Step Therapy Criteria 2014 4 Tier Standard Last Updated: 10/22/2013
ANGIOTENSIN RECEPTOR BLOCKERS Products Affected
Criteria
Step 1: First line therapy should be losartan or losartan/hctz or valsartan/hctz. Step 2: Second line therapy should be Benicar, Benicar HCT, Edarbi or Edarbyclor. Step 3: Once losartan or losartan/hctz or valsartan/hctz and Benicar, Benicar HCT, Edarbi or Edarbyclor have been tried, patients can receive therapy with Diovan.
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.
CALCIUM CHANNEL BLOCKERS Products Affected
Criteria
Step 1: First line therapy should be felodipine or amlodipine. Step 2: Once felodipine or amlodipine have been tried, patients can receive therapy with nifedipine ER or isradipine.
COX-2 INHIBITORS Products Affected
Criteria
Step 1: First line therapy must be trial of 1 formulary non-selective NSAID. Step 2: Once one 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.
EPLERENONE Products Affected
Criteria
Step 1: First line therapy should be spironolactone or spironolactone/hctz. Step 2: Once spironolactone or spironolactone/hctz have been tried, patients can receive therapy with eplerenone.
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, pioglitazone, pioglitazone/metformin, pioglitazone/glimepiride, 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.
TOPICAL IMMUNOMODULATORS Products Affected
Criteria
Step 1: First line therapy should be trial of 2 formulary topical corticosteroids. Step 2: Once two of these agents have been tried, patients can receive therapy with Elidel or Protopic.
A I J K L B N C O D P E H T
Texas Children's Hospital Dermatology Service PCP Referral Guidelines- Molluscum Contagiosum Diagnosis/symptom: MOLLUSCUM CONTAGIOSUM Please follow Guidelines for at least 2-3 months prior to the initiation of referral. Referring provider’s initial evaluation and management should include: Molluscum is a benign process in children. Lesions generally involute spontaneously
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