2017 Formulary Exclusions Drug List
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1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Formulary Exclusions Drug List aetna.com H (3/17)
2 These drugs are not covered under your plan. There are preferred alternatives for these conditions that are covered by your plan. Additional exclusions may apply to certain Small Group plans. Key UPPERCASE lowercase italics Brand-name medicine Generic medicine Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company, Aetna HealthAssurance Pennsylvania Inc. and/or Aetna Life Insurance Company (Aetna). In Florida by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company. In Maryland by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT Each insurer has sole financial responsibility for its own products. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.
3 Analgesics CAMBIA (diclofenac) diclofenac potassium (generic CATAFLAM), sumatriptan (generic IMITREX), naratriptan (generic AMERGE), rizatriptan (generic MAXALT) Antibiotics CONZIP* (tramadol ER capsules) DUEXIS (ibuprofen/famotidine) FLECTOR patch (diclofenac epolamine) PENNSAID* (diclofenac sodium topical solution) RYBIX ODT (tramadol) SOLARAZE* (diclofenac sodium 3% gel) VANATOL LQ (acetaminophen/butalbital/caffeine) VIMOVO (naproxen/esomeprazole) ZIPSOR ACTICLATE (doxycycline) ADOXA* (doxycycline) AVIDOXY* (doxycycline) DORYX* (doxycycline) doxycycline hyclate 75 mg, 100 mg delayed-release tablets doxycycline monohydrate 75 mg capsules MONODOX 75 mg* (doxycycline) MONDOXYNE NL 75 mg capsules ORACEA* (doxycycline) TARGADOX (doxycycline) DYNACIN* tablets (minocycline) SOLODYN (minocycline) tramadol immediate-release or extended-release tablets (generic ULTRAM, ULTRAM ER) ibuprofen (generic MOTRIN) plus famotidine (generic PEPCID) Generic oral nonsteroidal anti-inflammatory drug Generic oral nonsteroidal anti-inflammatory drug tramadol immediate-release or extended-release tablets (generic ULTRAM, ULTRAM ER) imiquimod (generic ALDARA), fluorouracil cream (generic CARAC) acetaminophen/butalbital/caffeine tablet (generic FIORICET) esomeprazole magnesium (generic NEXIUM) plus naproxen (generic NAPROSYN) Generic oral nonsteroidal anti-inflammatory drug doxycycline monohydrate 50 mg, 100 mg capsules (generic MONODOX) doxycycline hyclate 100 mg capsules (generic VIBRAMYCIN) DOXY-D 100 mg capsules MORGIDOX 50 mg, 100 mg capsules minocycline capsules (generic MINOCIN) Antidotes EVZIO (naloxone HCl injection) NARCAN nasal spray Antihyperlipidemic FENOGLIDE* (fenofibrate) Other generic fenofibrates Antivirals SITAVIG (acyclovir) acyclovir capsules, tablets, ointment (generic ZOVIRAX)
4 Cardiovascular CARDIZEM CD** (diltiazem) diltiazem ER Central nervous system (CNS) antidepressants/ other CADUET* (amlodipine/atorvastatin) DUTOPROL (metoprolol succinate/hydrochlorothiazide extended-release tablets) metoprolol succinate/hydrochlorothiazide extendedrelease tablets VASOTEC** (enalapril maleate) APLENZIN (bupropion HBr) FORFIVO XL (bupropion HCl extended release) WELLBUTRIN XL** (bupropion extended release) PEXEVA (paroxetine) ATIVAN** (lorazepam) amlodipine (generic NORVASC) plus atorvastatin (generic LIPITOR) metoprolol/hydrochlorothiazide tablets (generic LOPRESSOR HCT) metoprolol/hydrochlorothiazide tablets (generic LOPRESSOR HCT) enalapril maleate bupropion immediate or extended release (generic WELLBUTRIN, WELLBUTRIN SR, WELLBUTRIN XL) paroxetine immediate or extended release (generic PAXIL, PAXIL CR) lorazepam CNS antiseizure STAVZOR (valproic acid) valproic acid (generic DEPAKENE) CNS sedative/ hypnotics CNS attention deficit hyperactivity disorder (ADHD) EDLUAR (sublingual zolpidem) INTERMEZZO* (sublingual zolpidem) ZOLPIMIST oral spray (zolpidem) SILENOR (doxepin) ZENZEDI 2.5 mg, 7.5 mg, 15 mg, 20 mg, 30 mg (dextroamphetamine sulfate) zolpidem tablets (generic AMBIEN) doxepin (generic SINEQUAN) dextroamphetamine sulfate (generic DEXEDRINE) Dermatological ABSORICA (isotretinoin) AMNESTEEM, CLARAVIS, MYORISAN ACANYA gel pump (benzoyl peroxide/clindamycin) BENZACLIN* (benzoyl peroxide/clindamycin) DUAC* (benzoyl peroxide/clindamycin) NEUAC* (benzoyl peroxide/clindamycin) ONEXTON (benzoyl peroxide/clindamycin) Topical benzoyl peroxide plus clindamycin ATRALIN** (tretinoin) CARAC** (fluorouracil) ECOZA (econazole) ONMEL (itraconazole) SELRX shampoo (selenium sulfide) SORILUX TOPICORT spray (desoximetasone) VANOS** (fluocinonide) ZYCLARA (imiquimod) Topical tretinoin (generic RETIN-A, ATRALIN) Topical fluorouracil (generic CARAC, EFUDEX) econazole cream (generic SPECTAZOLE) itraconazole (generic SPORANOX) selenium sulfide shampoo (generic EXCEL) Topical corticosteroids desoximetasone cream, gel, ointment fluocinonide cream (generic VANOS) imiquimod (generic ALDARA) **Generic product is available and is covered as an alternative to the brand-name product.
5 Endocrine All non LIFESCAN/ABBOTT brand test strips LIFESCAN/ABBOTT brand test strips Gastrointestinal (GI) other GI prescription ulcer medicine ANDRODERM (testosterone) AXIRON (testosterone) FORTESTA** (testosterone) NATESTO (testosterone) STRIANT (testosterone) BINOSTO (alendronate) FORTAMET* (metformin extended release) GLUMETZA* (metformin extended release) GENOTROPIN HUMATROPE NORDITROPIN NUTROPIN/NUTROPIN AQ SAIZEN SEROSTIM TEV TROPIN VALTROPIN ZOMACTON RAYOS*** (prednisone) ZUPLENZ (ondansetron film) esomeprazole strontium DEXILANT*** (dexlansoprazole) PREVACID delayed-release capsules 30 mg* PRILOSEC powder packet (omeprazole) ZEGERID* (omeprazole/sodium bicarbonate) ANDROGEL 1.62% testosterone transdermal gel (generic FORTESTA, ANDROGEL 1%) alendronate tablets (generic FOSAMAX) metformin immediate and extended release (generic GLUCOPHAGE, GLUCOPHAGE XR) OMNITROPE prednisone immediate release ondansetron tablets (generic ZOFRAN) esomeprazole magnesium (generic NEXIUM) esomeprazole magnesium (generic NEXIUM), pantoprazole (generic PROTONIX), rabeprazole (generic ACIPHEX) PREVACID OTC, esomeprazole magnesium (generic NEXIUM), pantoprazole (generic PROTONIX), rabeprazole (generic ACIPHEX) PRILOSEC OTC, esomeprazole magnesium (generic NEXIUM), pantoprazole (generic PROTONIX), rabeprazole (generic ACIPHEX) ZEGERID OTC, esomeprazole magnesium (generic NEXIUM), pantoprazole (generic PROTONIX), rabeprazole (generic ACIPHEX) Gout COLCRYS** (colchicine) colchicine (generic COLCRYS, MITIGARE), MITIGARE **Generic product is available and is covered as an alternative to the brand-name product. ***Does not apply to Affordable Care Act-compliant formulary offerings. Coverage of over-the-counter (OTC) products may not be available under all plan designs.
6 Migraine products ALSUMA (sumatriptan injection) sumatriptan injection (generic IMITREX) SUMAVEL (sumatriptan needleless) MIGRANAL* (dihydroergotamine) TREXIMET (sumatriptan/naproxen) dihydroergotamine nasal spray (generic MIGRANAL) sumatriptan (generic IMITREX) plus naproxen (generic NAPROSYN) Multiple sclerosis COPAXONE** (glatiramer acetate) GLATOPA Muscle relaxants AMRIX (cyclobenzaprine) cyclobenzaprine (generic FLEXERIL) LORZONE (chlorzoxazone) SOMA 250 mg* (carisoprodol) ZANAFLEX* CAPSULES chlorzoxazone (generic PARAFON FORTE) carisoprodol 350 mg (generic SOMA 350 mg) tizanidine tablets (generic ZANAFLEX tablets) Oncology GLEEVEC** (imatinib) imatinib (generic GLEEVEC) Respiratory nasal/ cough and cold DYMISTA (azelastine/fluticasone) ZONATUSS** (benzonatate) azelastine (generic ASTELIN), mometasone (generic NASONEX), flunisolide (generic NASALIDE) benzonatate (generic ZONATUSS, TESSALON PERLES) **Generic product is available and is covered as an alternative to the brand-name product. Please remember that this is not a complete list of medications covered under your plan. Because there are thousands of medications included in your pharmacy benefit, we only list the most common ones. Certain drugs such as those for smoking cessation or vitamins may not be covered by your particular pharmacy plan. Diabetic supplies may be covered under your medical plan. If you have any questions about your pharmacy benefits, please visit aetna.com and log in to your secure member website. If you don t have access to our website, call the toll-free number on your member ID card. To check coverage and copay information for a specific medicine, visit aetna.com and log in to your secure member website. For more details, please call the toll-free number on your member ID card. This is not an inclusive list. Products that are not represented on this list may be subject to plan-specific copayment or coinsurance. Void where prohibited by law. Specific prescription benefits plan design may not cover certain categories or may be subject to additional charges or restrictions, regardless of their appearance in this document. Aetna may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. Information is believed to be accurate as of the production date; however, it is subject to change. For questions, please call the toll-free number on your member ID card. Policy forms issued in Missouri include: AL HGrpPol 01R5, HI HGrpAg 01, HO HGrpPol 01. Policy forms issued in Oklahoma include: HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23, GR-29/GR-29N. aetna.com 2017 Aetna Inc H (3/17)
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