Aetna Better Health FIDA Plan
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1 Aetna Better Health FIDA Plan May 2016 Formulary Updates ASCOMP/COD - QL; PA FYAVOLV 5MCG; 1MG- PA METOPROLOL TABS 37.5MG, 75MG CIPRODEX LETAIRIS - QL; PA OFEV - QL; PA OTREXUP - ST PRALUENT - QL; PA RASUVO - ST REPATHA - QL; PA REPATHA SURECLICK - QL; PA VP-HEME ONE VRAYLAR CAPS - QL; ST VRAYLAR PACK - QL; ST Prior Authorization Updates HARVONI-Criteria Revised SOVALDI- Criteria Revised OPDIVO - Criteria Revised
2 April 2016 Formulary Updates FLUOR-A-DAY SOLN FLUORITAB SOLN IMATINIB MESYLATE TABS 100MG - QL; PA IMATINIB MESYLATE TABS 400MG - QL; PA KAITLIB FE VIENVA EDARBI; QL EDARBYCLOR; QL Prior Authorization Updates ARISTADA PA removed EVZIO- PA removed MODERIBA TABS - PA removed NARCAN- PA removed RIBAVIRIN- PA removed TESTOSTERONE CYPIONATE INJ- PA removed TESTOSTERONE ENANTHATE INJ- PA removed Quantity Limit Removed INVEGA SUSTENNA-QL removed ELIQUIS TABS 5 MG; QL 74/30 days REXULTI
3 March 2016 Formulary Updates BEKYREE NORGESTIMATE/ETHINYL ESTRADIOL TRI-LO-ESTARYLLA TRI-LO-SPRINTEC TRINESSA LO ALECENSA; QL; PA BENDEKA ENTRESTO; QL; PA ENVARSUS XR; PA FERRIPROX SOLN 100MG/ML; PA IRESSA; QL; PA NARCAN; PA PORTRAZZA; PA PRADAXA CAPS 110MG; QL STRIVERDI RESPIMAT; QL TRESIBA FLEXTOUCH ULORIC TABS; ST Prior Authorizations Updates
4 February 2016 Formulary Updates ALA CORT CREA 1% ARIPIPRAZOLE ODT TBDP 10MG; QL ARIPIPRAZOLE ODT TBDP 15MG; QL BLISOVI 24 FE TABS 20MCG; 75MG; 1MG BLISOVI FE 1/20 TABS 20MCG; 75MG; 1MG BUDESONIDE SUSP 1MG/2ML; PA CEFAZOLIN CEFTRIAXONE SODIUM INJ 100GM DUTASTERIDE/TAMSULOSIN HYDROCHLORIDE CAPS 0.5MG; 0.4MG; QL FLORIVA CHEW LINEZOLID SUSR 100MG/5ML; QL; PA MICROGESTIN 24 FE MOLINDONE HYDROCHLORIDE TABS 10MG; QL MOLINDONE HYDROCHLORIDE TABS 25MG; QL MOLINDONE HYDROCHLORIDE TABS 5MG; QL OLOPATADINE SOLN 0.1% REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS 500MG; 1MG; QL REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS 500MG; 2MG; QL SPS COTELLIC TABS 20MG; QL; PA DARZALEX SOLN; PA EMPLICITI SOLR; PA FERRIPROX TABS 500MG; PA GENVOYA TABS 150MG; 150MG; 200MG; 10MG; QL GLEOSTINE CAPS 5MG NINLARO CAPS 2.3MG; QL; PA NINLARO CAPS 3MG; QL; PA NINLARO CAPS 4MG; QL; PA OB COMPLETE GOLD PREFERA OB TABS TAGRISSO TABS 40MG; QL; PA TAGRISSO TABS 80MG; QL; PA VITAFOL FE
5 Prior Authorizations Updates ONDANSETRON ODT TBDP 4MG- PA removed DIAZEPAM TABS 10MG- PA removed DIAZEPAM TABS 2MG- PA removed DIAZEPAM TABS 5MG- PA removed ONDANSETRON HCL TABS 4MG- PA removed DIAZEPAM SOLN 1MG/ML- PA removed ONDANSETRON HCL TABS 24MG- PA removed ONDANSETRON HCL SOLN 4MG/5ML- PA removed ONDANSETRON HCL TABS 8MG- PA removed ONDANSETRON ODT TBDP 8MG- PA removed INVEGA TRINZA-QL removed ANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH- ST removed AURYXIA TABS 210MG- ST removed BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" MISC- ST removed BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" MISC- ST removed BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" MISC - ST removed ADVAIR DISKUS AEPB 100MCG/DOSE; 50MCG/DOSE- ST removed ADVAIR DISKUS AEPB 250MCG/DOSE; 50MCG/DOSE- ST removed ADVAIR DISKUS AEPB 500MCG/DOSE; 50MCG/DOSE- ST removed ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT- ST removed ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT- ST removed ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT- ST removed
August 2016 Formulary Updates
August 2016 Formulary Updates DOXYCYCLINE HYCLATE TABS DR 50MG, 200MG NALOXONE HCL INJ 0.4MG/ML VANCOMYCIN HCL INJ 500MG, 750MG BRIVIACT INJ - PA BRIVIACT ORAL SOLN - QL; PA BRIVIACT TABS - QL; PA LENVIMA
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December 2016 Formulary Updates ABACAVIR/LAMIVUDINE AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-20MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-40MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 5-20MG QL AMLODIPINE/OLMESARTAN
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November 2016 Formulary Updates DAPTOMYCIN LARISSIA NITROGLYCERIN SUBL ORFADIN 20MG CAP PA RELISTOR 150MG TAB PA; QL Over-the-Counter (OTC) Drugs Added* COLEMAN SKINSMART INSECT REP CUTTER BACKWOODS AERO
December 2016 Formulary Updates
December 2016 Formulary Updates ABACAVIR/LAMIVUDINE AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-20MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 10-40MG QL AMLODIPINE/OLMESARTAN MEDOXOMIL TAB 5-20MG QL AMLODIPINE/OLMESARTAN
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Medicare Part D 2016 Formulary Changes Service To Senior and OC Preferred
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ANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET BANZEL 200 MG TABLET BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG TABLET FYCOMPA 0.5 MG/ML ORAL SUSPENSION
2019 Formulary (List of Covered Drugs)
Health Net Seniority Plus Employer (HMO) 09 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID