Drug coverage reviews
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1 Drug coverage reviews Drugs requiring prior authorization and step therapy 2018 Aetna Premier plan E (8/17) aetna.com
2 The drugs on this list require coverage reviews, like prior authorization or step therapy,* under the Aetna Premier plan. If you have a medical need for one of these drugs, your doctor can ask for an exception. *Prior authorization (also called preauthorization): Your doctor needs to get our approval ahead of time before we cover certain drugs. Step therapy: Your doctor needs to prescribe equally effective but less costly drugs first before we cover some drugs. Key UPPERCASE lowercase italics Brand-name medicine Generic medicine 2018 Premier prior authorization drug list Category Analgesics and anesthetics Antidotes Anti-gout agents lidocaine patch LIDODERM TIVORBEX VIVLODEX ZORVOLEX EVZIO ZURAMPIC Anti-infective agents GENVOYA IMPAVIDO STRIBILD XIFAXAN TABS Antineoplastic agents bicalutamide CASODEX XATMEP Cardiovascular agents CIALIS 2.5/5 MG CORLANOR ENTRESTO EPANED HEMANGEOL QBRELIS VELTASSA Central nervous system ABILIFY ODT, SOL, TAB CLOZARIL DESVENLAFAXINE ER desvenlafaxine ER desvenlafaxine tab FAZACLO FETIZIMA, STARTER FETZIMA, TITRATION GEODON INVEGA KHEDEZLA PRISTIQ REXULTI RISPERDAL RISPERDAL-M SAPHRIS SEROQUEL SEROQUEL XR TRINTELLIX VERSACLOZ VIIBRYD TITRATION VIIBRYD, STARTER VRAYLAR XADAGO ZYPREXA ZYPREXA ZYDIS Endocrine and metabolic ADLYXIN AFREZZA ANDRODERM ANDROGEL, PUMP AXIRON BYDUREON BYETTA FORTESTA NATESTO RAYALDEE SENSIPAR STIMATE STRIANT SYMLINPEN TANZEUM TESTIM testosterone, pump TRULICITY UCERIS VICTOZA VOGELXO, PUMP Gastrointestinal agents ACIPHEX, SPRINKLE AKYNZEO alosetron hydrochloride chlordiazepoxide/ clidinium DICLEGIS dronabinol esomeprazole GIAZO LIBRAX LOTRONEX MARINOL MYTESI omeprazole/ bicarbonate pow PREVACID, SOLUTAB PRILOSEC SYNDROS VIBERZI ZEGERID Genitourinary products finasteride tabs INTRAROSA PROSCAR Hematological agents EFFIENT YOSPRALA ZONTIVITY Miscellaneous psychotherapeutic and neurological BRISDELLE HORIZANT Health benefits and health insurance plans are offered, administered 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 Category Neuromuscular BRIVIACT RILUTEK riluzole Respiratory agents AIRDUO ARCAPTA NEOHALER AUVI-Q BEVESPI BROVANA CLARINEX-D COMBIVENT DALIRESP PERFOROMIST phenadoz PHENERGAN promethazine HCl promethazine HCl plain promethegan RYVENT SEEBRI NEOHALER STRIVERDI RESPIMAT UTIBRON Stimulants/ antiobesity/ anorexiants APTENSIO XR armodafinil clonidine HCl ER DAYTRANA DESOXYN DYANAVEL XR EVEKEO guanfacine ER INTUNIV KAPVAY modafinil MYDAYIS NUVIGIL PROCENTRA PROVIGIL QUILLICHEW QUILLIVANT XR Topical products ATRALIN avita ELIDEL EUCRISA LOCORT MIRVASO PROTOPIC REGRANEX RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP RHOFADE tacrolimus ointment tazarotene cream TAZORAC tretinoin cream, gel tretinoin microsphere, pump TRETIN-X CREAM 2018 Premier step therapy drug list Category Analgesics and anesthetics ABSTRAL ACTIQ ARYMO ER AVINZA BUNAVAIL CAMBIA DUEXIS DURAGESIC EXALDO fentanyl citrate loz FENTORA KADIAN LAZANDA LIDODERM 5% MORPHABOND MS CONTIN NAPRELAN CR NUCYNTA OPANA ER SPRIX SUBOXONE TAB SUBSYS TIVORBEX VANATOL LQ VIMOVO VIVLODEX XARTEMIS XR XTAMPZA ER ZOHYDRO ER ZORVOLEX ZUBSOLV Antidotes EVZIO Anti-gout agents COLCRYS ZURAMPIC Anti-infective agents SITAVIG VALTREX Anti-migraine agents AXERT dihydroergotamine spray MIGRANAL ONZETRA RELPAX TREXIMET ZEMBRACE Antineoplastic agents ALKERAN Cardiovascular agents ADRENACLICK AMTURNIDE AZOR CARDIZEM CD CORLANOR CRESTOR DIAMOX SEQUEL DUTOPROL EDARBYCLOR FENOGLIDE INDERAL LA LIVALO metoprolol succ/hctz NITROSTAT SUB TEKTURNA, HCT TRIBENZOR VASOTEC VYTORIN YOSPRALA ZETIA Central nervous system ABILIFY APLENZIN ATIVAN BELSOMRA CLOZARIL DESVENLAFAXINE ER DESYREL desvenlafaxine ER EDLUAR FANAPT, TITRATION FAZACLO FETZIMA, TITRATION GEODON CAPS INTERMEZZO SUBL INVEGA KHEDEZLA LEXAPRO nefazodone HCl OLEPTRO PEXEVA PRISTIQ REXULTI RISPERDAL M-TAB RISPERDAL TABS SAPHRIS SEROQUEL SEROQUEL XR SILENOR TRINTELLIX VERSACLOZ VIIBRYD, STARTER VRAYLAR WELLBUTRIN XL XADAGO XANAX / XR zolpidem tar sublingual ZYPREXA TABS ZYPREXA ZYDIS
4 Category Endocrine and metabolic ADLYXIN ANDRODERM ANDROGEL 1% APIDRA AXIRON BINOSTO BONIVA TAB 150 MG BYDUREON BYETTA ENTOCORT EC FORTAMET FORTESTA GLUMETZA HECTOROL CAP KAZANO MIACALICN NATESTO NESINA NOVOLIN 70/30 NOVOLIN 70/30 RELION NOVOLIN N NOVOLIN N RELION NOVOLIN N U-100 NOVOLIN R NOVOLIN R RELION NOVOLOG NOVOLOG MIX OSENI RAYALDEE RAYOS SOLIQUA STRIANT TANZEUM TESTIM testosterone, pump TRULICITY VICTOZA VOGELXO, PUMP XULTOPHY ZEMPLAR CAP Gastrointestinal agents ACIPHEX, SPRINKLE AKYNZEO ALOSETRON AMITIZA ASACOL AZULFIDINE AZULFIDINE EN-TABS COLAZAL DIPENTUM GIAZO HELIDAC LOTRONEX MYTESI PANCREAZE PERTZYE PREVACID SOLUTAB ULTRESA VIOKACE ZEGERID Genitourinary products DETROL DETROL LA DITROPAN DITROPAN XL ENABLEX GELNIQUE SANCTURA SANCTURA XR TOVIAZ Miscellaneous products NASCOBAL NON LIFESCAN TEST STRIPS NON ABBOTT TEST STRIPS Miscellaneous psychotherapeutic and neurological Neuromuscular GRALISE, STARTER HORIZANT ZELAPAR TAB SPRITAM Respiratory agents ACCUNEB AIRDUO AUVI-Q BECONASE AQ BEVESPI BROVANA DALIRESP KARBINAL ER MAXAIR NASONEX OMNARIS PERFOROMIST PROVENTIL HFA PULMICORT, FLEXHALER SUSP RYVENT SEEBRI NEOHALER STRIVERDI RESPIMAT TUDORZA PRESSAIR UTIBRON VERAMYST XOPENEX HFA ZETONNA Stimulants/ antiobesity/ anorexiants ADDERALL, XR ADZENYS XR APTENSIO XR CONCERTA DAYTRANA DESOXYN DEXEDRINE DYANAVEL XR EVEKEO FOCALIN, XR INTUNIV KAPVAY METADATE CD METHYLIN MYDAYIS PROCENTRA QUILLIVANT XR QUILLICHEW RITALIN, LA STRATTERA ZENZEDI zenzedi Topical products ATRALIN BENZEFOAM ULTRA CAPEX SHAMPOO CARAC CLOBEX SHAM CLODERM CORTIFOAM AER CUTIVATE DESONATE EFUDEX CREAM ELIDEL ERTACZO EUCRISA EXELDERM EXTINA FLUOROPLEX CREAM LOCOID LOCOID LIPOCREAM LOCORT LUXIQ LUZU MICORT-HC MIRVASO NAFTIN CREAM, GEL 2% NAFTIN GEL 1% OLUX OLUX-E OXISTAT CREAM, LOTION 1% PENNSAID PROCTOCORT CREAM PROCTOFOAM AER PROTOPIC RESCULA RETIN-A CREAM RETIN-A GEL RETIN-A MICR GEL RETIN-A MICR GEL PUMP RHOFADE RIAX SORILUX TACLONEX OINT TACROLIMUS OINT TOLAK CREAM TRETIN-X CREAM VERDESO XALATAN XOLEGEL GEL ZOVIRAX OINT
5 Medications on the drug coverage review lists are subject to change and may not be all-inclusive. For example, safety edits and specialty medications may require prior authorization and may be found on a separate list. Specific prescription plan designs may not cover certain categories or may be subject to additional restrictions, regardless of their appearance in this document. Prior authorization and step therapy programs are subject to state law restrictions and may not apply in all areas or for all plans. Step therapy does not apply to fully insured members in New Jersey. However, these programs are available to self-funded plans. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with Aetna. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. This material is for information only. Health benefits and health insurance plans contain exclusions and limitations. Information is believed to be accurate as of the production date; however, it is subject to change. If you have questions, see your plan materials or call Member Services. For more information about Aetna plans, refer to aetna.com. 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. Policy forms issued in Missouri include: Al HGrpPol 01R5, HI HGrpAg 01, HO HGrpPol Aetna Inc E (8/17) aetna.com
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Updates to your prescription benefits Effective Jan. 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
Generics. Lead with. Prescription Step Therapy Program
Lead with Generics Prescription Step Therapy Program WWW.BCBSLA.COM 04HQ3972 R11/10 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company GENERIC DRUGS: A
Data Class: Internal. 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption
To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a
2018 Step Therapy FID 18088
2018 Step Therapy FID 18088 Step Therapy ANTIDEPRESSANTS, SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS LEON 2018 Desvenlafaxine Er Fetzima Fetzima Titration Pack Khedezla Paxil SUSP Pristiq Trintellix
DRUG QUANTITY MANAGEMENT LIST (SUBECT TO CHANGE) MEDICATION (* = SPECIALTY DRUGS)
DRUG QUANTITY MANAGEMENT LIST (SUBECT TO CHANGE) MEDICATION (* = SPECIALTY DRUGS) MODULE ABSTRAL ACIPHEX SPRINKLE ACTIQ ACTONEL ACTOPLUS MET ACTOPLUS MET XR ACTOS ADCIRCA* PULMONARY HYPERTENSION ADLYXIN
Before a Step 2 medication is covered You get a prescription
Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
GA KS KY LA MD NJ NV NY TN TX WA Applicable X N/A N/A X N/A X X X X X X N/A N/A X *FHK- Florida Healthy Kids. ADHD Narcolepsy
Override(s) Prior Authorization ADHD Narcolepsy Approval Duration 1 year *Louisiana, Washington and Maryland Medicaid See State Specific Information Below Medications Atomoxetine: Strattera generic Clonidine
Subject: HPN/SHL COMMERCIAL PDL UPDATES EFFECTIVE JANUARY 1, 2018
Date: November 7, 2017 To: From: HPN/SHL Contracted Pharmacies and Providers Ryan Bitton, PharmD, MBA Senior Director, Pharmacy Subject: HPN/SHL COMMERCIAL PDL UPDATES EFFECTIVE JANUARY 1, 2018 Effective
PRESCRIPTION DRUG STEP THERAPY GUIDE
PRESCRIPTION DRUG STEP THERAPY GUIDE What is Step Therapy? Step therapy encourages safe and cost-effective medication use. Under our Step Therapy program, a step approach is required to receive coverage
Step Therapy Group Algorithm Steps
Step Therapy Group Algorithm Steps ACTONEL AMITIZA ANTICONVULSANT ANTIDEPRESSION Previous trial on alendronate Step 1: ALENDRONATE SODIUM Step 2: RISEDRONATE SODIUM, RISEDRONATE SODIUM DR Previous trial
True Health New Mexico List of Medications with Quantity Limits
True Health New Mexico List of Medications with Quantity Limits Specialty Medications Contact True Health New Mexico Pharmacy Services at 1-866- 341-8561 for quantity limits on specialty medications. Maximum
Prescription Step Therapy Program
Prescription Step Therapy Program 04HQ3972 R11/17 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross
Step Therapy Requirements. Effective: 11/01/2018
Effective: 11/01/2018 Updated 10/2018 ANTIDEPRESSANTS Sharp Health Plan (HMO) TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK
ADHD Medications Table
Stimulants are the first line treatment of choice for ADHD followed by Non-Stimulants, then off-label medications. We are providing this list of medications so that you can be familiar with the common
CVS Caremark Formulary Exclusions for PEBTF and non-medicare Eligible REHP Members
July 2017 CVS Caremark Formulary Exclusions for PEBTF and non-medicare Eligible REHP Members Below is a list of medicines by drug class that will not be covered without a prior authorization for medical