Blood Modifiers and Electrolytes
Antiplatelet Agents

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Aggrenox
dipyridamole-aspirin		 200-25 mg capsule, ER multiphase 12 hr   approved.gif (510 bytes)  

$$$$$
Agrylin generic.gif (400 bytes)
anagrelide		 0.5 mg capsule   approved.gif (510 bytes)  

$$$$
Brilinta
ticagrelor		 90 mg tablet   nonform.gif (625 bytes)

ql.gif

Not Applicable
Effient
prasugrel		 5 mg tablet; 10 mg tablet   nonform.gif (625 bytes)

ql.gif

Not Applicable
Persantine generic.gif (400 bytes)
dipyridamole		 25 mg tablet; 50 mg tablet; 75 mg tablet   approved.gif (510 bytes)  

$
Plavix generic.gif (400 bytes)
clopidogrel		 300 mg tablet   approved.gif (510 bytes)

ql.gif

$$$$
Plavix generic.gif (400 bytes)
clopidogrel		 75 mg tablet   approved.gif (510 bytes)

ql.gif

$$$$
Pletal generic.gif (400 bytes)
cilostazol		 tablet   approved.gif (510 bytes)  

$$$
Ticlid generic.gif (400 bytes)
ticlopidine		 250 mg tablet   approved.gif (510 bytes)  

$$$$

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans.
Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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