Aetna Better Health of Florida Supplemental Preferred Drug List
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- Isabella Noreen Johnston
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1 Aetna Better Health of Florida Medicaid
2 COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS OPHTHALMIC MEDICATIONS OTHER OPHTHALMIC DRUGS azelastine hcl epinastine hcl ZADITOR ketotifen fumarate AUTONOMIC AND CNS MEDICATIONS CNS STIMULANT DRUGS age < 6 requires PA ST: Use ketotifen first ST: Use ketotifen first methylphenidate CD capsules Metadate CD QL: #30 capsules/30 days ANTIINFECTIVES ANTIBIOTICS First-vancomycin suspension URINARY ANTISPASMODICS URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) tolterodine trospium trospium ER DERMATOLOGICALS CORTICOSTEROIDS - TOPICAL clobetasol propionate 0.5% sol, cream, gel, oint CHEMICALS BULK CHEMICALS Detrol Sanctura Sanctura XR hydroxyprogesterone caproate powder MISCELLANEOUS DURABLE MEDICAL EQUIPMENT Diabetic Supplies INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U-100 1/2 ML INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE/NEEDLE U-40 1 ML 25 X 5/8" INSULIN SYRINGE/NEEDLE U ML 29 G INSULIN SYRINGE/NEEDLE U ML 30 G INSULIN SYRINGE/NEEDLE U ML 28 X 1/2" INSULIN SYRINGE/NEEDLE U ML 29 X 1/2" INSULIN SYRINGE/NEEDLE U ML 30 X 3/8" INSULIN SYRINGE/NEEDLE U ML 30 X 5/16" INSULIN SYRINGE/NEEDLE U ML 30 X 1/2" QL: #60 gm/30 days ST: Use very high potency product first (Betamethasone Dip Aug Gel/Lotion/Ointment or Halobetasol Cream/Ointment)
3 INSULIN SYRINGE/NEEDLE U ML 30 X 7/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 27 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 G INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 7/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 G INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 3/8" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 7/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 29 X 1/2" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 5/16" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 30 X 1/2" INSULIN SYRINGE/NEEDLE U ML 25 X 5/8" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 3/8" INSULIN SYRINGE/NEEDLE U ML 31 X 3/8" INSULIN SYRINGE/NEEDLE U ML 31 X 15/64" INSULIN SYRINGE/NEEDLE U ML 25 X 1" INSULIN SYRINGE/NEEDLE U ML 26 X 1/2" INSULIN SYRINGE/NEEDLE U ML 27 X 1/2" INSULIN SYRINGE/NEEDLE U ML 27 X 5/8" INSULIN SYRINGE/NEEDLE U ML 28 X 5/16" INSULIN SYRINGE/NEEDLE U ML 28 X 1/2" INSULIN SYRINGE/NEEDLE U ML 29 G INSULIN SYRINGE/NEEDLE U ML 29 X 7/16" INSULIN SYRINGE/NEEDLE U ML 29 X 1/2" INSULIN SYRINGE/NEEDLE U ML 29 X 5/16" INSULIN SYRINGE/NEEDLE U ML 30 G INSULIN SYRINGE/NEEDLE U ML 30 X 5/16" INSULIN SYRINGE/NEEDLE U ML 30 X 7/16" INSULIN SYRINGE/NEEDLE U ML 30 X 1/2" INSULIN SYRINGE/NEEDLE U ML 31 X 5/16" INSULIN SYRINGE/NEEDLE U ML 31 X 5/16" INSULIN SYRINGE/NEEDLE U ML 31 X 3/8" INSULIN SYRINGE/NEEDLE U ML 27.5 X 5/8" INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 15/64" INSULIN SYRINGE/NEEDLE U ML 29 X 1/2" INSULIN SYRINGE/NEEDLE U ML 30 X 3/8" INSULIN SYRINGE/NEEDLE U ML 29 X 7/16" INSULIN SYRINGE/NEEDLE U ML 29 X 1" INSULIN SYRINGE/NEEDLE U ML 31 X 15/64" SYRINGE/NEEDLE (DISP) 1 ML 20 X 1" SYRINGE/NEEDLE (DISP) 1 ML 22 G X 1-1/2"
4 SYRINGE/NEEDLE (DISP) 1 ML 23 X 1" SYRINGE/NEEDLE (DISP) 1 ML 25 X 5/8" SYRINGE/NEEDLE (DISP) 1 ML 25 X 1" SYRINGE/NEEDLE (DISP) 1 ML 26 X 5/8" SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2" SYRINGE/NEEDLE (DISP) 1 ML 27 X 5/8" SYRINGE/NEEDLE (DISP) 1 ML 30 X 1/2" SYRINGE/NEEDLE (DISP) 6 ML 20 X 1" SYRINGE/NEEDLE (DISP) 6 ML 20 X 1-1/2" SYRINGE/NEEDLE (DISP) 6 ML 21 X 1" SYRINGE/NEEDLE (DISP) 6 ML 21 X 1-1/4" SYRINGE/NEEDLE (DISP) 6 ML 21 X 1-1/2" SYRINGE/NEEDLE (DISP) 6 ML 22 X 1" SYRINGE/NEEDLE (DISP) 6 ML 22 X 1-1/4" SYRINGE/NEEDLE (DISP) 6 ML 22 X 1-1/2" SYRINGE/NEEDLE (DISP) 6 ML 23 X 1" SYRINGE/NEEDLE (DISP) 12 ML 18 X 1" SYRINGE/NEEDLE (DISP) 12 ML 20 X 1" SYRINGE/NEEDLE (DISP) 12 ML 20 X 1-1/2" SYRINGE/NEEDLE (DISP) 12 ML 21 X 1" SYRINGE/NEEDLE (DISP) 12 ML 21 X 1-1/2" SYRINGE/NEEDLE (DISP) 12 ML 22 X 1" SYRINGE/NEEDLE (DISP) 12 ML 22 X 1-1/2" *BLOOD GLUCOSE CALIBRATION - LIQUID*** *BLOOD GLUCOSE CALIBRATION - LIQUID - HIGH*** *BLOOD GLUCOSE CALIBRATION - LIQUID - NORMAL*** *BLOOD GLUCOSE CALIBRATION - LIQUID - LOW*** *BLOOD GLUCOSE MONITORING MISC.*** *LANCETS*** *LANCET DEVICES*** *LANCETS MISC.*** *LANCETS KIT*** *ALCOHOL SWABS*** *ALCOHOL SHEETS*** ONETOUCH KIT VERIO IQ ONETOUCH TES VERIO QL: #200 strips/30 days ONETOUCH KIT VERIO ONETOUCH TES ULTRA BL QL: #200 strips/30 days ONETOUCH KIT ULT MINI ONETOUCH VER KIT SYNC ONETOUCH KIT ULTRA 2 ONETOUCH KIT ULTRALNK ONETOUCH MIS REMOTE ONE TCH SLVR KIT ULT MINI
5 ONE TOUCH KIT VERIO IQ RELION KETON TES KETOSTIX TES STRIP KETO-DIASTIX TES KETONE TEST TES KETOCARE TES BD PEN NEEDL MIS 32GX4MM BD PEN NEEDL MIS 31GX5/16 BD PEN NEEDL MIS 31GX3/16 BD ULTRA-FIN MIS 32GX6MM BD PEN NEEDL MIS 29GX1/2" AUTOSHIELD MIS 29X3/16" AUTOSHIELD MIS 29X5/16" AUTOSHIELD MIS 30GX3/16 INHALER ASSIST DEVICES (QL = #1 spacer/365 days) AEROCHAMBER MIS FLOSIGNA AEROCHAMBER MIS MV MICROCHAMBER MIS INSPIREASE MIS DD SYST AERCHMBR PLS MIS SM MASK AERCHMBR PLS MIS FLOW-VU AERCHMBR PLS MIS LRG MASK AEROCHAMBER MIS PLUS OPTIHALER MIS EASIVENT MIS EASIVENT MIS EASIVENT MIS MASK SM EASIVENT MIS MASK MED EASIVENT MIS MASK LG BREATHERITE MIS BREATHERITE MIS LG MASK BREATHERITE MIS MED MASK BREATHERITE MIS SM MASK BREATHERITE MIS BREATHERITE MIS LG MASK BREATHERITE MIS MED MASK BREATHERITE MIS SM MASK OPTIHALER MIS OPTIHALER MIS
6 OPTICHAMBER MIS ADVANTAG OPTICHAMBER MIS ADVANTAG OPTICHAMBER MIS ADV SM OPTICHAMBER MIS ADV MED OPTICHAMBER MIS ADV LRG OPTICHAMBER MIS FACE MAS OPTICHAMBER MIS FACE MAS OPTICHAMBER MIS FACE MAS POCKET SPACE MIS POCKET SPACE MIS POCKET SPACE MIS POCKET CHAMB MIS POCKET CHAMB MIS POCKET CHAMB MIS MICROSPACER MIS VORTEX VALVE MIS CHAMBER AERCHMBR PLS MIS MED MASK AERCHMBR PLS MIS SM MASK AEROCHAMBER MIS PLUS AEROCHAMBER MIS PLUS AERCHMBR PLS MIS LRG MASK E-Z SPACER MIS BODY GRD RITEFLO MIS LITEAIRE MIS WATCHHALER MIS E-Z SPACER MIS VALVD HOLDNG MIS CHAMBER AEROCHAMBER MIS CHAMBER OPTICHAMBER MIS DIA SM OPTICHAMBER MIS DIA MD OPTICHAMBER MIS DIA LG
7 ARIAL MIS CHAMBER OPTICHAMBER MIS DIA MD OPTICHAMBER MIS DIA LG VORTEX VALVE MIS CHAMBER INSPIRACHAMB MIS MOUTHPCE INSPIRACHAMB MIS SMALL INSPIRACHAMB MIS MEDIUM AEROVENT MIS PLUS AEROVENT MIS PLUS FLEXICHAMBER MIS INSPIRACHAMB MIS LARGE COMPACT SPAC MIS CHAMBER COMPACT SPAC MIS SM MASK COMPACT SPAC MIS MD MASK COMPACT SPAC MIS LG MASK HOLD CHAMBER MIS ADLT LG HOLD CHAMBER MIS MEDIUM HOLD CHAMBER MIS SMALL OTHER DME Normal Saline Flush QL: #150 syringes/30 days
PIN List. Product Name
PIN List 909661 ABDOMINAL PAD 907624 ACCU-CHEK MULTICLIX LANCETS 909670 ADHESIVE TAPE 900100 AEROCHAMBER 900200 AEROCHAMBER WITH MASK ADULT 900210 AEROCHAMBER WITH MASK CHILD 930610 AMES LANCETS 930116
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PIN List. Product Name
PIN List 909661 ABDOMINAL PAD 907622 ACCU-CHEK AVIVA BLOOD GLUCOSE TEST STRIPS 977999 ACCU-CHEK COMPACT BLOOD GLUCOSE TEST STRIPS 977993 ACCU-CHEK EASY BLOOD GLUCOSE TEST STRIPS 900418 ACCU-CHEK MOBILE
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