Aetna Better Health of Illinois Medicaid Formulary Updates
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- Mark Barrett
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1 October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary Updates o Albenza o Azelastine HCl Nasal Spray 0.1%-QL o Basaglar Kwikpen o Biltricide-PA o Corlanor-ST o Epoprostenol Sodium powder for injection-pa o ERGOCAL CAP 2500UNIT-QL o ISENTRESS HD TAB 600MG-QL o Kitabis, 300/5ml, Neb-PA o Kitabis, 300/5ml, Neb-PA o Letairis tablet-pa, QL o Lidocaine 4% Cream o Malathion Lotion 0.5%-ST o OLOPATADINE HCL 0.1% OPTHALMIC SOLUTION -ST, QL o OLOPATADINE HCL 0.2% OPTHALMIC SOLUTION-ST, QL o Permethrin Lotion 1%-QL o Pulmozyme-PA, QL o Ribasphere cap o Ribasphere tab o Spinosad Susp 0.9%-ST o Tracleer tablets, all strengths-pa, QL o Benzyl Alcohol Lotion 5% (Ulefsia) o Cetirizine HCl Chew Tab 5 MG, 10mg o Chlorpromazine HCl Tabs (all strengths) o Doxycycline Hyclate DR tablets o Doxycycline Mono 75mg Capsules o E.E.S 400mg o Econazole Nitrate Cream 1% o ERYTHROCIN TAB 250MG o ERYTHROMYCIN BASE TABLETS o Erythromycin w/ Delayed Release Cap o Fluoxetine 10mg tablet
2 June 2017 o Fluphenazine HCl Tabs (all strengths) o Lantus vials, Solostar pens o Levemir vials, Flextouch pen o Metronidazole 1% gel o Potassium Chloride Oral Soln 10%, 20% o Potassium Chloride Packet 20 meq, 25 meq o Ribavirin cap o Ribavirin tab o Tetracycline capsules, all strengths Step therapies o Adcirca-ST o Multaq-ST Step Therapies o Adapalene Gel 0.1% o Tretinoin cream, gel o Albuterol Nebulizer solution May 2017 Formulary additions o Hydroxyprogesterone Quantity Limit Required o METHYLPHENIDATE HCL CAP SR 24HR 60 MG (LA) o ADAPALENE GEL 0.1% o DESVENLAFAXINE TAB 25mg ER, 50MG ER, 100MG ER o Pristiq [all strengths] April 2017 Formulary additions o Selzentry 25mg and 75mg tablets o Vitamin D3 Chew 5000 units o Linzess 72 mcg capsule o Pyrantel Pamoate Suspension and tablets o Extavia o Gel-One Step Therapy Required o Jentadueto TAB XR MG o Jentadueto TAB XR MG o Levalbuterol tartrate inhal aerosol March 2017
3 Quantity Limits o AMPHETAMINE/DEXTROAMPHETAMINE CAP 30MG ER o AMPHETAMINE/DEXTROAMPHETAMINE TAB 30MG o DEXMETHYLPHENIDATE TAB 2.5mg, 5mg, and 10MG o DEXTROAMPHETAMINE CAP 5mg ER, 10MG ER, and 15mg ER o DEXTROAMPHETAMINE TAB 5mg and 10MG o GUANFACINE TAB 1MG, 2mg o METHYLPHENIDATE CAP 10MG ER, 20mg ER, 30mg ER, 40mg ER o METHYLPHENIDATE CAP 10MG, 20mg, 30mg, 40mg, 50mg, 60mg o METHYLPHENIDATE CHW 2.5mg, 5mg, 10MG o METHYLPHENIDATE SOL 5mg/5ml, 10MG/5ML o METHYLPHENIDATE TAB 5MG, 10MG, 20MG o METHYLPHENIDATE TAB 10MG ER, 20MG ER o MODAFINIL TAB 100MG, 200 MG o STRATTERA CAP 10MG, 18MG, 25MG, 40MG, 60MG, 80MG, 100MG o METHYLIN CHW (all strengths) February 2017 o Apriso o Breo Ellipta o CALCIUM ACET CAP 667MG o Chlorzoxazone 500mg o Dexmethlphenidate ER, [All] caps o Dulera o Epinephrine Inj.3/0.3Ml o Epinephrine Inj 0.15Mg o FIRST-LANSOPRAZOLE SUS 3MG/ML o Linzess (removed Step Therapy requirement) o Lopinavir/Ritonavir 80-20mg/mL, soln o MESALAMINE TAB 800MG DR o Orphenadrine o Viokace o Epogen o Gilenya o Glatopa 20mg o Imbruvica o Lidocaine 5% Patch o Montelukast Granules o Tecfidera
4 o o Tecfidera Starter pack Zarxio Step Therapy Required o Albuterol Neb 0.63MG/3mL o Ezetimibe 10 mg tabs o Albuterol Neb 1.25MG/3mL o Auryxia o Myorisan 10mg o Savella o Savella titration pack o Tacrolimus Ointment o Zenatane 40mg Quantity Limit o Adapalene o Colchicine 0.6mg o EPINEPHRINE PEN (all strengths) o LIDO/PRILOCN CRE % o Lidocaine 5% Ointment o MUPIROCIN OINTMENT 2% o Tretinoin cream o Tretinoin gel o Advair Diskus and HFA o Amitiza o Asacol 800 mg tab o Buspirone 30mg tablet o Carisoprodol 250mg o CIPRO HC SUSP OTIC o CIPRODEX SUSP OTIC o Clindamycin/Benzoyl Peroxide o Clomipramine capsules o Delzicol o Diltiazem ER/LA Tablets o Dipentum o DOXYCYCLINE HYCLATE 100mg tablet o DOXYCYCLINE HYCLATE CAP (all strengths) o DOXYCYCLINE MONOHYDRATE CAP 150MG o EPIPEN INJ 0.15MG, 0.3MG o Erythromycin/Benzoyl Peroxide o Farxiga
5 January 2017 o FLUOXETINE TAB 20MG o Glatiramer 20mg o Imipramine capsules o Isotretinoin Capsules o Kaletra 80-20mg/mL soln o Metaxalone o MUPIROCIN CREAM 2% o NAPROXEN SODIUM TAB 550MG o Neupogen o NYSTAT/TRIAM CREAM o NYSTAT/TRIAM OINTMENT o Pancreaze 2600, 4200, 21000,16800,10500 o Pentasa (all strengths) o Renvela/sevelamer o Spiriva o Sulfacetamide/Sulfur o Symbicort o Tizanidine capsules o Trazodone 300mg tablet o TRETINOIN (facial wrinkles) CREAM o Tudorza o VENLAFAXINE ER TABLETS (all strengths) o Zetia 10 mg Tab o Zepatier-PA o Sovaldi
JULY 2017 ADDITIONS. NP Thyroid 120mg NP Thyroid 15mg JUNE 2017 CHANGES
APRIL 2017 Ivermectin, Pin-X and Reeses (Pyrantel Pamoate) Selzentry 25mg and 75mg tablets Linzess 72 mcg capsule-with QLL Levalbuterol Tartrate Inhal Aerosol (Generic Xopenex HFA) with ST & QLL Jentadueto
Mercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
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ALBENDAZOLE Mercy Care ALBENZA TABLET 200 MG ORAL Refer to PA Guideline for approval criteria 1 BRIMONIDINE-TIMOLOL COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC Requires use of separate ingredients for at least
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Allergy Chlorpheniramine Tablet* Diphenhydramine Tablet* Diphenhydramine Liquid* Loratadine Tablet* Cetirizine Tablet* Loratadine 10mg ODT* Less than $10 Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
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