Step therapy Premium Formulary — Step therapy program (drug step therapy list)
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Defines medications placed on a step therapy program for AmeriHealth members and explains that members must try specified lower-step (step 1) drugs before higher-step (step 2) drugs will be covered; affects prescribing clinicians, pharmacists, and members under AmeriHealth benefit plans.
No material clinical or coverage changes in this revision.
Step Therapy Coverage Criteria
Step therapy coverage condition
Covered when the following step rule is met
If prior trial not shown, pharmacist may contact prescriber; exceptions and prior authorization pathways may exist per plan
Step therapy requirements may vary by benefit plan and are effective July 1, 2026. The listed step therapy medications are subject to change without notice. In addition to the step therapy rules, additional clinical programs — including quantity limits and prior authorization — may apply to drugs on this list and could affect prescription drug coverage.
Provider Responsibilities and Workflow
Follow the step therapy workflow before dispensing
Members must try a step 1 medication first; if pharmacy claims show prior use of the required step 1 medication, the step 2 medication may be filled. If prior step use is not shown, the pharmacist may contact the prescriber to explain next steps.
Check for prior authorization and quantity limits
Additional clinical programs may affect coverage for listed medications. Quantity limits and prior authorization may apply and could change coverage or processing.
Ensure prior-step documentation is available
Pharmacy claims history must document a prior trial of the designated step 1 medication for the step 2 medication to be filled without intervention; pharmacists may contact the prescriber if prior-step documentation is not present.
Missing step 1 trial may result in denial or manual processing
Claims for step 2 medications may be denied or not auto-processed unless pharmacy claims show prior use of the required step 1 medication; pharmacists may contact the prescriber if prior step is not documented.
Policy Background
Step therapy prioritizes use of lower-cost, clinically appropriate medications first. Members must try the designated Step 1 medication(s) before a Step 2 medication will be covered; if a member has tried and failed or cannot tolerate the Step 1 option, Step 2 coverage may be considered per plan rules. Pharmacy claims history or other acceptable documentation should demonstrate the prior trial of the required Step 1 medication to avoid processing delays or potential denials.
Key Definitions
Initial (Step 1) Therapy
Initial (Step 1) therapy — Step 1 medication examples
Step 1 medication examples
Documented trials of these generics are required prior to coverage of corresponding Step 2 brand products; see full drug list for additional classes and specific generic options
Step Therapy Drug Pairings and Table
| Therapeutic class / condition | Step 1 (required trial) | Step 2 (requires Step 1 trial) |
|---|---|---|
| Step 1: Any one of the following generics: clindamycin 2% vaginal cream; metronidazole 0.75% vaginal gel. Step 2: VANDAZOLE. | ||
| Step 2: SOLOSEC; brands for tetracyclines include AVIDOXY, MONDOXYNE NL, VIBRAMYCIN; other brand entries as listed. | ||
| Step 2: SEYSARA; CETRAXAL. | ||
| Step 2: ALTOPREV; EZALLOR; FLOLIPID; FENOGLIDE; FIBRICOR; LIPOFEN (per class-specific entries). | ||
| Step 2: EDARBI; EDARBYCLOR (and other brand combinations listed). | ||
| Step 2: Brands listed include APTENSIO XR; AZSTARYS; CONCERTA; DESOXYN; DEXEDRINE; JORNAY PM; METHYLIN; METHYLPHENIDATE ER; PROCENTRA; RELEXXII; VYVANSE; ONYDA XR (per document). | ||
| Step 2: TIGLUTIK; TEGLUTIK; BRIVIACT; XCOPRI; MOTPOLY XR (and other brand agents listed). | ||
| Step 2: Brands include APLENZIN; FETZIMA; DESVENLAFAXINE ER; DRIZALMA; PAXIL SUSPENSION; TRINTELLIX; VIIBRYD; CAPLYTA (per pairings in document). | ||
| Step 2: Brands include EDLUAR; ZOMIG; ZOLMITRIPTAN NASAL SPRAY; GRALISE; gabapentin once‑daily formulations; SAVELLA; others as listed. | ||
| Step 2: Brands include FINACEA GEL; ZILXI; ONEXTON; VTAMA; ZORYVE (cream/foam); SERNIVO; KLISYRI; OPZELURA; EUCRISA; ZORYVE CREAM 0.05%/0.15%; other named brand topicals. | ||
| Step 2: Brands include KLISYRI; imiquimod cream 3.75%; CYCLOSET; RIOMET; LINZESS; PRUCALOPRIDE; SYMPROIC; MOTEGRITY; FIRST‑OMEPRAZOLE; FIRST‑PANTOPRAZOLE; LANSOPRAZOLE SUSPENSION; PRILOSEC PACKET; PROTONIX PACKET (as listed). | ||
| Step 2: Brands include febuxostat (ULORIC); FERAHEME; ferumoxytol; INJECTAFER; FOSRENOL; IMVEXXY; OSPHENA; PREMARIN VAGINAL CREAM; XELPROS; EPIPEN; SYMBICORT; BREO/ADVAIR HFA; CARDURA XL; ENTADFI; GELNIQUE; OXYTROL; MYRBETRIQ; and other brand products cited in the document. |
Quantity Limits and Related Guidance
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