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 |
| Acne - Topical Cleansers | Branded Prescription Acne Cleansers |
| Acne - Topical Kits | Branded Prescription Acne Kits |
| Actinic Keratosis | Aldara 5% cream, Efudex 5% cream, Fluorouracil 2% solution, Fluorouracil 5% cream, Fluorouracil 5% solution, Imiquimod 5% cream, Picato 0.015% gel, Picato 0.05% gel |
| ADHD Non-Stimulants | Intuniv, Kapvay and Strattera |
| Angiotensin II Receptor Antagonists | Atacand, Atacand HCT, Avalide, Avapro, Azor, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Edarbi, Edarbyclor, Exforge, Exforge HCT, Hyzaar, Micardis, Micardis HCT, Prexxartan, Teveten, Teveten HCT, Tribenzor, Twynsta |
| Antidepressants – Bupropion LA Antidepressant Therapy | Auveility, Bupropion LA Products |
| Antiepileptics | Briviact, Elepsia XR, Keppra, Keppra XR, Elepsia XR and Spritam |
| Antiepileptics – Oxtellar XR, Trileptal | Oxtellar XR, Trileptal |
| Antifungal - topical | Ciclodan 8% Kit, CNL 8 Nail Kit, Kerydin, Pedipirox-4 Nail Kit, Penlac |
| Antipsychotic Agents | Caplyta, Rexulti |
| Atopic Dermatitis | Elidel, Eucrisa, generic tacrolimus 0.03% or 0.1% ointment, Protopic |
| Attention Deficit Hyperactivity Disorder | Adderall XR, Aptensio XR, Concerta, Daytrana, Dexedrine Spansules, Dyanavel XR, Focalin XR, Metadate CD, QuiliChew ER and IR, Ritalin LA and SR, Vyvanse, Adzenys ER suspension, Adzenys XR-ODT, Cotempla XR-ODT, Methylphenidate 72 mg ER (brand), Mydayis, Qullivant XR, methylphenidate transdermal system, Xelstrym |
| Avodart | Avodart, Jalyn, Proscar |
| Beta-Blocker | Branded Beta-blockers and Beta-blocker Combinations |
| Beta2 Agonists (short-acting) Inhalers | Proventil HFA, Xopenex HFA |
| Bile Acid Sequestrants | Cholestyramine, Colesevelam, Colestid, Colestipol, Prevalite, Questran, Welchol |
| Bisphosphonates | Actonel, Atelvia, Binosto, Boniva, Fosamax, Fosamax Plus D |
| Buprenorphine | Belbuca, Butrans, Subutex |
| Calcium Channel Blockers | Katerzia, Norliqva, Norvasc, Conjupri |
| Contraceptives (Oral and Patch) | Branded Contraceptives |
| Cyanocobalamin | Nascobal |
| Cyclooxygenase-2 (COX-2) Inhibitor | Celebrex, Celecoxib |
| Desmopressin | Desmopressin, Nocdurna |
| Diabetic Test Strips | All products targeted except listed preferred. For members using the National Preferred/National Preferred Plus Formulary: Lifescan (e.g., OneTouch Ultra, OneTouch Verio) are PREFERRED, For members using the Basic/Basic Plus Formulary: Abbott (e.g., Freestyle, Freestyle Lite, Freestyle InsuLinx, Freestyle Neo), Lifescan (e.g., OneTouch Ultra, OneTouch Verio), other Abbott (Optium EZ, Optium, Precision PCX, Precision PCX Plus, Precision Point of Care, Precision Q-I-D, Precision Xtra, Ultima) are PREFERRED |
| Dipeptidyl Peptidase-4 (DPP-4) Inhibitors | Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni (alogliptin and pioglitazone) |
| Epinephrine auto-injectors | Epipen, Epipen Jr. |
| Erectile Dysfunction | Levitra, Staxyn, Stendra, Viagra |
| Expendable | Alcortin A, Alkindi Sprinkle, Allzital tablet, Amrix and generic, Android, Astagraf XL, Bupap tablet, butalbital 50 mg, acetaminophen 300 mg capsule, Carospir, Consensi, DexPak 6 day/10 day/13 day and generics, Durlaza, Dxevo dose pack, Envarsus XR, Epaned, Esgic capsule, Fexmid, Fioricet capsule, Fiorinal capsule, Flowtuss, Hemady, HiDex 6 day, Hycofenix, LoCort 7 day/11 day, Lorzone, Novacort gel, Obredon, Pliaglis and lidocaine 7% and tetracaine 7% cream (brand), Procysbi, Qbrelis, Rayos, Sitavig, Synera, Taperdex, Testred, Tussicaps, Tuzistra XR, Vanatol LQ, Vanatol S, Vituz, Xatmep, Yosprala and authorized generic, Zcort, zileuton extended-release tablets, Zodex 6 day/12 day, Zonacort 7 day/11 day, Zyflo |
| Fenofibrate | Antara, fenofibrate 30mg, fenofibrate 40mg, fenofibrate 50mg, fenofibrate 90mg, fenofibrate 120mg, fenofibrate 150mg, Fenoglide, Fibricor, Lipofen, Tricor, Triglide and Trilipix |
| Gabapentin | Gralise, Horizant, Lyrica, Neurontin, pregabalin |
| Glaucoma Ophthalmic Alpha Adrenergic Agonist | Alphagan P 0.1%, Alphagan P 0.15%, Iopidine 0.5% and 1% |
| Glaucoma Ophthalmic Beta-Adrenergic Blocker | Istalol, Betagan, Timoptic, Timoptic XE, Timoptic Ocudose |
| Glaucoma Ophthalmic Carbonic Anhydrase Inhibitor | Trusopt |
| Glaucoma Ophthalmic Combination Product | Combigan, Cosopt, Cosopt PF |
| Gout | Allopurinol, Duzallo, Probenecid, Probenecid/Colchicine, Uloric, Zurampic |
| HMG-CoA Reductase Inhibitors | Altoprev, Caduet, Crestor, Livalo, Lescol, Lescol XL, Lipitor, Mevacor, Pravachol, Zocor |
| Hormone Replacement Therapy Combo Patches | ClimaraPro |
| Hydroxyurea | Siklos |
| Hypnotics | Ambien, Ambien CR, Belsomra, Dayvigo, Edular, Intermezzo, Lunesta, Quviviq, Rozerem, Silenor, Sonata, Zolpimist |
| Infertility - Follitropins | Bravelle, Follistim AQ, Fyremade, Gonal-F and Gonal-F RFF |
| Infertility - Gonadotropin Releasing Hormone (GnRH) Antagonists | Ganirelix, fyremadel |
| Inhaled Corticosteroid/Long-Acting Beta Agonists (ICS/LABA) | AirDuo Digihaler |
| Insulin (other) | Novolin 70/30, Novolin N, Novolin R |
| Insulin (rapid-acting) | Admelog, Apidra, Apidra Solostar, Novolog, Novolog Mix 70/30, Fiasp, NovoLog PenFill, NovoLog Flexpen, Novolog 70/30 FlexPen |
| Inflammatory Bowel | Asacol, Asacol HD, Azulfidine/Azulfidine Entab, Colazal, Delzicol, Dipentum, Giazo, Lialda, Mesalamine 800mg |
| Inhaled Corticosteroids | Alvesco |
| Intranasal Steroids | Beconase AQ, Dymista, Nasonex, Omnaris, Qnasl, Rhinocort , Ryaltris, azelastine/fluticasone and mometasone furoate, Ticalast, Veramyst, Zetonna |
| Isotretinoin | Absorica |
| Lacosamide | Vimpat tablet and oral solution |
| Long Acting Beta-Agonists (LABAs) for COPD | Brovana |
| Methotrexate | Otrexup, Rasuvo, RediTrex |
| Nonsteroidal Anti-inflammatory Drug (NSAID) | Branded NSAIDs, diclofenac sodium topical solution 2%, meloxicam suspension and topical diclofenac gel |
| Ophthalmic Antihistamines | Alrex, Bepreve, Lastacaft, Zerviate |
| Ophthalmic NSAIDS | Acular, Acular LS, Acuvail, Bromfenac, Bromsite, Ilevro, Nevanac, Prolensa |
| Ophthalmic Prostaglandin | Rhopressa and Rocklatan, tafluprost, Xalatan, Xelpros, Vyzulta, Zioptan |
| Ophthalmic Steroids | FFML Forte, FML Liquifilm, FML S.O.P, Maxidex, Pred Mild |
| Opioids (long-acting oral) | Arymo ER, Hysingla ER, Kadian, MS Contin, Nucynta ER, Oxycodone extended-release (branded products), OxyContin, Xtampza ER, Zohydro ER |
| Otic Antibiotics | Cetraxal, Ciprodex, Otovel |
| Overactive Bladder | Darifenacin ER, Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique, Myrbetriq, Oxybutynin, Oxybutynin ER, Oxytrol, Solifenacin, Tolterodine, Tolterodine ER, Toviaz, Trospium, Trospium ER, Vesicare |
| 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 |
| Proton Pump Inhibitors (PPI) | Esomeprazole, Lansoprazole, Lansoprazole capsules and Lansoprazole ODT, Omeprazole, Omeprazole/Sodium Bicarbonate, Pantoprazole, Rabeprazole, Zegerid |
| SGLT-2 Inhibitors | Farxiga, Invokana, Invokamet, Jardiance, Xigduo XR, Synjardy, Segluromet, Steglatro |
| SGLT-2/DPP-4 Inhibitor Combinations | SGLT-2/DPP-4 Inhibitor Combinations |
| SNRI Antidepressants Therapy | SNRI Products |
| Selective Serotonin Reuptake Inhibitors Antidepressants Therapy | SSRI Products |
| Tetracyclines (oral) | Acticlate, Adoxa, Alodox, Avidoxy, Dynacin, Minocin, Minocycline ER, Monodox, Morgidox, Oracea, Solodyn, Vibramycin, Doxycline IR-DR, Ximino |
| Topical Antibiotics | Altabax, Bactroban (mupirocin cream), Centany, Centany AT, Xepi |
| Topical Corticosteroids | Branded Topical Corticosteriods |
| Topical Podofilox | Condylox Gel |
| Topical Rosacea | Finacea, MetroCream, MetroGel, MetroLotion, Noritate Cream, Rosadan, Soolantra, Zilxi, Epsolay |
| Topical Vitamin D Analogs | Calcipotriene, Calcipotriene-Betamethasone and dipropionate, Enstilar, Sorilux, Taclonex, Wynzora |
| Topiramate | Qudexy XR, Topamax, Topax Sprinkle, Trokendi, and Topiramate ER |
| Transdermal Estrogen | Elestrin, EstroGel, Evamist, Divigel |
| Triptan & Ergot Migraine Agents | Alsuma, Amerge, Axert, Frova, Imitrex, Imitrex STATdose Pen, Imitrex STATdose System, Maxalt, Maxalt MLT, Onzetra Xsail, Zecuity, Relpax, Sumavel, Treximet, Trudhesa, zolmitriptan nasal spray, Zembrace, Zomig, Zomig-ZMT |
| Truvada ST | Truvada |
| Xeloda | Xeloda |
| Zetia, Vytorin and Roszet | Vytorin, Zetia, Roszet |