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Step therapy criteria

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: Alendronate. Step 2: Atelvia or Actonel BYDUREON THERAPY - FIDELIS
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 Selegiline. Step 2: Zelapar ZYFLO THERAPY - FIDELIS
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

Source: http://www.fidelisap.us/wordpress/wp-content/uploads/2013/10/2013-Fidelis-Formulary-Web-ST-File-2013_GOLDF.pdf

[version 1, 12/2005]

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Microsoft word - nutrient_information2.doc

Nutrient Information A - Candida Questionnaire Description: NAME____________________________DATE ________________ This questionnaire is designed for adults and the scoring system is not appropriate for children. It lists factors in your medical history which promote the growth of Candida Albicans (Section A), and symptoms commonly found in individuals with yeast-connected For ea

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