Select Step Therapy. Here s how it works:

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Select 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
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Select 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: You get a prescription Try a Step 1 medication first Before a Step 2 medication is covered 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. 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 your ID card. Step Therapy Program Step Therapy Medications 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. Anti-infectives Oral Brand Tetracyclines doxycycline AND any one of the following Doryx MPC Acticlate, Adoxa, Doryx, Monodox, Targadox Otic Agents ofloxacin Cetraxal, Ciprofloxacin Cardiovascular Beta Blockers carvedilol Coreg CR Calcium Channel Blockers Renin- Angiotensin System Agents Statins amlodipine, perindopril amlodipine-benazepril, amlodipineolmesartan, benazepril, benazepril-hctz, candesartan, candesartan-hctz, captopril, captopril-hctz, enalapril, enalapril-hctz, fosinopril, fosinopril-hctz, irbesartan, irbesartan-hctz, lisinopril, lisinopril- HCTZ, losartan, losartan-hctz, moexipril, moexipril-hctz, olmesartan, olmesartan- HCTZ, olmesartan-amlodipine-hctz, perindopril, quinapril, quinapril-hctz, ramipril, telmisartan, telmisartan-hctz, trandolapril, trandolapril-verapamil atorvastatin, fluvastatin, fluvastatin ER, lovastatin, pravastatin, rosuvastatin, simvastatin Prestalia Edarbi, Edarbyclor, Tekturna, Tekturna HCT Altoprev, Flolipid, Lipitor, Livalo, Nikita, Zypitamag OptumRx optumrx.com Step Therapy Medications Continued Fibric Acid Derivatives fenofibric cap, fenofibrate tab, fenofibrate micronized cap, fenofibric acid tab Fenoglide, Fibricor, Lofibra, Triglide Antianginals AND any one of the following Lipofen Any one of the following generics or acebutolol, amlodipine, amlodipinebenazepril, amlodipine-telmisartan, amlodipine-valsartan, atenolol, bextaxolol, bisoprolol, carvedilol, diltiazem, diltiazem ER, felodipine ER, isosorbide dinitrate ER, isosorbide mononitrate ER, isradipine, metoprolol, metoprolol ER, nadolol, nicardipine, nifedipine, nisoldipine SR, nitroglycerin ER, pindolol, propranolol, propranolol SR, timolol, trandolapril-verapamil, verapamil, verapamil ER Ranexa Central Nervous System ADHD Agents Bystolic, Dilatrate SR, Inderal XL, Innopran XL Any two of the following generics or amphetamine-dextroamphetamine IR or ER, dexmethylphenidate IR or ER, dextroamphetamine IR or SR, methylphenidate IR or ER, Vyvanse Anticonvulsants* topiramate Trokendi XR Adderall XR #, Adzenys XR ODT #, Aptensio XR #, Concerta #, Cotempla XR-ODT #, Daytrana #, Desoxyn #, Dyanavel XR #, Evekeo #, Focalin XR #, Kapvay, Metadate CD #, Methylin # solution, Methylin Chew #, Mydayis #, Procentra #, Quillichew ER #, Quillivant #, Ritalin LA #, Zenzedi # 3 Step Therapy Program Step Therapy Medications Continued Antidepressants* Antipsychotics* Any two of the following generics: bupropion, citalopram, desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, paroxetine ER, sertraline, venlafaxine, venlafaxine ER Any two of the following generics: desvenlafaxine succinate ER, duloxetine, venlafaxine, venlafaxine ER bupropion XL Any two of the following generics or aripiprazole, olanzapine, quetiapine, risperidone Trintellix # Fetzima # Alpenzin# Fanapt #, Latuda #, Vraylar # Insomnia Agents Migraine Agents Neurologic Agents Saphris, Seroquel XR eszopiclone, temazepam, zaleplon, zolpidem, zolpidem CR zolpidem, zolpidem CR rizatriptan, sumatriptan, zolmitriptan Any two of the following generics: rizatriptan, sumatriptan, zolmitriptan Belsomra # Edluar #, Zolpimist # Treximet #, Zecuity # Onzetra Xsail # gabapentin Gralise # Any one of the following generics or Savella # amitriptyline, cyclobenzaprine, duloxetine Lyrica OptumRx optumrx.com Step Therapy Medications Continued Non-Narcotic Analgesics Opioid Antagonists Parkinson s Disease Women s Health Dermatology Any two of the following generics: diclofenac, diclofenac CR, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin Narcan Nasal Spray carbidopa-levodopa, carbidopa-levodopa CR Both of the following generics: rasagiline, selegiline esterified estrogens-methyltestosterone, estradiol, estradiol-norethindrone, estropipate, paroxetine, fluoxetine Cambia, Tivorbex Evzio Rytary Xadago # Brisdelle # Rosacea Soolantra Finacea Skin Cancer Agents Topical Acne Treatments Mirvaso fluorouracil, imiquimod Any one of the following preferred brands: Epiduo/Epiduo Forte, Onexton Rhofade diclofenac gel 3% #, Picato, Solaraze #, Tolak Acanya, Aktipak, Benzaclin, Benzamycin, Duac, Veltin, Ziana 5 Step Therapy Program Step Therapy Medications Continued Topical Immunomodulators Endocrinology Basal Insulin Diabetic Agents Blood Glucose Meters and Strips alclometasone, amcinonide, betamethasone, calcipotrienebetamethasone, clobetasol, clocortolone, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide, fluticasone, halobetasol, hydrocortisone, mometasone, pramoxine-hc, prednicarbate, triamcinolone All of the following Lantus, Levemir, and Toujeo metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin Both of the following Accu-Check, Onetouch Elidel, Eucrisa Basaglar Actoplus Met XR Avandia, Cycloset Abbott #, Acon #, At Last #, Bayer #, Embrace #, EPS #, Fora Care #, Glucocard #, Gmate #, Liberty #, Neutek #, Quintet #, Relion #, Reveal #, Supreme #, True Metrix #, Truetest #, Truetrack #, Ultima #, Unistrip # OptumRx optumrx.com Step Therapy Medications Continued DPP4 Inhibitors GLP-1 Agonist Combinations SGLT2 Inhibitors metformin, metformin ER, glipizidemetformin, glyburide-metformin, pioglitazone-metformin Any one of the following Janumet, Janumet XR, Januvia AND any one of the following Jentadueto, Jentadueto XR, Tradjenta Any one of the following Bydureon, Byetta, Trulicity, Victoza, Lantus, Levemir, or Toujeo Any one of the following: Adlyxin, Bydureon, Byetta, Tanzeum, Trulicity, Victoza, Basaglar, Lantus, Levemir, Tresiba or Toujeo metformin, metformin ER, glipizidemetformin, glyburide-metformin, pioglitazone-metformin Any one of the following Invokamet, Invokana, Invokamet XR AND any one of the following Jardiance, Synjardy, Synjardy XR Janumet, Janumet XR, Januvia, Jentadueto, Jentadueto XR, Tradjenta alogliptin, alogliptin-metformin, alogliptin-pioglitazone, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni Xultophy # Soliqua # Invokamet, Invokamet XR, Invokana, Jardiance, Synjardy, Synjardy XR Farxiga, Glyxambi, Xigduo XR 7 Step Therapy Program Step Therapy Medications Continued Short-Acting Insulin Gastroenterology Constipation Agents Gastroprotective Agents Irritable Bowel Syndrome Opioid-Induced Constipation Pancreatic Enzymes Proton Pump Inhibitors Any one of the following Humalog, Novolog lactulose, polyethylene glycol lactulose, polyethylene glycol AND both of the following brands: Amitiza #, Linzess # diclofenac, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin Apriso Apidra Amitiza #, Linzess # Trulance # Duexis # Amitiza Movantik # Both of the following preferred brands: Creon, Zenpep Any two of the following generics or esomeprazole, omeprazole, lansoprazole, pantoprazole Dexilant Any one of the following Omeclamox-Pak, Pylera Asacol HD, Delzicol, mesalamine DR Pancreaze, Pertzye, Ultresa, Viokace Aciphex #, esomeprazole strontium #, First-Lansoprazole, First-Omeprazole, Prevacid #, Prilosec #, Protonix #, Zegerid # Prevpac OptumRx optumrx.com Step Therapy Medications Continued Miscellaneous Antigout Agents Colcrys Mitigare, colchicine Ophthalmology Ophthalmic Antihistamines Ophthalmic Antiinflammatory Agents allopurinol Any one of the following generics or azelastine, olopatadine Pataday Uloric, Zurampic Bepreve, Lastacaft Bromsite Prolensa # Respiratory Epinephrine Auto Injectors* Inhaled Corticosteroids Inhaled Cystic Fibrosis Agents Leukotriene Modifiers generic Epipen (manufactured by Mylan), generic Epipen-Jr (manufactured by Mylan) Any two of the following Arnuity Ellipta, Flovent, Pulmicort Flexhaler, QVAR Bethkis montelukast, zafirlukast Adrenaclick, Auvi-Q, Epipen, Epipen-Jr, epinephrine Alvesco #, Armonair Respiclick #, Asmanex # Kitabis, Tobi, Tobi Podhaler #, tobramycin nebulizer solution zileuton ER, Zyflo, Zyflo CR 9 Step Therapy Program Step Therapy Medications Continued Long-Acting Bronchodilators Long-Acting Bronchodilator Combinations Any two of the following Advair, Breo Ellipta, Serevent, Symbicort Both of the following Incruse Ellipta, Spiriva Any two of the following generics or fluticasone-salmeterol, Advair, Breo Ellipta, Symbicort Any one of the following preferred brands: Advair, Breo Ellipta, Serevent, Symbicort Arcapta #, Striverdi Respimat # Seebri Neohaler #, Tudorza Pressair # Airduo Respiclick #, Dulera # Bevespi Aerosphere #, Utibron Neohaler # Short-Acting Beta Agonist Inhalers Urology BPH Agents AND any one of the following Spiriva Any one of the following Ventolin HFA AND any one of the following ProAir HFA, ProAir Respiclick Any two of the following generics or alfuzosin, doxazosin, tamsulosin, terazosin levalbuterol HFA #, Proventil HFA #, Xopenex HFA # Cardura XL Rapaflo Step therapy requirements are effective as of January 1, 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. These agents are also subject to additional step requirements as indicated in table. # Quantity limits may also apply. Please refer to the Select Quantity Limits document. * Applies to new starts only OptumRx optumrx.com 11 optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum company a leading provider of integrated health services. Learn more at optum.com. All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners Optum, Inc. All rights reserved. ORX0785A
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