151 Farmington Avenue Hartford, CT 06156 September, 2015 Changes to your pharmacy plan The enclosed chart shows changes that start on January 1, 2016. We re adding some brand-name and generic drugs to our pharmacy plan and specialty drug list. We re also removing others. Your plan s coverage requirements may also change. You can get the most from your plan by knowing about these upcoming changes. We don t want there to be any surprises. These updates will affect the prescription drugs you take. So make sure you check out the summary of changes in the enclosed chart. Find a preferred drug that s right for you You can find a list of preferred drugs on your pharmacy plan and specialty drug list at www.aetna.com/formulary. You typically pay lower out-of-pocket costs when you use preferred drugs. You can still fill prescriptions for non-preferred drugs. But you may pay more. Don t worry. You can talk to your doctor about your treatment options. If your doctor agrees that a preferred alternative will work for you, ask to have your prescription changed. If your plan includes the Specialty Drug List, you may pay higher out of pocket costs and may be required to obtain these products at an Aetna Specialty Pharmacy Network Provider like Aetna Specialty Pharmacy. We re here to help If you have any questions, just visit your secure member website at www.aetna.com. Or, you can call us at the toll-free number on your member ID card. Enclosure 2015 Aetna Inc. 01/01/2016_FC_Subscriber Notice 05.32.657.1 (8/15)
Abbreviation Key UPPPERCASE = brand-name drug; lower case italics = generic drug Age Limit These drugs have an age limit requirement. You must meet the age requirement before the drug will be covered. Expect Gen Expect generic drugs to become available in the near future. When this happens, we may cover the brand-name drug at a higher copayment in open formulary plans, add it to the Formulary Exclusions List in closed formularies or add the brand-name drug to the precertification, quantity limit or steptherapy lists. Gender Drugs that have guidelines for use or safety checks in place in order to provide the best possible care based on gender. Medical These drugs are not covered under your Pharmacy benefit but may be covered under your Medical benefit. NC These drugs are not covered under your pharmacy benefit plan. You Not-Covered can still get these drugs but will need to pay the full cost of the drug. NPB/G These drugs aren t preferred. You may pay higher out-ofpocket costs when using a non-preferred brand-name or Non-preferred brand-name or generic drug generic drug. NPS Non-preferred specialty drug NPL National Precertification List PA Prior authorization or precertification PB Preferred brand-name drug PS Preferred specialty drugs PG Preferred generic QL Quantity limits SPB Specialty pharmacy coverage ST Step therapy These drugs aren t preferred. You may pay higher out-ofpocket costs when using a non-preferred drug on the Aetna Specialty Drug List. Prior authorization (PA) is required for all plans. Your doctor must contact us to request approval for coverage. Prior authorization only applies if your plan includes precertification. This means that we have to approve some drugs before we cover them. If this is required, your doctor must contact us to request approval of coverage. These are brand-name drugs that are covered at your 2 nd copay. You may pay lower out-of-pocket costs when you use preferred drugs, but this may not always be the case. You may pay lower out-of-pocket costs when you use preferred drugs on the Aetna Specialty Drug List. These are generic drugs that are covered at your 1 st tier copay. You may pay lower out-of-pocket costs when you use preferred drugs, but this may not always be the case. Quantity limits help ensure that you get a safe amount of your drug. They only apply if your plan includes precertification. If you go past the quantity limit, your doctor must contact us to request approval of coverage. You may pay higher out of pocket costs and may be required to get these products at an Aetna Specialty Pharmacy network provider, like Aetna Specialty Pharmacy. Specialty products aren t available at Aetna Rx Home Delivery and are limited to a 30 day supply. Step therapy only applies if your plan includes it. This means that you must try one or more prerequisite drug(s) before we cover a step-therapy drug.
ABSORICA NC NC doxycycline, minocycline Add PA, ABSTRAL NPB/G NPB/G Add QL ACEON NPB/G NPB/G Remove QL ACIPHEX NPB/G NPB/G omeprazole, pantoprazole, esomeprazole ACIPHEX SPR NPB/G NPB/G omeprazole, pantoprazole, esomeprazole ACTICLATE NC NC Add QL ACTIMMUNE PS NPS ACTOPLUS MET PB NPB/G pioglitazone/metformin acyclovir oint PG NPB/G ABREVA adapalene cre 0.1% PG NPB/G tretinoin adapalene gel 0.1% PG NPB/G tretinoin adapalene gel 0.3% PG NPB/G tretinoin ADCIRCA PS NPS sildenafil, LETAIRIS, OPSUMIT, TRACLEER ADVAIR DISKU NPB/G NPB/G Expect Gen ADVAIR HFA NPB/G NPB/G Expect Gen aero otic hc PG NC ALDURAZYME NPS PS ALINIA NPB/G NPB/G Remove QL ALKERAN TAB PS PB ALODOX NPB/G NC doxycycline 50mg caps altafluor PG NPB/G aluminum cl PG NC AMBIEN CR NPB/G NPB/G Remove ST amcinonide PG NPB/G fluocinolone acetonide amlod/benazp PG PG Remove QL amnesteem PG NPB/G claravis Add PA, amox-pot cla PG PG Remove QL AMTURNIDE150 NPB/G NPB/G amlodipine, hctz, losartan, valsartan AMTURNIDE300 NPB/G NPB/G amlodipine, hctz, losartan, valsartan
ANACAINE NPB/G NC ANALPRAM E NPB/G NC ANALPRAM-HC CRE 1-2.5% NPB/G NC ANALPRAM-HC LOT 2.5% PB NPB/G lidocaine hc ANDROID PB PB Remove QL anucort-hc PG NC ANUSOL-HC NPB/G NC ARICEPT NPB/G NPB/G Remove QL arnica PG NC atovaq/progu PG PG Remove QL atovaquone PG PG Remove QL ATRALIN NPB/G NPB/G ATRIPLA NPB/G PB ATROVENT HFA PB NPB/G ipratropium Remove QL AVAR NPB/G NC AVAR LS NPB/G NC avar-e emoll PG NPB/G avar-e green PG NPB/G AVELOX NPB/G NPB/G Remove QL AVELOX ABC NPB/G NPB/G Remove QL AVINZA NPB/G NPB/G Remove ST avita PG PG AVODART NPB/G PB Expect Gen azelastine PG NPB/G ZADITOR AZELEX PB NPB/G tretinoin, metronidazole 0.75% azithromycin PG PG Remove QL AZOR NPB/G NPB/G Expect Gen BELSOMRA NPB/G NPB/G BENICAR NPB/G NPB/G Expect Gen BENICAR HCT NPB/G NPB/G Expect Gen BENZACLIN NC NC Remove QL BENZAMYCIN PB NPB/G erythromycin/benzoyl peroxide BEPREVE NPB/G NPB/G Remove QL
betameth val PG NPB/G fluocinolone acetonide BETHKIS PS NPS tobramycin, TOBI PODHALER Remove PA BETIMOL PB NPB/G timolol, betaxolol bexarotene PS PS Add SPB BIAXIN NPB/G NPB/G Remove QL BIAXIN XL NPB/G NPB/G Remove QL BIEST/PROGES CRE NPB/G NC bio glo PG NPB/G BLEPH-10 PB NPB/G sulfacetamide sodium BOTOX NPS PS BRAVELLE NPS PS BREO ELLIPTA NPB/G NPB/G Remove PA brimonidine 0.15% PG NPB/G brimonidine 0.2% BRISDELLE NC NPB/G paroxetine Add PA bromfenac PG NPB/G ketorolac tromethamine BUPHENYL TAB NPS PS BUTRANS PB PB Expect Gen BYDUREON PB NPB/G metformin, VICTOZA, TRULICITY calcipotrien cre 0.005% PG NPB/G acitretin calcipotrien oin 0.005% PG NPB/G acitretin calcipotrien oin betameth (generic taclonex oin) PG NPB/G fluocinolone acetonide calcipotrien sol 0.005% PG NPB/G acitretin calcitrene PG NPB/G acitretin calcitriol PG NPB/G acitretin Remove ST capecitabine PS PS Add NPL CARBAGLU NPS NPS Add SPB carb-o-philc PG NC carisopr/asa PG NPB/G carisoprodol carisoprodol PG NPB/G carisoprodol CATAPRES-TTS NPB/G NPB/G Remove QL CAYSTON NPS NPS Remove PA cefaclor er PG PG Remove QL CELLCEPT CAP NPS NPS Add SPB CELLCEPT SUS PS NPS mycophenolate Add SPB CELLCEPT TAB NPS NPS Add SPB cerovel PG NC chlord/clidi PG NC dicyclomine, hyoscyamine, propantheline chlorhex glu PG NC chor gonadot NPS PS
CILOXAN PB NPB/G ciprofloxacn CINRYZE NPS PS CIPRO HC NPB/G NPB/G Expect Gen CIPRO XR NPB/G NPB/G Remove QL ciprofloxacn sol 0.2% PG NPB/G ofloxacin ciprofloxacn tab 1000mg PG PG Remove QL ciprofloxacn tab 500mg er PG PG Remove QL claravis PG PG doxycycline, minocycline Add PA, clarithromyc PG PG Remove QL CLEOCIN PB NPB/G metronidazol gel clindamy/ben gel 1-5% NC NC Remove QL clindamycin PG NPB/G generic CLEOCIN-T CLINDAP-T CRE NPB/G NC clinpro 5000 PG NC clobetasol PG NPB/G fluocinolone acetonide CLOBEX NPB/G PB clocortolone PG NPB/G fluocinolone acetonide clodan PG NPB/G fluocinolone acetonide clonidine PG PG Remove QL coal tar PG NC COARTEM NPB/G NPB/G Remove QL COMBIGAN NPB/G PB COMBIVENT PB PB Remove QL COMFORT PAC-MELOXICAM NPB/G NC COMPLERA NPB/G PB CORTANE-B DRO AQ OTIC NPB/G NC acetic acid otic, antipyrine-benzocaine, ofloxacin otic CORTANE-B DRO OTIC NPB/G NC acetic acid otic, antipyrine-benzocaine, ofloxacin otic cortic-nd PG NC CORTIFOAM PB NPB/G lidocaine hc COZAAR NPB/G NPB/G Add QL CUPRIMINE PB NPB/G DEPEN TITRA cycloserine PG NPB/G ethambutol, isoniazid, rifampin cyotic PG NC CYRAMZA Medical Medical Add PA, Add NPL CYSTADANE NPS PS Add PA CYSTAGON PS NPB/G CYTOGAM NPS PS D.H.E. 45 NPB/G NPB/G Remove QL DALIRESP NPB/G NPB/G SPIRIVA, SYMBICORT Add PA,
demeclocycl PG NPB/G doxycycline, minocycline dentagel PG NC DEPO-TESTOST NPB/G NPB/G Remove QL desloratadin PG NPB/G loratadine, cetirizine DESOXYN NPB/G NPB/G phentermine, phendimetrazine DETROL NPB/G NPB/G oxybutynin, trospium DETROL LA NPB/G NPB/G oxybutynin, trospium DEXILANT NPB/G NPB/G omeprazole, pantoprazole, esomeprazole DIFFERIN GEL 0.3% NPB/G NPB/G tretinoin cream/gel DIFFERIN LOT 0.1% NPB/G NPB/G tretinoin cream/gel dihydrocod/asa/caff PG NPB/G butalbital/aspirin/ caffeine dihydroergot inj 1mg/ml PG NPB/G Remove QL dihydroergot spr 4mg/ml PG NPB/G DIPENTOCAINE CRE 5-5-2% NPB/G NC DITROPAN XL NPB/G NPB/G oxybutynin, trospium donepezil tab 5mg PG PG Remove QL donepezil tab hcl 23mg PG NPB/G rivastigmine Remove QL DOVONEX NPB/G NPB/G acitretin doxycycline tab 20mg PG NPB/G doxycycline 50mg caps DURAGESIC NPB/G NPB/G Remove ST easygel NPB/G PG ELAPRASE NPS PS ELIDEL NPB/G NPB/G desoximetasone, fluticasone Remove QL ELIGARD NPS NPS Add PA ENABLEX NPB/G NPB/G oxybutynin, trospium, Expect Gen EPIDUO NPB/G NPB/G tretinoin cream/gel, Remove QL epinastine PG NPB/G ZADITOR EPIVIR PB NPB/G lamivudine eplerenone PG NPB/G spironolactone Remove QL EPOGEN PS NPS ARANESP, PROCRIT EPZICOM NPB/G NPB/G Expect Gen ERGOMAR PB NPB/G ERY-TAB TAB 500MG EC PB NPB/G erythromycin eszopiclone PG PG Remove ST etoposide PS PG EURAX PB NPB/G malathion, spinosad EVEKEO NPB/G NPB/G phentermine, phendimetrazine
EVZIO PB PB Add PA EXALGO TAB 12MG NPB/G NPB/G Add QL EXALGO TAB 16MG NPB/G NPB/G Remove ST EXALGO TAB 32MG NPB/G NPB/G Remove ST EXALGO TAB 8MG NPB/G NPB/G Remove ST EXELON CAP 1.5MG NPB/G NPB/G Remove QL EXELON CAP 3MG NPB/G NPB/G Remove QL EXELON CAP 4.5MG NPB/G NPB/G Remove QL EXELON CAP 6MG NPB/G NPB/G Remove QL EXELON DIS 13.3/24 NPB/G PB Remove QL EXELON DIS 4.6MG/24 NPB/G PB Remove QL EXELON DIS 9.5MG/24 NPB/G PB Remove QL exotic-hc PG NC acetic acid otic, antipyrine-benzocaine, ofloxacin otic EXTARDOL CRE NPB/G NC acetic acid otic, antipyrine-benzocaine, ofloxacin otic EYLEA NPS PS Add PA FABIOR NPB/G NPB/G tretinoin cream/gel FABRAZYME NPS PS FACTIVE NPB/G NPB/G Remove QL FASLODEX NPS NPS Add PA fenofibrate cap 130mg PG NPB/G generic TRICOR fenofibrate cap 150mg PG NPB/G generic TRICOR fenofibrate cap 43mg PG NPB/G generic TRICOR fenofibrate cap 50mg PG NPB/G generic TRICOR FENOGLIDE NPB/G NPB/G Expect Gen fentanyl patch PG PG Remove ST FINACEA NPB/G NPB/G Expect Gen FIRAZYR NPS PS FIRMAGON NPS NPS Add PA FIRST-OMEPRA PB NC omeprazole, pantoprazole, esomeprazole FIRST-PROGESTERONE VGS 25, 50, 100, 200, 400 NPB/G NC FIRST-TESTOS NC NC Remove Gender
flucaine PG NPB/G flucytosine PG NPB/G fluconazole fluocinonide PG PG clobetasol, betamethasone oint fluore-benox PG NPB/G fluorescein/ PG NPB/G fluoridex PG NC fluoridex dd PG NC fluor-i-stri PG NPB/G flurox PG NPB/G fluticasone PG NPB/G fluocinolone acetonide FUL-GLO PG NPB/G ful-glo PG NPB/G FUZEON NPS NPS Add PA, Expect Gen galantamine cap 16mg er PG PG Remove QL galantamine cap 24mg er PG PG Remove QL galantamine cap 8mg er PG PG Remove QL GAPEAUM CRE BUDIBAC NPB/G NC gatifloxacin PG NPB/G ciprofloxacn GELCLAIR NPB/G NC GELNIQUE GEL 10% NPB/G NPB/G oxybutynin, trospium, Remove QL GELNIQUE GEL 3% NPB/G NPB/G oxybutynin, trospium GENOTROPIN PS NPS OMNITROPE GILENYA NPS PS GLEEVEC PS PS Expect Gen GLUCAGON KIT+A289+A535 PB PB Remove QL GLUMETZA NPB/G NPB/G Expect Gen GOLYTELY PB NPB/G lactulose, SUPREP GONAL-F NPS PS GONAL-F RFF NPS PS GORDONS UREA NPB/G NC grafco silvr PG NPB/G GRANIX NPS NPS Add NPL green glo PG NC grx hicort PG NC GYNAZOLE-1 NPB/G NPB/G Remove QL HC PRAMOXINE CRE 2.5-1% PG NC HEMANGEOL NPB/G NPB/G propranolol Add PA hemorrhoidal sup PG NC hemril-30 PG NC
HEPAGAM B NPS PS HEPSERA PS NPS adefovir HEXALEN PS PB HIZENTRA PB NPS hyaluronate PG NC hydroco/apap PG NPB/G hydrocodone bitartrate/ acetaminophen tabs hydrocort ac PG NC hydrocort/pramoxin NPB/G NC hydromorphon tab 12mg er PG PG Add QL hydromorphon tab 16mg er PG PG Remove ST hydromorphon tab 32mg er PG PG Remove ST hydromorphon tab 8mg er PG PG Remove ST hygel PG NC hyophen PG NC hyoscyamine PG NC HYPERTET S/D NPS PS HYSINGLA ER NPB/G PB Expect Gen IBUDONE PG NPB/G hydrocodone bitartrate/ibuprofen ibudone 10-200MG PG NPB/G hydrocodone bitartrate/ibuprofen ILEVRO NPB/G NPB/G Remove QL imipram pam PG NPB/G amitriptyline, doxepin, nortriptylin IMOGAM RABIE NPS PS INCRELEX NPS PS INNOPRAX-5 CRE NPB/G NC INSPRA NPB/G NPB/G Remove QL INVOKAMET PB PB Remove ST INVOKANA PB PB Remove ST ISENTRESS NPB/G PB
isometh/apap PG NC CAFERGOT, dihydroergotamine nasal, naratriptan, rizatriptan, sumatriptan, zolmitriptan ivermectin NPB/G PG JALYN NPB/G PB Expect Gen JARDIANCE NPB/G NPB/G Add QL JENTADUETO NPB/G NPB/G metformin, JANUMET, KOMBIGLYZE JETREA NPS NPS Add PA KADIAN PB NPB/G hydromorphone hydrochloride Add QL KALETRA PB PB Expect Gen karigel PG NC KAZANO NPB/G NPB/G metformin, JANUMET, KOMBIGLYZE KERALYT NPB/G NC KRISTALOSE PB NPB/G lactulose, SUPREP KUVAN NPS PS lactic acid PG NPB/G LANOXIN TAB 0.125MG PB NPB/G digoxin LANOXIN TAB 0.25MG PB NPB/G digoxin omeprazole, LANSOPRAZOLE SUS 3MG/ML PB NC pantoprazole, esomeprazole LASTACAFT NPB/G NPB/G Remove QL latrix PG NC LAZANDA NPB/G NPB/G morphine, hydrocodone, oxycodone Add PA LEUKINE PS NPS Add NPL leuprolide PS PS Add PA LEVAQUIN NPB/G NPB/G Remove QL levocarnitin PG NC levocetirizi sol 2.5/5ml PG NPB/G loratadine, cetirizine levocetirizi tab 5mg PG NPB/G loratadine, cetirizine levofloxacin PG PG Remove QL LIBRAX NPB/G NC dicyclomine, hyoscyamine, propantheline
lidocaine sol 4% PG NC lidocaine pad 5% PG PG Remove PA lidocaine hcl 3% cre PB NC LIDORX NPB/G NC LIDOVEX NPB/G NC lissamine gr PG NC losartan pot PG PG Add QL LOTREL NPB/G NPB/G Remove QL LOTRONEX PB NPB/G hyoscyamine Add PA, LTA 360 KIT PG NC LUCENTIS NPS PS Add PA LUNESTA NPB/G NPB/G Remove ST LUPANETA NPS NPS Add PA LUPR DEP-PED NPS NPS Add PA LUPRON DEPOT NPS NPS Add PA, Expect Gen LYRICA NPB/G PB Remove QL MACRODANTIN PB NPB/G nitrofurantoin MACUGEN NPS NPS Add PA MALARONE NPB/G NPB/G Remove QL malathion NPB/G PG Remove QL maprotiline PG PG Add QL MATULANE PS PB mefloquine PG NPB/G atovaq/proguan, hydroxychloro Remove QL MENOPUR NPS PS meperidine/prometh PG NC MEPRON NPB/G NPB/G Remove QL metaxalone PG PG Remove QL metformin er (generic FORTAMET) PG NPB/G generic GLUCOPHAGE XR methadone PG PG Add QL methamphetam PG PG phentermine, phendimetrazine Add PA METROGEL NPB/G NPB/G Remove ST metronidazole gel PG NPB/G rosadan Remove ST miconazole 3 NPB/G NC migragesic PG NC
mirtazapine tab 15mg PG PG Add QL mirtazapine tab 15mg odt PG PG Add QL mirtazapine tab 30mg PG PG Add QL mirtazapine tab 30mg odt PG PG Add QL mirtazapine tab 45mg PG PG Add QL mirtazapine tab 45mg odt PG PG Add QL mirtazapine tab 7.5mg PG PG Add QL MIRVASO NPB/G NPB/G Remove QL morphine er (generic AVINZA) PG PG Remove ST morphine er (generic KADIAN) PG PG Add QL morphine sul tab er (generic MS CONTIN) PG PG Add QL MOXATAG NPB/G NPB/G Remove QL moxifloxacin PG PG Remove QL MS CONTIN NPB/G NPB/G Add QL MYALEPT NPS PS mycophenolate cap PS PS Add SPB mycophenolate sus PG PS Add SPB mycophenolate tab PS PS Add SPB mycophenolic NPS PS MYLERAN PS PB myorisan PG NPB/G claravis Add PA, MYOZYME NPS PS MYRBETRIQ PB PB oxybutynin, trospium NAGLAZYME NPS PS NAMENDA PB PB Expect Gen NAMENDA XR PB PB Remove QL NAMZARIC PB PB Remove QL NEORAL CAP PS NPS cyclosporine NESINA NPB/G NPB/G metformin, JANUVIA, ONGLYZA NEULASTA PS PS Add NPL NEUMEGA NPS NPS Add PA NEUPOGEN PS NPS Add NPL
neutragard PG NC NEUTRASAL NPB/G NC NEXIUM PB NPB/G nodolor PG NC omeprazole, pantoprazole, esomeprazole CAFERGOT, dihydroergotamine nasal, naratriptan, rizatriptan, sumatriptan, zolmitriptan NORDITROPIN PS NPS OMNITROPE NORPACE PB NPB/G disopyramide novarel NPS PS NOXAFIL NPB/G NPB/G Remove QL NPLATE NPS NPS Add PA NUCYNTA ER NPB/G NPB/G OXYCONTIN, HYSINGLA ER, BUTRANS, Expect Gen NUEDEXTA NPB/G PB nuquin hp NPB/G NC NYMALIZE NPB/G NPB/G Add QL ofloxacin PG PG Remove QL OMEPRAZOLE SUS NPB/G NC omeprazole, pantoprazole, esomeprazole OPANA NPB/G NPB/G Remove ST OPANA ER TAB 7.5, 10, 15, 20, 30, OXYCONTIN, HYSINGLA PB NPB/G 40MG ER, BUTRANS Add PA, OPANA ER TAB 5MG PB NPB/G OXYCONTIN, HYSINGLA Add PA,, ER, BUTRANS Add QL opium tinct PG NPB/G diphenoxylate hydrochloride/ atropine sulfate ORFADIN NPS PS Add PA OSENI NPB/G NPB/G metformin, JANUVIA, ONGLYZA OTICIN HC PG NC acetic acid otic, antipyrine-benzocaine, ofloxacin otic oto-end 10 PG NC acetic acid otic, antipyrine-benzocaine, ofloxacin otic otomax-hc PG NC OTREXUP NPS NPS methotrexate
oxycodone er PG NPB/G OXYCONTIN, HYSINGLA ER, BUTRANS Add PA, OXYCONTIN NPB/G PB Expect Gen oxymorphone PG PG Remove ST OZURDEX NPS PS Add PA PANCREAZE NPB/G NPB/G CREON, ZENPEP PANRETIN NPB/G PB paroex PG NC perindopril PG PG Remove QL periogard PG NC PERTZYE NPB/G NPB/G CREON, ZENPEP phenylbutyrate NPS PS phos-flur PG NC phosphasal PG NC PLEXION CLTH NPB/G NPB/G PRAMOSONE CRE 1% NPB/G NC pramoxine-hc NPB/G NC acetic acid otic, antipyrine-benzocaine, ofloxacin otic prednicarbat PG NPB/G fluocinolone acetonide pregnyl NPS PS PREVACID SOL TAB NPB/G NPB/G omeprazole, pantoprazole, esomeprazole PREZCOBIX NPB/G PB procainamide PG NC PROCTOCORT NPB/G NC PROCTOFOAM PB NPB/G lidocaine hc PROGESTERONE CRE 10% KIT PB NC PROLENSA NPB/G NPB/G Remove QL propanthelin PG NC PROSED/DS NPB/G NC PROTOPIC NPB/G NPB/G Remove QL pyrogall acd PG NC quinine sulf PG NPB/G atovaq/proguan, hydroxychloro omeprazole, rabeprazole PG NPB/G pantoprazole, esomeprazole RAPAFLO NPB/G PB Remove QL RAPAMUNE PS NPS tacrolimus
RASUVO NPS NPS methotrexate RAZADYNE ER NPB/G NPB/G Remove QL re 10 wash PG NPB/G rea lo 39 PG NC rea lo 40 PG NC REBETOL PS NPS ribavirin rectacort-hc PG NC REGENECARE NPB/G NC RELISTOR NPB/G NPB/G AMITIZA (ST required) Add PA, Add QL REMERON NPB/G NPB/G Add QL REMERON SLTB NPB/G NPB/G Add QL remeven PG NC repaglinide PG NPB/G nateglinide RESTASIS NPB/G PB Remove QL RETIN-A CRE 0.025% NPB/G NPB/G RETIN-A CRE 0.05% NPB/G NPB/G RETIN-A CRE 0.1% NPB/G NPB/G RETIN-A GEL 0.01% NPB/G NPB/G RETIN-A GEL 0.025% NPB/G NPB/G RETIN-A MICR NPB/G NPB/G RHOPHYLAC NPS PS RIDAURA PB NPB/G methotrexate rivastigmine PG PG Remove QL salacyn PG NPB/G podofilox salicylic PG NPB/G podofilox salicylic ac aer 6% PG NPB/G podofilox salicylic ac cre 6% PG NPB/G podofilox salicylic ac gel 6% PG NC salicylic ac liq 26% PG NPB/G podofilox salicylic ac liq 27.5% PG NPB/G podofilox salicylic ac lot 6% PG NPB/G podofilox salicylic ac sha 6% PG NPB/G podofilox salicylic ac sol 28.5% PG NPB/G podofilox SAMSCA NPS PS SANDIMMUNE PS NPS cyclosporine
SANDOSTATIN NPS NPS octreotide Add PA seb-prev PG NPB/G SENSIPAR PB NPS paricalcitol, doxercalciferol Remove ST sf gel PG NC sildenafil NPS PS silver nitra PG NPB/G sod sul/sulf cre 10-2% PG NPB/G sod sul/sulf cre 10-5% PG NPB/G sod sul/sulf cre 9.8-4.8% PG NPB/G sod sul/sulf gel 10-5% PG NC sod sul/sulf liq 10-2% PG NPB/G sod sul/sulf liq 9.8-4.8% PG NPB/G sod sul/sulf liq 9-4.5% PG NPB/G sod sul/sulf liq wash PG NPB/G sod sul/sulf lot 9.8-4.8% PG NPB/G sod sul/sulf pad 10-4% PG NPB/G sod sul/sulf sus 8-4% PG NPB/G sod sulfacet 10% PG NPB/G SOLIRIS NPS PS spinosad NPB/G PG Remove QL SPORANOX SOL 10MG/ML PB NPB/G itraconazole caps, fluconazole ss sol 10-2 PG NPB/G sss cre 10-5 PG NPB/G STRIBILD NPB/G NPB/G Add PA SUBSYS NPB/G NPB/G morphine, hydrocodone, oxycodone SUCRAID NPS NPS Add SPB sulfacleanse PG NPB/G
SUPPRELIN LA NPS PS Add PA SUPRAX NPB/G NPB/G Remove QL SUPREP BOWEL NPB/G PB SYMLIN NPB/G NPB/G Remove QL SYMLINPEN 60 NPB/G NPB/G Remove QL SYMLNPEN 120 NPB/G NPB/G Remove QL SYNAGIS NPS PS SYNAREL PB NPS Add PA TACLONEX NPB/G NPB/G acitretin tacrolimus PG NPB/G Remove QL TANZEUM NPB/G NPB/G metformin, VICTOZA, TRULICITY TARGRETIN PS PS Add SPB TAZORAC NPB/G NPB/G acitretin, TEKAMLO NPB/G NPB/G amlodipine and losartan, valsartan TEKTURNA NPB/G NPB/G losartan, valsartan TEKTURNA HCT TAB 150-12.5 NPB/G NPB/G hctz and losartan, valsartan TEKTURNA HCT TAB 150-25MG NPB/G NPB/G hctz and losartan, valsartan TEKTURNA HCT TAB 300-12.5 NPB/G NPB/G hctz and losartan, valsartan TEKTURNA HCT TAB 300-25MG NPB/G NPB/G hctz and losartan, valsartan TEMODAR PS NPS temozolomide Add NPL temozolomide PS PS Add NPL TESTIM PB NPB/G ANDROGEL (PA required) testost cyp PG PG Remove QL testost enan PG PG Remove QL testosterone gel PG NPB/G ANDROGEL (PA required) TEV-TROPIN PS NPS OMNITROPE THALOMID PS NPS THEO-24 PB PB Remove QL THYROGEN NPS PS TIKOSYN PB NPB/G amiodarone TINDAMAX NPB/G NPB/G Remove QL tinidazole PG NPB/G atovaquone Remove QL TIVICAY NPB/G PB TOBI PS NPS tobramycin, TOBI PODHALER Remove PA TOBI PODHALR NPS PS Remove PA tobramycin neb PS PS Remove PA
TOVIAZ NPB/G NPB/G oxybutynin, trospium TRACLEER PS PS Expect Gen TRADJENTA NPB/G NPB/G metformin, JANUVIA, ONGLYZA trando/verap NPB/G PG tranex acid PG NPB/G TRELSTAR NPS NPS Add PA, Expect Gen TRELSTAR MIX NPS NPS Add PA tretinoin cre 0.025% PG PG tretinoin cre 0.05% PG PG tretinoin cre 0.1% PG PG tretinoin gel 0.01% PG PG tretinoin gel 0.025% PG PG tretinoin gel 0.04% PG PG tretinoin gel 0.04%pmp PG PG tretinoin gel 0.1% PG PG tretinoin gel 0.1%pump PG PG TRETIN-X NPB/G NPB/G TRETIN-X KIT NC NC triamcinolon PG NC TRISEON CRE NPB/G NC TRIUMEQ NPB/G PB TRIZIVIR PB NPB/G abacavir/lamivudine TRULICITY NPB/G PB Remove PA TRUVADA PB PB Add PA TUDORZA PRES NPB/G NPB/G SPIRIVA, INCRUSE Remove PA turpentine PG NC UCERIS NPB/G NPB/G hydrocortisone enema Add PA, Remove ST u-kera e PG NC ULTRESA NPB/G NPB/G CREON, ZENPEP UMECTA NPB/G NC UMECTA NAIL NPB/G NC UMECTA PD NPB/G NC ur n-c PG NC
urea PG NC urea 40% PG NC urea hydrati PG NC urea nail PG NC urea topical PG NC urea-c40 PG NC urelle PG NC uretron d/s PG NC uribel PG NC URIMAR-T NPB/G NC urin d/s PG NC uro-blue PG NC uro-l PG NC uro-mp PG NC UROQID #2 PB NC ursodiol PG NPB/G ursodiol 300mg or 250 mg uryl PG NC ustell PG NC uticap PG NC utira-c PG NC utrona-c PG NC valacyclovir PG PG Remove QL VALCYTE TAB PS NPS valganciclovir VALCYTE SOL PB PS VALTREX NPB/G NPB/G Remove QL vancomycin PG NPB/G metronidazole Remove QL VANOS NPB/G NPB/G clobetasol, betamethasone oint VANTAS NPS NPS Add PA VECTICAL NPB/G NPB/G Remove ST VELTIN NPB/G NPB/G topical clindamycin and tretinoin VERSACLOZ NPB/G NPB/G clozapine VESICARE PB PB oxybutynin, trospium vicodin PG NPB/G hydrocodone bitartrate/ acetaminophen tabs vicodin es PG NPB/G hydrocodone bitartrate/ acetaminophen tabs vicodin hp PG NPB/G hydrocodone bitartrate/ acetaminophen tabs VICTOZA NPB/G PB Remove ST VIDEX EC PB NPB/G didanosine
VIMIZIM NPS PS VIOKACE NPB/G NPB/G CREON, ZENPEP VISUDYNE NPS NPS Add PA, Expect Gen VITEKTA NPB/G PB VOGELXO PB NPB/G ANDROGEL (PA required) VPRIV NPS PS WELCHOL PAK 3.75GM PB NPB/G colesevelam pak Expect Gen WELCHOL TAB 625MG NPB/G NPB/G Expect Gen XARTEMIS XR NPB/G NPB/G morphine, hydrocodone, oxycodone XELODA PS NPS capecitabine Add NPL XENAZINE PS PS Expect Gen XIAFLEX NPS PS XIFAXAN NPB/G NPB/G lactulose Add PA XOLAIR NPS PS x-viate NPB/G NC XYREM NPS NPS Add SPB ZEMPLAR CAP 1MCG PB NPS paricalcitol zenatane PG NPB/G claravis Add PA, zencia PG NPB/G ZIAGEN SOL NPB/G PB ZIANA NPB/G NPB/G topical clindamycin and tretinoin, Expect Gen ZITHROMAX NPB/G NPB/G Remove QL ZMAX NPB/G NPB/G Remove QL ZOLADEX NPS NPS Add PA zolpidem er PG PG Remove ST ZYMAXID NPB/G NPB/G Remove QL
This document is available in other languages: Please note that if your prescription drug benefits plan changes, the information in this letter may no longer apply. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Aetna Pharmacy Plan and Specialty Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a nonpreferred drug. Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining the Aetna Pharmacy Plan and Specialty Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Aetna Pharmacy Plan and Specialty Drug List will continue to have those medications covered at the same benefit level until their plan s renewal date. In Texas, precertification approval is known as preservice utilization review. It is not "verification" as defined by Texas law. In accordance with state law, fully insured commercial California HMO members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are to receive precertification or step-therapy reviews will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee's medical condition. In accordance with state law, fully insured commercial Connecticut PPO members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are to receive precertification or step-therapy reviews will continue to have those medications covered for as long as the treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. The drugs on the Aetna Pharmacy Plan and Specialty Drug List including formulary exclusions, precertification, quantity limit and step-therapy reviews are subject to change. The quantity limits and step-therapy drug coverage review programs are not available in all service areas. For example, step-therapy programs do not apply to fully insured members in Indiana. Step therapy does not apply to fully insured members in New Jersey. However, these programs are available to self-funded plans. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. For more information about Aetna plans, refer to www.aetna.com. 2015 Aetna Inc.