ACNE ADAPAL/BEN P GEL 0.1-2.5% AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL 0.3-2.5% TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA RISEDRON SOD RISEDRONATE APTIOM SPRITAM FETZIMA KHEDEZLA TRINTELLIX ARISTADA FANAPT LATUDA PALIPERIDONE SAPHRIS ADVAIR DISKU ADVAIR HFA BREO ELLIPTA Previous trial on at least ONE: Generic topical acne treatment alendronate carbamezapine, divalproex, epitol, ethosuximide, felbamate, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, tiagabine, topiramate, valproic acid, zonisamide bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, mirtazapine, paroxetine, sertraline, venlafaxine aripiprazole, clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone Previous trial on ONE of the following: 1. Symbicort 2. Fluticasone/Salmeterol BELSOMRA BELSOMRA eszopiclone, zaleplon, zolpidem, zolpidem ER BUDESONIDE BUDESONIDE TAB Previous trial of ONE of the following: Apriso, Delzicol, Mesalamine, Pentasa 1
CADUET AMLOD/ATORVA atorvastatin, lovastatin, pravastatin, simvastatin AND amlodipine CAPEX CAPEX clobetasol shampoo CLENPIQ CLENPIQ Previous trial of Suprep CORDRAN CORDRAN 80X3 Previous trial on at least ONE: Generic topical steroid CORLANOR CORLANOR acebutolol, atenolol, bisoprolol, labetolol, metoprolol, nadolol, pindolol, propranolol, timolol DEMSER DEMSER phenoxybenzamine DEPRESSION APLENZIN DESVENLAFAX EMSAM FORFIVO XL PEXEVA VIIBRYD bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, mirtazapine, paroxetine, sertraline, venlafaxine DERM ELIDEL tacrolimus AND betamethasone, clobetasol, hydrocortisone, triamcinolone DEXILANT DEXILANT lansoprazole, omeprazole, pantoprazole 2
DIABETES GLYXAMBI Previous trial on at metformin OR metformin ER INVOKAMET INVOKAMET XR INVOKANA JARDIANCE JENTADUETO SYNJARDY SYNJARDY XR TRULICITY VICTOZA EPLERENONE EPLERENONE spironolactone, spironolactone-hctz EUCRISA EUCRISA OIN Previous trial of at least ONE of the following: 1. Topical Corticosteroid 2. Topical tacrolimus EURAX EURAX Lindane Shampoo OR Permethrin Cream EXALGO HYDROMORPHON fentanyl patches, methadone, morphine ER, oxycodone er, oxymorphone ER, Zohydro GABAPENTIN GASTRO ICS GRALISE GRALISE STAR HORIZANT DELZICOL MESALAMINE ALVESCO PULMICORT QVAR REDIHA QVAR REDIHAL ER generic gabapentin OR pramipexole Apriso, balsalazide, Pentasa, sulfasalazine Flovent OR Arnuity AND Asmanex 3
LABA-LAMA ANORO ELLIPT UTIBRON Previous trail on at least ONE of the following: Stiolto OR Bevespi LAMA INCRUSE ELPT SEEBRI NEOHA Spiriva AND Tudorza LUNESTA ESZOPICLONE zolpidem or zaleplon NAMENDA MEMANTINE HC OAB NAMENDA XR DARIFENACIN GELNIQUE TOVIAZ VESICARE immediate release Memantine oxybutynin, oxybutynin er, tolterodine, tolterodine er, trospium, trospium er OXYCONTIN OXYCODONE fentanyl patches, hydromorphone er, methadone, morphine ER, oxymorphone ER, Zohydro ER PPI ESOMEPRA MAG CAP 20MG DR ESOMEPRA MAG CAP 40MG DR LANSOPRAZOLE TAB 15MG LANSOPRAZOLE TAB 30MG lansoprazole capsules, misoprostol, omeprazole, pantoprazole RANEXA RANEXA amlodipine, atenolol, diltiazem, isosorbide dinitrate, isosorbide mononitrate, metoprolol, propranolol, verapamil RASUVO RASUVO generic methotrexate 4
REXULTI REXULTI Previous therapy on: aripiprazole AND Latuda OR quetiapine ER RYTARY RYTARY carbidopa/levodopa SA OPIOID OXYMORPHONE APAP/codeine, codiene sulfate, hydrocodone/apap, hydrocodone/ibu, hydromorphone, morphine IR, oxycodone, oxycodone/apap, oxycodone/asa, oxycodone/ibu SABA STATIN STEGLATRO STIMULANTS PROAIR HFA PROAIR RESPI PROVENTIL EZETIM/SIMVA TAB 10-10MG EZETIM/SIMVA TAB 10-20MG EZETIM/SIMVA TAB 10-40MG EZETIM/SIMVA TAB 10-80MG LIVALO TAB 1MG LIVALO TAB 2MG LIVALO TAB 4MG SEGLUROMET TAB STEGLATRO TAB DAYTRANA VYVANSE SYMLIN SYMLINPEN 60 SYMLNPEN 120 Ventolin atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin 10 mg, simvastatin Jardiance OR Synjardy AND Invokana OR Invokamet Previous trial on at least ONE: generic long-acting stimulant OR Diagnosis of binge eating disorder insulin 5
SYMPROIC SYMPROIC Movantik TACLONEX TACLONEX TEKTURNA TIZANIDINE TEKTURNA TEKTURNA HCT TIZANIDINE CAP 2MG TIZANIDINE CAP 4MG TIZANIDINE CAP 6MG calcipotriene-betamethasone ointment benazepril, benazepril-hctz, captopril, captopril-hctz, enalapril, enalapril-hctz, fosinopril, fosinopril-hctz, lisinopril, lisinopril-hctz, quinapril, quinapril-hctz, ramipril AND candesartan, candesartan-hctz, eprosartan, irbesartan, irbesartan-hctz, losartan, losartan-hctz, olmesartan, olmesartan-hctz, telmisartan, telmisartan-hctz, valsartan, valsartan-hctz tizanidine tablets TRIPTAN FROVATRIPTAN sumatriptan OR rizatriptan TRULANCE TRULANCE Previous trial on Linzess UCERIS FOAM UCERIS colocort enema, hydrocortisone enema, or mesalamine enema ULORIC ULORIC allopurinol VELPHORO VELPHORO Renagel OR sevelamer VRAYLAR VRAYLAR aripiprazole AND clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone VYZULTA RHOPRESSA VYZULTA latanoprost 6
ZELAPAR ZELAPAR selegiline ZOHYDRO ZOHYDRO ER fentanyl patches, hydromorphone er, methadone, morphine ER, oxycodone er, oxymorphone ER 7