Step Therapy Criteria 2013 Fidelis Formulary Last Updated: 10/01/2013
ALPHA GLUCOSIDASE INHIBITOR THERAPY - PS PART D Products Affected
Criteria
Step 1: Any two of the following: Metformin, Sulfonylurea, Thiazolidinedione (TZD), Insulin, Byetta, any generic Tier 1 combination antidiabetic agent(s). Step 2: Glyset
ANTIDEPRESSANT THERAPY - FIDELIS Products Affected
Criteria
Step 1: One of the following Tier 1 or Tier 2 antidepressants: SSRI, SNRI, bupropion, mirtazepine. Step 2: Emsam or Pexeva
ARCAPTA THERAPY - PS PART D Products Affected
Criteria
Step 1: Inhaled corticosteroids or Inhaled anticholinergics or Advair or Symbicort. Step 2: Arcapta
ARICEPT THERAPY - PS PART D Products Affected
Criteria
Step 1: Aricept/donpezil 10 mg or Aricept/donpezil 10 mg ODT. Step 2: Aricept/donpezil 23mg
BISPHOSPHONATE THERAPY - PS PART D Products Affected
Criteria
Step 1: Any one of the following: 1. Metformin, 2. sulfonylurea, 3. thiazolidinedione (TZD), 4. Insulin, 5. any generic Tier 1 combination antidiabetic agent. Step 2: Bydureon
CHOLINERGIC AGONIST THERAPY - PS PART D Products Affected
Criteria CNS STIMULANT THERAPY - PS PART D Products Affected
Criteria
Step 1: Amphetamine/Dextroamphetamine combinations or Dextroamphetamine, or Dexmethylphenidate or Methylphenidate or a long acting methylphenidate. Step 2: Strattera
DIPEPTIDYL PEPTIDASE-4 INHIBITOR THERAPY - PS PART D Products Affected
Criteria
Step 1: Any ONE of the following: 1. Metformin, 2. Sulfonylurea, 3. Thiazolidinedione (TZD), 4. Insulin, 5. Byetta, 6. any generic Tier 1 combination antidiabetic agent. Step 2: Januvia or Onglyza.
DIPEPTIDYL PEPTIDASE-4 INHIBITOR/ METFORMIN COMBINATION THERAPY - PS PART D Products Affected
Criteria
Step 1: Any ONE of the following: 1. Metformin, 2. Sulfonylurea, 3. Thiazolidinedione (TZD), 4. Insulin, 5. Byetta, 6. any generic Tier 1 combination antidiabetic agent. Step 2: Janumet or Kombiglyze XR
DIPEPTIDYL PEPTIDASE-4 INHIBITOR/OTHER COMBINATION - PS PART D Products Affected
Criteria
Step 1: Any ONE of the following: 1)Januvia or 2)Onglyza or 3)Janumet or 4)Janumet XR or 5)Kombiglyze XR. Step 2: Tradjenta or Jentadueto
DUETACT THERAPY - PS PART D Products Affected
Criteria
Step 1: Sulfonylurea or Actos. Step 2: Duetact/Pioglitazone HCl - Glimepiride
FANAPT THERAPY - PS PART D Products Affected
Criteria
Step 1: One of the following atypical antipsychotics: Risperidone or Seroquel (quetiapine)/ Seroquel XR or olanzapine or olanzapine ODT. Step 2: Fanapt
INCRETIN MIMETIC THERAPY - PS PART D Products Affected
Criteria
Step 1: Any one of the following: 1. Metformin, 2. sulfonylurea, 3. thiazolidinedione (TZD), 4. Insulin, 5. any generic Tier 1 combination antidiabetic agent. Step 2: Byetta or Victoza.
INHALED CORTICOSTEROID THERAPY - PS PART D Products Affected
Criteria
Step 1: Any ONE preferred formulary non-nebulized inhaled corticosteroid. Step 2: Alvesco
INTUNIV THERAPY - FIDELIS Products Affected
Criteria
Step 1: Any ONE formulary ADHD stimulant. Step 2: Intuniv
JANUMET XR THERAPY - FIDELIS Products Affected
Criteria
Step 1: Any ONE of the following: 1. Metformin, 2. Sulfonylurea, 3. Thiazolidinedione (TZD), 4. Insulin, 5. Byetta, 6. any generic Tier 1 combination antidiabetic agent Step 2: Janumet XR
LEUKOTRIENE MODIFIER ASTHMA THERAPY - PS PART D Products Affected
Criteria
Step 1: Formulary Beta-agonist or Formulary Inhaled corticosteroid or Formulary Inhaled Beta-agonist/Corticosteroid combination or Formulary Oral Corticosteroid. Step 2: Zyflo CR
LONG ACTING BETA AGONIST THERAPY - PS PART D Products Affected
Criteria
Step 1: Inhaled corticosteroids or Inhaled anticholinergics. Step 2: Foradil or Serevent
MEGLITINIDE THERAPY - PS PART D Products Affected
Criteria
Step 1: Any two of the following: 1. Metformin, 2. Sulfonylurea, 3. Thiazolidinedione (TZD), 4. Insulin, 5. Byetta, 6. any generic Tier 1 combination antidiabetic agent. Step 2: Prandin/Repaglinide
OPHTHALMIC ANTIHISTAMINE THERAPY - PS PART D Products Affected
Criteria
Step 1: Azelastine, Pataday, or Patanol. Step 2: Emadine
OPHTHALMIC STEROID THERAPY - PS PART D Products Affected
Criteria
Step 1: Ophthalmic prednisolone acetate. Step 2: FML Forte or Vexol
OXYCONTIN THERAPY - PS PART D Products Affected
Criteria
Step 1: Generic morphine sulfate ER. Step 2: Oxycontin.
RANEXA THERAPY - PS PART D Products Affected
Criteria
Step 1: Long-acting nitrate, Beta-blocker, or Calcium-channel blocker. Step 2: Ranexa
RENAGEL THERAPY - PS PART D Products Affected
Criteria SKELETAL MUSCLE RELAXANTS - PS PART D Products Affected
Criteria
Step 1: Cyclobenzaprine (immediate-release). Step 2: Cyclobenzaprine (extended-release) or generic Cyclobenzaprine IR (generic Fexmid)
STALEVO THERAPY - PS PART D Products Affected
Criteria
Step 1: Carbidopa/Levodopa (immediate release) AND Comtan. Step 2: Stalevo
STATIN THERAPY: GROUP 1 - PS PART D Products Affected
Criteria
Step 1: Simvastatin or Lovastatin or Pravastatin or Atorvastatin or Fluvastatin or Crestor. Step 2: Altoprev
STATIN THERAPY: GROUP 2 - PS PART D Products Affected
Criteria
Step 1: Atorvastatin or Crestor. Step 2: Vytorin
TOPICAL IMMUNOMODULATOR THERAPY - PS PART D Products Affected
Criteria
Step 1: Topical Corticosteroid. Step 2: Elidel or Protopic
TRIPTAN THERAPY - PS PART D Products Affected
Criteria
Step 1: Naratriptan and Sumatriptan. Step 2: Axert or Frova or Relpax
ULORIC THERAPY - PS PART D Products Affected
Criteria VIIBRYD THERAPY - PS PART D Products Affected
Criteria
Step 1: One Tier 1 or Tier 2 SSRI or SNRI. Step 2: Viibryd
XOPENEX NEBULIZER THERAPY - PS PART D Products Affected
Criteria
Step 1: Albuterol (Nebulizer) Step 2: Xopenex Nebulizer or Generic Levalbuterol Nebulizer.
XYZAL SUSPENSION THERAPY - PS PART D Products Affected
Criteria
Step 1: cetirizine syrup. Step 2. levocetirizine syrup
ZELAPAR THERAPY - PS PART D Products Affected
Criteria
Step 1: Formulary Beta-agonist or Formulary Inhaled corticosteroid or Formulary Inhaled Beta-agonist/Corticosteroid combination or Formulary Oral Corticosteroid. Step 2: Zyflo
A coordinated care plan with a Medicare Advantage contract and a contract with Michigan Medicaid program. Formulary ID# 00013383 MCE 12_117 H2323, H5575, H5980 File & Use 04/18/2012
Earn 6 hrs of Law Society / Bar Council CPD Credit A review and analysis of major developments during 2002 Friday 18th October 2002 A special one-day conference allowing you to benefit from the expertise associated ■ Chairman: with Europe’s leading Julian Maitland-Walker competition law journal ■ Keynote Speaker: John Vickers ■ Sp
CYPROHEPTADINE, PIZOTIFEN AND AMITRYPTILINE AS PROPHYLACTIC THERAPY IN CYCLIC VOMITING SYNDROME S. Martinazzi, M. Fuoti, M. Brusati, A. Ravelli University Department of Pediatrics, Children’s Hospital, Spedali Civili – Brescia (Italy) BACKGROUND AND AIM. Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder of unknown origin that causes severe recurrent attack
Step Therapy Criteria 2013 Fidelis Formulary Last Updated: 10/01/2013
ALPHA GLUCOSIDASE INHIBITOR THERAPY - PS PART D