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ODS Health Plan, Inc. Contract H3813-003 ODS Health Plan, Inc.
Formulary ID #12157 version 12
Step Therapy Criteria
Effective 06/01/2012
ODS Health Plan, Inc. Contract H3813-003 DRUG NAME: ACTOPLUS MET | ACTOSPLUS MET XR |ACTOS | AVANDAMET | AVANDARYL | AVANDIA | DUETACT STEP THERAPY GROUP DESCRIPTION: THIAZOLIDINEDIONES STEP THERAPY CRITERIA: PRIOR CLAIM FOR METFORMIN (GLUCOPHAGE), METFORMIN ER, GLYBURIDE/METFORMIN (GLUCOVANCE), GLIPIZIDE/METFORMIN (METAGLIP) OR A FORMULARY ORAL SULFONYLUREA (E.G., GLYBURIDE, GLIPIZIDE) WITHIN THE PAST 120 DAYS.
ODS Health Plan, Inc. Contract H3813-003 DRUG NAME: AMTURNIDE | ATACAND | ATACAND HCT | AVALIDE | AVAPRO | AZOR | BENICAR | BENICAR HCT | DIOVAN | DIOVAN HCT | EXFORGE |EXFORGE HCT | MICARDIS | MICARDIS HCT | TEKAMLO | TEKTURNA | TEKTURNA HCT | TEVETEN | TEVETEN HCT | TRIBENZOR | VALTURNA STEP THERAPY GROUP DESCRIPTION: RENIN ANGIOTENSION SYSTEM INHIBITORS STEP THERAPY CRITERIA: PRIOR CLAIM FOR AN ANGIOTENSIN CONVERTING ENZYME INHIBITOR (ACE INHIBITOR), OR ACE INHIBITOR COMBINATION OR A GENERIC ANGIOTENSIN RECEPTOR BLOCKER (ARB), OR GENERIC ARB COMBINATION WITHIN THE PAST 120 DAYS. ODS Health Plan, Inc. Contract H3813-003 DRUG NAME: BESIVANCE STEP THERAPY GROUP DESCRIPTION: ANTIBACTERIALS (EENT) STEP THERAPY CRITERIA: PRIOR CLAIM FOR CIPROFLOXACIN OPHTHALMIC DROPS, CIPROFLOXACIN OPHTHALMIC OINTMENT, OR OFLOXACIN OPHTHALMIC DROPS WITHIN THE LAST 120 DAYS ODS Health Plan, Inc. Contract H3813-003
DRUG NAME:
BETASERON | EXTAVIA
STEP THERAPY GROUP DESCRIPTION:
MULTIPLE SCLEROSIS AGENTS
STEP THERAPY CRITERIA:
PRIOR CLAIM FOR REBIF (INTERFERON BETA-1A) OR AVONEX
(INTERFERON BETA-1A) OR COPAXONE (GLATIRAMIR ACETATE) WITHIN
THE PAST 120 DAYS.
ODS Health Plan, Inc. Contract H3813-003
DRUG NAME:
CELEBREX
STEP THERAPY GROUP DESCRIPTION:
NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE
STEP THERAPY CRITERIA:
PRIOR CLAIM FOR ONE (1) SEPARATE NON-STEROIDAL ANTI-
INFLAMMATORY AGENT WITHIN THE PAST 120 DAYS
ODS Health Plan, Inc. Contract H3813-003
DRUG NAME:
CYCLOPHOSPHAMIDE | METHOTREXATE | TREXALL
STEP THERAPY GROUP DESCRIPTION:
B VS D ADMINISTRATIVE STEP
STEP THERAPY CRITERIA:
PRIOR CLAIM FOR RHEUMATOID ARTHRITIS DRUG WITHIN THE PAST 120
DAYS.
ODS Health Plan, Inc. Contract H3813-003 DRUG NAME: DALIRESP STEP THERAPY GROUP DESCRIPTION: COPD STEP THERAPY CRITERIA: PRIOR CLAIM FOR INHALED TIOTROPIUM (SPIRIVA) AND AN INHALED LONG ACTING BETA AGONIST OR AN INHALED LONG ACTING BETA AGONIST COMBINATION WITHIN THE LAST 365 DAYS. ODS Health Plan, Inc. Contract H3813-003 DRUG NAME: DEXILANT | LANSOPRAZOLE STEP THERAPY GROUP DESCRIPTION: ANTIULCER AGENTS STEP THERAPY CRITERIA: PRIOR CLAIM FOR GENERIC FEDERAL LEGEND OMEPRAZOLE OR PANTOPRAZOLE WITHIN THE PAST 120 DAYS.
ODS Health Plan, Inc. Contract H3813-003 DRUG NAME: FLECTOR | VOLTAREN STEP THERAPY GROUP DESCRIPTION: TOPICAL NSAID THERAPY AGENTS STEP THERAPY CRITERIA: PRIOR CLAIM FOR AN ORAL NON-STEROIDAL ANTI-INFLAMMATORY AGENT (E.G., IBUPROFEN, NAPROSYN) WITHIN THE PAST 120 DAYS.
ODS Health Plan, Inc. Contract H3813-003
DRUG NAME:
JANUMET | JANUMET XR | JANUVIA | JENTADUETO | JUVISYNC |
KOMBIGLYZE XR | ONGLYZA | TRADJENTA
STEP THERAPY GROUP DESCRIPTION:
DIPEPTIDYL PEPTIDASE-4 ENZYME INHIBITORS
STEP THERAPY CRITERIA:
PRIOR CLAIM FOR METFORMIN (GLUCOPHAGE), METFORMIN ER,
GLYBURIDE/METFORMIN (GLUCOVANCE) OR GLIPIZIDE/METFORMIN
(METAGLIP) WITHIN THE PAST 180 DAYS.
ODS Health Plan, Inc. Contract H3813-003
DRUG NAME:
KADIAN | MORPHINE SULFATE ER
STEP THERAPY GROUP DESCRIPTION:
ANALGESICS, NARCOTICS
STEP THERAPY CRITERIA:
PRIOR CLAIM FOR MORPHINE SULFATE SUSTAINED ACTION TABLET (MS
CONTIN) WITHIN THE PAST 120 DAYS
ODS Health Plan, Inc. Contract H3813-003
DRUG NAME:
KETEK
STEP THERAPY GROUP DESCRIPTION:
KETOLIDES
STEP THERAPY CRITERIA:
PRIOR CLAIM FOR A MACROLIDE WITHIN THE PAST 120 DAYS.
ODS Health Plan, Inc. Contract H3813-003
DRUG NAME:
LEVEMIR
STEP THERAPY GROUP DESCRIPTION:
ANTIDIABETIC AGENTS - INSULINS
STEP THERAPY CRITERIA:
PRIOR CLAIM FOR A INSULIN GLARGINE (LANTUS OR LANTUS SOLOSTAR)
WITHIN THE PAST 120 DAYS.
ODS Health Plan, Inc. Contract H3813-003
DRUG NAME
PATADAY | PATANOL
STEP THERAPY GROUP DESCRIPTION:
OPHTHALMIC ANTIHISTAMINES
STEP THERAPY CRITERIA:
PRIOR PRESCRIPTION FOR PRESCRIPTION FEXOFENADINE,
LEVOCETIRIZINE OR CROMOLYN SODIUM EYE DROPS WITHIN THE PAST
120 DAYS.
ODS Health Plan, Inc. Contract H3813-003
DRUG NAME:
ULORIC
STEP THERAPY GROUP DESCRIPTION:
HYPERURICEMIC AGENTS
STEP THERAPY CRITERIA:
PRIOR CLAIM FOR ALLOPURINOL OR COLCHICINE WITHIN THE PAST 120
DAYS
ODS Health Plan, Inc. Contract H3813-003
DRUG NAME:
ZIRGAN
STEP THERAPY GROUP DESCRIPTION:
GANCICLOVIR OPHTHALMIC
STEP THERAPY CRITERIA:
PRIOR CLAIM FOR TRIFLURIDINE 1% OPHTHALMIC SOLUTION WITHIN
THE PAST 120 DAYS.

Source: https://www.modahealth.com/pdfs/odsadv/2012/step_therapy_guide.pdf