Step therapy criteria

Step Therapy Criteria 2013 4 Tier Standard Last Updated: 02/11/2013 ANGIOTENSION RECEPTOR BLOCKERS
Products Affected

Criteria
Step 1: First line therapy should be losartan or losartan/hctz. Step 2: Second line therapy should be Benicar or Benicar HCT. Step 3: Once losartan or losartan/hctz and Benicar or Benicar HCT have been tried, patients can receive therapy with Diovan or Diovan HCT. Products Affected

Criteria
Step 1: First line therapy should be selegiline tablets or capsules. Step 2: Once selegiline tablets or capsules have been tried, patients can receive therapy with Azilect. COX-2 INHIBITORS
Products Affected

Criteria
Step 1: First line therapy must be 2 formulary non-selective NSAIDs. Step 2: Once two of these agents have been tried, patients can receive therapy with Celebrex. Products Affected

Criteria
Step 1: First line therapy should be atorvastatin. Step 2: Once atorvastatin has been tried, patients can receive therapy with Crestor. HYPOGLYCEMICS
Products Affected

Criteria
Step 1: First line therapy should be a formulary sulfonylurea, metformin, or formulary insulin (if appropriate). Step 2: Once one of these agents has been tried, patients can receive therapy with other formulary hypoglycemics such as Actoplus Met, Actoplus Met XR, Actos, Avandamet, Avandaryl, Avandia, Duetact, Acarbose, Januvia, Janumet, Janumet XR, Onglyza, Prandin, nateglinide, Kombiglyze XR, Starlix, pioglitazone, pioglitazone/metformin, Tradjenta, and Jentadueto . OPHTHALMIC ANTIHISTAMINES
Products Affected

Criteria
Step 1: First line therapy should be Zaditor OTC, ketotifen OTC or Alaway OTC. Step 2: Second line therapy should be Patanol or Pataday. Step 3: Once Patanol or Pataday has been tried, patients can receive therapy with other formulary prescription ophthalmic antihistamines such as Elestat, azelastine, epinastine, and Optivar. PROTON PUMP INHIBITORS
Products Affected

Criteria
Step 1: First line therapy should be Omeprazole or pantoprazole. Step 2: Second line should be lansoprazole or Dexilant. Step 3: Once omeprazole or pantoprazole and lansoprazole or Dexilant has been tried, patients can receive therapy with Nexium or Aciphex. A
J
Actos. 5 Angiotension Receptor Blockers . 1 K
L
N
B
O
C
P
D
E
S
H
T

Source: http://clarianhealthplans.performrx.com/pdf/prior_auth2013/step-therapy-criteria.pdf