AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on July 1, 2017 ADAPALENE 0.1% CREAM ADAPALENE 0.1% GEL ATORVASTATIN 10 MG TABLET ATORVASTATIN 40 MG TABLET ATORVASTATIN 80 MG TABLET BLEPHAMIDE EYE DROPS BLEPHAMIDE EYE OINTMENT BRIMONIDINE TARTRATE 0.15% DRP CHOLESTYRAMINE LIGHT PACKET CHOLESTYRAMINE PACKET COLESTIPOL HCL GRANULES PACKET DILTIAZEM TABLET (all strengths) EPANED 1 MG/ML ORAL SOLUTION FENOFIBRATE 130 MG CAPSULE FENOFIBRATE 150 MG CAPSULE FENOFIBRATE 43 MG CAPSULE FENOFIBRATE 50 MG CAPSULE FENOFIBRIC ACID 105 MG TABLET FENOFIBRIC ACID 35 MG TABLET FLAREX 0.1% EYE DROPS FLUORIDE 0.25 MG TABLET CHEW FLUVASTATIN SODIUM 20 MG CAP FLUVASTATIN SODIUM 40 MG CAP FML FORTE 0.25% EYE DROPS FML S.O.P. 0.1% OINTMENT HYDROCHLOROTHIAZIDE 12.5 MG CP HYDROCHLOROTHIAZIDE 25 MG TAB HYDROCHLOROTHIAZIDE 50 MG TAB INVOKAMET XR 150-1,000 MG TAB INVOKAMET XR 150-500 MG TABLET INVOKAMET XR 50-1,000 MG TAB INVOKAMET XR 50-500 MG TABLET LONSURF 15 MG-6.14 MG TABLET LONSURF 20 MG-8.19 MG TABLET Update Type Change ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit Removed Quantity Limit ed to Formulary with Age Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit Removed Quantity Limit Removed Quantity Limit Removed Quantity Limit ed to Formulary with Step Therapy ed to Formulary with Step Therapy ed to Formulary with Step Therapy ed to Formulary with Step Therapy ed to Formulary with Prior Authorization ed to Formulary with Prior Authorization
LUDENT FLUORIDE 0.5 MG TB CHEW LUDENT FLUORIDE 1 MG TAB CHEW MEPHYTON 5 MG TABLET NIACIN 100 MG TABLET NIACIN 250 MG TABLET NIACIN 50 MG TABLET NIACIN 500 MG CAPSULE SA NIACIN ER 1,000 MG TABLET NIACIN ER 1,000 MG TABLET NIACIN ER 500 MG TABLET NIACIN ER 750 MG TABLET NIACIN FLUSH FREE 750 MG CAP NIACIN FLUSH-FREE 500 MG CAP NIACIN TR 250 MG CAPSULE NIACIN TR 500 MG CAPLET NIACINAMIDE 100 MG TABLET NIACINAMIDE ER 500 MG TABLET NO FLUSH NIACIN 400 MG CAP OMEPRAZOLE DR 20 MG TABLET OTEZLA 30 MG TABLET OTEZLA STARTER PACK POTASSIUM CL 10% (20 MEQ/15 ML POTASSIUM CL 20 MEQ PACKET POTASSIUM CL 20% (40 MEQ/15 ML PRED MILD 0.12% EYE DROPS PV NIACIN 500 MG TABLET ROSUVASTATIN CALCIUM 10 MG TAB ROSUVASTATIN CALCIUM 20 MG TAB ROSUVASTATIN CALCIUM 40 MG TAB ROSUVASTATIN CALCIUM 5 MG TAB SIMVASTATIN 40 MG TABLET SLO-NIACIN 250 MG TABLET SLO-NIACIN 750 MG TABLET SOTALOL AF 120 MG TABLET SOTALOL AF 160 MG TABLET SOTALOL AF 80 MG TABLET TIMOLOL 0.25% GEL-SOLUTION TIMOLOL 0.5% GFS GEL-SOLUTION TOBRADEX EYE OINTMENT Update Type ed Quantity Limit ed Quantity Limit ed to Formulary with Quantity Limit ed to Formulary ed to Formulary ed to Formulary ed to Formulary ed to Formulary ed to Formulary ed to Formulary ed to Formulary ed to Formulary ed to Formulary ed to Formulary ed to Formulary ed with Prior Authorization ed with Prior Authorization Removed from Formulary Removed from Formulary Removed from Formulary Removed from Formulary ed to Formulary ed with Quantity Limits ed with Quantity Limits ed with Quantity Limits ed with Quantity Limits ed Quantity Limit ed to Formulary ed to Formulary ed Quantity Limit ed Quantity Limit ed Quantity Limit
TRAVOPROST 0.004% EYE DROP TRETINOIN 0.01% GEL TRETINOIN 0.025% CREAM TRETINOIN 0.025% GEL TRETINOIN 0.05% CREAM TRETINOIN 0.1% CREAM VALSARTAN 160 MG TABLET VALSARTAN 320 MG TABLET VALSARTAN 40 MG TABLET VALSARTAN 80 MG TABLET VALSARTAN-HCTZ 160-12.5 MG TAB VALSARTAN-HCTZ 160-25 MG TAB VALSARTAN-HCTZ 320-12.5 MG TAB VALSARTAN-HCTZ 320-25 MG TAB VALSARTAN-HCTZ 80-12.5 MG TAB VIGAMOX 0.5% EYE DROPS Update Type ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit ed Quantity Limit The following updates will be made to the Aetna Better Health of MI formulary on April 1, 2017 ACETAMINOPHEN 160 MG/5 ML ELX ACETAMINOPHEN 80 MG RAPID TAB ACETAZOLAMIDE 125 MG TABLET ACETAZOLAMIDE 250 MG TABLET ACETAZOLAMIDE ER 500 MG CAP AMMONIUM LACTATE 12% CREAM AMMONIUM LACTATE 12% LOTION ARTIFICIAL TEAR OPHTH OINT CALCIPOTRIENE 0.005% CREAM CARBOXYMETHYLCELLULOSE 0.5% OPHTH Sol CHLORHEXIDINE 0.12% RINSE COLCHICINE 0.6 MG CAPSULE EPINEPHRINE SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML EPIPEN JR 2-PAK 0.15 MG INJCTR ETODOLAC 200 MG CAPSULE ETODOLAC 300 MG CAPSULE Update to formulary with cumulative acetaminophen edit of 4 gms/day to formulary with cumulative acetaminophen edit of 4 gms/day Quantity limit added Quantity limit added Quantity limit added Quantity limit removed Quantity limit removed Quantity limit removed to formulary with QUANTITY LIMIT ed to formulary with QUANTITY LIMIT to formulary with QUANTITY LIMIT
ETODOLAC 400 MG TABLET ETODOLAC 500 MG TABLET FLURBIPROFEN 100 MG TABLET GLUCOTEN CAPLET JENTADUETO TAB XR 5-1000 MG JENTADUETO TAB XR 2.5-1000 MG LIOTHYRONINE SOD 25 MCG TAB LIOTHYRONINE SOD 50 MCG TAB L-METHYLFOLATE-METHYLCOBALAMIN- ACETYLCYST TAB 6-2-600 L-METHYLFOLATE-METHYLCOBALAMIN- ACETYLCYST TAB 6-2-600 MACUVITE WITH LUTEIN TABLET MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML METHAZOLAMIDE 25 MG TABLET METHAZOLAMIDE 50 MG TABLET MG-PLUS TAB PROTEIN NAPROXEN 125 MG/5 ML SUSPEN OCUVITE LUTEIN & ZEAXANTHIN CP PEAK FLOW METER Pediatric MVI with minerals and vitamin C Pediatric MVI with minerals and vitamin C PILOCARPINE HCL 7.5 MG TABLET PIROXICAM CAPSULE POLYETHYLENE GLYCOL PROPYLENE GLYCOL 0.4-0.3% POLYVINYL ALCOHOL 1.4% OPHTH Sol PRENATAL TABLET PRENATAL VIT & MIN W/ FA-FISH OIL CHEW TAB 0.4-113.5 MG Prenatal Vit w/ DSS-Fe Fumarate-FA 29-1mg PRESERVISION AREDS 2 SOFTGEL PROSIGHT TABLET RANEXA to formulary with QUANTITY LIMIT to formulary with QUANTITY LIMIT to formulary with STEP THERAPY and QUANTITY LIMIT to formulary with STEP THERAPY and QUANTITY LIMIT, covered for CSHCS members, covered for CSHCS members Quantity limit changed to 1 ml per 75 days, covered for CSHCS members to formulary with QUANTITY LIMIT, covered for CSHCS members, covered for CSHCS members Quantity limit added to formulary with age limits and QUANTITY LIMIT Prior Authorization added
SODIUM CHLORIDE 5% EYE DROP SODIUM CHLORIDE 5% OPHTH OINT SODIUM FLUORIDE GEL 1.1% TRI-VI-SOL DROPS ULORIC 80 MG TABLET Vitamin D3 Chew 5000 units Remove age restrictions to formulary with QUANTITY LIMIT to formulary with QUANTITY LIMIT to formulary with QUANTITY LIMIT to formulary with QUANTITY LIMIT to formulary with QUANTITY LIMIT to formulary with QUANTITY LIMIT Quantity limit added ed to formulary The following updates will be made to the Aetna Better Health of MI formulary on March 1, 2017 ALFUZOSIN HCL ER 10 MG TABLET DOCU LIQUID 50 MG/5 ML MAGNESIUM CITRATE SOLUTION METHOTREXATE 25 MG/ML VIAL METHOTREXATE 50 MG/2 ML VIAL METRONIDAZOLE TOPICAL 0.75% GL OXYTROL FOR WOMEN 3.9 MG/24HR SELENIUM SULFIDE 2.25% SHAMPOO SOD SULFACET-SULFUR 10-5% CLSR BETAMETHASONE DP 0.05% LOT BETAMETHASONE DP 0.05% OINT FLUTICASONE PROP 0.005% OINT FLUTICASONE PROP 0.05% CREAM MOMETASONE FUROATE 0.1% OINT PANCREAZE DR 2,600 UNIT CAP TRADJENTA 5 MG TABLET PANCREAZE DR 10,500 UNIT CAP ZENPEP DR 15,000 UNITS CAPSULE PANCREAZE DR 16,800 UNIT CAP ZENPEP DR 20,000 UNITS CAPSULE PANCREAZE DR 21,000 UNIT CAP CREON DR 12,000 UNITS CAPSULE to formulary with quantity limit to formulary with quantity limit to formulary with quantity limit to formulary with quantity limit to formulary with quantity limit to formulary with quantity limit
CREON DR 24,000 UNITS CAPSULE CREON DR 36,000 UNITS CAPSULE ZENPEP DR 25,000 UNITS CAPSULE JENTADUETO 2.5 MG-500 MG TAB JENTADUETO 2.5 MG-850 MG TAB JENTADUETO 2.5 MG-1000 MG TAB ZENPEP DR 3,000 UNITS CAPSULE PANCREAZE DR 4,200 UNIT CAP ZENPEP DR 5,000 UNITS CAPSULE CREON DR 3,000 UNITS CAPSULE CREON DR 6,000 UNITS CAPSULE ZENPEP DR 10,000 UNITS CAPSULE ALOGLIPTIN-PIOGLIT 12.5-15 MG ALOGLIPTIN-PIOGLIT 12.5-30 MG ALOGLIPTIN-PIOGLIT 12.5-45 MG ALOGLIPTIN-PIOGLIT 25-15 MG TB ALOGLIPTIN-PIOGLIT 25-30 MG TB ALOGLIPTIN-PIOGLIT 25-45 MG TB MOMETASONE FUROATE 0.1% CREAM ONDANSETRON 4 MG/5 ML SOLUTION PROCHLORPERAZINE 10 MG TAB PROCHLORPERAZINE 5 MG TABLET BISACODYL 10 MG SUPPOS BISACODYL EC 5 MG TABLET CHLORPROPAMIDE 100 MG TABLET CHLORPROPAMIDE 250 MG TABLET GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE 2 MG TABLET GLIMEPIRIDE 4 MG TABLET GLIPIZIDE 10 MG TABLET GLIPIZIDE 5 MG TABLET GLIPIZIDE XL 10 MG TABLET GLIPIZIDE XL 2.5 MG TABLET GLIPIZIDE XL 5 MG TABLET GLUCAGEN 1 MG HYPOKIT GLYBURIDE 1.25 MG TABLET GLYBURIDE 2.5 MG TABLET GLYBURIDE 5 MG TABLET GLYBURIDE MICRO 1.5 MG TAB GLYBURIDE MICRO 3 MG TABLET
GLYBURIDE MICRO 6 MG TABLET GLYBURIDE-METFORMIN 2.5-500 MG GLYBURIDE-METFORMIN 5-500 MG ERYTHROMYCIN-BENZOYL GEL Removed from Formulary The following updates will be made to the Aetna Better Health of MI formulary on February 1, 2017 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 Age Limit Removed Age Limit Removed Age Limit Removed and Age Limit Removed Quantity Limit Change
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 ALOGLIPTIN-PIOGLIT 25-15 MG TB ALOGLIPTIN-PIOGLIT 25-30 MG TB Update Over the counter item added.
Drug Name 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 Update Quantity limit removed. Remove age edit.
Drug Name 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 Update ed to formulary. ed to formulary. ed to formulary. ed to formulary. ed to formulary. Quantity limit removed. Quantity limit removed. ed to formulary.
Drug Name 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 Update ed to formulary. Formulary addition with quantity limit. ed to formulary. The complete Aetna Better Health of MI formulary is available here. Please call with any questions.