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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsOklahoma Aggrenox Prior Auth Update | OpenPayer
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    ModifiedOklahoma Health Care AuthorityPolicy N/A

    Aggrenox (aspirin/dipyridamole extended-release) Approval Criteria

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    This policy governs SoonerCare reimbursement and prior authorization requirements for Aggrenox in adult members requiring prevention of recurrent thromboembolic stroke. Coverage requires an FDA-approved indication, age 18 or older, and patient-specific clinical justification for using Aggrenox instead of immediate-release dipyridamole with over-the-counter aspirin.

    Policy Summary
    PayerOklahoma Health Care Authority
    PolicyAggrenox (aspirin/dipyridamole extended-release) Approval Criteria
    Policy CodePolicy N/A
    Change TypeCoverage criteria update
    Effective DateMay 18, 2016
    Next Review DateN/A
    Key ActionSubmit a manual prior authorization for every member receiving Aggrenox, including an FDA-approved indication, age of at least 18 years, and patient-specific clinical justification.
    SourceLink
    POLICY UPDATE CHANGES

    Aggrenox coverage was changed to require a manual prior authorization for all members.

    Coverage criteria were established requiring an FDA-approved recurrent stroke prophylaxis indication, age 18 or older, and clinical justification for not using immediate-release dipyridamole with over-the-counter aspirin.

    A quantity limit of 60 capsules per 30-day supply was established.

    Manual PAPrior authorization required for all members
    18+Minimum member age
    60 capsulesMaximum quantity per 30-day supply
    No grandfatheringExisting therapy does not bypass prior authorization

    Aggrenox Coverage Criteria

    Initial Aggrenox coverage

    Covered when all of the following are met:

    Aggrenox approval criteria

    • Clinical eligibility

      • FDA-approved indication: The member has an FDA-approved indication for prophylaxis of recurrent thromboembolic stroke after transient ischemia of the brain or completed ischemic stroke due to thrombosis.
      • Age requirement: The member is 18 years of age or older.>= 18 years
      • Alternative regimen unsuitable: A patient-specific, clinically significant reason is provided why the member cannot use immediate-release dipyridamole and over-the-counter (OTC) aspirin in place of Aggrenox.
    Policy Summary
    PayerOklahoma Health Care Authority
    PolicyAggrenox (aspirin/dipyridamole extended-release) Approval Criteria
    Policy CodePolicy N/A
    Change TypeCoverage criteria update
    Effective DateMay 18, 2016
    Next Review DateN/A
    Key ActionSubmit a manual prior authorization for every member receiving Aggrenox, including an FDA-approved indication, age of at least 18 years, and patient-specific clinical justification.
    SourceLink
    On This Page
    Aggrenox Coverage CriteriaPrior Authorization and Provider RequirementsDrug and Clinical BackgroundCovered Clinical UseInitial Therapy RequirementsAlternative Regimen RequirementAggrenox Quantity Limit

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

  1. Administrative requirement: A manual prior authorization is submitted for the member.

    No grandfathering is allowed.

    2. Members receiving Aggrenox are not grandfathered into coverage. A manual prior authorization is required for every member, including those already receiving therapy, before coverage can be considered.

    Prior Authorization and Provider Requirements

    Prior Authorization

    Manual Prior Authorization Required

    Effective May 18, 2016, Aggrenox® (aspirin/dipyridamole extended-release [ER]) requires prior authorization. Every member receiving Aggrenox® must have a manual prior authorization submitted.

    • Manual prior authorization is required for all members, including existing users.
    • Include the required clinical documentation and supporting information with the request.
    Documentation Required

    Justify Use Over Alternative Regimen

    The request must explain why the member cannot use immediate-release dipyridamole together with over-the-counter (OTC) aspirin instead of Aggrenox®.

    • Provide a patient-specific, clinically significant reason for using Aggrenox® over the alternative regimen.
    Documentation Required

    Clinical Justification Required

    Prior authorization requests must include patient-specific, clinically significant supporting information demonstrating the medical need for Aggrenox®.

    • Document the member’s relevant clinical circumstances and the reason the requested extended-release combination is needed.
    Prior Authorization

    Submit the Manual PA

    Submit the manual prior authorization request to SoonerCare Pharmacy Services using the applicable prior authorization process.

    • Prior authorization request forms are available at www.okhca.org/forms.
    • Use form PHARM-04 and include the required patient-specific supporting information.

    Unsupported block type: denial_risk

    Denial Risk

    Missing Manual PA May Result in Denial

    Claims may be denied if a manual prior authorization has not been submitted. No grandfathering is allowed for Aggrenox® (aspirin/dipyridamole ER).

    • Manual prior authorization is required for every member receiving the medication.
    • Existing therapy does not exempt a member from the manual PA requirement.
    Denial Risk

    Quantity Limit Applies

    A quantity limit of 60 capsules per 30-day supply applies to Aggrenox®. Quantities exceeding this limit may be denied.

    • Maximum covered quantity: 60 capsules.
    • Supply limit: 30 days.

    Drug and Clinical Background

    Aggrenox combines aspirin with extended-release dipyridamole and is used for the secondary prevention of recurrent thromboembolic stroke in patients who have experienced transient ischemia of the brain or a completed ischemic stroke due to thrombosis. The policy establishes coverage requirements for adult SoonerCare members, including an FDA-approved indication, age 18 years or older, patient-specific clinical justification for using Aggrenox instead of immediate-release dipyridamole with over-the-counter aspirin, and manual prior authorization.

    Covered Clinical Use

    Definitions
    TermProphylaxis of recurrent thromboembolic stroke
    Covered indicationPrevention of another thromboembolic stroke
    Qualifying historyTransient ischemia of the brain or completed ischemic stroke due to thrombosis

    Initial Therapy Requirements

    Initial therapy

    Initial coverage requires all listed clinical and administrative criteria.

    Initial therapy criteria

    • Approved indication: The member has an FDA-approved indication for prophylaxis of recurrent thromboembolic stroke after transient ischemia of the brain or completed ischemic stroke due to thrombosis.
    • Age: The member is 18 years of age or older.>= 18 years
    • Clinical rationale: The provider supplies a patient-specific, clinically significant reason the member cannot use immediate-release dipyridamole and over-the-counter (OTC) aspirin instead of Aggrenox.
    • Prior authorization: A manual prior authorization request is submitted.

      No grandfathering is allowed.

    Alternative Regimen Requirement

    StepRequired clinical justificationAlternative regimen
    1Provide a patient-specific, clinically significant reason why the member cannot use the requested medication.Immediate-release dipyridamole with over-the-counter (OTC) aspirin

    Aggrenox Quantity Limit

    Quantity Limits
    MedicationAggrenox (aspirin/dipyridamole ER)
    Maximum quantity60 capsules
    Supply period30-day supply