Drugs that May Require a Trial of Another Agent (Step Therapy) or Prior Authorization
Click on the Drug Class to see the Criteria In Use by Medical Mutual for coverage approval.
| Drug Class | Drugs in Class |
|---|---|
| Acne - Other Topical Products | Branded Topical Prescription Acne Products, Clindagel |
| Acne - Topical Cleansers | Branded Prescription Acne Cleansers |
| Antidepressants – Bupropion LA Antidepressant Therapy | Auvelity, Bupropion LA Products |
| Antiepileptics | Briviact, Elepsia XR, and Spritam |
| Antiepileptics – Oxtellar XR, Trileptal | Oxtellar XR, Trileptal |
| Antifungal - topical | Tavaborole 5% solution |
| Atopic Dermatitis |
generic pimecrolimus 1% cream and generic tacrolimus 0.03% and 0.1% ointment |
| Attention Deficit Hyperactivity Disorder | Adderall XR, Adhansia XR, Adzenys XR-ODT (brand and authorized generic), Amphetamine ER ODT (generic), Aptensio XR (brand and generics), Azstarys, Concerta, Cotempla XR-ODT, Daytrana (brand and generic methylphenidate transdermal system), Dexedrine Spansules, Dyanavel XR (tablets and oral solution), Focalin XR, Jornay PM, Metadate CD, Generic methylphenidate extended-release 72 mg tablets, Mydayis, QuilliChew ER, Quillivant XR, Relexxii (brand and authorized generic), Ritalin LA, Vyvanse capsules, Vyvanse chewable tablets (brand and generic), Xelstrym |
| Atypical Antipsychotics | Bysanti, Caplyta, Cobenfy, Fanapt, Rexulti, Vraylar |
| Bisphosphonates | risedronate |
| BPH 5-Alpha Reductase Inhibitor | dutasteride and dutasteride/tamsulosin |
| Carbidopa-Levodopa Oral | Crexont, Rytary, Rytary AG |
| Contraceptives (Oral and Patch) | Branded Contraceptives |
| Cyanocobalamin | Generic cyanocobalamin nasal spray |
| Diabetic Test Strips |
All products targeted except listed preferred. PREFERRED Products are Abbott (e.g., Freestyle, Freestyle Lite, Freestyle InsuLinx, Freestyle Neo) and Trividia/Nipro (e.g., TRUEtrack, TRUEmetrix) |
| Epinephrine auto-injectors | Epipen, Epipen Jr. |
| Erectile Dysfunction | Generic avanafil tablets, generic vardenafil tablets |
| Expendable | Alcortin A, Alkindi Sprinkle, Allzital tablet, Amrix and generic, Antivert 50 mg tablet and authorized generic meclizine 50 mg, Astagraf XL, Bucapsol Capsules, Bupap tablet, butalbital 50 mg, acetaminophen 300 mg capsule, Carospir, Consensi, Desmoda, Dexabliss 11 daqy pack, DexPak 6 day/10 day/13 day and generics, Durlaza, Dxevo dose pack, Envarsus XR, Epaned, Esgic capsule, Fexmid, Fioricet capsule, Fiorinal capsule, Flowtuss, Fleqsuvy and baclofen oral suspension, Hemady, Hemangeol, Hemiclor, Javadin, Jylamvo, Lorzone, Lyvispah, Novacort gel, Pliaglis and lidocaine 7% and tetracaine 7% cream (brand), Procysbi, Qbrelis, Ozobax, Ozobax DS, and generics, Rayos, Sitavig, Taperdex, Thalitone, Tuzistra XR, Vituz, Xatmep, Yosprala and authorized generic, Zcort, zileuton extended-release tablets, Zodex 6 day/12 day, Zyflo |
| Gabapentin | Gabapentin ER, Gralise, Horizant, Lyrica, Neurontin, pregabalin |
| Glaucoma Ophthalmic Alpha Adrenergic Agonist | Iopidine 0.5% and 1% |
| Glaucoma Ophthalmic Beta-Adrenergic Blocker | Betagan, Betimol, Betopic, Betopic S, Istalol, Timoptic, Timoptic XE, Timoptic Ocudose |
| Gout | Febuxostat |
| Hypnotics | Belsomra (suvorexant), Dayvigo (lemborexant), doxepin 3 and 6 mg – generic to Silenor, Edluar (zolpidem 5 and 10 mg sublingual tablets), Quviviq (daridorexant), zaleplon capsules – generic only, zolpidem capsules – generic, zolpidem 1.75 and 3.5 mg sublingual tablets – generic only |
| Infertility - Follitropins | Gonal-F and Gonal-F RFF |
| Infertility - Gonadotropin Releasing Hormone (GnRH) Antagonists | Ganirelix, fyremadel |
| Insulin (rapid-acting) | Lyumjev Tempo |
| Inflammatory Bowel | Apriso, Azulfidine/Azulfidine Entab, Colazal, Dipentum, Giazo, Mesalamine 800mg |
| Isotretinoin | Absorica |
| Long Acting Beta-Agonists (LABAs) for COPD | Generic formoterol fumarate |
| Methotrexate | Rasuvo, RediTrex |
| Nonsteroidal Anti-inflammatory Drug (NSAID) | diclofenac potassium 25 mg capsules and tablets, ketoprofen ER 200 mg, Licart*, meloxicam suspension, generic naproxen suspension, Sprix, tolmetin 400 mg & 600 mg |
| Oncology Care Value | Bosulif, Ibrance, Iclusig, Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg, Scemblix, Tasigna |
| Ophthalmic Antihistamines | Bepotastine, Ioteprednol, Zerviate |
| Ophthalmic NSAIDS | Acular, Acular LS, Acuvail, Bromfenac, Ilevro, Nevanac |
| Ophthalmic Prostaglandin | Bimatoprost 0.03%, Rhopressa, Rocklatan, Travoprost, Tafluprost |
| Ophthalmic Steroids | Clobetasol propionate suspension, FML S.O.P, Inveltys, Lotemax |
| Opioids (long-acting oral) | Arymo ER, Kadian, MS Contin, Nucynta ER, Oxycodone extended-release (branded products), OxyContin, Xtampza ER, Zohydro ER |
| Otic Antibiotics | Cipro HC, Ciprodex, Otovel |
| Overactive Bladder | Darifenacin ER, Oxytrol, Solifenacin, Tolterodine ER, Trospium, Trospium ER |
| Pen Needles | Arkray, Home Aide Diagnostics, HTL-Strefa, Nipro Diagnostics, Novo Nordisk, Owen Mumford, Simple Diagnostics, Ultimed, all other diabetic pen needles that are not BD |
| Post-transplant Immunosuppresants | Azasan, Cellcept, Imuran, Myfortic, Myhibbin, Neoral, Prograf, Rapamune, Sandimmune, Sirolimus AvPak, Tacrolimus Novaplus |
| Proton Pump Inhibitors (PPI) |
Dexlansoprazole, esomeprazole oral packets, lansoprazole ODT tablets, pantoprazole oral packets |
| SGLT-2 Inhibitors | Brenzavvy, Farxiga, Jardiance, Xigduo XR, Synjardy, Segluromet, Steglatro |
| SGLT-2/DPP-4 Inhibitor Combinations | SGLT-2/DPP-4 Inhibitor Combinations |
| SNRI-SSRI | Generic escitalopram oral solution, generic fluoxetine delayed-release 90 mg capsule, generic fluoxetine immediate-release tablets, generic fluvoxamine extended-release capsules, generic paroxetine HCl controlled-release (CR)/extended-release (ER) tablets, generic paroxetine HCl oral suspension, generic paroxetine mesylate capsules, generic vilazodone hydrochloride tablets, Trintellix, Desvenlafaxine extended-release tablets (brand product), Fetzima, Savella, generic desvenlafaxine succinate extended-release tablets, generic duloxetine 40 mg delayed-release capsules, venlafaxine besylate extended-release tablets |
| Tetracyclines (oral) | Actilate, Avidoxy DK, doxycycline hyclate DR, doxycycline IR-ER, doxycycline monohydrate, Minolira ER, Monodox, Morgidox, Oracea, Seysara, Solodyn ER, Soloxide, Targadox, Vibramycin, Ximino ER |
| Topical Antibiotics | Bactroban (mupirocin cream) |
| Topical Corticosteroids | Branded Topical Corticosteriods |
| Topical Rosacea | Finacea Foam, Rosadan cream and gel kits, Soolantra |
| Topical Vitamin D Analogs | Calcipotriene, Calcipotriene-Betamethasone and dipropionate, Enstilar, Sorilux, Taclonex, Wynzora |
| Topiramate | Eprontia, topiramate capsule ER 24 hour sprinkle (generic to Qudexy XR), topiramate capsule extended release 24 hour (generic to Troxendi XR), Trokendi XR, Trokendi, and Topiramate ER |
| Transdermal Estrogen | Elestrin, EstroGel, Evamist, Divigel |
| Triptan & Ergot Migraine Agents | Almotriptan, Alsuma, Amerge, Axert, Eletriptan, Frovatriptan, Migranal, Naratriptan, sumatriptan/naproxen, Tosymra, Zecuity, Sumavel, Zolmitriptan, Zomig |