Fresenius step therapy criteria - october

Step Therapy Criteria
Step Therapy Group
Drug Names
Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.
Step 1 Drug(s): Actos, Actoplus Met, Duetact, Januvia, Janumet, Kombiglyze, Onglyza.
Step Therapy Group
Drug Names
Step Therapy Criteria
If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Diclofenac Potassium, Diclofenac Sodium, Etodolac, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Nabumetone, Naproxen, Naproxen Sodium, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Celebrex. Authorization for Celebrex may be given if the patient has tried two oral prescription strength NSAIDs (brand or generic) for the current condition. This step therapy program will exclude participants with a claims history of warfarin (Coumadin) Step Therapy Group
Drug Names
Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.
Step 1 Drug(s): Pancreaze. Step 2 Drug(s): Creon Step Therapy Group
Drug Names
Step Therapy Criteria
Fentanyl is covered for members who meet the following criteria: A.Patient must fill formulary long-acting oral narcotic (Morphine Sulfate Extended-release, Kadian®, or Step Therapy Group
Drug Names
AMTURNIDE, TEKAMLO, TEKTURNA, TEKTURNA HCT Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.
Step 1 Drug(s): Amlodipine Besylate-benazepril, Benazepril Hcl, Benazepril- hydrochlorothiazide, Captopril, Captopril-hydrochlorothiazide, Diovan, Diovan Hct, Enalapril Maleate, Enalapril-hydrochlorothiazide, Exforge, Exforge Hct, Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Lisinopril, Lisinopril-hydrochlorothiazide, Losartan Potassium, Losartan-Hydrochlorothiazide, Micardis, Micardis Hct, Moexipril Hcl, Moexipril-hydrochlorothiazide, Perindopril erbumine, Quinapril Hcl, Quinapril- hydrochlorothiazide, Ramipril, Trandolapril, Trandolapril-verapamil, Twynsta. Step 2 Drug(s): Amturnide, Tekamlo, Tekturna, Tekturna Hct. Authorization for a step 2 drug may be given if the patient tried an angiotensin converting enzyme (ACE) inhibitor or ACE inhibitor combination product in the past. Authorization for a step 2 drug may be given if the patient tried an angiotensin receptor blocker (ARB) or ARB combination product in the past they are not required to have a trial with an ACE inhibitor.
Step Therapy Group
Drug Names
Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.
Step 1 Drug(s): Alclometasone Dipropionate, Amcinonide, Betamethasone Dipropionate, Betamethasone Valerate, Clobetasol Emollient, Clobetasol Propionate, Desonide, Desoximetasone, Diflorasone Diacetate, Fluocinolone Acetonide, Fluocinonide, Fluocinonide Emollient, Fluticasone Propionate, Halobetasol Propionate, Hydrocortisone, Hydrocortisone Butyrate, Hydrocortisone Valerate, Mometasone Furoate, Prednicarbate, Triamcinolone Acetonide, Triderm. Step 2 Drug(s): Elidel, Protopic. Authorization may be given for Elidel or Protopic, if the patient has tried one prescription strength topical corticosteroid for atopic dermatitis or eczema in the previous 60 days. Authorization for Protopic or Elidel may be given for patients with a dermatologic condition on or around the eyes, eyelids or genitalia. Authorization for Protopic or Elidel may be given for patients with the following conditions after a trial of a prescription strength topical corticosteroid: lichen planus, seborrheic dermatitis, chronic hand dermatitis, cutaneous lupus erythematosus or dermatomyositis or discoid lupus erythematosus, psoriasis, and vitiligo. Authorization for Protopic may be given for patients with the following conditions after a trial of a prescription strength topical corticosteroid: dyshidrotic palmar eczema, pyoderma gangrenosum, orofacial or perineal Crohn's disease, erosive pustular dermatosis, chronic cutaneous graft-vs-host disease (GVHD), chronic actinic dermatitis, allergic contact dermatitis, and bullous pemphigoid. Authorization may be given for Elidel or Protopic, for steroid-induced rosacea if the patient has tried two therapies for rosacea (e.g., azelaic acid, topical metronidazole, topical tretinoin products, oral antibiotics [e.g., tetracycline, metronidazole, doxycycline, minocycline, clarithromycin], or oral isotretinoin).
Authorization may be given for Protopic, for severe uremic pruritus if the patient has tried two other therapies for this condition (e.g., emollients, capsaicin, topical corticosteroids, ultraviolet B irradiation).
Step Therapy Group
Drug Names
Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.
Step 1 Drug(s): ProAir. Step 2 Drug(s): Ventolin HFA Step Therapy Group
Drug Names
Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.
Step 1 Drug(s): Advicor, Crestor, Lovastatin, Pravastatin Sodium, Simcor, Simvastatin, Vytorin. Step 2 Drug(s): Zetia. Authorization of Zetia may be given if the patient has tried one HMG-CoA reductase inhibitor (statin) or HMG-CoA reductase inhibitor (statin) combination product or if Zetia is being initiated in combination with an HMG-CoA reductase inhibitor (statin). Authorization for Zetia may be given if the patient is taking or will be taking a medication that has a significant drug interaction with any of the HMG-CoA reductase inhibitors [statins] (eg, cyclosporine, fibrates, niacin more than 1 g/day, itraconazole, ketoconazole, erythromycin, clarithromycin, HIV protease inhibitors, nefazodone, amiodarone, and verapamil). Authorization of Zetia may be given if the patient has severe renal impairment (creatinine clearance of 30 mL/minute or less). Authorization of Zetia may be given if for management of homozygous familial sitosterolemia. Authorization of Zetia may be given for use in pregnant woman.
Authorization of Zetia may be given if the patient has active liver disease or unexplained persistent elevations of serum transaminases. Exceptions are NOT recommended for Zetia for use in patients with moderate or severe hepatic insufficiency. As reviewed by a pharmacist, authorization for Zetia may be given for use in patients who have been previously diagnosed with myopathy or rhabdomyolysis (either medication-related or not medication related) OR the patient has an underlying muscle/muscle-metabolism-related disorder (eg, myositis, McArdle disease).

Source: http://fmchp.com/static/public/fmchp/pdf/2012WindsorMAPD_StepTherapyCriteria_April.pdf