Step Therapy Medications

1 step Therapy Medications step Therapy is a limitation that requires you to try preferred Medications before the plan will pay for another medication for the same medical condition that the doctor may have originally prescribed. An automated, electronic review of your medication history is performed to determine whether other Medications have been tried first for your condition. This ensures clinically sound and cost-effective treatment options are tried. If a prescribed medication does not meet the step Therapy criteria, it may not be covered. You should consult with your doctor about alternative Therapy . If a medication does not meet the step Therapy criteria for automatic approval, it will reject at the pharmacy; your provider may request prior authorization. Questions? Log in to MyBlueSM to find participating retail pharmacies, review your specific benefit information, and compare medication pricing and options. If you have questions, please call us.

2 Member Services Phone Number Standard Hours of Operation Pharmacy Benefits 1 (866) 325-1794 24/7/365 BCBSAZ Call the number on your ID card 8:30 to 4:30 Monday - Friday step Therapy Drug ListTable of Contents*Adhd/Anti-Narcolepsy/Anti-Obesi ty/Anorexiants*..4*Analgesics - Opioid*..4*Antiasthmatic And Bronchodilator Agents*..4*Anticonvulsants*..6*Antidepre ssants*..7*Antidiabetics*..8*Antidotes And Specific Antagonists*..12*Antiemetics*..12*Antifu ngals*..12*Antihistamines*..12*Antihyper lipidemics*..12*Antimalarials*..13*Antip sychotics/Antimanic Agents*..13*Antivirals*..13*Beta Blockers*..13*Calcium Channel Blockers*..13*Cardiovascular Agents - Misc.*..14*Contraceptives*..14*Corticost eroids*..14*Cough/Cold/Allergy*..14*Derm atologicals*..15*Diagnostic Products*..17*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*.

3 32*Musculoskeletal Therapy Agents*..32*Ophthalmic Agents*..32*Psychotherapeutic And Neurological Agents - Misc.*..33*Ulcer Drugs/Antispasmodics/Anticholinergics*.. 3323 step 2 ProductStep 1 Product*Adhd/Anti-Narcolepsy/Anti-Obesit y/Anorexiants**Adhd Agent - Selective Norepinephrine Reuptake Inhibitor**QELBREEQL (1 capsule per day); step Therapy Required (EST as follows:ST through atomoxetine (generic for Strattera) for at least 3 months in the last 12 months.)*Amphetamine Mixtures**MYDAYISQL (1 capsule per day); step Therapy Required (Trial of the following for 3 months in last 12 months: ADDERALL XR or amphetamine/dextroamphetamine ER); AL (Min 6 Years)*Analgesics - Opioid**Opioid Agonists**tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mgQL (1 tablet per day); step Therapy Required (Trial of Non ER Tramadol tablets in last 3 months); AL (Min 16 Years)*Antiasthmatic And Bronchodilator Agents**5-Lipoxygenase Inhibitors**zileuton erQL (2 tablets per day); step Therapy Required (Trial of both of the following for at least 3 months each in last 12 months: montelukast, zafirlukast); AL (Min 12 Years)ZYFLOQL (4 tablets per day); step Therapy Required (Trial of both of the following for at least 3 months each in last 12 months: montelukast, zafirlukast); AL (Min 12 Years)*Adrenergic Combinations**AIRDUO DIGIHALERQL (1 inhaler per month).

4 step Therapy Required (Trial of two of the following for 3 months each in the last 12 months: ADVAIR (DISKUS or HFA), BREO ELLIPTA, fluticasone propionate/salmeterol, SYMBICORT); AL (Min 12 Years)AIRDUO RESPICLICK 113/14QL (1 inhaler per month); step Therapy Required (Trial of two the following for 3 months 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 Therapy Required (Trial of two the following for 3 months in the last 12 months: ADVAIR (DISKUS or HFA), BREO ELLIPTA, fluticasone propionate/salmeterol, SYMBICORT); AL (Min 12 Years)Last revision date:05/12/2022 To search for a drug use control + f 4 step 2 ProductStep 1 ProductAIRDUO RESPICLICK 55/14QL (1 inhaler per month); step Therapy Required (Trial of two the following for 3 months in the last 12 months: ADVAIR (DISKUS or HFA), BREO ELLIPTA, fluticasone propionate/salmeterol, SYMBICORT); AL (Min 12 Years)BEVESPI AEROSPHEREQL (1x or 1x inhaler per month); step Therapy Required (Trial of both of the following in the last 12 months: ANORO ELLIPTA, STIOLTO RESPIMAT); AL (Min 15 Years)BREZTRI AEROSPHEREStep Therapy Required (Trial of two of the following for 3 months each in the last 12 months: Bevespi, Duaklir Pressair, Lonhala Magnair)DUAKLIR PRESSAIRStep Therapy Required (Trial of both of the following in the last 6 months: ANORO ELLIPTA, SYMBICORT)DULERAQL (1x or 1x 13gm inhaler per month).

5 step Therapy Required (Trial of two the following for 3 months in the last 12 months: ADVAIR (DISKUS or HFA), BREO ELLIPTA, fluticasone propionate/salmeterol, SYMBICORT)fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/actQL (1 inhaler per month); step Therapy Required (Trial of the following in last 3 months: ADVAIR DISKUS); AL (Min 12 Years)*Beta Adrenergics**levalbuterol tartrateQL (1gm per day); step Therapy Required (Trial of the following in the last 1 month: Albuterol HFA)STRIVERDI RESPIMATStep Therapy Required (Trial of three of the following for 3 months each In the last 12 months: ANORO ELLIPTA, ARCAPTA NEOHALER, SEREVENT DISKUS, simultaneous use of SPIRIVA with SEREVENT DISKUS, simultaneous use of SPIRIVA with ARCAPTA NEOHALER)XOPENEX 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 the following for 3 months each in the last 12 months: INCRUSE ELLIPTA, SEEBRI NEOHALER, SPIRIVA (HANDIHALER or RESPIMAT), TUDORZA PRESSAIR); AL (Min 18 Years)Last revision date:05/12/2022 To search for a drug use control + f 5 step 2 ProductStep 1 ProductLONHALA MAGNAIR STARTER KITStep Therapy Required (Trial of two of the following for 3 months each in the last 12 months: INCRUSE ELLIPTA, SEEBRI NEOHALER, SPIRIVA (HANDIHALER or RESPIMAT), TUDORZA PRESSAIR); AL (Min 18 Years)*Steroid Inhalants**ARMONAIR DIGIHALERStep Therapy Required (Trial of the following in the last 3 months: Flovent)*Anticonvulsants**Anticonvulsant s - Benzodiazepines**SYMPAZANQL (2 films per day); step Therapy Required (Trial of the following in the last 3 months: ONFI)*Anticonvulsants - Misc.

6 **APTIOM ORAL TABLET 200 MG, 400 MGQL (1 tablet per day); step Therapy Required (Trial of three of the following in the last 12 months: gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, topiramate, zonisamide)APTIOM ORAL TABLET 600 MG, 800 MGQL (2 tablets per day); step Therapy Required (Trial of three of the following in the 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 the last 12 months: levetiracetam (generic for KEPPRA)); AL (Min 4 Years)BRIVIACT ORAL TABLETQL (2 tablets per day); step Therapy Required (Trial of the following for 2 months 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 Therapy Required (EST as follows: ST through levetircetam 24hr tablet (generic for KEPPRA ) for at least 3 months in the last 12 months.)

7 ; AL (Min 12 Years)ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 1500 MGQL (2 tablets per day); step Therapy Required (EST as follows: ST through levetircetam 24hr tablet (generic for KEPPRA ) for at least 3 months in the last 12 months.); AL (Min 12 Years)QUDEXY XRStep Therapy Required (Trial of the following for 3 months in the last 12 months: topiramate (generic for TOPAMAX)); AL (Min 3 Years)topiramate erStep Therapy Required (Trial of the following for 3 months in the last 12 months: topiramate (generic for TOPAMAX)); AL (Min 3 Years)Last revision date:05/12/2022 To search for a drug use control + f 6 step 2 ProductStep 1 ProductTROKENDI XRStep Therapy Required (Trial of both of the following for 3 months each in the last 12 months: topiramate (generic for TOPAMAX) and topiramate ER capsule (generic for QUDEXY XR)); AL (Min 6 Years)*Carbamates**XCOPRIQL (1 tablet per day); step Therapy Required (Trial of at least 3 of the following in the last 12 months: carbamazepine, lacosamide (generic for VIMPAT), lamotrigine, levetiracetam IR, oxcarbazepine, topiramate, valproic acid & derivatives)XCOPRI (350 MG DAILY DOSE)QL (2 tablets per day).

8 step Therapy Required (Trial of at least 3 of the following in the last 12 months: carbamazepine, lacosamide (generic for VIMPAT), lamotrigine, levetiracetam IR, oxcarbazepine, topiramate, valproic acid & derivatives)*Antidepressants**Serotonin Modulators**TRINTELLIX ORAL TABLET 10 MGQL (2 tablets per day); step Therapy Required (Trial of two drugs in either of the following classes for at least 2 months in last 12 months: selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors); AL (Min 18 Years)TRINTELLIX ORAL TABLET 20 MG, 5 MGQL (1 tablet per day); step Therapy Required (Trial of two drugs in either of the following classes for at least 2 months in last 12 months: selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors); AL (Min 18 Years)*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**DRIZALMA SPRINKLEQL (1 capsule per day); step Therapy Required (Trial of the following for 3 month in the last 6 months: CYMBALTA, duloxetine); AL (Min 7 Years)FETZIMAQL (1 capsule per day); step Therapy Required (Trial of two drugs in either of the following classes for at least 2 months in last 12 months: selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors)Last revision date:05/12/2022 To search for a drug use control + f 7 step 2 ProductStep 1 ProductFETZIMA TITRATIONQL (1 capsule per day); step Therapy Required (Trial of two drugs in either of the following classes for at least 2 months in last 12 months: selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors)*Antidiabetics**Biguanides**m etformin hcl er (osm) oral tablet extended release 24 hour 1000 mgQL (2 tablets per day).

9 step Therapy Required (Trial of the following for 3 months in the last 12 months: generic GLUCOPHAGE XR)metformin hcl er (osm) oral tablet extended release 24 hour 500 mgQL (4 tablets per day); step Therapy Required (Trial of the following for 3 months in the last 12 months: generic GLUCOPHAGE XR)RIOMET ERQL (20ml per day); step Therapy Required (Trial Metformin 500mg ER tab in last 6 months)*Diabetic Other**ZEGALOGUEQL ( with fill limit of 2 fills/month); DS (2); step Therapy Required (EST: step through generic Glucagon (NDC 00548585000) for at least 1 month in the last 12 months); AL (Min 6 Years)*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors**alogliptin benzoateStep Therapy Required (Trial of one the following for 3 months in the last 12 months: simultaneous use of metformin with ONGLYZA or simultaneous use of metformin with JANUVIA)NESINAStep Therapy Required (Trial of one the following for 3 months in the last 12 months: simultaneous use of metformin with ONGLYZA or simultaneous use of metformin with JANUVIA)*Human Insulin**ADMELOG SOLOSTARQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)ADMELOG SUBCUTANEOUSQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)APIDRAQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTORQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)BASAGLAR KWIKPENQL (2ml per day).

10 step Therapy Required (Trial history of LANTUS)Last revision date:05/12/2022 To search for a drug use control + f 8 step 2 ProductStep 1 ProductFIASPQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)FIASP FLEXTOUCHQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)insulin asp prot & asp flexpenQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG MIX 75/25)insulin aspart flexpenQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)insulin aspart penfillQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)insulin aspart prot & aspartQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG MIX 75/25)insulin aspart subcutaneousQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)insulin glargine-yfgn subcutaneous solutionQL (2ml per day); step Therapy Required (Trial history of LANTUS)insulin lispro (1 unit dial)QL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)insulin lispro junior kwikpenQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)insulin lispro prot & lisproQL (60ml per month); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)insulin lispro subcutaneousQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: HUMALOG)LEVEMIRQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: LANTUS)LEVEMIR FLEXTOUCHQL (2ml per day); step Therapy Required (Trial of the following in the last 12 months: LANTUS)NOVOLIN 70/30QL (2ml per day).