Effective date:

Step Therapy Requirements
Effective 2/1/2014
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
ANTI-INFLAMMATORY AGENTS - GI
DRUG NAME
ASACOL HD | DIPENTUM
STEP THERAPY CRITERIA
PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
ANTIDIABETIC AGENTS - INSULINS
DRUG NAME
LEVEMIR | LEVEMIR FLEXPEN
STEP THERAPY CRITERIA
PRIOR CLAIM FOR INSULIN GLARGINE (LANTUS OR LANTUS SOLOSTAR) WITHIN
THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
ANTIDIABETIC AGENTS - MISCELLANEOUS
DRUG NAME
INVOKANA
STEP THERAPY CRITERIA
PRIOR CLAIM FOR METFORMIN, METFORMIN ER, A SULFONYLUREA, A
COMBINATION OF SULFONYLUREA AND METFORMIN, PIOGLITAZONE, OR
COMBINATION PIOGLITAZONE AND METFORMIN IN THE LAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
ANTIPSYCHOTIC AGENTS
DRUG NAME
FANAPT | FAZACLO | INVEGA | LATUDA | SAPHRIS
STEP THERAPY CRITERIA
PRIOR CLAIM FOR FORMULARY VERSIONS OF ANTIPSYCHOTICS SUCH AS
RISPERIDONE TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE
TABLET, OLANZAPINE TABLET, OLANZAPINE ORAL DISINTEGRATING TABLET,
IMMEDIATE RELEASE QUETIAPINE FUMARATE, OR ZIPRASIDONE, AND ABILIFY
WITHIN THE PAST 365 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
ANTIULCER AGENTS
DRUG NAME
DEXILANT
STEP THERAPY CRITERIA
PRIOR CLAIM FOR GENERIC FEDERAL LEGEND OMEPRAZOLE OR PANTOPRAZOLE
WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
ARIPIPRAZOLE
DRUG NAME
ABILIFY | ABILIFY DISCMELT
STEP THERAPY CRITERIA
PRIOR CLAIM FOR FORMULARY VERISIONS OF ATYPICAL ANTIPSYCHOTICS SUCH
AS RISPERIDONE TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE
TABLET, OLANZAPINE TABLET, OLANZAPINE ORAL DISINTEGRATING TABLET,
IMMEDIATE RELEASE QUETIAPINE FUMARATE OR ZIPRASIDONE, OR A SSRI OR
SNRI SUCH AS CITALOPRAM, FLUOXETINE, PAROXETINE, SERTRALINE, OR
VENLAFAXINE WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
B VERSUS D ADMINISTRATIVE STEP
DRUG NAME
CYCLOPHOSPHAMIDE | METHOTREXATE | TREXALL
STEP THERAPY CRITERIA
IN ORDER TO ASSIST IN A PART B VS. D PAYMENT DETERMINATION, A PRIOR
CLAIM SEEN FOR A RHEUMATOID ARTHRITIS DRUG WITHIN THE PAST 120 DAYS
WILL QUALIFY FOR PART D PAYMENT. ALL OTHER INDICATIONS WILL HAVE A
PART B VS. D PAYMENT DETERMINATION MADE THROUGH THE FORMULARY
EXCEPTION PROCESS PRIOR TO THE APPROVAL OF THE DRUG.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
BUDESONIDE - UCERIS
DRUG NAME
UCERIS
STEP THERAPY CRITERIA
PRIOR CLAIM FOR BALSALAZIDE WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
BUDESONIDE-FORMOTEROL FUMARATE
DRUG NAME
SYMBICORT
STEP THERAPY CRITERIA
PRIOR CLAIM FOR ADVAIR OR DULERA WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
DRUG NAME
DALIRESP
STEP THERAPY CRITERIA
PRIOR CLAIM FOR ONE COPD AGENT (LAMA, LABA, SAMA, SAMA/SABA) SUCH AS
ATROVENT, COMBIVENT, SPIRIVA, ARCAPTA, SEREVENT, OR FORADIL WITHIN THE
LAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
GAPABENTIN SR
DRUG NAME
GRALISE
STEP THERAPY CRITERIA
PRIOR CLAIM FOR GABAPENTIN IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
GLP-1 ANALOGS
DRUG NAME
BYDUREON | BYETTA
STEP THERAPY CRITERIA
PRIOR CLAIM FOR EITHER METFORMIN, METFORMIN ER, A SULFONYLUREA
AGENT (E.G. GLYBURIDE, GLIPIZIDE), COMBINATION OF A SULFONYLUREA AND
METFORMIN, A THIAZOLIDINEDIONE (E.G. PIOGLITAZONE, ROSIGLITAZONE), OR A
COMBINATION THIAZOLIDINEDIONE AND METFORMIN WITHIN WITHIN THE PAST
120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
HYPERURICEMIC AGENTS
DRUG NAME
ULORIC
STEP THERAPY CRITERIA
PRIOR CLAIM FOR ALLOPURINOL OR COLCHICINE WITHIN THE PAST 120 DAYS
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
KETOLIDES
DRUG NAME
KETEK
STEP THERAPY CRITERIA
PRIOR CLAIM FOR A MACROLIDE WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
MULTIPLE SCLEROSIS AGENTS
DRUG NAME
AVONEX | AVONEX ADMINISTRATION PACK | BETASERON | EXTAVIA
STEP THERAPY CRITERIA
PRIOR CLAIM FOR REBIF (INTERFERON BETA-1A) OR COPAXONE (GLATIRAMIR
ACETATE) WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE
DRUG NAME
CELEBREX
STEP THERAPY CRITERIA
PRIOR CLAIM FOR ONE (1) NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
OPHTHALMIC ANTIHISTAMINES
DRUG NAME
BEPREVE | PATADAY | PATANOL
STEP THERAPY CRITERIA
PRIOR CLAIM FOR LEVOCETIRIZINE OR CROMOLYN SODIUM EYE DROPS WITHIN
THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
QUETIAPINE FUMARATE EXTENDED RELEASE
DRUG NAME
SEROQUEL XR
STEP THERAPY CRITERIA
PRIOR CLAIM FOR FORMULARY VERSIONS OF ATYPICAL ANTIPSYCHOTICS SUCH
AS RISPERIDONE TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE
TABLET, OLANZAPINE TABLET, OLANZAPINE ORAL DISINTEGRATING TABLET,
IMMEDIATE RELEASE QUETIAPINE FUMARATE, OR ZIPRASIDONE, OR A SSRI OR
SNRI SUCH AS CITALOPRAM, FLUOXETINE, PAROXETINE, SERTRALINE, OR
VENLAFAXINE, AND ABILIFY WITHIN THE PAST 365 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
RENIN ANGIOTENSION SYSTEM INHIBITORS
DRUG NAME
AZOR | BENICAR | BENICAR HCT | DIOVAN | EDARBI | EDARBYCLOR | EXFORGE |
EXFORGE HCT | MICARDIS HCT | TEVETEN | TEVETEN HCT | TRIBENZOR
STEP THERAPY CRITERIA
PRIOR CLAIM FOR AN ANGIOTENSIN CONVERTING ENZYME INHIBITOR (ACE
INHIBITOR), OR ACE INHIBITOR COMBINATION OR A GENERIC ANGIOTENSIN
RECEPTOR BLOCKER (ARB), OR GENERIC ARB COMBINATION WITHIN THE PAST 120
DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
RIFAXIMIN
DRUG NAME
XIFAXAN
STEP THERAPY CRITERIA
PRIOR CLAIM FOR LACTULOSE WITHIN THE PAST 120 DAYS.
Physicians United Plan
Step Therapy Requirements
Effective Date: 02/01/2014
STEP THERAPY GROUP DESCRIPTION
ROTIGOTINE
DRUG NAME
NEUPRO
STEP THERAPY CRITERIA
PRIOR CLAIM FOR IMMEDIATE RELEASE PRAMIPEXOLE OR IMMEDIATE RELEASE
ROPINIROLE WITHIN THE PAST 120 DAYS.

Source: http://www.uaskpup.com/Documents/2014/Formulary/STEPWEB_File_PUP_14556_10252013_102617_EFF_01012014_mj.pdf