Performance Formulary Step Therapy
August 10, 2023Primary Formulary Changes
August 10, 2023Step Therapy is a program designed to encourage appropriate utilization of lowest-net-cost medications for chronic medical conditions, helping to control healthcare costs. Step Therapy is a series of steps or medications that must be tried in a specific order. We review the prescription claim history for specific medications before the current claim can be processed to ensure the previous step has been met.
*Plan Design and Formulary Placement may affect coverage of medications listed. They supercede step therapy.
| Therapeutic Class | Disease State | 1 st Line Medications | 2 nd Line Medications | Rules |
|---|---|---|---|---|
| Standard | ||||
| Pepcid | GERD | cimetidine, famotidine, nizatidine | Pepcid (Rx only) | Approve second line medication if patient has at least a 30 day trial of a first line medication within 180 days |
| Accrufer | Iron Deficiency | ferrous sulfate, ferrous gluconate, ferrous fumarate | Accrufer | Approve second line medication if patient has at least a 30 day trial of a first line medication within 180 days |
| Auryxia | Phosphate-Removing Agent | Iron deficiency anemia: ferrous
sulfate, ferrous gluconate, ferrous
fumarate Hyperphosphatemia: calcium acetate, sevelamer, lanthanum carbonate | Auryxia | Approve second line medication if patient has at least a 30 day trial of a first line medication within 180 days |
| Nitroglycerin | Angina | nitroglycerin patch and sublingual tablets | Nitrostat, Nitrolingual, Nitro-DUR, Gonitro, nitroglycerin translingual spray | Approve second line medication if patient has at least a 30 day trial of a first line medication within 180 days |
| Calcitriol | Hyperparathyroidism | calcitriol capsules | Rocaltrol capsules and solution, calcitriol 1 mcg/mL solution, doxercalciferol capsules, paricalcitol capsules | Approve second line medication if patient has at least a 30 day trial of a first line medication within 180 days |