AETNA BETTER HEALTH January 2017 Formulary Change(s)

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1 AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on March 1, 2017 Drug Name, Strength, Dosage Form ALFUZOSIN HCL ER 10 MG TABLET DOCU LIQUID 50 MG/5 ML MAGNESIUM CITRATE SOLUTION METHOTREXATE 25 MG/ML VIAL METHOTREXATE 50 MG/2 ML VIAL METRONIDAZOLE TOPICAL 0.75% GL OXYTROL FOR WOMEN 3.9 MG/24HR SELENIUM SULFIDE 2.25% SHAMPOO SOD SULFACET-SULFUR 10-5% CLSR BETAMETHASONE DP 0.05% LOT BETAMETHASONE DP 0.05% OINT FLUTICASONE PROP 0.005% OINT FLUTICASONE PROP 0.05% CREAM MOMETASONE FUROATE 0.1% OINT PANCREAZE DR 2,600 UNIT CAP TRADJENTA 5 MG TABLET PANCREAZE DR 10,500 UNIT CAP ZENPEP DR 15,000 UNITS CAPSULE PANCREAZE DR 16,800 UNIT CAP ZENPEP DR 20,000 UNITS CAPSULE PANCREAZE DR 21,000 UNIT CAP CREON DR 12,000 UNITS CAPSULE CREON DR 24,000 UNITS CAPSULE CREON DR 36,000 UNITS CAPSULE ZENPEP DR 25,000 UNITS CAPSULE JENTADUETO 2.5 MG-500 MG TAB JENTADUETO 2.5 MG-850 MG TAB JENTADUETO 2.5 MG-1000 MG TAB ZENPEP DR 3,000 UNITS CAPSULE PANCREAZE DR 4,200 UNIT CAP ZENPEP DR 5,000 UNITS CAPSULE to formulary with quantity limit to formulary with quantity limit to formulary with quantity limit to formulary with quantity limit to formulary with quantity limit to formulary with quantity limit

2 CREON DR 3,000 UNITS CAPSULE CREON DR 6,000 UNITS CAPSULE ZENPEP DR 10,000 UNITS CAPSULE ALOGLIPTIN-PIOGLIT MG ALOGLIPTIN-PIOGLIT MG ALOGLIPTIN-PIOGLIT MG ALOGLIPTIN-PIOGLIT MG TB ALOGLIPTIN-PIOGLIT MG TB ALOGLIPTIN-PIOGLIT MG TB MOMETASONE FUROATE 0.1% CREAM ONDANSETRON 4 MG/5 ML SOLUTION PROCHLORPERAZINE 10 MG TAB PROCHLORPERAZINE 5 MG TABLET BISACODYL 10 MG SUPPOS BISACODYL EC 5 MG TABLET CHLORPROPAMIDE 100 MG TABLET CHLORPROPAMIDE 250 MG TABLET GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE 2 MG TABLET GLIMEPIRIDE 4 MG TABLET GLIPIZIDE 10 MG TABLET GLIPIZIDE 5 MG TABLET GLIPIZIDE XL 10 MG TABLET GLIPIZIDE XL 2.5 MG TABLET GLIPIZIDE XL 5 MG TABLET GLUCAGEN 1 MG HYPOKIT GLYBURIDE 1.25 MG TABLET GLYBURIDE 2.5 MG TABLET GLYBURIDE 5 MG TABLET GLYBURIDE MICRO 1.5 MG TAB GLYBURIDE MICRO 3 MG TABLET GLYBURIDE MICRO 6 MG TABLET GLYBURIDE-METFORMIN MG GLYBURIDE-METFORMIN MG ERYTHROMYCIN-BENZOYL GEL Removed from Formulary

3 The following updates will be made to the Aetna Better Health of MI formulary on February 1, 2017 Drug Name, Strength, Dosage Form IVERMECTIN 3 MG TABLET PIN-X 144 MG/ML(50 MG/ML BASE) PIN-X 250 MG (BASE) TAB CHEW ISONIAZID 50 MG/5 ML LEVOFLOXACIN 25 MG/ML Thalomid (all strengths) Tobramycin 300 MG/5 ML CIPROFLOXACIN 0.2% OTIC SOLN CLOTRIMAZOLE-BETAMETHASONE CRM CIPRODEX OTIC SUSPENSION TETRACYCLINE 250 MG CAPSULE TETRACYCLINE 500 MG CAPSULE CIPRODEX OTIC SUSPENSION ACETAMINOP-CODEINE MG/5 CLEMASTINE FUM 1.34 MG TABLET ALBUTEROL SULFATE 2 MG TAB ALBUTEROL SULFATE 4 MG TAB CETIRIZINE HCL 10 MG CHEW TAB CETIRIZINE HCL 5 MG CHEW TAB CHILD CETIRIZINE 10 MG CHEW TB CHILD CETIRIZINE 5 MG CHEW TAB DOXYCYCLINE MONO 150 MG CAP DOXYCYCLINE MONO 75 MG CAPSULE with Age Limit with Age Limit with PA with PA with Quantity Limit with Quantity Limit Age Limit Removed Age Limit Removed Age Limit Removed and Age Limit Removed Quantity Limit Change

4 E.E.S. 200 MG/5 ML GRANULES ERYTHROMYCIN DR 250 MG CAP ERYTHROMYCIN ES 400 MG TAB ERYTHROMYCIN FILMTAB (all strengths) MICONAZOLE MG VAG SUPP POTABA 500 MG CAPSULE RA CHILD CETIRIZINE 10 MG CHEW TERCONAZOLE 80 MG SUPPOSITORY TRIAMCINOLONE 55 MCG NASAL SPR Cervical Caps Asthma Spacers ed to Formulary Quantity limit increased to 4 per year The following updates will be made to the Aetna Better Health of MI formulary on January 1, 2017 Drug Name ALAWAY 0.025% EYE DROPS ALLOPURINOL 100 MG TABLET ALOGLIPTIN 12.5 MG TABLET ALOGLIPTIN 25 MG TABLET ALOGLIPTIN 6.25 MG TABLET ALOGLIPTIN-METFORMIN ALOGLIPTIN-METFORMIN ALOGLIPTIN-PIOGLIT MG ALOGLIPTIN-PIOGLIT MG ALOGLIPTIN-PIOGLIT MG ALOGLIPTIN-PIOGLIT MG TB ALOGLIPTIN-PIOGLIT MG TB ALOGLIPTIN-PIOGLIT MG TB AMANTADINE 100 MG/10 ML SOLN APIDRA SOLOSTAR 100 UNITS/ML APRACLONIDINE HCL 0.5% DROPS ASPIR EC 81 MG TABLET Update Over the counter item added.

5 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG TABLET CHEW ASPIRIN ADULT 81 MG CHEW TAB ASPIRIN EC 81 MG TABLET ASPIR-LOW EC 81 MG TABLET AZELASTINE HCL 0.05% DROPS BAYER ASPIRIN 81 MG CHEW TAB BAYER ASPIRIN 81 MG CHEW TAB BENZOYL PEROXIDE 10% GEL BETAMETHASONE DP 0.05% CRM BETAMETHASONE VA 0.1% CREAM BETHANECHOL 10 MG TABLET BETHANECHOL 25 MG TABLET BETHANECHOL 5 MG TABLET BETHANECHOL 50 MG TABLET BRIMONIDINE TARTRATE 0.15% DRP CALCIPOTRIENE 0.005% OINTMENT CEPHALEXIN 125 MG/5 ML SUSP CEPHALEXIN 250 MG/5 ML SUSP CHILD ASPIRIN 81 MG CHEW TAB CHILD ASPIRIN 81 MG TAB CHEW CIPROFLOXACIN 0.3% EYE DROP CLINDAMYCIN 2% VAGINAL CREAM CLOBETASOL 0.05% CREAM CLOBETASOL 0.05% OINTMENT CVS ASPIRIN 81 MG CHEWABLE TAB CVS ASPIRIN EC 81 MG TABLET CVS CHILD ASPIRIN 81 MG CHW TB CVS CHILD ASPIRIN CHEW TAB DILTIAZEM 24HR CD 180 MG CAP DILTIAZEM 24HR ER 180 MG CAP DIPHENHYDRAMINE 25 MG/10 ML ECOTRIN EC 81 MG TABLET ENTRESTO 24 MG-26 MG TABLET ENTRESTO 49 MG-51 MG TABLET ENTRESTO 97 MG-103 MG TABLET EQ ASPIRIN 81 MG CHEWABLE TAB EQ ASPIRIN EC 81 MG TABLET EQL ASPIRIN EC 81 MG TABLET FISH OIL 500 MG SOFTGEL Quantity limit removed. Remove age edit. ed to formulary.

6 FISH OIL EC 1,000 MG SOFTGEL GNP FISH OIL 1,200 MG SOFTGEL GNP FISH OIL EC 1,000 MG SFTGL GRANIX 300 MCG/0.5 ML SAFE SYR GRANIX 480 MCG/0.8 ML SAFE SYR HM ASPIRIN 81 MG CHEWABLE TAB HM ASPIRIN EC 81 MG TABLET HM FISH OIL EC 1,000 MG SFTGL HM LOW DOSE ASPIRIN EC 81 MG HUMALOG 100 UNITS/ML CARTRIDGE HUMALOG 100 UNITS/ML KWIKPEN HUMALOG MIX KWIKPEN HUMALOG MIX KWIKPEN HUMULIN 70/30 KWIKPEN HUMULIN N 100 UNITS/ML KWIKPEN ISOSORBIDE MN ER 120 MG TAB KETOROLAC 0.5% OPHTH SOLUTION KETOTIFEN FUM 0.025% EYE DROPS KRO ASPIRIN 81 MG CHEWABLE TAB LANTUS SOLOSTAR 100 UNITS/ML LOW DOSE ASPIRIN EC 81 MG TAB MOMETASONE FUROATE 0.1% CREAM NARCAN 4 MG NASAL SPRAY NOVOLOG 100 UNIT/ML CARTRIDGE NOVOLOG 100 UNITS/ML FLEXPEN NOVOLOG MIX FLEXPEN SYRN OMEPRAZOLE DR 40 MG CAPSULE PRED MILD 0.12% EYE DROPS PRENATAL DHA 200 MG SOFTGEL PUB ASPIRIN 81 MG CHEWABLE TAB PV ASPIRIN 81 MG CHEWABLE TAB PV ASPIRIN EC 81 MG TABLET PV CHILD ASPIRIN 81 MG CHW TAB QC CHILD ASPIRIN 81 MG CHW TAB QC LO-DOSE ASPIRIN EC 81 MG TB RA ASPIRIN 81 MG CHEWABLE TAB RA ASPIRIN EC 81 MG TABLET RA CHILD ASPIRIN 81 MG CHW TAB RA FISH OIL 1,000 MG SOFTGEL SB ASPIRIN EC 81 MG TABLET ed to formulary. ed to formulary. ed to formulary. ed to formulary. Quantity limit removed. Quantity limit removed. ed to formulary. ed to formulary.

7 SB CHILD ASPIRIN 81 MG CHW TAB SM ASPIRIN 81 MG CHEWABLE TAB SM ASPIRIN EC 81 MG TABLET SM CHILD ASPIRIN 81 MG CHW TAB SODIUM FLUORIDE 0.5 MG/ML DROP SPIRIVA RESPIMAT 1.25 MCG INH SV ALGAL OMEGA-3 DHA 200 MG TIMOLOL 0.25% GEL-SOLUTION TIMOLOL 0.25% GFS GEL-SOLUTION TIMOLOL 0.5% GEL-SOLUTION TIMOLOL 0.5% GFS GEL-SOLUTION TRIAMCINOLONE 0.025% CREAM TRIAMCINOLONE 0.025% OINT TRIAMCINOLONE 0.1% CREAM TRIAMCINOLONE 0.1% LOTION TRIAMCINOLONE 0.1% OINTMENT TRIAMCINOLONE 0.5% CREAM ZARXIO 300 MCG/0.5 ML SYRINGE ZARXIO 480 MCG/0.8 ML SYRINGE Formulary addition with quantity limit. ed to formulary. The complete Aetna Better Health of MI formulary is available here. Please call with any questions.

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