Step Therapy Criteria Last Updated 6/1/2018
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1 Step Therapy Last Updated 6/1/2018 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at or, for TTY/TDD users Our hours are October 1 to February 14 from 8:00 am to 8:00 pm 7 days a week and February 15 to September 30 from 8:00 am to 8:00 pm Monday through Friday or visit For an indexed list of drugs please go to page 13.
2 anti-emetics hrm PHENADOZ SUPPOSITORY 12.5 MG RECTAL promethazine hcl solution 25 mg/ml injection promethazine hcl solution 50 mg/ml injection promethazine hcl suppository 12.5 mg rectal promethazine hcl suppository 25 mg rectal promethazine hcl suppository 50 mg rectal promethazine hcl syrup 6.25 mg/5ml oral promethazine hcl tablet 12.5 mg oral promethazine hcl tablet 25 mg oral promethazine hcl tablet 50 mg oral PROMETHEGAN SUPPOSITORY 25 MG RECTAL PROMETHEGAN SUPPOSITORY 50 MG RECTAL trimethobenzamide hcl capsule 300 mg oral ANY ONE OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: Ondansetron, Granisetron. Step 2: Promethazine, Phenadoz, Promethagan, Trimethobenzamide. only applies for a diagnosis of nausea and vomiting. does not apply to the diagnosis of motion sickness. Step therapy only applies to members 65 years of age or older 2
3 anxiolytics hrm meprobamate tablet 200 mg oral meprobamate tablet 400 mg oral ANY ONE OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: Buspirone. Step 2: Meprobamate Step therapy only applies to members 65 years of age or older 3
4 atypicals FANAPT TABLET 1 MG ORAL FANAPT TABLET 10 MG ORAL FANAPT TABLET 12 MG ORAL FANAPT TABLET 2 MG ORAL FANAPT TABLET 4 MG ORAL FANAPT TABLET 6 MG ORAL FANAPT TABLET 8 MG ORAL FANAPT TITRATION PACK TABLET 1 & 2 & 4 & 6 MG ORAL INVEGA SUSTENNA SUSPENSION 117 MG/0.75ML INTRAMUSCULAR INVEGA SUSTENNA SUSPENSION 156 MG/ML INTRAMUSCULAR INVEGA SUSTENNA SUSPENSION 234 MG/1.5ML INTRAMUSCULAR INVEGA SUSTENNA SUSPENSION 39 MG/0.25ML INTRAMUSCULAR INVEGA SUSTENNA SUSPENSION 78 MG/0.5ML INTRAMUSCULAR INVEGA TRINZA SUSPENSION 273 MG/0.875ML INTRAMUSCULAR INVEGA TRINZA SUSPENSION 410 MG/1.315ML INTRAMUSCULAR INVEGA TRINZA SUSPENSION 546 MG/1.75ML INTRAMUSCULAR INVEGA TRINZA SUSPENSION 819 MG/2.625ML INTRAMUSCULAR LATUDA TABLET 120 MG ORAL LATUDA TABLET 20 MG ORAL LATUDA TABLET 40 MG ORAL LATUDA TABLET 60 MG ORAL LATUDA TABLET 80 MG ORAL REXULTI TABLET 0.25 MG ORAL REXULTI TABLET 0.5 MG ORAL REXULTI TABLET 1 MG ORAL REXULTI TABLET 2 MG ORAL REXULTI TABLET 3 MG ORAL REXULTI TABLET 4 MG ORAL RISPERDAL CONSTA SUSPENSION RECONSTITUTED 12.5 MG INTRAMUSCULAR RISPERDAL CONSTA SUSPENSION RECONSTITUTED 25 MG INTRAMUSCULAR RISPERDAL CONSTA SUSPENSION RECONSTITUTED 37.5 MG INTRAMUSCULAR RISPERDAL CONSTA SUSPENSION RECONSTITUTED 50 MG INTRAMUSCULAR SAPHRIS TABLET SUBLINGUAL 10 MG SUBLINGUAL SAPHRIS TABLET SUBLINGUAL 2.5 MG SUBLINGUAL SAPHRIS TABLET SUBLINGUAL 5 MG SUBLINGUAL TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: aripiprazole, aripiprazole disintegrating tab., clozapine, risperidone, olanzapine, paliperidone, quetiapine, quetiapine XR, ziprasidone. Step 2: Fanapt, Invega Sustenna, Invega Trinza, Latuda, Rexulti, Risperdal Consta, Saphris. Step Therapy only applies to new starts only. Enrollees stabilized on medication will not be required to go through step therapy. Step therpay criteria only applies for the diagnosis of schizophrenia. 4
5 diabetes AVANDIA TABLET 2 MG ORAL AVANDIA TABLET 4 MG ORAL ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: Acarbose, Glimepiride, Glipizide, Glipizide ER, Glipizide XL, Glipizide/Metformin Hcl, Humalog, Humalog Mix 50/50, Humalog Mix 75/25, Humulin 70/30, Humulin N, Humulin R, Lantus, Lantus Solostar, Levemir, Levemir Flexpen, Metformin Hcl, Metformin Hcl Er, Nateglinide, Novolog, Novolog Flexpen, Novolog Mix 70/30, Novolin N, Novolin R, Novolin 70/30, Pioglitazone/Metformin, Repaglinide, Toujeo, Tresiba Step 2: Avandia. 5
6 dpp-4 inhibitors JANUMET TABLET MG ORAL JANUMET TABLET MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUVIA TABLET 100 MG ORAL JANUVIA TABLET 25 MG ORAL JANUVIA TABLET 50 MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL ONGLYZA TABLET 2.5 MG ORAL ONGLYZA TABLET 5 MG ORAL ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: Glipizide/Metformin HCL, Metformin HCL, Metformin HCL ER, Pioglitazone/Metformin Step 2: Janumet, Januvia, Onglyza, Janumet XR, Kombiglyze 6
7 glp1 agonist BYETTA 10 MCG PEN SOLUTION PEN-INJECTOR 10 MCG/0.04ML SUBCUTANEOUS BYETTA 5 MCG PEN SOLUTION PEN- INJECTOR 5 MCG/0.02ML SUBCUTANEOUS TANZEUM PEN-INJECTOR 30 MG SUBCUTANEOUS TANZEUM PEN-INJECTOR 50 MG SUBCUTANEOUS VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: Acarbose, Glimepiride, Glipizide, Glipizide ER, Glipizide XL, Glipizide/Metformin HCL, Metformin HCL, Metformin HCL ER, Pioglitazone/Metformin, Nateglinide, Repaglinide. Step 2: Tanzeum, Victoza, Byetta 7
8 non-sedating antihistamines CLARINEX-D 12 HOUR TABLET EXTENDED RELEASE 12 HOUR MG ORAL desloratadine tablet 5 mg oral desloratadine tablet dispersible 2.5 mg oral desloratadine tablet dispersible 5 mg oral ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: Allegra OTC, Allegra D OTC, Loratadine OTC, Loratadine D OTC, Cetirizine OTC, Cetirizine D OTC. Step 2: Desloratadine, Clarinex D. Only one drug, cetirizine, is required to be tried for the diagnosis of perennial allergic rhinitis. 8
9 ppi PREVACID SOLUTAB TABLET DISPERSIBLE 15 MG ORAL PREVACID SOLUTAB TABLET DISPERSIBLE 30 MG ORAL ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: lansoprazole, lansoprazole OTC, Priolosec Otc, Nexium OTC, Omeprazole Otc, Omeprazole, Pantoprazole, Rabeprazole, Prevacid OTC, Zegerid OTC. Step 2: Prevacid For the diagnosis of risk reduction of NSAID associated gastric ulcer only lansoprazole is required. 9
10 renin inhibitors TEKTURNA HCT TABLET MG ORAL TEKTURNA HCT TABLET MG ORAL TEKTURNA HCT TABLET MG ORAL TEKTURNA HCT TABLET MG ORAL TEKTURNA TABLET 150 MG ORAL TEKTURNA TABLET 300 MG ORAL ANY TWO OF THE FOLLOWING DRUGS, 1 DRUG FROM EACH CLASS, IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: ACE-Inhibitors (including combinations with HCTZ) - Benazepril Hcl, Benazepril Hctz, Captopril, Captopril /Hctz, Enalapril Maleate, Enalapril Maleate/Hctz, Fosinopril Sodium, Fosinopril sodium/hctz, Lisinopril, Lisinopril /Hctz, Quinapril Hcl, Quinipril/HCTZ, Trandolapril, Ramipril. ARBs (including combinations with HCTZ) - Olmasartan, Olmasartan/Hct, losartan, losartan/hct, irbesartan, irbesartan/hctz, valsartan, valsartan/hctz. Step 2: Tekturna, Tekturna Hct 10
11 symlin SYMLINPEN 120 SOLUTION PEN- INJECTOR 2700 MCG/2.7ML SUBCUTANEOUS SYMLINPEN 60 SOLUTION PEN- INJECTOR 1500 MCG/1.5ML SUBCUTANEOUS ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: Humalog, Humalog Mix 50/50, Humalog Mix 75/25, Humulin 70/30, Humulin N, Humulin R, Lantus, Levemir, Novolog, Novolog Mix 70/30, Novolin R, Novolin N, Novolin 70/30, Toujeo, Tresiba Step 2: Symlin 11
12 topical_immunomodulators ELIDEL CREAM 1 % EXTERNAL tacrolimus ointment 0.03 % external tacrolimus ointment 0.1 % external ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 180 DAYS BEFORE MOVING TO STEP 2: Ala-Cort, Alclometasone Dipropionate, Amcinonide, Augmented Betamethasone Dipropionate, Betamethasone, Betamethasone Dipropionate, Betamethasone Valerate, Clobetasol Propionate, Clobetasol Propionate Emollient, Desonide, Desoximetasone, Diflorasone Diacetate, Fluocinolone Acetonide, Fluocinonide, Fluticasone, Halobetasol Propionate, Hydrocortisone Butyrate, Hydrocortisone Valerate, Mometasone Furoate, Prednicarbate, Triamcinolone Acetonide, Triamcinolone Acetonide In Absorbase. Step 2: Elidel, Tacrolimus 12
13 Index (Índice) A AVANDIA TABLET 2 MG ORAL 5 AVANDIA TABLET 4 MG ORAL 5 B BYETTA 10 MCG PEN SOLUTION PEN- INJECTOR 10 MCG/0.04ML SUBCUTANEOUS 7 BYETTA 5 MCG PEN SOLUTION PEN- INJECTOR 5 MCG/0.02ML SUBCUTANEOUS 7 C CLARINEX-D 12 HOUR TABLET EXTENDED RELEASE 12 HOUR MG ORAL 8 D desloratadine tablet 5 mg oral 8 desloratadine tablet dispersible 2.5 mg oral 8 desloratadine tablet dispersible 5 mg oral 8 E ELIDEL CREAM 1 % EXTERNAL 12 F FANAPT TABLET 1 MG ORAL 4 FANAPT TABLET 10 MG ORAL 4 FANAPT TABLET 12 MG ORAL 4 FANAPT TABLET 2 MG ORAL 4 FANAPT TABLET 4 MG ORAL 4 FANAPT TABLET 6 MG ORAL 4 FANAPT TABLET 8 MG ORAL 4 FANAPT TITRATION PACK TABLET 1 & 2 & 4 & 6 MG ORAL 4 I INVEGA SUSTENNA SUSPENSION 117 MG/0.75ML INTRAMUSCULAR 4 INVEGA SUSTENNA SUSPENSION 156 MG/ML INTRAMUSCULAR 4 INVEGA SUSTENNA SUSPENSION 234 MG/1.5ML INTRAMUSCULAR 4 INVEGA SUSTENNA SUSPENSION 39 MG/0.25ML INTRAMUSCULAR 4 INVEGA SUSTENNA SUSPENSION 78 MG/0.5ML INTRAMUSCULAR 4 INVEGA TRINZA SUSPENSION 273 MG/0.875ML INTRAMUSCULAR 4 INVEGA TRINZA SUSPENSION 410 MG/1.315ML INTRAMUSCULAR 4 INVEGA TRINZA SUSPENSION 546 MG/1.75ML INTRAMUSCULAR 4 INVEGA TRINZA SUSPENSION 819 MG/2.625ML INTRAMUSCULAR 4 J JANUMET TABLET MG ORAL 6 JANUMET TABLET MG ORAL 6 JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL 6 JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL 6 JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL 6 JANUVIA TABLET 100 MG ORAL 6 JANUVIA TABLET 25 MG ORAL 6 JANUVIA TABLET 50 MG ORAL 6 K KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL 6 KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL 6 KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL 6 L LATUDA TABLET 120 MG ORAL 4 LATUDA TABLET 20 MG ORAL 4 LATUDA TABLET 40 MG ORAL 4 LATUDA TABLET 60 MG ORAL 4 LATUDA TABLET 80 MG ORAL 4 M meprobamate tablet 200 mg oral 3 meprobamate tablet 400 mg oral 3 O ONGLYZA TABLET 2.5 MG ORAL 6 ONGLYZA TABLET 5 MG ORAL 6 P PHENADOZ SUPPOSITORY 12.5 MG RECTAL 2 PREVACID SOLUTAB TABLET DISPERSIBLE 15 MG ORAL 9 PREVACID SOLUTAB TABLET DISPERSIBLE 30 MG ORAL 9 promethazine hcl solution 25 mg/ml injection 2 promethazine hcl solution 50 mg/ml injection 2 promethazine hcl suppository 12.5 mg rectal 2 promethazine hcl suppository 25 mg rectal 2 promethazine hcl suppository 50 mg rectal 2 promethazine hcl syrup 6.25 mg/5ml oral 2 promethazine hcl tablet 12.5 mg oral 2 promethazine hcl tablet 25 mg oral 2 promethazine hcl tablet 50 mg oral 2 13
14 PROMETHEGAN SUPPOSITORY 25 MG RECTAL 2 PROMETHEGAN SUPPOSITORY 50 MG RECTAL 2 R REXULTI TABLET 0.25 MG ORAL 4 REXULTI TABLET 0.5 MG ORAL 4 REXULTI TABLET 1 MG ORAL 4 REXULTI TABLET 2 MG ORAL 4 REXULTI TABLET 3 MG ORAL 4 REXULTI TABLET 4 MG ORAL 4 RISPERDAL CONSTA SUSPENSION RECONSTITUTED 12.5 MG INTRAMUSCULAR 4 RISPERDAL CONSTA SUSPENSION RECONSTITUTED 25 MG INTRAMUSCULAR 4 RISPERDAL CONSTA SUSPENSION RECONSTITUTED 37.5 MG INTRAMUSCULAR 4 RISPERDAL CONSTA SUSPENSION RECONSTITUTED 50 MG INTRAMUSCULAR 4 S SAPHRIS TABLET SUBLINGUAL 10 MG SUBLINGUAL 4 SAPHRIS TABLET SUBLINGUAL 2.5 MG SUBLINGUAL 4 SAPHRIS TABLET SUBLINGUAL 5 MG SUBLINGUAL 4 SYMLINPEN 120 SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SUBCUTANEOUS 11 SYMLINPEN 60 SOLUTION PEN-INJECTOR 1500 MCG/1.5ML SUBCUTANEOUS 11 T tacrolimus ointment 0.03 % external 12 tacrolimus ointment 0.1 % external 12 TANZEUM PEN-INJECTOR 30 MG SUBCUTANEOUS 7 TANZEUM PEN-INJECTOR 50 MG SUBCUTANEOUS 7 TEKTURNA HCT TABLET MG ORAL 10 TEKTURNA HCT TABLET MG ORAL 10 TEKTURNA HCT TABLET MG ORAL 10 TEKTURNA HCT TABLET MG ORAL 10 TEKTURNA TABLET 150 MG ORAL 10 TEKTURNA TABLET 300 MG ORAL 10 trimethobenzamide hcl capsule 300 mg oral 2 V VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 7 14
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