Criteria
Step 1: One of the following Tier 1 or Tier 2 or Tier 3 antidepressants: SSRI, SNRI, bupropion, mirtazepine. Step 2: Emsam
CAMPTOSAR INJECTION THERAPY - UHCMR Products Affected
Criteria
Step 1: Amphetamine/Dextroamphetamine combinations or Dextroamphetamine, or Dexmethylphenidate or Methylphenidate or a long acting methylphenidate. Step 2: Strattera
COLY-MYCIN THERAPY - UHCMR Products Affected
Criteria
Step 1: Any one formulary preferred tier pancreatic enzyme. Step 2: Viokace
ZOFRAN INJECTION THERAPY - UHCMR Products Affected
Criteria
Step 1: ondansetron injection (generic). Step 2: Zofran injection
Plans are insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. [<OVEX3386716_000>] <Formulary ID#> 00014395 Y0066_130404_093413 CMS Approved
EMPLOYEE SUMMARY OF BENEFITS Connecticut General Life Insurance Co. This is a summary of benefits for your CIGNA Choice Fund/Open Access Plus with HRA plan. All deductibles and plan out-of-pocket maximums cross –accumulate between in- and out-of--network unless otherwise noted. Plan maximums and service-specific maximums (dollar and occurrence) cross-accumulate between in- and out-of-n
Step Therapy Criteria 2014 MSOFL_Medica Last Updated: 01/01/2014
ANTIDEPRESSANT THERAPY - UHCMR