Step Therapy Programs

Providers can initiate preauthorization by submitting a request online at www.dkc-pa.com.

NOTE

Not all plans cover these drugs or require preauthorization. Refer to the member’s policy (also known as the Master Contract, Certificate of Coverage or Plan Document) to determine coverage.

***This list does not guarantee coverage and is subject to change.***

	STEP ONE	STEP TWO
Albuterol Inhalers	albuterol HFA levalbuterol HFA ProAir Digihaler ProAir HFA ProAir Respiclick Ventolin HFA	Proventil HFA
Antidepressants-SNRI	buproprion citalopram desvenlafaxine ER (generic) duloxetine escitalopram fluoxetine fluvoxamine paroxetine sertraline venlafaxine	Desvenlafaxine ER (brand)
Antifungal Agents-topical	ciclodan/ciclopirox clotrimazole econazole ketoconazole miconazole naftifine nystatin oxiconazole	Ecoza Ertaczo Exelderm Jublia Naftin Oxistat Xolegel
Biliary Cirrhosis Agents	ursodiol	Ocaliva
Fibromyalgia	duloxetine gabapentin	Neurontin (brand)
Glaucoma	latanoprost	Lumigan (brand) Travatan Z (brand) Zioptan
Gout	allopurinol febuxostat	Zurampic
Pain	buprenorphine patch hydromorphone ER methadone morphine ER oxycodone ER	Arymo ER Butrans Embeda Hysingla ER Kadian ER Morphabond Nucynta ER Oxycontin Xtampza ER Zohydro ER