AGGRENOX. Products Affected. Details. Open 1 Last Updated: 12/01/2018. Aggrenox
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1 Open 1 Last Updated: 12/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_ /2014 Formulary ID: 18066: version 17 1
2 ANTICONVULSANTS Keppra Keppra Xr Oxtellar Xr Qudexy Xr Tegretol SUSP Tegretol TABS Tegretol-xr Topamax Topamax Sprinkle Trileptal Zonegran CAPS 100MG, 25MG A documented trial of one month each of two formulary generic anticonvulsants. 2
3 ANTI-DEMENTIA AGENTS Aricept Exelon PT24 Razadyne TABS Razadyne Er A documented trial of one month each of two formulary generic antidementia cholinesterase inhibitors. 3
4 ANTIDEPRESSANTS Aplenzin Celexa TABS Effexor Xr Fetzima Fetzima Titration Pack Forfivo XL Khedezla Paxil TABS Paxil Cr Pexeva Prozac CAPS Prozac Weekly Trintellix Wellbutrin Sr Wellbutrin XL Zoloft A documented trial of one month each of two of the following: formulary generic antidepressants or Pristiq. 4
5 APIDRA Apidra Apidra Solostar A documented trial of one month of Novolog (aspart only, not mix) or Fiasp. 5
6 ARB - ARB COMBOS Atacand Atacand Hct Avalide Avapro Azor Benicar Benicar Hct Byvalson Cozaar Diovan TABS Diovan Hct Edarbyclor Exforge Exforge Hct Hyzaar Micardis Micardis Hct Tribenzor Twynsta A documented trial of one month each of two formulary generic Angiotensin II Receptor Antagonists (ARBs) or ARB combination products. 6
7 ARYMO ER Arymo Er A documented trial of one week of formulary Hysingla ER 7
8 ATOPIC DERMATITIS Elidel Eucrisa Protopic A documented trial of one month of a formulary generic topical corticosteroid or formulary generic topical tacrolimus. 8
9 ATYPICAL ANTIPSYCHOTICS Abilify TABS Clozaril Fanapt Fanapt Titration Pack Fazaclo Invega Seroquel Seroquel Xr Symbyax Zyprexa TABS Zyprexa Zydis A documented trial of one month each of two formulary generic atypical antipsychotics. 9
10 BASAGLAR Basaglar Kwikpen A documented trial of one month of two of the following preferred agents: Lantus, Toujeo, Levemir or Tresiba 10
11 BELSOMRA Belsomra A documented trial of one month of one generic prescription sleep aid such as zolpidem, ezopiclone or zaleplon. 11
12 CADUET Caduet TABS 10MG; 10MG, 10MG; 20MG, 10MG; 40MG, 10MG; 80MG, 5MG; 10MG, 5MG; 20MG, 5MG; 40MG, 5MG; 80MG A documented trial of one month of formulary generic amlodipine/atorvastatin. 12
13 CORLANOR Corlanor A documented trial of one month of one formulary generic oral beta blocker. 13
14 CYMBALTA Cymbalta A documented trial of one month of formulary generic duloxetine. 14
15 DOXYCYCLINE Doryx TBEC 200MG, 50MG Doryx Mpc Targadox Vibramycin CAPS 100MG Vibramycin SUSR Vibramycin SYRP A documented trial of one month of a formulary generic doxycycline. 15
16 DPP4 PRODUCTS Alogliptin Alogliptin/metformin Hcl Alogliptin/pioglitazone Kazano Kombiglyze Xr Nesina Onglyza Oseni A documented trial of one month each of sitagliptin (Januvia, Janumet or Janumet XR) AND linagliptin (Tradjenta or Jentadueto) 16
17 DURAGESIC Duragesic A documented trial of one week of generic fentanyl patches 17
18 GEODON Geodon CAPS A documented trial of one month of formulary generic ziprasidone. 18
19 GLP-1 RECEPTOR AGONISTS Adlyxin Adlyxin Starter Pack A documented trial of one month each of two of the following: Victoza (liraglutide), Bydureon (exenatide), Byetta (exenatide), Trulicity (dulaglutide) 19
20 HEPSERA Hepsera A documented trial of one month of formulary generic adefovir. 20
21 HYPERLIPIDEMIA Altoprev TB24 20MG, 40MG, 60MG Crestor Flolipid Lescol XL Vytorin Zypitamag A documented trial of one month each of two of the following: formulary generic HMG CoA Reductase Inhibitors (statins) or formulary generic ezetimibe/simvastatin 21
22 INSULINS Admelog Admelog Solostar Humalog Humalog Junior Kwikpen Humalog Kwikpen Humalog MIX 50/50 Humalog MIX 50/50 Kwikpen Humalog MIX 75/25 Humalog MIX 75/25 Kwikpen Humulin 70/30 Humulin 70/30 Kwikpen Humulin N Humulin N Kwikpen Humulin R A documented trial of one month of a Novo insulin or have a documented contraindication to Novo Nordisk brand insulins. 22
23 INTUNIV Intuniv A documented trial of one month of formulary generic guanfacine ER. 23
24 KADIAN Kadian CP24 100MG, 10MG, 200MG, 20MG, 30MG, 40MG, 50MG, 60MG, 80MG A documented trial of one week of formulary generic morphine sulfate extended release. 24
25 KAPSPARGO Kapspargo Sprinkle A documented trial of one month of formulary generic metoprolol ER. 25
26 LAMICTAL Lamictal TABS Lamictal Chewable Dispersible Lamictal Odt Lamictal Starter/not Taking Carbamazepine Lamictal Starter/taking Carbamazepine/not Taking Valproate Lamictal Starter/taking Valproate Lamictal Xr Lamotrigine Starter Kit/blue Lamotrigine Starter Kit/green Lamotrigine Starter Kit/orange Subvenite Starter Kit/blue Subvenite Starter Kit/green Subvenite Starter Kit/orange A documented trial of one month of formulary generic lamotrigine. 26
27 LEXAPRO Lexapro A documented trial of one month of formulary generic escitalopram. 27
28 LIBRAX Librax A documented trial of one month of generic chlordiazepoxide hydrochloride/clidinium bromide capsule. 28
29 LONG ACTING NARCOTICS Buprenorphine Butrans Embeda Exalgo Morphabond Er Xtampza Er Zohydro Er C12A A documented trial of one week each of two of the following formulary generic long-acting opioid analgesics: hydromorphone extended release, fentanyl patches, methadone, morphine extended release, oxymorphone extended release. 29
30 LONHALA Lonhala Magnair Refill Kit Lonhala Magnair Starter Kit A documented trial of two weeks of two of the following: Advair Diskus (fluticasone/salmeterol), Breo Ellipta (fluticasone/vilanterol), Atrovent HFA (ipratropium), Incruse Ellipta (umeclidinium), Anoro Ellipta (umeclidinium bromide/vilanterol), Bevespi (glycopyrrolate/formoterol), Combivent (ipratropium/albuterol), Serevent Diskus (salmeterol), Symbicort (budesonide/formoterol) 30
31 LOTRONEX Lotronex A documented trial of one month of formulary generic alosetron. 31
32 LUZU Luliconazole Luzu A documented trial of two weeks of topical ketoconazole or econazole 32
33 LYRICA CR Lyrica Cr A documented trial of one month each of Lyrica and gabapentin. 33
34 MINOCYCLINE Minocin CAPS Minocycline Hcl TABS Minocycline Hcl Er Minocycline Hydrochlorideer Solodyn TB24 105MG, 115MG, 55MG, 65MG, 80MG Ximino A documented trial of one month of formulary generic minocycline IR capsules. 34
35 MIRAPEX Mirapex Mirapex Er A documented trial of one month of formulary generic pramipexole. 35
36 MOTOFEN Motofen A documented trial of 10 days of formulary generic diphenoxylate/ atropine. 36
37 NASONEX Nasonex A documented trial of one month of formulary generic mometasone nasal spray. 37
38 NIASPAN Niaspan TBCR 1000MG, 500MG, 750MG A documented trial of one month of formulary generic niacin ER. 38
39 NOAC Savaysa A documented trial of one month each of two of the following: Eliquis (apixaban), Pradaxa (dabigatran etexilate mesylate), Xarelto (rivaroxaban) 39
40 NSAIDS Celebrex Lodine TABS 400MG Nalfon CAPS 400MG Naprelan Vivlodex Zipsor A documented trial of two weeks each of two of the following: formulary generic Nonsteroidal Anti-inflammatory Drugs (NSAIDs), Profeno 40
41 NUCYNTA Nucynta A documented trial of two days each of two of the following: formulary generic immediate release morphine tablets or solution, formulary generic immediate release oxycodone tablets, capsules or solution, or formulary generic immediate release oxymorphone tablets. 41
42 OPHTHALMIC ANTIINFLAMMATORIES Acular Acular Ls Bromsite Ocufen A documented trial of one week each of two formulary generic ophthalmic anti-inflammatory drops. 42
43 ORAP Orap A documented trial of one month of pimozide (generic Orap). 43
44 OSMOLEX Osmolex Er A documented trial of one month of formulary generic amantadine. 44
45 OSTEOPOROSIS Actonel TABS 150MG, 30MG, 35MG, 5MG Atelvia Binosto Fosamax TABS 70MG Fosamax Plus D A documented trial of one month each of two formulary generic oral bisphosphonates. 45
46 PLAVIX Plavix A documented trial of one month of formulary generic clopidogrel. 46
47 PPI Aciphex Aciphex Sprinkle Nexium Nexium I.v. INJ 40MG Prevacid CPDR Prevacid Solutab Prilosec PACK Protonix Rabeprazole Sodium Zegerid A documented trial of one month each of two of the following formulary generic proton pump inhibitors (PPIs): lansoprazole, omeprazole, covered omeprazole/bicarbonate, pantoprazole, esomeprazole UNLESS being used for reduction of risk of upper GI bleed in critically ill patients. 47
48 RENAGEL Renagel TABS A documented trial of one month of formulary Renvela or sevelamer. 48
49 RESPIRATORY Airduo Respiclick 113/14 Airduo Respiclick 232/14 Airduo Respiclick 55/14 Alvesco Arcapta Neohaler Armonair Respiclick 113 Armonair Respiclick 232 Armonair Respiclick 55 Asmanex Hfa Asmanex Twisthaler 120 Metered Doses Asmanex Twisthaler 14 Metered Doses Asmanex Twisthaler 30 Metered Doses Asmanex Twisthaler 60 Metered Doses Asmanex Twisthaler 7 Metered Doses Dulera Fluticasone Propionate/salmeterol Qvar Qvar Redihaler Seebri Neohaler Spiriva Handihaler Spiriva Respimat Stiolto Respimat Striverdi Respimat Tudorza Pressair Utibron Neohaler A documented trial of two weeks of two of the following: Symbicort (budesonide/formoterol), Advair Diskus (fluticasone/salmeterol), Advair HFA (fluticasone/salmeterol), Breo Ellipta (fluticasone/vilanterol), Atrovent HFA (ipratropium), Incruse Ellipta (umeclidinium), Anoro Ellipta (umeclidinium bromide/vilanterol), Bevespi (glycopyrrolate/formoterol), Combivent (ipratropium/albuterol), Arnuity Ellipta (fluticasone furoate), Flovent Diskus (fluticasone propionate), Flovent HFA (fluticasone propionate), Pulmicort Flexhaler (budesonide), Serevent Diskus (salmeterol) 49
50 RHOPRESSA Rhopressa A documented trial of one week of generic timolol or latanoprost AND one week trial of Lumigan or Travatan Z 50
51 SGLT-2 Jardiance Steglatro A documented trial of one month each of Farxiga (dapagliflozin) AND Invokana (canagliflozin). 51
52 SGLT-2 + METFORMIN Segluromet Synjardy Synjardy Xr A documented trial of one month each of two of the following: Invokamet (canagliflozin/metformin hydrochloride), Invokamet XR (canagliflozin/metformin hydrochloride extended release), Xigduo XR (dapagliflozin/metformin hydrochloride extended release). 52
53 SINGULAIR Singulair A documented trial of one month of formulary generic montelukast. 53
54 SMOKING CESSATION Zyban A documented trial of 6 weeks of formulary generic smoking cessation agent bupropion SR. 54
55 SORILUX Sorilux A documented trial of one month of formulary generic calcipotriene. 55
56 STALEVO Stalevo 100 Stalevo 125 Stalevo 150 Stalevo 200 Stalevo 50 Stalevo 75 A documented trial of one month of formulary generic carbadopa/levodopa/entacapone. 56
57 TACLONEX Taclonex A documented trial of one month of formulary generic calcipotriene. 57
58 TIKOSYN Tikosyn A documented trial of one month of formulary generic dofetilide. 58
59 TOPICAL NSAIDS Pennsaid SOLN 2% Voltaren GEL A documented trial of two weeks each of formulary generic diclofenac gel AND one of the following: a formulary generic oral Nonsteroidal Antiinflammatory Drug (NSAID) or Profeno 59
60 TOPROL XL Toprol XL A documented trial of one month of formulary generic metoprolol ER. 60
61 TRIPTANS Amerge Axert Frova Imitrex Imitrex Statdose Refill Imitrex Statdose System Maxalt Maxalt-mlt Onzetra Xsail Sumavel Dosepro Treximet Zembrace Symtouch Zomig Zomig Zmt A documented trial of 14 days each of two formulary generic antimigraine agent triptans. 61
62 ULORIC Uloric Coverage will be provided if allopurinol has been tried (at least a 30-day supply in the prior 180 days) 62
63 VYZULTA Vyzulta A documented trial of one week each of two of the following ophthalmic agents: formulary generic latanoprost, Lumigan, Travatan Z 63
64 XADAGO Xadago A documented trial of one month of formulary generic selegiline and rasagiline. 64
65 XANAX Xanax Xanax Xr A documented one month trial of formulary generic alprazolam tablets. 65
66 ZIOPTAN Zioptan A documented trial of one week of formulary generic latanoprost. 66
67 INDEX A Abilify... 9 Aciphex Aciphex Sprinkle Actonel Acular Acular Ls Adlyxin Adlyxin Starter Pack Admelog Admelog Solostar Aggrenox... 1 Airduo Respiclick 113/ Airduo Respiclick 232/ Airduo Respiclick 55/ Alogliptin Alogliptin/metformin Hcl Alogliptin/pioglitazone Altoprev Alvesco Amerge Apidra... 5 Apidra Solostar... 5 Aplenzin... 4 Arcapta Neohaler Aricept... 3 Armonair Respiclick Armonair Respiclick Armonair Respiclick Arymo Er... 7 Asmanex Hfa Asmanex Twisthaler 120 Metered Doses Asmanex Twisthaler 14 Metered Doses Asmanex Twisthaler 30 Metered Doses Asmanex Twisthaler 60 Metered Doses Asmanex Twisthaler 7 Metered Doses Atacand... 6 Atacand Hct... 6 Atelvia Avalide... 6 Avapro... 6 Axert Azor... 6 B Basaglar Basaglar Kwikpen Belsomra Benicar... 6 Benicar Hct... 6 Binosto Bromsite Buprenorphine Butrans Byvalson... 6 C Caduet Celebrex Celexa... 4 Clozaril... 9 Corlanor Cozaar... 6 Crestor Cymbalta D Diovan... 6 Diovan Hct... 6 Doryx Doryx Mpc Doxycycline Dulera Duragesic
68 E Edarbyclor... 6 Effexor Xr... 4 Elidel... 8 Embeda Eucrisa... 8 Exalgo Exelon... 3 Exforge... 6 Exforge Hct... 6 F Fanapt... 9 Fanapt Titration Pack... 9 Fazaclo... 9 Fetzima... 4 Fetzima Titration Pack... 4 Flolipid Fluticasone Propionate/salmeterol Forfivo XL... 4 Fosamax Fosamax Plus D Frova G Geodon H Hepsera Humalog Humalog Junior Kwikpen Humalog Kwikpen Humalog MIX 50/ Humalog MIX 50/50 Kwikpen Humalog MIX 75/ Humalog MIX 75/25 Kwikpen Humulin 70/ Humulin 70/30 Kwikpen Humulin N Humulin N Kwikpen Humulin R Hyzaar... 6 I Imitrex Imitrex Statdose Refill Imitrex Statdose System Intuniv Invega... 9 J Jardiance K Kadian Kapspargo Kapspargo Sprinkle Kazano Keppra... 2 Keppra Xr... 2 Khedezla... 4 Kombiglyze Xr L Lamictal Lamictal Chewable Dispersible Lamictal Odt Lamictal Starter/not Taking Carbamazepine Lamictal Starter/taking Carbamazepine/not Taking Valproate Lamictal Starter/taking Valproate Lamictal Xr Lamotrigine Starter Kit/blue Lamotrigine Starter Kit/green Lamotrigine Starter Kit/orange Lescol XL Lexapro Librax Lodine Lonhala Lonhala Magnair Refill Kit Lonhala Magnair Starter Kit Lotronex Luliconazole Luzu Lyrica Cr M Maxalt Maxalt-mlt
69 Micardis... 6 Micardis Hct... 6 Minocin Minocycline Minocycline Hcl Minocycline Hcl Er Minocycline Hydrochlorideer Mirapex Mirapex Er Morphabond Er Motofen N Nalfon Naprelan Nasonex Nesina Nexium Nexium I.v Niaspan Nucynta O Ocufen Onglyza Onzetra Xsail Orap Oseni Osmolex Osmolex Er Oxtellar Xr... 2 P Paxil... 4 Paxil Cr... 4 Pennsaid Pexeva... 4 Plavix Prevacid Prevacid Solutab Prilosec Protonix Protopic... 8 Prozac... 4 Prozac Weekly... 4 Q Qudexy Xr... 2 Qvar Qvar Redihaler R Rabeprazole Sodium Razadyne... 3 Razadyne Er... 3 Renagel Respiratory Rhopressa S Savaysa Seebri Neohaler Segluromet Seroquel... 9 Seroquel Xr... 9 Singulair Solodyn Sorilux Spiriva Handihaler Spiriva Respimat Stalevo Steglatro Stiolto Respimat Striverdi Respimat Subvenite Starter Kit/blue Subvenite Starter Kit/green Subvenite Starter Kit/orange Sumavel Dosepro Symbyax... 9 Synjardy Synjardy Xr T Taclonex Targadox Tegretol... 2 Tegretol-xr... 2 Tikosyn Topamax... 2 Topamax Sprinkle... 2 Topical Nsaids
70 Toprol XL Treximet Tribenzor... 6 Trileptal... 2 Trintellix... 4 Triptans Tudorza Pressair Twynsta... 6 X U Zegerid Zembrace Symtouch Zioptan Zipsor Zohydro Er Zoloft... 4 Zomig Zomig Zmt Zonegran... 2 Zyban Zypitamag Zyprexa... 9 Zyprexa Zydis... 9 Uloric Utibron Neohaler V Vibramycin Vivlodex Voltaren Vytorin Vyzulta W Wellbutrin Sr... 4 Wellbutrin XL... 4 Xadago Xanax Xanax Xr Ximino Xtampza Er Z 70
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