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STEP THERAPY ALGORITHMS – Formulary 2
Treatment Group
Description
Step 1: metformin

Step 2: Actoplus Met
Step 1: metformin

Step 2: Actos
Step 1: metformin

Step 2: Glyset or acarbose
Step 1: One of the following:

Step 2
: Amitiza
Step 1: One of the following atypical antipsychotics:
Step 2: Abilify or Abilify Disc or Invega or Geodon
Step 1: metformin

Step 2: Avandamet
Treatment Group
Description
Step 1: metformin

Step 2: Avandaryl
Step 1: metformin

Step 2
: Avandia
Step 1: Tier 1 or Tier 2 bisphosphonate

Step 2: Fosamax Oral Solution
Step 1: ofloxacin otic

Step 2: Cetraxal
Step 1: One of the following sulfonylurea products:
a. glyburide b. glipizide c. glimepiride
Step 2: Diabinese (chlorpropamide)
Step 1: One of the following:
b. dextroamphetamine c. dexmethylphenidate d. methylphenidate
Step 2: Strattera
Dipeptidyl Peptidase 4 Inhibitor Therapy Step 1: metformin

Step 2: Januvia or Onglyza
Dipeptidyl Peptidase 4 Inhibitor/ Metformin Step 1: metformin
Step 2: Janumet
Step 1: metformin

Step 2: Duetact
Treatment Group
Description
Step 1: One of the following atypical antipsychotics:
Step 2: Fanapt
Step 1: metformin

Step 2: Byetta
Step 1: One tier 1 or tier 2 inhaled corticosteroid
Step 2: Aerobid/Aerobid-M or Asmanex or Azmacort or Alvesco
Step 1: Singulair

Step 2: Accolate or Zyflo CR
Step 1: One of the following:

Step 2: Foradil or Serevent
Step 1: metformin

Step 2: Prandin or nateglinide
Step 1: One of the following formulary opioid products
a. hydrocodone b. hydromorphone c. methadone d. morphine e. oxycodone
Step 2: meperidine
Step 1: One of the following:

Step 2: Xalatan
Treatment Group
Description
Step 1: One of the following formulary opioid products:
c. morphine d. oxycodone e. opiate/acetaminophen
Step 2: pentazocine/ naloxone or pentazocine/ acetaminophen
Step 1: metformin

Step 2: Prandimet
Step 1: One of the following:
b. Beta-blocker c. Calcium-channel blocker
Step 2: Ranexa
Step 1: One of the following:

Step 2: Selfemra
Step 1: sumatriptan injection
Step 2
: Sumavel
Step 1: One of the following:
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
Treatment Group
Description
Step 1: albuterol (nebulizer)
Step 2: Xopenex Nebulizer
Step 1: allopurinol

Step 2: Uloric

*Step therapy applies to new starts only

Source: https://www.uhcretiree.com/online_documents/ovation/pdf/mapd/en/2010/Step_Therapy_Criteria.pdf

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