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151 Farmington Avenue Hartford, CT 06156
©2015 Aetna Inc. 01/01/2016_FC_Subscriber Notice 05.32.657.1 (8/15)
September, 2015
Changes to your pharmacy plan The enclosed chart shows changes that start on January 1, 2016. We’re adding some brand-name and generic drugs to our pharmacy plan and specialty drug list. We’re also removing others. Your plan’s coverage requirements may also change. You can get the most from your plan by knowing about these upcoming changes. We don’t want there to be any surprises. These updates will affect the prescription drugs you take. So make sure you check out the summary of changes in the enclosed chart. Find a preferred drug that’s right for you You can find a list of preferred drugs on your pharmacy plan and specialty drug list at www.aetna.com/formulary. You typically pay lower out-of-pocket costs when you use preferred drugs. You can still fill prescriptions for non-preferred drugs. But you may pay more. Don’t worry. You can talk to your doctor about your treatment options. If your doctor agrees that a preferred alternative will work for you, ask to have your prescription changed. If your plan includes the Specialty Drug List, you may pay higher out of pocket costs and may be required to obtain these products at an Aetna Specialty Pharmacy Network Provider like Aetna Specialty Pharmacy. We’re here to help If you have any questions, just visit your secure member website at www.aetna.com. Or, you can call us at the toll-free number on your member ID card. Enclosure
Aetna Value Plus January 1, 2016 Updates
Abbreviation Key
UPPPERCASE = brand-name drug; lower case italics = generic drug Age Limit These drugs have an age limit requirement. You must meet the
age requirement before the drug will be covered. Expect Gen Expect generic drugs to become available in the near future.
When this happens, we may cover the brand-name drug at a higher copayment in open formulary plans, add it to the Formulary Exclusions List in closed formularies or add the brand-name drug to the precertification, quantity limit or step-therapy lists.
Gender
Drugs that have guidelines for use or safety checks in place in order to provide the best possible care based on gender.
Medical These drugs are not covered under your Pharmacy benefit but may be covered under your Medical benefit.
NC Not-Covered
These drugs are not covered under your pharmacy benefit plan. You can still get these drugs but will need to pay the full cost of the drug.
NPB/G Non-preferred brand-name or generic drug
These drugs aren’t preferred. You may pay higher out-of-pocket costs when using a non-preferred brand-name or generic drug.
NPS Non-preferred specialty drug
These drugs aren’t preferred. You may pay higher out-of-pocket costs when using a non-preferred drug on the Aetna Specialty Drug List.
NPL National Precertification List
Prior authorization (PA) is required for all plans. Your doctor must contact us to request approval for coverage.
PA Prior authorization or precertification
Prior authorization only applies if your plan includes precertification. This means that we have to approve some drugs before we cover them. If this is required, your doctor must contact us to request approval of coverage.
PB Preferred brand-name drug
These are brand-name drugs that are covered at your 2nd Tier copay. You may pay lower out-of-pocket costs when you use preferred drugs, but this may not always be the case.
PS Preferred specialty drugs
You may pay lower out-of-pocket costs when you use preferred drugs on the Aetna Specialty Drug List.
PG Preferred generic
These are generic drugs that are covered at your 1st tier copay. You may pay lower out-of-pocket costs when you use preferred drugs, but this may not always be the case.
QL Quantity limits
Quantity limits help ensure that you get a safe amount of your drug. They only apply if your plan includes precertification. If you go past the quantity limit, your doctor must contact us to request approval of coverage.
SPB Specialty pharmacy coverage
You may pay higher out of pocket costs and may be required to get these products at an Aetna Specialty Pharmacy network provider, like Aetna Specialty Pharmacy. Specialty products aren’t available at Aetna Rx Home Delivery and are limited to a 30 day supply.
ST Step therapy
Step therapy only applies if your plan includes it. This means that you must try one or more prerequisite drug(s) before we cover a step-therapy drug.
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
ABSORICA NC NC doxycycline, minocycline Add PA, Add ST
ABSTRAL NPB/G NPB/G Add QLACEON NPB/G NPB/G Remove QL
ACIPHEX NPB/G NPB/Gomeprazole, pantoprazole, esomeprazole
Add ST
ACIPHEX SPR NPB/G NPB/Gomeprazole, pantoprazole, esomeprazole
Add ST
ACTICLATE NC NC Add QLACTIMMUNE PS NPS
ACTOPLUS MET PB NPB/G pioglitazone/metformin
acyclovir oint PG NPB/G ABREVA
adapalene cre 0.1% PG NPB/G tretinoinadapalene gel 0.1% PG NPB/G tretinoinadapalene gel 0.3% PG NPB/G tretinoin
ADCIRCA PS NPSsildenafil , LETAIRIS, OPSUMIT, TRACLEER
ADVAIR DISKU NPB/G NPB/GRemove PA, Remove ST, Expect Gen
ADVAIR HFA NPB/G NPB/GRemove PA, Remove ST, Expect Gen
aero otic hc PG NCALDURAZYME NPS PSALINIA NPB/G NPB/G Remove QLALKERAN TAB PS PBALODOX NPB/G NC doxycycline 50mg capsaltafluor PG NPB/Galuminum cl PG NCAMBIEN CR NPB/G NPB/G Remove STamcinonide PG NPB/G fluocinolone acetonideamlod/benazp PG PG Remove QLamnesteem PG NPB/G claravis Add PA, Add STamox-pot cla PG PG Remove QL
AMTURNIDE150 NPB/G NPB/Gamlodipine, hctz, losartan, valsartan
Remove PA, Add ST
AMTURNIDE300 NPB/G NPB/Gamlodipine, hctz, losartan, valsartan
Remove PA, Add ST
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
ANACAINE NPB/G NC
ANALPRAM E NPB/G NCCORTIFOAM, PROCTOZONE-HC
ANALPRAM-HC CRE 1-2.5% NPB/G NCCORTIFOAM, PROCTOZONE-HC
ANALPRAM-HC LOT 2.5% PB NPB/G lidocaine hcANDROID PB PB Remove QL
anucort-hc PG NCCORTIFOAM, PROCTOZONE-HC
ANUSOL-HC NPB/G NCCORTIFOAM, PROCTOZONE-HC
ARICEPT NPB/G NPB/G Remove QLarnica PG NCatovaq/progu PG PG Remove QLatovaquone PG PG Remove QL
ATRALIN NPB/G NPB/GRemove QL, Add Age Limit
ATRIPLA NPB/G PBATROVENT HFA PB NPB/G ipratropium Remove QLAVAR NPB/G NCAVAR LS NPB/G NC
avar-e emoll PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
avar-e green PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
AVELOX NPB/G NPB/G Remove QLAVELOX ABC NPB/G NPB/G Remove QL
AVINZA NPB/G NPB/GRemove PA, Remove ST
avita PG PG Add Age Limit
AVODART NPB/G PBRemove ST, Expect Gen
azelastine PG NPB/G ZADITOR
AZELEX PB NPB/Gtretinoin, metronidazole 0.75%
azithromycin PG PG Remove QLAZOR NPB/G NPB/G Expect GenBELSOMRA NPB/G NPB/G Add Age LimitBENICAR NPB/G NPB/G Expect GenBENICAR HCT NPB/G NPB/G Expect GenBENZACLIN NC NC Remove QL
BENZAMYCIN PB NPB/Gerythromycin/benzoyl peroxide
BEPREVE NPB/G NPB/G Remove QL
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
betameth val PG NPB/G fluocinolone acetonide
BETHKIS PS NPStobramycin , TOBI PODHALER
Remove PA
BETIMOL PB NPB/G timolol, betaxololbexarotene PS PS Add SPBBIAXIN NPB/G NPB/G Remove QLBIAXIN XL NPB/G NPB/G Remove QLBIEST/PROGES CRE NPB/G NCbio glo PG NPB/GBLEPH-10 PB NPB/G sulfacetamide sodiumBOTOX NPS PSBRAVELLE NPS PSBREO ELLIPTA NPB/G NPB/G Remove PAbrimonidine 0.15% PG NPB/G brimonidine 0.2%BRISDELLE NC NPB/G paroxetine Add PAbromfenac PG NPB/G ketorolac tromethamine BUPHENYL TAB NPS PSBUTRANS PB PB Expect Gen
BYDUREON PB NPB/Gmetformin , VICTOZA, TRULICITY
calcipotrien cre 0.005% PG NPB/G acitretin Add STcalcipotrien oin 0.005% PG NPB/G acitretin Add STcalcipotrien oin betameth (generic taclonex oin)
PG NPB/G fluocinolone acetonide Add ST
calcipotrien sol 0.005% PG NPB/G acitretincalcitrene PG NPB/G acitretin Add STcalcitriol PG NPB/G acitretin Remove STcapecitabine PS PS Add NPLCARBAGLU NPS NPS Add SPBcarb-o-philc PG NCcarisopr/asa PG NPB/G carisoprodolcarisoprodol PG NPB/G carisoprodolCATAPRES-TTS NPB/G NPB/G Remove QLCAYSTON NPS NPS Remove PAcefaclor er PG PG Remove QLCELLCEPT CAP NPS NPS Add SPBCELLCEPT SUS PS NPS mycophenolate Add SPBCELLCEPT TAB NPS NPS Add SPBcerovel PG NC
chlord/clidi PG NCdicyclomine, hyoscyamine, propantheline
chlorhex glu PG NCchor gonadot NPS PS
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
CILOXAN PB NPB/G ciprofloxacnCINRYZE NPS PSCIPRO HC NPB/G NPB/G Expect GenCIPRO XR NPB/G NPB/G Remove QLciprofloxacn sol 0.2% PG NPB/G ofloxacinciprofloxacn tab 1000mg PG PG Remove QLciprofloxacn tab 500mg er PG PG Remove QLclaravis PG PG doxycycline, minocycline Add PA, Add STclarithromyc PG PG Remove QLCLEOCIN PB NPB/G metronidazol gelclindamy/ben gel 1-5% NC NC Remove QLclindamycin PG NPB/G generic CLEOCIN-TCLINDAP-T CRE NPB/G NCclinpro 5000 PG NCclobetasol PG NPB/G fluocinolone acetonideCLOBEX NPB/G PBclocortolone PG NPB/G fluocinolone acetonideclodan PG NPB/G fluocinolone acetonideclonidine PG PG Remove QLcoal tar PG NCCOARTEM NPB/G NPB/G Remove QLCOMBIGAN NPB/G PBCOMBIVENT PB PB Remove QLCOMFORT PAC-MELOXICAM NPB/G NCCOMPLERA NPB/G PB
CORTANE-B DRO AQ OTIC NPB/G NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic
CORTANE-B DRO OTIC NPB/G NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic
cortic-nd PG NCCORTIFOAM PB NPB/G lidocaine hcCOZAAR NPB/G NPB/G Add QLCUPRIMINE PB NPB/G DEPEN TITRA
cycloserine PG NPB/Gethambutol, isoniazid, rifampin
cyotic PG NCCYRAMZA Medical Medical Add PA, Add NPLCYSTADANE NPS PS Add PACYSTAGON PS NPB/GCYTOGAM NPS PSD.H.E. 45 NPB/G NPB/G Remove QLDALIRESP NPB/G NPB/G SPIRIVA, SYMBICORT Add PA, Add ST
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
demeclocycl PG NPB/G doxycycline, minocyclinedentagel PG NCDEPO-TESTOST NPB/G NPB/G Remove QLdesloratadin PG NPB/G loratadine, cetirizine
DESOXYN NPB/G NPB/Gphentermine, phendimetrazine
Add ST
DETROL NPB/G NPB/G oxybutynin, trospium Add STDETROL LA NPB/G NPB/G oxybutynin, trospium Add ST
DEXILANT NPB/G NPB/Gomeprazole, pantoprazole, esomeprazole
Add ST
DIFFERIN GEL 0.3% NPB/G NPB/G tretinoin cream/gel Add STDIFFERIN LOT 0.1% NPB/G NPB/G tretinoin cream/gel Add ST
dihydrocod/asa/caff PG NPB/Gbutalbital/aspirin/caffeine
dihydroergot inj 1mg/ml PG NPB/G Remove QLdihydroergot spr 4mg/ml PG NPB/GDIPENTOCAINE CRE 5-5-2% NPB/G NCDITROPAN XL NPB/G NPB/G oxybutynin, trospium Add STdonepezil tab 5mg PG PG Remove QLdonepezil tab hcl 23mg PG NPB/G rivastigmine Remove QLDOVONEX NPB/G NPB/G acitretin Add STdoxycycline tab 20mg PG NPB/G doxycycline 50mg caps
DURAGESIC NPB/G NPB/GRemove PA, Remove ST
easygel NPB/G PGELAPRASE NPS PS
ELIDEL NPB/G NPB/Gdesoximetasone, fluticasone
Remove QL
ELIGARD NPS NPS Add PAENABLEX NPB/G NPB/G oxybutynin, trospium Add ST, Expect GenEPIDUO NPB/G NPB/G tretinoin cream/gel Add ST, Remove QLepinastine PG NPB/G ZADITOREPIVIR PB NPB/G lamivudineeplerenone PG NPB/G spironolactone Remove QLEPOGEN PS NPS ARANESP, PROCRITEPZICOM NPB/G NPB/G Expect GenERGOMAR PB NPB/GERY-TAB TAB 500MG EC PB NPB/G erythromycineszopiclone PG PG Remove STetoposide PS PGEURAX PB NPB/G malathion, spinosad
EVEKEO NPB/G NPB/Gphentermine, phendimetrazine
Add ST
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
EVZIO PB PB Add PA
EXALGO TAB 12MG NPB/G NPB/GRemove PA, Remove ST, Add QL
EXALGO TAB 16MG NPB/G NPB/GRemove PA, Remove ST
EXALGO TAB 32MG NPB/G NPB/GRemove PA, Remove ST
EXALGO TAB 8MG NPB/G NPB/GRemove PA, Remove ST
EXELON CAP 1.5MG NPB/G NPB/G Remove QLEXELON CAP 3MG NPB/G NPB/G Remove QLEXELON CAP 4.5MG NPB/G NPB/G Remove QLEXELON CAP 6MG NPB/G NPB/G Remove QLEXELON DIS 13.3/24 NPB/G PB Remove QLEXELON DIS 4.6MG/24 NPB/G PB Remove QLEXELON DIS 9.5MG/24 NPB/G PB Remove QL
exotic-hc PG NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic
EXTARDOL CRE NPB/G NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic
EYLEA NPS PS Add PAFABIOR NPB/G NPB/G tretinoin cream/gel Add STFABRAZYME NPS PSFACTIVE NPB/G NPB/G Remove QLFASLODEX NPS NPS Add PAfenofibrate cap 130mg PG NPB/G generic TRICORfenofibrate cap 150mg PG NPB/G generic TRICORfenofibrate cap 43mg PG NPB/G generic TRICORfenofibrate cap 50mg PG NPB/G generic TRICORFENOGLIDE NPB/G NPB/G Expect Gen
fentanyl patch PG PGRemove PA, Remove ST
FINACEA NPB/G NPB/G Expect GenFIRAZYR NPS PSFIRMAGON NPS NPS Add PA
FIRST-OMEPRA PB NComeprazole, pantoprazole, esomeprazole
FIRST-PROGESTERONE VGS 25, 50, 100, 200, 400
NPB/G NC
FIRST-TESTOS NC NC Remove Gender
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
flucaine PG NPB/Gflucytosine PG NPB/G fluconazole
fluocinonide PG PGclobetasol, betamethasone oint
Add ST
fluore-benox PG NPB/Gfluorescein/ PG NPB/Gfluoridex PG NCfluoridex dd PG NCfluor-i-stri PG NPB/Gflurox PG NPB/Gfluticasone PG NPB/G fluocinolone acetonideFUL-GLO PG NPB/Gful-glo PG NPB/GFUZEON NPS NPS Add PA, Expect Gengalantamine cap 16mg er PG PG Remove QLgalantamine cap 24mg er PG PG Remove QLgalantamine cap 8mg er PG PG Remove QLGAPEAUM CRE BUDIBAC NPB/G NCgatifloxacin PG NPB/G ciprofloxacnGELCLAIR NPB/G NCGELNIQUE GEL 10% NPB/G NPB/G oxybutynin, trospium Add ST, Remove QLGELNIQUE GEL 3% NPB/G NPB/G oxybutynin, trospium Add STGENOTROPIN PS NPS OMNITROPEGILENYA NPS PSGLEEVEC PS PS Expect GenGLUCAGON KIT+A289+A535 PB PB Remove QLGLUMETZA NPB/G NPB/G Expect GenGOLYTELY PB NPB/G lactulose , SUPREPGONAL-F NPS PSGONAL-F RFF NPS PSGORDONS UREA NPB/G NCgrafco silvr PG NPB/GGRANIX NPS NPS Add NPLgreen glo PG NC
grx hicort PG NCCORTIFOAM, PROCTOZONE-HC
GYNAZOLE-1 NPB/G NPB/G Remove QL
HC PRAMOXINE CRE 2.5-1% PG NCCORTIFOAM, PROCTOZONE-HC
HEMANGEOL NPB/G NPB/G propranolol Add PA
hemorrhoidal sup PG NCCORTIFOAM, PROCTOZONE-HC
hemril-30 PG NCCORTIFOAM, PROCTOZONE-HC
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
HEPAGAM B NPS PSHEPSERA PS NPS adefovir
HEXALEN PS PB
HIZENTRA PB NPShyaluronate PG NC
hydroco/apap PG NPB/Ghydrocodone bitartrate/acetaminophen tabs
hydrocort ac PG NCCORTIFOAM, PROCTOZONE-HC
hydrocort/pramoxin NPB/G NCCORTIFOAM, PROCTOZONE-HC
hydromorphon tab 12mg er PG PGRemove PA, Remove ST, Add QL
hydromorphon tab 16mg er PG PGRemove PA,Remove ST
hydromorphon tab 32mg er PG PGRemove PA, Remove ST
hydromorphon tab 8mg er PG PGRemove PA, Remove ST
hygel PG NChyophen PG NChyoscyamine PG NCHYPERTET S/D NPS PS
HYSINGLA ER NPB/G PBRemove PA, Remove ST, Expect Gen
IBUDONE PG NPB/Ghydrocodone bitartrate/ibuprofen
ibudone 10-200MG PG NPB/Ghydrocodone bitartrate/ibuprofen
ILEVRO NPB/G NPB/G Remove QL
imipram pam PG NPB/Gamitriptyline, doxepin, nortriptylin
IMOGAM RABIE NPS PSINCRELEX NPS PSINNOPRAX-5 CRE NPB/G NCINSPRA NPB/G NPB/G Remove QLINVOKAMET PB PB Remove STINVOKANA PB PB Remove STISENTRESS NPB/G PB
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
isometh/apap PG NC
CAFERGOT, dihydroergotamine nasal, naratriptan, rizatriptan, sumatriptan, zolmitriptan
ivermectin NPB/G PG
JALYN NPB/G PBRemove ST, Remove QL, Expect Gen
JARDIANCE NPB/G NPB/G Add QL
JENTADUETO NPB/G NPB/Gmetformin , JANUMET, KOMBIGLYZE
Add ST
JETREA NPS NPS Add PA
KADIAN PB NPB/Ghydromorphone hydrochloride
Remove PA, Remove ST, Add QL
KALETRA PB PB Expect Genkarigel PG NC
KAZANO NPB/G NPB/Gmetformin , JANUMET, KOMBIGLYZE
Add ST
KERALYT NPB/G NCKRISTALOSE PB NPB/G lactulose , SUPREPKUVAN NPS PSlactic acid PG NPB/GLANOXIN TAB 0.125MG PB NPB/G digoxinLANOXIN TAB 0.25MG PB NPB/G digoxin
LANSOPRAZOLE SUS 3MG/ML PB NComeprazole, pantoprazole, esomeprazole
LASTACAFT NPB/G NPB/G Remove QLlatrix PG NC
LAZANDA NPB/G NPB/Gmorphine, hydrocodone, oxycodone
Add PA
LEUKINE PS NPS Add NPLleuprolide PS PS Add PALEVAQUIN NPB/G NPB/G Remove QLlevocarnitin PG NC
levocetirizi sol 2.5/5ml PG NPB/G loratadine, cetirizine
levocetirizi tab 5mg PG NPB/G loratadine, cetirizinelevofloxacin PG PG Remove QL
LIBRAX NPB/G NCdicyclomine, hyoscyamine, propantheline
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
lidocaine sol 4% PG NClidocaine pad 5% PG PG Remove PAlidocaine hcl 3% cre PB NCLIDORX NPB/G NCLIDOVEX NPB/G NClissamine gr PG NClosartan pot PG PG Add QLLOTREL NPB/G NPB/G Remove QL
LOTRONEX PB NPB/G hyoscyamine Add PA, Add ST
LTA 360 KIT PG NC
LUCENTIS NPS PS Add PA
LUNESTA NPB/G NPB/G Remove STLUPANETA NPS NPS Add PALUPR DEP-PED NPS NPS Add PALUPRON DEPOT NPS NPS Add PA, Expect Gen
LYRICA NPB/G PBRemove PA, Remove QL
MACRODANTIN PB NPB/G nitrofurantoin MACUGEN NPS NPS Add PAMALARONE NPB/G NPB/G Remove QLmalathion NPB/G PG Remove QLmaprotiline PG PG Add QLMATULANE PS PB
mefloquine PG NPB/Gatovaq/proguan, hydroxychloro
Remove QL
MENOPUR NPS PSmeperidine/prometh PG NCMEPRON NPB/G NPB/G Remove QLmetaxalone PG PG Remove QLmetformin er (generic FORTAMET) PG NPB/G generic GLUCOPHAGE XRmethadone PG PG Add QL
methamphetam PG PGphentermine, phendimetrazine
Add PA
METROGEL NPB/G NPB/G Remove ST
metronidazole gel PG NPB/G rosadan Remove ST
miconazole 3 NPB/G NCmigragesic PG NC
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
mirtazapine tab 15mg PG PG Add QL
mirtazapine tab 15mg odt PG PG Add QL
mirtazapine tab 30mg PG PG Add QLmirtazapine tab 30mg odt PG PG Add QLmirtazapine tab 45mg PG PG Add QL
mirtazapine tab 45mg odt PG PG Add QL
mirtazapine tab 7.5mg PG PG Add QL
MIRVASO NPB/G NPB/GRemove ST, Remove QL
morphine er (generic AVINZA) PG PGRemove PA, Remove ST
morphine er (generic KADIAN) PG PGRemove PA, Remove ST, Add QL
morphine sul tab er (generic MS CONTIN)
PG PG Add QL
MOXATAG NPB/G NPB/G Remove QLmoxifloxacin PG PG Remove QLMS CONTIN NPB/G NPB/G Add QLMYALEPT NPS PSmycophenolate cap PS PS Add SPBmycophenolate sus PG PS Add SPBmycophenolate tab PS PS Add SPBmycophenolic NPS PSMYLERAN PS PBmyorisan PG NPB/G claravis Add PA, Add STMYOZYME NPS PSMYRBETRIQ PB PB oxybutynin, trospium Add STNAGLAZYME NPS PS
NAMENDA PB PBRemove QL, Expect Gen
NAMENDA XR PB PB Remove QLNAMZARIC PB PB Remove QLNEORAL CAP PS NPS cyclosporine
NESINA NPB/G NPB/Gmetformin , JANUVIA, ONGLYZA
Add ST
NEULASTA PS PS Add NPLNEUMEGA NPS NPS Add PANEUPOGEN PS NPS Add NPL
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
neutragard PG NCNEUTRASAL NPB/G NC
NEXIUM PB NPB/Gomeprazole, pantoprazole, esomeprazole
nodolor PG NC
CAFERGOT, dihydroergotamine nasal, naratriptan, rizatriptan, sumatriptan, zolmitriptan
NORDITROPIN PS NPS OMNITROPENORPACE PB NPB/G disopyramidenovarel NPS PSNOXAFIL NPB/G NPB/G Remove QLNPLATE NPS NPS Add PA
NUCYNTA ER NPB/G NPB/GOXYCONTIN, HYSINGLA ER, BUTRANS
Add ST, Expect Gen
NUEDEXTA NPB/G PBnuquin hp NPB/G NCNYMALIZE NPB/G NPB/G Remove PA, Add QLofloxacin PG PG Remove QL
OMEPRAZOLE SUS NPB/G NComeprazole, pantoprazole, esomeprazole
OPANA NPB/G NPB/G Remove STOPANA ER TAB 7.5, 10, 15, 20, 30, 40MG
PB NPB/GOXYCONTIN, HYSINGLA ER, BUTRANS
Add PA, Add ST
OPANA ER TAB 5MG PB NPB/GOXYCONTIN, HYSINGLA ER, BUTRANS
Add PA, Add ST, Add QL
opium tinct PG NPB/Gdiphenoxylate hydrochloride/atropine sulfate
ORFADIN NPS PS Add PA
OSENI NPB/G NPB/Gmetformin , JANUVIA, ONGLYZA
Add ST
OTICIN HC PG NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic
oto-end 10 PG NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic
otomax-hc PG NCOTREXUP NPS NPS methotrexate Add ST
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
oxycodone er PG NPB/GOXYCONTIN, HYSINGLA ER, BUTRANS
Add PA, Add ST
OXYCONTIN NPB/G PBRemove ST, Expect Gen
oxymorphone PG PG Remove STOZURDEX NPS PS Add PAPANCREAZE NPB/G NPB/G CREON, ZENPEP Add STPANRETIN NPB/G PBparoex PG NCperindopril PG PG Remove QLperiogard PG NCPERTZYE NPB/G NPB/G CREON, ZENPEP Add STphenylbutyrate NPS PSphos-flur PG NCphosphasal PG NC
PLEXION CLTH NPB/G NPB/Gsodium sulfacetamide/sulfur 10%-5%
Add ST
PRAMOSONE CRE 1% NPB/G NC
pramoxine-hc NPB/G NCacetic acid otic, antipyrine-benzocaine , ofloxacin otic
prednicarbat PG NPB/G fluocinolone acetonidepregnyl NPS PS
PREVACID SOL TAB NPB/G NPB/Gomeprazole, pantoprazole, esomeprazole
Add ST
PREZCOBIX NPB/G PBprocainamide PG NC
PROCTOCORT NPB/G NCCORTIFOAM, PROCTOZONE-HC
PROCTOFOAM PB NPB/G lidocaine hcPROGESTERONE CRE 10% KIT PB NCPROLENSA NPB/G NPB/G Remove QLpropanthelin PG NCPROSED/DS NPB/G NCPROTOPIC NPB/G NPB/G Remove QLpyrogall acd PG NC
quinine sulf PG NPB/Gatovaq/proguan, hydroxychloro
rabeprazole PG NPB/Gomeprazole, pantoprazole, esomeprazole
RAPAFLO NPB/G PB Remove QLRAPAMUNE PS NPS tacrolimus
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
RASUVO NPS NPS methotrexate Add STRAZADYNE ER NPB/G NPB/G Remove QLre 10 wash PG NPB/Grea lo 39 PG NCrea lo 40 PG NCREBETOL PS NPS ribavirin
rectacort-hc PG NCCORTIFOAM, PROCTOZONE-HC
REGENECARE NPB/G NCRELISTOR NPB/G NPB/G AMITIZA (ST required) Add PA, Add QLREMERON NPB/G NPB/G Add QLREMERON SLTB NPB/G NPB/G Add QLremeven PG NCrepaglinide PG NPB/G nateglinideRESTASIS NPB/G PB Remove QL
RETIN-A CRE 0.025% NPB/G NPB/GRemove QL, Add Age Limit
RETIN-A CRE 0.05% NPB/G NPB/GRemove QL, Add Age Limit
RETIN-A CRE 0.1% NPB/G NPB/GRemove QL, Add Age Limit
RETIN-A GEL 0.01% NPB/G NPB/GRemove QL, Add Age Limit
RETIN-A GEL 0.025% NPB/G NPB/GRemove ST, Remove QL, Add Age Limit
RETIN-A MICR NPB/G NPB/GRemove ST, Remove QL, Add Age Limit
RHOPHYLAC NPS PSRIDAURA PB NPB/G methotrexaterivastigmine PG PG Remove QLsalacyn PG NPB/G podofiloxsalicylic PG NPB/G podofiloxsalicylic ac aer 6% PG NPB/G podofiloxsalicylic ac cre 6% PG NPB/G podofiloxsalicylic ac gel 6% PG NCsalicylic ac liq 26% PG NPB/G podofiloxsalicylic ac liq 27.5% PG NPB/G podofiloxsalicylic ac lot 6% PG NPB/G podofiloxsalicylic ac sha 6% PG NPB/G podofiloxsalicylic ac sol 28.5% PG NPB/G podofiloxSAMSCA NPS PSSANDIMMUNE PS NPS cyclosporine
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
SANDOSTATIN NPS NPS octreotide Add PAseb-prev PG NPB/G
SENSIPAR PB NPSparicalcitol, doxercalciferol
Remove ST
sf gel PG NC
sildenafil NPS PSsilver nitra PG NPB/G
sod sul/sulf cre 10-2% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sul/sulf cre 10-5% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sul/sulf cre 9.8-4.8% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sul/sulf gel 10-5% PG NC
sod sul/sulf liq 10-2% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sul/sulf liq 9.8-4.8% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sul/sulf liq 9-4.5% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sul/sulf liq wash PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sul/sulf lot 9.8-4.8% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sul/sulf pad 10-4% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sul/sulf sus 8-4% PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sod sulfacet 10% PG NPB/G
SOLIRIS NPS PSspinosad NPB/G PG Remove QL
SPORANOX SOL 10MG/ML PB NPB/Gitraconazole caps, fluconazole
ss sol 10-2 PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
sss cre 10-5 PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
STRIBILD NPB/G NPB/G Add PA
SUBSYS NPB/G NPB/Gmorphine, hydrocodone, oxycodone
Add ST
SUCRAID NPS NPS Add SPB
sulfacleanse PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
SUPPRELIN LA NPS PS Add PASUPRAX NPB/G NPB/G Remove QLSUPREP BOWEL NPB/G PBSYMLIN NPB/G NPB/G Remove QLSYMLINPEN 60 NPB/G NPB/G Remove QLSYMLNPEN 120 NPB/G NPB/G Remove QLSYNAGIS NPS PSSYNAREL PB NPS Add PATACLONEX NPB/G NPB/G acitretin Add STtacrolimus PG NPB/G Remove QL
TANZEUM NPB/G NPB/Gmetformin , VICTOZA, TRULICITY
Remove PA, Add ST
TARGRETIN PS PS Add SPBTAZORAC NPB/G NPB/G acitretin Add ST, Add Age Limit
TEKAMLO NPB/G NPB/Gamlodipine and losartan, valsartan
Remove PA, Add ST
TEKTURNA NPB/G NPB/G losartan, valsartan Remove PA, Add ST
TEKTURNA HCT TAB 150-12.5 NPB/G NPB/Ghctz and losartan, valsartan
Remove PA, Add ST
TEKTURNA HCT TAB 150-25MG NPB/G NPB/Ghctz and losartan, valsartan
Remove PA, Add ST
TEKTURNA HCT TAB 300-12.5 NPB/G NPB/Ghctz and losartan, valsartan
Remove PA, Add ST
TEKTURNA HCT TAB 300-25MG NPB/G NPB/Ghctz and losartan, valsartan
Remove PA, Add ST
TEMODAR PS NPS temozolomide Add NPLtemozolomide PS PS Add NPLTESTIM PB NPB/G ANDROGEL (PA required) Add STtestost cyp PG PG Remove QLtestost enan PG PG Remove QL
testosterone gel PG NPB/G ANDROGEL (PA required)
TEV-TROPIN PS NPS OMNITROPETHALOMID PS NPSTHEO-24 PB PB Remove QLTHYROGEN NPS PSTIKOSYN PB NPB/G amiodaroneTINDAMAX NPB/G NPB/G Remove QLtinidazole PG NPB/G atovaquone Remove QLTIVICAY NPB/G PB
TOBI PS NPStobramycin , TOBI PODHALER
Remove PA
TOBI PODHALR NPS PS Remove PA
tobramycin neb PS PS Remove PA
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
TOVIAZ NPB/G NPB/G oxybutynin, trospium Add STTRACLEER PS PS Expect Gen
TRADJENTA NPB/G NPB/Gmetformin , JANUVIA, ONGLYZA
Add ST
trando/verap NPB/G PGtranex acid PG NPB/GTRELSTAR NPS NPS Add PA, Expect GenTRELSTAR MIX NPS NPS Add PAtretinoin cre 0.025% PG PG Add Age Limittretinoin cre 0.05% PG PG Add Age Limittretinoin cre 0.1% PG PG Add Age Limittretinoin gel 0.01% PG PG Add Age Limittretinoin gel 0.025% PG PG Add Age Limit
tretinoin gel 0.04% PG PGRemove ST, Remove QL, Add Age Limit
tretinoin gel 0.04%pmp PG PGRemove ST, Remove QL, Add Age Limit
tretinoin gel 0.1% PG PGRemove ST, Remove QL, Add Age Limit
tretinoin gel 0.1%pump PG PGRemove ST, Remove QL, Add Age Limit
TRETIN-X NPB/G NPB/GRemove QL, Add Age Limit
TRETIN-X KIT NC NC Add Age Limit
triamcinolon PG NCTRISEON CRE NPB/G NCTRIUMEQ NPB/G PBTRIZIVIR PB NPB/G abacavir/lamivudineTRULICITY NPB/G PB Remove PATRUVADA PB PB Add PATUDORZA PRES NPB/G NPB/G SPIRIVA, INCRUSE Remove PAturpentine PG NCUCERIS NPB/G NPB/G hydrocortisone enema Add PA, Remove STu-kera e PG NCULTRESA NPB/G NPB/G CREON, ZENPEP Add STUMECTA NPB/G NCUMECTA NAIL NPB/G NCUMECTA PD NPB/G NCur n-c PG NC
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
urea PG NCurea 40% PG NCurea hydrati PG NCurea nail PG NCurea topical PG NCurea-c40 PG NCurelle PG NCuretron d/s PG NCuribel PG NCURIMAR-T NPB/G NCurin d/s PG NCuro-blue PG NCuro-l PG NCuro-mp PG NCUROQID #2 PB NC
ursodiol PG NPB/G ursodiol 300mg or 250 mg
uryl PG NCustell PG NCuticap PG NCutira-c PG NCutrona-c PG NCvalacyclovir PG PG Remove QLVALCYTE TAB PS NPS valganciclovirVALCYTE SOL PB PSVALTREX NPB/G NPB/G Remove QLvancomycin PG NPB/G metronidazole Remove QL
VANOS NPB/G NPB/Gclobetasol, betamethasone oint
Add ST
VANTAS NPS NPS Add PAVECTICAL NPB/G NPB/G Remove ST
VELTIN NPB/G NPB/Gtopical clindamycin and tretinoin
Add ST
VERSACLOZ NPB/G NPB/G clozapine Add STVESICARE PB PB oxybutynin, trospium Add ST
vicodin PG NPB/Ghydrocodone bitartrate/acetaminophen tabs
vicodin es PG NPB/Ghydrocodone bitartrate/acetaminophen tabs
vicodin hp PG NPB/Ghydrocodone bitartrate/acetaminophen tabs
VICTOZA NPB/G PBRemove PA, Remove ST
VIDEX EC PB NPB/G didanosine
Aetna Value PlusJanuary 1, 2016 Updates
05.03.452.1
Drug NameCurrent
TierTier as of
1/1/16Formulary Alternative(s) Notes
VIMIZIM NPS PSVIOKACE NPB/G NPB/G CREON, ZENPEP Add STVISUDYNE NPS NPS Add PA, Expect GenVITEKTA NPB/G PBVOGELXO PB NPB/G ANDROGEL (PA required)VPRIV NPS PSWELCHOL PAK 3.75GM PB NPB/G colesevelam pak Expect GenWELCHOL TAB 625MG NPB/G NPB/G Expect Gen
XARTEMIS XR NPB/G NPB/Gmorphine, hydrocodone, oxycodone
Add ST
XELODA PS NPS capecitabine Add NPLXENAZINE PS PS Expect GenXIAFLEX NPS PSXIFAXAN NPB/G NPB/G lactulose Add PAXOLAIR NPS PSx-viate NPB/G NCXYREM NPS NPS Add SPBZEMPLAR CAP 1MCG PB NPS paricalcitolzenatane PG NPB/G claravis Add PA, Add ST
zencia PG NPB/Gsodium sulfacetamide/sulfur 10%-5%
ZIAGEN SOL NPB/G PB
ZIANA NPB/G NPB/Gtopical clindamycin and tretinoin
Add ST, Expect Gen
ZITHROMAX NPB/G NPB/G Remove QLZMAX NPB/G NPB/G Remove QLZOLADEX NPS NPS Add PAzolpidem er PG PG Remove STZYMAXID NPB/G NPB/G Remove QL
©2015 Aetna Inc. 05.03.452.1
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Please note that if your prescription drug benefits plan changes, the information in this letter may no longer apply. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Aetna Pharmacy Plan and Specialty Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug. Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining the Aetna Pharmacy Plan and Specialty Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Aetna Pharmacy Plan and Specialty Drug List will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “preservice utilization review.” It is not "verification" as defined by Texas law. In accordance with state law, fully insured commercial California HMO members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are to receive precertification or step-therapy reviews will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee's medical condition. In accordance with state law, fully insured commercial Connecticut PPO members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are to receive precertification or step-therapy reviews will continue to have those medications covered for as long as the treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. The drugs on the Aetna Pharmacy Plan and Specialty Drug List including formulary exclusions, precertification, quantity limit and step-therapy reviews are subject to change. The quantity limits and step-therapy drug coverage review programs are not available in all service areas. For example, step-therapy programs do not apply to fully insured members in Indiana. Step therapy does not apply to fully insured members in New Jersey. However, these programs are available to self-funded plans. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. For more information about Aetna plans, refer to www.aetna.com.