AGGRENOX. Products Affected. Details. GRP B2 Last Updated: 09/01/2018. Aggrenox
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1 GRP B2 Last Updated: 09/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_ /2014 Formulary ID: 18066: version 15 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 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 ARB - ARB COMBOS Atacand Atacand Hct Avalide Avapro Azor Benicar Benicar Hct Cozaar Diovan TABS Diovan Hct 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. 5
6 ATOPIC DERMATITIS Elidel Protopic A documented trial of one month of a formulary generic topical corticosteroid or formulary generic topical tacrolimus. 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 Vibramycin CAPS 100MG Vibramycin SUSR A documented trial of one month of a formulary generic doxycycline. 11
12 GEODON Geodon CAPS A documented trial of one month of formulary generic ziprasidone. 12
13 HYPERLIPIDEMIA Altoprev TB24 20MG, 40MG Crestor Lescol XL Vytorin A documented trial of one month each of two of the following: formulary generic HMG CoA Reductase Inhibitors (statins) or formulary generic ezetimibe/simvastatin 13
14 INTUNIV Intuniv A documented trial of one month of formulary generic guanfacine ER. 14
15 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. 15
16 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 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. 16
17 LEXAPRO Lexapro A documented trial of one month of formulary generic escitalopram. 17
18 LONG ACTING NARCOTICS Buprenorphine Butrans Exalgo 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. 18
19 LOTRONEX Lotronex A documented trial of one month of formulary generic alosetron. 19
20 MINOCYCLINE Minocin CAPS Minocycline Hcl TABS Minocycline Hcl Er Minocyc line Hydrochlorideer Solodyn TB24 105MG, 115MG, 55MG, 65MG, 80MG A documented trial of one month of formulary generic minocycline IR capsules. 20
21 MIRAPEX Mirapex Mirapex Er A documented trial of one month of formulary generic pramipexole. 21
22 NASONEX Nasonex A documented trial of one month of formulary generic mometasone nasal spray. 22
23 NIASPAN Niaspan TBCR 1000MG, 500MG, 750MG A documented trial of one month of formulary generic niacin ER. 23
24 NSAIDS Celebrex Naprelan Vivlodex Zipsor A documented trial of two weeks each of two of the following: formulary generic Nonsteroidal Anti-inflammatory Drugs (NSAIDs), Profeno 24
25 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. 25
26 OPHTHALMIC ANTIINFLAMMATORIES Acular Acular Ls Ocufen A documented trial of one week each of two formulary generic ophthalmic anti-inflammatory drops. 26
27 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. 27
28 PLAVIX Plavix A documented trial of one month of formulary generic clopidogrel. 28
29 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, covered omeprazole/bicarbonate, pantoprazole, esomeprazole UNLESS being used for reduction of risk of upper GI bleed in critically ill patients. 29
30 RENAGEL Renagel TABS A documented trial of one month of formulary Renvela or sevelamer. 30
31 SINGULAIR Singulair A documented trial of one month of formulary generic montelukast. 31
32 SMOKING CESSATION Zyban A documented trial of 6 weeks of formulary generic smoking cessation agent bupropion SR. 32
33 SORILUX Sorilux A documented trial of one month of formulary generic calcipotriene. 33
34 STALEVO Stalevo 100 Stalevo 150 Stalevo 200 Stalevo 50 A documented trial of one month of formulary generic carbadopa/levodopa/entacapone. 34
35 TACLONEX Taclonex A documented trial of one month of formulary generic calcipotriene. 35
36 TIKOSYN Tikosyn A documented trial of one month of formulary generic dofetilide. 36
37 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 37
38 TOPROL XL Toprol XL A documented trial of one month of formulary generic metoprolol ER. 38
39 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. 39
40 ULORIC Uloric Coverage will be provided if allopurinol has been tried (at least a 30-day supply in the prior 180 days) 40
41 XANAX Xanax Xanax Xr A documented one month trial of formulary generic alprazolam tablets. 41
42 ZIOPTAN Zioptan A documented trial of one week of formulary generic latanoprost. 42
43 INDEX A Aciphex Actonel Acular Acular Ls Aggrenox... 1 Altoprev Amerge Anticonvulsants... 2 Anti-dementia Agents... 3 Antidepressants... 4 Arb - Arb Combos... 5 Aricept... 3 Atacand... 5 Atacand Hct... 5 Atelvia Atopic Dermatitis... 6 Atypical Antipsychotics... 7 Avalide... 5 Avapro... 5 Axert Azor... 5 B Benicar... 5 Benicar Hct... 5 Binosto Buprenorphine Butrans C Caduet... 8 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 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 Hyperlipidemia Hyzaar... 5 I Imitrex Imitrex Statdose Refill Imitrex Statdose System Intuniv Invega
44 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 Lamotrigine Starter Kit/blue Lamotrigine Starter Kit/green Lamotrigine Starter Kit/orange Lescol XL Lexapro Long Acting Narcotics Lotronex M Maxalt Maxalt-mlt Micardis... 5 Micardis Hct... 5 Minocin Minocycline Minocycline Hcl Minocycline Hcl Er Minocycline Hydrochlorideer Mirapex Mirapex Er N Naprelan Nasonex Niaspan Nsaids Nucynta O Ocufen Onzetra Xsail Ophthalmic Antiinflammatories Osteoporosis Oxtellar Xr... 2 P Paxil... 4 Paxil Cr... 4 Pennsaid Plavix Ppi Prevacid Prevacid Solutab Prilosec Protonix Protopic... 6 Prozac... 4 Prozac Weekly... 4 Q Qudexy Xr... 2 R Rabeprazole Sodium Razadyne... 3 Razadyne Er... 3 Renagel S Singulair Smoking Cessation Solodyn Sorilux Stalevo Stalevo Stalevo Stalevo Stalevo Subvenite Starter Kit/blue Subvenite Starter Kit/green Subvenite Starter Kit/orange Sumavel Dosepro Symbyax... 7 T Taclonex Tegretol
45 Tegretol-xr... 2 Tikosyn Topamax... 2 Topamax Sprinkle... 2 Topical Nsaids Toprol XL Treximet Tribenzor... 5 Trileptal... 2 Trintellix... 4 Triptans 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. First Health Part D Value Plus (PDP) Last Updated: 10/01/2017. Aggrenox
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_3742 09/2014 Formulary ID: 18059:
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
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Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
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Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70 mg Fosamax Arthritis
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STEP THERAPY NOTE: The medications in each category are subject to change. Please make sure to check with the Fund (Phone: Toll Free in PA: 1-800-422-8330; Toll Free in USA: 1-800-331-0420) or on the Fund