1. No category

STANDARD Step Therapy Agents ~ 2015
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit
a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care
will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor
cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Selfadministered injectable agents also require prior authorization and can be found on a separate list.
Drug
Requires Step Through
Abilify (aripiprazole) ODT or solution
Altoprev (lovastatin er)
Ambien CR* (zolpidem extended release)
Amitiza (lubiprostone)
Apidra (insulin glulisine) vial, pen
Apriso(Mesalamine, 5-ASA)
Atralin gel (tretinoin)
Avita gel (tretinoin)
Avodart (dutasteride)
Axert (almotriptan)
Azor (amlodipine/olmesartan)
Azulfidine (sulfasalazine)
Beconase AQ (beclomethasone)
Benicar (olmesartan)
Benicar HCT (olmesartan HCT)
Bydureon (exenatide)
Byetta (exenatide)
Celebrex (celecoxib)
Colazal (balsalazide)
Detrol* / Detrol LA* (tolterodine / extended release)
Differin gel* 0.3% (adapalene)
Differin lotion 0.1% (adapalene)
Dipentum (olsalazine)
Ditropan XL* (oxybutynin extended release)
Dovonex* (calcipotriene)
Edarbi (azilsartan)
Edarbyclor (azilsartan/chlorthalidone)
Enablex (darifenacin)
Epiduo gel (adapalene/benzoyl peroxide)
Exforge* (amlodipine/valsartan)
Exforge HCT (amlodipine/valsartan HCT)
Fabior (tazarotene)
Fanapt (iloperdone)
Farxiga(dapagliflozin)
Frova (frovatriptan)
Gelnique (oxybutynin)
Hectorol* (doxercalciferol)
Invega (paliperidone)
Abilify oral tablet
Colestid*, Lescol*, Lipitor*, Mevacor*, Pravachol*, or Zocor*, AND Crestor
Ambien* or Sonata*
Lactulose* or Miralax*
HumaLOG product
Asacol, Asacol HD, Lialda, Pentasa, Canasa, or Delzicol
Retin-A*
Retin-A*
Proscar*
3 of the following: Amerge*, Imitex*, Maxalt*, Zomig* tablets
Amlodipine in combination with 2 of the following: Atacand*, Avapro*, Cozaar*,
Micardis*
Asacol, Asacol HD, Lialda, Pentasa, Canasa, or Delzicol
Flonase*, Nasalide*, or Nasacort 24HR OTC AND Nasonex
2 of the following: Atacand*, Avapro*, Cozaar*, Micardis*
2 of the following: Avalide*, Diovan HCT*, Hyzaar*, Micardis HCT*
Metformin/ER (at least 1500mg/d)
Metformin/ER (at least 1500mg/d)
Two Non-steroidal anti-inflammatory drug (NSAIDs)
Asacol, Asacol HD, Lialda, Pentasa, Canasa, or Delzicol
Ditropan* or Sanctura* AND Vesicare AND Myrbetriq
Retin-A*
Retin-A*
Asacol, Asacol HD, Lialda, Pentasa, Canasa, or Delzicol
Ditropan* or Sanctura* AND Vesicare AND Myrbetriq
a medium to high potency topical steroid
2 of the following: Atacand*, Avapro*, Cozaar*, Micardis*
2 of the following: Avalide*, Diovan HCT*, Hyzaar*, Micardis HCT*
Ditropan* or Sanctura* AND Vesicare AND Myrbetriq
Retin-A*
Amlodipine in combination with 2 of the following: Atacand*, Avapro*, Cozaar*,
Micardis*
Amlodipine in combination with 2 of the following: Atacand HCT*, Avalide*,
Hyzaar*, Micardis HCT*
Retin-A*
2 of the following: Risperdal*, Seroquel*, Geodon*, Zyprexa* AND Latuda
Metformin/ER (at least 1500mg/d), AND Invokana
3 of the following: Amerge*, Imitex*, Maxalt*, Zomig* tablets
Oxybutynin or Sanctura AND Myrbetriq AND Sanctura
Rocaltrol*
2 of the following: Risperdal*, Seroquel*, Geodon*, Zyprexa* AND Latuda
* indicates generic available
Italics indicate Non-Formulary agents
# indicates Prior Auth required for age 19yr and over; Step Therapy required for age 18yr and under
Page 1 of 3
This is the most current list at the time of printing and is subject to change.
Last update January 16, 2015
STANDARD Step Therapy Agents ~ 2015
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit
a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care
will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor
cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Selfadministered injectable agents also require prior authorization and can be found on a separate list.
Drug
Requires Step Through
Invokamet (canagliflozin/metformin)
Invokana (canagliflozin)
Jalyn (dutasteride/tamsulosin)
Janumet (sitagliptin / metformin)
Janumet XR (sitagliptin / metformin ext rel)
Januvia (sitagliptin)
Jardiance (empagliflozin)
Karbinal ER (carbinoxamine)
Novolin vial, pen
Metformin/ER (at least 1500mg/d)
Metformin/ER (at least 1500mg/d)
Proscar*
Metformin/ER (at least 1500mg/d)
Metformin/ER (at least 1500mg/d)
Metformin/ER (at least 1500mg/d)
Metformin/ER (at least 1500mg/d) AND Invokana
1 OTC antihistamine (Allegra, Claritin, Zyrtec) AND carbinoxamine
Metformin/ER (at least 1500mg/d)
For Epilepsy: Lamictal IR*
Levemir vial or pen
Levemir pen
2 of the following: Risperdal*, Seroquel*, Geodon*, Zyprexa*
Lactulose* or Miralax* AND Amitiza
Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor
Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor
Niaspan* or Advicor, a generic fenofibrate product, AND Vascepa.
Ambien* or Sonata*
Metrogel 0.75%*
topical metronidazole
Ditropan* or Sanctura*
2 of the following: Neurontin*, Requip*, Mirapex* (covered without trials for
Parkinson’s)
Humulin product
NovoLOG vial, pen
Nucynta IR (tapentradol)
Opana IR* (oxymorphone)
Osphena (ospemiphene)
Oxtellar XR (oxcarbazepine)
Oxytrol (oxybutynin transdermal)
Pancreaze (pancrelipase)
Pertzye (pancrelipase)
Plexion (sulfacetamide/sulfur)
Pradaxa (dabigatran)
Qnasl (beclomethasone )
Qudexy XR (topiramate er)
Rayos (prednisone)
Relpax (eletriptan)
Retin-A Micro* (tretinoin)
Rhinocort Aqua* (budesonide)
Risperdal (risperidone) ODT* or solution*
HumaLOG product
2 of the following: morphine, oxycodone, hydromorphone
2 of the following: morphine, oxycodone, hydromorphone
Vagifem or Estrace cream
Trileptal*
Ditropan* or Sanctura* AND Vesicare AND Myrbetriq
Creon AND Zenpep
Creon AND Zenpep
2 generic sulfacetamide sodium w/sulfur produts
Xarelto AND Eliquis
Flonase*, Nasalide*, or Nasacort 24HR OTC AND Nasonex
Topamax* tablets
Prednisone tablets
3 of the following: Amerge*, Imitex*, Maxalt*, Zomig* tablets
Retin-A*
Flonase*, Nasalide*, or Nasacort 24HR OTC AND Nasonex
Risperdal* oral tablet
Kombiglyze XR (saxagliptin / metformin)
Lamictal ODT/XR*(lamotrigine)
Lantus (insulin glargine) vial
Lantus (insulin glargine) pen
Latuda (lurasidone)
Linzess (linaclotide)
Liptruzet (ezetimibe/atorvastatin Calcium)
Livalo (pitavastatin)
Lovaza* (Omega-3 Fatty Acids)
Lunesta* (eszopiclone)
Metrogel* 1% (metronidazole)
Mirvaso (brimonidine)
Myrbetriq (mirabegron)
Neupro (rotigotine)
* indicates generic available
Italics indicate Non-Formulary agents
# indicates Prior Auth required for age 19yr and over; Step Therapy required for age 18yr and under
Page 2 of 3
This is the most current list at the time of printing and is subject to change.
Last update January 16, 2015
STANDARD Step Therapy Agents ~ 2015
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit
a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care
will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor
cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Selfadministered injectable agents also require prior authorization and can be found on a separate list.
Drug
Requires Step Through
Rozerem (ram elteon)
Sanctura XR* (trospium extended release)
Saphris (asenapine)
Sensipar (cinacalcet)
Taclonex* (calcipotriene/betamethasone dip)
Tazorac gel, cream (tazarotene)
Teveten HCT (eprosartan HCT)
Toviaz (fesoterodine)
Tretin-X 0.0375% cream (Combo pack not covered)
Ambien* or Sonata*
Ditropan* or Sanctura* AND Vesicare AND Myrbetriq
2 of the following: Risperdal*, Seroquel*, Geodon*. Zyprexa* AND Latuda
Rocaltrol* (covered without trials for hyperparathyroidism & parathyroid
carcinoma)
Dovonex AND a medium to high potency topical steroid
Uceris (budesonide)
Retin-A* (covered without trials for psoriasis)
2 of the following: Avalide*, Diovan HCT*, Hyzaar*, Micardis HCT*
Ditropan* or Sanctura* AND Vesicare AND Myrbetriq
Retin-A*
Amlodipine in combination with 2 of the following: Atacand HCT*, Avalide*,
Hyzaar*, Micardis HCT*
Topamax*
Amlodipine in combination with 2 of the following: Atacand*, Avapro*, Cozaar*,
Micardis*
2 of the following: sulfasalazine, Colazal, Apriso, Asacol, Asacol HD, Delzicol
Uloric (febuxostat)
Ultresa (pancrelipase)
Vanos cream* (fluocinonide)
Vascepa (Icosapent ethyl)
(calcitriol)
Vectical ointment
Veltin gel (tretinoin/clindamycin)
Veramyst (fluticasone furoate)
Versacloz Oral Suspension (clozapine)
Vesicare (solifenacin)
Viekira (Dasabuvir; Ombitasvir; Paritaprevir; Ritonavir)
Viokace (pancrelipase)
Vytorin (simvastatin/ezetimibe) 10/10, 10/20, 10/40
Vytorin (simvastatin/ezetimibe) 10/80
Xartemis XR (oxycodone/acetaminophen)
Zemplar* (paricalcitol)
Zetonna (ciclesonide)
Ziana gel (tretinoin/clindamycin)
Zomig Nasal Spray (zolmitriptan)
Zorvolex (diclofenac)
Allopurinol
Creon AND Zenpep
Two very high potency topical steroids
Niaspan* OR Advicor, AND a generic fenofibrate
a medium to high potency topical steroid
Retin-A*
Flonase*, Nasalide*, or Nasacort 24HR OTC AND Nasonex
Clozaril* tablets
Ditropan* or Sanctura*
Harvoni
Creon AND Zenpep
Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor
Zocor 80mg*
2 of the following: morphine, oxycodone, hydromorphone
Rocaltrol*
Flonase*, Nasalide*, or Nasacort 24HR OTC AND Nasonex
Retin-A*
3 of the following: Amerge*, Imitex*, Maxalt*, Zomig* tablets
Two Non-steroidal anti-inflammatory drug (NSAIDs)
Tribenzor (olmesartan/amlodipine/hctz)
Trokendi XR (extended release topiramate)
Twynsta* (telmisartan/amlodipine)
* indicates generic available
Italics indicate Non-Formulary agents
# indicates Prior Auth required for age 19yr and over; Step Therapy required for age 18yr and under
Page 3 of 3
This is the most current list at the time of printing and is subject to change.
Last update January 16, 2015