Drug Name Step Therapy Criteria Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2. : Allegra OTC, Allegra D OTC, Astelin, Astepro, Beconase AQ,
Cetirizine, Cetirizine-D, Clemastine Fumarate, Cyproheptadine Hcl, Diphenhydramine Hcl, Fluticasone Propionate,
Singulair
Hydroxyzine Hcl, Hydroxyzine Pamoate, Loratadine, Loratadine-D, Nasacort AQ, Flunisolide, Nasonex, Palgic, Rhinocort
Aqua. Step 2: Singulair Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS, 1 DRUG FROM EACH CLASS, IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: ACE-Inhibitor (including combinations with HCTZ) Benazepril Hcl, Benazepril Hcl/Hydrochlorothiazide, Captopril, Captopril /Hydrochlorothiazide,
Enalapril Maleate, Enalapril Maleate/Hydrochlorothiazide, Fosinopril Sodium, Fosinopril sodium/Hydrochlorothiazide,
Benicar, Benicar Hct, Diovan,
Lisinopril, Lisinopril /Hydrochlorothiazide, Quinapril Hcl, Quinaretic, Trandolapril, Ramipril. ARB (including combinations
Diovan Hct, Micardis, Micardis Hct
with HCTZ), losartan, losartan/HCTZ Step 2: Benicar, Benicar Hct, Diovan, Diovan Hct, Micardis, Micardis Hct Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Advair Diskus, Advair HFA, Aerobid, Aerobid-M, Albuterol
Sulfate, Albuterol Sulfate Er, Alupent, Aminophylline, Dulera, Elixophyllin, Flovent HFA, Lufyllin, Metaproterenol Sulfate,
Singulair
Proair HFA, Qvar, Serevent Diskus, Symbicort, Spiriva Handihaler, Terbutaline Sulfate, Theo-24, Theophylline Cr,
Theophylline Er, Theophylline Td, Ventolin HFA. Step 2: Singulair
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: clozapine, risperidone, olanzapine, Seroquel, Geodon Step 2: Abilify, Fanapt, Fazaclo, Invega, Latuda, Risperdal Consta, Risperdal M-Tab, Saphris, Seroquel XR, Zyprexa. Step Therapy only applies to new starts only. Enrollees stabilized on medication will not be required to go through step therapy. Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Chlorpropamide, Fortamet, Glimepiride, Glipizide, Glipizide Er,
Glipizide Xl, Glipizide/Metformin Hcl, Glyburide, Glyburide Micronized, Glyburide/Metformin Hcl, Glycron, Metformin Hcl,
Metformin Hcl Er, Prandin, Precose, Starlix, Tolazamide, Tolbutamide. Step 2: Byetta
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF THE FOLLOWING DRUG IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: bupropion, bupropion SR, bupropion XL, mirtazapine, nefazodone, trazodone,
fluoxetine, Lexapro, paroxetine, sertraline, venlafaxine, venlafaxine XR, Seroquel Step 2: Abilify, Seroquel XR Step Abilify, Seroquel XR Therapy only applies to new starts only. Enrollees stabilized on medication will not be required to go through step therapy. Drug Name Step Therapy Criteria Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Chlorpropamide, Fortamet, Glimepiride, Glipizide, Glipizide Er, Glipizide Xl, Glipizide/Metformin Hcl, Glyburide, Glyburide Micronized, Glyburide/Metformin Hcl, Glycron, Humalog,
Humalog Mix 50/50, Humalog Mix 75/25, Humulin 50/50, Humulin 70/30, Humulin N, Humulin R, Lantus, Lantus
Actos, Avandamet, Avandamet,
Solostar, Levemir, Metformin Hcl, Metformin Hcl Er, Novolog, Novolog Flexpen, Novolog Mix 70/30, Prandin, Precose,
Avandaryl, Avandia, Duetact
Relion 70/30, Relion 70/30 Innolet, Relion N, Relion N Innolet, Relion R, Starlix, Tolazamide. Step 2: Actos, Avandamet, Avandamet, Avandaryl, Avandia, Duetact
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
Janumet, Januvia, Onglyza
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Fortamet, Glipizide/Metformin Hcl, Glyburide/Metformin Hcl,
Metformin Hcl, Metformin Hcl ER. Step 2: Janumet, Januvia, Onglyza Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Diclofenac Potassium, Diclofenac Sodium, Diclofenac Sodium Dr, Diclofenac Sodium Ec, Diclofenac Sodium Er, Diflunisal, Etodolac, Etodolac Er, Fenoprofen Calcium, Flurbiprofen,
Ibuprofen, Indomethacin, Indomethacin Er, Ketoprofen, Ketoprofen Er, Ketorolac Tromethamine, Meloxicam,
Celebrex
Nabumetone, Naproxen, Naproxen Dr, Naproxen Sodium, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2: Celebrex
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
Clarinex, Clarinex D
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Allegra OTC, Allegra D OTC, Loratadine,
Loratadine/Pseudoephedrine, Cetirizine, Cetirizine/Pseudoephedrine. Step 2: Clarinex, Clarinex D
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
Prevacid, Nexium, Protonix IV
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: lansoprazole, Priolosec Otc, Omeprazole Otc, Omeprazole,
Omeprazole/Sodium Bicarbonate, Pantoprazole, Prevacid OTC, Zegerid OTC. Step 2: Prevacid, Nexium, Protonix IV
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF THE FOLLOWING DRUG IN THE PREVIOUS 120
DAYS BEFORE MOVING TO STEP 2: Warfarin Step 2: Pradaxa Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS, 1 DRUG FROM EACH CLASS, IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: • ACE-Inhibitors (including combinations with HCTZ) - Benazepril Hcl, Benazepril Hctz, Captopril, Captopril /Hctz, Enalapril Maleate, Enalapril Maleate/Hctz, Fosinopril Sodium, Fosinoprilsodium/Hctz, Lisinopril, Lisinopril /Hctz, Quinapril Hcl, Quinaretic,
Trandolapril, Ramipril. • ARBs (including combinations with HCTZ) - Benicar, Benicar Hct, Diovan Hct, losartan,
Tekturna, Tekturna Hct
losartan/HCT, Micardis, Micardis Hct. Step 2: Tekturna, Tekturna Hct
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL THE FOLLOWING DRUG IN THE PREVIOUS 120 DAYS
BEFORE MOVING TO STEP 2: Gleevec. Step 2: Sprycel Step Therapy only applies to new starts only. Enrollees
stabilized on medication will not be required to go through step therapy.
Drug Name Step Therapy Criteria
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE
PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Atorvastatin, Simvastatin, Pravastatin, Lovastatin. Step 2:Crestor
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Humalog, Humalog Mix 50/50, Humalog Mix 75/25, Lantus,
Levemir, Novolog, Novolog Flexpen, Novolog Mix 70/30, Novolin R, Novolin N, Novolin 70/30. Step 2: Symlin Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Alclometasone Dipropionate, Amcinonide, Augmented Betamethasone Dipropionate, Betamethasone Dipropionate, Betamethasone Valerate, Clobetasol Propionate,
Clobetasol Propionate Emollient, Desonide, Desoximetasone, Diflorasone Diacetate, Fluocinolone Acetonide,
Elidel, Protopic
Fluticasone, Halobetasol Propionate, Hydrocortisone Butyrate, Hydrocortisone Valerate, Mometasone Furoate,
Prednicarbate, Triamcinolone Acetonide, Triamcinolone Acetonide In Absorbase. Step 2: Elidel, Protopic
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Chlorpropamide, Fortamet, Glimepiride, Glipizide, Glipizide Er,
Glipizide Xl, Glipizide/Metformin Hcl, Glyburide, Glyburide Micronized, Glyburide/Metformin Hcl, Glycron, Metformin Hcl,
Metformin Hcl Er, Prandin, Precose, Starlix, Tolazamide, Tolbutamide. Step 2:Victoza Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Chlorpropamide, Fortamet, Glimepiride, Glipizide, Glipizide Er, Glipizide Xl, Glipizide/Metformin Hcl, Glyburide, Glyburide Micronized, Glyburide/Metformin Hcl, Glycron, Humalog, Humalog Mix 50/50, Humalog Mix 75/25, Humulin 50/50, Humulin 70/30, Humulin N, Humulin R, Metformin Hcl, Metformin Hcl Er, Novolog, Novolog Mix 70/30, Prandin, Precose, Relion 70/30, Relion 70/30 Innolet, Relion N, Relion
N Innolet, Relion R, Starlix, Tolazamide. Step 2: Welchol
Step 1- PATIENT NEEDS TO HAVE A DOCUMENTED TRIAL OF ANY TWO OF THE FOLLOWING DRUGS IN THE PREVIOUS 120 DAYS BEFORE MOVING TO STEP 2: Atorvastatin, Simvastatin, Pravastatin, Lovastatin. Step 2:
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Consent Form for Exercise Treadmill Testing Authorization I authorize Edward J. Lind M.D. to perform an exercise treadmill test (stress test). Possibility of other procedures As a result of having this test, I understand there is a possibility I may need other urgent procedures that were unanticipated. I consent to the performance of any additional procedures determined to be in my b
The new england journal of medicine d r u g t h e r a p y From the Department of Medicine, Divisionrritable bowel syndrome, a common disorder in which bowelhabits are altered in association with abdominal pain or discomfort, has a preva-of Radiology and Radiological Sciences,Vanderbilt University, Nashville. Addresslence of 12 percent among adults in the United States and a similar prev
Step Therapy Criteria