STANDARD Stepped Therapy Agents ~ 2010 The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self- administered injectable agents also require prior authorization and can be found on a separate list. Drug Condition
Trial & failure of Risperdal* or Seroquel
Trial & failure of two oral antibiotics for acne
Trial & failure of metformin (at least 1500mg/d)
ActoPLUS Met (pioglitazone / metformin)
Trial & failure of metformin (at least 1500mg/d)
Ambien CR (zolpidem extended release)
Trial & failure of Ambien* or Sonata*, AND Lunesta
Trial & failure of Lactulose* or Miralax*
Trial & failure of metformin (at least 1500mg/d)
Trial & failure of metformin (at least 1500mg/d)
Avandaryl (rosiglitazone / glimepiride)
Trial & failure of metformin (at least 1500mg/d)
Trial & failure of Claritin* AND Zyrtec OTC
Coreg CR (carvedilol extended rel) Detrol / Detrol LA (tolterodine / extended release)
Trial & failure of Ditropan* or Sanctura/Sanctura XL
Duetact (pioglitazone / glimepiride)
Trial & failure of metformin (at least 1500mg/d)
Effexor / Effexor XR (venlafaxine / extended rel)
Trial & failure of Ditropan* or Sanctura/Sanctura XL
Trial & failure of Risperdal* or Seroquel
Trial & failure of Risperdal* or Seroquel
Gelnique (oxybutynin topical gel)
Trial & failure of Ditropan* or Sanctura/Sanctura XL
Trial & failure of Risperdal* or Seroquel
Janumet (sitagliptin / metformin)
Trial & failure of metformin (at least 1500mg/d)
Trial & failure of metformin (at least 1500mg/d)
Lipitor (atorvastatin) 10mg & 20mg Lipitor (atorvastatin) 40mg & 80mg
Trial & failure of Crestor or Vytorin
Trial & failure of Ambien* or Sonata*
Luvox CR (fluvoxamine extended release) Niravam ODT (alprazolam immediate rel)
Trial & failure of metformin (at least 1500mg/d)
Trial & failure of Ditropan* or Sanctura/Sanctura XL
Paxil CR* (paroxetine extended release)
Trial & failure of any SSRI AND Effexor
This is the most current list at the time of printing and is subject to change. Last update April 13, 2010
Prozac Weekly (fluoxetine extended rel) Trial & failure of Ambien* or Sonata*, AND Lunesta
Ryzolt (tramadol extended release)
Trial & failure of Risperdal* or Seroquel
Symbyax (olanzapine / fluoxetine)
Trial & failure of Risperdal* or Seroquel
Trial & failure of Ditropan* or Sanctura/Sanctura XL
Ultram ER (tramadol extended release)
Trial & failure of Ditropan* or Sanctura/Sanctura XL
Vytorin (simvastatin/ezetimibe) 10/10 only
Trial & failure of Claritin* AND Zyrtec OTC
Trial & failure of Risperdal* or Seroquel
Italics indicate non-formulary agents ^ indicates agent is not covered
* indicates generic form available – lowest copay charged
This is the most current list at the time of printing and is subject to change. Last update April 13, 2010
Detailed Program Description for ACVD Website Clinical and Investigative Dermatology Residency Dermatology Service Veterinary Health Complex 2. Is the program currently on ACVD Probation? No If yes, please describe the reasons for probation, what is being done to correct them and when the program is scheduled to be off probation? Thierry Olivry, DrVet, PhD, DipACVD, DipECVD Petra Bizikova
STANDARD Stepped Therapy Agents ~ 2010 
Prozac Weekly (fluoxetine extended rel)
Trial & failure of Ambien* or Sonata*, AND Lunesta
Ryzolt (tramadol extended release)
Trial & failure of Risperdal* or Seroquel
Symbyax (olanzapine / fluoxetine)
Trial & failure of Risperdal* or Seroquel
Trial & failure of Ditropan* or Sanctura/Sanctura XL
Ultram ER (tramadol extended release)
Trial & failure of Ditropan* or Sanctura/Sanctura XL
Vytorin (simvastatin/ezetimibe) 10/10 only
Trial & failure of Claritin* AND Zyrtec OTC
Trial & failure of Risperdal* or Seroquel
Italics indicate non-formulary agents
^ indicates agent is not covered
* indicates generic form available – lowest copay charged
This is the most current list at the time of printing and is subject to change. Last update April 13, 2010