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
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
Physicians Health Choice Total (HMO) and Select (HMO SNP) plans