents*. 32*Psychotherapeutic And Neurological Agents - Misc.*. 32*Ulcer Drugs/Antispasmodics/Anticholinergics*. 33*Vaccines*. 332

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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)*Antiasthmatic And Bronchodilator Agents**5-Lipoxygenase Inhibitors***zileuton erQL (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)ZYFLOStep Therapy Required (Trial of both of thefollowing for at least 3 months each in last12 months: montelukast, zafirlukast)ZYFLO CRQL (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 DIGIHALERQL (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)AIRDUO 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)Last revision date:07/15/2021 To search for a drug use control f4

Step 2 ProductStep 1 ProductAIRDUO 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 AEROSPHEREStep Therapy Required (Trial of two of thefollowing for 3 months each in the last 12months: Bevespi, Duaklir Pressair, LonhalaMagnair)DUAKLIR PRESSAIRStep Therapy Required (Trial of both of thefollowing in the last 6 months: ANOROELLIPTA, SYMBICORT)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)fluticasone-salmeterol inhalation aerosol powder breath activated 100-50mcg/dose, 250-50 mcg/dose, 500-50 mcg/doseQL (2 blisters per day); Step TherapyRequired (Trial of the following in last 3months: ADVAIR DISKUS)fluticasone-salmeterol inhalation aerosol powder breath activated 113-14mcg/act, 232-14 mcg/act, 55-14 mcg/actQL (1 inhaler per month); Step TherapyRequired (Trial of the following in last 3months: ADVAIR DISKUS); AL (Min 12Years)UTIBRON NEOHALERStep Therapy Required (Trial of both of thefollowing in the last 12 months: ANOROELLIPTA, STIOLTO RESPIMAT)WIXELA INHUBQL (2 blisters per day); Step TherapyRequired (Trial of the following in last 3months: ADVAIR DISKUS)*Beta Adrenergics***levalbuterol tartrateQL (1gm per day); Step Therapy Required(Trial of the following in the last 1 month:Albuterol HFA)PROVENTIL HFAStep Therapy Required (Trial of both of thefollowing in the last 12 months: PROAIR(HFA or RESPICLICK) and VENTOLINHFA)STRIVERDI RESPIMATStep Therapy Required (Trial of three ofthe following for 3 months each In the last12 months: ANORO ELLIPTA, ARCAPTANEOHALER, SEREVENT DISKUS,simultaneous use of SPIRIVA withSEREVENT DISKUS, simultaneous use ofSPIRIVA with ARCAPTA NEOHALER)Last revision date:07/15/2021 To search for a drug use control f5

Step 2 ProductStep 1 ProductXOPENEX HFAQL (1gm per day); Step Therapy Required(Trial of the following in the last 1 month:Albuterol HFA)*Bronchodilators - Anticholinergics***LONHALA MAGNAIR REFILL KITStep Therapy Required (Trial of two of thefollowing for 3 months each in the last 12months: INCRUSE ELLIPTA, SEEBRINEOHALER, SPIRIVA (HANDIHALER orRESPIMAT), TUDORZA PRESSAIR); AL(Min 18 Years)LONHALA MAGNAIR STARTER KITStep Therapy Required (Trial of two of thefollowing for 3 months each in the last 12months: INCRUSE ELLIPTA, SEEBRINEOHALER, SPIRIVA (HANDIHALER orRESPIMAT), TUDORZA PRESSAIR); AL(Min 18 Years)*Steroid Inhalants***ARMONAIR DIGIHALERStep Therapy Required (Trial of thefollowing in the last 3 months: Flovent)*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)BRIVIACT 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)Last revision date:07/15/2021 To search for a drug use control f6

Step 2 ProductStep 1 ProductELEPSIA 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 XRStep Therapy Required (Trial of thefollowing for 3 months in the last 12months: topiramate (generic forTOPAMAX)); AL (Min 3 Years)topiramate erStep Therapy Required (Trial of thefollowing for 3 months in the last 12months: topiramate (generic forTOPAMAX)); AL (Min 3 Years)TROKENDI XRStep Therapy Required (Trial of both of thefollowing for 3 months each in the last 12months: topiramate (generic forTOPAMAX) and topiramate ER capsule(generic for QUDEXY XR)); AL (Min 6Years)*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)QL (2 tablets per day); Step TherapyRequired (Trial of at least 3 of the followingin the last 12 months: carbamazepine,XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 50 & 200lacosamide (generic for VIMPAT),MGlamotrigine, levetiracetam IR,oxcarbazepine, topiramate, valproic acid &derivatives)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),lamo