Changes to your pharmacy plan - Aetna › email_images › member › eCommunications... · 2015-09-24 · 05.32.657.1 (8/15) September, 2015 . Changes to your pharmacy plan . The

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©2015 Aetna Inc. 01/01/2016_FC_Subscriber Notice 05.32.657.1 (8/15)

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

Aetna Value Plus January 1, 2016 Updates

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 step-therapy 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 Not-Covered

These drugs are not covered under your pharmacy benefit plan. You can still get these drugs but will need to pay the full cost of the drug.

NPB/G Non-preferred brand-name or generic drug

These drugs aren’t preferred. You may pay higher out-of-pocket costs when using a non-preferred brand-name or generic drug.

NPS Non-preferred specialty drug

These drugs aren’t preferred. You may pay higher out-of-pocket costs when using a non-preferred drug on the Aetna Specialty Drug List.

NPL National Precertification List

Prior authorization (PA) is required for all plans. Your doctor must contact us to request approval for coverage.

PA Prior authorization or precertification

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.

PB Preferred brand-name drug

These are brand-name drugs that are covered at your 2nd Tier copay. You may pay lower out-of-pocket costs when you use preferred drugs, but this may not always be the case.

PS Preferred specialty drugs

You may pay lower out-of-pocket costs when you use preferred drugs on the Aetna Specialty Drug List.

PG Preferred generic

These are generic drugs that are covered at your 1st tier copay. You may pay lower out-of-pocket costs when you use preferred drugs, but this may not always be the case.

QL Quantity limits

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.

SPB Specialty pharmacy 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.

ST Step therapy

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.

Aetna Value PlusJanuary 1, 2016 Updates

05.03.452.1

Drug NameCurrent

TierTier as of

1/1/16Formulary Alternative(s) Notes

ABSORICA NC NC doxycycline, minocycline Add PA, Add ST

ABSTRAL NPB/G NPB/G Add QLACEON NPB/G NPB/G Remove QL

ACIPHEX NPB/G NPB/Gomeprazole, pantoprazole, esomeprazole

Add ST

ACIPHEX SPR NPB/G NPB/Gomeprazole, pantoprazole, esomeprazole

Add ST

ACTICLATE NC NC Add QLACTIMMUNE PS NPS

ACTOPLUS MET PB NPB/G pioglitazone/metformin

acyclovir oint PG NPB/G ABREVA

adapalene cre 0.1% PG NPB/G tretinoinadapalene gel 0.1% PG NPB/G tretinoinadapalene gel 0.3% PG NPB/G tretinoin

ADCIRCA PS NPSsildenafil , LETAIRIS, OPSUMIT, TRACLEER

ADVAIR DISKU NPB/G NPB/GRemove PA, Remove ST, Expect Gen

ADVAIR HFA NPB/G NPB/GRemove PA, Remove ST, Expect Gen

aero otic hc PG NCALDURAZYME NPS PSALINIA NPB/G NPB/G Remove QLALKERAN TAB PS PBALODOX NPB/G NC doxycycline 50mg capsaltafluor PG NPB/Galuminum cl PG NCAMBIEN CR NPB/G NPB/G Remove STamcinonide PG NPB/G fluocinolone acetonideamlod/benazp PG PG Remove QLamnesteem PG NPB/G claravis Add PA, Add STamox-pot cla PG PG Remove QL

AMTURNIDE150 NPB/G NPB/Gamlodipine, hctz, losartan, valsartan

Remove PA, Add ST

AMTURNIDE300 NPB/G NPB/Gamlodipine, hctz, losartan, valsartan

Remove PA, Add ST


05.03.452.1

Drug NameCurrent

TierTier as of


ANACAINE NPB/G NC

ANALPRAM E NPB/G NCCORTIFOAM, PROCTOZONE-HC

ANALPRAM-HC CRE 1-2.5% NPB/G NCCORTIFOAM, PROCTOZONE-HC

ANALPRAM-HC LOT 2.5% PB NPB/G lidocaine hcANDROID PB PB Remove QL

anucort-hc PG NCCORTIFOAM, PROCTOZONE-HC

ANUSOL-HC NPB/G NCCORTIFOAM, PROCTOZONE-HC

ARICEPT NPB/G NPB/G Remove QLarnica PG NCatovaq/progu PG PG Remove QLatovaquone PG PG Remove QL

ATRALIN NPB/G NPB/GRemove QL, Add Age Limit

ATRIPLA NPB/G PBATROVENT HFA PB NPB/G ipratropium Remove QLAVAR NPB/G NCAVAR LS NPB/G NC

avar-e emoll PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

avar-e green PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

AVELOX NPB/G NPB/G Remove QLAVELOX ABC NPB/G NPB/G Remove QL

AVINZA NPB/G NPB/GRemove PA, Remove ST

avita PG PG Add Age Limit

AVODART NPB/G PBRemove ST, Expect Gen

azelastine PG NPB/G ZADITOR

AZELEX PB NPB/Gtretinoin, metronidazole 0.75%

azithromycin PG PG Remove QLAZOR NPB/G NPB/G Expect GenBELSOMRA NPB/G NPB/G Add Age LimitBENICAR NPB/G NPB/G Expect GenBENICAR HCT NPB/G NPB/G Expect GenBENZACLIN NC NC Remove QL

BENZAMYCIN PB NPB/Gerythromycin/benzoyl peroxide

BEPREVE NPB/G NPB/G Remove QL


05.03.452.1

Drug NameCurrent

TierTier as of


betameth val PG NPB/G fluocinolone acetonide

BETHKIS PS NPStobramycin , TOBI PODHALER

Remove PA

BETIMOL PB NPB/G timolol, betaxololbexarotene PS PS Add SPBBIAXIN NPB/G NPB/G Remove QLBIAXIN XL NPB/G NPB/G Remove QLBIEST/PROGES CRE NPB/G NCbio glo PG NPB/GBLEPH-10 PB NPB/G sulfacetamide sodiumBOTOX NPS PSBRAVELLE NPS PSBREO ELLIPTA NPB/G NPB/G Remove PAbrimonidine 0.15% PG NPB/G brimonidine 0.2%BRISDELLE NC NPB/G paroxetine Add PAbromfenac PG NPB/G ketorolac tromethamine BUPHENYL TAB NPS PSBUTRANS PB PB Expect Gen

BYDUREON PB NPB/Gmetformin , VICTOZA, TRULICITY

calcipotrien cre 0.005% PG NPB/G acitretin Add STcalcipotrien oin 0.005% PG NPB/G acitretin Add STcalcipotrien oin betameth (generic taclonex oin)

PG NPB/G fluocinolone acetonide Add ST

calcipotrien sol 0.005% PG NPB/G acitretincalcitrene PG NPB/G acitretin Add STcalcitriol PG NPB/G acitretin Remove STcapecitabine PS PS Add NPLCARBAGLU NPS NPS Add SPBcarb-o-philc PG NCcarisopr/asa PG NPB/G carisoprodolcarisoprodol PG NPB/G carisoprodolCATAPRES-TTS NPB/G NPB/G Remove QLCAYSTON NPS NPS Remove PAcefaclor er PG PG Remove QLCELLCEPT CAP NPS NPS Add SPBCELLCEPT SUS PS NPS mycophenolate Add SPBCELLCEPT TAB NPS NPS Add SPBcerovel PG NC

chlord/clidi PG NCdicyclomine, hyoscyamine, propantheline

chlorhex glu PG NCchor gonadot NPS PS


05.03.452.1

Drug NameCurrent

TierTier as of


CILOXAN PB NPB/G ciprofloxacnCINRYZE NPS PSCIPRO HC NPB/G NPB/G Expect GenCIPRO XR NPB/G NPB/G Remove QLciprofloxacn sol 0.2% PG NPB/G ofloxacinciprofloxacn tab 1000mg PG PG Remove QLciprofloxacn tab 500mg er PG PG Remove QLclaravis PG PG doxycycline, minocycline Add PA, Add STclarithromyc PG PG Remove QLCLEOCIN PB NPB/G metronidazol gelclindamy/ben gel 1-5% NC NC Remove QLclindamycin PG NPB/G generic CLEOCIN-TCLINDAP-T CRE NPB/G NCclinpro 5000 PG NCclobetasol PG NPB/G fluocinolone acetonideCLOBEX NPB/G PBclocortolone PG NPB/G fluocinolone acetonideclodan PG NPB/G fluocinolone acetonideclonidine PG PG Remove QLcoal tar PG NCCOARTEM NPB/G NPB/G Remove QLCOMBIGAN NPB/G PBCOMBIVENT PB PB Remove QLCOMFORT PAC-MELOXICAM NPB/G NCCOMPLERA NPB/G PB

CORTANE-B DRO AQ OTIC NPB/G NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic

CORTANE-B DRO OTIC NPB/G NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic

cortic-nd PG NCCORTIFOAM PB NPB/G lidocaine hcCOZAAR NPB/G NPB/G Add QLCUPRIMINE PB NPB/G DEPEN TITRA

cycloserine PG NPB/Gethambutol, isoniazid, rifampin

cyotic PG NCCYRAMZA Medical Medical Add PA, Add NPLCYSTADANE NPS PS Add PACYSTAGON PS NPB/GCYTOGAM NPS PSD.H.E. 45 NPB/G NPB/G Remove QLDALIRESP NPB/G NPB/G SPIRIVA, SYMBICORT Add PA, Add ST


05.03.452.1

Drug NameCurrent

TierTier as of


demeclocycl PG NPB/G doxycycline, minocyclinedentagel PG NCDEPO-TESTOST NPB/G NPB/G Remove QLdesloratadin PG NPB/G loratadine, cetirizine

DESOXYN NPB/G NPB/Gphentermine, phendimetrazine

Add ST

DETROL NPB/G NPB/G oxybutynin, trospium Add STDETROL LA NPB/G NPB/G oxybutynin, trospium Add ST

DEXILANT NPB/G NPB/Gomeprazole, pantoprazole, esomeprazole

Add ST

DIFFERIN GEL 0.3% NPB/G NPB/G tretinoin cream/gel Add STDIFFERIN LOT 0.1% NPB/G NPB/G tretinoin cream/gel Add ST

dihydrocod/asa/caff PG NPB/Gbutalbital/aspirin/caffeine

dihydroergot inj 1mg/ml PG NPB/G Remove QLdihydroergot spr 4mg/ml PG NPB/GDIPENTOCAINE CRE 5-5-2% NPB/G NCDITROPAN XL NPB/G NPB/G oxybutynin, trospium Add STdonepezil tab 5mg PG PG Remove QLdonepezil tab hcl 23mg PG NPB/G rivastigmine Remove QLDOVONEX NPB/G NPB/G acitretin Add STdoxycycline tab 20mg PG NPB/G doxycycline 50mg caps

DURAGESIC NPB/G NPB/GRemove PA, Remove ST

easygel NPB/G PGELAPRASE NPS PS

ELIDEL NPB/G NPB/Gdesoximetasone, fluticasone

Remove QL

ELIGARD NPS NPS Add PAENABLEX NPB/G NPB/G oxybutynin, trospium Add ST, Expect GenEPIDUO NPB/G NPB/G tretinoin cream/gel Add ST, Remove QLepinastine PG NPB/G ZADITOREPIVIR PB NPB/G lamivudineeplerenone PG NPB/G spironolactone Remove QLEPOGEN PS NPS ARANESP, PROCRITEPZICOM NPB/G NPB/G Expect GenERGOMAR PB NPB/GERY-TAB TAB 500MG EC PB NPB/G erythromycineszopiclone PG PG Remove STetoposide PS PGEURAX PB NPB/G malathion, spinosad

EVEKEO NPB/G NPB/Gphentermine, phendimetrazine

Add ST


05.03.452.1

Drug NameCurrent

TierTier as of


EVZIO PB PB Add PA

EXALGO TAB 12MG NPB/G NPB/GRemove PA, Remove ST, Add QL

EXALGO TAB 16MG NPB/G NPB/GRemove PA, Remove ST



EXELON CAP 1.5MG NPB/G NPB/G Remove QLEXELON CAP 3MG NPB/G NPB/G Remove QLEXELON CAP 4.5MG NPB/G NPB/G Remove QLEXELON CAP 6MG NPB/G NPB/G Remove QLEXELON DIS 13.3/24 NPB/G PB Remove QLEXELON DIS 4.6MG/24 NPB/G PB Remove QLEXELON DIS 9.5MG/24 NPB/G PB Remove QL

exotic-hc PG NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic

EXTARDOL CRE NPB/G NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic

EYLEA NPS PS Add PAFABIOR NPB/G NPB/G tretinoin cream/gel Add STFABRAZYME NPS PSFACTIVE NPB/G NPB/G Remove QLFASLODEX NPS NPS Add PAfenofibrate cap 130mg PG NPB/G generic TRICORfenofibrate cap 150mg PG NPB/G generic TRICORfenofibrate cap 43mg PG NPB/G generic TRICORfenofibrate cap 50mg PG NPB/G generic TRICORFENOGLIDE NPB/G NPB/G Expect Gen

fentanyl patch PG PGRemove PA, Remove ST

FINACEA NPB/G NPB/G Expect GenFIRAZYR NPS PSFIRMAGON NPS NPS Add PA

FIRST-OMEPRA PB NComeprazole, pantoprazole, esomeprazole

FIRST-PROGESTERONE VGS 25, 50, 100, 200, 400

NPB/G NC

FIRST-TESTOS NC NC Remove Gender


05.03.452.1

Drug NameCurrent

TierTier as of


flucaine PG NPB/Gflucytosine PG NPB/G fluconazole

fluocinonide PG PGclobetasol, betamethasone oint

Add ST

fluore-benox PG NPB/Gfluorescein/ PG NPB/Gfluoridex PG NCfluoridex dd PG NCfluor-i-stri PG NPB/Gflurox PG NPB/Gfluticasone PG NPB/G fluocinolone acetonideFUL-GLO PG NPB/Gful-glo PG NPB/GFUZEON NPS NPS Add PA, Expect Gengalantamine cap 16mg er PG PG Remove QLgalantamine cap 24mg er PG PG Remove QLgalantamine cap 8mg er PG PG Remove QLGAPEAUM CRE BUDIBAC NPB/G NCgatifloxacin PG NPB/G ciprofloxacnGELCLAIR NPB/G NCGELNIQUE GEL 10% NPB/G NPB/G oxybutynin, trospium Add ST, Remove QLGELNIQUE GEL 3% NPB/G NPB/G oxybutynin, trospium Add STGENOTROPIN PS NPS OMNITROPEGILENYA NPS PSGLEEVEC PS PS Expect GenGLUCAGON KIT+A289+A535 PB PB Remove QLGLUMETZA NPB/G NPB/G Expect GenGOLYTELY PB NPB/G lactulose , SUPREPGONAL-F NPS PSGONAL-F RFF NPS PSGORDONS UREA NPB/G NCgrafco silvr PG NPB/GGRANIX NPS NPS Add NPLgreen glo PG NC

grx hicort PG NCCORTIFOAM, PROCTOZONE-HC

GYNAZOLE-1 NPB/G NPB/G Remove QL

HC PRAMOXINE CRE 2.5-1% PG NCCORTIFOAM, PROCTOZONE-HC

HEMANGEOL NPB/G NPB/G propranolol Add PA

hemorrhoidal sup PG NCCORTIFOAM, PROCTOZONE-HC

hemril-30 PG NCCORTIFOAM, PROCTOZONE-HC


05.03.452.1

Drug NameCurrent

TierTier as of


HEPAGAM B NPS PSHEPSERA PS NPS adefovir

HEXALEN PS PB

HIZENTRA PB NPShyaluronate PG NC

hydroco/apap PG NPB/Ghydrocodone bitartrate/acetaminophen tabs

hydrocort ac PG NCCORTIFOAM, PROCTOZONE-HC

hydrocort/pramoxin NPB/G NCCORTIFOAM, PROCTOZONE-HC

hydromorphon tab 12mg er PG PGRemove PA, Remove ST, Add QL

hydromorphon tab 16mg er PG PGRemove PA,Remove ST

hydromorphon tab 32mg er PG PGRemove PA, Remove ST

hydromorphon tab 8mg er PG PGRemove PA, Remove ST

hygel PG NChyophen PG NChyoscyamine PG NCHYPERTET S/D NPS PS

HYSINGLA ER NPB/G PBRemove PA, Remove ST, Expect Gen

IBUDONE PG NPB/Ghydrocodone bitartrate/ibuprofen

ibudone 10-200MG PG NPB/Ghydrocodone bitartrate/ibuprofen

ILEVRO NPB/G NPB/G Remove QL

imipram pam PG NPB/Gamitriptyline, doxepin, nortriptylin

IMOGAM RABIE NPS PSINCRELEX NPS PSINNOPRAX-5 CRE NPB/G NCINSPRA NPB/G NPB/G Remove QLINVOKAMET PB PB Remove STINVOKANA PB PB Remove STISENTRESS NPB/G PB


05.03.452.1

Drug NameCurrent

TierTier as of


isometh/apap PG NC

CAFERGOT, dihydroergotamine nasal, naratriptan, rizatriptan, sumatriptan, zolmitriptan

ivermectin NPB/G PG

JALYN NPB/G PBRemove ST, Remove QL, Expect Gen

JARDIANCE NPB/G NPB/G Add QL

JENTADUETO NPB/G NPB/Gmetformin , JANUMET, KOMBIGLYZE

Add ST

JETREA NPS NPS Add PA

KADIAN PB NPB/Ghydromorphone hydrochloride

Remove PA, Remove ST, Add QL

KALETRA PB PB Expect Genkarigel PG NC

KAZANO NPB/G NPB/Gmetformin , JANUMET, KOMBIGLYZE

Add ST

KERALYT NPB/G NCKRISTALOSE PB NPB/G lactulose , SUPREPKUVAN NPS PSlactic acid PG NPB/GLANOXIN TAB 0.125MG PB NPB/G digoxinLANOXIN TAB 0.25MG PB NPB/G digoxin

LANSOPRAZOLE SUS 3MG/ML PB NComeprazole, pantoprazole, esomeprazole

LASTACAFT NPB/G NPB/G Remove QLlatrix PG NC

LAZANDA NPB/G NPB/Gmorphine, hydrocodone, oxycodone

Add PA

LEUKINE PS NPS Add NPLleuprolide PS PS Add PALEVAQUIN NPB/G NPB/G Remove QLlevocarnitin PG NC

levocetirizi sol 2.5/5ml PG NPB/G loratadine, cetirizine

levocetirizi tab 5mg PG NPB/G loratadine, cetirizinelevofloxacin PG PG Remove QL

LIBRAX NPB/G NCdicyclomine, hyoscyamine, propantheline


05.03.452.1

Drug NameCurrent

TierTier as of


lidocaine sol 4% PG NClidocaine pad 5% PG PG Remove PAlidocaine hcl 3% cre PB NCLIDORX NPB/G NCLIDOVEX NPB/G NClissamine gr PG NClosartan pot PG PG Add QLLOTREL NPB/G NPB/G Remove QL

LOTRONEX PB NPB/G hyoscyamine Add PA, Add ST

LTA 360 KIT PG NC

LUCENTIS NPS PS Add PA

LUNESTA NPB/G NPB/G Remove STLUPANETA NPS NPS Add PALUPR DEP-PED NPS NPS Add PALUPRON DEPOT NPS NPS Add PA, Expect Gen

LYRICA NPB/G PBRemove PA, Remove QL

MACRODANTIN PB NPB/G nitrofurantoin MACUGEN NPS NPS Add PAMALARONE NPB/G NPB/G Remove QLmalathion NPB/G PG Remove QLmaprotiline PG PG Add QLMATULANE PS PB

mefloquine PG NPB/Gatovaq/proguan, hydroxychloro

Remove QL

MENOPUR NPS PSmeperidine/prometh PG NCMEPRON NPB/G NPB/G Remove QLmetaxalone PG PG Remove QLmetformin er (generic FORTAMET) PG NPB/G generic GLUCOPHAGE XRmethadone PG PG Add QL

methamphetam PG PGphentermine, phendimetrazine

Add PA

METROGEL NPB/G NPB/G Remove ST

metronidazole gel PG NPB/G rosadan Remove ST

miconazole 3 NPB/G NCmigragesic PG NC


05.03.452.1

Drug NameCurrent

TierTier as of


mirtazapine tab 15mg PG PG Add QL

mirtazapine tab 15mg odt PG PG Add QL

mirtazapine tab 30mg PG PG Add QLmirtazapine tab 30mg odt PG PG Add QLmirtazapine 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/GRemove ST, Remove QL

morphine er (generic AVINZA) PG PGRemove PA, Remove ST

morphine er (generic KADIAN) PG PGRemove PA, Remove ST, Add QL

morphine sul tab er (generic MS CONTIN)

PG PG Add QL

MOXATAG NPB/G NPB/G Remove QLmoxifloxacin PG PG Remove QLMS CONTIN NPB/G NPB/G Add QLMYALEPT NPS PSmycophenolate cap PS PS Add SPBmycophenolate sus PG PS Add SPBmycophenolate tab PS PS Add SPBmycophenolic NPS PSMYLERAN PS PBmyorisan PG NPB/G claravis Add PA, Add STMYOZYME NPS PSMYRBETRIQ PB PB oxybutynin, trospium Add STNAGLAZYME NPS PS

NAMENDA PB PBRemove QL, Expect Gen

NAMENDA XR PB PB Remove QLNAMZARIC PB PB Remove QLNEORAL CAP PS NPS cyclosporine

NESINA NPB/G NPB/Gmetformin , JANUVIA, ONGLYZA

Add ST

NEULASTA PS PS Add NPLNEUMEGA NPS NPS Add PANEUPOGEN PS NPS Add NPL


05.03.452.1

Drug NameCurrent

TierTier as of


neutragard PG NCNEUTRASAL NPB/G NC

NEXIUM PB NPB/Gomeprazole, pantoprazole, esomeprazole

nodolor PG NC

CAFERGOT, dihydroergotamine nasal, naratriptan, rizatriptan, sumatriptan, zolmitriptan

NORDITROPIN PS NPS OMNITROPENORPACE PB NPB/G disopyramidenovarel NPS PSNOXAFIL NPB/G NPB/G Remove QLNPLATE NPS NPS Add PA

NUCYNTA ER NPB/G NPB/GOXYCONTIN, HYSINGLA ER, BUTRANS

Add ST, Expect Gen

NUEDEXTA NPB/G PBnuquin hp NPB/G NCNYMALIZE NPB/G NPB/G Remove PA, Add QLofloxacin PG PG Remove QL

OMEPRAZOLE SUS NPB/G NComeprazole, pantoprazole, esomeprazole

OPANA NPB/G NPB/G Remove STOPANA ER TAB 7.5, 10, 15, 20, 30, 40MG

PB NPB/GOXYCONTIN, HYSINGLA ER, BUTRANS

Add PA, Add ST

OPANA ER TAB 5MG PB NPB/GOXYCONTIN, HYSINGLA ER, BUTRANS

Add PA, Add ST, Add QL

opium tinct PG NPB/Gdiphenoxylate hydrochloride/atropine sulfate

ORFADIN NPS PS Add PA

OSENI NPB/G NPB/Gmetformin , JANUVIA, ONGLYZA

Add ST

OTICIN HC PG NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic

oto-end 10 PG NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic

otomax-hc PG NCOTREXUP NPS NPS methotrexate Add ST


05.03.452.1

Drug NameCurrent

TierTier as of


oxycodone er PG NPB/GOXYCONTIN, HYSINGLA ER, BUTRANS

Add PA, Add ST

OXYCONTIN NPB/G PBRemove ST, Expect Gen

oxymorphone PG PG Remove STOZURDEX NPS PS Add PAPANCREAZE NPB/G NPB/G CREON, ZENPEP Add STPANRETIN NPB/G PBparoex PG NCperindopril PG PG Remove QLperiogard PG NCPERTZYE NPB/G NPB/G CREON, ZENPEP Add STphenylbutyrate NPS PSphos-flur PG NCphosphasal PG NC

PLEXION CLTH NPB/G NPB/Gsodium sulfacetamide/sulfur 10%-5%

Add ST

PRAMOSONE CRE 1% NPB/G NC

pramoxine-hc NPB/G NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic

prednicarbat PG NPB/G fluocinolone acetonidepregnyl NPS PS

PREVACID SOL TAB NPB/G NPB/Gomeprazole, pantoprazole, esomeprazole

Add ST

PREZCOBIX NPB/G PBprocainamide PG NC

PROCTOCORT NPB/G NCCORTIFOAM, PROCTOZONE-HC

PROCTOFOAM PB NPB/G lidocaine hcPROGESTERONE CRE 10% KIT PB NCPROLENSA NPB/G NPB/G Remove QLpropanthelin PG NCPROSED/DS NPB/G NCPROTOPIC NPB/G NPB/G Remove QLpyrogall acd PG NC

quinine sulf PG NPB/Gatovaq/proguan, hydroxychloro

rabeprazole PG NPB/Gomeprazole, pantoprazole, esomeprazole

RAPAFLO NPB/G PB Remove QLRAPAMUNE PS NPS tacrolimus


05.03.452.1

Drug NameCurrent

TierTier as of


RASUVO NPS NPS methotrexate Add STRAZADYNE ER NPB/G NPB/G Remove QLre 10 wash PG NPB/Grea lo 39 PG NCrea lo 40 PG NCREBETOL PS NPS ribavirin

rectacort-hc PG NCCORTIFOAM, PROCTOZONE-HC

REGENECARE NPB/G NCRELISTOR NPB/G NPB/G AMITIZA (ST required) Add PA, Add QLREMERON NPB/G NPB/G Add QLREMERON SLTB NPB/G NPB/G Add QLremeven PG NCrepaglinide PG NPB/G nateglinideRESTASIS NPB/G PB Remove QL

RETIN-A CRE 0.025% NPB/G NPB/GRemove QL, Add Age Limit



RETIN-A GEL 0.01% NPB/G NPB/GRemove QL, Add Age Limit

RETIN-A GEL 0.025% NPB/G NPB/GRemove ST, Remove QL, Add Age Limit

RETIN-A MICR NPB/G NPB/GRemove ST, Remove QL, Add Age Limit

RHOPHYLAC NPS PSRIDAURA PB NPB/G methotrexaterivastigmine PG PG Remove QLsalacyn PG NPB/G podofiloxsalicylic PG NPB/G podofiloxsalicylic ac aer 6% PG NPB/G podofiloxsalicylic ac cre 6% PG NPB/G podofiloxsalicylic ac gel 6% PG NCsalicylic ac liq 26% PG NPB/G podofiloxsalicylic ac liq 27.5% PG NPB/G podofiloxsalicylic ac lot 6% PG NPB/G podofiloxsalicylic ac sha 6% PG NPB/G podofiloxsalicylic ac sol 28.5% PG NPB/G podofiloxSAMSCA NPS PSSANDIMMUNE PS NPS cyclosporine


05.03.452.1

Drug NameCurrent

TierTier as of


SANDOSTATIN NPS NPS octreotide Add PAseb-prev PG NPB/G

SENSIPAR PB NPSparicalcitol, doxercalciferol

Remove ST

sf gel PG NC

sildenafil NPS PSsilver nitra PG NPB/G

sod sul/sulf cre 10-2% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sul/sulf cre 10-5% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sul/sulf cre 9.8-4.8% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sul/sulf gel 10-5% PG NC

sod sul/sulf liq 10-2% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sul/sulf liq 9.8-4.8% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sul/sulf liq 9-4.5% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sul/sulf liq wash PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sul/sulf lot 9.8-4.8% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sul/sulf pad 10-4% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sul/sulf sus 8-4% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sod sulfacet 10% PG NPB/G

SOLIRIS NPS PSspinosad NPB/G PG Remove QL

SPORANOX SOL 10MG/ML PB NPB/Gitraconazole caps, fluconazole

ss sol 10-2 PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

sss cre 10-5 PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

STRIBILD NPB/G NPB/G Add PA

SUBSYS NPB/G NPB/Gmorphine, hydrocodone, oxycodone

Add ST

SUCRAID NPS NPS Add SPB

sulfacleanse PG NPB/Gsodium sulfacetamide/sulfur 10%-5%


05.03.452.1

Drug NameCurrent

TierTier as of


SUPPRELIN LA NPS PS Add PASUPRAX NPB/G NPB/G Remove QLSUPREP BOWEL NPB/G PBSYMLIN NPB/G NPB/G Remove QLSYMLINPEN 60 NPB/G NPB/G Remove QLSYMLNPEN 120 NPB/G NPB/G Remove QLSYNAGIS NPS PSSYNAREL PB NPS Add PATACLONEX NPB/G NPB/G acitretin Add STtacrolimus PG NPB/G Remove QL

TANZEUM NPB/G NPB/Gmetformin , VICTOZA, TRULICITY

Remove PA, Add ST

TARGRETIN PS PS Add SPBTAZORAC NPB/G NPB/G acitretin Add ST, Add Age Limit

TEKAMLO NPB/G NPB/Gamlodipine and losartan, valsartan

Remove PA, Add ST

TEKTURNA NPB/G NPB/G losartan, valsartan Remove PA, Add ST

TEKTURNA HCT TAB 150-12.5 NPB/G NPB/Ghctz and losartan, valsartan

Remove PA, Add ST

TEKTURNA HCT TAB 150-25MG NPB/G NPB/Ghctz and losartan, valsartan

Remove PA, Add ST

TEKTURNA HCT TAB 300-12.5 NPB/G NPB/Ghctz and losartan, valsartan

Remove PA, Add ST

TEKTURNA HCT TAB 300-25MG NPB/G NPB/Ghctz and losartan, valsartan

Remove PA, Add ST

TEMODAR PS NPS temozolomide Add NPLtemozolomide PS PS Add NPLTESTIM PB NPB/G ANDROGEL (PA required) Add STtestost cyp PG PG Remove QLtestost enan PG PG Remove QL

testosterone gel PG NPB/G ANDROGEL (PA required)

TEV-TROPIN PS NPS OMNITROPETHALOMID PS NPSTHEO-24 PB PB Remove QLTHYROGEN NPS PSTIKOSYN PB NPB/G amiodaroneTINDAMAX NPB/G NPB/G Remove QLtinidazole PG NPB/G atovaquone Remove QLTIVICAY NPB/G PB

TOBI PS NPStobramycin , TOBI PODHALER

Remove PA

TOBI PODHALR NPS PS Remove PA

tobramycin neb PS PS Remove PA


05.03.452.1

Drug NameCurrent

TierTier as of


TOVIAZ NPB/G NPB/G oxybutynin, trospium Add STTRACLEER PS PS Expect Gen

TRADJENTA NPB/G NPB/Gmetformin , JANUVIA, ONGLYZA

Add ST

trando/verap NPB/G PGtranex acid PG NPB/GTRELSTAR NPS NPS Add PA, Expect GenTRELSTAR MIX NPS NPS Add PAtretinoin cre 0.025% PG PG Add Age Limittretinoin cre 0.05% PG PG Add Age Limittretinoin cre 0.1% PG PG Add Age Limittretinoin gel 0.01% PG PG Add Age Limittretinoin gel 0.025% PG PG Add Age Limit

tretinoin gel 0.04% PG PGRemove ST, Remove QL, Add Age Limit

tretinoin gel 0.04%pmp PG PGRemove ST, Remove QL, Add Age Limit

tretinoin gel 0.1% PG PGRemove ST, Remove QL, Add Age Limit

tretinoin gel 0.1%pump PG PGRemove ST, Remove QL, Add Age Limit

TRETIN-X NPB/G NPB/GRemove QL, Add Age Limit

TRETIN-X KIT NC NC Add Age Limit

triamcinolon PG NCTRISEON CRE NPB/G NCTRIUMEQ NPB/G PBTRIZIVIR PB NPB/G abacavir/lamivudineTRULICITY NPB/G PB Remove PATRUVADA PB PB Add PATUDORZA PRES NPB/G NPB/G SPIRIVA, INCRUSE Remove PAturpentine PG NCUCERIS NPB/G NPB/G hydrocortisone enema Add PA, Remove STu-kera e PG NCULTRESA NPB/G NPB/G CREON, ZENPEP Add STUMECTA NPB/G NCUMECTA NAIL NPB/G NCUMECTA PD NPB/G NCur n-c PG NC


05.03.452.1

Drug NameCurrent

TierTier as of


urea PG NCurea 40% PG NCurea hydrati PG NCurea nail PG NCurea topical PG NCurea-c40 PG NCurelle PG NCuretron d/s PG NCuribel PG NCURIMAR-T NPB/G NCurin d/s PG NCuro-blue PG NCuro-l PG NCuro-mp PG NCUROQID #2 PB NC

ursodiol PG NPB/G ursodiol 300mg or 250 mg

uryl PG NCustell PG NCuticap PG NCutira-c PG NCutrona-c PG NCvalacyclovir PG PG Remove QLVALCYTE TAB PS NPS valganciclovirVALCYTE SOL PB PSVALTREX NPB/G NPB/G Remove QLvancomycin PG NPB/G metronidazole Remove QL

VANOS NPB/G NPB/Gclobetasol, betamethasone oint

Add ST

VANTAS NPS NPS Add PAVECTICAL NPB/G NPB/G Remove ST

VELTIN NPB/G NPB/Gtopical clindamycin and tretinoin

Add ST

VERSACLOZ NPB/G NPB/G clozapine Add STVESICARE PB PB oxybutynin, trospium Add ST

vicodin PG NPB/Ghydrocodone bitartrate/acetaminophen tabs

vicodin es PG NPB/Ghydrocodone bitartrate/acetaminophen tabs

vicodin hp PG NPB/Ghydrocodone bitartrate/acetaminophen tabs

VICTOZA NPB/G PBRemove PA, Remove ST

VIDEX EC PB NPB/G didanosine


05.03.452.1

Drug NameCurrent

TierTier as of


VIMIZIM NPS PSVIOKACE NPB/G NPB/G CREON, ZENPEP Add STVISUDYNE NPS NPS Add PA, Expect GenVITEKTA NPB/G PBVOGELXO PB NPB/G ANDROGEL (PA required)VPRIV NPS PSWELCHOL PAK 3.75GM PB NPB/G colesevelam pak Expect GenWELCHOL TAB 625MG NPB/G NPB/G Expect Gen

XARTEMIS XR NPB/G NPB/Gmorphine, hydrocodone, oxycodone

Add ST

XELODA PS NPS capecitabine Add NPLXENAZINE PS PS Expect GenXIAFLEX NPS PSXIFAXAN NPB/G NPB/G lactulose Add PAXOLAIR NPS PSx-viate NPB/G NCXYREM NPS NPS Add SPBZEMPLAR CAP 1MCG PB NPS paricalcitolzenatane PG NPB/G claravis Add PA, Add ST

zencia PG NPB/Gsodium sulfacetamide/sulfur 10%-5%

ZIAGEN SOL NPB/G PB

ZIANA NPB/G NPB/Gtopical clindamycin and tretinoin

Add ST, Expect Gen

ZITHROMAX NPB/G NPB/G Remove QLZMAX NPB/G NPB/G Remove QLZOLADEX NPS NPS Add PAzolpidem er PG PG Remove STZYMAXID NPB/G NPB/G Remove QL

©2015 Aetna Inc. 05.03.452.1

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 non-preferred 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.

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Changes to your pharmacy plan - Aetna › email_images › member › eCommunications... · 2015-09-24 · 05.32.657.1 (8/15) September, 2015 . Changes to your pharmacy plan . The