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Step therapy criteria

Step Therapy Criteria 2014 MSOFL_Medica Last Updated: 01/01/2014 ANTIDEPRESSANT THERAPY - UHCMR
Products Affected

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: Irinotecan 20 mg/mL injection (generic). Step 2: Camptosar 20 mg/mL injection CNS STIMULANT 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: Colistimethate sodium 150 mg injection (generic). Step 2: Coly-Mycin 150 mg injection DDAVP INJECTION THERAPY - UHCMR
Products Affected

Criteria
Step 1: Desmopressin acetate 4 mcg/mL injection (generic). Step 2: DDAVP 4 mcg/mL injection ELLENCE INJECTION THERAPY - UHCMR
Products Affected

Criteria
Step 1: Epirubicin Injection Step 2: Ellence Injection EXELON THERAPY - UHCMR
Products Affected

Criteria
Step 1: One formulary oral acetylcholinesterase inhibitor. Step 2: Exelon transdermal systems FANAPT THERAPY - UHCMR
Products Affected

Criteria
Step 1: One of the following atypical antipsychotics: Geodon, Risperidone, Seroquel, Seroquel XR, Olanzapine, or Olanzapine ODT. Step 2: Fanapt IDAMYCIN INJECTION THERAPY - UHCMR
Products Affected

Criteria
Step 1: idarubicin injection (generic) Step 2: Idamycin PFS injection LEUKOTRIENE MODIFIER ASTHMA THERAPY - UHCMR
Products Affected

Criteria
Step 1: Formulary Singulair or generic montelukast. Step 2: Zyflo CR or Zyflo NIPENT THERAPY - UHCMR
Products Affected

Criteria
Step 1: Pentostatin injection (generic). Step 2: Nipent injection PHOSLYRA THERAPY - UHCMR
Products Affected

Criteria
Step 1: Calcium acetate or Renvela. Step 2: Phoslyra RANEXA THERAPY - UHCMR
Products Affected

Criteria
Step 1: Any one preferred tier: Long-acting nitrate, Beta-blocker, or Calcium-channel blocker. Step 2: Ranexa RENAGEL THERAPY - UHCMR
Products Affected

Criteria
TOPICAL IMMUNOMODULATOR THERAPY - UHCMR
Products Affected

Criteria
Step 1: Any one preferred tier topical Corticosteroid. Step 2: Elidel or Protopic UCERIS THERAPY- UHCMR
Products Affected

Criteria
Step 1: Any ONE formulary preferred agent from the following: rectal 5-ASA, oral 5-ASA, oral corticosteroid, or rectal corticosteroid. Step 2: Uceris ULORIC THERAPY - UHCMR
Products Affected

Criteria
VFEND THERAPY - UHCMR
Products Affected

Criteria
Step 1: Generic voriconazole. Step 2: Brand Vfend VIOKACE 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

Source: http://mypreferredportal.com/media/2489/14395_Formulary-MSOFL_ST-Web-File-MEDICA-Mike-Haran-edits-092313-236pm.pdf