AGGRENOX. Products Affected. Details. First Health Part D Value Plus (PDP) Last Updated: 10/01/2017. Aggrenox
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1 First Health Part D Value Plus (PDP) Last Updated: 10/01/2017 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_ /2014 Formulary ID: 18059: version 8 1
2 ANTICONVULSANTS Keppra SOLN Keppra TABS 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 Celexa TABS Effexor Xr Fetzima Fetzima Titration Pack Forfivo XL Paxil TABS Paxil Cr Pristiq TB24 25MG Prozac CAPS Prozac Weekly Trintellix Wellbutrin Sr Wellbutrin XL Zoloft A documented trial of one month each of two formulary generic antidepressants. 4
5 ARB - ARB COMBOS Atacand Atacand Hct Avalide Avapro Azor Cozaar Diovan TABS Diovan Hct Exforge Exforge Hct Hyzaar Micardis Micardis Hct Tribenzor Twynsta Pending CMS Approval 5
6 ATOPIC DERMATITIS Elidel Protopic A documented trial of one month each of two formulary generic topical corticosteroids. 6
7 ATYPICAL ANTIPSYCHOTICS Clozaril Fanapt Fanapt Titration Pack Fazaclo Invega Symbyax Zyprexa TABS Zyprexa Zydis A documented trial of one month each of two formulary generic atypical antipsychotics. 7
8 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. 8
9 CORLANOR Corlanor A documented trial of one month of one formulary generic oral beta blocker. 9
10 CYMBALTA Cymbalta A documented trial of one month of formulary generic duloxetine. 10
11 DOXYCYCLINE Oracea Vibramycin CAPS 100MG Vibramycin SUSR Pending CMS Approval 11
12 GEODON Geodon CAPS A documented trial of one month of formulary generic ziprasidone. 12
13 HUMALOG Humalog Humalog Kwikpen Humalog MIX 75/25 Humalog MIX 75/25 Kwikpen A documented trial of one month of the preferred agent Novolog. 13
14 HYPERLIPIDEMIA Altoprev TB24 20MG, 40MG Crestor Ezetimibe/simvastatin Lescol XL Vytorin A documented trial of one month each of two formulary generic HMG CoA Reductase Inhibitors (statins). 14
15 INTUNIV Intuniv A documented trial of one month of formulary generic guanfacine ER. 15
16 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. 16
17 LAMICTAL Lamictal TABS Lamictal Chewable Dispersible Lamictal Odt TBDP Lamictal Starter/not Taking Carbamazepine Lamictal Starter/taking Carbamazepine/not Taking Valproate Lamictal Starter/taking Valproate Lamictal Xr A documented trial of one month of formulary generic lamotrigine. 17
18 LAMISIL Lamisil TABS A documented trial of one month of formulary generic terbinafine tablets. 18
19 LEXAPRO Lexapro A documented trial of one month of formulary generic escitalopram. 19
20 LONG ACTING NARCOTICS Buprenorphine PTWK 10MCG/HR, 15MCG/HR, 20MCG/HR, 5MCG/HR Butrans Exalgo Nucynta Er Pending CMS Approval 20
21 LOTRONEX Lotronex A documented trial of one month of formulary generic alosetron. 21
22 MINOCYCLINE Minocin CAPS Minocycline Hcl TABS Minocycline Hcl Er Solodyn TB24 105MG, 115MG, 55MG, 65MG, 80MG A documented trial of one month of formulary generic minocycline IR capsules. 22
23 MIRAPEX Mirapex Mirapex Er A documented trial of one month of formulary generic pramipexole. 23
24 NASONEX Nasonex A documented trial of one month of formulary generic mometasone nasal spray. 24
25 NIASPAN Niaspan TBCR 1000MG, 500MG, 750MG A documented trial of one month of formulary generic niacin ER. 25
26 NSAIDS Cambia Celebrex Naprelan Vivlodex Zipsor Pending CMS Approval 26
27 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. 27
28 OPHTHALMIC ANTIINFLAMMATORIES Acular Acular Ls Ocufen A documented trial of one week each of two of the following formulary generic ophthalmic anti-inflammatory drops: bromfenac, diclofenac, flurbiprofen, ketorolac 28
29 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. 29
30 PLAVIX Plavix A documented trial of one month of formulary generic clopidogrel. 30
31 PPI Aciphex 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, pantoprazole, esomeprazole UNLESS being used for reduction of risk of upper GI bleed in critically ill patients. 31
32 RENAGEL Renagel TABS A documented trial of one month of formulary Renvela. 32
33 SINGULAIR Singulair A documented trial of one month of formulary generic montelukast. 33
34 SMOKING CESSATION Zyban A documented trial of 6 weeks of formulary generic smoking cessation agent bupropion SR. 34
35 SORILUX Sorilux A documented trial of one month of formulary generic calcipotriene. 35
36 SPIRIVA Spiriva Handihaler A documented trial of one month of two of the following preferred agents: Atrovent HFA (ipratropium), Incruse Ellipta (umeclidinium), Anoro Ellipta (umeclidinium bromide/vilanterol), Bevespi (glycopyrrolate/formoterol), Combivent (ipratropium/albuterol). 36
37 STALEVO Stalevo 100 Stalevo 150 Stalevo 200 Stalevo 50 A documented trial of one month of formulary generic carbadopa/levodopa/entacapone. 37
38 TACLONEX Taclonex A documented trial of one month of formulary generic calcipotriene. 38
39 TIKOSYN Tikosyn A documented trial of one month of formulary generic dofetilide. 39
40 TOPICAL NSAIDS Pennsaid SOLN 2% Voltaren GEL A documented trial of two weeks each of a formulary generic oral Nonsteroidal Anti-inflammatory Drug (NSAID) AND formulary generic diclofenac gel. 40
41 TOPROL XL Toprol XL A documented trial of one month of formulary generic metoprolol ER. 41
42 TRIPTANS Amerge Axert Frova Imitrex Imitrex Statdose Refill Imitrex Statdose System Maxalt Maxalt-mlt Onzetra Xsail Sumavel Dosepro Treximet TABS 500MG; 85MG Zembrace Symtouch Zomig A documented trial of 14 days each of two formulary generic antimigraine agent triptans. 42
43 ULORIC Uloric Coverage will be provided if allopurinol has been tried (at least a 30-day supply in the prior 180 days) 43
44 XANAX Xanax Xanax Xr A documented one month trial of formulary generic alprazolam tablets. 44
45 ZIOPTAN Zioptan A documented trial of one week of formulary generic latanoprost. 45
46 INDEX A Aciphex Actonel Acular Acular Ls Aggrenox... 1 Altoprev Amerge Aricept... 3 Atacand... 5 Atacand Hct... 5 Atelvia Avalide... 5 Avapro... 5 Axert Azor... 5 B Binosto Buprenorphine Butrans C Caduet... 8 Cambia Celebrex Celexa... 4 Clozaril... 7 Corlanor... 9 Cozaar... 5 Crestor Cymbalta D Diovan... 5 Diovan Hct... 5 Doxycycline E Effexor Xr... 4 Elidel... 6 Exalgo Exelon... 3 Exforge... 5 Exforge Hct... 5 Ezetimibe/simvastatin F Fanapt... 7 Fanapt Titration Pack... 7 Fazaclo... 7 Fetzima... 4 Fetzima Titration Pack... 4 Forfivo XL... 4 Fosamax Fosamax Plus D Frova G Geodon H Humalog Humalog Kwikpen Humalog MIX 75/ Humalog MIX 75/25 Kwikpen Hyzaar I Imitrex Imitrex Statdose Refill Imitrex Statdose System Intuniv Invega
47 K Kadian Keppra... 2 Keppra Xr... 2 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 Lamisil Lescol XL Lexapro Lotronex M Maxalt Maxalt-mlt Micardis... 5 Micardis Hct... 5 Minocin Minocycline Minocycline Hcl Minocycline Hcl Er Mirapex Mirapex Er N Naprelan Nasonex Niaspan Nucynta Nucynta Er O Ocufen Onzetra Xsail Oracea Oxtellar Xr... 2 P Paxil... 4 Paxil Cr... 4 Pennsaid Plavix Prevacid Prevacid Solutab Prilosec Pristiq... 4 Protonix Protopic... 6 Prozac... 4 Prozac Weekly... 4 Q Qudexy Xr... 2 R Rabeprazole Sodium Razadyne... 3 Razadyne Er... 3 Renagel S Singulair Solodyn Sorilux Spiriva Spiriva Handihaler Stalevo Sumavel Dosepro Symbyax... 7 T Taclonex Tegretol... 2 Tegretol-xr... 2 Tikosyn Topamax... 2 Topamax Sprinkle... 2 Toprol XL Treximet Tribenzor... 5 Trileptal... 2 Trintellix
48 Twynsta... 5 U Uloric V Vibramycin Vivlodex Voltaren Vytorin W Wellbutrin Sr... 4 Wellbutrin XL... 4 X Xanax Xanax Xr Z Zegerid Zembrace Symtouch Zioptan Zipsor Zoloft... 4 Zomig Zonegran... 2 Zyban Zyprexa... 7 Zyprexa Zydis
AGGRENOX. Products Affected. Details. GRP B2 Last Updated: 09/01/2018. Aggrenox
GRP B2 Last Updated: 09/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18066: version 15 1 ANTICONVULSANTS
AGGRENOX. Products Affected. Details. Open 1 Last Updated: 12/01/2018. Aggrenox
Open 1 Last Updated: 12/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18066: version 17 1 ANTICONVULSANTS
AGGRENOX. Products Affected. Details. Open 1 Last Updated: 10/01/2018. Aggrenox
Open 1 Last Updated: 10/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 19076: version 7 1 ANTIDEPRESSANTS
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