Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy

Restricted Use Drug -A Prescription Medication or Drug that may require Prior Approval and/or be subject to a Limited Dispensing amount and/or Step Therapy requirement. CONTRACEPTIVES: Oral contraceptives, if covered, are covered for females only. Prior approval (PA) required for males. Oral contraceptives may be excluded from coverage under the drug benefit. In all cases, plan inclusions/exclusions determine specific coverage. BENEFIT QUANTITY LIMIT RESTRICTION (See separate document): Cialis, Ampyra, and Zyvox The following List of Drugs represents the drugs requiring Prior Approval (PA) for Step Therapy • Specific criteria must be met before medication is covered under the pharmacy benefit. • For Step Therapy Drugs requiring prior approval, only branded drugs are subject to the program unless noted below. Generic products marked with an (*) are also subject to the program. For Step Therapy, members must try either a generic or a preferred brand before a non-preferred brand drug. BRAND DRUG NAME

GENERIC DRUG NAME

ABILIFY

ARIPIPRAZOLE TABS

CORRESPONDING FORM TO SUBMIT STEP THERAPY

ABILIFY

ARIPIPRAZOLE SOLN

STEP THERAPY

ABILIFY DISCMELT

ARIPIPRAZOLE TBDP

STEP THERAPY

ABILIFY MAINTENA

ARIPIPRAZOLE SUSR

STEP THERAPY

ACANYA

CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE

STEP THERAPY

ACTONEL

RISEDRONATE SODIUM TABS

STEP THERAPY

ACZONE

DAPSONE (TOPICAL) GEL

STEP THERAPY

ADDERALL

AMPHETAMINE-DEXTROAMPHETAMINE

STEP THERAPY

ADDERALL XR

AMPHETAMINE-DEXTROAMPHETAMINE

STEP THERAPY

ADZENYS XR-ODT

AMPHETAMINE

STEP THERAPY

ADVICOR

NIACIN-LOVASTATIN

STATIN STEP THERAPY

AKNE-MYCIN

ERYTHROMYCIN OINT 2%

STEP THERAPY

ALSUMA

SUMATRIPTAN SUCCINATE

MIGRAINE STEP THERAPY

ALTOCOR

LOVASTATIN TB24

STATIN STEP THERAPY

ALTOPREV

LOVASTATIN TAB SR

STATIN STEP THERAPY

AMBIEN

ZOLPIDEM TARTRATE TABS

STEP THERAPY

AMBIEN CR

ZOLPIDEM TARTRATE TBCR

STEP THERAPY

AMERGE

NARATRIPTAN HCL TABS

MIGRAINE STEP THERAPY

AMTURNIDE

ALISKIREN-AMLODIPINE-HYDROCHLOROTHIAZIDE

STEP THERAPY

ANDRODERM

TESTOSTERONE PT24

STEP THERAPY

ANDROGEL

TESTOSTERONE GEL*

STEP THERAPY

ANTARA

FENOFIBRATE MICRONIZED CAPS

STEP THERAPY

APIDRA

INSULIN GLULISINE SOLN

INSULIN PRIOR APPROVAL

APIDRA SOLOSTAR

INSULIN GLULISINE

INSULIN PRIOR APPROVAL

APLENZIN

BUPROPION HYDROBROMIDE TB24

STEP THERAPY

APTENSIO XR

METHYLPHENIDATE ER CAP

STEP THERAPY

ARICEPT

DONEPEZIL HYDROCHLORIDE TABS

STEP THERAPY

ARICEPT ODT

DONEPEZIL HYDROCHLORIDE TBDP

STEP THERAPY

ARISTADA

ARIPIPRAZOLE INJECTION

STEP THERAPY

Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association

Updated 1/1/17 Page 1 of 10 Information subject to change

Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy CORRESPONDING FORM TO SUBMIT GLUCOSE TEST STRIP PRIOR APPROVAL STEP THERAPY

BRAND DRUG NAME

GENERIC DRUG NAME

ASSURE

GLUCOSE BLOOD STRP

ATACAND

ATELVIA

CANDESARTAN CILEXETIL TABS CANDESARTAN CILEXETILHYDROCHLOROTHIAZIDE RISEDRONATE SODIUM TBEC

ATRALIN

TRETINOIN GEL

STEP THERAPY

AVALIDE

IRBESARTAN-HYDROCHLOROTHIAZIDE

STEP THERAPY

AVAPRO

IRBESARTAN TABS SULFACETAMIDE SODIUM W/ SULFUR CLEANSING PAD SULFACETAMIDE SODIUM W/ SULFUR AEROSOL

STEP THERAPY

STEP THERAPY

AVAR LS AEROSOL

SULFACETAMIDE SODIUM W/ SULFUR SULFACETAMIDE SODIUM W/ SULFUR CLEANSING PAD SULFACETAMIDE SODIUM W/ SULFUR AEROSOL

AVAR LS CLEANSER

SULFACETAMIDE SODIUM W/ SULFUR CLEANSER

STEP THERAPY

AXERT

ALMOTRIPTAN MALATE TABS

MIGRAINE STEP THERAPY

AXIRON

TESTOSTERONE SOLN

STEP THERAPY

AZELEX

AZELAIC ACID (ACNE) CREA AMLODIPINE BESYLATE-OLMESARTAN MEDOXOMIL SUVOREXANT

STEP THERAPY

OLMESARTAN MEDOXOMIL TABS OLMESARTAN MEDOXOMILHYDROCHLOROTHIAZIDE BENZOYL PEROXIDE LIQ 5%

STEP THERAPY

STEP THERAPY

BENZAMYCIN

BENZOYL PEROXIDE LIQ 5% CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL BENZOYL PEROXIDE-ERYTHROMYCIN

BENZAMYCINPAK

BENZOYL PEROXIDE-ERYTHROMYCIN

STEP THERAPY

BENZEFOAM

BENZOYL PEROXIDE FOAM

STEP THERAPY

BENZIQ

BENZOYL PEROXIDE GEL

STEP THERAPY

BENZOYL PEROXIDE

BENZOYL PEROXIDE POWDER

STEP THERAPY

BENZOYL PEROXIDE

BENZOYL PEROXIDE LOTION

STEP THERAPY

BINOSTO

ALENDRONATE SODIUM TBEF

STEP THERAPY

BONIVA

IBANDRONATE SODIUM TABS

STEP THERAPY

BONIVA

IBANDRONATE SODIUM SOLN

STEP THERAPY

BPO

BENZOYL PEROXIDE GEL

STEP THERAPY

BPO FOAMING CLOTHS

BENZOYL PEROXIDE CLOTH

STEP THERAPY

TRINTELLIX

VORTIOXETINE HBR TABS

STEP THERAPY

BYDUREON

EXENATIDE

STEP THERAPY

BYDUREON

EXENATIDE SUSR

STEP THERAPY

BYETTA

EXENATIDE

STEP THERAPY

ATACAND HCT

AVAR AVAR AEROSOL AVAR-E LS AVAR LS

AZOR BELSOMRA BENICAR BENICAR HCT BENZAC AC WASH BENZAC W WASH BENZACLIN

Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association

STEP THERAPY STEP THERAPY

STEP THERAPY STEP THERAPY STEP THERAPY STEP THERAPY

STEP THERAPY STEP THERAPY STEP THERAPY STEP THERAPY STEP THERAPY STEP THERAPY

Updated 1/1/17 Page 2 of 10 Information subject to change

Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy BRAND DRUG NAME

GENERIC DRUG NAME

BYVALSON

NEBIVOLOL/VALSARTAN

CORRESPONDING FORM TO SUBMIT STEP THERAPY

CELEXA

CITALOPRAM HYDROBROMIDE TABS

STEP THERAPY

CLARIFOAM EF

SULFACETAMIDE SODIUM W/ SULFUR FOAM

STEP THERAPY

CLEOCIN-T

CLINDAMYCIN PHOSPHATE (TOPICAL) SOLN

STEP THERAPY

CLEOCIN-T

CLINDAMYCIN PHOSPHATE (TOPICAL) LOTN

STEP THERAPY

CLEOCIN-T

CLINDAMYCIN PHOSPHATE (TOPICAL) SWAB

STEP THERAPY

CLINDACIN

CLINDAMYCIN PHOSPHATE & CLEANSER

STEP THERAPY

CLINDAGEL

CLINDAMYCIN PHOSPHATE (TOPICAL) GEL

STEP THERAPY

CLOZARIL

CLOZAPINE TABS

STEP THERAPY

CONCERTA

METHYLPHENIDATE HCL TBCR*

STEP THERAPY

COZAAR

LOSARTAN POTASSIUM TABS

STEP THERAPY

CRESTOR

ROSUVASTATIN CALCIUM TABS

STATIN STEP THERAPY

CYMBALTA

DULOXETINE HCL CPEP

STEP THERAPY

DAYTRANA

METHYLPHENIDATE PTCH

STEP THERAPY

DELOS

BENZOYL PEROXIDE LOTION

STEP THERAPY

DERMAKPAK PLUS

TRETINOIN CREAM

STEP THERAPY

DESOXYN

METHAMPHETAMINE HCL TABS

STEP THERAPY

DESVENLAFAXINE ER

DESVENLAFAXINE TB24

STEP THERAPY

DETROL

TOLTERODINE TARTRATE TABS

STEP THERAPY

DETROL LA

TOLTERODINE TARTRATE CP24

STEP THERAPY

DEXEDRINE

DEXTROAMPHETAMINE SULFATE CP24

STEP THERAPY

DIFFERIN

ADAPALENE CREA

STEP THERAPY

DIFFERIN

ADAPALENE GEL

STEP THERAPY

DIFFERIN

ADAPALENE LOTN

STEP THERAPY

DIOVAN

VALSARTAN TABS

STEP THERAPY

DIOVAN HCT

VALSARTAN-HYDROCHLOROTHIAZIDE

STEP THERAPY

DITROPAN XL

OXYBUTYNIN CHLORIDE TB24

STEP THERAPY

DUAC

CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE

DUEXIS

IBUPROFEN-FAMOTIDINE

DYANAVEL XR

AMPHETAMINE XR SUSPENSION

STEP THERAPY NSAID/GI PROTECTANT STEP THERAPY STEP THERAPY

EDARBI

AZILSARTAN MEDOXOMIL TABS

STEP THERAPY

EDARBYCLOR

AZILSARTAN MEDOXOMIL-CHLORTHALIDONE

STEP THERAPY

EDLUAR

ZOLPIDEM TARTRATE SUBL

STEP THERAPY

EFFEXOR XR

VENLAFAXINE HCL CP24

STEP THERAPY

ELIDEL

PIMECROLIMUS CREAM

STEP THERAPY

ENABLEX

DARIFENACIN HYDROBROMIDE TAB SR

STEP THERAPY

EPIDUO

ADAPALENE-BENZOYL PEROXIDE

STEP THERAPY

EPIDUO FORTE

ADAPALENE-BENZOYL PEROXIDE

STEP THERAPY

EQUAPAX

ATORVASTATIN –COENZYME Q10 TABS

STATIN STEP THERAPY

ERYGEL

ERYTHROMYCIN (ACNE AID) GEL

STEP THERAPY

EVEKEO

AMPHETAMINE SULFATE

STEP THERAPY

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Updated 1/1/17 Page 3 of 10 Information subject to change

Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy BRAND DRUG NAME

GENERIC DRUG NAME

EVOCLIN

CLINDAMYCIN PHOSPHATE (TOPICAL) FOAM

CORRESPONDING FORM TO SUBMIT STEP THERAPY

EXELON

RIVASTIGMINE PT24

STEP THERAPY

EXELON

RIVASTIGMINE TARTRATE CAPS

STEP THERAPY

EXFORGE

STEP THERAPY

FABIOR

AMLODIPINE BESYLATE-VALSARTAN AMLODIPINE-VALSARTANHYDROCHLOROTHIAZIDE TAZAROTENE (ACNE) FOAM

FANAPT

ILOPERIDONE TABS

STEP THERAPY

FANAPT TITRATION PACK

ILOPERIDONE MISC

STEP THERAPY

FARXIGA

DAPAGLIFLOZIN PROPANEDIOL TABS

STEP THERAPY

FAZACLO

CLOZAPINE TBDP*

STEP THERAPY

FENOGLIDE

FENOFIBRATE TAB

STEP THERAPY

FETZIMA

LEVOMILNACIPRAN HCL CP24

STEP THERAPY

FETZIMA TITRATION PACK

LEVOMILNACIPRAN HCL

STEP THERAPY

FIBRICOR

FENOFIBRIC ACID TABS*

STEP THERAPY

FLECTOR

DICLOFENAC EPOLAMINE PTCH

STEP THERAPY

FLUOXETINE HCL

FLUOXETINE HCL TAB 60 MG*

STEP THERAPY

FOCALIN

DEXMETHYLPHENIDATE HCL TABS

STEP THERAPY

FOCALIN XR

DEXMETHYLPHENIDATE HCL CP24

STEP THERAPY

FORFIVO XL

BUPROPION HCL TAB SR

STEP THERAPY

FORTESTA

TESTOSTERONE TD GEL

STEP THERAPY

FOSAMAX

ALENDRONATE SODIUM TABS*

STEP THERAPY

FOSAMAX PLUS D

ALENDRONATE SODIUM-CHOLECALCIFEROL TABS

STEP THERAPY

FROVA

FROVATRIPTAN SUCCINATE TABS

MIGRAINE STEP THERAPY

GALANTAMINE HYDROBROMIDE

GALANTAMINE HYDROBROMIDE ORAL SOLN*

STEP THERAPY

GELNIQUE

OXYBUTYNIN GEL

STEP THERAPY

GELNIQUE

OXYBUTYNIN CHLORIDE GEL

STEP THERAPY

GEODON

ZIPRASIDONE HCL CAPS

STEP THERAPY

GEODON

ZIPRASIDONE MESYLATE SOLR

STEP THERAPY

GLYXAMBI

EMPAGLIFLOZIN-LINAGLIPTIN

STEP THERAPY

GRALISE

GABAPENTIN (PHN) TABS

STEP THERAPY

GRALISE STARTER

GABAPENTIN (PHN) MISC

STEP THERAPY

HORIZANT

GABAPENTIN ENACARBIL TAB CR

STEP THERAPY

HUMALOG

INSULIN LISPRO (HUMAN)

INSULIN PRIOR APPROVAL

HUMALOG

INSULIN LISPRO (HUMAN) SOLN

INSULIN PRIOR APPROVAL

HUMALOG KWIKPEN

INSULIN PRIOR APPROVAL

HUMALOG MIX 50/50 KWIKPEN

INSULIN LISPRO (HUMAN) INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSP INSULIN LISPRO PROTAMINE & LISPRO (HUMAN)

HUMULIN 70/30

INSULIN ISOPHANE & REG (HUMAN) SUSP

INSULIN PRIOR APPROVAL

HUMULIN 70/30 KWIKPEN

INSULIN ISOPHANE & REG (HUMAN)

INSULIN PRIOR APPROVAL

HUMULIN N

INSULIN ISOPHANE (HUMAN) SUSP

INSULIN PRIOR APPROVAL

EXFORGE HCT

HUMALOG MIX 50/50

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STEP THERAPY STEP THERAPY

INSULIN PRIOR APPROVAL INSULIN PRIOR APPROVAL

Updated 1/1/17 Page 4 of 10 Information subject to change

Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy CORRESPONDING FORM TO SUBMIT INSULIN PRIOR APPROVAL

BRAND DRUG NAME

GENERIC DRUG NAME

HUMULIN N KWIKPEN

INSULIN ISOPHANE (HUMAN)

HUMULIN R

INSULIN PRIOR APPROVAL

IMITREX

INSULIN REGULAR (HUMAN) SOLN LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE SUMATRIPTAN SUCCINATE TABS

IMITREX

SUMATRIPTAN SUCCINATE SOLN

MIGRAINE STEP THERAPY

IMITREX STATDOSE REFILL

SUMATRIPTAN SUCCINATE

MIGRAINE STEP THERAPY

INOVA INOVA 4/1 & 8/2 ACNE CONTROL THERAPY INTERMEZZO

BENZOYL PEROXIDE & VITAMIN E BENZOYL PEROXIDE & SALICYLIC ACID & VITAMIN E ZOLPIDEM TARTRATE SL TAB

STEP THERAPY

INTUNIV

GUANFACINE HCL (ADHD) TB24

STEP THERAPY

INVEGA

PALIPERIDONE TB24

STEP THERAPY

INVEGA SUSTENNA

PALIPERIDONE PALMITATE SUSP

STEP THERAPY

INVOKAMET/INVOKAMET XR

CANAGLIFLOZIN-METFORMIN HCL

STEP THERAPY

INVOKANA

CANAGLIFLOZIN TABS

STEP THERAPY

IRENKA

DULOXETINE CAPS

STEP THERAPY

JANUMET

SITAGLIPTIN-METFORMIN HCL

STEP THERAPY

JANUMET XR

SITAGLIPTIN-METFORMIN HCL

STEP THERAPY

JANUVIA

SITAGLIPTIN PHOSPHATE TABS

STEP THERAPY

JARDIANCE

EMPAGLIFLOZIN TABS

STEP THERAPY

JENTADUETO/JENTADUETO XR

LINAGLIPTIN-METFORMIN HCL

STEP THERAPY

JUVISYNC

SITAGLIPTIN-SIMVASTATIN TAB

STEP THERAPY

KAPVAY

CLONIDINE HCL (ADHD) TB12

STEP THERAPY

KAZANO

ALOGLIPTIN-METFORMIN HCL

STEP THERAPY

KHEDEZLA

DESVENLAFAXINE TAB SR 24HR

STEP THERAPY

KOMBIGLYZE XR

SAXAGLIPTIN-METFORMIN HCL

STEP THERAPY

LATUDA

LURASIDONE HCL TABS

STEP THERAPY

LAVOCLEN CREAMY WASH

BENZOYL PEROXIDE LIQ

STEP THERAPY

LESCOL

FLUVASTATIN SODIUM CAPS

STATIN STEP THERAPY

LESCOL XL

FLUVASTATIN SODIUM TB24

STATIN STEP THERAPY

LEXAPRO

ESCITALOPRAM OXALATE TABS

STEP THERAPY

LEXAPRO

ESCITALOPRAM OXALATE SOLN

STEP THERAPY

LIPITOR

ATORVASTATIN CALCIUM TABS

STATIN STEP THERAPY

LIPOFEN

FENOFIBRATE CAPS*

STEP THERAPY

LIPTRUZET

EZETIMIBE-ATORVASTATIN

STATIN STEP THERAPY

LIVALO

PITAVASTATIN CALCIUM TABS

STATIN STEP THERAPY

LOFIBRA

FENOFIBRATE TAB

STEP THERAPY

LOROXIDE

BENZOYL PEROXIDE LOTN

STEP THERAPY

LUDIOMIL

MAPROTILINE HCL TABS

STEP THERAPY

LUMIGAN

BIMATOPROST SOLN

STEP THERAPY

LUNESTA

ESZOPICLONE TABS

STEP THERAPY

HYZAAR

Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association

STEP THERAPY MIGRAINE STEP THERAPY

STEP THERAPY STEP THERAPY

Updated 1/1/17 Page 5 of 10 Information subject to change

Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy BRAND DRUG NAME

GENERIC DRUG NAME

LUVOX CR

FLUVOXAMINE MALEATE CP24

CORRESPONDING FORM TO SUBMIT STEP THERAPY

LYRICA

PREGABALIN CAPS

STEP THERAPY

LYRICA

PREGABALIN SOLN

STEP THERAPY

MAPROTILINE HCL

MAPROTILINE HCL TAB*

STEP THERAPY

MAXALT

RIZATRIPTAN BENZOATE TABS

MIGRAINE STEP THERAPY

MAXALT-MLT

RIZATRIPTAN BENZOATE TBDP

MIGRAINE STEP THERAPY

METADATE CD

METHYLPHENIDATE HCL CPCR

STEP THERAPY

METHYLIN

METHYLPHENIDATE HCL CHEW

STEP THERAPY

METHYLIN

METHYLPHENIDATE HCL SOLN

STEP THERAPY

METROCREAM

METRONIDAZOLE CREAM

STEP THERAPY

METROGEL

METRONIDAZOLE (TOPICAL) GEL

STEP THERAPY

METROGEL 1% KIT

METRONIDAZOLE W/ CLEANSER (TOPICAL) KIT

STEP THERAPY

METROLOTION

METRONIDAZOLE (TOPICAL) LOTN

STEP THERAPY

MEVACOR

LOVASTATIN TABS

STATIN STEP THERAPY

MICARDIS

TELMISARTAN TABS

STEP THERAPY

MICARDIS HCT

TELMISARTAN-HYDROCHLOROTHIAZIDE

STEP THERAPY

MYRBETRIQ

MIRABEGRON TB24

STEP THERAPY

NAMENDA

MEMANTINE HCL TABS

STEP THERAPY

NAMENDA

MEMANTINE HCL SOLN

STEP THERAPY

NAMENDA XR

MEMANTINE HCL CP24

STEP THERAPY

NAMZARIC

MEMANTINE-DONEPEZIL

STEP THERAPY

NATESTO

TESTOSTERONE NASAL GEL

STEP THERAPY

NEOBENZ MICRO WASH PLUS PACK

BENZOYL PEROXIDE KIT

STEP THERAPY

NESINA

STEP THERAPY

NORITATE

ALOGLIPTIN BENZOATE TABS CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE & MOISTURIZER METRONIDAZOLE (TOPICAL) CREAM

NOVACET

SULFACETAMIDE SODIUM W/ SULFUR

STEP THERAPY

NUOX

BENZOYL PEROXIDE-SULFUR GEL

STEP THERAPY

OLEPTRO

TRAZODONE HCL TB24

STEP THERAPY

ONEXTON

CLINDAMYCIN-BENZOYL PEROXIDE

STEP THERAPY

ONEZTRA

SUMATRIPTAN

MIGRAINE STEP THERAPY

ONGLYZA

SAXAGLIPTIN HCL TABS

STEP THERAPY

OSENI

ALOGLIPTIN-PIOGLITAZONE

STEP THERAPY

OXYTROL FOR WOMEN

OXYBUTYNIN PTTW

STEP THERAPY

PACNEX MX

BENZOYL PEROXIDE LIQD

STEP THERAPY

PANOXYL

BENZOYL PEROXIDE CREA

STEP THERAPY

PAXIL

PAROXETINE HCL TABS

STEP THERAPY

PAXIL

PAROXETINE HCL SUSP

STEP THERAPY

PAXIL CR

PAROXETINE HCL TB24

STEP THERAPY

PENNSAID

DICLOFENAC SODIUM (TOPICAL) SOLN

STEP THERAPY

PEXEVA

PAROXETINE MESYLATE TABS

STEP THERAPY

NEUAC KIT

Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association

STEP THERAPY STEP THERAPY

Updated 1/1/17 Page 6 of 10 Information subject to change

Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy CORRESPONDING FORM TO SUBMIT STEP THERAPY

BRAND DRUG NAME

GENERIC DRUG NAME

PLEXION CLEANSER

PRAVACHOL

SULFACETAMIDE SODIUM W/ SULFUR SULFACETAMIDE SODIUM W/ SULFUR CLEANSING CLOTH PRAVASTATIN SODIUM TABS

PRISTIQ

DESVENLAFAXINE SUCCINATE TB24

STEP THERAPY

PROCENTRA

DEXTROAMPHETAMINE SULFATE SOLN

STEP THERAPY

PROTOPIC

TACROLIMUS (TOPICAL) OINT

STEP THERAPY

PROZAC

FLUOXETINE HCL CAPS

STEP THERAPY

PROZAC

FLUOXETINE HCL TABS

STEP THERAPY

PROZAC WEEKLY

FLUOXETINE HCL CPDR

STEP THERAPY

QUILLICHEW ER

METHYLPHENIDATE ER CHEW TAB

STEP THERAPY

QUILLIVANT XR

METHYLPHENIDATE HCL SUSR

STEP THERAPY

RAZADYNE

GALANTAMINE HYDROBROMIDE TAB

STEP THERAPY

RAZADYNE ER

GALANTAMINE HYDROBROMIDE CP24

STEP THERAPY

RELPAX

ELETRIPTAN HYDROBROMIDE TABS

MIGRAINE STEP THERAPY

REMERON

MIRTAZAPINE TABS

STEP THERAPY

REMERON SOLTAB

MIRTAZAPINE TBDP

STEP THERAPY

REMINYL

GALANTAMINE HYDROBROMIDE TABS

STEP THERAPY

REMINYL

GALANTAMINE HYDROBROMIDE SOLN

STEP THERAPY

RESCULA

UNOPROSTONE ISOPROPYL SOLN

STEP THERAPY

REXULTI

BREXPIPRAZOLE TABS

STEP THERAPY

RETIN-A

TRETINOIN CREAM

STEP THERAPY

RETIN-A MICRO

TRETINOIN MICROSPHERE GEL

STEP THERAPY

RETINOIC ACID

TRETINOIN POWDER*

STEP THERAPY

RIAX

BENZOYL PEROXIDE FOAM

STEP THERAPY

RISPERDAL

RISPERIDONE TABS

STEP THERAPY

RISPERDAL

RISPERIDONE SOLN

STEP THERAPY

RISPERDAL CONSTA

RISPERIDONE MICROSPHERES SUSR

STEP THERAPY

RISPERDAL M-TAB

RISPERIDONE ODT

STEP THERAPY

RITALIN

METHYLPHENIDATE HCL TABS

STEP THERAPY

RITALIN LA

METHYLPHENIDATE HCL CP24

STEP THERAPY

RITALIN SR

METHYLPHENIDATE HCL TAB CR*

STEP THERAPY

ROSADAN KIT

STEP THERAPY

ROSULA

METRONIDAZOLE GEL W/ CLEANSER KIT SULFACETAMIDE SOD-SULFUR EMUL & SKIN CLEANSER SULFACETAMIDE SODIUM W/ SULFUR

ROSUVASTATIN

ROSUVASTATIN

STATIN STEP THERAPY

ROZEREM

RAMELTEON TABS

STEP THERAPY

SANCTURA

TROSPIUM CHLORIDE TAB

STEP THERAPY

SANCTURA XR

TROSPIUM CHLORIDE CAP SR 24H

STEP THERAPY

SANCUSO

GRANISETRON PTCH

STEP THERAPY

SAPHRIS

ASENAPINE MALEATE SUBL

STEP THERAPY

PLEXION CLEANSING CLOTHS

ROSANIL

Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association

STEP THERAPY STATIN STEP THERAPY

STEP THERAPY STEP THERAPY

Updated 1/1/17 Page 7 of 10 Information subject to change

Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy BRAND DRUG NAME

GENERIC DRUG NAME

SAVELLA

MILNACIPRAN HCL TABS

CORRESPONDING FORM TO SUBMIT STEP THERAPY

SAVELLA TITRATION PACK

MILNACIPRAN HCL MISC

STEP THERAPY

SEROQUEL

QUETIAPINE FUMARATE TABS

STEP THERAPY

SEROQUEL XR

QUETIAPINE FUMARATE TB24

STEP THERAPY

SE BPO WASH KIT

BENZOYL PER WASH & BENZOYL PER CR KIT

STEP THERAPY

SILENOR

DOXEPIN HCL (SLEEP) TABS

STEP THERAPY

SIMCOR

NIACIN-SIMVASTATIN

STATIN STEP THERAPY

SODIUM SULFACETAMIDE/SULFUR SODIUM SULFACETAMIDE/SULFUR CLEANSER IN UREA SODIUM SULFACETAMIDE/SULFUR IN UREA SONATA

SULFACETAMIDE SODIUM W/ SULFUR SUSP SULFACETAMIDE SODIUM-SULFUR IN UREA EMULSION

STEP THERAPY

SULFACETAMIDE SODIUM-SULFUR IN UREA GEL

STEP THERAPY

ZALEPLON CAPS

STEP THERAPY

SSS 10-4

SULFACETAMIDE SODIUM W/ SULFUR FOAM

STEP THERAPY

STRATTERA

ATOMOXETINE HCL CAPS

STEP THERAPY

STRIANT

STEP THERAPY

SUMADAN WASH

TESTOSTERONE MISC SULFACETAMIDE SOD-SULFUR WASH & SKIN CLEANSER KIT SULFACETAMIDE SOD-SULFUR WASH & SUNSCREEN KIT SULFACETAMIDE SODIUM W/ SULFUR WASH

SUMATRIPTAN

SUMATRIPTAN SOLN

MIGRAINE STEP THERAPY

SUMATRIPTAN SUCCINATE

SUMATRIPTAN SUCCINATE

MIGRAINE STEP THERAPY

SUMAVEL DOSEPRO

SUMATRIPTAN SUCCINATE

MIGRAINE STEP THERAPY

SUMAXIN

SULFACETAMIDE SODIUM W/ SULFUR

STEP THERAPY

SUMAXIN WASH

SULFACETAMIDE SODIUM W/ SULFUR

STEP THERAPY

SYNJARDY

EMPAGLIFLOZIN-METFORMIN TABS

STEP THERAPY

TANZEUM

ALBIGLUTIDE

STEP THERAPY

TEKAMLO

ALISKIREN-AMLODIPINE

STEP THERAPY

TEKTURNA

ALISKIREN FUMARATE TABS

STEP THERAPY

TEKTURNA HCT

ALISKIREN-HYDROCHLOROTHIAZIDE

STEP THERAPY

TESTIM

TESTOSTERONE GEL*

STEP THERAPY

TESTOSTERONE

TESTOSTERONE TD GEL*

STEP THERAPY

TEVETEN

STEP THERAPY

TOVIAZ

EPROSARTAN MESYLATE TABS EPROSARTAN MESYLATEHYDROCHLOROTHIAZIDE FESOTERODINE FUMARATE TB24

TRADJENTA

LINAGLIPTIN TABS

STEP THERAPY

TRAVATAN

TRAVOPROST OPHTH SOLN*

STEP THERAPY

TRAVOPROST

TRAVOPROST OPHTH SOLN

STEP THERAPY

TRETINOIN

TRETINOIN POWDER*

STEP THERAPY

TRETIN-X

TRETINOIN W/ CLEANSER & MOISTURIZER KIT

STEP THERAPY

TREXIMET

SUMATRIPTAN-NAPROXEN SODIUM

MIGRAINE STEP THERAPY

TRIAZ

BENZOYL PEROXIDE GEL

STEP THERAPY

SUMADAN KIT SUMADAN XLT

TEVETEN HCT

Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association

STEP THERAPY

STEP THERAPY STEP THERAPY STEP THERAPY

STEP THERAPY STEP THERAPY

Updated 1/1/17 Page 8 of 10 Information subject to change

Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy CORRESPONDING FORM TO SUBMIT STEP THERAPY

BRAND DRUG NAME

GENERIC DRUG NAME

TRIAZ FOAMING CLOTHS

TRICOR

BENZOYL PEROXIDE MISC OLMESARTAN MEDOXOMIL-AMLODIPINEHYDROCHLOROTHIAZIDE FENOFIBRATE TABS

TRIGLIDE

FENOFIBRATE TAB

STEP THERAPY

TRILIPIX

CHOLINE FENOFIBRATE CPDR

STEP THERAPY

TRULICITY

DULAGLUTIDE

STEP THERAPY

TWYNSTA

TELMISARTAN-AMLODIPINE

STEP THERAPY

ULORIC

FEBUXOSTAT TABS

STEP THERAPY

VANOXIDE-HC

BENZOYL PEROXIDE-HC

STEP THERAPY

VELTIN

CLINDAMYCIN PHOSPHATE-TRETINOIN GEL

STEP THERAPY

VENLAFAXINE HCL ER

VENLAFAXINE HCL TB24

STEP THERAPY

VERSACLOZ

CLOZAPINE SUSP

STEP THERAPY

VESICARE

SOLIFENACIN SUCCINATE TABS

STEP THERAPY

VICTOZA

LIRAGLUTIDE

STEP THERAPY

VIIBRYD

VILAZODONE HCL TABS

STEP THERAPY

VIIBRYD

VILAZODONE HCL KIT

VIMOVO

NAPROXEN-ESOMEPRAZOLE MAGNESIUM

VOGELXO

TESTOSTERONE GEL*

STEP THERAPY NSAID/GI PROTECTANT STEP THERAPY STEP THERAPY

VOLTAREN

DICLOFENAC SODIUM (TOPICAL) GEL

STEP THERAPY

VRAYLAR

CARIPRAZINE

STEP THERAPY

VYTORIN

EZETIMIBE-SIMVASTATIN

STATIN STEP THERAPY

VYVANSE

LISDEXAMFETAMINE DIMESYLATE CAPS

STEP THERAPY

WELLBUTRIN

BUPROPION HCL TABS

STEP THERAPY

WELLBUTRIN SR

BUPROPION HCL TB12

STEP THERAPY

WELLBUTRIN XL

BUPROPION HCL TB24

STEP THERAPY

XALATAN

LATANOPROST SOLN

STEP THERAPY

XIGDUO XR

DAPAGLIFLOZIN-METFORMIN HCL

YOSPRALA

ASPIRIN & OMEPRAZOLE

ZACARE KIT

BENZOYL PEROXIDE & HYALURONATE SODIUM

STEP THERAPY NSAID/GI PROTECTANT STEP THERAPY STEP THERAPY

ZACLIR CLEANSING

BENZOYL PEROXIDE LOTION

STEP THERAPY

ZECUITY PAD

SUMATRIPTAN TD PATCHES

MIGRAINE STEP THERAPY

ZEMBRANCE SYMTOUCH

SUMATRIPTAN

MIGRAINE STEP THERAPY

ZENZEDI

DEXTROAMPHETAMINE SULFATE TAB

STEP THERAPY

ZETIA

EZETIMIBE TABS

STEP THERAPY

ZIANA

CLINDAMYCIN PHOSPHATE-TRETINOIN

STEP THERAPY

ZIOPTAN

TAFLUPROST SOLN

STEP THERAPY

ZOCOR

SIMVASTATIN TABS

STATIN STEP THERAPY

ZOLOFT

SERTRALINE HCL TABS

STEP THERAPY

ZOLOFT

SERTRALINE HCL CONC

STEP THERAPY

ZOLPIMIST

ZOLPIDEM TARTRATE SOLN

STEP THERAPY

TRIBENZOR

Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association

STEP THERAPY STEP THERAPY

Updated 1/1/17 Page 9 of 10 Information subject to change

Blue Cross Blue Shield of North Dakota Restricted Use List – Step Therapy BRAND DRUG NAME

GENERIC DRUG NAME

ZOMIG

ZOLMITRIPTAN TABS

CORRESPONDING FORM TO SUBMIT MIGRAINE STEP THERAPY

ZOMIG

ZOLMITRIPTAN SOLN

MIGRAINE STEP THERAPY

ZOMIG NASAL SPRAY

ZOLMITRIPTAN NASAL SPRAY

MIGRAINE STEP THERAPY

ZOMIG ZMT

ZOLMITRIPTAN TBDP

MIGRAINE STEP THERAPY

ZYPREXA

OLANZAPINE TABS

STEP THERAPY

ZYPREXA

OLANZAPINE SOLR

STEP THERAPY

ZYPREXA RELPREVV

OLANZAPINE PAMOATE SUSR

STEP THERAPY

ZYPREXA ZYDIS

OLANZAPINE TBDP

STEP THERAPY

Blue Cross Blue Shield of North Dakota An Independent Licensee of the Blue Cross and Blue Shield Association

Updated 1/1/17 Page 10 of 10 Information subject to change