2019 Step Therapy Criteria

For BlueJourney HMO and BlueJourney PPO Members

Step therapy encourages safe and cost-effective medication use. This may mean you need to first try a proven and cost-effective medication before using a costly alternative. Always ask your doctor about the best options for you.

Generic Standard Formulary (Updated 01/2017)

Group
Drug Name
Criteria
ULORIC
ULORIC
Coverage will be provided if allopurinol has been tried (at least a 30-day supply in the prior 180 days

Expanded Performance Formulary (Updated 03/2017)

Group
Drug Name
Criteria
BENIGN PROSTATIC HYPERPLASIA
RAPAFLO Coverage will be provided if terazosin, alfuzosin, doxazosin extended-release, or tamsulosin has been tried (at least a 30-day supply in the prior 180 days).
BISPHOSPHONATES FOSAMAX PLUS D Coverage will be provided if alendronate, ibandronate, pamidronate, or risedronate has been tried (at least a 30-day supply in the prior 180 days).
HMG-COA INHIBITORS VYTORIN Coverage will be provided if atorvastatin, fluvastatin, fluvastatin extended-release, lovastatin, lovastatin extended-release, pitavastatin, pravastatin, simvastatin, rosuvastatin, or amlodipine/atorvastatin has been tried (at least a 30-day supply in the prior 180 days).
PROSTAGLANDINS ZIOPTAN Coverage will be provided if latanoprost, bimatoprost, or travoprost has been tried (at least a 30-day supply in the prior 180 days).
TRIPTANS ONZETRA XSAIL, TREXIMET, ZEMBRACE SYMTOUCH Coverage will be provided if almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, rizatriptan ODT, sumatriptan nasal spray, sumatriptan tabs, sumatriptan injection, zolmitriptan, zolmitriptan ODT, or zolmitriptan nasal spray has been tried (at least a 30-day supply in the prior 180 days).
ULORIC ULORIC Coverage will be provided if allopurinol has been tried (at least a 30-day supply in the prior 180 days)
URINARY ANTISPASMODICS GELNIQUE Coverage will be provided if oxybutynin, oxybutynin extended-release, tolterodine, tolterodine extended-release, trospium, trospium extended-release, oxybutynin patch, fesoterodine, or darifenacin extended-release has been tried (at least a 30-day supply in the prior 180 days).

Web Content Viewer - Fixed Context

Updated November 1, 2019

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