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Physicians Health Choice Total (HMO) and Select (HMO SNP) plans
STEP THERAPY ALGORITHMS – Physicians Health Choice Total (HMO) and Select (HMO SNP) plans
Treatment Group
Description
Step 1: One of the following Tier 1 or Tier 2 or Tier 3 antidepressants:
a. SSRI b. SNRI c. Bupropion d. Mirtazepine
Step 2: Emsam
Step 1: Irinotecan 20 mg/mL injection (generic)

Step 2: Camptosar 20 mg/mL injection
Step 1: One of the following:
a. Amphetamine/Dextroamphetamine combinations b. Dextroamphetamine c. Dexmethylphenidate d. Methylphenidate e. Long acting methylphenidate
Step 2: Strattera
Step 1: Colistimethate sodium 150 mg injection (generic)

Step 2: Coly-Mycin 150 mg injection
Step 1: Desmopressin acetate 4 mcg/mL injection (generic)

Step 2:
DDAVP 4 mcg/mL injection
Step 1: Epirubicin Injection
Step 2
: Ellence Injection
05/01/2013
Treatment Group
Description
Step 1: One formulary oral acetylcholinesterase inhibitor

Step 2
: Exelon transdermal systems
Step 1: One of the following atypical antipsychotics:
a. Geodon b. Risperidone c. Seroquel/Seroquel XR d. Olanzapine e. Olanzapine ODT Step 2: Fanapt
Step 1: Idarubicin injection (generic)

Step 2: Idamycin PFS injection
Step 1: One of the following:
a. Inhaled corticosteroids b. Inhaled anticholinergics c. Advair d. Symbicort
Step 2: Foradil or Serevent or Arcapta
Step 1: Pentostatin injection (generic)
Step 2: Nipent injection
Step 1: Nortriptyline capsules
Step 2: Pamelor capsules
Step 1: One of the following:

Step 2: Phoslyra
05/01/2013
Treatment Group
Description
Step 1: One of the following:
c. Long-acting nitrate d. Beta-blocker e. Calcium-channel blocker
Step 2: Ranexa
Step 1: Renvela
Step 2: Renagel
Step 1: One of the following:
b. ACE inhibitor combination c. Angiotensin II receptor blocker d. Angiotensin II receptor blocker combination
Step 2: Tekturna or Tekturna HCT
Step 1: Topical Corticosteroid

Step 2: Elidel or Protopic
Step 1: Any ONE formulary agent from the following: rectal 5-ASA, oral 5-ASA,
oral corticosteroid, or rectal corticosteroid.
Step 2: Uceris
Step 1: Allopurinol

Step 2: Uloric
Step 1: Generic voriconazole
Step 2: Brand Vfend
05/01/2013
Treatment Group
Description
Step 1: One Tier 1 or Tier 2 or Tier 3 SSRI or SNRI
Step 2:
Viibryd
Step 1: Albuterol (nebulizer)

Step 2: Levalbuterol Nebulizer
Step 1: Ondansetron Injection (generic)
Step 2: Zofran Injection
Plans are insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. [<OVEX3386716_000>] Formulary ID # 00013520 Y0066_120105_190336 CMS Approved 02222012 *Step therapy applies to new starts only
05/01/2013

Source: http://www.saludphc.com/pdf/2013_F12_StepTherapy-PHC_2013-0501.pdf

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Investigational pharmacy manual for investigators

Tufts Medical Center/Tufts University Health Sciences Institutional Review Board Instructions for completing the FORM II: Pharmacy Please note that the Tufts Medical Center Department of Pharmacy Services Investigational Drug Service (IDS) should be consulted during the development of the study and/or prior to submission of a new study to the Tufts MC/TUHS IRB. Please include the fo

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