AGGRENOX. Products Affected. Details. Open 1 Last Updated: 10/01/2018. Aggrenox
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1 Open 1 Last Updated: 10/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_ /2014 Formulary ID: 19076: version 7 1
2 ANTIDEPRESSANTS Aplenzin Celexa TABS Effexor Xr Forfivo XL Khedezla Paxil TABS Paxil Cr Pexeva Pristiq Prozac CAPS Wellbutrin Sr Wellbutrin XL Zoloft TABS A documented trial of one month each of two of the following: formulary generic antidepressants, Fetzima (levomilnacipran), Trintellix (vortioxetine), Viibryd (vilazodone) 2
3 ARB - ARB COMBOS Atacand Atacand Hct Avalide Avapro Azor Benicar Benicar Hct Byvalson Cozaar Diovan TABS Diovan Hct Edarbi 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. 3
4 ATOPIC DERMATITIS Elidel Eucrisa Protopic A documented trial of one month of a formulary generic topical corticosteroid or formulary generic topical tacrolimus. 4
5 AUVI-Q Auvi-q A documented trial of one day of formulary generic Epinephrine. 5
6 BELSOMRA Belsomra A documented trial of one month of one generic prescription sleep aid such as zolpidem, zolpidem er, zolpidem sublingual, ezopiclone or zaleplon. 6
7 DEXAMETHASONE Dexamethasone Intensol Dexpak 10 Day TBPK Dexpak 13 Day TBPK Dexpak 6 Day Taperdex 12-day Taperdex 6-day Zodex 12-day Zodex 6-day A documented trial of one week of formulary generic oral dexamethasone. 7
8 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. 8
9 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, Jentadueto, or Jentadueto XR). 9
10 EFFIENT Effient A documented trial of one month each of formulary Brilinta (ticagrelor) and clopidogrel. 10
11 GLP-1 RECEPTOR AGONISTS Adlyxin Adlyxin Starter Pack Tanzeum A documented trial of one month each of two of the following: Victoza (liraglutide), Bydureon (exenatide), Byetta (exenatide), Trulicity (dulaglutide), Ozempic (semaglutide). 11
12 GOUT Uloric Coverage will be provided if oral allopurinol has been tried (at least a 30- day supply in the prior 180 days) 12
13 HEPSERA Hepsera A documented trial of one month of formulary generic adefovir. 13
14 HYPERLIPIDEMIA Altoprev TB24 20MG, 40MG, 60MG Crestor Flolipid Lescol XL Lipitor Livalo Pravachol TABS 20MG, 40MG, 80MG Vytorin Zocor 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 14
15 INSULIN GLARGINE Lantus Lantus Solostar Toujeo Max Solostar Toujeo Solostar A documented trial of one month each of two of the following preferred agents: Basaglar (insulin glargine), Levemir (insulin detemir), or Tresiba (insulin degludec) 15
16 INSULINS Admelog Admelog Solostar Apidra Apidra 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 Novolin 70/30 Relion Novolin N Relion Novolin R Relion A documented trial of one month of a Novo insulin (non-relion version) or have a documented contraindication to Novo Nordisk brand insulins (non-relion version). 16
17 INTUNIV Intuniv A documented trial of one month of formulary generic guanfacine ER. 17
18 LAMISIL Lamisil TABS A documented trial of one month of formulary generic terbinafine tablets. 18
19 LIBRAX Librax A documented trial of one month of generic chlordiazepoxide hydrochloride/clidinium bromide capsule. 19
20 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), Incruse Ellipta (umeclidinium), Anoro Ellipta (umeclidinium bromide/vilanterol), Bevespi (glycopyrrolate/formoterol), Serevent Diskus (salmeterol), Symbicort (budesonide/formoterol), Trelegy Ellipta (fluticasone furoate/umeclidinium bromide/vilanterol trifenatate) 20
21 LOTRONEX Lotronex A documented trial of one month of formulary generic alosetron. 21
22 LUZU Luzu A documented trial of two weeks of topical ketoconazole or econazole 22
23 MINOCYCLINE Minocin CAPS 100MG, 50MG 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. 23
24 MIRAPEX Mirapex Mirapex Er A documented trial of one month of formulary generic pramipexole or pramipexole er. 24
25 MOTOFEN Motofen A documented trial of 10 days of formulary generic diphenoxylate/ atropine. 25
26 NASONEX Nasonex A documented trial of one month of formulary generic mometasone nasal spray. 26
27 NIASPAN Niaspan TBCR 1000MG, 500MG, 750MG A documented trial of one month of formulary generic niacin ER. 27
28 NOAC Savaysa A documented trial of one month each of two of the following: Eliquis (apixaban), Pradaxa (dabigatran etexilate mesylate), Xarelto (rivaroxaban) 28
29 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). 29
30 ORAP Orap A documented trial of one month of formulary generic pimozide. 30
31 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. 31
32 PLAVIX Plavix A documented trial of one month of formulary generic clopidogrel. 32
33 RENAGEL Renagel TABS Renvela A documented trial of one month of formulary sevelamer. 33
34 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), Incruse Ellipta (umeclidinium), Anoro Ellipta (umeclidinium bromide/vilanterol), Bevespi (glycopyrrolate/formoterol), Arnuity Ellipta (fluticasone furoate), Flovent Diskus (fluticasone propionate), Flovent HFA (fluticasone propionate), Pulmicort Flexhaler (budesonide), Serevent Diskus (salmeterol), Trelegy Ellipta (fluticasone furoate/umeclidinium bromide/vilanterol trifenatate) 34
35 RHOPRESSA Rhopressa A documented trial of one week of generic timolol or latanoprost AND one week trial of Lumigan or Travatan Z. 35
36 SGLT-2 Invokana Steglatro A documented trial of one month each of Jardiance (empagliflozin) AND Farxiga (dapagliflozin). 36
37 SGLT-2 + METFORMIN Invokamet Invokamet Xr Segluromet A documented trial of one month each of two of the following: Synjardy (empagliflozin-metformin), Synjardy XR (empagliflozin-metformin extended release), Xigduo XR (dapagliflozin-metformin HCl extendedrelease) 37
38 SINGULAIR Singulair A documented trial of one month of formulary generic montelukast. 38
39 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. 39
40 TIKOSYN Tikosyn A documented trial of one month of formulary generic dofetilide. 40
41 TRIPTANS Amerge Axert Frova Imitrex Imitrex Statdose Refill Imitrex Statdose System Maxalt Maxalt-mlt Onzetra Xsail Treximet Zembrace Symtouch Zomig Zomig Zmt A documented trial of 14 days each of two formulary generic antimigraine agent triptans. 41
42 VYZULTA Vyzulta A documented trial of one week each of two of the following ophthalmic agents: formulary generic latanoprost, Lumigan, Travatan Z 42
43 XADAGO Xadago A documented trial of one month of formulary generic selegiline and rasagiline. 43
44 XANAX Xanax Xanax Xr A documented one month trial of formulary generic alprazolam, alprazolam ODT, alprazolam er, or alprazolam xr. 44
45 ZIOPTAN Zioptan A documented trial of one week of formulary generic latanoprost. 45
46 INDEX A Actonel Adlyxin Adlyxin Starter Pack Admelog Admelog Solostar Aggrenox... 1 Airduo Respiclick 113/ Airduo Respiclick 232/ Airduo Respiclick 55/ Alogliptin... 9 Alogliptin/metformin Hcl... 9 Alogliptin/pioglitazone... 9 Altoprev Alvesco Amerge Antidepressants... 2 Apidra Apidra Solostar Aplenzin... 2 Arb - Arb Combos... 3 Arcapta Neohaler Armonair Respiclick Armonair Respiclick Armonair Respiclick 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... 3 Atacand Hct... 3 Atelvia Atopic Dermatitis... 4 Auvi-q Avalide... 3 Avapro... 3 Axert Azor... 3 B Belsomra... 6 Benicar Benicar Hct... 3 Binosto Byvalson... 3 C Celebrex Celexa... 2 Cozaar... 3 Crestor D Dexamethasone... 7 Dexamethasone Intensol... 7 Dexpak 10 Day... 7 Dexpak 13 Day... 7 Dexpak 6 Day... 7 Diovan... 3 Diovan Hct... 3 Doryx... 8 Doryx Mpc... 8 Doxycycline... 8 Dpp4 Products... 9 Dulera E Edarbi... 3 Edarbyclor... 3 Effexor Xr... 2 Effient Elidel... 4 Eucrisa... 4 Exforge
47 Exforge Hct... 3 F Flolipid Fluticasone Propionate/salmeterol Forfivo XL... 2 Fosamax Fosamax Plus D Frova G Glp-1 Receptor Agonists Gout 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 Hyperlipidemia Hyzaar... 3 I Imitrex Imitrex Statdose Refill Imitrex Statdose System Insulin Glargine Insulins Intuniv Invokamet Invokamet Xr Invokana K Kazano... 9 Khedezla... 2 Kombiglyze Xr... 9 L Lamisil Lantus Lantus Solostar Lescol XL Librax Lipitor Livalo Lodine Lonhala Lonhala Magnair Refill Kit Lonhala Magnair Starter Kit Lotronex Luzu M Maxalt Maxalt-mlt Micardis... 3 Micardis Hct... 3 Minocin Minocycline Minocycline Hcl Minocycline Hcl Er Minocycline Hydrochlorideer Mirapex Mirapex Er Motofen N Nalfon Naprelan Nasonex Nesina... 9 Niaspan Noac Novolin 70/30 Relion Novolin N Relion Novolin R Relion Nsaids O Onglyza... 9 Onzetra Xsail Orap
48 Oseni... 9 Osteoporosis P Paxil... 2 Paxil Cr... 2 Pexeva... 2 Plavix Pravachol Pristiq... 2 Protopic... 4 Prozac... 2 Q Qvar Qvar Redihaler R Renagel Renvela Respiratory Rhopressa S Savaysa Seebri Neohaler Segluromet Sglt Sglt-2 + Metformin Singulair Solodyn Spiriva Handihaler Spiriva Respimat Stalevo Stalevo Stalevo Stalevo Stalevo Stalevo Stalevo Steglatro Stiolto Respimat Striverdi Respimat T Tanzeum Taperdex 12-day... 7 Taperdex 6-day... 7 Targadox... 8 Tikosyn Toujeo Max Solostar Toujeo Solostar Treximet Tribenzor... 3 Triptans Tudorza Pressair Twynsta... 3 U Uloric Utibron Neohaler V Vibramycin... 8 Vivlodex Vytorin Vyzulta W Wellbutrin Sr... 2 Wellbutrin XL... 2 X Xadago Xanax Xanax Xr Ximino Z Zembrace Symtouch Zioptan Zipsor Zocor Zodex 12-day... 7 Zodex 6-day... 7 Zoloft... 2 Zomig Zomig Zmt Zypitamag
49 49
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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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:
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