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Step Therapy Programs Step therapy programs require a “step” approach to receive coverage for certain high-cost medications, including: Antidepressants (SSRIs/SNRIs) Pristiq  Proton Pump Inhibitors (PPIs)  Sedative Hypnotics  Singulair (Leukotriene Modifiers)  Fibrates Triptan  Xyzal

This means that to receive coverage, you may need to first try a proven, cost-effective medication before moving to a more costly treatment, if necessary. If your doctor wants you to “skip” steps, your doctor must submit a prior authorization request and receive approval for the drug to be covered.

Antidepressants (SSRIs/SNRIs) Step Therapy Program 

The antidepressants (SSRIs/SNRIs) covered under this program include:

• Cymbalta       
• Effexor XR                                                                             
• Lexapro                                                                                  
• Luvox CR                                                                               
• Pexeva
• Prozac Weekly
• Venlafaxine ER   

To receive coverage for these drugs, you must first try one of these generic drugs:

• fluoxetine
• citalopram
• fluvoxamine
• paroxetine/SR
• sertraline
• venlafaxine

If your doctor determines any of these drugs were not successful in your treatment, you may then be eligible for one of these brand-name drugs as a covered benefit.

Pristiq Step Therapy Program

Pristiq is used to treat depression. To receive coverage for Pristiq, you must first try a generic (Tier 1) antidepressant and then a preferred (Tier 2) antidepressant. If your doctor determines these are not effective, you then have coverage for Pristiq.

Proton Pump Inhibitor (PPI) Step Therapy Program

PPIs are drugs used to treat various stomach and digestive problems, including heartburn. These drugs include:

• Prevacid
• Nexium
• Aciphex
• Prilosec
• Protonix
• Zegerid
• Kapidex

To receive coverage for PPIs, you must:

• First try two generic PPI’s of either omeprazole (generic Prilosec), pantroprazole (generic Protonix), or lansoprazole (generic Prevacid).

• If your doctor determines that neither generic versions of PPI medications were successful, you then have coverage for Nexium, Aciphex, Prilosec, Prevacid, Protonix, Kapidex, or Zegerid.

Sedative Hypnotics Step Therapy Program

Sedative hypnotics are used to treat insomnia. These drugs include:

• Generic Ambien (zolpidem tartrate)
• Ambien
• Ambien CR
• Sonata
• Lunesta
• Rozerem

To receive coverage for sedative hypnotics, you must first try generic Ambien. If your doctor determines generic Ambien is not effective, you then have coverage for any of the other sedative hypnotics.

Singulair (Leukotriene Modifiers) Step Therapy Program

Leukotriene Modifiers are used to treat asthma and allergies. These drugs include:

• Singulair
• Accolate
• Zyflo CR

If you are 18 and older, you must first try both a non-sedating antihistamine and a nasal corticosteroid. If your doctor determines these are not effective to treat your condition, you then have coverage for a Leukotriene Modifier.

Fibrates Step Therapy Program

Fibrates are drugs used to lower triglycerides and raise HDL or good cholesterol. These brand-name drugs include:

• Antara
• Fenoglide
• Lipofen
• Tricor
• Triglide
• Trilipix  

To receive coverage for any of the brand fibrates listed above, you must first try one of these generic drugs:

• Fenofibrate
• Fenofibrate micronized
• Gemfibrozil

If your doctor determines these drugs are not effective, you then have coverage for a brand-name fibrate. Your prescription for the brand fibrate will automatically approve as long as there is prior history in our claims system of a generic fibrate.

Triptan Step Therapy Program

Triptans are drugs used to treat migraine headaches. These drugs include:

• Amerge
• Axert
• Frova
• Maxalt
• Relpax
• Zomig

To receive coverage for these drugs, you must:

• First try sumatriptan (generic Imitrex)
• If you doctor determines the generic drug is not effective, you then have coverage for the brand-name drugs listed above.

Xyzal Step Therapy Program

Xyzal is used to treat allergies. To receive coverage for Xyzal, you must first try both Zyrtec (an over-the-counter antihistamine) and generic Allegra. If your doctor determines these are not effective, you then have coverage for Xyzal.