Step Therapy Programs

Some Benefit Plans require the Member to try one or more preferred medications before a non‑preferred medication will be allowed for payment.

Program Name	Type of Program	MSHO/SNBC	PMAP
ACE Inhibitor/ Angiotensin Receptor Blocker	Step Therapy	X
Byetta	Step Therapy	X
Depression SNRI	Step Therapy	X
Depression SSRI	Step Therapy	X
Enbrel™	Step Therapy	X	X
Leukotriene Modifiers	Step Therapy	X
Lunesta™	Step Therapy	X
Lyrica™ & Topamax™	Step Therapy	X
Protopic™	Step Therapy	X
Zetia™	Step Therapy	X

Quantity Limit

The Quantity Limit programs follow clinical based guidelines to restrict the potential for misuse. Each particular program will automatically reject if a claim is submitted for a quantity in excess of the threshold established. The online claim system should prompt the pharmacy to only fill the maximum allowed. For members requiring greater quantities than allowed under the program a formulary exception form with medical history should be submitted to PrimeTherapeutic, LLC Clinical Review Area. Specific quantity limits for individual products is available under the following link: Quantity Limit Grid.

Program Name	Type of Program	MSHO/SNBC	PMAP
Abortive Triptan Therapy	Quantity Limits	X	X
Bisphosphonates	Quantity Limits	X
Celebrex™	Quantity Limits	X
Fentanyl Transdermal	Quantity Limits	X
Januvia™ & Janumet™	Quantity Limits	X
Ketorolac	Quantity Limits	X	X
Low Molecular Weight Heparin	Quantity Limits	X
Nasal Inhalers	Quantity Limits	X	X
Ophthalmic Prostaglandin	Quantity Limits	X
Oral Inhalers Asthma/COPD	Quantity Limits	X	X
Oxycodone ER	Quantity Limits	X	X
Proton Pump Inhibitors	Quantity Limits	X	X
Statins	Quantity Limits	X	X
Urinary Incontinence	Quantity Limits	X
Zostavax™	Quantity Limits	X

Prior Authorization

Some medications require a prior authorization before they will adjudicate on-line. These drugs will reject with a code of 76, “Step Therapy not met, PA required”. PrimeWest Health requires clinical documentation from the Prescribing Provider before a prior authorization will be granted.

Program Name
Type of Program MSHO/SNBC PMAP
Forteo™ Prior Authorization X X
Erythropoetin Stimulating Agents Prior Authorization X
Hepatitis C Treatments Prior Authorization X X
Human Growth Hormone Prior Authorization X X
Intravenous Immune Globulin Prior Authorization X
Lamisil & Sporonox Antifungals Prior Authorization X
Provigil™ Prior Authorization X
Regranex™ Prior Authorization X
Revatio™ Prior Authorization X
Strattera™ Prior Authorization X
Xolair™ Prior Authorization X X

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Utilization Management Programs

Utilization Management Programs

Step Therapy Programs

Quantity Limit

Prior Authorization