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: 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 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
BIJSLUITER: INFORMATIE VOOR DE GEBRUIK(ST)ER A-CQ 100, 100 mg tablet Chloroquinefosfaat Lees zorgvuldig de hele bijsluiter door voordat u dit geneesmiddel gaat gebruiken - Bewaar deze bijsluiter. Misschien heeft u hem later weer nodig. Heeft u nog vragen? Raadpleeg dan de arts of apotheker. Geef dit geneesmiddel niet door aan anderen, want het is alleen aan u voorgeschreven. H
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
Step Therapy Criteria 2013 Fidelis Formulary Last Updated: 10/01/2013
ALPHA GLUCOSIDASE INHIBITOR THERAPY - PS PART D