ACNE ACZONE ADAPAL/BEN P AZELEX DAPSONE EPIDUO EPIDUO FORTE TRETINOIN ACTONEL RISEDRON SOD RISEDRONATE SelectHealth Advantage Previous trial on at least ONE: Generic topical acne treatment alendronate ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA APTIOM SPRITAM FETZIMA KHEDEZLA TRINTELLIX ARIPIPRAZOLE ARISTADA FANAPT LATUDA PALIPERIDONE SAPHRIS ADVAIR DISKU ADVAIR HFA BREO ELLIPTA carbamezapine, divalproex, epitol, ethosuximide, felbamate, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, tiagabine, topiramate, valproic acid, zonisamide bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, mirtazapine, paroxetine, sertraline, venlafaxine 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 CADUET AMLOD/ATORVA atorvastatin, lovastatin, pravastatin, simvastatin AND amlodipine 2
CAPEX CAPEX clobetasol shampoo 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 DIABETES GLYXAMBI INVOKAMET INVOKAMET XR INVOKANA JARDIANCE JENTADUETO SYNJARDY TRULICITY VICTOZA metformin OR metformin ER AND acarbose, Actoplus Met XR, alogliptin, alogliptin-metformin, alogliptin-pioglitazone, glimepiride, glimepiride-pioglitazone, glipizide, glipizide-metformin, Jentadueto, miglitol, nateglinide, pioglitazone, pioglitazone-metformin, repaglinide, repaglinide-metformin, tolazamide, tolbutamide, Tradjenta EPLERENONE EPLERENONE spironolactone, spironolactone-hctz 3
EURAX EURAX Lindane Shampoo OR Permethrin Cream EXALGO HYDROMORPHON fentanyl patches, methadone, morphine ER, oxycodone er, oxymorphone ER, Zohydro ER GABAPENTIN GASTRO ICS LABA-LAMA LAMA GRALISE GRALISE STAR HORIZANT DELZICOL MESALAMINE AEROSPAN ALVESCO PULMICORT QVAR ANORO ELLIPT UTIBRON INCRUSE ELPT SEEBRI NEOHA generic gabapentin OR pramipexole Apriso, balsalazide, Pentasa, sulfasalazine Flovent OR Arnuity AND Asmanex Previous trail on at least ONE of the following: Spiriva OR Tudorza, AND Stiolto OR Bevespi Spiriva AND Tudorza LUNESTA ESZOPICLONE zolpidem or zaleplon NAMENDA NAMENDA XR immediate release Memantine OAB DARIFENACIN GELNIQUE MYRBETRIQ TOVIAZ VESICARE oxybutynin, oxybutynin er, tolterodine, tolterodine er, trospium, trospium er 4
OXYCONTIN OXYCODONE fentanyl patches, hydromorphone er, methadone, morphine ER, oxymorphone ER, Zohydro ER PPI ESOMEPRA MAG PREVACID lansoprazole, misoprostol, omeprazole, pantoprazole RANEXA RANEXA amlodipine, atenolol, diltiazem, isosorbide dinitrate, isosorbide mononitrate, metoprolol, propranolol, verapamil RASUVO RASUVO generic methotrexate 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 PROAIR HFA PROAIR RESPI PROVENTIL Ventolin 5
STATIN 10-10MG 10-20MG 10-40MG 10-80MG LIVALO TAB 1MG LIVALO TAB 2MG LIVALO TAB 4MG STIMULANTS DAYTRANA VYVANSE SelectHealth Advantage SYMLIN SYMLINPEN 60 SYMLNPEN 120 insulin SYMPROIC SYMPROIC Movantik TACLONEX TACLONEX TEKTURNA TIZANIDINE TEKTURNA TEKTURNA HCT TIZANIDINE CAP 2MG TIZANIDINE CAP 4MG TIZANIDINE CAP 6MG atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin 10 mg, simvastatin Previous trial on at least ONE: generic long-acting stimulant OR Diagnosis of binge eating disorder 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 TRELEGY TRELEGY Previous trial on of Stiolto, Symbicort, or Fluticasone/Salmeterol 6
TRIPTAN FROVATRIPTAN sumatriptan OR rizatriptan UCERIS FOAM UCERIS colocort enema, hydrocortisone enema, or mesalamine enema ULORIC ULORIC allopurinol VELPHORO AURYXIA VELPHORO Renagel OR Renvela VRAYLAR VRAYLAR aripiprazole AND clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone VYZULTA VYZULTA latanoprost ZELAPAR ZELAPAR selegiline ZOHYDRO ZOHYDRO ER fentanyl patches, hydromorphone er, methadone, morphine ER, oxycodone er, oxymorphone ER 7