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Plan for your best health
2018 Aetna Pharmacy Drug Guide Aetna Value Small Group Plan: IA, NE
aetna.com 05.02.378.1 N (12/18)
How to use this guide
Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.
Your plan includes
• Brand and generic drugs that are hand-picked for their quality and effectiveness
• Aetna Specialty Pharmacy® fills specialty drug prescriptions (ones that are injected, infused or taken by mouth) — and provides services that include personal support, helpful resources and training, and free secure home delivery
• Aetna Rx Home Delivery® pharmacy that delivers maintenance drugs to your home or wherever you choose (for drugs that are taken regularly to treat conditions like arthritis, diabetes or asthma)
What you can expect to pay
With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the drug’s/medicine’s price.
Each drug is grouped as a generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non-preferred drug. Generic drugs are less expensive than brands.
Specialty prescription drugs typically include higher-cost drugs that require special handling, special storage or monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.
You’re covered for all types of medicine — some more expensive, and some less.
• Generic: the lowest cost
• Preferred brand: a slightly higher cost
• Non-preferred brand: a higher cost
• Preferred Specialty: lower cost for specialty drugs
• Non-preferred specialty: higher cost for non-preferred specialty drugs
Your pharmacy plan may not have all the coverage levels listed above so check your plan documents to see how much you will pay.
For your exact coverage and cost, and to learn more about your plan
Visit the website that’s on your member ID card. Then log in to your account, where you can:
• Find out the coverage and estimate of cost for specific drugs
• View your deductibles and plan limits
• Order medications
• Check your pharmacy order status
• Get a member ID card
• View your claims, Explanation of Benefits and more
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Pharmacy Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefits portion of your health plan and has no financial responsibility therefor. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment.
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Have more questions about your pharmacy benefits?
We’re here to help. There are several ways you can learn more about your benefits:
• Check your Plan Design and Benefits Summary in your enrollment kit.
• Call the toll-free number on your member ID card.
• Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on your member ID card to search for the “Pharmacy FAQ.”
Aetna Specialty Pharmacy
Aetna Specialty Pharmacy® medicine and support services is our in-house specialty pharmacy that can fill your prescriptions for specialty drugs. These are the types of drugs that may be injected, infused or taken by mouth. They often need special storage and handling. And they need to be delivered quickly. A nurse or pharmacist may monitor you during your treatment, if needed. With Aetna Specialty Pharmacy, you can get this medicine sent right to your mailbox.
How to get started with Aetna Specialty Pharmacy
Ordering your prescription through Aetna Specialty Pharmacy is easy. And we typically offer a 30-day medicine supply.
• To transfer your prescription, just call us toll-free at 1-866-353-1892.
• For a new prescription, your doctor can send it to us in one of four ways:
1. Electronically: Through e-prescribe
2. Fax: 1-866-FAX-ASRX (1-866-329-2779)
3. Mail: Aetna Specialty Pharmacy 503 Sunport Lane Orlando, FL 32809
4. Phone: 1-866-782-ASRX (1-866-782-2779), option 2
If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that’s on your member ID card, to search for the “Patient Profile Form.”
Aetna Rx Home Delivery
You can have maintenance drugs sent right to your home or anywhere else you choose with Aetna Rx Home Delivery® pharmacy. These are drugs that are taken regularly for chronic conditions like arthritis, diabetes or asthma. Depending on your plan, you can get up to a 90-day supply of medicine for less cost. It’s fast and convenient, and standard shipping is always free.
Get started right away
You can submit your order using one of these options:
1. Online — Visit your secure member website and sign in to your account. There you can add or remove your prescriptions.
2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. If you need the help of a telephone device for the deaf, call 1-877-833-2779.
3. Mail — Get a new prescription from your doctor. Then mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form.
Your doctor can submit your order using one of these options:
1. Online — They can submit your prescriptions using the e-prescribe services on our provider website.
2. Fax — They can fax your prescription to 1-877-270-3317. Make sure they include your member ID number, date of birth and mailing address on the fax cover sheet. Only a doctor may fax a prescription.
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Frequently asked questions
How can I save on prescriptions?
Here are some tips to pay less out of pocket for your prescription drugs:
• Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary).
• Ask your doctor to consider prescribing generic drugs instead of brand-name drugs.
• Check to see if your plan includes our home delivery pharmacy service. Depending upon your plan, our home delivery service may save you money. For more information, visit the website on your member ID card and log in to your account.
• Remind your doctor to check your plan to make sure you get maximum coverage.
What are generic drugs?
Generic drugs are proven to be just as safe and effective as brand-name drugs. They contain the same active ingredients in the same amounts as the brand-name drugs and work the same way. So they have the same risks and benefits as brand-name drugs. However, they typically cost less.
When appropriate, your doctor may decide to prescribe a generic drug or allow the pharmacist to substitute a generic drug.
What is precertification?
Precertification is one way that we can help you and your doctor find safe, appropriate drugs and keep costs down. Precertification means that you or your doctor need to get approval from the plan before certain drugs will be covered. Generally, precertification applies to drugs that:
• Are often taken in the wrong way
• Should only be used for certain conditions
• Often cost more than other drugs that are proven to be just as effective
Keep in mind that your doctor must contact us to request approval of coverage for these drugs.
What is step therapy?
Some drugs require step therapy. This means that you must try one or more prerequisite drug(s) before a step therapy drug is covered.
The prerequisite drugs are equally effective, have U.S. Food and Drug Administration (FDA) approval and may cost less. They treat the same condition as the step therapy drug.
If you don’t try the appropriate alternative drug first, you may need to pay full cost for the brand-name version.
What are quantity limits?
Quantity limits help your doctor and pharmacist make sure that you use your drug correctly and safely. We use medical guidelines and FDA-approved recommendations from drug makers to set these coverage limits. The quantity limit program includes:
• Dose efficiency edits — Limits prescription coverage to one dose per day for drugs that have approval for once-daily dosing
• Maximum daily dose — If a prescription is lower than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy
• Quantity limits over time — Limits prescription coverage to a specific number of units over a specific amount of time
What if I need a drug that requires an exception to the precertification, step therapy or quantity limits requirements? Or what if I need a drug that’s not covered under my plan?
In certain cases, you or your prescriber can request a medical exception to the precertification, step therapy or quantity limits requirements. And also for a drug that’s not covered in your plan. If you ask for your request to be expedited, a coverage determination will be made within 24 hours of receiving it.
We’ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design.
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How can your provider request a medical exception?
• Submit their request through our secure provider website on NaviNet®.
• Call the Aetna Pharmacy Precertification Unit at 1-855-240-0535.
• Fax the completed request form to 1-877-269-9916.
• Mail the completed request form to: Aetna Pharmacy Management 1300 East Campbell Road Richardson, TX 75081
How is the formulary (drug list) developed?
Our Pharmacy and Therapeutics Committee meets regularly to review new drugs and new information about current drugs. We review them for their safety, effectiveness and current use in therapy.
This committee includes licensed pharmacists and doctors. They are currently in practice or are Aetna employees.
Once we complete our clinical review, we also consider overall value before adding or removing a drug from the formulary. We may recommend moving a drug to a different coverage level. Or that it be placed on our Formulary Exclusions List and no longer be covered.
Can the formulary change during the year?
The formulary can change throughout the year. Some reasons why they can change include:
• New drugs are approved.
• Existing drugs are removed from the market.
• Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs are not generally covered in a formulary.
• Brand-name drugs lose patent protection and generic versions become available. When this happens, the brand-name drug is likely to be covered at a higher cost. And the generic versions cost less. See the “What are generic drugs?” section above for more information.
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Commercial 1557 Nondiscrimination Notice
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.
Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at:
U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).
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Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.
Please note that if your prescription drug benefits plan changes, the information here 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 Preferred 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. Louisiana members: depending on your specific plan and the prescription medication in question, you may in some instances be subject to an excess consumer cost burden for prescription drugs as defined by your state. 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 Aetna’s Pharmacy Drug (formulary) Guide. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. The drugs on the Pharmacy Drug (formulary) Guide, Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and drug coverage review programs are not available in all service areas. 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 Pharmacy Drug (formulary) Guide, Precertification, Quantity Limits or Step-Therapy Lists during the plan year 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 “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law, fully insured Commercial California health maintenance organization (HMO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists 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 preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists 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. 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. Information is subject to change.
aetna.com ©2018 Aetna Inc. 05.02.378.1 N (12/18)
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
Table of Contents
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................17*AGENTS FOR NARCOTIC WITHDRAWAL***.................................................................................19*AGENTS FOR OPIOID WITHDRAWAL***........................................................................................19*AMEBICIDES*........................................................................................................................................19*AMINO ACIDS***..................................................................................................................................19*AMINOGLYCOSIDES*..........................................................................................................................19*ANALGESICS - ANTI-INFLAMMATORY*........................................................................................ 20*ANALGESICS - NONNARCOTIC*.......................................................................................................22*ANALGESICS - OPIOID*.......................................................................................................................23*ANDROGENS-ANABOLIC*................................................................................................................. 27*ANORECTAL AGENTS*....................................................................................................................... 28*ANTHELMINTICS*............................................................................................................................... 29*ANTIANGINAL AGENTS*................................................................................................................... 29*ANTIANXIETY AGENTS*....................................................................................................................30*ANTIARRHYTHMICS*.........................................................................................................................30*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*.............................................................. 31*ANTICOAGULANTS*........................................................................................................................... 33*ANTICONVULSANTS*......................................................................................................................... 34*ANTIDEMENTIA AGENT COMBINATIONS***............................................................................... 37*ANTIDEPRESSANTS*........................................................................................................................... 37*ANTIDIABETICS*..................................................................................................................................39*ANTIDIARRHEAL/PROBIOTIC AGENTS*........................................................................................43*ANTIDIARRHEALS*.............................................................................................................................43*ANTIDOTES AND SPECIFIC ANTAGONISTS*.................................................................................44*ANTIDOTES*..........................................................................................................................................44*ANTIEMETICS*..................................................................................................................................... 44*ANTIFUNGALS*....................................................................................................................................45*ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***...........................................46*ANTIHISTAMINES*.............................................................................................................................. 46*ANTIHYPERLIPIDEMICS*.................................................................................................................. 47*ANTIHYPERTENSIVES*.......................................................................................................................49*ANTI-INFECTIVE AGENTS - MISC.*..................................................................................................52*ANTIMALARIALS*............................................................................................................................... 53*ANTIMYASTHENIC AGENTS*........................................................................................................... 54*ANTIMYASTHENIC/CHOLINERGIC AGENTS*.............................................................................. 54*ANTIMYCOBACTERIAL AGENTS*................................................................................................... 54*ANTINEOPLASTIC - BCL-2 INHIBITORS***.....................................................................................55*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................. 55*ANTIPARKINSON AGENTS*.............................................................................................................. 59*ANTIPSYCHOTICS/ANTIMANIC AGENTS*..................................................................................... 60*ANTIRETROVIRALS ADJUVANTS***...............................................................................................62*ANTISEPTICS & DISINFECTANTS*................................................................................................... 62*ANTIVIRALS*........................................................................................................................................ 62*ASSORTED CLASSES*.......................................................................................................................... 66*ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES***............................................................67*BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB***............................. 68*BETA BLOCKERS*................................................................................................................................ 68
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*BILE ACID SYNTHESIS DISORDER AGENTS***............................................................................ 69*BIOLOGICALS MISC*........................................................................................................................... 69*BULK CHEMICALS - NY***.................................................................................................................69*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***................................69*CALCIUM CHANNEL BLOCKERS*................................................................................................... 69*CARDIOTONICS*.................................................................................................................................. 71*CARDIOVASCULAR AGENTS - MISC.*.............................................................................................71*CEPHALOSPORINS*............................................................................................................................. 72*CHEMICALS*......................................................................................................................................... 73*CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS***.................................................73*CONTRACEPTIVES*............................................................................................................................. 73*CORTICOSTEROIDS*........................................................................................................................... 78*COUGH/COLD/ALLERGY*..................................................................................................................79*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***.............................................................. 80*CYSTIC FIBROSIS AGENT - COMBINATIONS***............................................................................80*DERMATOLOGICALS*........................................................................................................................ 81*DIAGNOSTIC PRODUCTS*................................................................................................................. 93*DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS*.................................................98*DIGESTIVE AIDS*............................................................................................................................... 102*DIRECT-ACTING P2Y12 INHIBITORS***........................................................................................102*DIURETICS*......................................................................................................................................... 102*ENDOCRINE AND METABOLIC AGENTS - MISC.*...................................................................... 103*ESTROGENS*....................................................................................................................................... 108*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***............................ 109*FARNESOID X RECEPTOR (FXR) AGONISTS***.......................................................................... 109*FLUOROQUINOLONES*.................................................................................................................... 109*GASTROINTESTINAL AGENTS - MISC.*........................................................................................ 110*GENITOURINARY AGENTS - MISCELLANEOUS*....................................................................... 111*GLYCOPEPTIDES***...........................................................................................................................112*GOUT AGENTS*.................................................................................................................................. 112*HEMATOLOGICAL AGENTS - MISC.*.............................................................................................113*HEMATOPOIETIC AGENTS*.............................................................................................................115*HEMOSTATICS*...................................................................................................................................118*HEPATITIS C AGENT - COMBINATIONS***.................................................................................. 118*HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS**.................................................119*HYPNOTICS*........................................................................................................................................119*HYPOPHOSPHATASIA (HPP) AGENTS***...................................................................................... 120*IBS AGENT - MU-OPIOID RECEPTOR AGONISTS***................................................................... 120*INSULIN-INCRETIN MIMETIC COMBINATIONS***................................................................... 120*INTEGRIN RECEPTOR ANTAGONISTS***.................................................................................... 120*INTERLEUKIN ANTAGONISTS***.................................................................................................. 120*INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)***.................................................................... 120*INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)***.................................................................... 120*ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS***.......................................................120*ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS***.......................................................120*LAXATIVES*........................................................................................................................................ 120*LEPTIN ANALOGUES***................................................................................................................... 122*LHRH/GNRH AGONIST ANALOG COMBINATIONS***.............................................................. 122*LOCAL ANESTHETICS-PARENTERAL*..........................................................................................122*LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG***............................122
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*LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS***.................................................. 122*MACROLIDES*.................................................................................................................................... 123*MEDICAL DEVICES*.......................................................................................................................... 123*MIGRAINE PRODUCTS*....................................................................................................................127*MINERALS & ELECTROLYTES*.......................................................................................................129*MONOBACTAMS***........................................................................................................................... 130*MOUTH/THROAT/DENTAL AGENTS*............................................................................................130*MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS***............................................................ 131*MULTIVITAMINS*..............................................................................................................................131*MUSCULOSKELETAL THERAPY AGENTS*.................................................................................. 133*NASAL AGENTS - SYSTEMIC AND TOPICAL*.............................................................................. 134*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***.............................135*NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS***.......................................135*NEUROMUSCULAR AGENTS*.........................................................................................................135*OPHTHALMIC AGENTS*................................................................................................................... 135*OPHTHALMIC RHO KINASE INHIBITORS***...............................................................................140*OREXIN RECEPTOR ANTAGONISTS***.........................................................................................140*OTIC AGENTS*.................................................................................................................................... 140*OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***............................................................. 141*OXYTOCICS*........................................................................................................................................141*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***............................................................. 141*PASSIVE IMMUNIZING AGENTS*...................................................................................................141*PCSK9 INHIBITORS***....................................................................................................................... 142*PENICILLINS*......................................................................................................................................142*PHARMACEUTICAL ADJUVANTS*.................................................................................................143*PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS***................................................... 143*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***.....................................................143*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***.........................................................................143*PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES***................................ 143*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS**......................................................143*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS***.....................................................144*POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS***................................144*POTASSIUM REMOVING AGENTS***.............................................................................................144*PROGESTINS*...................................................................................................................................... 144*PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS***.......................................... 144*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*..........................................144*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***....................................................148*PULMONARY FIBROSIS AGENTS***..............................................................................................148*PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST***........................148*RESPIRATORY AGENTS - MISC.*.................................................................................................... 148*SEROTONIN MODULATORS***.......................................................................................................148*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***......................................................148*SINUS NODE INHIBITORS**.............................................................................................................148*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***..................... 149*SPLEEN TYROSINE KINASE (SYK) INHIBITORS***.................................................................... 149*SULFONAMIDES*............................................................................................................................... 149*TETRACYCLINES*..............................................................................................................................149*THYROID AGENTS*........................................................................................................................... 150*TOPICAL ANESTHETIC GASES***...................................................................................................151*TOXOIDS*............................................................................................................................................. 151
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*TRYPTOPHAN HYDROXYLASE INHIBITORS***......................................................................... 151*ULCER DRUGS*.................................................................................................................................. 151*URINARY ANTI-INFECTIVES*.........................................................................................................154*URINARY ANTISPASMODICS*........................................................................................................ 154*VAGINAL PRODUCTS*...................................................................................................................... 155*VASOPRESSORS*.................................................................................................................................155*VITAMINS*........................................................................................................................................... 156
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2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
lowercase = Brand name drugslowercase italics = Generic drugs
Drug StatusCE = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations may apply.G = Preferred GenericLGC = Lowest Generic Copay AppliesM = Coverage where required by state lawNC = Not Covered NP = Non-Preferred BrandPB = Preferred BrandSP = Specialty
Drug Details# = Brand-name drug expected to become available generically in the near future. After the generic drug becomes available, the brand-name drug may be covered at a higher non-preferred copay and/or added to the Formulary Exclusion List. The brand-name drug may also be subject to precertification and/or step-therapy.AL = Age LimitLGC = Lowest Generic Copay AppliesMPG = PG tier applies to members residing in MassachusettsMST = Step Therapy does not apply to members residing in Massachusetts.N1 = Refer to member plan documents for Erectile Dysfuncition use/coverageN5 = Drug may be covered by some plansPA = Prior Authorization PPA = Prior Authorization does not apply to members residing in Pennsylvania. QL = Quantity LimitSelect OTC = Select OTC Program if your pharmacy plan includes this program you may have coverage for products noted with a doctors prescription. Please see your plan benefit information for specific coverage details.
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201816
SP = You may pay higher out of pocket costs and may be required to get these products at an Aetna Specialty Pharmacy network provider, such as Aetna Specialty Pharmacy. Specialty products are limited to a 30 day supply.ST = Step Therapy
Drug Name Drug Status Drug Details
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*
adderall NC N5
adderall xr NC N5
adzenys er NP PA; ST; QL
adzenys xr-odt NP PA; ST; QL
amphetamine sulfate G QL
amphetamine-dextroamphet er G QL
amphetamine-dextroamphetamine G QL
aptensio xr NP PA; ST; #; QL
armodafinil G PA; QL
atomoxetine hcl G QL
benzphetamine hcl oral tablet 50 mg MOnly covered in states: DC and excluded elsewhere; TIER 3
caffeine citrate oral solution 20 mg/ml G
clonidine hcl er G PA; QL
concerta NC N5
cotempla xr-odt NP PA; ST; QL
daytrana NP PA; ST; #; QL
desoxyn NC N5
dexedrine oral capsule extended release 24 hour
NC N5
dexmethylphenidate hcl G QL
dexmethylphenidate hcl er G QL
dextroamphetamine sulfate er G QL
dextroamphetamine sulfate oral solution G PA; QL
dextroamphetamine sulfate oral tablet G QL
diethylpropion hcl er MOnly covered in states: DC and excluded elsewhere; TIER 3
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201817
Drug Name Drug Status Drug Details
diethylpropion hcl oral MOnly covered in states: DC and excluded elsewhere; TIER 3
dyanavel xr NP PA; ST; QL
evekeo NP PA; ST; QL
focalin NC N5
focalin xr oral capsule extended release 24 hour 10 mg, 15 mg, 30 mg, 40 mg, 5 mg
NC N5
focalin xr oral capsule extended release 24 hour 20 mg, 25 mg, 35 mg
NP ST; QL
guanfacine hcl er G PA; QL
intuniv NC N5
kapvay oral tablet extended release 12 hour NC N5
metadate er oral tablet extended release 20 mg G QL
methamphetamine hcl G PA; QL
methylin oral solution NC N5
methylphenidate hcl er G QL
methylphenidate hcl er (cd) G QL
methylphenidate hcl er (la) G QL
methylphenidate hcl oral G QL
modafinil G PA; QL
mydayis NP PA; ST; QL
nuvigil NP PA; QL
phendimetrazine tartrate MOnly covered in states: DC and excluded elsewhere; TIER 3
phendimetrazine tartrate er MOnly covered in states: DC and excluded elsewhere; TIER 3
phentermine hcl oral MOnly covered in states: DC and excluded elsewhere; TIER 3
procentra NC N5
provigil NC N5
quillichew er NP PA; ST; QL
quillivant xr NP PA; ST; #; QL
regimex MOnly covered in states: DC and excluded elsewhere; TIER 3
relexxii G QL
ritalin NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201818
Drug Name Drug Status Drug Details
ritalin la oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg
NC N5
strattera NP ST; QL
vyvanse PB QL
xenical MOnly covered in states: DC and excluded elsewhere; TIER 3
zenzedi oral tablet 10 mg, 5 mg G QL
zenzedi oral tablet 15 mg, 2.5 mg, 20 mg, 30 mg, 7.5 mg
NC N5
*AGENTS FOR NARCOTIC WITHDRAWAL***
lucemyra NP QL
*AGENTS FOR OPIOID WITHDRAWAL***
lucemyra NP QL
*AMEBICIDES*
solosec NC
*AMINO ACIDS***
endari NP PA; ST; QL
*AMINOGLYCOSIDES*
amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml
G
arikayce SP PA; ST; SP
bethkis SP SP; QL
gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-%
G
gentamicin sulfate injection SP
kitabis pak NC N5
neomycin sulfate oral G
paromomycin sulfate oral G
streptomycin sulfate intramuscular SP
tobi NC N5; SP
tobi podhaler SP SP; QL
tobramycin inhalation SP SP; QL
tobramycin sulfate injection SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201819
Drug Name Drug Status Drug Details
*ANALGESICS - ANTI-INFLAMMATORY*
actemra intravenous SP PA; ST; SP
actemra subcutaneous SP PA; ST; SP; QL
anaprox ds NC N5
arava NC N5
arcalyst SP PA; SP
arthrotec oral tablet delayed release NC N5
celebrex NC N5
celecoxib oral G QL
daypro NC N5
diclofenac potassium G
diclofenac sodium er G
diclofenac sodium oral G
diclofenac-misoprostol oral tablet delayed release
G
duexis NC N5
ec-naprosyn NC N5
enbrel mini SP PA; ST; SP; QL
enbrel subcutaneous solution prefilled syringe SP PA; ST; SP; QL
enbrel subcutaneous solution reconstituted SP PA; ST; QL
enbrel sureclick subcutaneous solution auto-injector
SP PA; ST; SP; QL
etodolac er G
etodolac oral G
feldene NC N5
fenoprofen calcium oral G
flurbiprofen oral G
humira pediatric crohns start subcutaneous prefilled syringe kit 40 mg/0.8ml, 80 mg/0.8ml, 80 mg/0.8ml & 40mg/0.4ml
SP PA; ST; SP; QL
humira pen subcutaneous pen-injector kit SP PA; ST; SP; QL
humira pen-cd/uc/hs starter SP PA; ST; SP; QL
humira pen-ps/uv starter SP PA; ST; SP; QL
humira subcutaneous prefilled syringe kit SP PA; ST; SP; QL
ibuprofen comfort pac NC N5
ibuprofen oral tablet 400 mg, 600 mg, 800 mg G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201820
Drug Name Drug Status Drug Details
ic 400 NC N5
ic 800 NC N5
ilaris subcutaneous solution SP PA; SP
indocin oral NP
indocin rectal NP
indomethacin er G
indomethacin oral G QL
ketoprofen er G
ketorolac tromethamine injection solution 15 mg/ml
G
ketorolac tromethamine intramuscular solution60 mg/2ml
G
ketorolac tromethamine oral G QL
kevzara SP PA; ST; SP; QL
kineret subcutaneous solution prefilled syringe SP PA; ST; SP; QL
leflunomide oral G QL
meclofenamate sodium oral G
mefenamic acid oral G QL
meloxicam oral tablet G
mobic oral tablet NC N5
nabumetone oral G
nalfon oral capsule 400 mg NP
naprelan oral tablet extended release 24 hour 375 mg, 500 mg, 750 mg
NC N5
naprosyn oral tablet 250 mg, 500 mg NC N5
naproxen dr G
naproxen oral G
naproxen sodium er NC N5
naproxen sodium oral tablet 275 mg, 550 mg G
olumiant SP PA; ST; SP; QL
orencia clickject SP PA; ST; SP; QL
orencia intravenous SP PA; ST; SP
orencia subcutaneous solution prefilled syringe SP PA; ST; SP; QL
otrexup subcutaneous solution auto-injector 10 mg/0.4ml, 15 mg/0.4ml, 17.5 mg/0.4ml, 20 mg/0.4ml, 22.5 mg/0.4ml, 25 mg/0.4ml
SP ST; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201821
Drug Name Drug Status Drug Details
otrexup subcutaneous solution auto-injector 12.5 mg/0.4ml
SP ST
oxaprozin G
piroxicam oral G
ponstel NC N5
rasuvo subcutaneous solution auto-injector 10 mg/0.2ml, 12.5 mg/0.25ml, 15 mg/0.3ml, 17.5 mg/0.35ml, 20 mg/0.4ml, 22.5 mg/0.45ml, 25 mg/0.5ml, 30 mg/0.6ml, 7.5 mg/0.15ml
SP ST; SP
ridaura NP
simponi aria SP PA; ST; SP
simponi subcutaneous solution auto-injector SP PA; ST; SP; QL
simponi subcutaneous solution prefilled syringe
SP PA; ST; SP; QL
sprix NC LGC; N5; #
sulindac oral G
tivorbex NC N5
tolmetin sodium G
vimovo NC N5
vivlodex NC N5; #
xeljanz SP PA; ST; SP; QL
xeljanz xr SP PA; ST; SP; QL
zipsor NC N5
zorvolex NC N5
*ANALGESICS - NONNARCOTIC*
allzital NC
aspir-81 CE
aspir-low CE
bayer aspirin ec low dose CE
bayer low dose oral tablet chewable CE
bupap oral tablet 50-300 mg NC
butalbital-acetaminophen oral capsule NC
butalbital-acetaminophen oral tablet 50-300 mg NC
butalbital-acetaminophen oral tablet 50-325 mg G
butalbital-apap-caffeine oral capsule 50-325-40 mg
G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201822
Drug Name Drug Status Drug Details
butalbital-apap-caffeine oral tablet 50-325-40 mg
G
butalbital-aspirin-caffeine oral capsule G
childrens aspirin CE
diflunisal oral G
ec-81 aspirin CE
ecotrin CE
ecotrin low strength CE
ecpirin CE
esgic oral capsule G
esgic oral tablet NC N5
fiorinal NC N5
miniprin low dose CE
prialt SP SP
qc aspirin low dose oral tablet delayed release CE
st joseph aspirin oral tablet delayed release CE
tgt aspirin oral tablet delayed release CE
vanatol lq NC N5
*ANALGESICS - OPIOID*
abstral NP PA; ST; #; QL
acetaminophen-codeine G PA; QL
acetaminophen-codeine #2 G PA; QL
acetaminophen-codeine #3 G PA; QL
acetaminophen-codeine #4 G PA; QL
actiq NC N5
apap-caff-dihydrocodeine oral capsule G PA; QL
apap-caff-dihydrocodeine oral tablet 325-30-16 mg
NC N5
arymo er NP PA; ST; MPG; QL
ascomp-codeine G PA; QL
belbuca NP PA; QL
bunavail NP ST; MST; QL
buprenorphine G PA; QL
buprenorphine hcl injection solution 0.3 mg/ml G
buprenorphine hcl sublingual G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201823
Drug Name Drug Status Drug Details
buprenorphine hcl-naloxone hcl sublingual tablet sublingual
G QL
butalbital-apap-caff-cod G PA; QL
butalbital-asa-caff-codeine G PA; QL
butorphanol tartrate injection G
butorphanol tartrate nasal G PA; QL
butrans NP PA; QL
codeine sulfate oral tablet G PA; QL
conzip NC N5
demerol injection solution 75 mg/1.5ml NP
demerol injection solution 75 mg/ml NC
dilaudid injection solution 2 mg/ml NP
dilaudid oral NC N5
dolophine oral tablet 10 mg NP PA; PPA; QL
dolophine oral tablet 5 mg NC N5; PPA
duragesic-100 NC N5
duragesic-12 NC N5
duragesic-25 NC N5
duragesic-50 NC N5
duragesic-75 NC N5
duramorph G
embeda PB PA; MPG; QL
endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
G PA; QL
endocet oral tablet 2.5-325 mg G PA; QL
exalgo oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 8 mg
NC N5
exalgo oral tablet er 24 hour abuse-deterrent 32 mg
NP PA; ST; QL
fentanyl G PA; QL
fentanyl citrate buccal G PA; ST; QL
fentora buccal tablet 100 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg
NP PA; ST; #; QL
fioricet/codeine oral capsule 50-300-40-30 mg NP PA; QL
fiorinal/codeine #3 NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201824
Drug Name Drug Status Drug Details
hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml
G PA; QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
G PA; QL
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
G PA; QL
hydromorphone hcl er G PA; QL
hydromorphone hcl injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml
G
hydromorphone hcl oral G PA; QL
hydromorphone hcl pf injection solution 50 mg/5ml
G
hydromorphone hcl rectal G PA; QL
hysingla er PB PA; #; QL
ibudone oral tablet 10-200 mg NC N5
ibudone oral tablet 5-200 mg G PA; QL
infumorph 200 NP
infumorph 500 NP
kadian oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg
NC N5
kadian oral capsule extended release 24 hour 200 mg, 40 mg
NP PA; ST; QL
lazanda NC
levorphanol tartrate oral G PA; QL
lorcet G PA; QL
lorcet hd G PA; QL
lorcet plus oral tablet 7.5-325 mg G PA; QL
meperidine hcl injection solution 10 mg/ml, 100 mg/ml, 25 mg/ml, 50 mg/ml
G
meperidine hcl oral G PA; QL
methadone hcl intensol G PA; PPA; QL
methadone hcl oral concentrate G PA; PPA; QL
methadone hcl oral solution G PA; PPA; QL
methadone hcl oral tablet G PA; PPA; QL
methadose oral concentrate 10 mg/ml NC N5; PPA
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201825
Drug Name Drug Status Drug Details
methadose sugar-free NC N5; PPA
morphabond er NP PA; ST; MPG; QL
morphine sulfate (concentrate) oral solution 100 mg/5ml
G PA; QL
morphine sulfate (concentrate) oral solution 20 mg/ml
G QL
morphine sulfate (pf) injection solution 0.5 mg/ml
G
morphine sulfate (pf) intravenous solution 10 mg/ml
G
morphine sulfate er beads G PA; QL
morphine sulfate er oral capsule extended release 24 hour
G PA; QL
morphine sulfate er oral tablet extended release G PA; QL
morphine sulfate injection solution 10 mg/ml, 5 mg/ml, 8 mg/ml
G
morphine sulfate oral G PA; QL
morphine sulfate rectal G PA; QL
ms contin oral tablet extended release NC N5
nalbuphine hcl injection SP
nalocet NC
norco NC N5
nucynta NP PA; ST; QL
nucynta er NP PA; ST; QL
opana oral NC N5
oxaydo PB PA; MPG; QL
oxycodone hcl er oral tablet er 12 hour abuse-deterrent
G PA; QL
oxycodone hcl oral capsule G PA; QL
oxycodone hcl oral concentrate 100 mg/5ml G PA; QL
oxycodone hcl oral solution G PA; QL
oxycodone hcl oral tablet G PA; QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
G PA; QL
oxycodone-aspirin oral tablet 4.8355-325 mg G PA; QL
oxycodone-ibuprofen G PA; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201826
Drug Name Drug Status Drug Details
oxycontin oral tablet er 12 hour abuse-deterrent
PB PA; QL
oxymorphone hcl G PA; QL
oxymorphone hcl er G PA; QL
pentazocine-naloxone hcl G PA; QL
percocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
NC N5
primlev NC
roxicodone oral tablet NC N5
roxybond NP PA; ST; MPG; QL
suboxone sublingual film NP #; QL
subsys NC
tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg
G PA; QL
tramadol hcl er oral capsule extended release 24 hour
NC N5
tramadol hcl er oral tablet extended release 24 hour
G PA; QL
tramadol hcl oral G PA; QL
tramadol-acetaminophen G PA; QL
trezix oral capsule 320.5-30-16 mg NP PA; QL
tylenol with codeine #3 NC N5
tylenol with codeine #4 NC N5
ultracet NC N5
ultram NC N5
verdrocet NP PA; QL
vicodin es oral tablet 7.5-300 mg G PA; QL
vicodin hp oral tablet 10-300 mg G PA; QL
vicodin oral tablet 5-300 mg G PA; QL
xodol oral tablet 5-300 mg, 7.5-300 mg NC N5
xtampza er NP PA; ST; QL
zohydro er oral capsule er 12 hour abuse-deterrent
NP PA; ST; #; QL
zubsolv NP ST; MST; #; QL
*ANDROGENS-ANABOLIC*
anadrol-50 NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201827
Drug Name Drug Status Drug Details
androderm transdermal patch 24 hour NC N5
androgel pump transdermal gel 20.25 mg/act (1.62%)
NC #
androgel transdermal gel 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm (1.62%)
NC #
androgel transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%)
NC N5
danazol oral G
depo-testosterone intramuscular solution NC N5
fortesta NC N5
methitest NP
methyltestosterone oral G
natesto NC N5
oxandrin oral tablet 10 mg NC N5
oxandrolone oral G
striant NC N5; #
testim NC N5
testosterone cypionate intramuscular solution100 mg/ml, 200 mg/ml
G
testosterone enanthate intramuscular solution G
testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)
G PA; QL
testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)
G QL
testosterone transdermal solution NP PA; ST; QL
vogelxo pump NC N5
vogelxo transdermal gel 50 mg/5gm (1%) NC N5
*ANORECTAL AGENTS*
ana-lex NC
analpram-hc rectal cream NC N5
anusol-hc rectal cream NC N5
colocort G
cortenema NC N5
cortifoam NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201828
Drug Name Drug Status Drug Details
hydrocortisone ace-pramoxine rectal cream 1-1 %
G
hydrocortisone rectal enema G
lidocaine-hydrocortisone ace rectal NC
pramcort rectal G
proctocort rectal cream NC N5
proctofoam hc NC N5
procto-pak G
proctosol hc G
proctozone-hc rectal G
rectiv NP QL
uceris rectal NP PA; #; QL
*ANTHELMINTICS*
albendazole oral G QL
albenza NP QL
benznidazole NP PA; QL
biltricide NP
emverm G QL
ivermectin oral G
praziquantel oral G
stromectol NC N5
*ANTIANGINAL AGENTS*
dilatrate-sr NP
gonitro NP
isordil titradose oral tablet 40 mg NP
isordil titradose oral tablet 5 mg NC N5
isosorbide dinitrate er G
isosorbide dinitrate oral G
isosorbide mononitrate G
isosorbide mononitrate er G
minitran G
nitro-bid NP
nitro-dur transdermal patch 24 hour 0.3 mg/hr, 0.8 mg/hr
NP
nitroglycerin in d5w G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201829
Drug Name Drug Status Drug Details
nitroglycerin intravenous G
nitroglycerin sublingual G
nitroglycerin transdermal patch 24 hour G
nitroglycerin translingual solution G
nitrolingual NC N5
nitromist NP
nitrostat NP ST
nitro-time oral capsule extended release 2.5 mg, 6.5 mg
G
ranexa PB #; QL
*ANTIANXIETY AGENTS*
alprazolam er G QL
alprazolam intensol NP
alprazolam oral G
alprazolam xr G QL
ativan oral NC N5
buspirone hcl oral G
chlordiazepoxide hcl G AL
clorazepate dipotassium G AL
diazepam intensol G
diazepam oral concentrate G
diazepam oral tablet G
hydroxyzine hcl intramuscular G
hydroxyzine hcl oral syrup G
hydroxyzine pamoate oral G
lorazepam oral G
meprobamate G
oxazepam G AL
tranxene-t oral tablet 7.5 mg NC N5
valium NC N5
vistaril NC N5
xanax NC N5
xanax xr NC N5
*ANTIARRHYTHMICS*
amiodarone hcl oral tablet 200 mg, 400 mg G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201830
Drug Name Drug Status Drug Details
disopyramide phosphate oral G
dofetilide G
flecainide acetate G
lidocaine hcl (cardiac) intravenous solution 20 mg/ml
G
lidocaine in d5w G
mexiletine hcl oral G
multaq NP QL
nexterone NP
norpace cr NP
pacerone oral tablet 100 mg, 200 mg, 400 mg G
procainamide hcl injection G
propafenone hcl G
propafenone hcl er G SP; QL
quinidine gluconate er G
quinidine gluconate injection G
quinidine sulfate oral G
rythmol sr NC N5
tikosyn NP
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*
accolate NP QL
advair diskus NP #; QL
advair hfa NP QL
airduo respiclick 113/14 NP PA; ST; QL
airduo respiclick 232/14 NP PA; ST; QL
airduo respiclick 55/14 NP PA; ST; QL
albuterol sulfate er G
albuterol sulfate inhalation G
albuterol sulfate oral G
alvesco NP PA; ST; QL
aminophylline intravenous G
anoro ellipta PB QL
arcapta neohaler NP PA; ST; QL
armonair respiclick 113 NP PA; ST; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201831
Drug Name Drug Status Drug Details
armonair respiclick 232 NP PA; ST; QL
armonair respiclick 55 NP PA; ST; QL
arnuity ellipta NP QL
asmanex 120 metered doses PB #; QL
asmanex 14 metered doses PB #; QL
asmanex 30 metered doses PB #; QL
asmanex 60 metered doses PB #; QL
asmanex 7 metered doses PB #; QL
asmanex hfa PB QL
atrovent hfa NP QL
bevespi aerosphere NP PA; ST; QL
breo ellipta PB QL
brovana NP PA; ST; QL
budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml
G PA; QL
budesonide inhalation suspension 1 mg/2ml G PA; QL; AL
combivent respimat PB QL
cromolyn sodium inhalation G
daliresp NP PA; ST; QL
dulera PB QL
elixophyllin NP
flovent diskus NP #; QL
flovent hfa NP #; QL
fluticasone-salmeterol G QL
ipratropium bromide inhalation G
ipratropium-albuterol G
levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml
G
lonhala magnair refill kit NP PA; ST; QL
lonhala magnair starter kit NP PA; ST; QL
metaproterenol sulfate oral G
montelukast sodium oral G QL
perforomist NP PA; ST; QL
proair hfa PB #
proventil hfa NP ST; #
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201832
Drug Name Drug Status Drug Details
pulmicort NC N5
pulmicort flexhaler NP PA; ST; QL
qvar redihaler PB QL
seebri neohaler NP PA; ST; QL
serevent diskus PB QL
singulair NC N5
spiriva handihaler PB QL
spiriva respimat inhalation aerosol solution 1.25 mcg/act, 2.5 mcg/act
PB QL
stiolto respimat inhalation aerosol solution 2.5-2.5 mcg/act
PB QL
striverdi respimat NP PA; ST; QL
symbicort PB QL
terbutaline sulfate injection G
terbutaline sulfate oral G
theo-24 oral capsule extended release 24 hour 100 mg, 200 mg, 400 mg
PB
theochron oral tablet extended release 12 hour100 mg, 200 mg, 300 mg
G
theophylline G
theophylline er G
trelegy ellipta PB QL
tudorza pressair inhalation aerosol powder breath activated
NP PA; ST; QL
utibron neohaler NP PA; ST; QL
ventolin hfa PB
xolair SP PA; ST; SP
xopenex NC N5
xopenex concentrate NC N5
xopenex hfa NP ST; QL
zafirlukast G QL
zileuton er G QL
zyflo NP QL
zyflo cr NP QL
*ANTICOAGULANTS*
arixtra NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201833
Drug Name Drug Status Drug Details
bevyxxa NP PA; ST; QL
coumadin oral NC N5
eliquis PB QL
eliquis starter pack PB QL
enoxaparin sodium G QL
fondaparinux sodium G QL
fragmin subcutaneous solution 10000 unit/ml, 12500 unit/0.5ml, 15000 unit/0.6ml, 18000 unt/0.72ml, 2500 unit/0.2ml, 5000 unit/0.2ml, 7500 unit/0.3ml, 95000 unit/3.8ml
NP QL
heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml
G
heparin sodium (porcine) pf G
jantoven G
lovenox NC N5
pradaxa NP ST; QL
savaysa NP ST; QL
warfarin sodium oral G
xarelto PB QL
xarelto starter pack PB QL
*ANTICONVULSANTS*
aptiom NP PA; QL
banzel oral suspension NP PA
banzel oral tablet NP PA; QL
briviact oral NP PA; QL
carbamazepine er G
carbamazepine oral G
carbatrol NC N5
celontin PB
cerebyx SP
clonazepam oral G
depakene oral capsule NC N5
depakene oral solution NC N5
depakote NC N5
depakote er NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201834
Drug Name Drug Status Drug Details
depakote sprinkles oral capsule delayed release sprinkle
NC N5
diastat acudial PB QL
diastat pediatric PB QL
diazepam rectal G QL
dilantin infatabs NC N5
dilantin oral capsule 100 mg NC N5
dilantin oral capsule 30 mg PB
dilantin oral suspension NC N5
divalproex sodium er oral tablet extended release 24 hour
G
divalproex sodium oral capsule delayed release sprinkle
G
divalproex sodium oral tablet delayed release G
epidiolex SP PA; ST; SP; QL
epitol G
ethosuximide oral G
felbamate G
felbatol NC N5
fosphenytoin sodium SP
fycompa oral suspension NP
fycompa oral tablet NP PA; QL
gabapentin oral capsule G QL
gabapentin oral solution 250 mg/5ml G QL
gabapentin oral tablet G QL
gabitril oral tablet 12 mg, 16 mg NP QL
gabitril oral tablet 2 mg, 4 mg NC N5
keppra oral NC N5
keppra xr NC N5
klonopin NC N5
lamictal odt oral kit NP
lamictal odt oral tablet dispersible NC N5
lamictal oral tablet NC N5
lamictal oral tablet chewable 25 mg, 5 mg NC N5
lamictal starter NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201835
Drug Name Drug Status Drug Details
lamictal xr oral kit NP
lamictal xr oral tablet extended release 24 hour NC N5
lamotrigine er G PA; ST; QL
lamotrigine oral tablet G
lamotrigine oral tablet chewable G
lamotrigine oral tablet dispersible G PA; ST; QL
lamotrigine starter kit-blue G
lamotrigine starter kit-green G
lamotrigine starter kit-orange G
levetiracetam er G QL
levetiracetam in nacl G
levetiracetam oral G
lyrica PB #
mysoline NC N5
neurontin NC N5
onfi oral suspension NP PA; #
onfi oral tablet 10 mg, 20 mg NP PA; #; QL
oxcarbazepine G
oxtellar xr NP ST; QL
peganone NP
phenytek PB
phenytoin infatabs G
phenytoin oral suspension 125 mg/5ml G
phenytoin oral tablet chewable G
phenytoin sodium extended oral capsule 100 mg G
phenytoin sodium injection G
primidone oral G
qudexy xr NP ST; QL
sabril oral packet SP PA; SP; QL
sabril oral tablet SP PA; #; SP; QL
spritam NP ST; QL
tegretol oral suspension NC N5
tegretol oral tablet NC N5
tegretol-xr NC N5
tiagabine hcl G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201836
Drug Name Drug Status Drug Details
topamax NC N5
topamax sprinkle NC N5
topiramate oral capsule sprinkle NC
topiramate oral tablet G
trileptal NC N5
trokendi xr NP ST; #; QL
valproate sodium intravenous solution 100 mg/ml G
valproate sodium oral solution G
valproic acid oral capsule G
vigabatrin SP PA; SP; QL
vigadrone SP PA; SP; QL
vimpat intravenous NP
vimpat oral NP #; QL
zarontin NC N5
zonegran NC N5
zonisamide oral G
*ANTIDEMENTIA AGENT COMBINATIONS***
namzaric oral capsule er 24 hour therapy pack PB PA; AL
namzaric oral capsule extended release 24 hour 14-10 mg, 28-10 mg
PB PA; AL
namzaric oral capsule extended release 24 hour 21-10 mg, 7-10 mg
PB PA
*ANTIDEPRESSANTS*
amitriptyline hcl oral G
amoxapine G
anafranil NC N5
aplenzin NC N5
bupropion hcl er (sr) G QL
bupropion hcl er (xl) G QL
bupropion hcl oral G QL
celexa oral tablet NC N5
citalopram hydrobromide oral solution G
citalopram hydrobromide oral tablet G QL
clomipramine hcl oral G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201837
Drug Name Drug Status Drug Details
cymbalta NC N5
desipramine hcl oral G
desvenlafaxine er G PA; ST; QL
desvenlafaxine succinate er G PA; ST; QL
doxepin hcl oral G
duloxetine hcl oral G QL
effexor xr NC N5
emsam NP #; QL
escitalopram oxalate oral solution G
escitalopram oxalate oral tablet G QL
fetzima NP PA; ST; QL
fetzima titration NP PA; ST; QL
fluoxetine hcl oral capsule G QL
fluoxetine hcl oral capsule delayed release G QL
fluoxetine hcl oral solution G
fluoxetine hcl oral tablet G QL
fluvoxamine maleate G QL
fluvoxamine maleate er G QL
forfivo xl NC N5; #
imipramine hcl oral G
imipramine pamoate G
khedezla NP PA; ST; QL
lexapro oral tablet NC N5
maprotiline hcl G QL
marplan NP
mirtazapine oral G QL
nardil NC N5
nefazodone hcl G
norpramin oral tablet 10 mg, 25 mg NC N5
nortriptyline hcl oral G
pamelor oral capsule NC N5
parnate NC N5
paroxetine hcl er G QL
paroxetine hcl oral tablet G QL
paxil cr NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201838
Drug Name Drug Status Drug Details
paxil oral suspension NP QL
paxil oral tablet NC N5
pexeva NC N5
phenelzine sulfate oral G
pristiq NP PA; ST; QL
protriptyline hcl G
prozac oral capsule NC N5
remeron oral tablet 15 mg, 30 mg NC N5
remeron soltab NC N5
sertraline hcl oral concentrate G
sertraline hcl oral tablet G QL
surmontil NP
tranylcypromine sulfate G
trazodone hcl oral G
trimipramine maleate oral G
trintellix NP PA; ST; QL
venlafaxine hcl G QL
venlafaxine hcl er oral capsule extended release 24 hour
G QL
venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 37.5 mg, 75 mg
NC N5
venlafaxine hcl er oral tablet extended release 24 hour 225 mg
G QL
viibryd oral tablet NP PA; ST; QL
viibryd starter pack NP PA
wellbutrin sr NC N5
wellbutrin xl NC N5
zoloft oral tablet NC N5
*ANTIDIABETICS*
acarbose G
actoplus met NC N5
actoplus met xr NP QL
actos NC N5
adlyxin NC N5
adlyxin starter pack NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201839
Drug Name Drug Status Drug Details
admelog NC
admelog solostar NC
afrezza inhalation powder 12 unit, 4 & 8 & 12 unit, 4 (90) & 8 (90) unit, 4 unit, 8 unit
NP PA
alogliptin benzoate G QL
alogliptin-metformin hcl G QL
alogliptin-pioglitazone G QL
amaryl NC N5
apidra NC N5
apidra solostar subcutaneous solution pen-injector
NC N5
avandia oral tablet 2 mg, 4 mg NP QL
basaglar kwikpen PB
bydureon bcise NC N5
bydureon subcutaneous pen-injector NC N5
bydureon subcutaneous suspension reconstituted er
NC N5
byetta 10 mcg pen subcutaneous solution pen-injector
NC N5; #
byetta 5 mcg pen subcutaneous solution pen-injector
NC N5; #
chlorpropamide G
cycloset NP QL
duetact NC N5
farxiga NP QL
fiasp NC N5
fiasp flextouch NC N5
fortamet NC N5
glimepiride G
glipizide oral G
glipizide xl G
glipizide-metformin hcl G
glucagen hypokit PB QL
glucagon emergency PB QL
glucophage oral tablet 1000 mg NC
glucophage oral tablet 500 mg, 850 mg NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201840
Drug Name Drug Status Drug Details
glucophage xr oral tablet extended release 24 hour 500 mg
NP
glucophage xr oral tablet extended release 24 hour 750 mg
NC N5
glucotrol NC N5
glucotrol xl NC N5
glumetza NC N5
glyburide micronized G
glyburide oral G
glyburide-metformin G
glynase NC N5
glyset NP
humalog PB
humalog kwikpen subcutaneous solution pen-injector 100 unit/ml, 200 unit/ml
PB
humalog mix 50/50 PB
humalog mix 50/50 kwikpen subcutaneous suspension pen-injector
PB
humalog mix 75/25 PB
humalog mix 75/25 kwikpen subcutaneous suspension pen-injector
PB
humulin 70/30 PB
humulin 70/30 kwikpen subcutaneous suspension pen-injector
PB
humulin n PB
humulin n kwikpen subcutaneous suspension pen-injector
PB
humulin r PB
humulin r u-500 (concentrated) PB
humulin r u-500 kwikpen subcutaneous solution pen-injector
PB
invokana PB QL
janumet PB QL
janumet xr PB QL
januvia PB QL
jardiance PB QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201841
Drug Name Drug Status Drug Details
jentadueto PB QL
jentadueto xr PB QL
kazano NC N5
kombiglyze xr NC N5
korlym SP PA; SP; QL
lantus NC N5
lantus solostar subcutaneous solution pen-injector
NC N5
levemir PB
levemir flextouch PB
metformin hcl er (mod) NC N5
metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg
NC N5
metformin hcl er oral tablet extended release 24 hour 500 mg
NC
metformin hcl er oral tablet extended release 24 hour 750 mg
G
metformin hcl oral G
miglitol G
nateglinide G
nesina NC N5
novolin 70/30 NC N5
novolin 70/30 relion NC N5
novolin n NC N5
novolin n relion NC N5
novolin r NC N5
novolin r relion NC N5
novolog NC N5
novolog flexpen subcutaneous solution pen-injector
NC N5
novolog mix 70/30 NC N5
novolog mix 70/30 flexpen subcutaneous suspension pen-injector
NC N5
novolog penfill subcutaneous solution cartridge
NC N5
onglyza NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201842
Drug Name Drug Status Drug Details
oseni NC N5
ozempic NC
pioglitazone hcl G QL
pioglitazone hcl-glimepiride G QL
pioglitazone hcl-metformin hcl G QL
prandin oral tablet 1 mg, 2 mg NC N5
precose NC N5
proglycem NP
repaglinide G
repaglinide-metformin hcl G QL
riomet NC
starlix NC N5
steglatro NC
symlinpen 120 subcutaneous solution pen-injector
NP PA; #; QL
symlinpen 60 subcutaneous solution pen-injector
NP PA; #
tolazamide G
tolbutamide G
toujeo max solostar NC
toujeo solostar NC N5
tradjenta PB QL
tresiba flextouch PB
trulicity PB PA; ST; QL
victoza subcutaneous solution pen-injector PB PA; ST; QL
*ANTIDIARRHEAL/PROBIOTIC AGENTS*
vsl#3 ds NP
*ANTIDIARRHEALS*
diphenoxylate-atropine G
lomotil oral tablet NC N5
motofen NP
mytesi NP PA; ST; QL
opium G
vsl#3 ds NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201843
Drug Name Drug Status Drug Details
*ANTIDOTES AND SPECIFIC ANTAGONISTS*
deferoxamine mesylate SP SP
desferal injection solution reconstituted 500 mg NC N5; SP
vistogard SP SP; QL
*ANTIDOTES*
chemet NP
deferoxamine mesylate SP SP
desferal injection solution reconstituted 500 mg NC N5; SP
evzio injection solution auto-injector 2 mg/0.4ml
NC N5
exjade SP PA; #; SP
ferriprox oral solution SP PA
ferriprox oral tablet SP PA; #; SP
jadenu SP PA; #; SP
jadenu sprinkle SP PA; #; SP
naloxone hcl injection solution 0.4 mg/ml G
naltrexone hcl oral G
narcan PB #; QL
vistogard SP SP; QL
vivitrol NP
*ANTIEMETICS*
akynzeo oral NP PA; ST; QL
aloxi intravenous solution 0.25 mg/5ml SP SP
anzemet oral NP QL
aprepitant G QL
bonjesta NP PA; ST; QL
cesamet NP QL
diclegis NP PA; #; QL
dronabinol G PA; QL
emend oral capsule 125 mg, 40 mg, 80 mg NP QL
emend oral suspension reconstituted PB #
granisetron hcl intravenous SP
granisetron hcl oral G
marinol NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201844
Drug Name Drug Status Drug Details
meclizine hcl oral tablet G
ondansetron G
ondansetron hcl injection solution 4 mg/2ml G
ondansetron hcl oral G
palonosetron hcl intravenous solution 0.25 mg/5ml
SP SP
sancuso NP QL
syndros NC N5; #
tigan intramuscular NP
tigan oral NC N5
transderm-scop (1.5 mg) NP
trimethobenzamide hcl oral G
varubi oral NP QL
zofran oral solution NP
zofran oral tablet 4 mg NP
zofran oral tablet 8 mg NC N5
zuplenz NC N5
*ANTIFUNGALS*
ambisome NP
ancobon NP
cresemba oral NP
diflucan NC N5
fluconazole in sodium chloride intravenous solution 400-0.9 mg/200ml-%
G
fluconazole oral G
flucytosine oral G
griseofulvin microsize oral G
griseofulvin ultramicrosize G
itraconazole oral capsule G QL
itraconazole oral solution G
ketoconazole oral G QL
lamisil oral tablet NC N5
noxafil intravenous NP
noxafil oral suspension NP
noxafil oral tablet delayed release NP #; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201845
Drug Name Drug Status Drug Details
nystatin oral tablet G
sporanox oral capsule NC N5
sporanox oral solution NC
sporanox pulsepak NC N5
terbinafine hcl oral G
vfend NC N5
voriconazole intravenous G
voriconazole oral tablet G
*ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***
hemlibra SP PA; SP
*ANTIHISTAMINES*
alavert oral tablet dispersible G Select OTC
allegra allergy G Select OTC
allegra allergy childrens oral suspension G Select OTC
allegra allergy childrens oral tablet dispersible G Select OTC
allergy relief oral tablet dispersible G Select OTC
carbinoxamine maleate oral solution G
carbinoxamine maleate oral tablet 4 mg G
carbinoxamine maleate oral tablet 6 mg NC
cetirizine hcl oral tablet G Select OTC
cetirizine hcl oral tablet chewable G Select OTC
childrens loratadine G Select OTC
clarinex oral syrup NP
clarinex oral tablet NC N5
claritin oral capsule G Select OTC
claritin oral syrup NC N5; Select OTC
claritin oral tablet NC N5; Select OTC
claritin oral tablet chewable G Select OTC
claritin reditabs G Select OTC
cyproheptadine hcl oral G
desloratadine oral tablet G QL
desloratadine oral tablet dispersible 2.5 mg G QL
desloratadine oral tablet dispersible 5 mg G
diphenhydramine hcl injection G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201846
Drug Name Drug Status Drug Details
fexofenadine hcl childrens G Select OTC
fexofenadine hcl oral tablet 180 mg, 60 mg G Select OTC
karbinal er oral suspension extended release NP ST
levocetirizine dihydrochloride oral NC
loratadine childrens oral solution G Select OTC
loratadine childrens oral syrup G Select OTC
loratadine oral capsule G Select OTC
loratadine oral solution G Select OTC
loratadine oral tablet G LGC; Select OTC
loratadine oral tablet chewable G Select OTC
phenadoz rectal suppository 12.5 mg G
promethazine hcl injection G
promethazine hcl oral G
promethazine hcl rectal G
promethegan G
ryvent NC N5
triaminic allerchews G Select OTC
xyzal allergy 24hr G Select OTC
xyzal allergy 24hr childrens G Select OTC
zyrtec allergy oral capsule G Select OTC
zyrtec allergy oral tablet G Select OTC
*ANTIHYPERLIPIDEMICS*
altoprev NP ST; #; QL
antara oral capsule 30 mg, 90 mg NP #; QL
atorvastatin calcium oral tablet 10 mg CE QL
atorvastatin calcium oral tablet 20 mg, 40 mg, 80 mg
G QL
cholestyramine light oral powder G
colesevelam hcl G
colestid NC N5
colestid flavored NC N5
colestipol hcl oral granules G
crestor NP ST; QL
ezetimibe G QL
ezetimibe-simvastatin G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201847
Drug Name Drug Status Drug Details
fenofibrate micronized G QL
fenofibrate oral capsule 150 mg, 50 mg G QL
fenofibrate oral tablet 120 mg, 40 mg NC N5
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg
G QL
fenofibric acid G QL
fenoglide NC N5
fibricor NP QL
flolipid NC
fluvastatin sodium G QL
fluvastatin sodium er G QL
gemfibrozil oral G
juxtapid SP PA; ST; SP; QL
kynamro subcutaneous solution prefilled syringe
SP PA; ST; SP; QL
lescol oral capsule 20 mg NC N5
lescol xl NC N5
lipitor NC N5
lipofen NP QL
livalo NP ST; QL
lovastatin G QL
lovaza NC N5
mevacor oral tablet 40 mg NC N5
niacin er (antihyperlipidemic) G
niacor NP
niaspan NC N5
omega-3-acid ethyl esters G QL
pravachol oral tablet 20 mg, 40 mg, 80 mg NC N5
pravastatin sodium G QL
prevalite oral packet G
questran light oral powder NC N5
rosuvastatin calcium G QL
simvastatin oral tablet 10 mg, 5 mg CE QL
simvastatin oral tablet 20 mg, 40 mg, 80 mg G QL
tricor NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201848
Drug Name Drug Status Drug Details
triglide oral tablet 160 mg NC N5
trilipix NC N5
vascepa PB QL
vytorin NP ST; QL
welchol NP #
zetia NP ST; QL
zocor NC N5
zypitamag NC
*ANTIHYPERTENSIVES*
accupril oral tablet 10 mg, 20 mg, 5 mg NC N5
accupril oral tablet 40 mg NC
accuretic NC N5
altace oral capsule NC N5
amlodipine besy-benazepril hcl G
amlodipine besylate-valsartan G QL
amlodipine-olmesartan G QL
amlodipine-valsartan-hctz G QL
atacand oral tablet 16 mg, 4 mg, 8 mg NC N5
atacand oral tablet 32 mg NP ST; QL
atenolol-chlorthalidone G
avalide oral tablet 150-12.5 mg, 300-12.5 mg NC N5
avapro NC N5
azor NP ST; QL
benazepril hcl oral G
benazepril-hydrochlorothiazide G
benicar NP ST; QL
benicar hct NP ST; QL
bisoprolol-hydrochlorothiazide G
candesartan cilexetil oral tablet 16 mg, 4 mg, 8 mg
G QL
candesartan cilexetil-hctz G QL
captopril oral G
captopril-hydrochlorothiazide G
cardura NC N5
catapres NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201849
Drug Name Drug Status Drug Details
catapres-tts-1 NC N5
catapres-tts-2 NC N5
catapres-tts-3 NC N5
clonidine hcl oral G
corzide NC N5
cozaar NC N5
demser SP ST; SP
dibenzyline NC N5
diovan NC N5
diovan hct NC N5
doxazosin mesylate oral G
dutoprol NC N5
edarbi NP ST; QL
edarbyclor NP ST; QL
enalapril maleate oral NC
enalapril-hydrochlorothiazide G
epaned oral solution NP PA; #; QL
eplerenone G
eprosartan mesylate G QL
exforge NC N5
exforge hct NP ST; QL
fosinopril sodium G
fosinopril sodium-hctz G
guanfacine hcl oral G
hydralazine hcl oral G
hyzaar NC N5
inspra NC N5
irbesartan G QL
irbesartan-hydrochlorothiazide G QL
lisinopril oral G
lisinopril-hydrochlorothiazide G
lopressor hct oral tablet 50-25 mg NC N5
losartan potassium oral tablet 100 mg G
losartan potassium oral tablet 25 mg, 50 mg G QL
losartan potassium-hctz G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201850
Drug Name Drug Status Drug Details
lotensin hct oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg
NC N5
lotensin oral tablet 10 mg, 20 mg, 40 mg NC N5
lotrel oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg
NC N5
methyldopa oral G
methyldopa-hydrochlorothiazide G
methyldopate hcl G
metoprolol-hctz er NC N5
metoprolol-hydrochlorothiazide G
micardis NC N5
micardis hct NC N5
minipress NC N5
minoxidil oral G
moexipril hcl G
moexipril-hydrochlorothiazide G
nadolol-bendroflumethiazide oral tablet 40-5 mg G
olmesartan medoxomil oral G QL
olmesartan medoxomil-hctz G QL
olmesartan-amlodipine-hctz G QL
perindopril erbumine G
phenoxybenzamine hcl oral SP QL
prazosin hcl oral G
prestalia NP #
prinivil NC N5
propranolol-hctz G
qbrelis NP PA
quinapril hcl oral tablet 10 mg, 20 mg, 5 mg G
quinapril-hydrochlorothiazide G
ramipril G
tarka oral tablet extended release 2-180 mg, 2-240 mg, 4-240 mg
NC N5
tekturna NP ST; #; QL
tekturna hct NP ST; QL
telmisartan G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201851
Drug Name Drug Status Drug Details
telmisartan-amlodipine G QL
telmisartan-hctz G QL
terazosin hcl oral G
trandolapril G
trandolapril-verapamil hcl er G
tribenzor NP ST; QL
twynsta NC N5
valsartan G QL
valsartan-hydrochlorothiazide G QL
vaseretic NC N5
vasotec NC N5
vecamyl SP PA; ST; SP; QL
zestril oral tablet 10 mg, 20 mg, 5 mg NC N5
ziac NC N5
*ANTI-INFECTIVE AGENTS - MISC.*
alinia NP #; QL
atovaquone oral G
bactrim NC N5
bactrim ds NP
cleocin in d5w intravenous solution 300 mg/50ml
NC
cleocin oral capsule 150 mg, 300 mg NC N5
cleocin oral capsule 75 mg NC
cleocin oral solution reconstituted NC N5
cleocin phosphate injection NC N5
cleocin phosphate intravenous solution 600 mg/4ml, 900 mg/6ml
NC
clindamycin hcl oral G
clindamycin palmitate hcl G
clindamycin phosphate injection SP
clindamycin phosphate intravenous solution 150 mg/ml, 900 mg/6ml
SP
coly-mycin m NC N5; SP
dapsone oral G
flagyl oral capsule NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201852
Drug Name Drug Status Drug Details
flagyl oral tablet 250 mg NC N5
flagyl oral tablet 500 mg NP
impavido NP PA; QL
linezolid oral G QL
mepron NC N5
metronidazole in nacl intravenous solution 500-0.79 mg/100ml-%
G
metronidazole oral capsule G
metronidazole oral tablet 250 mg G
nebupent PB
primsol NP
sivextro oral NP QL
sulfamethoxazole-trimethoprim intravenous G
sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml
G
sulfamethoxazole-trimethoprim oral tablet 400-80 mg
G
tindamax oral tablet 500 mg NC N5
tinidazole oral G
trimethoprim oral G
trimpex NP
xifaxan oral tablet 200 mg NP QL
xifaxan oral tablet 550 mg PB PA; QL
zyvox oral NC N5
*ANTIMALARIALS*
atovaquone-proguanil hcl G
chloroquine phosphate oral G
coartem NP
daraprim PB
hydroxychloroquine sulfate oral G
malarone NC N5
mefloquine hcl G
plaquenil NC N5
primaquine phosphate oral G
qualaquin NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201853
Drug Name Drug Status Drug Details
quinine sulfate oral G
*ANTIMYASTHENIC AGENTS*
guanidine hcl oral G
mestinon oral syrup NP
mestinon oral tablet NC N5
mestinon oral tablet extended release NC N5
pyridostigmine bromide er G
pyridostigmine bromide oral G
regonol intravenous NP
*ANTIMYASTHENIC/CHOLINERGIC AGENTS*
guanidine hcl oral G
mestinon oral syrup NP
mestinon oral tablet NC N5
mestinon oral tablet extended release NC N5
pyridostigmine bromide er G
pyridostigmine bromide oral G
regonol intravenous NP
*ANTIMYCOBACTERIAL AGENTS*
capastat sulfate SP
cycloserine oral G
ethambutol hcl oral G
isoniazid injection G
isoniazid oral G
myambutol NC N5
mycobutin NC N5
paser NP
priftin NP
pyrazinamide oral G
rifabutin G
rifadin oral NC N5
rifamate NP
rifampin oral G
rifater NP
sirturo SP PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201854
Drug Name Drug Status Drug Details
trecator NP
*ANTINEOPLASTIC - BCL-2 INHIBITORS***
venclexta SP PA; SP; QL
venclexta starting pack SP PA; SP; QL
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*
actimmune SP PA; SP
adcetris SP
adrucil intravenous solution 5 gm/100ml NP
afinitor SP PA; SP; QL
afinitor disperz SP PA; SP; QL
alecensa SP PA; SP; QL
alferon n SP SP
alkeran intravenous NP
alkeran oral NP ST
alunbrig SP PA; SP; QL
anastrozole oral G
arimidex NC N5
aromasin NC N5
arzerra SP PA
bexarotene SP PA; SP
bicalutamide G QL
bosulif SP PA; ST; SP; QL
braftovi SP PA; SP; QL
busulfex SP
cabometyx SP PA; SP; QL
calquence SP PA; SP; QL
camptosar NC N5
capecitabine G PA; SP
caprelsa SP PA; SP; QL
casodex NC N5
cometriq (100 mg daily dose) SP PA; SP; QL
cometriq (140 mg daily dose) SP PA; SP; QL
cometriq (60 mg daily dose) SP PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201855
Drug Name Drug Status Drug Details
cotellic SP PA; SP; QL
cyclophosphamide injection G
cyclophosphamide oral capsule G
depo-provera intramuscular suspension 400 mg/ml
NP
eligard SP PA; SP
emcyt PB
erivedge SP PA; SP; QL
erleada SP PA; SP; QL
ethyol SP
etoposide intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml
SP
etoposide oral G
exemestane G
fareston PB
farydak SP PA; SP; QL
faslodex intramuscular solution 250 mg/5ml SP PA; #; SP
femara NC N5
firmagon SP PA; SP
fluorouracil intravenous solution 5 gm/100ml G
flutamide G
gilotrif SP PA; SP; QL
gleevec NC N5; SP
gleostine oral capsule 10 mg, 100 mg, 40 mg NP PA
hycamtin oral SP PA; SP
hydrea NP
hydroxyurea oral G
iclusig SP PA; SP; QL
imatinib mesylate G PA; SP; QL
imbruvica oral capsule 70 mg SP PA; SP; QL
imbruvica oral tablet SP PA; SP; QL
inlyta SP PA; SP; QL
intron a NP PA; SP
iressa SP PA; QL
irinotecan hcl SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201856
Drug Name Drug Status Drug Details
jakafi SP PA; SP; QL
jevtana SP PA
kepivance SP PA
kisqali femara 200 dose SP PA; SP; QL
kisqali femara 400 dose SP PA; SP; QL
kisqali femara 600 dose SP PA; SP; QL
lenvima 10 mg daily dose SP PA; SP; QL
lenvima 12 mg daily dose SP PA; SP; QL
lenvima 14 mg daily dose SP PA; SP; QL
lenvima 18 mg daily dose SP PA; SP; QL
lenvima 20 mg daily dose SP PA; SP; QL
lenvima 24 mg daily dose SP PA; SP; QL
lenvima 4 mg daily dose SP PA; SP; QL
lenvima 8 mg daily dose SP PA; SP; QL
letrozole oral G
leucovorin calcium injection solution reconstituted 350 mg, 500 mg
G
leucovorin calcium oral G
leukeran SP
leuprolide acetate injection G PA; SP
lonsurf SP PA; QL
lupron depot (1-month) SP PA; #; SP
lupron depot (3-month) SP PA; #; SP
lupron depot (4-month) SP PA; #; SP
lupron depot (6-month) SP PA; #; SP
lysodren PB
matulane SP
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml
G
megestrol acetate oral tablet G
mekinist SP PA; SP; QL
mektovi SP PA; SP; QL
melphalan G
melphalan hcl SP
mercaptopurine oral G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201857
Drug Name Drug Status Drug Details
mesnex oral PB
methotrexate oral G
methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml
G
mitoxantrone hcl G
myleran PB
nerlynx SP PA; SP; QL
nexavar SP PA; SP; QL
nilandron PB
nilutamide G
ninlaro SP PA; QL
odomzo SP PA; QL
pomalyst SP PA; SP; QL
purixan SP PA; SP; QL
rituxan intravenous solution SP PA; ST
rydapt SP PA; SP; QL
soltamox NP #
sprycel SP PA; ST; SP; QL
stivarga SP PA; SP; QL
sutent PB PA; SP; QL
sylatron subcutaneous kit 200 mcg, 300 mcg, 600 mcg
SP PA; SP
synribo SP PA; ST
tabloid PB
tafinlar SP PA; SP; QL
tagrisso SP PA; SP; QL
tamoxifen citrate oral CE
tarceva NP PA; #; SP; QL
targretin oral NC N5; SP
tasigna SP PA; ST; SP; QL
temodar oral NC N5
temozolomide G PA; SP
temsirolimus SP SP
toposar intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml
SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201858
Drug Name Drug Status Drug Details
torisel SP #; SP
trelstar mixject SP PA; #; SP
tretinoin oral G SP; AL
trexall NP
tykerb SP PA; SP
vantas SP PA; SP
vizimpro SP PA; SP; QL
voraxaze SP
votrient SP PA; SP; QL
xalkori SP PA; SP; QL
xatmep NP PA
xeloda NC N5; SP
xtandi SP PA; ST; SP; QL
yervoy SP PA
yonsa SP PA; ST; SP; QL
zaltrap SP
zanosar SP
zelboraf SP PA; SP; QL
zoladex SP PA; SP
zolinza SP PA; SP; QL
zykadia SP PA; SP; QL
zytiga PB PA; #; SP; QL
*ANTIPARKINSON AGENTS*
amantadine hcl oral G
azilect NP QL
benztropine mesylate injection SP
benztropine mesylate oral G
bromocriptine mesylate oral G
carbidopa oral G
carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg
G
carbidopa-levodopa oral tablet G
carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-250 mg
G
comtan NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201859
Drug Name Drug Status Drug Details
duopa enteral SP PA; ST; QL
entacapone G
gocovri NC
lodosyn NC N5
mirapex NC N5
mirapex er NC N5
neupro NP #; QL
osmolex er NC
pramipexole dihydrochloride G
pramipexole dihydrochloride er G QL
rasagiline mesylate oral G QL
requip oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 4 mg, 5 mg
NC N5
requip xl NC N5
ropinirole hcl G
ropinirole hcl er G QL
rytary NP #
selegiline hcl oral G
sinemet NC N5
sinemet cr NC N5
stalevo 100 NP
stalevo 125 NP
stalevo 150 NP
stalevo 200 NP
stalevo 50 NP
stalevo 75 NP
tasmar oral tablet 100 mg NC N5
tolcapone G
trihexyphenidyl hcl G
xadago NP PA; ST; QL
zelapar NC N5
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*
abilify oral tablet NC N5
aripiprazole oral solution G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201860
Drug Name Drug Status Drug Details
aripiprazole oral tablet 10 mg, 15 mg, 2 mg G QL
aripiprazole oral tablet dispersible G QL
chlorpromazine hcl injection solution 25 mg/ml G
chlorpromazine hcl oral G
clozapine G QL
clozaril NC N5
compro G
equetro NP
fanapt NP ST; QL
fanapt titration pack NP ST
fazaclo oral tablet dispersible 100 mg, 12.5 mg, 25 mg
NC N5
fazaclo oral tablet dispersible 150 mg, 200 mg NP PA; ST; QL
fluphenazine decanoate injection G
fluphenazine hcl injection G
fluphenazine hcl oral G
geodon oral NC N5
haldol NP
haldol decanoate intramuscular solution 100 mg/ml
NP
haldol decanoate intramuscular solution 50 mg/ml
NC
haloperidol lactate oral G
haloperidol oral G
invega NC N5
latuda oral tablet 120 mg, 20 mg, 40 mg, 80 mg PB ST; #; QL
latuda oral tablet 60 mg PB ST; #
lithium G
lithium carbonate er G
lithium carbonate oral G
lithobid NP
loxapine succinate oral G
nuplazid SP PA; SP; QL
olanzapine oral G QL
paliperidone er G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201861
Drug Name Drug Status Drug Details
perphenazine oral G
prochlorperazine G
prochlorperazine maleate oral G
quetiapine fumarate G QL
quetiapine fumarate er G QL
rexulti NP PA; ST; QL
risperdal NC N5
risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg
G QL
risperidone oral solution G
risperidone oral tablet G QL
risperidone oral tablet dispersible 0.25 mg G
risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
G QL
saphris NP PA; ST; #; QL
seroquel NC N5
seroquel xr NP ST; QL
thioridazine hcl oral G
thiothixene oral G
trifluoperazine hcl oral G
versacloz NP PA; ST
vraylar oral capsule NP PA; ST; QL
vraylar oral capsule therapy pack NP PA; ST
ziprasidone hcl G QL
zyprexa oral NC N5
zyprexa zydis NC N5
*ANTIRETROVIRALS ADJUVANTS***
tybost NP QL
*ANTISEPTICS & DISINFECTANTS*
formadon NP
formaldehyde external solution 10 % G
iodosorb NP
kerr triple dye swabs NP
*ANTIVIRALS*
abacavir sulfate G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201862
Drug Name Drug Status Drug Details
abacavir sulfate-lamivudine G
abacavir-lamivudine-zidovudine G
acyclovir oral G
adefovir dipivoxil G SP; QL
aptivus PB
atazanavir sulfate G QL
atripla NP QL
baraclude oral solution SP SP
baraclude oral tablet NC N5; SP
biktarvy NP PA
cidofovir intravenous SP SP
cimduo NP QL
combivir NC N5
complera NP QL
crixivan oral capsule 200 mg, 400 mg PB
cytovene NC N5; SP
daklinza SP PA; ST; SP; QL
delstrigo NP PA; QL
descovy NP QL
didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg
G
edurant PB QL
efavirenz G
emtriva oral capsule PB QL
emtriva oral solution PB
entecavir G SP; QL
epivir NC N5
epivir hbv oral solution NP #; SP
epivir hbv oral tablet NC N5
epzicom NP
evotaz NP
famciclovir oral G QL
flumadine NC N5
fosamprenavir calcium G
fuzeon subcutaneous solution reconstituted SP #; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201863
Drug Name Drug Status Drug Details
ganciclovir sodium intravenous solution reconstituted
SP SP
genvoya SP PA; QL
hepsera NC N5; SP
intelence PB QL
invirase NP
isentress hd NP QL
isentress oral packet NP
isentress oral tablet NP QL
isentress oral tablet chewable NP QL
juluca NP ST; QL
kaletra oral solution NC N5
kaletra oral tablet PB #
lamivudine G
lamivudine-zidovudine G
lexiva PB #
lopinavir-ritonavir G
moderiba 1200 dose pack NP SP
moderiba 800 dose pack NP SP
moderiba oral tablet 200 mg G SP
nevirapine er G QL
nevirapine oral tablet G
norvir oral packet PB
norvir oral solution PB #
norvir oral tablet PB
odefsey NP QL
oseltamivir phosphate oral G QL
pegasys proclick PB PA; SP
pegasys subcutaneous solution PB PA; SP
pifeltro NP
prevymis oral SP PA; SP; QL
prezcobix PB
prezista oral suspension PB QL
prezista oral tablet 150 mg, 600 mg, 75 mg, 800 mg
PB QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201864
Drug Name Drug Status Drug Details
rebetol oral capsule NC N5; SP
rebetol oral solution NP SP; QL
relenza diskhaler NP QL
rescriptor NP
retrovir intravenous NP
retrovir oral capsule NC N5
retrovir oral syrup NC N5
reyataz oral capsule 150 mg, 200 mg, 300 mg NP QL
reyataz oral packet NP #
ribasphere G SP
ribasphere ribapak oral tablet 400 mg, 600 mg G SP
ribavirin oral capsule G SP
ribavirin oral tablet 200 mg G SP
rimantadine hcl G
ritonavir G
selzentry oral solution PB QL
selzentry oral tablet 150 mg, 25 mg, 75 mg PB QL
selzentry oral tablet 300 mg PB
sitavig NC N5
sovaldi SP PA; SP; QL
stavudine oral capsule G
stribild SP PA; QL
sustiva NP
symfi NP
symfi lo NP
symtuza NP PA
tamiflu oral capsule NP QL
tamiflu oral suspension reconstituted 6 mg/ml NP QL
tenofovir disoproxil fumarate G QL
tivicay NP QL
triumeq PB QL
trizivir NC N5
truvada NP
valacyclovir hcl oral G
valcyte oral solution reconstituted SP PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201865
Drug Name Drug Status Drug Details
valcyte oral tablet NC N5; SP
valganciclovir hcl G PA; SP; QL
valtrex NC N5
vemlidy SP PA; ST; SP; QL
videx PB
videx ec NC N5
viracept oral tablet NP
viramune oral suspension NC
viramune oral tablet NC N5
viramune xr NC N5
viread oral powder NP #
viread oral tablet 150 mg, 200 mg, 250 mg NP #; QL
viread oral tablet 300 mg NP QL
zerit oral capsule NC N5
ziagen NC N5
zidovudine G
zovirax oral NC N5
*ASSORTED CLASSES*
astagraf xl oral capsule extended release 24 hour 0.5 mg, 1 mg
SP #; SP; QL
astagraf xl oral capsule extended release 24 hour 5 mg
SP #; SP
atgam SP SP
azasan NP
azathioprine oral G
benlysta intravenous SP PA; ST; SP
benlysta subcutaneous SP PA; ST; SP; QL
cellcept SP SP
cellcept intravenous SP
cuprimine oral capsule 250 mg SP PA; ST; #
cyclosporine intravenous G SP
cyclosporine modified G
cyclosporine oral capsule G
depen titratabs SP PA
envarsus xr SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201866
Drug Name Drug Status Drug Details
gengraf oral capsule 100 mg, 25 mg G
gengraf oral solution G
hylafem NC
imuran NC N5
lokelma NP PA
morcin NC
mycophenolate mofetil G SP
myfortic SP SP
neoral oral capsule SP SP
neoral oral solution NP SP
nulojix SP SP
physiolyte G
prograf SP SP
rapamune SP SP
revlimid SP PA; SP; QL
sandimmune SP SP
simulect SP SP
sirolimus oral G SP
sodium polystyrene sulfonate oral powder G
sterile water for irrigation G
syprine SP PA; SP
tacrolimus oral G SP
thalomid PB PA; #; SP
thymoglobulin SP SP
tis-u-sol G
traumeel external ointment NC
trientine hcl SP PA; SP
veltassa NP PA; QL
xiaflex SP SP
zortress oral tablet 0.25 mg, 0.5 mg, 0.75 mg SP #; SP
*ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES***
dupixent subcutaneous solution prefilled syringe 300 mg/2ml
SP PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201867
Drug Name Drug Status Drug Details
*BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB***
byvalson NP PA; ST; QL
*BETA BLOCKERS*
acebutolol hcl oral G
atenolol oral G
betapace af oral tablet 80 mg NP
betaxolol hcl oral G
bisoprolol fumarate G
bystolic NP PA; ST; QL
carvedilol G
carvedilol phosphate er G QL
coreg NC N5
coreg cr NP QL
corgard NC N5
hemangeol NP PA
inderal la NC N5
inderal xl oral capsule extended release 24 hour 80 mg
NP QL
innopran xl NP QL
kapspargo sprinkle NP
labetalol hcl intravenous solution G
labetalol hcl oral G
lopressor oral NC N5
metoprolol succinate er G QL
metoprolol tartrate intravenous solution 5 mg/5ml
G
metoprolol tartrate oral G
nadolol oral tablet 20 mg, 40 mg, 80 mg G
pindolol G
propranolol hcl er G
propranolol hcl intravenous G
propranolol hcl oral G
sorine G
sotalol hcl (af) oral tablet 120 mg, 160 mg G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201868
Drug Name Drug Status Drug Details
sotalol hcl intravenous G
sotalol hcl oral tablet 240 mg, 80 mg G
sotylize NP
timolol maleate oral G
toprol xl NC N5
*BILE ACID SYNTHESIS DISORDER AGENTS***
cholbam SP PA
*BIOLOGICALS MISC*
adagen SP PA; SP
mixed vespid venom protein injection solution reconstituted
G
venomil mixed vespid venom SP
*BULK CHEMICALS - NY***
nystatin G
*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***
aimovig NP PA; ST; QL
aimovig 140 dose NP PA; ST; QL
ajovy NP PA; ST; QL
emgality NP PA; ST; QL
*CALCIUM CHANNEL BLOCKERS*
adalat cc NC N5
afeditab cr G QL
amlodipine besylate oral G
calan sr NC N5
cardene iv intravenous solution 20-4.8 mg/200ml-%
NP
cardizem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg
NC N5
cardizem la oral tablet extended release 24 hour 120 mg
NP QL
cardizem la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
NC N5
cartia xt G QL
diltiazem hcl er beads G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201869
Drug Name Drug Status Drug Details
diltiazem hcl er coated beads oral capsule extended release 24 hour
G QL
diltiazem hcl er coated beads oral tablet extended release 24 hour 420 mg
G
diltiazem hcl er oral capsule extended release 12 hour
G
diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg
G
diltiazem hcl er oral capsule extended release 24 hour 240 mg
G QL
diltiazem hcl intravenous solution 50 mg/10ml G
diltiazem hcl intravenous solution reconstituted G
diltiazem hcl oral G
dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg
G
dilt-xr oral capsule extended release 24 hour 240 mg
G QL
felodipine er G QL
isoptin sr oral tablet extended release 240 mg NC N5
isradipine G
matzim la oral tablet extended release 24 hour180 mg, 240 mg, 300 mg, 360 mg
NP QL
matzim la oral tablet extended release 24 hour420 mg
NP
nicardipine hcl intravenous G
nicardipine hcl oral G
nifedical xl oral tablet extended release 24 hour60 mg
G QL
nifedipine er G QL
nifedipine er osmotic release G QL
nifedipine oral G
nimodipine oral G
nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
G QL
nisoldipine er oral tablet extended release 24 hour 25.5 mg
G
norvasc NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201870
Drug Name Drug Status Drug Details
nymalize oral solution 60 mg/20ml NP QL
procardia xl NC N5
sular oral tablet extended release 24 hour 17 mg, 34 mg, 8.5 mg
NC N5
taztia xt G QL
tiazac NC N5
verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg
G QL
verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg
G
verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg
G
verapamil hcl intravenous G
verapamil hcl oral G
verelan NC N5
*CARDIOTONICS*
digitek G
digox G
digoxin oral G
lanoxin oral tablet 125 mcg, 250 mcg NC N5
*CARDIOVASCULAR AGENTS - MISC.*
adcirca SP PA; ST; #; SP; QL
adempas SP PA; ST; SP; QL
amlodipine-atorvastatin NC N5
bidil NP
caduet oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
NC N5
epoprostenol sodium G PA; SP
flolan SP PA; SP
isoxsuprine hcl oral tablet 10 mg G
letairis SP PA; #; SP
opsumit SP PA; SP; QL
orenitram SP PA; SP
remodulin SP PA; #; SP
revatio intravenous SP PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201871
Drug Name Drug Status Drug Details
revatio oral suspension reconstituted SP PA; ST; #; SP
revatio oral tablet NC N5; SP
sildenafil citrate oral tablet 20 mg G PA; SP; QL
tadalafil (pah) SP PA; SP; QL
tadalafil oral tablet 2.5 mg, 5 mg G PA
tracleer oral tablet SP PA; #; SP
tracleer oral tablet soluble SP PA; SP
tyvaso SP PA; SP; QL
tyvaso refill SP PA; SP; QL
tyvaso starter SP PA; SP; QL
veletri SP PA; #; SP
ventavis SP PA; SP
*CEPHALOSPORINS*
cefaclor G
cefaclor er G
cefadroxil oral suspension reconstituted G
cefadroxil oral tablet G
cefazolin sodium injection SP
cefazolin sodium intravenous solution reconstituted
SP
cefdinir G
cefditoren pivoxil G
cefepime hcl SP
cefixime G
cefotaxime sodium injection solution reconstituted 1 gm, 500 mg
SP
cefotetan disodium SP
cefoxitin sodium SP
cefpodoxime proxetil G
cefprozil G
ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm
SP
ceftriaxone sodium in dextrose G
ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg
SP
ceftriaxone sodium intravenous SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201872
Drug Name Drug Status Drug Details
cefuroxime axetil oral tablet G
cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg
SP
cefuroxime sodium intravenous solution reconstituted 1.5 gm
SP
cephalexin oral capsule 250 mg, 500 mg G
cephalexin oral suspension reconstituted G
cephalexin oral tablet G
keflex NC N5
maxipime injection solution reconstituted 1 gm, 2 gm
NC N5
maxipime intravenous NC
spectracef oral tablet 400 mg NP
suprax oral capsule NP #
suprax oral suspension reconstituted NP
suprax oral tablet chewable NP #
tazicef injection SP
tazicef intravenous solution reconstituted SP
teflaro SP
*CHEMICALS*
cholestyramine G
pentylene glycol G
quinidine sulfate dihydrate G
sodium hydroxide pellet G
testosterone cypionate G
testosterone powder G
triacetin G
zinc acetate powder G
*CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS***
trulance PB QL
*CONTRACEPTIVES*
altavera CE
alyacen 1/35 CE
alyacen 7/7/7 CE
amethia CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201873
Drug Name Drug Status Drug Details
amethia lo CE
apri CE
aranelle CE
aubra eq CE
aviane CE
azurette CE
balcoltra NP
balziva CE
beyaz NP
briellyn CE
camila CE
camrese CE
camrese lo CE
caziant CE
cesia CE
chateal CE
chateal eq CE
cryselle-28 CE
cyclafem 1/35 CE
cyclafem 7/7/7 CE
dasetta 1/35 CE
dasetta 7/7/7 CE
daysee CE
deblitane CE
depo-provera intramuscular suspension 150 mg/ml
NP
desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg
CE
drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg
CE
drospirenone-ethinyl estradiol oral tablet 3-0.03 mg
CE
elinest CE
ella CE #
emoquette CE
enpresse-28 CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201874
Drug Name Drug Status Drug Details
enskyce oral tablet 0.15-30 mg-mcg CE
errin CE
estrostep fe NP
falessa oral kit 20-1-0.1 mcg-mg CE
falmina CE
fayosim CE
generess fe NP
gianvi CE
gildess fe 1.5/30 CE
gildess fe 1/20 CE
heather CE
introvale CE
isibloom CE
jolessa CE
jolivette CE
junel 1.5/30 CE
junel 1/20 CE
junel fe 1.5/30 CE
junel fe 1/20 CE
kariva CE
kelnor 1/35 CE
kurvelo CE
kyleena CE
larin fe 1.5/30 CE
leena CE
lessina CE
levonest CE
levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 mg
CE
levonorgestrel-ethinyl estrad CE
levora 0.15/30 (28) CE
lo loestrin fe NP
loestrin 1.5/30 (21) NP
loestrin 1/20 (21) NP
loryna CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201875
Drug Name Drug Status Drug Details
loseasonique NP
low-ogestrel CE
lutera CE
lyza CE
marlissa CE
medroxyprogesterone acetate intramuscular suspension
CE
mibelas 24 fe CE
microgestin 1.5/30 CE
microgestin 1/20 CE
microgestin fe 1.5/30 CE
microgestin fe 1/20 CE
minastrin 24 fe NP
mircette NP N5
mirena (52 mg) CE #
mono-linyah CE
mononessa CE
myzilra CE
natazia NP
necon 0.5/35 (28) CE
necon 1/35 (28) CE
nexplanon CE
next choice one dose CE QL
nikki CE
nora-be CE
norethin ace-eth estrad-fe CE
norethindrone oral CE
norethin-eth estradiol-fe CE
norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg
CE
norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-35 mcg
CE
norlyroc CE
nortrel 0.5/35 (28) CE
nortrel 1/35 (21) CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201876
Drug Name Drug Status Drug Details
nortrel 1/35 (28) CE
nortrel 7/7/7 CE
nuvaring CE #
ocella CE
ogestrel CE
option 2 CE
orsythia CE
ortho micronor NP
ortho tri-cyclen (28) NP
ortho tri-cyclen lo NP
ortho-cyclen (28) NP
ortho-novum 1/35 (28) NP
ortho-novum 7/7/7 (28) NP
paragard intrauterine copper CE
philith CE
plan b one-step NP
portia-28 CE
previfem CE
quartette CE
quasense CE
rajani CE
reclipsen CE
rivelsa CE
safyral NP
seasonique NP N5
sharobel CE
skyla CE
solia CE QL
sprintec 28 CE
sronyx CE
syeda CE
take action CE QL
taytulla NP #
tilia fe CE
tri femynor CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201877
Drug Name Drug Status Drug Details
tri-legest fe CE
tri-linyah CE
tri-mili CE
trinessa (28) CE
tri-norinyl (28) NP
tri-previfem CE
tri-sprintec CE
trivora (28) CE
tulana CE
tydemy CE
velivet CE
vestura CE
viorele CE
wera CE
wymzya fe CE
xulane CE
yasmin 28 NP
yaz NP
zarah CE
zovia 1/35e (28) CE
*CORTICOSTEROIDS*
budesonide er oral tablet extended release 24 hour
G QL
budesonide oral G
cortef NC N5
depo-medrol NP
dexamethasone intensol NP
dexamethasone oral elixir G
dexamethasone oral tablet G
dexamethasone oral tablet therapy pack G
dexamethasone sod phosphate pf G
dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml
G
emflaza NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201878
Drug Name Drug Status Drug Details
entocort ec oral capsule delayed release particles
NC N5
fludrocortisone acetate oral G
hydrocortisone oral G
medrol oral tablet NC N5
methylprednisolone oral G
methylprednisolone sodium succ injection solution reconstituted 40 mg
G
millipred oral solution NP
orapred odt NC N5
prednisolone oral solution G
prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
G
prednisolone sodium phosphate oral tablet dispersible
G
prednisone intensol NP
prednisone oral G
rayos NP ST
solu-cortef injection solution reconstituted 100 mg, 500 mg
NP
solu-medrol injection solution reconstituted 2 gm, 500 mg
NP
taperdex 12-day NC
taperdex 6-day NC
uceris oral NP ST; #; QL
*COUGH/COLD/ALLERGY*
acetylcysteine inhalation G
alavert allergy/sinus G Select OTC
allegra-d allergy & congestion G Select OTC
benzonatate G
cetirizine-pseudoephedrine er G Select OTC
clarinex-d 12 hour NP QL
claritin-d 12 hour G Select OTC
claritin-d 24 hour NC N5; Select OTC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201879
Drug Name Drug Status Drug Details
fexofenadine-pseudoephed er oral tablet extended release 24 hour
G Select OTC
guaifenesin ac NC
hydrocod polst-cpm polst er oral suspension extended release
G QL
hydromet G
loratadine-d 12hr G Select OTC
loratadine-d 24hr G Select OTC
lortuss ex oral liquid 30-10-100 mg/5ml NP
nebusal inhalation nebulization solution 3 % G
nebusal inhalation nebulization solution 6 % PB
promethazine vc/codeine G
promethazine-dm G
pseudoeph-chlorphen-hydrocod G
semprex-d NP
sodium chloride inhalation nebulization solution10 %, 7 %
G
sski NP
tessalon perles NC N5
tusnel c NC
tussicaps oral capsule extended release 12 hour 10-8 mg
NP QL
tussionex pennkinetic er oral suspension extended release
NP QL
tuzistra xr oral suspension extended release NP
zyrtec-d allergy & congestion NC N5; Select OTC
*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***
ibrance SP PA; SP; QL
kisqali 200 dose SP PA; SP; QL
kisqali 400 dose SP PA; SP; QL
kisqali 600 dose SP PA; SP; QL
verzenio SP PA; SP; QL
*CYSTIC FIBROSIS AGENT - COMBINATIONS***
orkambi oral packet SP PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201880
Drug Name Drug Status Drug Details
orkambi oral tablet SP PA; QL
symdeko SP PA; SP; QL
*DERMATOLOGICALS*
abreva G Select OTC
absorica NC N5
acanya NC N5; #
acitretin G QL
acyclovir external G
aczone external gel 5 % NP ST; QL
aczone external gel 7.5 % NP ST; #; QL
adapalene external cream G PA; AL
adapalene external gel 0.1 % NC
adapalene external gel 0.3 % G PA; AL
adapalene external lotion G PA; AL
adapalene external solution NC
adapalene-benzoyl peroxide G PA; AL
aktipak NP
ala scalp NP
ala-quin NC
alclometasone dipropionate G
alcortin a NC
aldara NC N5
altabax NP
altreno NC
amcinonide external cream G ST
amcinonide external lotion G ST
amcinonide external ointment G
ameluz NP #
ammonium lactate external G
amnesteem G PA; QL
apexicon e NP ST
astero NC
atralin NC N5
avage NP
avar cleanser NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201881
Drug Name Drug Status Drug Details
avar ls cleanser NC N5
avar-e emollient NC
avar-e green NC
avar-e ls NC N5
avita G PA; AL
avo cream NP
azelex NP
bactroban external cream NC N5
bensal hp NC
benzaclin NC N5
benzaclin with pump NC N5
benzoyl peroxide-erythromycin G
betamethasone dipropionate aug external cream G
betamethasone dipropionate aug external gel G QL
betamethasone dipropionate aug external lotion G QL
betamethasone dipropionate aug external ointment
G QL
betamethasone dipropionate external G
betamethasone valerate external cream G ST
betamethasone valerate external foam G
betamethasone valerate external lotion G ST
betamethasone valerate external ointment G ST
biafine NP
bionect external cream NP
bionect external gel NP
botox cosmetic intramuscular solution reconstituted 100 unit
NC N5
bp 10-1 NC
bp cleansing wash NP
calcipotriene external cream G ST
calcipotriene external ointment G ST
calcipotriene external solution G
calcipotriene-betameth diprop NC N5
calcitrene NP ST
calcitriol external G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201882
Drug Name Drug Status Drug Details
cantharidin G
capex NC N5
carac NC N5
cem-urea NC
centany NC N5
centany at NP
ciclodan external solution G PA
ciclodan solution NC N5
ciclopirox external gel G
ciclopirox external shampoo G
ciclopirox external solution G PA
ciclopirox olamine external G
ciclopirox treatment NC N5
claravis G PA; QL
cleocin-t NC N5
clindacin etz external kit NC N5
clindacin pac NC N5
clindagel NC N5
clindamycin phos-benzoyl perox external gel1.2-2.5 %
NC
clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-5 %
NC N5
clindamycin phosphate external foam G
clindamycin phosphate external gel G ST
clindamycin phosphate external lotion G ST
clindamycin phosphate external solution G ST
clindamycin phosphate external swab G
clindamycin-tretinoin G PA; AL
clobetasol propionate e G ST; QL
clobetasol propionate emulsion G QL
clobetasol propionate external cream G ST; QL
clobetasol propionate external foam G QL
clobetasol propionate external gel G ST; QL
clobetasol propionate external liquid G QL
clobetasol propionate external lotion G ST; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201883
Drug Name Drug Status Drug Details
clobetasol propionate external ointment G ST; QL
clobetasol propionate external shampoo G QL
clobetasol propionate external solution G ST; QL
clobex NC N5
clobex spray NC N5
clocortolone pivalate G
clodan external shampoo NP QL
cloderm NP
clotrimazole-betamethasone G
coal tar external solution G
collagenase G
condylox external gel NP
cordran external cream 0.05 % NP QL
cordran external lotion NP QL
cordran external ointment NP QL
cordran external tape NP #; QL
cortisporin external PB
cosentyx SP PA; ST; SP
cosentyx sensoready pen subcutaneous solution auto-injector 150 mg/ml
SP PA; ST; SP
crotan G
cutivate external lotion NC N5
dapsone external G QL
denavir NP
derma-smoothe/fs body NC N5
dermasorb ta NP
desonate NP #
desonide external G ST
desowen external cream NC N5
desowen external lotion NC N5
desoximetasone external cream G ST
desoximetasone external gel G ST
desoximetasone external liquid NC
desoximetasone external ointment G ST
diclofenac sodium transdermal gel 1 % G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201884
Drug Name Drug Status Drug Details
diclofenac sodium transdermal gel 3 % NC N5
diclofenac sodium transdermal solution NC N5
diclofex dc NC
differin external cream NC N5
differin external gel 0.1 % G PA; Select OTC; AL
differin external gel 0.3 % NC N5
differin external lotion NP PA; ST; AL
diflorasone diacetate external cream G ST
diflorasone diacetate external ointment G
diprolene NC N5
diprolene af NC N5
dovonex external cream NC N5
doxepin hcl external G QL
doxycycline NC N5
dritho-creme hp NP
duac NC N5
econazole nitrate external G QL
ecoza NC N5
efudex external cream NC N5
elidel NP PA; ST; #
elocon external cream NC N5
elocon external ointment NC N5
enstilar NP QL
epiceram NP
epiduo PB PA; AL
epiduo forte PB PA; #; AL
epifoam NP
ertaczo NC N5
ery G
erygel NC N5
erythromycin external G
eurax NP
exelderm NC N5
exoderm external lotion NP
extina NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201885
Drug Name Drug Status Drug Details
fabior NP PA; ST; AL
finacea external foam NP
finacea external gel NP #
finasteride oral tablet 1 mg G
flector NC N5; #
fluocinolone acetonide G
fluocinolone acetonide body G
fluocinolone acetonide external cream G ST
fluocinolone acetonide external ointment G ST
fluocinolone acetonide external solution G
fluocinonide external cream G ST; QL
fluocinonide external gel G ST; QL
fluocinonide external ointment G ST; QL
fluocinonide external solution G QL
fluoroplex NC N5
fluorouracil external cream 0.5 % NC N5
fluorouracil external cream 5 % G
fluorouracil external solution G
flurandrenolide G QL
fluticasone propionate external cream G ST
fluticasone propionate external lotion G
fluticasone propionate external ointment G
gebauers pain ease NP
gebauers spray and stretch NP
genadur external NP
gentamicin sulfate external G
geri-hydrolac 12 external cream NP
halobetasol propionate G ST; QL
halog NP
hydrocortisone ace-pramoxine external cream2.5-1 %
NC
hydrocortisone butyr lipo base G
hydrocortisone butyrate external lotion G
hydrocortisone butyrate external ointment G
hydrocortisone butyrate external solution G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201886
Drug Name Drug Status Drug Details
hydrocortisone external cream 2.5 % G
hydrocortisone external lotion 2.5 % G
hydrocortisone external ointment 2.5 % G
hydrocortisone valerate G
hylatopic plus external cream NP
ilumya SP PA; ST; SP; QL
imiquimod external G QL
imiquimod pump G ST
impoyz NC
inova 4/1 acne control therapy NP
inova 8/2 acne control therapy NP
isotretinoin oral G PA; QL
jublia NP PA; ST
kenalog external NC N5
keralyt scalp NP
ketoconazole external cream G
ketoconazole external foam NC N5
ketoconazole external shampoo G
klaron NC N5
klofensaid ii NC N5
lactic acid e G
lactic acid external lotion G
latisse NP
ldo plus NC
levulan kerastick NP QL
lidocaine external ointment G PA; QL
lidocaine external patch 5 % G PA; ST; QL
lidocaine hcl external solution G
lidocaine pak G PA; QL
lidocaine-prilocaine external cream G PA; QL
lidocaine-tetracaine G QL
lidoderm NC N5
lindane external shampoo G
locoid external cream NC N5
locoid external lotion NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201887
Drug Name Drug Status Drug Details
locoid lipocream NC N5
loprox external cream NC N5
loprox external kit 0.77 % NC N5
loprox external shampoo NC N5
lotrisone external cream NC N5
luliconazole NC
luxiq NC N5
luzu NC N5
lycelle NP
malathion external G
melpaque hp G
methoxsalen rapid G
metrocream NP
metrogel external gel NC N5
metrolotion NP
metronidazole external gel G
micort-hc NC N5
mirvaso NC N5
mometasone furoate external cream G ST
mometasone furoate external ointment G ST
mometasone furoate external solution G
mupirocin calcium G QL
mupirocin external G QL
myorisan oral capsule 10 mg, 20 mg, 40 mg G PA; QL
myorisan oral capsule 30 mg G PA; QL
naftifine hcl external cream 2 % NC N5
naftin external cream 2 % NC N5
naftin external gel 1 % NC N5
naftin external gel 2 % NC LGC; N5; #
napro external NC N5
natroba NP
neosalus cp NP
neosalus external foam NP
neosalus external lotion NP
neo-synalar external cream NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201888
Drug Name Drug Status Drug Details
neuac external gel NC N5
nizoral NC N5
nolix external lotion G QL
noritate NP
nucort NC N5
nyamyc G
nystatin external G
nystatin-triamcinolone G
nystop G
olux NC N5
olux-e NC N5
onexton NC N5; #
oracea NC N5
ovace plus external shampoo NC N5
ovace plus wash NC N5
ovace wash NC N5
ovide NC N5
oxiconazole nitrate NC N5
oxistat NC N5
oxsoralen ultra NC N5
pandel NP
panretin PB
penlac NC N5
pennsaid transdermal solution 2 % NC N5
permethrin external cream G
picato PB QL
plexion NC N5
plexion cleanser external liquid NC N5
plexion cleansing cloth external pad NC
plixda NC
podocon G
pramosone external cream 1-1 % NP
pramosone external lotion 1-2.5 % NP
pramosone external ointment 1-2.5 % NP
prednicarbate G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201889
Drug Name Drug Status Drug Details
promiseb NP
propecia NP
protopic NC N5
prudoxin NP QL
prutect NP
psorcon G ST
qbrexza NP PA; ST; QL
radiagel NP
radiaplexrx NP
refissa NP
regenecare NP
regranex NP PA; QL
renova NP
retin-a NC N5
retin-a micro NC N5
retin-a micro pump external gel 0.04 %, 0.1 % NC N5
retin-a micro pump external gel 0.06 % NC
retin-a micro pump external gel 0.08 % NP PA; ST; AL
rhofade NP QL
rosadan external gel G
rosadan external kit NC N5
rosanil cleanser NC
rynoderm NC
salex NP
salicylic acid external cream G
salicylic acid external liquid 26 % G
salicylic acid external lotion G
salicylic acid external shampoo G
salicylic acid wart remover G
santyl NP QL
selenium sulfide external lotion G
selenium sulfide external shampoo 2.25 % NC
selrx NC N5
sernivo NP
siliq SP PA; ST; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201890
Drug Name Drug Status Drug Details
silvadene NC N5
silver nitrate external G
silver sulfadiazine external G
sklice NP
sodium sulfacetamide external shampoo G
sonafine NP
soolantra NP ST
soriatane oral capsule 10 mg, 25 mg NC N5
sorilux NC N5
spinosad G
sss 10-5 NC
stelara subcutaneous solution 45 mg/0.5ml SP PA; ST; SP; QL
stelara subcutaneous solution prefilled syringe SP PA; ST; SP; QL
sulfacetamide sodium (acne) G
sulfacetamide sodium external gel G
sulfacetamide sodium external liquid G
sulfacetamide sodium-sulfur external cream NC
sulfacetamide sodium-sulfur external emulsion NC
sulfacetamide sodium-sulfur external liquid 10-2 %, 9.8-4.8 %
NC
sulfacetamide sodium-sulfur external lotion NC
sulfacetamide sodium-sulfur external pad 10-4 % NC
sulfacetamide sodium-sulfur external suspension NC
sulfacetamide sod-sulfur wash external kit NC N5
sulfacleanse 8/4 NC
sulfamylon NP
sumadan NC N5
sumaxin NC
sumaxin cp NC N5
synalar (cream) NC N5
synalar (ointment) NC N5
synalar external cream NP ST
synalar external ointment G ST
synalar ts NC N5
synera NP QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201891
Drug Name Drug Status Drug Details
taclonex external ointment NC N5
taclonex external suspension NP #; QL
tacrolimus external G PA; ST
taltz SP PA; ST; SP
targretin external SP PA; SP
tazarotene external G PA; AL
tazorac NP PA; ST; AL
temovate external cream NP ST; QL
temovate external ointment NC N5
texacort PB
tolak NC N5; #
topicort external cream NC N5
topicort external gel NC N5
topicort external ointment NC N5
topicort spray NC N5
tremfya SP PA; ST; SP; QL
tretinoin (emollient) G
tretinoin external cream G PA; AL
tretinoin external gel 0.01 %, 0.025 % G PA; AL
tretinoin external gel 0.05 % G PA
tretinoin microsphere G PA; AL
tretinoin microsphere pump G PA; AL
triamcinolone acetonide external aerosol solution
G
triamcinolone acetonide external cream G
triamcinolone acetonide external lotion G
triamcinolone acetonide external ointment 0.025 %
G
triamcinolone acetonide external ointment 0.1 %, 0.5 %
G LGC
triderm external cream 0.1 % LGC LGC
triderm external cream 0.5 % LGC LGC
tridesilon NC N5
tri-luma NP
ulesfia NP #; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201892
Drug Name Drug Status Drug Details
ultravate external cream NC N5
ultravate external lotion NP QL
ultravate external ointment NC N5
utopic NC
valchlor SP PA; SP; QL
vaniqa NP
vanos NC N5
vectical NP
veltin NP PA; ST; AL
venipuncture cpi NC
verdeso NC N5
virasal NP
voltaren transdermal PB QL
vusion NP
xelitral NC
xepi NP QL
xerese NP
xolegel NC N5
zenatane oral capsule 10 mg, 20 mg, 40 mg G PA; QL
zenatane oral capsule 30 mg G PA; QL
ziana NP PA; ST; AL
zonalon NP QL
zovirax external ointment NC N5
ztlido NC
zyclara NC N5; #
zyclara pump external cream 2.5 % NC N5
zyclara pump external cream 3.75 % NC N5; #
*DIAGNOSTIC PRODUCTS*
accu-chek aviva plus in vitro NC N5
accu-chek compact plus NC N5
accu-chek smartview NC N5
accutrend glucose NC N5
advance intuition test NC N5
advance micro-draw test NC N5
advocate redi-code in vitro NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201893
Drug Name Drug Status Drug Details
advocate redi-code+ test NC N5
advocate test NC N5
agamatrix amp test NC N5
agamatrix jazz test NC N5
agamatrix keynote test NC N5
agamatrix presto test NC N5
assure 3 test NC N5
assure 4 test NC N5
assure ii NC N5
assure ii check NC N5
assure platinum NC N5
assure prism multi test NC N5
assure pro test NC N5
bayer breeze 2 test NC N5
bayer contour test NC N5
bioscanner glucose test NC N5
blood glucose test NC N5
caresens n glucose test NC N5
chemstrip k NP
clever chek auto-code test NC N5
clever chek auto-code voice in vitro NC N5
clever chek test NC N5
clever choice auto-code test NC N5
clever choice micro test NC N5
cool blood glucose test strips NC N5
cvs advanced glucose test NC N5
diatrue plus test NC N5
duo-care test NC N5
easy plus ii glucose test NC N5
easy step test NC N5
easy talk blood glucose test NC N5
easy touch healthpro test NC N5
easy touch test NC N5
easy trak blood glucose test NC N5
easygluco in vitro NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201894
Drug Name Drug Status Drug Details
easygluco plus in vitro NC N5
easymax 15 test NC N5
easymax test NC N5
easyplus blood glucose test NC N5
easypro blood glucose test NC N5
easypro plus in vitro NC N5
element compact test NC N5
element test NC N5
embrace blood glucose test NC N5
embrace evo blood glucose test NC N5
embrace pro glucose test NC N5
evencare + blood glucose test NC N5
evencare blood glucose test NC N5
evencare g2 test NC N5
evencare g3 test NC N5
evencare mini glucose test NC N5
evolution autocode in vitro NC N5
ez smart blood glucose test NC N5
ez smart plus glucose test NC N5
fifty50 glucose test 2.0 NC N5
fora d15g blood glucose test NC N5
fora d20 blood glucose test NC N5
fora d40/g31 blood glucose NC N5
fora g20 blood glucose test NC N5
fora g30/prem v10 glucose test NC N5
fora gd20 test NC N5
fora gd50 blood glucose test NC N5
fora tn'g/tn'g voice NC N5
fora v10 blood glucose test NC N5
fora v12 blood glucose test NC N5
fora v20 blood glucose test NC N5
fora v30a blood glucose test NC N5
foracare gd40 test NC N5
foracare premium v10 test NC N5
foracare test n go test NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201895
Drug Name Drug Status Drug Details
fortiscare test NC N5
freestyle insulinx test PB QL
freestyle lite test PB QL
freestyle precision neo test PB QL
freestyle test PB QL
gastrografin NC N5
ge100 blood glucose test NC N5
genstrip 50 NC N5
ght test NC N5
glucagen diagnostic PB QL
gluco perfect 3 test NC N5
glucocard 01 sensor plus NC N5
glucocard expression test NC N5
glucocard shine test NC N5
glucocard vital test NC N5
glucocard x-sensor NC N5
glucocom test NC N5
gluconavii blood glucose test NC N5
in touch blood glucose test NC N5
infinity blood glucose test NC N5
ketocare NP
ketostix NP
kroger blood glucose test NC N5
kroger test NC N5
liberty next generation test NC N5
liberty test NC N5
md-gastroview NP
meijer blood glucose test NC N5
meijer truetest test NC N5
meijer truetrack test NC N5
metopirone NP
microdot test NC N5
myglucohealth test NC N5
neutek 2tek test NC N5
nova max glucose test NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201896
Drug Name Drug Status Drug Details
on call express blood glucose NC N5
on call plus blood glucose NC N5
on call vivid blood glucose NC N5
onetouch ultra blue PB QL
onetouch verio in vitro strip PB QL
optumrx blood glucose test NC N5
pocketchem ez test NC N5
precision pcx PB QL
precision pcx plus test PB QL
precision point of care test PB QL
precision qid test PB QL
precision sof-tact test PB QL
precision xtra blood glucose PB QL
precision xtra ketone NP
prodigy no coding blood gluc NC N5
pts panels glucose test NC N5
quicktek test NC N5
quintet ac blood glucose test NC N5
quintet blood glucose test NC N5
ra truetest test NC N5
refuah plus blood glucose test NC N5
reveal blood glucose test NC N5
rightest gs100 blood glucose NC N5
rightest gs300 blood glucose NC N5
rightest gs550 blood glucose NC N5
smart sense value test NC N5
smartest blood glucose test NC N5
solus v2 test NC N5
supreme test NC N5
sure edge test NC N5
surechek blood glucose test NC N5
sure-test easyplus mini test NC N5
telcare blood glucose test NC N5
thyrogen SP SP
true metrix blood glucose test NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201897
Drug Name Drug Status Drug Details
truetest test NC N5
truetrack test NC N5
ultima test NC N5
ultratrak pro test NC N5
ultratrak ultimate test NC N5
unistrip1 generic NC N5
victory agm-4000 test NC N5
vocal point blood glucose test NC N5
wavesense presto NC N5
*DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS*
apptrim MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
apptrim-d MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
availnex MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
axona MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
cardiotek rx oral tablet MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
cerefolin MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
cerefolin nac MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
deplin 15 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
deplin 7.5 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201898
Drug Name Drug Status Drug Details
enlyte MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
enteragam MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
folbic MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
folbic rf MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
foltanx MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
foltanx rf MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
foltx oral tablet 1.13-25-2 mg MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
fosteum MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
fosteum plus MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
fovex MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
gabadone MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
hypertensa MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
limbrel MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/201899
Drug Name Drug Status Drug Details
limbrel250 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
limbrel500 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
lipichol 540 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
lister-v MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
l-methylfolate ca me-cbl nac MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
l-methylfolate forte MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
l-methylfolate-algae-b12-b6 MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 1
l-methylfolate-b6-b12 oral tablet 3-35-2 mg MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 1
l-methyl-mc MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
l-methyl-mc nac MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
macutek MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
metafolbic MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
metafolbic plus MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018100
Drug Name Drug Status Drug Details
metafolbic plus rf MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
metanx oral capsule MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
percura MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
proteolin ds MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
proteolin oral tablet MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
pulmona MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
sentra am MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
sentra pm MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
theramine MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; Tier 3
theramine plus MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
trepadone MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
vascazen MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
vasculera MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018101
Drug Name Drug Status Drug Details
vayacog MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
vayarin MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
vayarol MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
vsl#3 junior MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
vsl#3 oral packet MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
zytaze MOnly covered in states: CT, DE, IN, KY, LA and TX and excluded elsewhere; TIER 3
*DIGESTIVE AIDS*
creon PB
pancreaze NP ST
pertzye NP ST
sucraid SP SP
viokace NP ST
zenpep oral capsule delayed release particles 10000-32000 unit, 15000-47000 unit, 20000-63000 unit, 25000-79000 unit, 3000-14000 unit, 40000-126000 unit, 5000-24000 unit
PB
*DIRECT-ACTING P2Y12 INHIBITORS***
brilinta PB QL
*DIURETICS*
acetazolamide er NC N5
acetazolamide oral G
aldactazide NC N5
aldactone NC N5
amiloride hcl oral G
amiloride-hydrochlorothiazide G
bumetanide injection G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018102
Drug Name Drug Status Drug Details
bumetanide oral G
carospir NC N5
chlorothiazide oral G
chlorothiazide sodium G
chlorthalidone oral tablet 25 mg, 50 mg G
demadex oral tablet 10 mg, 20 mg NC N5
diuril NP
dyazide NC N5
dyrenium NP
edecrin NP
ethacrynic acid oral G
furosemide oral solution 10 mg/ml, 8 mg/ml G
furosemide oral tablet G
hydrochlorothiazide oral tablet G
indapamide oral G
keveyis SP PA; QL
lasix NC N5
maxzide NC N5
maxzide-25 NC N5
methazolamide oral tablet 25 mg G
methyclothiazide oral G
metolazone G
sodium edecrin NP
spironolactone oral G
spironolactone-hctz G
torsemide oral G
triamterene-hctz oral capsule 37.5-25 mg G
triamterene-hctz oral tablet G
*ENDOCRINE AND METABOLIC AGENTS - MISC.*
actonel oral tablet 150 mg, 30 mg, 35 mg, 5 mg NC N5
aldurazyme SP PA; SP
alendronate sodium oral solution G
alendronate sodium oral tablet G QL
ammonul SP SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018103
Drug Name Drug Status Drug Details
atelvia NC N5
binosto NC N5
boniva intravenous NC N5; SP
boniva oral tablet 150 mg NC N5
bravelle M
PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; Tier 4; SP
buphenyl oral powder 3 gm/tsp NC N5; SP
buphenyl oral tablet NC SP
cabergoline G
calcitonin (salmon) G QL
calcitriol oral G
carbaglu SP PA; #; SP
carnitor oral solution NP
carnitor sf NP
cetrotide subcutaneous kit 0.25 mg M
PA; #; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 5; SP
chorionic gonadotropin intramuscular G PA; SP
clomiphene citrate oral MOnly covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 3
cystadane SP SP
ddavp injection solution 4 mcg/ml NC N5
ddavp oral NC N5
ddavp rhinal tube NC N5
desmopressin ace spray refrig G
desmopressin acetate injection G
desmopressin acetate oral G
doxercalciferol intravenous NC
doxercalciferol oral G QL
egrifta subcutaneous solution reconstituted 1 mg
NC N5
elaprase SP PA; SP
etidronate disodium G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018104
Drug Name Drug Status Drug Details
evista NP
fabrazyme SP PA; SP
follistim aq subcutaneous M
PA; ST; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; Tier 4; SP
forteo subcutaneous solution 600 mcg/2.4ml SP PA; ST; #; SP
fosamax oral tablet 70 mg NC N5
fosamax plus d NP ST; QL
galafold SP SP; QL
ganirelix acetate SP PA; SP
genotropin SP PA; ST; SP
genotropin miniquick SP PA; ST; SP
gonal-f injection solution reconstituted 1050 unit
M
PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; Tier 4; SP
gonal-f injection solution reconstituted 450 unit
M
PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 5; SP
gonal-f rff M
PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; Tier 4; SP
gonal-f rff rediject M
PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; Tier 4; SP
hectorol intravenous solution 2 mcg/ml NC
hectorol intravenous solution 4 mcg/2ml NC N5
hp acthar SP PA; SP
humatrope SP PA; ST; SP
ibandronate sodium intravenous solution 3 mg/3ml
SP ST; SP
ibandronate sodium oral G ST; QL
increlex SP PA; SP
jynarque SP PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018105
Drug Name Drug Status Drug Details
kuvan SP PA; SP
levocarnitine oral solution G
lumizyme SP PA; SP
lupron depot-ped (1-month) SP PA; #; SP
lupron depot-ped (3-month) SP PA; #; SP
menopur M
PA; ST; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 5; SP
miacalcin injection SP PA
miacalcin nasal NC N5
naglazyme SP PA; SP
natpara SP PA; QL
nityr SP PA; SP
nocdurna NP PA; QL
noctiva PB QL; AL
norditropin flexpro SP PA; ST; SP
novarel intramuscular solution reconstituted10000 unit
G
PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; Tier 4; SP
nutropin aq nuspin 10 SP PA; ST; SP
nutropin aq nuspin 20 SP PA; ST; SP
nutropin aq nuspin 5 SP PA; ST; SP
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml
G PA; SP
omnitrope SP PA; SP
orfadin oral capsule 10 mg, 2 mg, 5 mg SP PA; SP
orfadin oral capsule 20 mg SP PA
orfadin oral suspension SP PA; SP
orilissa SP PA; SP; QL
osphena NP QL
ovidrel M
PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; TIER 5; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018106
Drug Name Drug Status Drug Details
palynziq SP PA; ST; SP; QL
pamidronate disodium SP SP
paricalcitol intravenous NC
paricalcitol oral G QL
pregnyl G
PA; Only covered in states: CT,IL, KS, MD, NC, and WV and excluded elsewhere; Tier 4; SP
prolia SP PA; ST; SP
raloxifene hcl CE
ravicti SP PA; ST; SP; QL
rayaldee NP PA; ST; QL
reclast NC N5; SP
risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg
G ST; QL
risedronate sodium oral tablet delayed release G QL
rocaltrol oral capsule NC N5
saizen SP PA; ST; SP
samsca SP PA; #; SP; QL
sandostatin injection solution 100 mcg/ml, 50 mcg/ml, 500 mcg/ml
NC N5; SP
sandostatin lar depot SP PA; #; SP
sensipar NP PA; #; QL
serostim subcutaneous solution reconstituted 4 mg, 5 mg, 6 mg
SP PA; SP
signifor SP PA; SP; QL
signifor lar intramuscular suspension reconstituted er
SP PA; SP; QL
sod benz-sod phenylacet G
sodium phenylbutyrate oral powder 3 gm/tsp SP PA; SP
sodium phenylbutyrate oral tablet SP PA; SP
somatuline depot SP PA; #; SP
somavert SP PA; #; SP
stimate NP PA
supprelin la SP PA; SP
synarel SP PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018107
Drug Name Drug Status Drug Details
triptodur SP PA; SP
tymlos SP PA; ST; SP; QL
xgeva SP PA; ST; SP
zemplar intravenous NC N5
zemplar oral capsule 1 mcg, 2 mcg NC N5
zoledronic acid intravenous concentrate SP SP
zoledronic acid intravenous solution SP SP
zomacton SP PA; ST; SP
zometa intravenous concentrate NC N5; SP
zometa intravenous solution NC SP
zorbtive SP PA; SP
*ESTROGENS*
activella NC N5
alora NC N5
angeliq NP
climara NC N5
climara pro NP #; QL
combipatch NP QL
delestrogen intramuscular oil 10 mg/ml, 40 mg/ml
NP
delestrogen intramuscular oil 20 mg/ml NC N5
depo-estradiol NP
elestrin NP QL
estrace oral NC N5
estradiol oral G
estradiol transdermal G QL
estradiol valerate intramuscular oil 20 mg/ml G
estradiol-norethindrone acet G QL
estrogel NP QL
evamist NP QL
femhrt low dose NP
fyavolv G
jinteli G
menest oral tablet 0.3 mg, 0.625 mg PB
menest oral tablet 1.25 mg NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018108
Drug Name Drug Status Drug Details
menostar NP #; QL
mimvey G QL
minivelle NC N5; #
norethindrone-eth estradiol G
prefest NP QL
premarin injection NP
premarin oral PB
premphase PB
prempro PB
vivelle-dot NC N5
*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***
duavee PB QL
*FARNESOID X RECEPTOR (FXR) AGONISTS***
ocaliva oral tablet 5 mg SP PA; ST; SP; QL
*FLUOROQUINOLONES*
avelox intravenous NP
avelox oral NC N5
baxdela oral NP PA; QL
cipro oral suspension reconstituted NP
cipro oral tablet 250 mg, 500 mg NC N5
cipro xr NC N5
ciprofloxacin hcl oral G
ciprofloxacin in d5w intravenous solution 400 mg/200ml
G
ciprofloxacin oral suspension reconstituted 500 mg/5ml (10%)
G
ciprofloxacin-ciproflox hcl er G
levaquin oral tablet NC N5
levofloxacin in d5w intravenous solution 750 mg/150ml
G
levofloxacin oral G
moxifloxacin hcl oral G
ofloxacin oral tablet 300 mg G QL
ofloxacin oral tablet 400 mg G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018109
Drug Name Drug Status Drug Details
*GASTROINTESTINAL AGENTS - MISC.*
actigall NC N5
alosetron hcl G PA; ST
amitiza NP ST; QL
apriso NP ST; #; QL
asacol hd NP ST; QL
azulfidine NC N5
azulfidine en-tabs NC N5
balsalazide disodium G QL
canasa PB #; QL
chenodal SP PA
cimzia prefilled SP PA; ST; SP; QL
cimzia starter kit SP PA; ST; SP; QL
cimzia subcutaneous kit 2 x 200 mg SP PA; ST; SP; QL
colazal NC N5
cromolyn sodium oral G
delzicol PB #; QL
dipentum NP ST; QL
enulose G
fosrenol oral packet NP
fosrenol oral tablet chewable 1000 mg, 500 mg, 750 mg
NP
gastrocrom NC N5
gattex SP PA; SP; QL
generlac G
inflectra SP PA; ST; SP
lactulose encephalopathy G
lanthanum carbonate G
lialda PB QL
linzess oral capsule 145 mcg, 290 mcg PB QL
linzess oral capsule 72 mcg PB
lotronex NC N5
mesalamine oral G QL
mesalamine rectal G
mesalamine-cleanser G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018110
Drug Name Drug Status Drug Details
metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml
G
metoclopramide hcl oral tablet G
metoclopramide hcl oral tablet dispersible G
movantik PB QL
pentasa PB QL
phoslo NP
phoslyra NP
reglan oral NC N5
relistor oral NP PA; #; QL
relistor subcutaneous solution 12 mg/0.6ml, 8 mg/0.4ml
NP PA; QL
remicade SP PA; ST; SP
renagel oral tablet 800 mg NP #
renflexis SP PA; ST; SP
renvela PB
rowasa rectal NC N5
sevelamer carbonate G
sfrowasa NP
sulfasalazine oral G QL
sulfazine G QL
symproic NP PA; ST; QL
urso 250 NC N5
urso forte NC N5
ursodiol oral G
velphoro NP #
*GENITOURINARY AGENTS - MISCELLANEOUS*
acetic acid irrigation G
alfuzosin hcl er G QL
argyle sterile saline G
avodart NC N5
cardura xl NP QL
cystagon NP PA
cytra-2 NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018111
Drug Name Drug Status Drug Details
dutasteride oral G QL
dutasteride-tamsulosin hcl G
elmiron PB QL
finasteride oral tablet 5 mg G PA
flomax NC N5
jalyn NC N5
lithostat PB
neomycin-polymyxin b gu G
phenazopyridine hcl oral tablet 100 mg G
potassium citrate er oral tablet extended release10 meq (1080 mg), 15 meq (1620 mg)
G
potassium citrate-citric acid oral solution G
procysbi SP PA; ST; SP; QL
proscar NC N5
pyridium oral tablet 100 mg NP
rapaflo PB #
renacidin PB
shohls modified NC
sod citrate-citric acid NC
sodium chloride irrigation solution 0.9 % G
tamsulosin hcl G
thiola SP PA; ST
urocit-k 10 NC N5
urocit-k 15 NC N5
urocit-k 5 NC N5
*GLYCOPEPTIDES***
firvanq oral solution reconstituted 25 mg/ml NP
vancomycin hcl oral G
*GOUT AGENTS*
aloprim NP
colchicine oral G QL
colchicine-probenecid G
colcrys NC N5
duzallo NP PA; ST; QL
krystexxa SP PA; ST; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018112
Drug Name Drug Status Drug Details
mitigare PB QL
probenecid oral G
uloric NP ST; QL
zurampic NP PA; ST; QL
zyloprim NP
*HEMATOLOGICAL AGENTS - MISC.*
advate SP PA; SP
adynovate intravenous solution reconstituted 1000 unit, 2000 unit, 250 unit, 500 unit
SP PA
adynovate intravenous solution reconstituted 1500 unit, 3000 unit, 750 unit
SP PA; SP
afstyla SP PA; SP
aggrenox NP
alphanate/vwf complex/human NC N5
alphanine sd NC N5; SP
alprolix NC N5; SP
anagrelide hcl G
aspirin-dipyridamole er G
bebulin NC N5; SP
benefix intravenous kit SP PA; SP
berinert SP PA; ST; SP
brilinta PB QL
cilostazol G
cinryze SP PA; ST; SP; QL
clopidogrel bisulfate oral G QL
coagadex SP PA
corifact NC N5; SP
dipyridamole oral G
durlaza NP
effient NP PA; QL
eloctate intravenous solution reconstituted 1000 unit, 1500 unit, 2000 unit, 250 unit, 3000 unit, 500 unit, 750 unit
NC N5; SP
eloctate intravenous solution reconstituted 4000 unit, 5000 unit, 6000 unit
NC N5
feiba SP PA
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018113
Drug Name Drug Status Drug Details
fibryga NC
firazyr NC N5; #
haegarda SP PA; ST; SP; QL
helixate fs intravenous kit 1000 unit, 2000 unit, 250 unit, 500 unit
NC N5
helixate fs intravenous kit 3000 unit SP PA; SP
hemofil m intravenous solution reconstituted 1000 unit, 1700 unit, 250 unit, 500 unit
NC N5; SP
humate-p intravenous solution reconstituted 1000-2400 unit, 250-600 unit, 500-1200 unit
NC N5; SP
idelvion SP PA; SP
ixinity SP PA
jivi SP PA; SP
kalbitor SP PA; ST; SP
koate NC N5
koate-dvi NC N5; SP
kogenate fs intravenous kit 1000 unit, 2000 unit, 250 unit, 500 unit
NC N5
kogenate fs intravenous kit 3000 unit SP PA; SP
kovaltry NC N5; SP
monoclate-p intravenous kit 1000 unit NC N5; SP
mononine intravenous solution reconstituted 1000 unit
SP PA; SP
novoeight NC N5; SP
novoseven rt NC N5; SP
nuwiq intravenous kit 1000 unit, 2000 unit, 250 unit, 500 unit
NC N5; SP
nuwiq intravenous kit 2500 unit, 3000 unit, 4000 unit
NC N5
nuwiq intravenous solution reconstituted 1000 unit, 2000 unit, 250 unit, 500 unit
NC N5; SP
nuwiq intravenous solution reconstituted 2500 unit, 3000 unit, 4000 unit
NC N5
pentoxifylline er G
plavix NC N5
prasugrel hcl G PA; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018114
Drug Name Drug Status Drug Details
profilnine intravenous solution reconstituted 1000 unit, 500 unit
NC N5; SP
profilnine intravenous solution reconstituted 1500 unit
NC N5
profilnine sd NC N5; SP
rebinyn SP PA; SP
recombinate NC N5; SP
riastap NC N5; SP
rixubis SP PA; SP
ruconest SP PA; SP
tretten NC N5; SP
vonvendi SP PA
wilate intravenous kit NC N5; SP
xyntha intravenous kit 1000 unit, 2000 unit, 250 unit, 500 unit
NC N5; SP
xyntha solofuse NC N5; SP
yosprala NC N5
*HEMATOPOIETIC AGENTS*
abaneu-sl NC
active fe NC
airavite NC
animi-3 NC
animi-3/vitamin d NC
aranesp (albumin free) injection solution 100 mcg/ml, 200 mcg/ml, 25 mcg/ml, 300 mcg/ml, 40 mcg/ml, 60 mcg/ml
SP PA; SP
aranesp (albumin free) injection solution prefilled syringe 100 mcg/0.5ml, 150 mcg/0.3ml, 200 mcg/0.4ml, 25 mcg/0.42ml, 300 mcg/0.6ml, 40 mcg/0.4ml, 500 mcg/ml, 60 mcg/0.3ml
SP PA; SP
av-vite fb NC
b-6 folic acid NC
bp vit 3 NC
cenfol NC
centratex NC
cerdelga PB PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018115
Drug Name Drug Status Drug Details
cerezyme intravenous solution reconstituted 400 unit
SP PA; SP
ciferex NC
corvita 150 NC
corvite 150 oral tablet 150-1.25 mg NC
corvite fe G
cyanocobalamin injection G
divista NC
doptelet oral tablet 20 mg SP PA; SP; QL
droxia NP
durachol NC
elelyso SP PA; SP
epogen injection solution 10000 unit/ml, 2000 unit/ml, 20000 unit/ml, 3000 unit/ml, 4000 unit/ml
SP PA; SP
fabb NC
fa-vitamin b-6-vitamin b-12 NC
feriva 21/7 NC
ferocon NC
ferotrinsic NC
ferraplus 90 NC
ferrlecit NC N5; SP
ferrocite plus oral tablet NC
ferro-plex hematinic NC
ferrotrin NC
folbee NC
folgard rx NC N5
folic acid oral tablet 1 mg G
folic acid oral tablet 400 mcg, 800 mcg CE
folivane-f NC
folivane-plus NC
folplex 2.2 NC
foltrin NC
fulphila SP PA; SP
fusion plus NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018116
Drug Name Drug Status Drug Details
gnp folic acid CE
granix SP PA; ST; SP
hematinic plus vit/minerals NC
hematinic/folic acid NC
hematogen fa NC
hematogen forte NC
hemetab NC
hemocyte plus NC
hemocyte-f oral tablet NC
hemocyte-plus oral tablet 106-1 mg NC
integra f NC
integra plus NC
irospan 24/6 NC
is 24/6 NC
k-tan plus NC
leukine intravenous SP PA; SP
maxfe oral tablet NC
miglustat SP PA; SP; QL
mircera injection solution prefilled syringe 100 mcg/0.3ml, 200 mcg/0.3ml, 50 mcg/0.3ml, 75 mcg/0.3ml
SP PA
mircera injection solution prefilled syringe 150 mcg/0.3ml, 30 mcg/0.3ml
SP PA; SP
mozobil SP PA
mulpleta SP PA; SP; QL
multigen NC
multigen folic NC
multigen plus NC
na ferric gluc cplx in sucrose G SP
nascobal NC N5
nephron fa NC
neulasta subcutaneous solution prefilled syringe
SP PA
neupogen injection solution 300 mcg/ml, 480 mcg/1.6ml
SP PA; ST; SP
neupogen injection solution prefilled syringe SP PA; ST
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018117
Drug Name Drug Status Drug Details
neurin-sl NC
nivestym SP PA; SP
nplate SP SP
nufol NC
procrit SP PA; SP
proferrin-forte NC
promacta SP PA; SP; QL
protectiron NC
purefe plus NC
purevit dualfe plus NC
retacrit SP PA; SP
revesta NC
se-tan plus NC
siklos NP PA
tandem f NC
tandem plus NC
taron forte NC
tl gard rx NC
tl icon NC
tricon NC
trigels-f forte NC
venofer SP SP
virt-gard NC
vpriv SP PA; SP
zarxio SP PA
zavara NC
zavesca SP PA; #; SP; QL
*HEMOSTATICS*
amicar oral solution NP
amicar oral tablet PB
lysteda NC N5
tranexamic acid oral G QL
*HEPATITIS C AGENT - COMBINATIONS***
epclusa SP PA; #; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018118
Drug Name Drug Status Drug Details
harvoni SP PA; #; SP
mavyret SP PA; ST; SP; QL
technivie SP PA; ST; QL
viekira pak SP PA; ST; SP; QL
viekira xr SP PA; ST; QL
vosevi SP PA; PPA; SP; QL
zepatier SP PA; SP; QL
*HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS**
xuriden SP PA; SP; QL
*HYPNOTICS*
ambien NC N5
ambien cr NC N5
butisol sodium oral tablet 30 mg NP
doral NP
edluar NC N5
estazolam G
eszopiclone G QL; AL
flurazepam hcl G
halcion NC N5
hetlioz SP PA; SP; QL
intermezzo NC N5
lunesta NC N5
midazolam hcl oral G
phenobarbital oral elixir G
phenobarbital oral tablet G
quazepam G AL
restoril NC N5
rozerem NP ST; #; QL
seconal NP
silenor NC N5; #; SP
temazepam oral capsule 15 mg, 30 mg G
temazepam oral capsule 22.5 mg, 7.5 mg G QL
triazolam G
zaleplon G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018119
Drug Name Drug Status Drug Details
zolpidem tartrate er G ST; QL
zolpidem tartrate oral G QL
zolpidem tartrate sublingual NC N5
zolpimist NC N5; #
*HYPOPHOSPHATASIA (HPP) AGENTS***
strensiq SP PA; SP
*IBS AGENT - MU-OPIOID RECEPTOR AGONISTS***
viberzi PB PA; QL
*INSULIN-INCRETIN MIMETIC COMBINATIONS***
soliqua PB ST; QL
xultophy PB ST; QL
*INTEGRIN RECEPTOR ANTAGONISTS***
entyvio SP PA; ST; SP
*INTERLEUKIN ANTAGONISTS***
stelara intravenous SP PA; ST; SP
*INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)***
nucala SP PA; SP; QL
*INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)***
cinqair SP PA; SP
*ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS***
tibsovo SP PA; SP; QL
*ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS***
idhifa SP PA; SP; QL
*LAXATIVES*
clearlax oral powder CE
clenpiq CE
constulose G
cvs purelax CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018120
Drug Name Drug Status Drug Details
eq clearlax CE
eql clearlax CE
gavilax CE
gavilyte-c G
gavilyte-g G
gavilyte-h CE
gavilyte-n with flavor pack G
gentlelax oral powder CE
gialax CE
glycolax CE
gnp clearlax oral powder CE
golytely oral solution reconstituted 227.1 gm NP
golytely oral solution reconstituted 236 gm NC N5
healthylax CE
hm clearlax CE
kls laxaclear CE
kristalose NP QL
lactulose oral packet G QL
lactulose oral solution G
miralax oral packet NC N5
miralax oral powder CE
moviprep CE#; Only covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere
nulytely with flavor packs NC N5
osmoprep CE#; Only covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere
peg 3350 CE
peg 3350/electrolytes CEOnly covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere
peg 3350-kcl-na bicarb-nacl GOnly covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018121
Drug Name Drug Status Drug Details
peg-3350/electrolytes GOnly covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere
peg-prep CE
pegylax CE
plenvu CE
polyethylene glycol 3350 oral CE
prepopik CE#; Only covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere
qc natura-lax CE
ra laxative oral packet CE
ra laxative oral powder CE
sb polyethylene glycol 3350 CE
sm clearlax CE
smooth lax oral powder CE
suprep bowel prep kit CEOnly covered in states: CT,GA,IL,MI,NV,PA,TN,TX and excluded elsewhere
tgt powderlax CE
trilyte CE
*LEPTIN ANALOGUES***
myalept SP PA; SP; QL
*LHRH/GNRH AGONIST ANALOG COMBINATIONS***
lupaneta pack SP PA; SP
*LOCAL ANESTHETICS-PARENTERAL*
lidocaine hcl (pf) injection solution 0.5 %, 1 % G
lidocaine hcl injection solution 0.5 % G
*LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG***
xiidra PB
*LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS***
kanuma SP PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018122
Drug Name Drug Status Drug Details
*MACROLIDES*
azithromycin intravenous solution reconstituted500 mg
G
azithromycin oral packet G
azithromycin oral suspension reconstituted G
azithromycin oral tablet 250 mg, 500 mg, 600 mg
G
biaxin oral tablet 500 mg NC N5
clarithromycin er G
clarithromycin oral G
dificid NP QL
e.e.s. 400 oral tablet NP
e.e.s. granules NP
eryped 200 NP
eryped 400 NP
ery-tab NP
erythrocin lactobionate intravenous solution reconstituted 500 mg
NP
erythrocin stearate oral tablet 250 mg NP
erythromycin base oral capsule delayed release particles
G
erythromycin base oral tablet G
erythromycin ethylsuccinate oral G
zithromax oral packet NP
zithromax oral suspension reconstituted NC N5
zithromax oral tablet NC N5
zithromax tri-pak NC N5
zithromax z-pak NC N5
*MEDICAL DEVICES*
accu-chek fastclix lancets NP
accu-chek multiclix lancet dev NP QL
accu-chek multiclix lancets NP
accu-chek soft touch lancets NP
accu-chek softclix lancets NP
advocate duo device NP QL
assure lancets NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018123
Drug Name Drug Status Drug Details
bayer microlet lancets NP
bd autoshield 29g x 5mm , 29g x 8mm PB
bd insulin syringe 25g x 1" 1 ml, 25g x 5/8" 1 ml, 26g x 1/2" 1 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, u-100 1 ml
PB
bd insulin syringe half-unit PB
bd insulin syringe microfine 28g x 1/2" 0.5 ml PB
bd insulin syringe u/f 30g x 1/2" 1 ml PB
bd insulin syringe ultrafine 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml
PB
bd lancet ultrafine 30g NP
bd lancet ultrafine 33g NP
bd microtainer lancets NP
bd pen PB
bd pen mini PB
bd pen needle mini u/f PB
bd pen needle nano u/f PB
bd pen needle short u/f PB
bd pen needle ultrafine PB
bd safetyglide insulin syringe 30g x 5/16" 0.5 ml PB
bullseye mini safety lancets NP
bullseye safety lancets NP
clever chek auto-code NP QL
coaguchek lancets NP
comfort assured lancets 28g NP
comfort assured lancets 33g NP
drug mart unifine pentips 31g x 5 mm G
easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml
G
easy touch insulin syringe 31g x 5/16" 1 ml NP
easy touch lancets 21g NP
easy touch lancets 23g NP
easy touch lancets 26g NP
easy touch lancets 26g/twist NP
easy touch lancets 28g NP
easy touch lancets 28g/twist NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018124
Drug Name Drug Status Drug Details
easy touch lancets 30g NP
easy touch lancets 30g/twist NP
easy touch lancets 32g NP
easy touch lancets 32g/twist NP
easy touch lancets 33g/twist NP
easy touch lancing device NP
easy touch safety lancets 21g NP
easy touch safety lancets 23g NP
easy touch safety lancets 26g NP
easy touch safety lancets 28g NP
easy twist & cap lancets NP
fc2 female condom CE
fingerstix lancets NP
fora d10 2-in-1 monitor NP QL
fora d15g 2-in-1 monitor NP QL
fora d20 2-in-1 monitor NP QL
freestyle lancets NP
freestyle precision ins syr 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
NP
freestyle unistick ii lancets NP
global inject ease insulin syr 28g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
G
gnp clickfine pen needles 31g x 8 mm G
gnp insulin syringe 28g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 31g x 5/16" 0.5 ml
G
gnp ultra com insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml
G
healthy accents unifine pentip 31g x 5 mm , 31g x 6 mm
G
insulin syringe G
insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 1 ml
G
insulin syringe/needle 28g x 1/2" 0.5 ml G
insulin syringe-needle u-100 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml
G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018125
Drug Name Drug Status Drug Details
kroger insulin syringe 29g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
G
lancets G
lancets super thin 28g NP
lancets ultra thin NP
lancets ultra thin 30g NP
lifescan unistik 2 NP
lifescan unistik ii lancets NP
lite touch lancets NP
litetouch lancets NP
magellan insulin safety syr 29g x 1/2" 1 ml NP
microlet lancets NP
microtainer safety flow lancet NP
neutek 2tek glucose/pressure NP QL
novofine 32g x 6 mm NP
novotwist 32g x 5 mm NP
onetouch club lancets fine pt NP
onetouch combo pack NP
onetouch delica lancets 33g NP
onetouch delica lancets fine NP
onetouch delica lancing dev NP
onetouch finepoint lancets NP
onetouch ultrasoft lancets NP
pen needles G
pen needles 1/2" G
pen needles 3/16" G
pen needles 5/16" G
precision suredose plus syr 29g x 1/2" 1 ml NP
precision sure-dose syringe 28g x 1/2" 0.5 ml NP
relion insulin syringe 29g x 1/2" 1 ml NP
reli-on insulin syringe 29g x 1/2" 1 ml NP
relion pen needles 31g x 8 mm NP
safety let lancets NP
sapscare twist top lancets NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018126
Drug Name Drug Status Drug Details
simple diagnostics lancing dev NP
super thin lancets NP
trueplus insulin syringe 29g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
NP
trueplus lancets 26g NP
trueplus lancets 30g NP
trueplus safety lancets 28g NP
ulticare insulin syringe 28g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml
NP
ulticare short pen needles NP
unifine pentips plus 31g x 5 mm G
vanishpoint insulin syringe 30g x 3/16" 0.5 ml, 30g x 3/16" 1 ml
NP
vida mia unifine pentips 31g x 6 mm NP
wide-seal diaphragm 60 CE
wide-seal diaphragm 65 CE
wide-seal diaphragm 70 CE
wide-seal diaphragm 75 CE
wide-seal diaphragm 80 CE
wide-seal diaphragm 85 CE
wide-seal diaphragm 90 CE
wide-seal diaphragm 95 CE
*MIGRAINE PRODUCTS*
almotriptan malate G QL
amerge NC N5
cafergot NP
cambia NC N5
d.h.e. 45 NC N5
dihydroergotamine mesylate injection G
dihydroergotamine mesylate nasal G ST; QL
eletriptan hydrobromide G QL
ergomar NP
frova NP ST; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018127
Drug Name Drug Status Drug Details
frovatriptan succinate G QL
imitrex nasal NP QL
imitrex oral NC N5
imitrex statdose refill subcutaneous solution cartridge 4 mg/0.5ml
NC N5
imitrex statdose refill subcutaneous solution cartridge 6 mg/0.5ml
NP QL
imitrex statdose system subcutaneous solution auto-injector 4 mg/0.5ml
NP N5; QL
imitrex statdose system subcutaneous solution auto-injector 6 mg/0.5ml
NP QL
imitrex subcutaneous NC N5
maxalt oral tablet 10 mg NC N5
maxalt-mlt NC N5
migergot NP
migranal NC N5
naratriptan hcl G QL
onzetra xsail NP ST; QL
relpax NP ST; QL
rizatriptan benzoate G QL
sumatriptan nasal G QL
sumatriptan succinate oral G QL
sumatriptan succinate refill subcutaneous solution cartridge
G QL
sumatriptan succinate subcutaneous solution 6 mg/0.5ml
G QL
sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml
G QL
sumatriptan-naproxen sodium NC
treximet oral tablet 10-60 mg NC N5; #
treximet oral tablet 85-500 mg NC N5
zembrace symtouch NP ST; QL
zolmitriptan oral G QL
zomig nasal NP ST; QL
zomig oral NC N5
zomig zmt NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
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Drug Name Drug Status Drug Details
*MINERALS & ELECTROLYTES*
effer-k oral tablet effervescent 20 meq PB
effer-k oral tablet effervescent 25 meq G
fluorabon CE
fluoritab oral tablet chewable 0.55 (0.25 f) mg G
fluoritab oral tablet chewable 1.1 (0.5 f) mg CE
flura-drops oral solution 0.55 (0.25 f) mg/drop CE
galzin NP
iodine strong oral G
isolyte-s NP
isolyte-s ph 7.4 NP
k-effervescent G
klor-con 10 G
klor-con m10 G
klor-con m20 G
klor-con oral packet 20 meq G QL
k-phos PB
k-phos-neutral NP
k-tab oral tablet extended release 10 meq NC N5
k-vescent oral tablet effervescent G
ludent oral tablet chewable 0.55 (0.25 f) mg G
ludent oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg
CE
magnebind 400 NP
magnesium sulfate injection solution 50 % G
micro-k NC N5
monoject sodium chloride flush intravenous G
normosol-r NP
normosol-r ph 7.4 NP
phospha 250 neutral G
plasma-lyte 148 NP
plasma-lyte a NP
pot bicarb-pot chloride G
potassium bicarbonate oral G
potassium chloride crys er G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018129
Drug Name Drug Status Drug Details
potassium chloride er G
potassium chloride in nacl intravenous solution20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%
G
potassium chloride intravenous solution 0.4 meq/ml, 10 meq/100ml, 10 meq/50ml, 2 meq/ml, 20 meq/100ml, 20 meq/50ml, 40 meq/100ml
G
potassium chloride oral packet G QL
potassium chloride oral solution 40 meq/15ml (20%)
G
sodium chloride injection solution 2.5 meq/ml G
sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 %
G
sodium fluoride oral solution CE
sodium fluoride oral tablet chewable 0.55 (0.25 f) mg
G
sodium fluoride oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg
CE
swabflush saline flush NP
*MONOBACTAMS***
azactam NC N5
aztreonam SP
cayston SP SP; QL
*MOUTH/THROAT/DENTAL AGENTS*
cevimeline hcl G QL
chlorhexidine gluconate mouth/throat G
clotrimazole mouth/throat lozenge G
debacterol NP
denta 5000 plus CE
evoxac NC N5
first-mouthwash blm NP
nystatin mouth/throat G
oralone G
oramagicrx NP
oravig NP QL
paroex G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018130
Drug Name Drug Status Drug Details
periomed NP
pilocarpine hcl oral G
salagen NC N5
triamcinolone acetonide mouth/throat G
*MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS***
vimizim SP PA; SP
*MULTIVITAMINS*
citranatal 90 dha oral 90-1 & 300 mg NP
citranatal assure oral 35-1 & 300 mg NP
citranatal b-calm NP
citranatal dha NP
citranatal harmony oral capsule 27-1-260 mg NP
citranatal medley NP
citranatal rx NP
co-natal fa G
concept dha NP
concept ob NP
corvita G
corvite NP
dialyvite 5000 NP
dialyvite supreme d NP
hemenatal ob NP
marnatal-f NP
multivitamin/fluoride oral tablet chewable 0.5 mg, 1 mg
NP
multi-vitamin/fluoride/iron G
multivitamins/fluoride oral tablet chewable 0.5 mg
G
mynatal advance G
mynatal oral tablet G
mynatal plus G
mynatal-z G
nephplex rx NP
nestabs NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018131
Drug Name Drug Status Drug Details
nexa plus NP
ob complete gold NP
ob complete premier NP
ob complete/dha NP
o-cal fa NP
o-cal prenatal NP
ocuvel oral capsule 0.5 mg NP
pnv-dha G
pnv-omega NP
pnv-select G
poly-vi-flor PB
poly-vi-flor fs oral strip 1 mg NP
poly-vi-flor/iron oral suspension PB
prenata NP
prenatabs rx G
prenatal 19 oral tablet G
prenatal 19 oral tablet chewable G
prenatal plus iron NP
prenate dha oral capsule 18-0.6-0.4-300 mg NP
quflora fe pediatric NP
se-natal 19 oral tablet chewable G
synagex NC
synatek NC
taron-c dha NP
tricare NP
tricare prenatal dha one oral capsule 27-1-500 mg
NP
triveen-duo dha NP
udamin sp NP
virt-pn NP
virt-pn dha NP
vitafol fe+ NP
vitafol gummies NP
vitafol-ob+dha PB
vitafol-one NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018132
Drug Name Drug Status Drug Details
vital-d rx NP
vol-plus PB
vol-tab rx NP
zatean-pn dha NP
zatean-pn plus NP
*MUSCULOSKELETAL THERAPY AGENTS*
amrix NC N5; #
baclofen oral G
carisoprodol oral tablet 250 mg NC
carisoprodol oral tablet 350 mg G
carisoprodol-aspirin G
carisoprodol-aspirin-codeine G
chlorzoxazone oral tablet 250 mg NC N5
chlorzoxazone oral tablet 500 mg G
cyclobenzaprine hcl oral G
dantrolene sodium oral G
durolane intra-articular SP PA; ST; SP
euflexxa intra-articular solution prefilled syringe
SP PA; SP
fexmid NC N5
gablofen intrathecal solution 10000 mcg/20ml, 20000 mcg/20ml, 40000 mcg/20ml
SP
gel-one intra-articular prefilled syringe SP PA; ST; SP
gelsyn-3 SP PA; ST
genvisc 850 SP PA; ST
hyalgan SP PA; ST; SP
hymovis SP PA; ST; SP
lorzone NC N5
metaxalone G
methocarbamol oral G
monovisc SP PA; SP
orphenadrine citrate er G
orthovisc intra-articular solution prefilled syringe
SP PA; SP
robaxin injection solution 1000 mg/10ml NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018133
Drug Name Drug Status Drug Details
skelaxin NC N5
soma NC N5
supartz fx SP PA; ST
synvisc intra-articular solution prefilled syringe SP PA; ST; SP
synvisc one intra-articular solution prefilled syringe
SP PA; ST; SP
tizanidine comfort pac NC N5
tizanidine hcl oral capsule NC N5
tizanidine hcl oral tablet G
trivisc SP PA; ST; SP
zanaflex NC N5
*NASAL AGENTS - SYSTEMIC AND TOPICAL*
adrenalin nasal PB
astepro nasal solution 0.15 % NC N5
azelastine hcl nasal solution 0.1 %, 0.15 % G
bactroban nasal PB SP
beconase aq NP ST
budesonide nasal G Select OTC
dymista NC N5
flonase NC
flonase allergy relief G Select OTC
flunisolide nasal solution 25 mcg/act (0.025%) G
fluticasone propionate nasal G Select OTC
ipratropium bromide nasal G QL
mometasone furoate nasal G
nasacort allergy 24hr G Select OTC; QL
nasacort allergy 24hr children G Select OTC; QL
nasal allergy 24 hour G Select OTC; QL
nasonex NP ST
olopatadine hcl nasal G
omnaris NP ST; #
patanase NC N5
qnasl NP ST
qnasl childrens NP ST
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
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Drug Name Drug Status Drug Details
rhinocort allergy G Select OTC
triamcinolone acetonide nasal aerosol G Select OTC; QL
xhance NC N5
zetonna NP ST
*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***
entresto PB PA; QL
*NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS***
northera SP PA; ST; SP; QL
*NEUROMUSCULAR AGENTS*
botox SP PA; ST; SP
dysport SP PA; SP
myobloc intramuscular solution 2500 unit/0.5ml, 5000 unit/ml
SP PA
rilutek NC N5
riluzole G PA
tiglutik NP PA; QL
xeomin SP PA; SP
*OPHTHALMIC AGENTS*
acular NC N5
acular ls NC N5
acuvail NP
akten NC
alaway G Select OTC
alaway childrens allergy G Select OTC
alcaine NC N5
allergy eye drops G Select OTC
alocril NP
alomide NP
alphagan p ophthalmic solution 0.1 % NP
alphagan p ophthalmic solution 0.15 % NC N5
alrex PB
altacaine G
altafluor NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018135
Drug Name Drug Status Drug Details
altafrin ophthalmic solution 10 % G
apraclonidine hcl G
atropine sulfate ophthalmic G
azasite NP #
azelastine hcl ophthalmic G
azopt PB
bacitracin ophthalmic G
bacitracin-polymyxin b ophthalmic ointment500-10000 unit/gm
G
bacitra-neomycin-polymyxin-hc G
bepreve NP #
besivance NP
betadine ophthalmic prep NP
betagan NC N5
betaxolol hcl ophthalmic G
betimol NP
betoptic-s NP
bimatoprost ophthalmic G PA; ST
bio glo NP
bleph-10 NC N5
blephamide NP
blephamide s.o.p. NP
brimonidine tartrate ophthalmic G
bromfenac sodium (once-daily) G
bromsite NP
carteolol hcl G
ciloxan ophthalmic ointment NP
ciloxan ophthalmic solution NC N5
ciprofloxacin hcl ophthalmic G
claritin eye G Select OTC
combigan PB
cosopt pf NC #
cromolyn sodium ophthalmic G
cyclogyl ophthalmic solution 0.5 %, 2 % NC N5
cyclogyl ophthalmic solution 1 % NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018136
Drug Name Drug Status Drug Details
cyclomydril NP
cyclopentolate hcl ophthalmic solution 0.5 %, 2 %
G
cystaran SP PA; #; SP; QL
dexamethasone sodium phosphate ophthalmic G
diclofenac sodium ophthalmic G
dorzolamide hcl ophthalmic G
dorzolamide hcl-timolol mal G
dorzolamide hcl-timolol mal pf G
durezol PB #
elestat NC N5
emadine NP
epinastine hcl G
eye itch relief G Select OTC
eylea intravitreal SP PA; SP
flarex NP
flucaine NP
fluorescein-benoxinate G
fluor-i-strips a.t. NP
fluorometholone ophthalmic G
flura-safe NP
flurbiprofen sodium G
fml PB
fml forte NP
fml liquifilm NC N5
ful-glo ophthalmic strip 0.6 mg NP
ful-glo ophthalmic strip 1 mg NP
gatifloxacin ophthalmic G
gentak ophthalmic ointment NP
gentamicin sulfate ophthalmic solution G
homatropaire NP
homatropine hbr ophthalmic G
ilevro NP
inveltys NP
iopidine ophthalmic solution 0.5 % NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018137
Drug Name Drug Status Drug Details
iopidine ophthalmic solution 1 % NP
isopto homatropine ophthalmic solution 5 % NC N5
istalol NP
jetrea intravitreal solution 0.375 mg/0.3ml SP PA; SP
ketorolac tromethamine ophthalmic G
ketotifen fumarate ophthalmic G Select OTC
lacrisert NP
lastacaft NP
latanoprost ophthalmic G
levobunolol hcl ophthalmic solution 0.5 % G
levofloxacin ophthalmic G
lotemax ophthalmic gel PB #
lotemax ophthalmic ointment PB
lotemax ophthalmic suspension PB
lucentis intravitreal solution prefilled syringe SP PA; SP
lumigan ophthalmic solution 0.01 % NP PA; ST
macugen SP PA; SP
maxidex NP
moxeza NP #
moxifloxacin hcl ophthalmic G
mydriacyl NC N5
natacyn NP
neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000
G
neomycin-polymyxin-dexameth ophthalmic ointment
G
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
G
neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025
G
neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1
G
nevanac NP
ocuflox NC N5
ofloxacin ophthalmic G
olopatadine hcl ophthalmic G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018138
Drug Name Drug Status Drug Details
omnipred NC N5
pataday NP
patanol NC N5
pazeo NP
phenylephrine hcl ophthalmic solution 2.5 % G
phospholine iodide PB
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %
G
polymyxin b-trimethoprim G
polytrim NC N5
pred forte NC N5
pred mild NP
pred-g NP
pred-g s.o.p. NP
prednisolone acetate ophthalmic G
prednisolone sodium phosphate ophthalmic G
prolensa NP
proparacaine hcl ophthalmic G
proparacaine-fluorescein G
restasis PB #
restasis multidose PB #
simbrinza NP
sulfacetamide sodium ophthalmic G
sulfacetamide-prednisolone ophthalmic solution G
tetcaine G
tetracaine hcl ophthalmic G
tetravisc G
timolol maleate ophthalmic gel forming solution G
timolol maleate ophthalmic solution 0.25 %, 0.5 %
G
timolol maleate ophthalmic solution 0.5 % (daily)
NP
timoptic NC N5
timoptic ocudose NP
timoptic-xe ophthalmic gel forming solution 0.5 %
NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018139
Drug Name Drug Status Drug Details
tobradex ophthalmic ointment NP
tobradex ophthalmic suspension NC N5
tobradex st NP
tobramycin-dexamethasone G
tobrex ophthalmic ointment NP
travatan z PB #
trifluridine ophthalmic G
tropicamide ophthalmic G
trusopt NC N5
vigamox NP
visionblue NP
visudyne SP PA; #; SP
vyzulta NC N5
xalatan NC N5
zaditor NC N5; Select OTC
zioptan NP PA; ST
zirgan NP #
zylet NP
zymaxid NC N5
*OPHTHALMIC RHO KINASE INHIBITORS***
rhopressa NP ST
*OREXIN RECEPTOR ANTAGONISTS***
belsomra NP ST; QL; AL
*OTIC AGENTS*
acetasol hc G
acetic acid otic G
cetraxal NP
cipro hc NP #
ciprodex PB #
ciprofloxacin hcl otic G
coly-mycin s NP
dermotic NC N5
floxin otic NC
fluocinolone acetonide otic G
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018140
Drug Name Drug Status Drug Details
hydrocortisone-acetic acid G
neomycin-polymyxin-hc otic G
ofloxacin otic G
otovel NP
*OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***
kerydin NP PA; ST
*OXYTOCICS*
methergine oral G QL
*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***
hyqvia SP PA; ST; SP
*PASSIVE IMMUNIZING AGENTS*
bivigam NC N5; SP
carimune nf intravenous solution reconstituted 12 gm, 6 gm
NC N5; SP
cuvitru NC N5
cytogam NC N5; SP
flebogamma dif SP PA; SP
gamastan s/d intramuscular injectable SP SP
gammagard NC N5; SP
gammagard s/d less iga NC N5; SP
gammaked NC N5; SP
gammaplex intravenous solution 10 gm/200ml, 20 gm/400ml, 5 gm/100ml
SP PA; SP
gamunex-c SP PA; SP
hizentra subcutaneous solution 1 gm/5ml, 10 gm/50ml, 2 gm/10ml, 4 gm/20ml
SP PA; SP
hyperhep b s/d NC N5; SP
hyperrab NC
hyperrho s/d intramuscular solution prefilled syringe
NC N5; SP
hypertet s/d NC N5; SP
micrhogam ultra-filtered plus intramuscular solution prefilled syringe
NC N5; SP
nabi-hb NC N5; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018141
Drug Name Drug Status Drug Details
octagam SP PA; SP
panzyga SP PA; ST; SP
privigen NC N5; SP
rhogam ultra-filtered plus intramuscular solution prefilled syringe
NC N5; SP
rhophylac injection solution prefilled syringe NC N5; SP
synagis SP PA; SP
winrho sdf NC N5; SP
*PCSK9 INHIBITORS***
praluent subcutaneous solution pen-injector SP PA; ST; QL
repatha SP PA; ST; QL
repatha pushtronex system SP PA; ST; QL
repatha sureclick SP PA; ST; QL
*PENICILLINS*
amoxicillin oral capsule G
amoxicillin oral suspension reconstituted G
amoxicillin oral tablet G
amoxicillin oral tablet chewable 125 mg, 250 mg G
amoxicillin-pot clavulanate er G
amoxicillin-pot clavulanate oral suspension reconstituted
G
amoxicillin-pot clavulanate oral tablet G
amoxicillin-pot clavulanate oral tablet chewable200-28.5 mg
G
ampicillin oral capsule 500 mg G
ampicillin sodium injection SP
ampicillin sodium intravenous SP
ampicillin-sulbactam sodium injection SP
ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm
SP
augmentin oral suspension reconstituted 125-31.25 mg/5ml
PB
augmentin oral suspension reconstituted 250-62.5 mg/5ml
NC N5
augmentin oral tablet 500-125 mg, 875-125 mg NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018142
Drug Name Drug Status Drug Details
augmentin xr NC N5
bactocill in dextrose NP
dicloxacillin sodium G
moxatag NP
penicillin g pot in dextrose G
penicillin v potassium G
piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm
SP
unasyn injection solution reconstituted 15 (10-5) gm, 3 (2-1) gm
NP
zosyn intravenous solution reconstituted NC N5
*PHARMACEUTICAL ADJUVANTS*
saline bacteriostatic G
saline-benzyl alcohol G
sodium chloride bacteriostatic G
*PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS***
copiktra SP PA; SP; QL
zydelig SP PA; SP; QL
*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***
eucrisa NC N5
*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***
otezla oral tablet SP PA; ST; SP; QL
otezla oral tablet therapy pack SP PA; ST; SP; QL
*PLASMA KALLIKREIN INHIBITORS - MONOCLONAL ANTIBODIES***
takhzyro SP PA; SP; QL
*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS**
lynparza oral tablet SP PA; SP; QL
rubraca oral tablet 200 mg, 300 mg SP PA; QL
rubraca oral tablet 250 mg SP PA; SP; QL
talzenna SP PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018143
Drug Name Drug Status Drug Details
zejula SP PA; SP; QL
*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS***
lynparza oral tablet SP PA; SP; QL
rubraca oral tablet 200 mg, 300 mg SP PA; QL
rubraca oral tablet 250 mg SP PA; SP; QL
talzenna SP PA; SP; QL
zejula SP PA; SP; QL
*POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS***
gralise NP ST; QL
gralise starter NP ST; QL
lyrica cr PB QL
*POTASSIUM REMOVING AGENTS***
lokelma NP PA
sodium polystyrene sulfonate oral powder G
veltassa NP PA; QL
*PROGESTINS*
aygestin NC N5
hydroxyprogesterone caproate intramuscular oil SP PA; SP
makena intramuscular NC #
makena subcutaneous SP PA; SP; QL
medroxyprogesterone acetate oral tablet 10 mg, 5 mg
G
megace es NC N5
megestrol acetate oral suspension 625 mg/5ml G
norethindrone acetate oral G
progesterone micronized oral G QL
prometrium NC N5
provera NC N5
*PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS***
zontivity NP PA; QL
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*
acamprosate calcium G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018144
Drug Name Drug Status Drug Details
ampyra NC #
antabuse NC N5
aricept oral tablet 10 mg, 5 mg NC N5
aricept oral tablet 23 mg NC N5; AL
aubagio SP PA; SP; QL
austedo SP PA; ST; SP; QL
avonex SP PA; SP; QL
avonex pen intramuscular auto-injector kit SP PA; SP; QL
avonex prefilled intramuscular prefilled syringe kit
SP PA; SP; QL
betaseron subcutaneous kit SP PA; SP; QL
brisdelle NP PA; ST; QL
bupropion hcl er (smoking det) CE QL
chantix CE QL
chantix continuing month pak CE QL
chantix starting month pak CE
chlordiazepoxide-amitriptyline G
copaxone subcutaneous solution prefilled syringe 20 mg/ml
NC N5; SP
copaxone subcutaneous solution prefilled syringe 40 mg/ml
SP PA; SP
cvs nicotine polacrilex mouth/throat lozenge 4 mg
G QL
cvs nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr
CE QL
dalfampridine er SP PA; SP; QL
disulfiram oral G
donepezil hcl oral tablet 10 mg, 23 mg G PA
donepezil hcl oral tablet 5 mg G PA; AL
donepezil hcl oral tablet dispersible G PA
eq nicotine transdermal CE QL
ergoloid mesylates oral G
exelon transdermal NC N5
extavia subcutaneous kit SP PA; ST; SP; QL
fluoxetine hcl (pmdd) G
galantamine hydrobromide G PA; AL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018145
Drug Name Drug Status Drug Details
galantamine hydrobromide er G PA; AL
gilenya oral capsule 0.25 mg SP PA; SP; QL
gilenya oral capsule 0.5 mg SP PA; #; SP; QL
glatiramer acetate SP PA; SP
glatopa SP PA; SP
gralise NP ST; QL
gralise starter NP ST; QL
hm nicotine CE QL
hm nicotine polacrilex mouth/throat lozenge 2 mg
G QL
horizant oral tablet extended release NP PA; ST; QL
ingrezza oral capsule 40 mg SP PA; SP; QL
ingrezza oral capsule 80 mg SP PA; PPA; QL
lemtrada SP PA; SP; QL
lyrica cr PB QL
memantine hcl er G PA; AL
memantine hcl oral tablet G AL
namenda oral tablet NC N5
namenda titration pak NC N5
namenda xr PB PA; AL
namenda xr titration pack PB PA; #
nicoderm cq CE QL
nicorelief mouth/throat gum NP QL
nicorette mouth/throat gum CE QL
nicorette mouth/throat lozenge CE
nicotine polacrilex mouth/throat gum 4 mg G
nicotine step 1 CE QL
nicotine step 2 CE QL
nicotine step 3 CE QL
nicotine transdermal patch 24 hour CE QL
nicotrol CE QL
nicotrol ns CE QL
nuedexta PB QL
olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-25 mg, 6-50 mg
G QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018146
Drug Name Drug Status Drug Details
olanzapine-fluoxetine hcl oral capsule 3-25 mg G
orap NC N5
paroxetine mesylate G PA; QL
perphenazine-amitriptyline G
pimozide G
plegridy SP PA; SP; QL
plegridy starter pack SP PA; SP; QL
ra nicotine transdermal CE QL
razadyne er NC N5; AL
razadyne oral tablet NC N5
rebif rebidose subcutaneous solution auto-injector
SP PA; SP; QL
rebif rebidose titration pack subcutaneous solution auto-injector
SP PA; SP; QL
rebif subcutaneous solution prefilled syringe SP PA; SP; QL
rebif titration pack subcutaneous solution prefilled syringe
SP PA; SP; QL
rivastigmine G PA
rivastigmine tartrate G PA
sarafem oral tablet 10 mg, 20 mg NP
savella NP PA; ST; QL
savella titration pack NP PA; ST; QL
sm nicotine transdermal CE QL
symbyax NC N5
tecfidera SP PA; SP; QL
tetrabenazine SP PA; QL
tgt nicotine step one CE QL
tgt nicotine step three CE QL
tgt nicotine step two CE QL
thrive mouth/throat gum 2 mg NP QL
tysabri SP PA; ST; SP
xenazine NC N5; SP
xyrem SP PA; SP
zyban CE QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018147
Drug Name Drug Status Drug Details
*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***
ofev SP PA; SP; QL
*PULMONARY FIBROSIS AGENTS***
esbriet SP PA; SP; QL
*PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST***
uptravi oral tablet 1000 mcg, 1200 mcg, 1400 mcg, 1600 mcg, 400 mcg, 600 mcg, 800 mcg
SP PA; SP; QL
uptravi oral tablet 200 mcg SP PA; SP
uptravi oral tablet therapy pack SP PA; SP
*RESPIRATORY AGENTS - MISC.*
aralast np intravenous solution reconstituted 1000 mg, 500 mg
SP PA; SP
glassia SP PA; SP
kalydeco SP PA; SP; QL
prolastin-c intravenous solution SP PA; SP
prolastin-c intravenous solution reconstituted 1000 mg
SP PA; SP
pulmozyme SP PA; SP; QL
zemaira SP PA; SP
*SEROTONIN MODULATORS***
nefazodone hcl G
trazodone hcl oral G
trintellix NP PA; ST; QL
viibryd oral tablet NP PA; ST; QL
viibryd starter pack NP PA
*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***
glyxambi PB QL
qtern NC N5
steglujan NC
*SINUS NODE INHIBITORS**
corlanor NP PA; ST; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018148
Drug Name Drug Status Drug Details
*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***
invokamet PB QL
invokamet xr PB QL
segluromet NC
synjardy PB QL
synjardy xr PB QL
xigduo xr oral tablet extended release 24 hour 10-1000 mg, 10-500 mg, 5-500 mg
NP
xigduo xr oral tablet extended release 24 hour 2.5-1000 mg, 5-1000 mg
NP QL
*SPLEEN TYROSINE KINASE (SYK) INHIBITORS***
tavalisse SP PA; SP; QL
*SULFONAMIDES*
sulfadiazine oral G
*TETRACYCLINES*
acticlate NC N5
avidoxy NC N5
avidoxy dk NC N5
coremino NC
demeclocycline hcl oral G
doryx mpc NC N5
doryx oral tablet delayed release 200 mg, 50 mg NC N5
doxy 100 NP
doxycycline hyclate oral capsule G
doxycycline hyclate oral tablet 100 mg, 20 mg, 50 mg
G
doxycycline hyclate oral tablet 150 mg, 75 mg NC N5
doxycycline hyclate oral tablet delayed release NC N5
doxycycline monohydrate oral capsule 150 mg, 75 mg
NC N5
doxycycline monohydrate oral capsule 50 mg G
doxycycline monohydrate oral tablet NC N5
minocin oral capsule 100 mg, 50 mg NC N5
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018149
Drug Name Drug Status Drug Details
minocycline hcl er oral tablet extended release 24 hour 115 mg, 65 mg
NC
minocycline hcl er oral tablet extended release 24 hour 135 mg, 45 mg, 90 mg
NC N5
minocycline hcl oral capsule G
minocycline hcl oral tablet NC N5
minolira NC
morgidox combination NC N5
morgidox oral capsule 100 mg G
solodyn oral tablet extended release 24 hour 105 mg, 55 mg, 80 mg
NC N5; #
solodyn oral tablet extended release 24 hour 115 mg, 65 mg
NC N5
targadox NC
tetracycline hcl oral G
vibramycin oral capsule NC N5
vibramycin oral suspension reconstituted NP
vibramycin oral syrup NP
ximino NC N5
*THYROID AGENTS*
armour thyroid oral tablet 120 mg G
armour thyroid oral tablet 15 mg, 180 mg, 240 mg, 30 mg, 300 mg, 90 mg
NP
armour thyroid oral tablet 60 mg NC N5
cytomel NC N5
levothyroxine sodium oral G
levoxyl G
liothyronine sodium intravenous G
liothyronine sodium oral G
methimazole oral G
nature-throid NP
np thyroid oral tablet 60 mg G
propylthiouracil oral G
synthroid NC N5
tapazole oral tablet 5 mg NC N5
tirosint NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018150
Drug Name Drug Status Drug Details
unithroid direct G
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
G
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg
NP
wp thyroid NP
*TOPICAL ANESTHETIC GASES***
gebauers pain ease NP
gebauers spray and stretch NP
*TOXOIDS*
adacel intramuscular suspension 5-2-15.5 lf-mcg/0.5
PB
*TRYPTOPHAN HYDROXYLASE INHIBITORS***
xermelo SP PA; QL
*ULCER DRUGS*
acid control maximum strength oral tablet 20 mg
NC
acid controller max st NC
acid reducer maximum strength oral tablet 20 mg
NC
acid reducer oral tablet 150 mg NC
aciphex NC N5
aciphex sprinkle NP PA; ST; #; QL
amoxicill-clarithro-lansopraz G
anaspaz NC N5
belladonna alkaloids-opium G
belladonna-opium G
bentyl intramuscular NP
carafate oral suspension NP
carafate oral tablet NC N5
cimetidine oral tablet 300 mg, 400 mg, 800 mg G
cuvposa NP #
cvs acid controller max st NC
dexilant NP PA; ST; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018151
Drug Name Drug Status Drug Details
dicyclomine hcl oral G
donnatal oral tablet NP
eq acid reducer max st NC
eql heartburn prevention oral tablet 20 mg NC
esomeprazole magnesium oral capsule delayed release 20 mg
G Select OTC; QL
esomeprazole magnesium oral capsule delayed release 40 mg
G QL
esomeprazole strontium oral capsule delayed release 49.3 mg
NC N5
famotidine oral suspension reconstituted G
famotidine oral tablet 20 mg NC
famotidine oral tablet 40 mg G
famotidine premixed G
glycopyrrolate injection solution 4 mg/20ml G
glycopyrrolate oral tablet 1 mg, 2 mg G
gnp acid reducer max st NC
heartburn relief max st oral tablet 20 mg NC
hm famotidine oral tablet 20 mg NC
kls acid controller max st NC
lansoprazole oral capsule delayed release 15 mg G Select OTC; QL
lansoprazole oral capsule delayed release 30 mg NC
lansoprazole oral tablet dispersible G PA; QL
levbid NC N5
levsin oral tablet NC N5
levsin/sl NC N5
librax NC N5
methscopolamine bromide oral G
misoprostol oral G
nexium 24hr G Select OTC; QL
nexium i.v. intravenous solution reconstituted 40 mg
NP
nexium oral capsule delayed release 40 mg NC N5
nexium oral packet NP ST; #; QL
nizatidine G
omeclamox-pak NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018152
Drug Name Drug Status Drug Details
omeprazole magnesium G Select OTC
omeprazole oral capsule delayed release 10 mg, 40 mg
G
omeprazole oral capsule delayed release 20 mg NC
omeprazole oral tablet delayed release G Select OTC
omeprazole-sodium bicarbonate oral capsule 20-1100 mg
G Select OTC; QL
omeprazole-sodium bicarbonate oral capsule 40-1100 mg
NC N5
omeprazole-sodium bicarbonate oral packet NC N5
pantoprazole sodium oral G
pepcid ac maximum strength oral tablet NC
pepcid oral suspension reconstituted NC N5
pepcid oral tablet 20 mg NC
prevacid NC
prevacid 24hr NC
prevacid solutab NP PA; ST; QL; AL
prevpac NC N5
prilosec oral packet NC N5; #
prilosec otc G Select OTC
propantheline bromide oral G
protonix intravenous NP
protonix oral packet NP ST
protonix oral tablet delayed release NC N5
px acid reducer max st oral tablet 20 mg NC
pylera NP #
qc acid controller max st NC
ra acid reducer max st oral tablet 20 mg NC
rabeprazole sodium G QL
ranitidine hcl injection solution 50 mg/2ml G
ranitidine hcl oral capsule G
ranitidine hcl oral syrup 75 mg/5ml G
ranitidine hcl oral tablet 300 mg G
sb acid controller max st NC
sm acid reducer max st oral tablet 20 mg NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018153
Drug Name Drug Status Drug Details
sucralfate oral tablet G
symax duotab NC
zantac injection solution 1000 mg/40ml NP
zantac oral tablet 300 mg NC N5
zegerid oral capsule 20-1100 mg NC
zegerid oral capsule 40-1100 mg NC N5
zegerid oral packet NC N5
zegerid otc G Select OTC; QL
*URINARY ANTI-INFECTIVES*
furadantin NC N5
hiprex NC N5
macrobid NC N5
macrodantin NC N5
methenamine hippurate G
methenamine mandelate oral tablet 0.5 gm G
nitrofurantoin macrocrystal oral capsule 50 mg G
nitrofurantoin monohyd macro G
nitrofurantoin oral suspension G
*URINARY ANTISPASMODICS*
bethanechol chloride oral tablet 10 mg, 5 mg, 50 mg
G
darifenacin hydrobromide er G QL
detrol NC N5
detrol la NC N5
ditropan xl oral tablet extended release 24 hour 10 mg, 5 mg
NC N5
enablex NP ST; QL
flavoxate hcl G
gelnique transdermal gel 10 % NP ST
myrbetriq PB ST; QL
oxybutynin chloride er G QL
oxybutynin chloride oral syrup G
oxybutynin chloride oral tablet G QL
oxytrol NC #
oxytrol for women G #; Select OTC; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018154
Drug Name Drug Status Drug Details
tolterodine tartrate G
tolterodine tartrate er G QL
toviaz NP ST; QL
trospium chloride G QL
trospium chloride er G QL
urecholine NC N5
vesicare NP ST; #; QL
*VAGINAL PRODUCTS*
avc vaginal NP
cleocin vaginal cream NC N5
cleocin vaginal suppository NP
clindamycin phosphate vaginal G
crinone NP
endometrin NP #
estrace vaginal NP
estradiol vaginal G
estring NP
fem ph NP
femring NP #; QL
gynazole-1 NP
imvexxy maintenance pack NP ST
imvexxy starter pack NP ST
intrarosa NP QL
metrogel-vaginal NC N5
metronidazole vaginal G
miconazole 3 vaginal suppository G
premarin vaginal PB
relagard NP
terconazole G
vagifem vaginal tablet 10 mcg NP
vandazole G
yuvafem G
*VASOPRESSORS*
adrenalin injection NC
adyphren NP QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018155
Drug Name Drug Status Drug Details
adyphren amp ii NP QL
adyphren ii NP QL
auvi-q injection solution auto-injector 0.1 mg/0.1ml
NC
auvi-q injection solution auto-injector 0.15 mg/0.15ml, 0.3 mg/0.3ml
NC N5
epinephrine injection solution auto-injector G QL
epipen 2-pak injection solution auto-injector PB #; QL
epipen jr 2-pak injection solution auto-injector PB #; QL
episnap NP QL
midodrine hcl G SP
*VITAMINS*
aqueous vitamin d CE
calcidol NC
calciferol NC
cvs d3 oral capsule 2000 unit, 5000 unit NC
d 10000 NC
d 5000 oral capsule NC
d-2000 maximum strength NC
d2000 ultra strength NC
d3 dots NC
d3 maximum strength NC
d3 super strength NC
d3-1000 oral capsule CE
d-3-5 NC
d-5000 NC
ddrops oral liquid 2000 unt/0.03ml, 2000 ut/0.028ml
NC
decara oral capsule 25000 unit, 50000 unit NC
delta d3 CE
dialyvite vitamin d 5000 NC
dialyvite vitamin d3 max NC
drisdol oral capsule NC N5
d-vi-sol CE
eql vitamin d3 oral capsule 2000 unit, 5000 unit NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018156
Drug Name Drug Status Drug Details
ergocal NP
ergocalciferol oral capsule G
gnp vitamin d maximum strength NC
gnp vitamin d oral tablet 1000 unit CE
gnp vitamin d super strength NC
hm vitamin d3 NC
maximum d3 NC
mephyton PB QL
nat-rul vitamin d oral tablet 2000 unit, 5000 unit NC
natural vitamin d-3 NC
optimal d3 m NC
optimal-d NC
opurity vitamin d NC
pa vitamin d-3 oral capsule 5000 unit NC
phytonadione oral G QL
potaba oral capsule NP
ra vitamin d-3 oral capsule 5000 unit NC
replesta NC
replesta childrens NC
replesta nx NC
sm vitamin d3 oral capsule 2000 unit, 4000 unit NC
super daily d3 oral liquid 2000 ut/0.028ml NC
thera-d 2000 NC
thera-d 4000 NC
thera-d rapid repletion NC
vitamin d (ergocalciferol) oral capsule 50000 unit
G
vitamin d oral capsule 2000 unit NC
vitamin d oral tablet 2000 unit NC
vitamin d2 oral tablet 2000 unit NC
vitamin d3 maximum strength NC
vitamin d3 oral capsule 10000 unit, 5000 unit, 50000 unit
NC
vitamin d3 oral liquid 5000 unit/ml NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018157
Drug Name Drug Status Drug Details
vitamin d3 oral tablet 10000 unit, 3000 unit, 5000 unit, 50000 unit
NC
vitamin d3 oral tablet 400 unit CE
vitamin d3 oral tablet chewable 2000 unit, 5000 unit
NC
vitamin d3 super strength oral tablet NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018158
2018 Aetna Pharmacy Drug Guide - Aetna Value Small Group Plan: IA, NE
The formulary is updated the first week of each month.
12/01/2018159
Index
abacavir sulfate ........................ 62abacavir sulfate-lamivudine ...... 63abacavir-lamivudine-zidovudine 63abaneu-sl............................... 115abilify...................................... 60abreva......................................81absorica................................... 81abstral..................................... 23acamprosate calcium .............. 144acanya..................................... 81acarbose ...................................39accolate................................... 31accu-chek aviva plus................93accu-chek compact plus...........93accu-chek fastclix lancets.......123accu-chek multiclix lancet dev123accu-chek multiclix lancets.... 123accu-chek smartview................93accu-chek soft touch lancets.. 123accu-chek softclix lancets.......123accupril....................................49accuretic.................................. 49accutrend glucose.................... 93acebutolol hcl ........................... 68acetaminophen-codeine .............23acetaminophen-codeine #2 ........23acetaminophen-codeine #3 ........23acetaminophen-codeine #4 ........23acetasol hc ..............................140acetazolamide .........................102acetazolamide er .....................102acetic acid .......................111, 140acetylcysteine ...........................79acid control maximum strength...............................................151acid controller max st ............. 151acid reducer ............................151acid reducer maximum strength...............................................151aciphex.................................. 151aciphex sprinkle.....................151acitretin ................................... 81actemra....................................20acticlate................................. 149actigall................................... 110actimmune...............................55actiq........................................ 23active fe ..................................115activella................................. 108
actonel................................... 103actoplus met............................ 39actoplus met xr........................ 39actos........................................ 39acular.....................................135acular ls................................. 135acuvail................................... 135acyclovir .............................63, 81aczone..................................... 81adacel.................................... 151adagen..................................... 69adalat cc.................................. 69adapalene .................................81adapalene-benzoyl peroxide ......81adcetris.................................... 55adcirca.....................................71adderall................................... 17adderall xr............................... 17adefovir dipivoxil ......................63adempas.................................. 71adlyxin.....................................39adlyxin starter pack................. 39admelog...................................40admelog solostar..................... 40adrenalin........................ 134, 155adrucil ......................................55advair diskus........................... 31advair hfa................................ 31advance intuition test.............. 93advance micro-draw test..........93advate.................................... 113advocate duo......................... 123advocate redi-code...................93advocate redi-code+ test..........94advocate test............................94adynovate.............................. 113adyphren............................... 155adyphren amp ii.....................156adyphren ii.............................156adzenys er................................17adzenys xr-odt......................... 17afeditab cr ................................69afinitor.................................... 55afinitor disperz........................ 55afrezza..................................... 40afstyla.................................... 113agamatrix amp test.................. 94agamatrix jazz test...................94agamatrix keynote test.............94
agamatrix presto test............... 94aggrenox................................113aimovig....................................69aimovig 140 dose..................... 69airavite...................................115airduo respiclick 113/14........... 31airduo respiclick 232/14........... 31airduo respiclick 55/14.............31ajovy........................................69akten......................................135aktipak.................................... 81akynzeo................................... 44ala scalp...................................81ala-quin................................... 81alavert ......................................46alavert allergy/sinus ..................79alaway ....................................135alaway childrens allergy.........135albendazole .............................. 29albenza.................................... 29albuterol sulfate ....................... 31albuterol sulfate er ................... 31alcaine................................... 135alclometasone dipropionate .......81alcortin a................................. 81aldactazide.............................102aldactone............................... 102aldara...................................... 81aldurazyme............................ 103alecensa................................... 55alendronate sodium .................103alferon n.................................. 55alfuzosin hcl er ....................... 111alinia....................................... 52alkeran.................................... 55allegra allergy.......................... 46allegra allergy childrens........... 46allegra-d allergy & congestion. 79allergy eye drops .................... 135allergy relief .............................46allzital......................................22almotriptan malate ................. 127alocril.................................... 135alogliptin benzoate ................... 40alogliptin-metformin hcl ........... 40alogliptin-pioglitazone .............. 40alomide..................................135aloprim.................................. 112alora...................................... 108
160
alosetron hcl ...........................110aloxi........................................ 44alphagan p.............................135alphanate/vwf complex/human..................... 113alphanine sd...........................113alprazolam ............................... 30alprazolam er ........................... 30alprazolam intensol................. 30alprazolam xr ...........................30alprolix.................................. 113alrex.......................................135altabax.....................................81altacaine .................................135altace....................................... 49altafluor ................................. 135altafrin ................................... 136altavera ....................................73altoprev................................... 47altreno..................................... 81alunbrig................................... 55alvesco.....................................31alyacen 1/35 ............................. 73alyacen 7/7/7 ............................ 73amantadine hcl ......................... 59amaryl..................................... 40ambien...................................119ambien cr...............................119ambisome................................ 45amcinonide ...............................81ameluz..................................... 81amerge................................... 127amethia .................................... 73amethia lo ................................ 74amicar....................................118amikacin sulfate ....................... 19amiloride hcl ...........................102amiloride-hydrochlorothiazide 102aminophylline ...........................31amiodarone hcl .........................30amitiza...................................110amitriptyline hcl ....................... 37amlodipine besy-benazepril hcl ..49amlodipine besylate .................. 69amlodipine besylate-valsartan ...49amlodipine-atorvastatin ............ 71amlodipine-olmesartan ............. 49amlodipine-valsartan-hctz .........49ammonium lactate .................... 81ammonul............................... 103
amnesteem ............................... 81amoxapine ............................... 37amoxicill-clarithro-lansopraz ..151amoxicillin ............................. 142amoxicillin-pot clavulanate ..... 142amoxicillin-pot clavulanate er . 142amphetamine sulfate .................17amphetamine-dextroamphet er . 17amphetamine-dextroamphetamine ..................17ampicillin ............................... 142ampicillin sodium ....................142ampicillin-sulbactam sodium ... 142ampyra.................................. 145amrix..................................... 133anadrol-50............................... 27anafranil.................................. 37anagrelide hcl ......................... 113ana-lex.....................................28analpram-hc............................ 28anaprox ds...............................20anaspaz..................................151anastrozole ...............................55ancobon...................................45androderm...............................28androgel.................................. 28androgel pump........................ 28angeliq................................... 108animi-3.................................. 115animi-3/vitamin d.................. 115anoro ellipta............................ 31antabuse................................ 145antara...................................... 47anusol-hc................................. 28anzemet................................... 44apap-caff-dihydrocodeine ......... 23apexicon e................................81apidra...................................... 40apidra solostar.........................40aplenzin................................... 37apptrim....................................98apptrim-d................................ 98apraclonidine hcl .................... 136aprepitant ................................ 44apri .......................................... 74apriso.....................................110aptensio xr...............................17aptiom..................................... 34aptivus.....................................63aqueous vitamin d ................... 156
aralast np...............................148aranelle .................................... 74aranesp (albumin free)........... 115arava....................................... 20arcalyst.................................... 20arcapta neohaler......................31argyle sterile saline .................111aricept....................................145arikayce................................... 19arimidex.................................. 55aripiprazole ........................ 60, 61arixtra......................................33armodafinil .............................. 17armonair respiclick 113........... 31armonair respiclick 232........... 32armonair respiclick 55............. 32armour thyroid...................... 150arnuity ellipta.......................... 32aromasin..................................55arthrotec..................................20arymo er.................................. 23arzerra..................................... 55asacol hd................................110ascomp-codeine ........................ 23asmanex 120 metered doses..... 32asmanex 14 metered doses....... 32asmanex 30 metered doses....... 32asmanex 60 metered doses....... 32asmanex 7 metered doses.........32asmanex hfa.............................32aspir-81 ....................................22aspirin-dipyridamole er ...........113aspir-low .................................. 22assure 3 test............................. 94assure 4 test............................. 94assure ii....................................94assure ii check..........................94assure lancets.........................123assure platinum....................... 94assure prism multi test............. 94assure pro test..........................94astagraf xl................................66astepro...................................134astero.......................................81atacand....................................49atazanavir sulfate ..................... 63atelvia.................................... 104atenolol .................................... 68atenolol-chlorthalidone ............. 49atgam...................................... 66
161
ativan...................................... 30atomoxetine hcl ........................17atorvastatin calcium ................. 47atovaquone ...............................52atovaquone-proguanil hcl ..........53atralin......................................81atripla......................................63atropine sulfate .......................136atrovent hfa.............................32aubagio..................................145aubra eq.................................. 74augmentin..............................142augmentin xr......................... 143austedo.................................. 145auvi-q.................................... 156avage....................................... 81availnex................................... 98avalide..................................... 49avandia....................................40avapro..................................... 49avar cleanser ............................ 81avar ls cleanser........................ 82avar-e emollient ........................82avar-e green ............................. 82avar-e ls................................... 82avc vaginal.............................155avelox.................................... 109aviane ...................................... 74avidoxy .................................. 149avidoxy dk.............................149avita .........................................82avo cream................................ 82avodart.................................. 111avonex................................... 145avonex pen.............................145avonex prefilled..................... 145av-vite fb ................................ 115axona.......................................98aygestin..................................144azactam................................. 130azasan......................................66azasite....................................136azathioprine ............................. 66azelastine hcl .................. 134, 136azelex.......................................82azilect...................................... 59azithromycin .......................... 123azopt......................................136azor......................................... 49aztreonam .............................. 130
azulfidine............................... 110azulfidine en-tabs...................110azurette ....................................74b-6 folic acid ...........................115bacitracin ............................... 136bacitracin-polymyxin b ........... 136bacitra-neomycin-polymyxin-hc ...........................................136baclofen ..................................133bactocill in dextrose...............143bactrim.................................... 52bactrim ds................................52bactroban................................ 82bactroban nasal..................... 134balcoltra.................................. 74balsalazide disodium ...............110balziva ..................................... 74banzel...................................... 34baraclude.................................63basaglar kwikpen.....................40baxdela.................................. 109bayer aspirin ec low dose .......... 22bayer breeze 2 test................... 94bayer contour test....................94bayer low dose ..........................22bayer microlet lancets............ 124bd autoshield......................... 124bd insulin syringe...................124bd insulin syringe half-unit.... 124bd insulin syringe microfine...124bd insulin syringe u/f..............124bd insulin syringe ultrafine.... 124bd lancet ultrafine 30g........... 124bd lancet ultrafine 33g........... 124bd microtainer lancets........... 124bd pen....................................124bd pen mini............................124bd pen needle mini u/f............124bd pen needle nano u/f...........124bd pen needle short u/f...........124bd pen needle ultrafine.......... 124bd safetyglide insulin syringe. 124bebulin...................................113beconase aq........................... 134belbuca.................................... 23belladonna alkaloids-opium .....151belladonna-opium ................... 151belsomra................................ 140benazepril hcl ........................... 49benazepril-hydrochlorothiazide . 49
benefix................................... 113benicar.....................................49benicar hct...............................49benlysta................................... 66bensal hp................................. 82bentyl.....................................151benzaclin................................. 82benzaclin with pump............... 82benznidazole .............................29benzonatate ..............................79benzoyl peroxide-erythromycin .82benzphetamine hcl .................... 17benztropine mesylate ................ 59bepreve.................................. 136berinert.................................. 113besivance............................... 136betadine ophthalmic prep...... 136betagan..................................136betamethasone dipropionate ..... 82betamethasone dipropionate aug ...........................................82betamethasone valerate ............ 82betapace af.............................. 68betaseron............................... 145betaxolol hcl ..................... 68, 136bethanechol chloride ............... 154bethkis.....................................19betimol.................................. 136betoptic-s...............................136bevespi aerosphere...................32bevyxxa................................... 34bexarotene ............................... 55beyaz....................................... 74biafine..................................... 82biaxin.....................................123bicalutamide .............................55bidil......................................... 71biktarvy................................... 63biltricide.................................. 29bimatoprost ............................ 136binosto...................................104bio glo .................................... 136bionect.....................................82bioscanner glucose test............ 94bisoprolol fumarate .................. 68bisoprolol-hydrochlorothiazide ..49bivigam..................................141bleph-10.................................136blephamide............................ 136blephamide s.o.p....................136
162
blood glucose test ..................... 94boniva....................................104bonjesta................................... 44bosulif..................................... 55botox..................................... 135botox cosmetic.........................82bp 10-1 .....................................82bp cleansing wash....................82bp vit 3...................................115braftovi....................................55bravelle.................................. 104breo ellipta.............................. 32briellyn .....................................74brilinta........................... 102, 113brimonidine tartrate ................136brisdelle................................. 145briviact.................................... 34bromfenac sodium (once-daily)...............................................136bromocriptine mesylate ............ 59bromsite.................................136brovana................................... 32budesonide .................. 32, 78, 134budesonide er ............................78bullseye mini safety lancets ..... 124bullseye safety lancets............ 124bumetanide ..................... 102, 103bunavail...................................23bupap...................................... 22buphenyl................................104buprenorphine .......................... 23buprenorphine hcl ..................... 23buprenorphine hcl-naloxone hcl .24bupropion hcl ........................... 37bupropion hcl er (smoking det)...............................................145bupropion hcl er (sr) ................ 37bupropion hcl er (xl) ................37buspirone hcl ............................ 30busulfex................................... 55butalbital-acetaminophen ......... 22butalbital-apap-caff-cod ........... 24butalbital-apap-caffeine ...... 22, 23butalbital-asa-caff-codeine ....... 24butalbital-aspirin-caffeine .........23butisol sodium....................... 119butorphanol tartrate ................. 24butrans.................................... 24bydureon................................. 40bydureon bcise.........................40
byetta 10 mcg pen....................40byetta 5 mcg pen......................40bystolic.................................... 68byvalson.................................. 68cabergoline .............................104cabometyx............................... 55caduet......................................71cafergot..................................127caffeine citrate ......................... 17calan sr.................................... 69calcidol.................................. 156calciferol................................ 156calcipotriene .............................82calcipotriene-betameth diprop ...82calcitonin (salmon) ................ 104calcitrene ................................. 82calcitriol ........................... 82, 104calquence.................................55cambia................................... 127camila ...................................... 74camptosar................................55camrese ....................................74camrese lo ................................ 74canasa....................................110candesartan cilexetil .................49candesartan cilexetil-hctz ......... 49cantharidin ...............................83capastat sulfate........................54capecitabine ............................. 55capex....................................... 83caprelsa................................... 55captopril ...................................49captopril-hydrochlorothiazide ... 49carac........................................83carafate..................................151carbaglu.................................104carbamazepine ......................... 34carbamazepine er ..................... 34carbatrol..................................34carbidopa ................................. 59carbidopa-levodopa .................. 59carbidopa-levodopa er .............. 59carbinoxamine maleate .............46cardene iv................................ 69cardiotek rx............................. 98cardizem cd............................. 69cardizem la.............................. 69cardura.................................... 49cardura xl.............................. 111caresens n glucose test............. 94
carimune nf............................141carisoprodol ........................... 133carisoprodol-aspirin ................133carisoprodol-aspirin-codeine ... 133carnitor..................................104carnitor sf.............................. 104carospir..................................103carteolol hcl ............................136cartia xt ................................... 69carvedilol ................................. 68carvedilol phosphate er ............. 68casodex....................................55catapres................................... 49catapres-tts-1........................... 50catapres-tts-2........................... 50catapres-tts-3........................... 50cayston.................................. 130caziant ..................................... 74cefaclor .................................... 72cefaclor er ................................ 72cefadroxil .................................72cefazolin sodium .......................72cefdinir .....................................72cefditoren pivoxil ......................72cefepime hcl ............................. 72cefixime ................................... 72cefotaxime sodium ....................72cefotetan disodium ....................72cefoxitin sodium ....................... 72cefpodoxime proxetil ................ 72cefprozil ................................... 72ceftazidime ...............................72ceftriaxone sodium ................... 72ceftriaxone sodium in dextrose . 72cefuroxime axetil ..................... 73cefuroxime sodium ................... 73celebrex................................... 20celecoxib .................................. 20celexa.......................................37cellcept.................................... 66cellcept intravenous................. 66celontin....................................34cem-urea..................................83cenfol.....................................115centany.................................... 83centany at................................ 83centratex................................115cephalexin ................................ 73cerdelga................................. 115cerebyx.................................... 34
163
cerefolin...................................98cerefolin nac............................ 98cerezyme................................ 116cesamet....................................44cesia .........................................74cetirizine hcl .............................46cetirizine-pseudoephedrine er .... 79cetraxal.................................. 140cetrotide.................................104cevimeline hcl ......................... 130chantix...................................145chantix continuing month pak...............................................145chantix starting month pak....145chateal ..................................... 74chateal eq................................ 74chemet..................................... 44chemstrip k..............................94chenodal................................ 110childrens aspirin ....................... 23childrens loratadine .................. 46chlordiazepoxide hcl ................. 30chlordiazepoxide-amitriptyline145chlorhexidine gluconate .......... 130chloroquine phosphate .............. 53chlorothiazide .........................103chlorothiazide sodium ............. 103chlorpromazine hcl ................... 61chlorpropamide ........................ 40chlorthalidone .........................103chlorzoxazone ........................ 133cholbam...................................69cholestyramine ......................... 73cholestyramine light ................. 47chorionic gonadotropin ........... 104ciclodan................................... 83ciclodan solution..................... 83ciclopirox ................................. 83ciclopirox olamine .................... 83ciclopirox treatment ................. 83cidofovir ...................................63ciferex.................................... 116cilostazol ................................ 113ciloxan................................... 136cimduo.................................... 63cimetidine ...............................151cimzia.................................... 110cimzia prefilled...................... 110cimzia starter kit.................... 110cinqair................................... 120
cinryze................................... 113cipro...................................... 109cipro hc..................................140cipro xr.................................. 109ciprodex.................................140ciprofloxacin .......................... 109ciprofloxacin hcl ......109, 136, 140ciprofloxacin in d5w ............... 109ciprofloxacin-ciproflox hcl er ..109citalopram hydrobromide ..........37citranatal 90 dha....................131citranatal assure.....................131citranatal b-calm....................131citranatal dha........................ 131citranatal harmony................ 131citranatal medley................... 131citranatal rx........................... 131claravis .................................... 83clarinex....................................46clarinex-d 12 hour................... 79clarithromycin ........................ 123clarithromycin er .................... 123claritin..................................... 46claritin eye............................. 136claritin reditabs........................46claritin-d 12 hour.....................79claritin-d 24 hour.....................79clearlax .................................. 120clenpiq................................... 120cleocin..............................52, 155cleocin in d5w..........................52cleocin phosphate.................... 52cleocin-t...................................83clever chek auto-code............ 124clever chek auto-code test........94clever chek auto-code voice..... 94clever chek test........................ 94clever choice auto-code test..... 94clever choice micro test............94climara...................................108climara pro............................ 108clindacin etz.............................83clindacin pac............................83clindagel.................................. 83clindamycin hcl .........................52clindamycin palmitate hcl ......... 52clindamycin phos-benzoyl perox ....................................... 83clindamycin phosphate .52, 83, 155clindamycin-tretinoin ................83
clobetasol propionate .......... 83, 84clobetasol propionate e ............. 83clobetasol propionate emulsion . 83clobex...................................... 84clobex spray.............................84clocortolone pivalate .................84clodan ...................................... 84cloderm................................... 84clomiphene citrate .................. 104clomipramine hcl ...................... 37clonazepam .............................. 34clonidine hcl ............................. 50clonidine hcl er ......................... 17clopidogrel bisulfate ................113clorazepate dipotassium ............30clotrimazole ........................... 130clotrimazole-betamethasone ..... 84clozapine .................................. 61clozaril.....................................61coagadex................................113coaguchek lancets.................. 124coal tar .................................... 84coartem................................... 53codeine sulfate ..........................24colazal................................... 110colchicine ............................... 112colchicine-probenecid ..............112colcrys................................... 112colesevelam hcl .........................47colestid.................................... 47colestid flavored...................... 47colestipol hcl ............................ 47collagenase ...............................84colocort ....................................28coly-mycin m........................... 52coly-mycin s...........................140combigan...............................136combipatch............................108combivent respimat................. 32combivir.................................. 63cometriq (100 mg daily dose)...55cometriq (140 mg daily dose)...55cometriq (60 mg daily dose).....55comfort assured lancets 28g .... 124comfort assured lancets 33g .... 124complera..................................63compro .....................................61comtan.................................... 59co-natal fa ..............................131concept dha........................... 131
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concept ob............................. 131concerta...................................17condylox..................................84constulose ...............................120conzip......................................24cool blood glucose test strips... 94copaxone............................... 145copiktra................................. 143cordran....................................84coreg........................................68coreg cr....................................68coremino................................149corgard.................................... 68corifact.................................. 113corlanor................................. 148cortef....................................... 78cortenema................................28cortifoam.................................28cortisporin............................... 84corvita ....................................131corvita 150.............................116corvite....................................131corvite 150............................. 116corvite fe................................116corzide.....................................50cosentyx...................................84cosentyx sensoready pen..........84cosopt pf................................136cotellic..................................... 56cotempla xr-odt....................... 17coumadin.................................34cozaar......................................50creon......................................102cresemba..................................45crestor..................................... 47crinone...................................155crixivan....................................63cromolyn sodium ....... 32, 110, 136crotan...................................... 84cryselle-28 ................................74cuprimine................................ 66cutivate....................................84cuvitru................................... 141cuvposa..................................151cvs acid controller max st ........151cvs advanced glucose test.........94cvs d3 ..................................... 156cvs nicotine .............................145cvs nicotine polacrilex .............145cvs purelax.............................120
cyanocobalamin ......................116cyclafem 1/35 ........................... 74cyclafem 7/7/7 .......................... 74cyclobenzaprine hcl .................133cyclogyl..................................136cyclomydril............................137cyclopentolate hcl ................... 137cyclophosphamide .................... 56cycloserine ............................... 54cycloset....................................40cyclosporine ............................. 66cyclosporine modified ............... 66cymbalta..................................38cyproheptadine hcl ....................46cystadane...............................104cystagon................................ 111cystaran................................. 137cytogam.................................141cytomel.................................. 150cytovene.................................. 63cytra-2 ................................... 111d 10000 .................................. 156d 5000 .................................... 156d.h.e. 45................................. 127d-2000 maximum strength ...... 156d2000 ultra strength ................156d3 dots...................................156d3 maximum strength ............. 156d3 super strength .................... 156d3-1000 .................................. 156d-3-5 ...................................... 156d-5000 ....................................156daklinza...................................63dalfampridine er ..................... 145daliresp....................................32danazol .................................... 28dantrolene sodium ...................133dapsone .............................. 52, 84daraprim..................................53darifenacin hydrobromide er ... 154dasetta 1/35 ..............................74dasetta 7/7/7 .............................74daypro..................................... 20daysee ...................................... 74daytrana.................................. 17ddavp.....................................104ddavp rhinal tube.................. 104ddrops................................... 156debacterol..............................130deblitane..................................74
decara.................................... 156deferoxamine mesylate ............. 44delestrogen............................ 108delstrigo...................................63delta d3 .................................. 156delzicol.................................. 110demadex................................ 103demeclocycline hcl .................. 149demerol................................... 24demser..................................... 50denavir.................................... 84denta 5000 plus .......................130depakene................................. 34depakote..................................34depakote er..............................34depakote sprinkles...................35depen titratabs.........................66deplin 15..................................98deplin 7.5.................................98depo-estradiol........................108depo-medrol............................ 78depo-provera..................... 56, 74depo-testosterone.................... 28derma-smoothe/fs body........... 84dermasorb ta........................... 84dermotic................................ 140descovy....................................63desferal.................................... 44desipramine hcl .........................38desloratadine ............................46desmopressin ace spray refrig . 104desmopressin acetate .............. 104desogestrel-ethinyl estradiol ......74desonate.................................. 84desonide ................................... 84desowen...................................84desoximetasone ........................ 84desoxyn................................... 17desvenlafaxine er ......................38desvenlafaxine succinate er .......38detrol..................................... 154detrol la................................. 154dexamethasone .........................78dexamethasone intensol...........78dexamethasone sod phosphate pf ............................................. 78dexamethasone sodium phosphate ......................... 78, 137dexedrine................................. 17dexilant..................................151
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dexmethylphenidate hcl ............ 17dexmethylphenidate hcl er ........ 17dextroamphetamine sulfate .......17dextroamphetamine sulfate er ...17dialyvite 5000.........................131dialyvite supreme d................131dialyvite vitamin d 5000.........156dialyvite vitamin d3 max........156diastat acudial......................... 35diastat pediatric.......................35diatrue plus test ........................ 94diazepam ............................ 30, 35diazepam intensol ..................... 30dibenzyline.............................. 50diclegis.....................................44diclofenac potassium .................20diclofenac sodium .. 20, 84, 85, 137diclofenac sodium er ................. 20diclofenac-misoprostol ..............20diclofex dc............................... 85dicloxacillin sodium ................ 143dicyclomine hcl .......................152didanosine ................................ 63diethylpropion hcl .....................18diethylpropion hcl er .................17differin.....................................85dificid.................................... 123diflorasone diacetate .................85diflucan................................... 45diflunisal .................................. 23digitek..................................... 71digox ........................................71digoxin .....................................71dihydroergotamine mesylate ... 127dilantin.................................... 35dilantin infatabs...................... 35dilatrate-sr...............................29dilaudid................................... 24diltiazem hcl .............................70diltiazem hcl er .........................70diltiazem hcl er beads ............... 69diltiazem hcl er coated beads .... 70dilt-xr ...................................... 70diovan..................................... 50diovan hct................................50dipentum............................... 110diphenhydramine hcl .................46diphenoxylate-atropine .............43diprolene................................. 85diprolene af............................. 85
dipyridamole .......................... 113disopyramide phosphate ............31disulfiram ...............................145ditropan xl............................. 154diuril......................................103divalproex sodium .................... 35divalproex sodium er ................ 35divista.................................... 116dofetilide .................................. 31dolophine................................ 24donepezil hcl ...........................145donnatal................................ 152doptelet..................................116doral...................................... 119doryx..................................... 149doryx mpc..............................149dorzolamide hcl ...................... 137dorzolamide hcl-timolol mal ....137dorzolamide hcl-timolol mal pf 137dovonex...................................85doxazosin mesylate ...................50doxepin hcl ......................... 38, 85doxercalciferol ....................... 104doxy 100 ................................ 149doxycycline .............................. 85doxycycline hyclate ................ 149doxycycline monohydrate ....... 149drisdol................................... 156dritho-creme hp.......................85dronabinol ................................44drospiren-eth estrad-levomefol ..74drospirenone-ethinyl estradiol ...74droxia.................................... 116drug mart unifine pentips...... 124duac.........................................85duavee................................... 109duetact.....................................40duexis...................................... 20dulera...................................... 32duloxetine hcl ........................... 38duo-care test............................ 94duopa...................................... 60dupixent.................................. 67durachol ................................. 116duragesic-100...........................24duragesic-12............................ 24duragesic-25............................ 24duragesic-50............................ 24duragesic-75............................ 24duramorph ............................... 24
durezol...................................137durlaza...................................113durolane................................ 133dutasteride ............................. 112dutasteride-tamsulosin hcl .......112dutoprol.................................. 50duzallo...................................112d-vi-sol...................................156dyanavel xr.............................. 18dyazide.................................. 103dymista.................................. 134dyrenium............................... 103dysport.................................. 135e.e.s. 400................................ 123e.e.s. granules.........................123easy comfort insulin syringe...124easy plus ii glucose test ............. 94easy step test............................94easy talk blood glucose test .......94easy touch healthpro test......... 94easy touch insulin syringe...... 124easy touch lancets 21g............124easy touch lancets 23g............124easy touch lancets 26g............124easy touch lancets 26g/twist... 124easy touch lancets 28g............124easy touch lancets 28g/twist... 124easy touch lancets 30g............125easy touch lancets 30g/twist... 125easy touch lancets 32g............125easy touch lancets 32g/twist... 125easy touch lancets 33g/twist... 125easy touch lancing device.......125easy touch safety lancets 21g..125easy touch safety lancets 23g..125easy touch safety lancets 26g..125easy touch safety lancets 28g..125easy touch test......................... 94easy trak blood glucose test ...... 94easy twist & cap lancets......... 125easygluco................................. 94easygluco plus..........................95easymax 15 test........................95easymax test............................ 95easyplus blood glucose test ........95easypro blood glucose test....... 95easypro plus.............................95ec-81 aspirin .............................23ec-naprosyn............................. 20econazole nitrate ...................... 85
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ecotrin..................................... 23ecotrin low strength .................. 23ecoza....................................... 85ecpirin ......................................23edarbi...................................... 50edarbyclor............................... 50edecrin................................... 103edluar.................................... 119edurant.................................... 63efavirenz .................................. 63effer-k.................................... 129effer-k .................................... 129effexor xr................................. 38effient.................................... 113efudex......................................85egrifta.................................... 104elaprase..................................104elelyso....................................116element compact test ................ 95element test..............................95elestat.................................... 137elestrin................................... 108eletriptan hydrobromide ..........127elidel........................................ 85eligard..................................... 56elinest ...................................... 74eliquis...................................... 34eliquis starter pack...................34elixophyllin..............................32ella...........................................74elmiron.................................. 112elocon......................................85eloctate.................................. 113emadine................................. 137embeda.................................... 24embrace blood glucose test...... 95embrace evo blood glucose test...........................................95embrace pro glucose test..........95emcyt.......................................56emend......................................44emflaza.................................... 78emgality...................................69emoquette .................................74emsam..................................... 38emtriva.................................... 63emverm....................................29enablex.................................. 154enalapril maleate ......................50enalapril-hydrochlorothiazide ... 50
enbrel...................................... 20enbrel mini.............................. 20enbrel sureclick........................20endari...................................... 19endocet .....................................24endocet.................................... 24endometrin............................ 155enlyte.......................................99enoxaparin sodium ................... 34enpresse-28 .............................. 74enskyce.................................... 75enstilar.....................................85entacapone ............................... 60entecavir .................................. 63enteragam................................99entocort ec...............................79entresto..................................135entyvio...................................120enulose ................................... 110envarsus xr.............................. 66epaned..................................... 50epclusa...................................118epiceram.................................. 85epidiolex.................................. 35epiduo..................................... 85epiduo forte............................. 85epifoam................................... 85epinastine hcl ..........................137epinephrine .............................156epipen 2-pak.......................... 156epipen jr 2-pak.......................156episnap.................................. 156epitol ........................................35epivir....................................... 63epivir hbv................................ 63eplerenone ................................ 50epogen................................... 116epoprostenol sodium ................. 71eprosartan mesylate ..................50epzicom................................... 63eq acid reducer max st ............ 152eq clearlax..............................121eq nicotine .............................. 145eql clearlax.............................121eql heartburn prevention ......... 152eql vitamin d3 ......................... 156equetro.................................... 61ergocal ................................... 157ergocalciferol ......................... 157ergoloid mesylates .................. 145
ergomar................................. 127erivedge................................... 56erleada.....................................56errin .........................................75ertaczo.....................................85ery ........................................... 85erygel.......................................85eryped 200............................. 123eryped 400............................. 123ery-tab................................... 123erythrocin lactobionate..........123erythrocin stearate................. 123erythromycin ............................85erythromycin base .................. 123erythromycin ethylsuccinate ....123esbriet.................................... 148escitalopram oxalate ................ 38esgic .........................................23esgic.........................................23esomeprazole magnesium ........152esomeprazole strontium .......... 152estazolam ............................... 119estrace............................ 108, 155estradiol ..........................108, 155estradiol valerate .................... 108estradiol-norethindrone acet ... 108estring....................................155estrogel.................................. 108estrostep fe.............................. 75eszopiclone ............................. 119ethacrynic acid ....................... 103ethambutol hcl ..........................54ethosuximide ............................ 35ethyol...................................... 56etidronate disodium ................ 104etodolac ................................... 20etodolac er ............................... 20etoposide .................................. 56eucrisa................................... 143euflexxa................................. 133eurax....................................... 85evamist.................................. 108evekeo..................................... 18evencare + blood glucose test.. 95evencare blood glucose test......95evencare g2 test........................95evencare g3 test........................95evencare mini glucose test........95evista..................................... 105evolution autocode.................. 95
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evotaz...................................... 63evoxac....................................130evzio........................................ 44exalgo...................................... 24exelderm.................................. 85exelon.................................... 145exemestane ...............................56exforge.....................................50exforge hct...............................50exjade...................................... 44exoderm...................................85extavia................................... 145extina.......................................85eye itch relief ..........................137eylea...................................... 137ez smart blood glucose test...... 95ez smart plus glucose test.........95ezetimibe ..................................47ezetimibe-simvastatin ............... 47fabb ........................................116fabior.......................................86fabrazyme..............................105falessa......................................75falmina .....................................75famciclovir ............................... 63famotidine .............................. 152famotidine premixed ...............152fanapt...................................... 61fanapt titration pack................61fareston................................... 56farxiga..................................... 40farydak.................................... 56faslodex................................... 56fa-vitamin b-6-vitamin b-12 .....116fayosim....................................75fazaclo..................................... 61fc2 female condom.................125feiba.......................................113felbamate ................................. 35felbatol.................................... 35feldene..................................... 20felodipine er ............................. 70fem ph................................... 155femara..................................... 56femhrt low dose..................... 108femring.................................. 155fenofibrate ............................... 48fenofibrate micronized ..............48fenofibric acid .......................... 48fenoglide..................................48
fenoprofen calcium ................... 20fentanyl ....................................24fentanyl citrate .........................24fentora.....................................24feriva 21/7..............................116ferocon ................................... 116ferotrinsic ...............................116ferraplus 90............................116ferriprox.................................. 44ferrlecit.................................. 116ferrocite plus .......................... 116ferro-plex hematinic...............116ferrotrin................................. 116fetzima.....................................38fetzima titration.......................38fexmid....................................133fexofenadine hcl ....................... 47fexofenadine hcl childrens .........47fexofenadine-pseudoephed er .... 80fiasp.........................................40fiasp flextouch......................... 40fibricor.................................... 48fibryga................................... 114fifty50 glucose test 2.0............. 95finacea..................................... 86finasteride .........................86, 112fingerstix lancets.................... 125fioricet/codeine........................ 24fiorinal.....................................23fiorinal/codeine #3.................. 24firazyr.................................... 114firmagon..................................56first-mouthwash blm..............130firvanq................................... 112flagyl..................................52, 53flarex..................................... 137flavoxate hcl ...........................154flebogamma dif......................141flecainide acetate ......................31flector...................................... 86flolan....................................... 71flolipid ..................................... 48flomax................................... 112flonase................................... 134flonase allergy relief...............134flovent diskus.......................... 32flovent hfa............................... 32floxin otic.............................. 140flucaine .................................. 137fluconazole ...............................45
fluconazole in sodium chloride .. 45flucytosine ................................45fludrocortisone acetate ............. 79flumadine................................ 63flunisolide ...............................134fluocinolone acetonide .......86, 140fluocinolone acetonide body ...... 86fluocinonide ..............................86fluorabon...............................129fluorescein-benoxinate ............ 137fluor-i-strips a.t. ..................... 137fluoritab ................................. 129fluorometholone ..................... 137fluoroplex................................ 86fluorouracil .........................56, 86fluoxetine hcl ............................38fluoxetine hcl (pmdd) .............145fluphenazine decanoate .............61fluphenazine hcl ........................61flura-drops.............................129flurandrenolide ......................... 86flura-safe............................... 137flurazepam hcl ........................119flurbiprofen .............................. 20flurbiprofen sodium .................137flutamide ..................................56fluticasone propionate ....... 86, 134fluticasone-salmeterol ...............32fluvastatin sodium .................... 48fluvastatin sodium er ................ 48fluvoxamine maleate .................38fluvoxamine maleate er .............38fml......................................... 137fml forte.................................137fml liquifilm...........................137focalin..................................... 18focalin xr................................. 18folbee ..................................... 116folbic ........................................99folbic rf....................................99folgard rx...............................116folic acid ................................ 116folivane-f............................... 116folivane-plus.......................... 116follistim aq.............................105folplex 2.2 .............................. 116foltanx..................................... 99foltanx rf................................. 99foltrin .....................................116foltx.........................................99
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fondaparinux sodium ................ 34fora d10 2-in-1 monitor......... 125fora d15g 2-in-1 monitor........125fora d15g blood glucose test.... 95fora d20 2-in-1 monitor......... 125fora d20 blood glucose test...... 95fora d40/g31 blood glucose......95fora g20 blood glucose test...... 95fora g30/prem v10 glucose test.95fora gd20 test...........................95fora gd50 blood glucose test.... 95fora tn'g/tn'g voice................... 95fora v10 blood glucose test...... 95fora v12 blood glucose test...... 95fora v20 blood glucose test...... 95fora v30a blood glucose test.... 95foracare gd40 test.................... 95foracare premium v10 test....... 95foracare test n go test...............95forfivo xl..................................38formadon ................................. 62formaldehyde ........................... 62fortamet...................................40forteo.....................................105fortesta.................................... 28fortiscare test........................... 96fosamax................................. 105fosamax plus d.......................105fosamprenavir calcium ..............63fosinopril sodium ...................... 50fosinopril sodium-hctz ...............50fosphenytoin sodium ................. 35fosrenol..................................110fosteum....................................99fosteum plus............................ 99fovex........................................99fragmin....................................34freestyle insulinx test................96freestyle lancets......................125freestyle lite test....................... 96freestyle precision ins syr....... 125freestyle precision neo test....... 96freestyle test.............................96freestyle unistick ii lancets..... 125frova...................................... 127frovatriptan succinate ............. 128ful-glo.................................... 137ful-glo .................................... 137fulphila.................................. 116furadantin..............................154
furosemide ..............................103fusion plus............................. 116fuzeon......................................63fyavolv...................................108fycompa...................................35gabadone.................................99gabapentin ............................... 35gabitril.....................................35gablofen.................................133galafold..................................105galantamine hydrobromide ..... 145galantamine hydrobromide er ..146galzin..................................... 129gamastan s/d..........................141gammagard............................141gammagard s/d less iga.......... 141gammaked............................. 141gammaplex............................ 141gamunex-c............................. 141ganciclovir sodium ....................64ganirelix acetate .....................105gastrocrom............................ 110gastrografin............................. 96gatifloxacin ............................ 137gattex.....................................110gavilax ................................... 121gavilyte-c ................................121gavilyte-g ............................... 121gavilyte-h...............................121gavilyte-n with flavor pack ......121ge100 blood glucose test ........... 96gebauers pain ease............86, 151gebauers spray and stretch......................................... 86, 151gelnique................................. 154gel-one................................... 133gelsyn-3..................................133gemfibrozil ............................... 48genadur................................... 86generess fe............................... 75generlac ..................................110gengraf .....................................67genotropin............................. 105genotropin miniquick............ 105genstrip 50............................... 96gentak .................................... 137gentamicin in saline .................. 19gentamicin sulfate ....... 19, 86, 137gentlelax ................................ 121genvisc 850.............................133
genvoya................................... 64geodon.....................................61geri-hydrolac 12 ....................... 86ght test .....................................96gialax..................................... 121gianvi ....................................... 75gildess fe 1.5/30 ........................ 75gildess fe 1/20 ...........................75gilenya................................... 146gilotrif..................................... 56glassia.................................... 148glatiramer acetate .................. 146glatopa...................................146gleevec..................................... 56gleostine.................................. 56glimepiride ............................... 40glipizide ................................... 40glipizide xl ............................... 40glipizide-metformin hcl ............. 40global inject ease insulin syr...125glucagen diagnostic................. 96glucagen hypokit..................... 40glucagon emergency................ 40gluco perfect 3 test...................96glucocard 01 sensor plus..........96glucocard expression test......... 96glucocard shine test................. 96glucocard vital test.................. 96glucocard x-sensor...................96glucocom test...........................96gluconavii blood glucose test... 96glucophage.............................. 40glucophage xr.......................... 41glucotrol.................................. 41glucotrol xl.............................. 41glumetza.................................. 41glyburide .................................. 41glyburide micronized ................ 41glyburide-metformin .................41glycolax ................................. 121glycopyrrolate ........................ 152glynase.....................................41glyset....................................... 41glyxambi................................148gnp acid reducer max st .......... 152gnp clearlax........................... 121gnp clickfine pen needles....... 125gnp folic acid .......................... 117gnp insulin syringe.................125gnp ultra com insulin syringe.125
169
gnp vitamin d ..........................157gnp vitamin d maximum strength ..................................157gnp vitamin d super strength ... 157gocovri.................................... 60golytely.................................. 121gonal-f................................... 105gonal-f rff.............................. 105gonal-f rff rediject..................105gonitro.....................................29gralise.............................144, 146gralise starter..................144, 146granisetron hcl ......................... 44granix.................................... 117griseofulvin microsize ............... 45griseofulvin ultramicrosize ........45guaifenesin ac ...........................80guanfacine hcl .......................... 50guanfacine hcl er ...................... 18guanidine hcl ............................ 54gynazole-1............................. 155haegarda................................114halcion...................................119haldol...................................... 61haldol decanoate..................... 61halobetasol propionate ..............86halog....................................... 86haloperidol ............................... 61haloperidol lactate ....................61harvoni.................................. 119healthy accents unifine pentip 125healthylax .............................. 121heartburn relief max st ........... 152heather .....................................75hectorol................................. 105helixate fs...............................114hemangeol............................... 68hematinic plus vit/minerals ......117hematinic/folic acid .................117hematogen fa......................... 117hematogen forte ......................117hemenatal ob......................... 131hemetab................................. 117hemlibra.................................. 46hemocyte plus........................117hemocyte-f ............................. 117hemocyte-plus .........................117hemofil m.............................. 114heparin sodium (porcine) ......... 34heparin sodium (porcine) pf ..... 34
hepsera.................................... 64hetlioz....................................119hiprex.................................... 154hizentra..................................141hm clearlax............................ 121hm famotidine ........................ 152hm nicotine .............................146hm nicotine polacrilex .............146hm vitamin d3 .........................157homatropaire ..........................137homatropine hbr ..................... 137horizant................................. 146hp acthar............................... 105humalog.................................. 41humalog kwikpen.................... 41humalog mix 50/50.................. 41humalog mix 50/50 kwikpen....41humalog mix 75/25.................. 41humalog mix 75/25 kwikpen....41humate-p............................... 114humatrope............................. 105humira.....................................20humira pediatric crohns start...20humira pen.............................. 20humira pen-cd/uc/hs starter..... 20humira pen-ps/uv starter..........20humulin 70/30..........................41humulin 70/30 kwikpen........... 41humulin n................................ 41humulin n kwikpen..................41humulin r.................................41humulin r u-500 (concentrated)......................... 41humulin r u-500 kwikpen.........41hyalgan..................................133hycamtin..................................56hydralazine hcl ......................... 50hydrea..................................... 56hydrochlorothiazide ................ 103hydrocod polst-cpm polst er ...... 80hydrocodone-acetaminophen .....25hydrocodone-ibuprofen ............. 25hydrocortisone .............. 29, 79, 87hydrocortisone ace-pramoxine...........................................29, 86hydrocortisone butyr lipo base .. 86hydrocortisone butyrate ............86hydrocortisone valerate ............ 87hydrocortisone-acetic acid ...... 141hydromet ..................................80
hydromorphone hcl ...................25hydromorphone hcl er ............... 25hydromorphone hcl pf ...............25hydroxychloroquine sulfate .......53hydroxyprogesterone caproate 144hydroxyurea .............................56hydroxyzine hcl ........................ 30hydroxyzine pamoate ............... 30hylafem....................................67hylatopic plus.......................... 87hymovis................................. 133hyperhep b s/d....................... 141hyperrab................................ 141hyperrho s/d.......................... 141hypertensa............................... 99hypertet s/d............................141hyqvia....................................141hysingla er............................... 25hyzaar......................................50ibandronate sodium ................ 105ibrance.....................................80ibudone................................... 25ibudone .................................... 25ibuprofen ..................................20ibuprofen comfort pac.............20ic 400....................................... 21ic 800....................................... 21iclusig...................................... 56idelvion..................................114idhifa..................................... 120ilaris.........................................21ilevro..................................... 137ilumya..................................... 87imatinib mesylate ..................... 56imbruvica................................ 56imipramine hcl ..........................38imipramine pamoate ................. 38imiquimod ................................ 87imiquimod pump .......................87imitrex................................... 128imitrex statdose refill ............. 128imitrex statdose system.......... 128impavido................................. 53impoyz.....................................87imuran.....................................67imvexxy maintenance pack.... 155imvexxy starter pack..............155in touch blood glucose test...... 96increlex.................................. 105indapamide .............................103
170
inderal la................................. 68inderal xl................................. 68indocin.................................... 21indomethacin ............................21indomethacin er ........................21infinity blood glucose test........96inflectra................................. 110infumorph 200.........................25infumorph 500.........................25ingrezza................................. 146inlyta....................................... 56innopran xl.............................. 68inova 4/1 acne control therapy.87inova 8/2 acne control therapy.87inspra...................................... 50insulin syringe ........................ 125insulin syringe/needle ..............125insulin syringe/needle.............125insulin syringe-needle u-100 .... 125integra f................................. 117integra plus............................ 117intelence.................................. 64intermezzo............................. 119intrarosa................................ 155intron a....................................56introvale ...................................75intuniv..................................... 18invega...................................... 61inveltys.................................. 137invirase.................................... 64invokamet..............................149invokamet xr......................... 149invokana..................................41iodine strong ...........................129iodosorb.................................. 62iopidine.......................... 137, 138ipratropium bromide ......... 32, 134ipratropium-albuterol ............... 32irbesartan .................................50irbesartan-hydrochlorothiazide . 50iressa....................................... 56irinotecan hcl ............................56irospan 24/6........................... 117is 24/6.................................... 117isentress................................... 64isentress hd.............................. 64isibloom...................................75isolyte-s..................................129isolyte-s ph 7.4....................... 129isoniazid ...................................54
isoptin sr..................................70isopto homatropine............... 138isordil titradose........................29isosorbide dinitrate ................... 29isosorbide dinitrate er ............... 29isosorbide mononitrate ............. 29isosorbide mononitrate er ..........29isotretinoin ...............................87isoxsuprine hcl ..........................71isradipine ................................. 70istalol.....................................138itraconazole ............................. 45ivermectin ................................ 29ixinity.................................... 114jadenu......................................44jadenu sprinkle........................ 44jakafi....................................... 57jalyn.......................................112jantoven ................................... 34janumet................................... 41janumet xr............................... 41januvia.....................................41jardiance..................................41jentadueto................................42jentadueto xr........................... 42jetrea......................................138jevtana.....................................57jinteli ......................................108jivi..........................................114jolessa ...................................... 75jolivette .................................... 75jublia....................................... 87juluca.......................................64junel 1.5/30 ...............................75junel 1/20 ................................. 75junel fe 1.5/30 ...........................75junel fe 1/20 ..............................75juxtapid................................... 48jynarque.................................105kadian..................................... 25kalbitor..................................114kaletra..................................... 64kalydeco................................ 148kanuma..................................122kapspargo sprinkle.................. 68kapvay.....................................18karbinal er............................... 47kariva .......................................75kazano.....................................42k-effervescent ......................... 129
keflex.......................................73kelnor 1/35 ............................... 75kenalog....................................87kepivance.................................57keppra..................................... 35keppra xr................................. 35keralyt scalp............................ 87kerr triple dye swabs................62kerydin.................................. 141ketocare...................................96ketoconazole .......................45, 87ketoprofen er ............................21ketorolac tromethamine .... 21, 138ketostix....................................96ketotifen fumarate .................. 138keveyis................................... 103kevzara.................................... 21khedezla.................................. 38kineret..................................... 21kisqali 200 dose....................... 80kisqali 400 dose....................... 80kisqali 600 dose....................... 80kisqali femara 200 dose........... 57kisqali femara 400 dose........... 57kisqali femara 600 dose........... 57kitabis pak...............................19klaron......................................87klofensaid ii............................. 87klonopin.................................. 35klor-con................................. 129klor-con 10 ............................. 129klor-con m10 .......................... 129klor-con m20 .......................... 129kls acid controller max st ........152kls laxaclear ...........................121koate......................................114koate-dvi............................... 114kogenate fs.............................114kombiglyze xr.......................... 42korlym.....................................42kovaltry................................. 114k-phos....................................129k-phos-neutral....................... 129kristalose............................... 121kroger blood glucose test .......... 96kroger insulin syringe............ 126kroger test ................................96krystexxa............................... 112k-tab...................................... 129k-tan plus...............................117
171
kurvelo .....................................75kuvan.....................................106k-vescent ................................ 129kyleena.................................... 75kynamro.................................. 48labetalol hcl ..............................68lacrisert..................................138lactic acid .................................87lactic acid e .............................. 87lactulose ................................. 121lactulose encephalopathy ........ 110lamictal....................................35lamictal odt............................. 35lamictal starter.........................35lamictal xr............................... 36lamisil......................................45lamivudine ................................64lamivudine-zidovudine .............. 64lamotrigine ...............................36lamotrigine er ...........................36lamotrigine starter kit-blue ....... 36lamotrigine starter kit-green ..... 36lamotrigine starter kit-orange ...36lancets ....................................126lancets super thin 28g ............. 126lancets ultra thin....................126lancets ultra thin 30g .............. 126lanoxin.................................... 71lansoprazole ........................... 152lanthanum carbonate .............. 110lantus.......................................42lantus solostar......................... 42larin fe 1.5/30...........................75lasix....................................... 103lastacaft................................. 138latanoprost ............................. 138latisse.......................................87latuda...................................... 61lazanda.................................... 25ldo plus....................................87leena ........................................ 75leflunomide ...............................21lemtrada................................ 146lenvima 10 mg daily dose.........57lenvima 12 mg daily dose.........57lenvima 14 mg daily dose.........57lenvima 18 mg daily dose.........57lenvima 20 mg daily dose.........57lenvima 24 mg daily dose.........57lenvima 4 mg daily dose...........57
lenvima 8 mg daily dose...........57lescol........................................48lescol xl....................................48lessina ...................................... 75letairis......................................71letrozole ................................... 57leucovorin calcium ....................57leukeran...................................57leukine................................... 117leuprolide acetate ..................... 57levalbuterol hcl ......................... 32levaquin................................. 109levbid.....................................152levemir.....................................42levemir flextouch..................... 42levetiracetam ............................36levetiracetam er ........................36levetiracetam in nacl .................36levobunolol hcl ........................138levocarnitine ...........................106levocetirizine dihydrochloride ... 47levofloxacin .................... 109, 138levofloxacin in d5w ................. 109levonest .................................... 75levonorgest-eth estrad 91-day ... 75levonorgestrel-ethinyl estrad ..... 75levora 0.15/30 (28) .................. 75levorphanol tartrate ..................25levothyroxine sodium ..............150levoxyl ................................... 150levsin..................................... 152levsin/sl.................................. 152levulan kerastick......................87lexapro.................................... 38lexiva....................................... 64lialda......................................110liberty next generation test...... 96liberty test ................................96librax..................................... 152lidocaine ...................................87lidocaine hcl ......................87, 122lidocaine hcl (cardiac) ............. 31lidocaine hcl (pf) ....................122lidocaine in d5w ........................31lidocaine pak ............................ 87lidocaine-hydrocortisone ace .....29lidocaine-prilocaine .................. 87lidocaine-tetracaine .................. 87lidoderm.................................. 87lifescan unistik 2.................... 126
lifescan unistik ii lancets........ 126limbrel..................................... 99limbrel250..............................100limbrel500..............................100lindane ..................................... 87linezolid ................................... 53linzess.................................... 110liothyronine sodium ................ 150lipichol 540............................ 100lipitor...................................... 48lipofen..................................... 48lisinopril ...................................50lisinopril-hydrochlorothiazide ... 50lister-v....................................100lite touch lancets .....................126litetouch lancets.....................126lithium ..................................... 61lithium carbonate ..................... 61lithium carbonate er ................. 61lithobid....................................61lithostat................................. 112livalo....................................... 48l-methylfolate ca me-cbl nac.. 100l-methylfolate forte................ 100l-methylfolate-algae-b12-b6 .... 100l-methylfolate-b6-b12 ............. 100l-methyl-mc........................... 100l-methyl-mc nac..................... 100lo loestrin fe.............................75locoid...................................... 87locoid lipocream...................... 88lodosyn....................................60loestrin 1.5/30 (21)................... 75loestrin 1/20 (21)......................75lokelma............................ 67, 144lomotil.....................................43lonhala magnair refill kit......... 32lonhala magnair starter kit...... 32lonsurf..................................... 57lopinavir-ritonavir .................... 64lopressor..................................68lopressor hct............................ 50loprox......................................88loratadine .................................47loratadine childrens .................. 47loratadine-d 12hr ......................80loratadine-d 24hr ......................80lorazepam ................................ 30lorcet....................................... 25lorcet hd.................................. 25
172
lorcet plus................................25lortuss ex................................. 80loryna ...................................... 75lorzone...................................133losartan potassium ....................50losartan potassium-hctz ............ 50loseasonique............................ 76lotemax..................................138lotensin....................................51lotensin hct.............................. 51lotrel........................................51lotrisone.................................. 88lotronex................................. 110lovastatin ................................. 48lovaza...................................... 48lovenox....................................34low-ogestrel ..............................76loxapine succinate .................... 61lucemyra..................................19lucentis.................................. 138ludent ..................................... 129luliconazole .............................. 88lumigan..................................138lumizyme............................... 106lunesta................................... 119lupaneta pack........................ 122lupron depot (1-month)........... 57lupron depot (3-month)........... 57lupron depot (4-month)........... 57lupron depot (6-month)........... 57lupron depot-ped (1-month).. 106lupron depot-ped (3-month).. 106lutera ....................................... 76luxiq........................................ 88luzu..........................................88lycelle.......................................88lynparza......................... 143, 144lyrica....................................... 36lyrica cr.......................... 144, 146lysodren...................................57lysteda................................... 118lyza..........................................76macrobid............................... 154macrodantin.......................... 154macugen................................ 138macutek................................. 100magellan insulin safety syr..... 126magnebind 400...................... 129magnesium sulfate .................. 129makena.................................. 144
malarone................................. 53malathion .................................88maprotiline hcl ......................... 38marinol....................................44marlissa ................................... 76marnatal-f..............................131marplan................................... 38matulane..................................57matzim la ................................. 70mavyret..................................119maxalt....................................128maxalt-mlt............................. 128maxfe.....................................117maxidex................................. 138maximum d3..........................157maxipime.................................73maxzide................................. 103maxzide-25............................ 103md-gastroview .......................... 96meclizine hcl .............................45meclofenamate sodium ............. 21medrol..................................... 79medroxyprogesterone acetate......................................... 76, 144mefenamic acid .........................21mefloquine hcl .......................... 53megace es...............................144megestrol acetate .............. 57, 144meijer blood glucose test ...........96meijer truetest test................... 96meijer truetrack test.................96mekinist...................................57mektovi................................... 57meloxicam ................................21melpaque hp ............................. 88melphalan .................................57melphalan hcl ........................... 57memantine hcl ........................ 146memantine hcl er .................... 146menest................................... 108menopur................................ 106menostar................................109meperidine hcl .......................... 25mephyton.............................. 157meprobamate ........................... 30mepron.................................... 53mercaptopurine ........................ 57mesalamine ............................ 110mesalamine-cleanser ...............110mesnex.....................................58
mestinon..................................54metadate er..............................18metafolbic..............................100metafolbic plus...................... 100metafolbic plus rf...................101metanx...................................101metaproterenol sulfate ..............32metaxalone .............................133metformin hcl ........................... 42metformin hcl er ....................... 42metformin hcl er (mod) ............42metformin hcl er (osm) ............ 42methadone hcl .......................... 25methadone hcl intensol ..............25methadose............................... 25methadose sugar-free...............26methamphetamine hcl ...............18methazolamide ....................... 103methenamine hippurate ...........154methenamine mandelate ..........154methergine.............................141methimazole ........................... 150methitest..................................28methocarbamol .......................133methotrexate ............................58methotrexate sodium (pf) ........ 58methoxsalen rapid .................... 88methscopolamine bromide .......152methyclothiazide .....................103methyldopa .............................. 51methyldopa-hydrochlorothiazide ..................51methyldopate hcl ...................... 51methylin.................................. 18methylphenidate hcl ..................18methylphenidate hcl er ..............18methylphenidate hcl er (cd) ......18methylphenidate hcl er (la) ...... 18methylprednisolone ...................79methylprednisolone sodium succ ..........................................79methyltestosterone ................... 28metoclopramide hcl .................111metolazone ............................. 103metopirone.............................. 96metoprolol succinate er .............68metoprolol tartrate ................... 68metoprolol-hctz er .................... 51metoprolol-hydrochlorothiazide 51metrocream............................. 88
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metrogel.................................. 88metrogel-vaginal....................155metrolotion..............................88metronidazole ..............53, 88, 155metronidazole in nacl ................53mevacor...................................48mexiletine hcl ........................... 31miacalcin............................... 106mibelas 24 fe............................76micardis...................................51micardis hct............................. 51miconazole 3 ...........................155micort-hc................................. 88micrhogam ultra-filtered plus 141microdot test........................... 96microgestin 1.5/30 .................... 76microgestin 1/20 ....................... 76microgestin fe 1.5/30 ................ 76microgestin fe 1/20 ................... 76micro-k.................................. 129microlet lancets......................126microtainer safety flow lancet 126midazolam hcl ........................ 119midodrine hcl ..........................156migergot................................ 128miglitol .................................... 42miglustat ................................ 117migranal................................ 128millipred.................................. 79mimvey ...................................109minastrin 24 fe.........................76minipress................................. 51miniprin low dose ......................23minitran ................................... 29minivelle................................ 109minocin..................................149minocycline hcl .......................150minocycline hcl er ................... 150minolira................................. 150minoxidil ..................................51miralax.................................. 121mirapex................................... 60mirapex er............................... 60mircera.................................. 117mircette................................... 76mirena (52 mg)........................ 76mirtazapine .............................. 38mirvaso....................................88misoprostol .............................152mitigare................................. 113
mitoxantrone hcl ...................... 58mixed vespid venom protein ...... 69mobic...................................... 21modafinil ..................................18moderiba .................................. 64moderiba 1200 dose pack........ 64moderiba 800 dose pack.......... 64moexipril hcl ............................ 51moexipril-hydrochlorothiazide .. 51mometasone furoate ..........88, 134monoclate-p...........................114monoject sodium chloride flush129mono-linyah ............................. 76mononessa ................................76mononine...............................114monovisc............................... 133montelukast sodium ..................32morcin ......................................67morgidox............................... 150morphabond er........................26morphine sulfate .......................26morphine sulfate (concentrate) .26morphine sulfate (pf) ............... 26morphine sulfate er ...................26morphine sulfate er beads ......... 26motofen................................... 43movantik............................... 111moviprep............................... 121moxatag.................................143moxeza.................................. 138moxifloxacin hcl ............. 109, 138mozobil..................................117ms contin.................................26mulpleta.................................117multaq..................................... 31multigen.................................117multigen folic.........................117multigen plus......................... 117multivitamin/fluoride .............. 131multi-vitamin/fluoride/iron ......131multivitamins/fluoride .............131mupirocin ................................. 88mupirocin calcium .................... 88myalept..................................122myambutol.............................. 54mycobutin............................... 54mycophenolate mofetil ..............67mydayis................................... 18mydriacyl...............................138myfortic...................................67
myglucohealth test...................96myleran................................... 58mynatal..................................131mynatal advance....................131mynatal plus ...........................131mynatal-z ............................... 131myobloc.................................135myorisan .................................. 88myorisan..................................88myrbetriq...............................154mysoline.................................. 36mytesi...................................... 43myzilra .....................................76na ferric gluc cplx in sucrose ... 117nabi-hb.................................. 141nabumetone ..............................21nadolol ..................................... 68nadolol-bendroflumethiazide .....51naftifine hcl .............................. 88naftin.......................................88naglazyme..............................106nalbuphine hcl .......................... 26nalfon...................................... 21nalocet ..................................... 26naloxone hcl ............................. 44naltrexone hcl ...........................44namenda................................146namenda titration pak........... 146namenda xr............................146namenda xr titration pack..... 146namzaric..................................37naprelan.................................. 21napro ....................................... 88naprosyn..................................21naproxen ..................................21naproxen dr ..............................21naproxen sodium ...................... 21naproxen sodium er .................. 21naratriptan hcl ........................128narcan..................................... 44nardil.......................................38nasacort allergy 24hr............. 134nasacort allergy 24hr children 134nasal allergy 24 hour .............. 134nascobal.................................117nasonex..................................134natacyn..................................138natazia.....................................76nateglinide ................................42natesto.....................................28
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natpara.................................. 106natroba....................................88nat-rul vitamin d .....................157natural vitamin d-3 ................. 157nature-throid......................... 150nebupent..................................53nebusal .....................................80nebusal.................................... 80necon 0.5/35 (28) .....................76necon 1/35 (28) ........................76nefazodone hcl .................. 38, 148neomycin sulfate .......................19neomycin-bacitracin zn-polymyx ................................. 138neomycin-polymyxin b gu ....... 112neomycin-polymyxin-dexameth...............................................138neomycin-polymyxin-gramicidin .............................. 138neomycin-polymyxin-hc .. 138, 141neoral...................................... 67neosalus...................................88neosalus cp.............................. 88neo-synalar..............................88nephplex rx............................ 131nephron fa............................. 117nerlynx.................................... 58nesina...................................... 42nestabs...................................131neuac....................................... 89neulasta................................. 117neupogen............................... 117neupro..................................... 60neurin-sl ................................. 118neurontin.................................36neutek 2tek glucose/pressure..126neutek 2tek test........................96nevanac..................................138nevirapine .................................64nevirapine er .............................64nexa plus................................132nexavar....................................58nexium...................................152nexium 24hr...........................152nexium i.v.............................. 152nexplanon................................76next choice one dose ................. 76nexterone.................................31niacin er (antihyperlipidemic) .. 48niacor...................................... 48
niaspan.................................... 48nicardipine hcl .......................... 70nicoderm cq........................... 146nicorelief ................................ 146nicorette.................................146nicotine .................................. 146nicotine polacrilex .................. 146nicotine step 1 .........................146nicotine step 2 .........................146nicotine step 3 .........................146nicotrol.................................. 146nicotrol ns..............................146nifedical xl ............................... 70nifedipine ................................. 70nifedipine er ............................. 70nifedipine er osmotic release ..... 70nikki........................................ 76nilandron.................................58nilutamide ................................ 58nimodipine ................................70ninlaro.....................................58nisoldipine er ............................ 70nitro-bid.................................. 29nitro-dur..................................29nitrofurantoin ......................... 154nitrofurantoin macrocrystal .... 154nitrofurantoin monohyd macro154nitroglycerin .............................30nitroglycerin in d5w ..................29nitrolingual..............................30nitromist..................................30nitrostat...................................30nitro-time ................................. 30nityr.......................................106nivestym................................ 118nizatidine ................................152nizoral..................................... 89nocdurna............................... 106noctiva...................................106nolix........................................ 89nora-be .....................................76norco....................................... 26norditropin flexpro................ 106norethin ace-eth estrad-fe ......... 76norethindrone ........................... 76norethindrone acetate ............. 144norethindrone-eth estradiol ..... 109norethin-eth estradiol-fe ........... 76norgestimate-eth estradiol ........ 76norgestim-eth estrad triphasic ...76
noritate....................................89norlyroc...................................76normosol-r.............................129normosol-r ph 7.4.................. 129norpace cr................................31norpramin............................... 38northera.................................135nortrel 0.5/35 (28) ................... 76nortrel 1/35 (21) ...................... 76nortrel 1/35 (28) ...................... 77nortrel 7/7/7 ............................. 77nortriptyline hcl ........................38norvasc.................................... 70norvir...................................... 64nova max glucose test..............96novarel ................................... 106novoeight...............................114novofine.................................126novolin 70/30...........................42novolin 70/30 relion.................42novolin n................................. 42novolin n relion....................... 42novolin r..................................42novolin r relion........................42novolog................................... 42novolog flexpen....................... 42novolog mix 70/30................... 42novolog mix 70/30 flexpen.......42novolog penfill.........................42novoseven rt.......................... 114novotwist...............................126noxafil..................................... 45np thyroid ...............................150nplate.....................................118nucala.................................... 120nucort......................................89nucynta....................................26nucynta er................................26nuedexta................................ 146nufol...................................... 118nulojix..................................... 67nulytely with flavor packs......121nuplazid...................................61nutropin aq nuspin 10............106nutropin aq nuspin 20............106nutropin aq nuspin 5............. 106nuvaring.................................. 77nuvigil..................................... 18nuwiq.....................................114nyamyc .................................... 89
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nymalize.................................. 71nystatin ................. 46, 69, 89, 130nystatin-triamcinolone ..............89nystop ...................................... 89ob complete gold................... 132ob complete premier.............. 132ob complete/dha.................... 132o-cal fa...................................132o-cal prenatal.........................132ocaliva................................... 109ocella ....................................... 77octagam.................................142octreotide acetate ................... 106ocuflox...................................138ocuvel.................................... 132odefsey.................................... 64odomzo................................... 58ofev........................................148ofloxacin ................. 109, 138, 141ogestrel .................................... 77olanzapine ................................61olanzapine-fluoxetine hcl .146, 147olmesartan medoxomil ............. 51olmesartan medoxomil-hctz ...... 51olmesartan-amlodipine-hctz ......51olopatadine hcl ................134, 138olumiant.................................. 21olux......................................... 89olux-e...................................... 89omeclamox-pak..................... 152omega-3-acid ethyl esters ..........48omeprazole .............................153omeprazole magnesium ...........153omeprazole-sodium bicarbonate ............................ 153omnaris..................................134omnipred............................... 139omnitrope..............................106on call express blood glucose...97on call plus blood glucose........97on call vivid blood glucose.......97ondansetron ..............................45ondansetron hcl ........................ 45onetouch club lancets fine pt. 126onetouch combo pack............126onetouch delica lancets 33g....126onetouch delica lancets fine... 126onetouch delica lancing dev... 126onetouch finepoint lancets.....126onetouch ultra blue................. 97
onetouch ultrasoft lancets......126onetouch verio.........................97onexton................................... 89onfi..........................................36onglyza.................................... 42onzetra xsail...........................128opana...................................... 26opium .......................................43opsumit................................... 71optimal d3 m......................... 157optimal-d...............................157option 2................................... 77optumrx blood glucose test......97opurity vitamin d...................157oracea......................................89oralone ................................... 130oramagicrx............................ 130orap....................................... 147orapred odt..............................79oravig.................................... 130orencia.....................................21orencia clickject....................... 21orenitram.................................71orfadin...................................106orilissa................................... 106orkambi............................. 80, 81orphenadrine citrate er ............133orsythia ....................................77ortho micronor........................77ortho tri-cyclen (28).................77ortho tri-cyclen lo.................... 77ortho-cyclen (28)..................... 77ortho-novum 1/35 (28).............77ortho-novum 7/7/7 (28)............77orthovisc................................133oseltamivir phosphate ............... 64oseni........................................ 43osmolex er............................... 60osmoprep...............................121osphena................................. 106otezla..................................... 143otovel.....................................141otrexup.............................. 21, 22ovace plus................................89ovace plus wash....................... 89ovace wash.............................. 89ovide........................................89ovidrel................................... 106oxandrin.................................. 28oxandrolone ............................. 28
oxaprozin .................................22oxaydo.....................................26oxazepam .................................30oxcarbazepine .......................... 36oxiconazole nitrate ................... 89oxistat......................................89oxsoralen ultra........................ 89oxtellar xr................................ 36oxybutynin chloride ................ 154oxybutynin chloride er ............ 154oxycodone hcl .......................... 26oxycodone hcl er .......................26oxycodone-acetaminophen ........26oxycodone-aspirin .................... 26oxycodone-ibuprofen ................ 26oxycontin.................................27oxymorphone hcl ...................... 27oxymorphone hcl er .................. 27oxytrol................................... 154oxytrol for women................. 154ozempic................................... 43pa vitamin d-3 .........................157pacerone ...................................31paliperidone er ..........................61palonosetron hcl ....................... 45palynziq................................. 107pamelor................................... 38pamidronate disodium .............107pancreaze...............................102pandel......................................89panretin................................... 89pantoprazole sodium ...............153panzyga................................. 142paragard intrauterine copper...77paricalcitol ............................. 107parnate.................................... 38paroex....................................130paromomycin sulfate ................ 19paroxetine hcl ...........................38paroxetine hcl er .......................38paroxetine mesylate ................147paser........................................54pataday..................................139patanase................................ 134patanol.................................. 139paxil........................................ 39paxil cr.....................................38pazeo..................................... 139peg 3350 .................................121peg 3350/electrolytes .............. 121
176
peg 3350-kcl-na bicarb-nacl .... 121peg-3350/electrolytes .............. 122peganone................................. 36pegasys.................................... 64pegasys proclick...................... 64peg-prep.................................122pegylax.................................. 122pen needles ............................. 126pen needles 1/2" ...................... 126pen needles 3/16" .................... 126pen needles 5/16" .................... 126penicillin g pot in dextrose ...... 143penicillin v potassium ..............143penlac...................................... 89pennsaid.................................. 89pentasa.................................. 111pentazocine-naloxone hcl ..........27pentoxifylline er ..................... 114pentylene glycol ........................73pepcid.................................... 153pepcid ac maximum strength. 153percocet................................... 27percura.................................. 101perforomist..............................32perindopril erbumine .................51periomed ................................ 131permethrin ................................89perphenazine ............................ 62perphenazine-amitriptyline ..... 147pertzye................................... 102pexeva..................................... 39phenadoz ..................................47phenazopyridine hcl ................ 112phendimetrazine tartrate .......... 18phendimetrazine tartrate er ...... 18phenelzine sulfate ..................... 39phenobarbital ......................... 119phenoxybenzamine hcl ..............51phentermine hcl ........................ 18phenylephrine hcl ....................139phenytek..................................36phenytoin ................................. 36phenytoin infatabs .................... 36phenytoin sodium ......................36phenytoin sodium extended ....... 36philith ...................................... 77phoslo....................................111phoslyra.................................111phospha 250 neutral ................129phospholine iodide................ 139
physiolyte .................................67phytonadione ..........................157picato...................................... 89pifeltro.....................................64pilocarpine hcl .................131, 139pimozide .................................147pindolol .................................... 68pioglitazone hcl ........................ 43pioglitazone hcl-glimepiride ...... 43pioglitazone hcl-metformin hcl ..43piperacillin sod-tazobactam so 143piroxicam .................................22plan b one-step........................ 77plaquenil..................................53plasma-lyte 148......................129plasma-lyte a......................... 129plavix.....................................114plegridy..................................147plegridy starter pack.............. 147plenvu....................................122plexion.....................................89plexion cleanser....................... 89plexion cleansing cloth............ 89plixda...................................... 89pnv-dha .................................. 132pnv-omega.............................132pnv-select ............................... 132pocketchem ez test...................97podocon.................................. 89polyethylene glycol 3350 .........122polymyxin b-trimethoprim ...... 139polytrim.................................139poly-vi-flor............................ 132poly-vi-flor fs.........................132poly-vi-flor/iron..................... 132pomalyst..................................58ponstel.....................................22portia-28 .................................. 77pot bicarb-pot chloride ............129potaba................................... 157potassium bicarbonate ............ 129potassium chloride .................. 130potassium chloride crys er .......129potassium chloride er .............. 130potassium chloride in nacl ....... 130potassium citrate er ................ 112potassium citrate-citric acid ....112pradaxa................................... 34praluent................................. 142pramcort .................................. 29
pramipexole dihydrochloride .....60pramipexole dihydrochloride er .60pramosone...............................89prandin....................................43prasugrel hcl ...........................114pravachol.................................48pravastatin sodium ................... 48praziquantel ............................. 29prazosin hcl .............................. 51precision pcx............................97precision pcx plus test..............97precision point of care test.......97precision qid test......................97precision sof-tact test...............97precision suredose plus syr.....126precision sure-dose syringe.... 126precision xtra blood glucose.... 97precision xtra ketone............... 97precose.................................... 43pred forte...............................139pred mild............................... 139pred-g.................................... 139pred-g s.o.p............................139prednicarbate ........................... 89prednisolone ............................. 79prednisolone acetate ............... 139prednisolone sodium phosphate......................................... 79, 139prednisone ................................79prednisone intensol..................79prefest....................................109pregnyl ................................... 107premarin........................ 109, 155premphase............................. 109prempro.................................109prenata.................................. 132prenatabs rx ........................... 132prenatal 19 ............................. 132prenatal plus iron...................132prenate dha............................132prepopik................................ 122prestalia...................................51prevacid................................. 153prevacid 24hr.........................153prevacid solutab.................... 153prevalite ................................... 48previfem ................................... 77prevpac.................................. 153prevymis.................................. 64prezcobix................................. 64
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prezista.................................... 64prialt........................................23priftin...................................... 54prilosec.................................. 153prilosec otc............................ 153primaquine phosphate ...............53primidone ................................. 36primlev.................................... 27primsol.................................... 53prinivil.....................................51pristiq...................................... 39privigen..................................142proair hfa................................ 32probenecid ..............................113procainamide hcl ...................... 31procardia xl............................. 71procentra................................. 18prochlorperazine .......................62prochlorperazine maleate ..........62procrit....................................118proctocort................................29proctofoam hc......................... 29procto-pak ................................29proctosol hc ..............................29proctozone-hc ...........................29procysbi................................. 112prodigy no coding blood gluc.. 97proferrin-forte....................... 118profilnine............................... 115profilnine sd...........................115progesterone micronized ......... 144proglycem................................43prograf.................................... 67prolastin-c............................. 148prolensa................................. 139prolia..................................... 107promacta............................... 118promethazine hcl ...................... 47promethazine vc/codeine ........... 80promethazine-dm ......................80promethegan ............................ 47prometrium........................... 144promiseb..................................90propafenone hcl ........................ 31propafenone hcl er .................... 31propantheline bromide ............ 153proparacaine hcl ..................... 139proparacaine-fluorescein .........139propecia...................................90propranolol hcl ......................... 68
propranolol hcl er ..................... 68propranolol-hctz .......................51propylthiouracil ......................150proscar...................................112protectiron.............................118proteolin................................ 101proteolin ds............................101protonix.................................153protopic...................................90protriptyline hcl ........................39proventil hfa............................ 32provera.................................. 144provigil.................................... 18prozac......................................39prudoxin..................................90prutect..................................... 90pseudoeph-chlorphen-hydrocod . 80psorcon .................................... 90pts panels glucose test..............97pulmicort.................................33pulmicort flexhaler.................. 33pulmona................................ 101pulmozyme............................ 148purefe plus ..............................118purevit dualfe plus .................. 118purixan.................................... 58px acid reducer max st ............153pylera.....................................153pyrazinamide ............................54pyridium................................ 112pyridostigmine bromide ............ 54pyridostigmine bromide er ........ 54qbrelis......................................51qbrexza....................................90qc acid controller max st .........153qc aspirin low dose ....................23qc natura-lax ..........................122qnasl...................................... 134qnasl childrens.......................134qtern...................................... 148qualaquin................................ 53quartette.................................. 77quasense ...................................77quazepam ............................... 119qudexy xr.................................36questran light...........................48quetiapine fumarate ..................62quetiapine fumarate er ..............62quflora fe pediatric................ 132quicktek test............................ 97
quillichew er............................ 18quillivant xr............................. 18quinapril hcl ............................. 51quinapril-hydrochlorothiazide ... 51quinidine gluconate ...................31quinidine gluconate er ...............31quinidine sulfate ....................... 31quinidine sulfate dihydrate ........73quinine sulfate .......................... 54quintet ac blood glucose test....97quintet blood glucose test........ 97qvar redihaler.......................... 33ra acid reducer max st ............ 153ra laxative .............................. 122ra nicotine .............................. 147ra truetest test..........................97ra vitamin d-3 ......................... 157rabeprazole sodium .................153radiagel....................................90radiaplexrx.............................. 90rajani....................................... 77raloxifene hcl ..........................107ramipril ....................................51ranexa......................................30ranitidine hcl .......................... 153rapaflo................................... 112rapamune................................ 67rasagiline mesylate ................... 60rasuvo......................................22ravicti.................................... 107rayaldee................................. 107rayos........................................79razadyne................................ 147razadyne er............................ 147rebetol..................................... 65rebif....................................... 147rebif rebidose......................... 147rebif rebidose titration pack...147rebif titration pack.................147rebinyn.................................. 115reclast.................................... 107reclipsen ...................................77recombinate...........................115rectiv....................................... 29refissa...................................... 90refuah plus blood glucose test..97regenecare................................90regimex....................................18reglan.....................................111regonol.................................... 54
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regranex...................................90relagard................................. 155relenza diskhaler......................65relexxii.....................................18relion insulin syringe..............126reli-on insulin syringe............ 126relion pen needles.................. 126relistor................................... 111relpax.....................................128remeron................................... 39remeron soltab.........................39remicade................................ 111remodulin................................ 71renacidin................................112renagel................................... 111renflexis................................. 111renova..................................... 90renvela................................... 111repaglinide ............................... 43repaglinide-metformin hcl .........43repatha.................................. 142repatha pushtronex system.... 142repatha sureclick....................142replesta.................................. 157replesta childrens................... 157replesta nx............................. 157requip...................................... 60requip xl.................................. 60rescriptor................................. 65restasis................................... 139restasis multidose...................139restoril................................... 119retacrit................................... 118retin-a......................................90retin-a micro............................90retin-a micro pump..................90retrovir.................................... 65revatio................................71, 72reveal blood glucose test..........97revesta................................... 118revlimid................................... 67rexulti...................................... 62reyataz.....................................65rhinocort allergy.................... 135rhofade.................................... 90rhogam ultra-filtered plus......142rhophylac.............................. 142rhopressa............................... 140riastap....................................115ribasphere ................................ 65
ribasphere ribapak ....................65ribavirin ................................... 65ridaura.....................................22rifabutin ................................... 54rifadin......................................54rifamate................................... 54rifampin ................................... 54rifater...................................... 54rightest gs100 blood glucose.... 97rightest gs300 blood glucose.... 97rightest gs550 blood glucose.... 97rilutek.................................... 135riluzole ................................... 135rimantadine hcl ........................ 65riomet......................................43risedronate sodium ..................107risperdal.................................. 62risperidone ............................... 62risperidone m-tab.................... 62ritalin.......................................18ritalin la...................................19ritonavir ................................... 65rituxan.....................................58rivastigmine ............................147rivastigmine tartrate ............... 147rivelsa...................................... 77rixubis....................................115rizatriptan benzoate ................128robaxin.................................. 133rocaltrol.................................107ropinirole hcl ............................ 60ropinirole hcl er ........................ 60rosadan .................................... 90rosadan....................................90rosanil cleanser .........................90rosuvastatin calcium ................. 48rowasa................................... 111roxicodone...............................27roxybond.................................27rozerem..................................119rubraca...........................143, 144ruconest................................. 115rydapt......................................58rynoderm ..................................90rytary.......................................60rythmol sr................................31ryvent...................................... 47sabril....................................... 36safety let lancets.....................126safyral......................................77
saizen.....................................107salagen...................................131salex........................................ 90salicylic acid .............................90salicylic acid wart remover ....... 90saline bacteriostatic ................ 143saline-benzyl alcohol ...............143samsca................................... 107sancuso....................................45sandimmune............................ 67sandostatin............................ 107sandostatin lar depot............. 107santyl.......................................90saphris..................................... 62sapscare twist top lancets ........126sarafem.................................. 147savaysa.................................... 34savella....................................147savella titration pack............. 147sb acid controller max st .........153sb polyethylene glycol 3350 .....122seasonique............................... 77seconal...................................119seebri neohaler.........................33segluromet............................. 149selegiline hcl .............................60selenium sulfide ........................ 90selrx.........................................90selzentry.................................. 65semprex-d................................ 80se-natal 19 ..............................132sensipar..................................107sentra am............................... 101sentra pm...............................101serevent diskus.........................33sernivo.....................................90seroquel................................... 62seroquel xr...............................62serostim................................. 107sertraline hcl ............................ 39se-tan plus .............................. 118sevelamer carbonate ............... 111sfrowasa................................ 111sharobel...................................77shohls modified..................... 112signifor.................................. 107signifor lar............................. 107siklos..................................... 118sildenafil citrate ........................72silenor....................................119
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siliq..........................................90silvadene..................................91silver nitrate ............................. 91silver sulfadiazine ..................... 91simbrinza............................... 139simple diagnostics lancing dev...............................................127simponi....................................22simponi aria.............................22simulect................................... 67simvastatin ...............................48sinemet.................................... 60sinemet cr................................ 60singulair...................................33sirolimus .................................. 67sirturo......................................54sitavig...................................... 65sivextro....................................53skelaxin..................................134sklice........................................91skyla........................................ 77sm acid reducer max st ........... 153sm clearlax.............................122sm nicotine ............................. 147sm vitamin d3 ......................... 157smart sense value test...............97smartest blood glucose test...... 97smooth lax............................. 122sod benz-sod phenylacet ..........107sod citrate-citric acid .............. 112sodium chloride ......... 80, 112, 130sodium chloride bacteriostatic .143sodium edecrin.......................103sodium fluoride .......................130sodium hydroxide ..................... 73sodium phenylbutyrate ............107sodium polystyrene sulfonate......................................... 67, 144sodium sulfacetamide ................91solia ......................................... 77soliqua................................... 120solodyn.................................. 150solosec..................................... 19soltamox..................................58solu-cortef............................... 79solu-medrol............................. 79solus v2 test............................. 97soma...................................... 134somatuline depot................... 107somavert................................107
sonafine................................... 91soolantra................................. 91soriatane..................................91sorilux..................................... 91sorine ....................................... 68sotalol hcl .................................69sotalol hcl (af) ......................... 68sotylize.................................... 69sovaldi..................................... 65spectracef.................................73spinosad ................................... 91spiriva handihaler....................33spiriva respimat....................... 33spironolactone ........................ 103spironolactone-hctz .................103sporanox..................................46sporanox pulsepak...................46sprintec 28 ................................77spritam.................................... 36sprix........................................ 22sprycel..................................... 58sronyx ......................................77sski.......................................... 80sss 10-5 .................................... 91st joseph aspirin ........................23stalevo 100...............................60stalevo 125...............................60stalevo 150...............................60stalevo 200...............................60stalevo 50.................................60stalevo 75.................................60starlix...................................... 43stavudine .................................. 65steglatro...................................43steglujan................................ 148stelara.............................. 91, 120sterile water for irrigation .........67stimate................................... 107stiolto respimat........................33stivarga....................................58strattera................................... 19strensiq.................................. 120streptomycin sulfate ................. 19striant...................................... 28stribild..................................... 65striverdi respimat.....................33stromectol................................29suboxone................................. 27subsys...................................... 27sucraid................................... 102
sucralfate ............................... 154sular........................................ 71sulfacetamide sodium ........ 91, 139sulfacetamide sodium (acne) .... 91sulfacetamide sodium-sulfur ......91sulfacetamide sod-sulfur wash ...91sulfacetamide-prednisolone ..... 139sulfacleanse 8/4 ........................ 91sulfadiazine ............................ 149sulfamethoxazole-trimethoprim 53sulfamylon...............................91sulfasalazine ...........................111sulfazine ................................. 111sulindac ....................................22sumadan.................................. 91sumatriptan ............................ 128sumatriptan succinate ............. 128sumatriptan succinate refill .....128sumatriptan-naproxen sodium .128sumaxin................................... 91sumaxin cp.............................. 91supartz fx...............................134super daily d3 ......................... 157super thin lancets ....................127supprelin la............................ 107suprax......................................73supreme test.............................97suprep bowel prep kit............ 122sure edge test........................... 97surechek blood glucose test..... 97sure-test easyplus mini test...... 97surmontil................................. 39sustiva..................................... 65sutent.......................................58swabflush saline flush ..............130syeda ........................................77sylatron................................... 58symax duotab........................ 154symbicort.................................33symbyax................................ 147symdeko.................................. 81symfi........................................65symfi lo....................................65symlinpen 120..........................43symlinpen 60............................43symproic................................ 111symtuza................................... 65synagex..................................132synagis................................... 142synalar.....................................91
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synalar (cream)........................91synalar (ointment)................... 91synalar ts................................. 91synarel................................... 107synatek.................................. 132syndros.................................... 45synera...................................... 91synjardy.................................149synjardy xr.............................149synribo.................................... 58synthroid............................... 150synvisc................................... 134synvisc one.............................134syprine.....................................67tabloid..................................... 58taclonex................................... 92tacrolimus ...........................67, 92tadalafil ................................... 72tadalafil (pah) ......................... 72tafinlar.....................................58tagrisso.................................... 58take action ............................... 77takhzyro................................ 143taltz......................................... 92talzenna..........................143, 144tamiflu.....................................65tamoxifen citrate ......................58tamsulosin hcl .........................112tandem f................................ 118tandem plus........................... 118tapazole................................. 150taperdex 12-day....................... 79taperdex 6-day.........................79tarceva.....................................58targadox................................ 150targretin............................. 58, 92tarka........................................51taron forte ..............................118taron-c dha............................ 132tasigna..................................... 58tasmar..................................... 60tavalisse................................. 149taytulla.................................... 77tazarotene ................................ 92tazicef ...................................... 73tazorac.....................................92taztia xt ................................... 71tecfidera.................................147technivie................................ 119teflaro......................................73
tegretol.................................... 36tegretol-xr................................36tekturna...................................51tekturna hct............................. 51telcare blood glucose test.........97telmisartan ...............................51telmisartan-amlodipine ............. 52telmisartan-hctz ....................... 52temazepam ............................. 119temodar................................... 58temovate..................................92temozolomide ........................... 58temsirolimus .............................58tenofovir disoproxil fumarate ....65terazosin hcl ............................. 52terbinafine hcl .......................... 46terbutaline sulfate .....................33terconazole .............................155tessalon perles..........................80testim.......................................28testosterone ........................ 28, 73testosterone cypionate .........28, 73testosterone enanthate .............. 28tetcaine .................................. 139tetrabenazine ..........................147tetracaine hcl ..........................139tetracycline hcl ....................... 150tetravisc ................................. 139texacort................................... 92tgt aspirin .................................23tgt nicotine step one ................147tgt nicotine step three ............. 147tgt nicotine step two ................147tgt powderlax.........................122thalomid.................................. 67theo-24.................................... 33theochron ................................. 33theophylline ..............................33theophylline er ..........................33thera-d 2000...........................157thera-d 4000...........................157thera-d rapid repletion...........157theramine...............................101theramine plus....................... 101thiola..................................... 112thioridazine hcl .........................62thiothixene ............................... 62thrive ......................................147thymoglobulin......................... 67thyrogen.................................. 97
tiagabine hcl .............................36tiazac....................................... 71tibsovo...................................120tigan........................................ 45tiglutik................................... 135tikosyn.....................................31tilia fe ...................................... 77timolol maleate ................. 69, 139timoptic................................. 139timoptic ocudose................... 139timoptic-xe............................ 139tindamax................................. 53tinidazole ................................. 53tirosint................................... 150tis-u-sol .................................... 67tivicay......................................65tivorbex................................... 22tizanidine comfort pac........... 134tizanidine hcl .......................... 134tl gard rx ................................118tl icon .....................................118tobi..........................................19tobi podhaler........................... 19tobradex................................ 140tobradex st.............................140tobramycin ...............................19tobramycin sulfate ....................19tobramycin-dexamethasone .... 140tobrex.................................... 140tolak........................................ 92tolazamide ................................43tolbutamide .............................. 43tolcapone ..................................60tolmetin sodium ........................22tolterodine tartrate ................. 155tolterodine tartrate er ............. 155topamax.................................. 37topamax sprinkle.....................37topicort....................................92topicort spray.......................... 92topiramate ............................... 37toposar .....................................58toprol xl...................................69torisel...................................... 59torsemide ................................103toujeo max solostar................. 43toujeo solostar.........................43toviaz.....................................155tracleer.................................... 72tradjenta.................................. 43
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tramadol hcl ............................. 27tramadol hcl er ......................... 27tramadol hcl er (biphasic) ........ 27tramadol-acetaminophen .......... 27trandolapril .............................. 52trandolapril-verapamil hcl er .... 52tranexamic acid ......................118transderm-scop (1.5 mg).......... 45tranxene-t................................ 30tranylcypromine sulfate ............ 39traumeel.................................. 67travatan z...............................140trazodone hcl .................... 39, 148trecator....................................55trelegy ellipta........................... 33trelstar mixject.........................59tremfya.................................... 92trepadone.............................. 101tresiba flextouch...................... 43tretinoin ..............................59, 92tretinoin (emollient) .................92tretinoin microsphere ................92tretinoin microsphere pump ...... 92tretten.................................... 115trexall...................................... 59treximet................................. 128trezix....................................... 27tri femynor.............................. 77triacetin ................................... 73triamcinolone acetonide..................................92, 131, 135triaminic allerchews.................47triamterene-hctz ..................... 103triazolam ................................119tribenzor..................................52tricare .................................... 132tricare prenatal dha one.........132tricon ..................................... 118tricor....................................... 48triderm .....................................92triderm.................................... 92tridesilon................................. 92trientine hcl .............................. 67trifluoperazine hcl .................... 62trifluridine ..............................140trigels-f forte .......................... 118triglide..................................... 49trihexyphenidyl hcl ................... 60tri-legest fe ...............................78trileptal....................................37
tri-linyah .................................. 78trilipix......................................49tri-luma................................... 92trilyte ..................................... 122trimethobenzamide hcl ..............45trimethoprim ............................ 53tri-mili..................................... 78trimipramine maleate ............... 39trimpex .................................... 53trinessa (28) ............................ 78tri-norinyl (28).........................78trintellix........................... 39, 148tri-previfem .............................. 78triptodur................................108tri-sprintec ............................... 78triumeq....................................65triveen-duo dha..................... 132trivisc.....................................134trivora (28) ..............................78trizivir......................................65trokendi xr...............................37tropicamide ............................ 140trospium chloride ....................155trospium chloride er ................155true metrix blood glucose test..97trueplus insulin syringe.......... 127trueplus lancets 26g............... 127trueplus lancets 30g............... 127trueplus safety lancets 28g..... 127truetest test.............................. 98truetrack test........................... 98trulance................................... 73trulicity....................................43trusopt................................... 140truvada.................................... 65tudorza pressair.......................33tulana...................................... 78tusnel c.................................... 80tussicaps.................................. 80tussionex pennkinetic er.......... 80tuzistra xr................................ 80twynsta.................................... 52tybost...................................... 62tydemy.....................................78tykerb...................................... 59tylenol with codeine #3........... 27tylenol with codeine #4........... 27tymlos....................................108tysabri....................................147tyvaso...................................... 72
tyvaso refill ..............................72tyvaso starter...........................72uceris................................. 29, 79udamin sp.............................. 132ulesfia...................................... 92uloric..................................... 113ulticare insulin syringe........... 127ulticare short pen needles.......127ultima test................................98ultracet.................................... 27ultram......................................27ultratrak pro test..................... 98ultratrak ultimate test..............98ultravate.................................. 93unasyn................................... 143unifine pentips plus................127unistrip1 generic...................... 98unithroid ................................ 151unithroid direct .......................151uptravi................................... 148urecholine.............................. 155urocit-k 10............................. 112urocit-k 15............................. 112urocit-k 5............................... 112urso 250................................. 111urso forte............................... 111ursodiol .................................. 111utibron neohaler......................33utopic...................................... 93vagifem.................................. 155valacyclovir hcl .........................65valchlor................................... 93valcyte................................65, 66valganciclovir hcl ......................66valium..................................... 30valproate sodium ...................... 37valproic acid .............................37valsartan .................................. 52valsartan-hydrochlorothiazide ...52valtrex..................................... 66vanatol lq................................ 23vancomycin hcl ....................... 112vandazole ............................... 155vaniqa......................................93vanishpoint insulin syringe.... 127vanos....................................... 93vantas...................................... 59varubi...................................... 45vascazen.................................101vascepa.................................... 49
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vasculera................................101vaseretic...................................52vasotec.....................................52vayacog................................. 102vayarin...................................102vayarol...................................102vecamyl................................... 52vectical.................................... 93veletri...................................... 72velivet .......................................78velphoro................................ 111veltassa.............................67, 144veltin....................................... 93vemlidy....................................66venclexta..................................55venclexta starting pack............ 55venipuncture cpi...................... 93venlafaxine hcl ......................... 39venlafaxine hcl er ..................... 39venofer...................................118venomil mixed vespid venom...69ventavis................................... 72ventolin hfa............................. 33verapamil hcl ............................71verapamil hcl er ........................71verdeso.................................... 93verdrocet................................. 27verelan.....................................71versacloz..................................62verzenio................................... 80vesicare.................................. 155vestura ..................................... 78vfend....................................... 46viberzi....................................120vibramycin.............................150vicodin ..................................... 27vicodin es ................................. 27vicodin hp .................................27victory agm-4000 test...............98victoza..................................... 43vida mia unifine pentips.........127videx........................................66videx ec....................................66viekira pak.............................119viekira xr............................... 119vigabatrin .................................37vigadrone.................................37vigamox.................................140viibryd..............................39, 148viibryd starter pack.......... 39, 148
vimizim..................................131vimovo.................................... 22vimpat..................................... 37viokace.................................. 102viorele ...................................... 78viracept....................................66viramune................................. 66viramune xr............................. 66virasal......................................93viread...................................... 66virt-gard................................ 118virt-pn....................................132virt-pn dha.............................132visionblue.............................. 140vistaril..................................... 30vistogard..................................44visudyne.................................140vitafol fe+.............................. 132vitafol gummies..................... 132vitafol-ob+dha...................... 132vitafol-one............................. 132vital-d rx................................ 133vitamin d ................................ 157vitamin d (ergocalciferol) .......157vitamin d2 .............................. 157vitamin d3 .......................157, 158vitamin d3 maximum strength .157vitamin d3 super strength ........ 158vivelle-dot..............................109vivitrol.....................................44vivlodex................................... 22vizimpro.................................. 59vocal point blood glucose test..98vogelxo.................................... 28vogelxo pump..........................28vol-plus..................................133vol-tab rx............................... 133voltaren................................... 93vonvendi................................115voraxaze.................................. 59voriconazole ............................. 46vosevi.....................................119votrient....................................59vpriv...................................... 118vraylar..................................... 62vsl#3......................................102vsl#3 ds................................... 43vsl#3 junior........................... 102vusion......................................93vytorin.....................................49
vyvanse....................................19vyzulta................................... 140warfarin sodium ....................... 34wavesense presto..................... 98welchol.................................... 49wellbutrin sr............................ 39wellbutrin xl............................ 39wera .........................................78westhroid...............................151wide-seal diaphragm 60......... 127wide-seal diaphragm 65......... 127wide-seal diaphragm 70......... 127wide-seal diaphragm 75......... 127wide-seal diaphragm 80......... 127wide-seal diaphragm 85......... 127wide-seal diaphragm 90......... 127wide-seal diaphragm 95......... 127wilate..................................... 115winrho sdf..............................142wp thyroid............................. 151wymzya fe ................................ 78xadago.....................................60xalatan...................................140xalkori..................................... 59xanax.......................................30xanax xr...................................30xarelto..................................... 34xarelto starter pack..................34xatmep.....................................59xelitral..................................... 93xeljanz..................................... 22xeljanz xr................................. 22xeloda......................................59xenazine.................................147xenical..................................... 19xeomin...................................135xepi..........................................93xerese.......................................93xermelo..................................151xgeva..................................... 108xhance................................... 135xiaflex......................................67xifaxan.....................................53xigduo xr............................... 149xiidra..................................... 122ximino................................... 150xodol....................................... 27xolair....................................... 33xolegel..................................... 93xopenex................................... 33
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xopenex concentrate................ 33xopenex hfa............................. 33xtampza er...............................27xtandi...................................... 59xulane......................................78xultophy................................ 120xuriden.................................. 119xyntha....................................115xyntha solofuse......................115xyrem.....................................147xyzal allergy 24hr.................... 47xyzal allergy 24hr childrens..... 47yasmin 28................................ 78yaz...........................................78yervoy......................................59yonsa....................................... 59yosprala.................................115yuvafem.................................155zaditor................................... 140zafirlukast ................................33zaleplon ..................................119zaltrap..................................... 59zanaflex................................. 134zanosar.................................... 59zantac.................................... 154zarah ........................................78zarontin................................... 37zarxio.....................................118zatean-pn dha........................ 133zatean-pn plus....................... 133zavara .................................... 118zavesca...................................118zegerid................................... 154zegerid otc............................. 154zejula..................................... 144zelapar.....................................60zelboraf................................... 59zemaira.................................. 148zembrace symtouch............... 128zemplar..................................108zenatane ...................................93zenatane.................................. 93zenpep................................... 102zenzedi.....................................19zepatier.................................. 119zerit......................................... 66zestril.......................................52zetia.........................................49zetonna.................................. 135ziac.......................................... 52
ziagen...................................... 66ziana........................................93zidovudine ................................ 66zileuton er ................................ 33zinc acetate .............................. 73zioptan...................................140ziprasidone hcl ..........................62zipsor.......................................22zirgan.....................................140zithromax.............................. 123zithromax tri-pak...................123zithromax z-pak.....................123zocor....................................... 49zofran...................................... 45zohydro er............................... 27zoladex.................................... 59zoledronic acid ....................... 108zolinza..................................... 59zolmitriptan ............................128zoloft....................................... 39zolpidem tartrate .................... 120zolpidem tartrate er ................ 120zolpimist................................ 120zomacton...............................108zometa................................... 108zomig.....................................128zomig zmt.............................. 128zonalon....................................93zonegran..................................37zonisamide ............................... 37zontivity.................................144zorbtive..................................108zortress.................................... 67zorvolex...................................22zosyn..................................... 143zovia 1/35e (28) .......................78zovirax............................... 66, 93ztlido....................................... 93zubsolv.................................... 27zuplenz.................................... 45zurampic................................113zyban..................................... 147zyclara..................................... 93zyclara pump........................... 93zydelig................................... 143zyflo........................................ 33zyflo cr.....................................33zykadia.................................... 59zylet....................................... 140zyloprim................................ 113
zymaxid................................. 140zypitamag................................49zyprexa.................................... 62zyprexa zydis........................... 62zyrtec allergy........................... 47zyrtec-d allergy & congestion...80zytaze.....................................102zytiga.......................................59zyvox....................................... 53
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