AETNA BETTER HEALTH January 2017 Formulary Change(s) 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 120-12 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 with Age Limit with Age Limit with PA with PA with Quantity Limit with Quantity Limit Quantity Limit ed and Quantity Limit Change Quantity Limit Removed
Drug Name, Strength, Dosage Form CHILD CETIRIZINE 5 MG CHEW TAB DOXYCYCLINE MONO 150 MG CAP DOXYCYCLINE MONO 75 MG CAPSULE E.E.S. 200 MG/5 ML GRANULES ERYTHROMYCIN DR 250 MG CAP ERYTHROMYCIN ES 400 MG TAB ERYTHROMYCIN FILMTAB (all strengths) MICONAZOLE 3 200 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 12.5-1000 ALOGLIPTIN-METFORMIN 12.5-500 ALOGLIPTIN-PIOGLIT 12.5-15 MG ALOGLIPTIN-PIOGLIT 12.5-30 MG ALOGLIPTIN-PIOGLIT 12.5-45 MG Update Over the counter item added.
ALOGLIPTIN-PIOGLIT 25-15 MG TB ALOGLIPTIN-PIOGLIT 25-30 MG TB ALOGLIPTIN-PIOGLIT 25-45 MG TB AMANTADINE 100 MG/10 ML SOLN APIDRA SOLOSTAR 100 UNITS/ML APRACLONIDINE HCL 0.5% DROPS ASPIR EC 81 MG TABLET 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 Remove age edit.
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 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 50-50 KWIKPEN HUMALOG MIX 75-25 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 70-30 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 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. The complete Aetna Better Health of MI formulary is available here. Please call with any questions.