Step Therapy Criteria
CW 2016
Last Updated: 2/17/2016
5-HT3 ANTAGONIST ANTIEMETICS
MEDICATION(S) SUBJECT TO STEP THERAPY
ANZEMET, EMEND 125 MG CAPSULE, EMEND 40 MG CAPSULE, EMEND 80 MG CAPSULE,
EMEND TRIPACK, GRANISETRON HCL, ONDANSETRON 4 MG/2 ML AMPULE, ONDANSETRON 4
MG/5 ML SOLUTION, ONDANSETRON HCL 24 MG TABLET, ONDANSETRON HCL 4 MG/2 ML
VIAL
CRITERIA
Beneficiary must try ondansetron 4mg or 8mg tablets or ondansetron 4mg or 8mg ODTs for seven
days as step one before being able to receive ondansetron 24mg, ondansetron injectable solution,
ondansetron oral solution, or any of the forms of granisetron for thirty days as step two before being
able to receive dolasetron or any of the forms of aprepitant as step three.
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LAST UPDATED 02/2016
ACNE AGENTS
MEDICATION(S) SUBJECT TO STEP THERAPY
ADAPALENE 0.1% GEL, ERYTHROMYCIN-BENZOYL PEROXIDE, METRONIDAZOLE TOPICAL
0.75% GL, TAZORAC, TRETINOIN 0.01% GEL, TRETINOIN 0.025% CREAM, TRETINOIN 0.025%
GEL, TRETINOIN 0.05% CREAM, TRETINOIN 0.1% CREAM
CRITERIA
Beneficiary must try sulfacetamide suspension, erythromycin gel or solution, or clindamyacin lotion or
solution for thirty days as step one before receiving metronidazole gel, benzoyl peroxide/erythromycin
gel, tretinoin cream, or tretinoin gel for thirty days as step two and trial two step two therapies before
receiving adapalene 1% gel, tazarotene cream, or tazarotene gel as step three. Beneficiaries
requesting tazarotene for the indication of psoriasis should refer to the psoriasis agents group for
relevant step therapy criteria. Beneficiaries requesting metronidazole topical gel for rosacea will be
eligible for an exception to the step one requirement.
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LAST UPDATED 02/2016
ALPHA- ADRENERGIC AGONISTS
MEDICATION(S) SUBJECT TO STEP THERAPY
DEXTROAMPHETAMINE-AMPHET ER
CRITERIA
Beneficiary must try immediate release amphetamine/dextroamphetamine mixed salts for sixty days as
step one before receiving extended release amphetamine/dextroamphetamine mixed salts as step two.
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LAST UPDATED 02/2016
ANGIOTENSIN RECEPTOR ANTAGONISTS
MEDICATION(S) SUBJECT TO STEP THERAPY
TEKTURNA, TELMISARTAN, TELMISARTAN-HYDROCHLOROTHIAZID, VALSARTAN,
VALSARTAN-HYDROCHLOROTHIAZIDE
CRITERIA
Beneficiary must try losartan, losartan/hydrochlorothiazide, irbesartan, irbesartan/hydrochlorothiazide,
candesartan, or candesartan/hydrochlorothiazide as step one for thirty days before being able to
receive telmisartan, telmisartan/hydrochlorothiazide, valsartan, or valsartan/hydrochlorothiazide for
thirty days as step two before receiving sacubitril/valsartan or aliskiren (Tekturna) as step three.
Beneficiaries requesting valsartan or valsartan/hydrochlorothiazide for an indication for reduction of
cardiovascular mortality with left ventricular failure or left ventricular dysfunction following myocardial
infarction will be eligible for an exception to the step one requirement. Beneficiaries requesting
telmisartan or telmisartan/hydrochlorothiazide for an indication of cardiovascular event risk reduction
will be eligible for an exception to the step one requirement.
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ANGIOTENSIN RECEPTOR ANTAGONISTS II
MEDICATION(S) SUBJECT TO STEP THERAPY
ENTRESTO, TEKTURNA, TELMISARTAN, TELMISARTAN-HYDROCHLOROTHIAZID, VALSARTAN
160 MG TABLET, VALSARTAN 320 MG TABLET, VALSARTAN 80 MG TABLET, VALSARTANHYDROCHLOROTHIAZIDE
CRITERIA
Beneficiary must try losartan, losartan/hydrochlorothiazide, irbesartan, irbesartan/hydrochlorothiazide,
candesartan, or candesartan/hydrochlorothiazide as step one for thirty days before being able to
receive telmisartan, telmisartan/hydrochlorothiazide, valsartan, or valsartan/hydrochlorothiazide for
thirty days as step two before receiving sacubitril/valsartan or aliskiren (Tekturna) as step three.
Beneficiaries requesting valsartan or valsartan/hydrochlorothiazide for an indication for reduction of
cardiovascular mortality with left ventricular failure or left ventricular dysfunction following myocardial
infarction will be eligible for an exception to the step one requirement. Beneficiaries requesting
telmisartan or telmisartan/hydrochlorothiazide for an indication of cardiovascular event risk reduction
will be eligible for an exception to the step one requirement.
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ANTI-PSYCHOTIC
MEDICATION(S) SUBJECT TO STEP THERAPY
FANAPT, LATUDA, ZIPRASIDONE HCL
CRITERIA
Beneficiary must try risperidone or quetiapine for thirty days as step one before receiving oral
ziprasidone or injectable ziprasidone for thirty days as step two before being able to receive iloperidone
(Fanapt) or lurasidone (Latuda) as step three. Any beneficiary currently taking a step two or step three
medication will not be subject to the step therapy restrictions. Beneficiaries requesting injectable
ziprasidone for acute agitation in schizophrenia will be eligible for an exception to the step one criteria.
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ANTICHOLINERGIC BRONCHODILATORS
MEDICATION(S) SUBJECT TO STEP THERAPY
SPIRIVA, SPIRIVA RESPIMAT 1.25 MCG INH
CRITERIA
Beneficiary must try ipratropium bromide or albuterol/ipratropium for thirty days as step one before
being able to receive tiotropium bromide as step two.
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ANTICHOLINERGIC BRONCHODILATORS II
MEDICATION(S) SUBJECT TO STEP THERAPY
TUDORZA PRESSAIR
CRITERIA
Beneficiary must try ipratropium bromide or albuterol/ipratropium for thirty days as step one before
being able to receive aclidinium bromide as step two.
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LAST UPDATED 02/2016
ANTICOAGULATION
MEDICATION(S) SUBJECT TO STEP THERAPY
PRADAXA, XARELTO
CRITERIA
Beneficiary must try warfarin for thirty days as step one before being able to receive dabigatran or
rivaroxaban as step two.
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ANTIHISTAMINES
MEDICATION(S) SUBJECT TO STEP THERAPY
AZELASTINE 0.1% (137 MCG) SPRY, AZELASTINE 0.15% NASAL SPRAY, OLOPATADINE 665
MCG NASAL SPRY
CRITERIA
Beneficiaries must trial OTC loratadine, OTC fexofenadine, or OTC cetirizine for thirty days before
receiving azelastine nasal or olopatadine nasal as step two. Beneficiaries requesting azelastine nasal
for vasomotor rhinitis will be eligible for an exception to this step therapy.
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LAST UPDATED 02/2016
ANTILEUKOTRIENES
MEDICATION(S) SUBJECT TO STEP THERAPY
ZYFLO, ZYFLO CR
CRITERIA
Beneficiary must try montelukast or zafirlukast as step one for thirty days before receiving zileuton as
step two.
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APOMORPHINE
MEDICATION(S) SUBJECT TO STEP THERAPY
APOKYN
CRITERIA
Beneficiary must try carbidopa/levodopa or amantadine capsules as step one for thirty days before
receiving apomorphine (Apokyn) as step two.
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ATYPICAL ANTIPSYCHOTICS
MEDICATION(S) SUBJECT TO STEP THERAPY
REXULTI
CRITERIA
Beneficiary must try and fail aripiprazole tablets for sixty days as step one before receiving
brexpiprazole as step two. This applies to new starts only.
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BETA BLOCKERS - EXTENDED RELEASE
MEDICATION(S) SUBJECT TO STEP THERAPY
COREG CR
CRITERIA
Beneficiary must try metoprolol ER or propranolol ER for thirty days as step one before receiving
carvedilol CR as step two. Beneficiaries requesting carvedilol ER for left ventricular dysfunction
following myocardial infarction will be eligible for an exception to the step one criteria.
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LAST UPDATED 02/2016
CARDIOVASCULAR
MEDICATION(S) SUBJECT TO STEP THERAPY
REPATHA SURECLICK, REPATHA SYRINGE
CRITERIA
Beneficiary must try simvastatin/ezetimibe and atorvastatin for sixty days as step one and try and fail
both step one medications before being able to receive evolocumab as step two. Patients with a
contraindication to ezetimibe and statins will be eligible for an exception for this step criteria.
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LAST UPDATED 02/2016
CLOSTRIDIUM DIFFICILE TREATMENT
MEDICATION(S) SUBJECT TO STEP THERAPY
DIFICID
CRITERIA
Beneficiary must try oral vancomycin for seven days as step one before receiving fidaxomicin as step
two.
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DESVENLAFAXINE
MEDICATION(S) SUBJECT TO STEP THERAPY
DESVENLAFAXINE ER
CRITERIA
Beneficiary must try venlafaxine for thirty days as step one before receiving desvenlafaxine as step
two. Any beneficiary currently taking desvenlafaxine will not be subject to the step therapy restrictions.
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DIABETES TREATMENT
MEDICATION(S) SUBJECT TO STEP THERAPY
AVANDAMET 2 MG-1,000 MG TAB, AVANDIA, BYETTA, FARXIGA, INVOKAMET, INVOKANA,
JANUMET, JANUVIA, PIOGLITAZONE HCL, PIOGLITAZONE-METFORMIN, SYMLINPEN 120,
SYMLINPEN 60, VICTOZA 2-PAK, VICTOZA 3-PAK, WELCHOL 625 MG TABLET
CRITERIA
Beneficiary must trial metformin, metformin ER, metformin/glipizide, or glipizide as step one before
receiving sitagliptin, sitagliptin/metformin, rosiglitazone, rosiglitazone/metformin, pramlintide,
pioglitizone, pioglitazone/metformin, liraglutide, exenatide, colesevelam, dapagliflozin propanediol,
canaglifloin, or canagliflozin/metformin as step two. Beneficiaries requesting colesevelam for the
indication of primary hyperlipidemia will be eligible for an exception to the step one criteria.
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DRONEDARONE (MULTAQ)
MEDICATION(S) SUBJECT TO STEP THERAPY
MULTAQ
CRITERIA
Beneficiary must try diltiazem, flecanide, propafenone, or quinidine for 30 days as step one before
receiving dronedarone as step two.
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ERGOTAMINE
MEDICATION(S) SUBJECT TO STEP THERAPY
DIHYDROERGOTAMINE 1 MG/ML AM, DIHYDROERGOTAMINE 1 MG/ML VL
CRITERIA
Beneficiary must trial ergotamine or caffeine/ergotamine for sixty days as step one before receiving
dihydroergotamine as step two.
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ESCITALOPRAM
MEDICATION(S) SUBJECT TO STEP THERAPY
ESCITALOPRAM 10 MG TABLET, ESCITALOPRAM 20 MG TABLET, ESCITALOPRAM 5 MG
TABLET
CRITERIA
Beneficiary must try citalopram for thirty days as step one before receiving escitalopram as step two.
Any beneficiary currently taking a step two medication will not be subject to the step therapy
restrictions.
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FIBRIC ACID DYSLIPIDEMICS
MEDICATION(S) SUBJECT TO STEP THERAPY
FENOFIBRATE, FENOFIBRIC ACID 105 MG TABLET, FENOPROFEN CALCIUM 400 MG CAP,
FIBRICOR
CRITERIA
Beneficiary must try gemfibrozil for sixty days as step one before receiving fenofibrate as step two.
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HEPATIC ENCEPHALOPATHY
MEDICATION(S) SUBJECT TO STEP THERAPY
XIFAXAN
CRITERIA
Beneficiary must try lactulose for fourteen days as step one before being eligible to receive rifaximin
(Xifaxan) as step two for hepatic encephalopathy. Beneficiaries requiring rifaximin for traveler's
diarrhea or irritable bowel syndrome with diarrhea will be eligible for an exception to the step one
criteria.
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INJECTABLE ANTICOAGULANTS
MEDICATION(S) SUBJECT TO STEP THERAPY
FONDAPARINUX SODIUM, FRAGMIN
CRITERIA
Beneficiary must try enoxaparin for 14 days as step one before receiving dalteparin or fondaparinux as
step two.
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IRON CHELATION
MEDICATION(S) SUBJECT TO STEP THERAPY
FERRIPROX
CRITERIA
Beneficiary must try deferasirox for thirty days as step one before receiving deferiprone as step two.
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LAST UPDATED 02/2016
IV PROTON PUMP INHIBITORS
MEDICATION(S) SUBJECT TO STEP THERAPY
ESOMEPRAZOLE SODIUM
CRITERIA
Beneficiary must try pantoprazole IV for 30 days as step one before receiving esomeprazole IV as step
two.
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LAST UPDATED 02/2016
MAJOR DEPRESSIVE DISORDER
MEDICATION(S) SUBJECT TO STEP THERAPY
BRINTELLIX, FETZIMA
CRITERIA
Beneficiary must try venlafaxine, citalopram, or sertraline for thirty days as step one before receiving
levomilnacipran or vortioxetine as step two. Any beneficiary currently taking a step two or step three
medication will not be subject to the step therapy restrictions.
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MEGLITINIDE
MEDICATION(S) SUBJECT TO STEP THERAPY
PRANDIMET, REPAGLINIDE, REPAGLINIDE-METFORMIN HCL
CRITERIA
Beneficiary must try nataglinide for thirty days as step one before receiving repaglinide or
repaglinide/metformin as step two.
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MESALAMINE
MEDICATION(S) SUBJECT TO STEP THERAPY
CANASA, LIALDA
CRITERIA
Beneficiary must try mesalamine (Asacol), mesalamine (Pentasa), mesalamine (Delzicol), or
mesalamine (Apriso) for thirty days as step one. Beneficiary must trial two (2) step one mesalamine
formulations before being able to receive mesalamine (Canasa) or mesalamine (Lialda) as step two.
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MIGRAINE ABORTIVE AGENTS (5)
MEDICATION(S) SUBJECT TO STEP THERAPY
SUMATRIPTAN 4 MG/0.5 ML CART, SUMATRIPTAN 4 MG/0.5 ML INJECT, SUMATRIPTAN 6
MG/0.5 ML REFILL, SUMATRIPTAN 6 MG/0.5 ML VIAL, ZOLMITRIPTAN 2.5 MG TABLET,
ZOLMITRIPTAN 5 MG TABLET, ZOLMITRIPTAN ODT, ZOMIG 2.5 MG NASAL SPRAY, ZOMIG 5 MG
NASAL SPRAY
CRITERIA
Beneficiary must try sumatriptan tablets or naratriptan tablets or rizatriptan tablets for thirty days as
step one and trial two step one therapies before being able to receive zolmitriptan tablets, zolmitriptan
orally disintegrating tablets, zolmitriptan nasal spray, or sumatriptan injection as step two. Beneficiaries
requesting injectable sumatriptan for the indication of acute treatment of cluster headaches will be
eligible for an exception to the step one criteria.
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MONOAMINE OXIDASE B (MOA-B) INHIBITORS
MEDICATION(S) SUBJECT TO STEP THERAPY
AZILECT
CRITERIA
Beneficiary must try selegiline as step one before receiving rasagiline mesylate as step two.
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MUCOLYTICS
MEDICATION(S) SUBJECT TO STEP THERAPY
PULMOZYME
CRITERIA
Beneficiary must try acetylcysteine for thirty days as step one before being able to receive dornase alfa
as step two.
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NASAL STEROIDS
MEDICATION(S) SUBJECT TO STEP THERAPY
FLUTICASONE PROP 50 MCG SPRAY, TRIAMCINOLONE 55 MCG NASAL SPR
CRITERIA
OTCs: "NASACORT ALLERGY 24HR", "FLONASE ALLERGY RELIEF". Beneficiary must trial OTC
nasal triamcinolone or OTC nasal fluticasone before receiving legend nasal triamcinolone or legend
nasal fluticasone.
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NON-OPIOID ANALGESICS
MEDICATION(S) SUBJECT TO STEP THERAPY
CELECOXIB 100 MG CAPSULE, CELECOXIB 200 MG CAPSULE, CELECOXIB 400 MG CAPSULE,
CELECOXIB 50 MG CAPSULE
CRITERIA
Beneficiary must try oxaprozin, ibuprofen, or naproxen on a scheduled basis for thirty days as step one
and try two step one therapies before receiving celecoxib as step two. Beneficiaries requesting
celecoxib for ankylosing spondylitis will be eligible for an exception to the step one criteria.
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NOREPINEPHRINE REUPTAKE INHIBITORS
MEDICATION(S) SUBJECT TO STEP THERAPY
STRATTERA
CRITERIA
Beneficiary must try methylphenidate for thirty days as step one before receiving atomoxetine as step
two.
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OPIOID ANALGESICS
MEDICATION(S) SUBJECT TO STEP THERAPY
FENTANYL 100 MCG/HR PATCH, FENTANYL 12 MCG/HR PATCH, FENTANYL 25 MCG/HR
PATCH, FENTANYL 50 MCG/HR PATCH, FENTANYL 75 MCG/HR PATCH, FENTANYL CIT OTFC
1,200 MCG, FENTANYL CIT OTFC 1,600 MCG, FENTANYL CITRATE OTFC 200 MCG, FENTANYL
CITRATE OTFC 400 MCG, FENTANYL CITRATE OTFC 600 MCG, FENTANYL CITRATE OTFC 800
MCG, OXYCODONE HCL ER
CRITERIA
Beneficiary must try scheduled doses of methadone or extended release morphine for thirty days as
step one before receiving scheduled doses of oxycodone SR for thirty days as step two before
receiving fentanyl patches or lozenges as step three. Beneficiaries receiving fentanyl lozenges for
breakthrough cancer pain will be eligible for an exception to this Step Therapy.
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OPIOID-INDUCED CONSTIPATION
MEDICATION(S) SUBJECT TO STEP THERAPY
RELISTOR 12 MG/0.6 ML KIT, RELISTOR 12 MG/0.6 ML VIAL, RELISTOR 8 MG/0.4 ML SYRINGE
CRITERIA
Beneficiary must trial naloxegol for thirty days as step one before receiving methylnaltrexone as step
two.
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OSTEOPOROSIS
MEDICATION(S) SUBJECT TO STEP THERAPY
FORTEO, IBANDRONATE 3 MG/3 ML VIAL, IBANDRONATE SODIUM 150 MG TAB, PROLIA,
ZOLEDRONIC ACID 5 MG/100 ML
CRITERIA
Beneficiary must try alendronate or etidronate for six months as step one before receiving ibandronate,
zoledronic acid (Reclast formulation only) or denosumab (Prolia) for six months as step two before
receiving teriparatide (Forteo) as step three. Beneficiaries receiving denosumab (Prolia) for cancer
treatment associated bone loss or receiving teriparatide (Forteo) for glucocorticoid-induced
osteoporosis will be eligible for an exception to this step therapy.
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OXCARBAZEPINE
MEDICATION(S) SUBJECT TO STEP THERAPY
OXTELLAR XR
CRITERIA
Beneficiary must try immediate release oxcarbazepine for thirty days as step one before receiving
extended release oxcarbazepine as step two. Beneficiaries currently receiving a step two product will
be eligible for an exception to this step therapy.
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PALIPERIDONE
MEDICATION(S) SUBJECT TO STEP THERAPY
GEODON 20 MG/ML VIAL, INVEGA, INVEGA SUSTENNA, PALIPERIDONE ER, ZIPRASIDONE HCL
CRITERIA
Beneficiary must try risperidone or quetiapine for thirty days as step one before receiving oral or
injectable ziprasidone for thirty days as step two before being able to receive paliperidone (Invega) as
step three. Any beneficiary currently taking a step two or step three medication will not be subject to
the step therapy restrictions. Beneficiaries requesting injectable ziprasidone for acute agitation in
schizophrenia will be eligible for an exception to the step one criteria. Any beneficiary with a diagnosis
of schizoaffective disorder will be eligible for an exception to this step.
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PROTON PUMP INHIBITORS
MEDICATION(S) SUBJECT TO STEP THERAPY
LANSOPRAZOLE DR 15 MG CAPSULE, LANSOPRAZOLE DR 30 MG CAPSULE, OMEPRAZOLE
DR 40 MG CAPSULE, PANTOPRAZOLE SOD DR 20 MG TAB, PANTOPRAZOLE SOD DR 40 MG
TAB
CRITERIA
Beneficiary must try OTC omeprazole, OTC lansoprazole, or OTC esomeprazole, legend omeprazole
10mg, or legend omeprazole 20mg for thirty days as step one before receiving legend omeprazole
40mg or legend pantoprazole for thirty days as step two before receiving legend lansoprazole as step
three. Beneficiaries with an indication for NSAID-induced gastric ulcer prophylaxis or treatment will be
eligible for an exception to this Step Therapy requirement.
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PSORIASIS AGENTS
MEDICATION(S) SUBJECT TO STEP THERAPY
ACITRETIN
CRITERIA
Beneficiary must trial topical fluocinonide cream, fluocinonide solution, fluocinonide gel, triamcinolone
ointment, or sulfacetamide solution for thirty days as step one before receiving a topical tazarotene for
thirty days as step two before receiving acitretin (Soriatane) as step three. Beneficiaries receiving
tazarotene for acne should refer to the "acne agents" group for relevant step therapy criteria.
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PULMONARY ANTIHYPERTENSIVES
MEDICATION(S) SUBJECT TO STEP THERAPY
ADEMPAS, LETAIRIS, OPSUMIT, REMODULIN, TRACLEER
CRITERIA
Beneficiary must try sildenafil or tadalafil for sixty days as step one before receiving bosentan,
treprostinil, or ambrisentan for thirty days as step two before receiving riociguat or macitentan as step
three. Beneficiaries requesting riociguat for Chronic Thromboembolic Pulmonary Hypertension will be
eligible for an exception to this step therapy.
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ROTIGOTINE
MEDICATION(S) SUBJECT TO STEP THERAPY
NEUPRO
CRITERIA
Beneficiary must trial gabapentin enacarbil (if for restless legs) or carbidopa-levodopa-entacapone (if
for Parkinsons Disease) as step one for thirty days before receiving rotigotine transdermal as step two.
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SMOKING CESSATION
MEDICATION(S) SUBJECT TO STEP THERAPY
NICOTROL
CRITERIA
Beneficiary must trial nasal nicotine for at least thirty days as step one before receiving nicotine
inhalers as step two.
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SYMPATHOMIMETIC BRONCHODILATORS
MEDICATION(S) SUBJECT TO STEP THERAPY
PROAIR HFA
CRITERIA
Beneficiary must first try Ventolin HFA for thirty days as step one receiving Proair as step two.
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LAST UPDATED 02/2016
TOPICAL DICLOFENAC
MEDICATION(S) SUBJECT TO STEP THERAPY
VOLTAREN
CRITERIA
Beneficiary must try scheduled doses of ketoprofen or naproxen for thirty days as step one and trial
two step one products before being able to receive topical diclofenac as step two.
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TOPIRAMATE
MEDICATION(S) SUBJECT TO STEP THERAPY
QUDEXY XR, TOPIRAMATE ER, TROKENDI XR
CRITERIA
Beneficiary must try immediate release topiramate for thirty days as step one before receiving
extended release topiramate as step two.
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LAST UPDATED 02/2016
TRAMADOL
MEDICATION(S) SUBJECT TO STEP THERAPY
TRAMADOL ER 100 MG TABLET, TRAMADOL ER 200 MG TABLET, TRAMADOL ER 300 MG
TABLET, TRAMADOL HCL ER 100 MG TABLET, TRAMADOL HCL ER 200 MG TABLET,
TRAMADOL HCL ER 300 MG TABLET
CRITERIA
Beneficiary must try tramadol or acetaminophen/tramadol for thirty days as step one before receiving
tramadol ER.
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TRICYCLICS
MEDICATION(S) SUBJECT TO STEP THERAPY
CLOMIPRAMINE 25 MG CAPSULE, CLOMIPRAMINE 50 MG CAPSULE, CLOMIPRAMINE 75 MG
CAPSULE, IMIPRAMINE HCL 10 MG TABLET, IMIPRAMINE HCL 25 MG TABLET, IMIPRAMINE
HCL 50 MG TABLET, SURMONTIL, TRIMIPRAMINE MALEATE
CRITERIA
Beneficiary must try amitriptyline, nortriptyline, or desipramine as step one for thirty days and try two
step one therapies before receiving trimipramine, imipramine, or clomipramine as step two. Any
beneficiary currently taking trimipramine imipramine, or clomipramine will not be subject to this step
therapy. Beneficiaries requesting clomipramine for an indication of obsessive compulsive disorder will
be eligible for an exception to these Step Therapy requirements.
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URINARY ANTISPASMODICS
MEDICATION(S) SUBJECT TO STEP THERAPY
ENABLEX, OXYTROL, TOLTERODINE TARTRATE, TOLTERODINE TARTRATE ER, TOVIAZ,
TROSPIUM CHLORIDE, TROSPIUM CHLORIDE ER, VESICARE
CRITERIA
Beneficiary must try oxybutynin or oxybutynin ER for thirty days as step one before receiving
tolterodine, tolterodine ER, or trospium IR for thirty days as step two before receiving darifenacin,
solifenacin, trospium ER, fesoterodine, or oxybutynin patches (Oxytrol) as step three.
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