Post on 02-Oct-2020
AETNA BETTER HEALTH® Formulary Guide
Aetna Better Health of Michigan
Formulary Guide October 2015
http://www.aetnabetterhealth.com/michigan
AETNA BETTER HEALTH® Formulary Guide
What is the Aetna Better Health of Michigan Formulary?
This is a drug list created by Aetna Better Health (“plan”). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy.
Can the Plan’s Drug List change?
The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website.
How do I use the Plan’s Formulary?
Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug).
Column #2: shows coverage rules for the drug
Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, “Ear-Nose-Throat Medications.” If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug.
What are generic drugs?
The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA).
Are Over-The-Counter (OTC) drugs covered?
The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan.
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Are there Medication Copays?
Copays for brand drugs are $0 and copays for generic drugs are $0.
What are some types of coverage rules?
Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.
Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs.
Step Therapy (ST): This means you may need to try certain drugs first to treat your condition.
After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered.
What if my drug is not on the plan’s Formulary?
First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then:
Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval
process.
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Drug Requirements
*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*
*Analeptics**-*Analeptics*** Caffeine Anhydrous
Caffeine Citrate
Caffeine Citrated
*Amebicides*
*Amebicides**-*Amebicides*** YODOXIN
*Aminoglycosides*
*Aminoglycosides**-*Aminoglycosides*** Neomycin Sulfate
Paromomycin Sulfate
Tobramycin
*Analgesics - Anti-Inflammatory*
*Antirheumatic Antimetabolites**-*Antirheumatic Antimetabolites*** RHEUMATREX
*Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PA
HUMIRA PEDIATRIC CROHNS START
HUMIRA PEN PA
HUMIRA PEN-CROHNS STARTER
HUMIRA PEN-PSORIASIS STARTER
*Gold Compounds**-*Gold Compounds*** RIDAURA
*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors*** Celecoxib ST
*Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** Diclofenac Potassium
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Drug Requirements Diclofenac Sodium
Diclofenac Sodium ER
Etodolac
Etodolac ER
Fenoprofen Calcium
Flurbiprofen
Ibuprofen
Indomethacin
Indomethacin ER
Ketoprofen
Ketorolac Tromethamine QLL (20 per 30 days)
Meclofenamate Sodium
Meloxicam
Nabumetone
Naproxen
Naproxen DR
Naproxen Kit
Naproxen Sodium
Oxaprozin
Piroxicam
Sulindac
Tolmetin Sodium
*Pyrimidine Synthesis Inhibitors**-*Pyrimidine Synthesis Inhibitors*** Leflunomide
*Soluble Tumor Necrosis Factor Receptor Agents**-*Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL PA
ENBREL SURECLICK PA
*Analgesics - Nonnarcotic*
*Analgesic Combinations**-*Analgesics-Sedatives*** Butalbital-APAP-Caffeine ORAL CAPSULE
Butalbital-APAP-Caffeine ORAL TABLET QLL (180 per 30 days)
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Drug Requirements Butalbital-Aspirin-Caffeine QLL (180 per 30 days)
CAPACET (Butalbital-APAP-Caffeine)
ESGIC (Butalbital-APAP-Caffeine)
Margesic QLL (180 per 30 days)
Marten-Tab
TENCON (Butalbital-Acetaminophen)
ZEBUTAL (Butalbital-APAP-Caffeine)
*Salicylates**-*Salicylate Combinations*** Choline & Mag Trisalicylate
Choline-Mag Trisalicylate
*Salicylates**-*Salicylates*** Diflunisal
Salsalate
*Analgesics - Opioid*
*Opioid Agonists**-*Opioid Agonists*** Codeine Sulfate QLL (30 per 30 days)
FentaNYL QLL (10 per 30 days)
FentaNYL Citrate QLL (90 per 30 days)
HYDROmorphone HCl
HYDROmorphone HCl ORAL TABLET 2 MG
HYDROmorphone HCl ORAL TABLET 4 MG QLL (180 per 30 days)
HYDROmorphone HCl ORAL TABLET 8 MG QLL (120 per 30 days)
METHADONE HCL INTENSOL
Methadone HCl ORAL CONCENTRATE
Methadone HCl ORAL SOLUTION
Methadone HCl ORAL TABLET QLL (240 per 30 days)
Methadone HCl ORAL TABLET SOLUBLE QLL (240 per 30 days)
METHADOSE
Morphine Sulfate
Morphine Sulfate (Concentrate)
Morphine Sulfate ER QLL (60 per 30 days)
Morphine Sulfate ORAL SOLUTION
Morphine Sulfate ORAL TABLET QLL (60 per 30 days)
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Drug Requirements OxyCODONE HCl ORAL CAPSULE QLL (240 per 30 days)
OxyCODONE HCl ORAL CONCENTRATE
OxyCODONE HCl ORAL SOLUTION
OxyCODONE HCl ORAL TABLET 10 MG, 15 MG, 20 MG, 30 MG QLL (180 per 30 days)
OxyCODONE HCl ORAL TABLET 5 MG QLL (240 per 30 days)
Oxymorphone HCl
Oxymorphone HCl ER ST; QLL (60 per 30 days)
TraMADol HCl QLL (240 per 30 days)
*Opioid Combinations**-*Codeine Combinations*** Acetaminophen-Codeine
Acetaminophen-Codeine #2
Acetaminophen-Codeine #3
Acetaminophen-Codeine #4
ASCOMP-CODEINE
Butalbital-APAP-Caff-Cod ORAL CAPSULE 50-300-40-30 MG
Butalbital-APAP-Caff-Cod ORAL CAPSULE 50-325-40-30 MG QLL (180 per 30 days)
Butalbital-ASA-Caff-Codeine QLL (180 per 30 days)
*Opioid Combinations**-*Hydrocodone Combinations*** Hydrocodone-Ibuprofen QLL (240 per 30 days)
IBUDONE QLL (240 per 30 days)
LORCET (Hydrocodone-Acetaminophen)
LORCET HD (Hydrocodone-Acetaminophen)
LORCET PLUS (Hydrocodone-Acetaminophen)
LORTAB (Hydrocodone-Acetaminophen)
VERDROCET (Hydrocodone-Acetaminophen)
*Opioid Combinations**-*Opioid Combinations*** ENDOCET (Oxycodone-Acetaminophen)
ENDODAN
Oxycodone-Aspirin QLL (240 per 30 days)
ROXICET (Oxycodone-Acetaminophen)
*Opioid Combinations**-*Tramadol Combinations*** Tramadol-Acetaminophen QLL (240 per 30 days)
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Drug Requirements
*Opioid Partial Agonists**-*Opioid Partial Agonists*** Butorphanol Tartrate QLL (1 per 30 days)
Pentazocine-Naloxone HCl
*Androgens-Anabolic*
*Androgens**-*Androgens*** ANDRODERM
ANDROGEL
ANDROGEL PUMP
ANDROID
Danazol
Testosterone
Testosterone Cypionate
*Anorectal Agents*
*Intrarectal Steroids**-*Intrarectal Steroids*** COLOCORT (Hydrocortisone)
CORTIFOAM
*Rectal Combinations**-*Rectal Anesthetic/Steroids*** LIDAZONE HC (Lidocaine-Hydrocortisone Ace)
PROCTOFOAM HC
*Rectal Steroids**-*Rectal Steroids*** Hydrocortisone Acetate
PROCTO-PAK
PROCTOSOL HC
PROCTOZONE-HC
*Antacids*
*Antacids - Bicarbonate**-*Antacids - Bicarbonate*** Sodium Bicarbonate
*Anthelmintics*
*Anthelmintics**-*Anthelmintics*** ALBENZA
Ivermectin
*Antianginal Agents*
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Drug Requirements
*Nitrates**-*Nitrates*** Isosorbide Dinitrate
Isosorbide Dinitrate ER
Isosorbide Mononitrate
Isosorbide Mononitrate ER
MINITRAN (Nitroglycerin)
NITRO-BID
Nitroglycerin
NITROSTAT
NITRO-TIME (Nitroglycerin ER)
*Antianxiety Agents*
*Antianxiety Agents - Misc.**-*Antianxiety Agents - Misc.*** HydrOXYzine HCl
HydrOXYzine Pamoate
*Antiarrhythmics*
*Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A*** Disopyramide Phosphate
QuiNIDine Gluconate ER
QuiNIDine Sulfate
QuiNIDine Sulfate ER
*Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B*** Mexiletine HCl
*Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C*** Flecainide Acetate
Propafenone HCl
*Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii*** MULTAQ
PACERONE (Amiodarone HCl)
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Drug Requirements
*Antiasthmatic And Bronchodilator Agents*
*Anti-Inflammatory Agents**-*Anti-Inflammatory Agents*** Cromolyn Sodium
*Bronchodilators - Anticholinergics**-*Bronchodilators -Anticholinergics*** ATROVENT HFA
Ipratropium Bromide
SPIRIVA HANDIHALER ST; QLL (30 per 30 days)
SPIRIVA RESPIMAT
TUDORZA PRESSAIR
*Leukotriene Modulators**-*Leukotriene Receptor Antagonists*** Montelukast Sodium QLL (30 per 30 days)
Zafirlukast QLL (60 per 30 days)
*Steroid Inhalants**-*Steroid Inhalants*** Budesonide QLL (120 per 30 days)
FLOVENT DISKUS
FLOVENT HFA
PULMICORT
PULMICORT FLEXHALER QLL (1 per 30 days)
QVAR
*Sympathomimetics**-*Adrenergic Combinations*** ADVAIR DISKUS
ADVAIR HFA
COMBIVENT RESPIMAT
DULERA
Ipratropium-Albuterol
SYMBICORT
*Sympathomimetics**-*Beta Adrenergics*** Albuterol Sulfate ER
Albuterol Sulfate INHALATION QLL (13 per 1 day)
Albuterol Sulfate ORAL
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Drug Requirements Levalbuterol HCl
Metaproterenol Sulfate
PROAIR HFA
PROVENTIL HFA
SEREVENT DISKUS
Terbutaline Sulfate
VENTOLIN HFA
*Xanthines**-*Xanthines*** THEOCHRON (Theophylline ER)
Theophylline
*Anticoagulants*
*Coumarin Anticoagulants**-*Coumarin Anticoagulants*** JANTOVEN (Warfarin Sodium)
*Heparins And Heparinoid-Like Agents**-*Heparins And Heparinoid-Like Agents*** Heparin Sodium (Porcine)
Heparin Sodium (Porcine) PF
*Heparins And Heparinoid-Like Agents**-*Low Molecular Weight Heparins*** Enoxaparin Sodium INJECTION
Enoxaparin Sodium SUBCUTANEOUS* QLL (20 per 10 days)
FRAGMIN QLL (10 per 10 days)
*Heparins And Heparinoid-Like Agents**-*Synthetic Heparinoid-Like Agents*** Fondaparinux Sodium
*Antidiabetics*
*Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors*** Acarbose
*Antidiabetic Combinations**-*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ST
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Drug Requirements JANUMET XR ST
*Antidiabetic Combinations**-*Meglitinide-Biguanide Combinations*** PRANDIMET
*Antidiabetic Combinations**-*Sulfonylurea-Biguanide Combinations*** GlipiZIDE-MetFORMIN HCl
GlyBURIDE-MetFORMIN
*Antidiabetic Combinations**-*Sulfonylurea-Thiazolidinedione Combinations*** Pioglitazone HCl-Glimepiride QLL (30 per 30 days)
*Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations*** AVANDAMET QLL (60 per 30 days)
Pioglitazone HCl-Metformin HCl QLL (90 per 30 days)
*Biguanides**-*Biguanides*** MetFORMIN HCl
MetFORMIN HCl ER
*Diabetic Other**-*Diabetic Other*** GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY
*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors**-*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** JANUVIA ST
*Incretin Mimetic Agents (Glp-1 Receptor Agonists)**-*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYETTA 10 MCG PEN ST
BYETTA 5 MCG PEN ST
*Insulin Sensitizing Agents**-*Thiazolidinediones*** AVANDIA QLL (30 per 30 days)
Pioglitazone HCl QLL (30 per 30 days)
*Insulin**-*Human Insulin*** HUMALOG
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Drug Requirements HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMULIN R U-500 (CONCENTRATED)
LANTUS
LEVEMIR
NOVOLOG
NOVOLOG MIX 70/30
*Meglitinide Analogues**-*Meglitinide Analogues*** Nateglinide
Repaglinide
*Sulfonylureas**-*Sulfonylureas*** ChlorproPAMIDE
Glimepiride
GlipiZIDE
GLIPIZIDE XL (GlipiZIDE ER)
GlyBURIDE
GlyBURIDE Micronized
TOLAZamide
TOLBUTamide
*Antidiarrheals*
*Antiperistaltic Agents**-*Antiperistaltic Agents*** Lofene
LONOX (Diphenoxylate-Atropine)
Loperamide HCl
Opium Tincture (Paregoric)
*Antidotes*
*Antidotes - Chelating Agents**-*Antidotes - Chelating Agents*** CHEMET
*Opioid Antagonists**-*Opioid Antagonists*** Naltrexone HCl
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Drug Requirements
*Antiemetics*
*5-Ht3 Receptor Antagonists**-*5-Ht3 Receptor Antagonists*** Granisetron HCl
Ondansetron
Ondansetron HCl
*Antiemetics - Anticholinergic**-*Antiemetics -Anticholinergic*** Meclizine HCl
Trimethobenzamide HCl
*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists**-*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND
*Antifungals*
*Antifungals**-*Antifungals*** Bio-Statin
Griseofulvin Microsize
Griseofulvin Ultramicrosize
Nystatin
Terbinafine HCl QLL (84 per 1 Year)
*Imidazole-Related Antifungals**-*Imidazoles*** Ketoconazole
*Imidazole-Related Antifungals**-*Triazoles*** Fluconazole
Itraconazole
SPORANOX
*Antihistamines*
*Antihistamines - Alkylamines**-*Antihistamines - Alkylamines*** Brompheniramine Tannate
*Antihistamines - Ethanolamines**-*Antihistamines -Ethanolamines***
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Drug Requirements ARBINOXA (Carbinoxamine Maleate)
Clemastine Fumarate
DiphenhydrAMINE HCl
Pharbedryl
*Antihistamines - Non-Sedating**-*Antihistamines - Non-Sedating*** Cetirizine HCl
Fexofenadine HCl
*Antihistamines - Phenothiazines**-*Antihistamines - Phenothiazines*** PHENADOZ (Promethazine HCl)
PHENERGAN (Promethazine HCl)
Promethazine HCl
PROMETHEGAN (Promethazine HCl)
*Antihistamines - Piperidines**-*Antihistamines -Piperidines*** Cyproheptadine HCl
*Antihyperlipidemics*
*Bile Acid Sequestrants**-*Bile Acid Sequestrants*** Cholestyramine
Colestipol HCl
Micronized Colestipol HCl
PREVALITE (Cholestyramine Light)
*Fibric Acid Derivatives**-*Fibric Acid Derivatives*** Fenofibrate
Fenofibrate Micronized
Fenofibric Acid
Gemfibrozil QLL (60 per 30 days)
*Hmg Coa Reductase Inhibitors**-*Hmg Coa Reductase Inhibitors*** Atorvastatin Calcium QLL (30 per 30 days)
Fluvastatin Sodium QLL (30 per 30 days)
LESCOL XL QLL (30 per 30 days)
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Drug Requirements Lovastatin ORAL TABLET 10 MG, 20 MG QLL (30 per 30 days)
Lovastatin ORAL TABLET 40 MG QLL (60 per 30 days)
Pravastatin Sodium QLL (30 per 30 days)
Simvastatin QLL (30 per 30 days)
*Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors*** ZETIA ST
*Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives*** Niacin ER (Antihyperlipidemic)
*Antihypertensives*
*Ace Inhibitors**-*Ace Inhibitors*** Benazepril HCl
Captopril
Enalapril Maleate
Fosinopril Sodium
Lisinopril ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 5 MG QLL (30 per 30 days)
Lisinopril ORAL TABLET 40 MG QLL (60 per 30 days)
Moexipril HCl
Perindopril Erbumine
Quinapril HCl
Ramipril
Trandolapril
*Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists*** BENICAR ST; QLL (30 per 30 days)
Candesartan Cilexetil
Irbesartan
Losartan Potassium
Valsartan QLL (60 per 30 days)
*Antiadrenergic Antihypertensives**-*Antiadrenergics - Centrally Acting*** CloNIDine HCl
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Drug Requirements GuanFACINE HCl
Methyldopa
*Antiadrenergic Antihypertensives**-*Antiadrenergics - Peripherally Acting*** Doxazosin Mesylate QLL (30 per 30 days)
Prazosin HCl
Terazosin HCl QLL (30 per 30 days)
*Antiadrenergic Antihypertensives**-*Reserpine*** Reserpine
*Antihypertensive Combinations**-*Ace Inhibitor & Calcium Channel Blocker Combinations*** Amlodipine Besy-Benazepril HCl
*Antihypertensive Combinations**-*Ace Inhibitors & Thiazide/Thiazide-Like*** Benazepril-Hydrochlorothiazide
Captopril-Hydrochlorothiazide
Enalapril-Hydrochlorothiazide
Fosinopril Sodium-HCTZ
Lisinopril-Hydrochlorothiazide
Moexipril-Hydrochlorothiazide
Quinapril-Hydrochlorothiazide
*Antihypertensive Combinations**-*Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** Methyldopa-Hydrochlorothiazide
*Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** BENICAR HCT ST; QLL (30 per 30 days)
Candesartan Cilexetil-HCTZ
Irbesartan-Hydrochlorothiazide
Losartan Potassium-HCTZ
Valsartan-Hydrochlorothiazide QLL (30 per 30 days)
*Antihypertensive Combinations**-*Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides***
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Drug Requirements Amlodipine-Valsartan-HCTZ QLL (30 per 30 days)
*Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations*** Atenolol-Chlorthalidone
Bisoprolol-Hydrochlorothiazide
Metoprolol-Hydrochlorothiazide
Nadolol-Bendroflumethiazide
Propranolol-HCTZ
*Vasodilators**-*Vasodilators*** HydrALAZINE HCl
Minoxidil
*Anti-Infective Agents - Misc.*
*Anti-Infective Agents - Misc.**-*Anti-Infective Agents - Misc.*** MetroNIDAZOLE
Trimethoprim
Vancomycin HCl
*Anti-Infective Misc. - Combinations**-*Anti-Infective Misc. - Combinations*** Sulfamethoxazole-Trimethoprim
SULFATRIM PEDIATRIC (Sulfamethoxazole-Trimethoprim)
*Leprostatics**-*Leprostatics*** Dapsone
*Lincosamides**-*Lincosamides*** Clindamycin HCl
Clindamycin Palmitate HCl
*Antimalarials*
*Antimalarials**-*Antimalarials*** Chloroquine Phosphate
DARAPRIM
Hydroxychloroquine Sulfate
Mefloquine HCl
*Antimyasthenic/Cholinergic Agents*
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Drug Requirements
*Antimyasthenic/Cholinergic Agents**-*Antimyasthenic/Cholinergic Agents*** Pyridostigmine Bromide
*Antimycobacterial Agents*
*Anti Tb Combinations**-*Anti Tb Combinations*** RIFAMATE
*Antimycobacterial Agents**-*Antimycobacterial Agents*** Ethambutol HCl
Isoniazid
PRIFTIN
Pyrazinamide
Rifabutin
Rifampin
*Antineoplastics And Adjunctive Therapies*
*Alkylating Agents**-*Alkylating Agents*** HEXALEN
MYLERAN
*Alkylating Agents**-*Imidazotetrazines*** Temozolomide
*Alkylating Agents**-*Nitrogen Mustards*** ALKERAN
LEUKERAN
*Alkylating Agents**-*Nitrosoureas*** GLEOSTINE
*Antimetabolites**-*Antimetabolites*** Capecitabine
Mercaptopurine
Methotrexate
TABLOID
TREXALL
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Drug Requirements
*Antineoplastic - Hormonal And Related Agents**-*Antiadrenals*** LYSODREN
*Antineoplastic - Hormonal And Related Agents**-*Antiandrogens*** Bicalutamide
Flutamide
NILANDRON
*Antineoplastic - Hormonal And Related Agents**-*Antiestrogens*** FARESTON
SOLTAMOX
Tamoxifen Citrate
*Antineoplastic - Hormonal And Related Agents**-*Aromatase Inhibitors*** Anastrozole
Exemestane
Letrozole
*Antineoplastic - Hormonal And Related Agents**-*Estrogens-Antineoplastic*** EMCYT
*Antineoplastic - Hormonal And Related Agents**-*Lhrh Analogs*** VANTAS PA
ZOLADEX PA
*Antineoplastic - Hormonal And Related Agents**-*Progestins-Antineoplastic*** Megestrol Acetate
*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA PA
*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Mtor Kinase Inhibitors***
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Drug Requirements AFINITOR PA
*Antineoplastic Enzyme Inhibitors**-*Antineoplastic - Tyrosine Kinase Inhibitors*** IRESSA
TYKERB
VOTRIENT
*Antineoplastics Misc.**-*Antineoplastics Misc.*** Hydroxyurea
MATULANE PA
*Antineoplastics Misc.**-*Retinoids*** Tretinoin PA
*Chemotherapy Rescue/Antidote Agents**-*Folic Acid Antagonists Rescue Agents*** Leucovorin Calcium
*Chemotherapy Rescue/Antidote Agents**-*Urinary Tract Protective Agents*** MESNEX
*Mitotic Inhibitors**-*Mitotic Inhibitors*** Etoposide
*Antiparkinson Agents*
*Antiparkinson Comt Inhibitors**-*Peripheral Comt Inhibitors*** Entacapone QLL (120 per 30 days)
*Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics*** Amantadine HCl
Bromocriptine Mesylate
*Antiparkinson Dopaminergics**-*Levodopa Combinations*** Carbidopa-Levodopa
Carbidopa-Levodopa ER
Carbidopa-Levodopa-Entacapone QLL (270 per 30 days)
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Drug Requirements
*Antiparkinson Dopaminergics**-*Nonergoline Dopamine Receptor Agonists*** MIRAPEX (Pramipexole Dihydrochloride)
Pramipexole Dihydrochloride
ROPINIRole HCl QLL (90 per 30 days)
ROPINIRole HCl ER
*Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors*** Selegiline HCl
*Antipsychotics/Antimanic Agents*
*Phenothiazines**-*Phenothiazines*** COMPAZINE (Prochlorperazine)
COMPRO (Prochlorperazine)
Prochlorperazine Maleate
*Antiseptics & Disinfectants*
*Chlorine Antiseptics**-*Chlorine Antiseptics*** Chlorhexidine Gluconate
*Antivirals*
*Hepatitis Agents**-*Hepatitis B Agents*** BARACLUDE
Entecavir
TYZEKA
*Hepatitis Agents**-*Hepatitis C Agents*** MODERIBA ORAL ST
MODERIBA ORAL TABLET
PEGASYS PA
PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML
PA
PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML
PEGINTRON
PEG-INTRON REDIPEN PAK 4
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Drug Requirements PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120 MCG/0.5ML, 50 MCG/0.5ML
PA
PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 150 MCG/0.5ML, 80 MCG/0.5ML
PEG-INTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 50 MCG/0.5ML
PEG-INTRON SUBCUTANEOUS* KIT 150 MCG/0.5ML, 80 MCG/0.5ML
PA
REBETOL ST
RIBASPHERE ORAL CAPSULE
RIBASPHERE ORAL TABLET 200 MG
RIBASPHERE ORAL TABLET 400 MG, 600 MG ST
RIBASPHERE RIBAPAK
RIBATAB
Ribavirin ST
*Herpes Agents**-*Herpes Agents - Purine Analogues*** Acyclovir ORAL CAPSULE QLL (60 per 30 days)
Acyclovir ORAL SUSPENSION
Acyclovir ORAL TABLET QLL (60 per 30 days)
ValACYclovir HCl ORAL TABLET 1 GM QLL (30 per 30 days)
ValACYclovir HCl ORAL TABLET 500 MG QLL (60 per 30 days)
*Herpes Agents**-*Herpes Agents - Thymidine Analogues*** Famciclovir
*Influenza Agents**-*Influenza Agents*** Rimantadine HCl QLL (14 Max Qty Per Fill Retail)
*Influenza Agents**-*Neuraminidase Inhibitors*** RELENZA DISKHALER QLL (1 Max Qty Per Fill Retail)
TAMIFLU ORAL CAPSULE 30 MG QLL (20 Max Qty Per Fill Retail)
TAMIFLU ORAL CAPSULE 45 MG, 75 MG QLL (10 Max Qty Per Fill Retail)
TAMIFLU ORAL SUSPENSION RECONSTITUTED QLL (3 Max Qty Per Fill Retail)
*Assorted Classes*
*Chelating Agents**-*Chelating Agents***
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements CUPRIMINE
*Immunomodulators**-*Antileprotics*** THALOMID
*Immunomodulators**-*Immunomodulators For Myelodysplastic Syndromes*** REVLIMID
*Immunosuppressive Agents**-*Cyclosporine Analogs*** CycloSPORINE
GENGRAF (CycloSPORINE Modified)
*Immunosuppressive Agents**-*Inosine Monophosphate Dehydrogenase Inhibitors*** Mycophenolate Mofetil
Mycophenolic Acid
*Immunosuppressive Agents**-*Macrolide Immunosuppressants*** RAPAMUNE
Sirolimus
Tacrolimus
*Immunosuppressive Agents**-*Purine Analogs*** AZASAN
AzaTHIOprine
*Irrigation Solutions**-*Irrigation Solutions*** ARGYLE STERILE WATER (Sterile Water for Irrigation)
*Potassium Removing Resins**-*Potassium Removing Resins*** KIONEX (Sodium Polystyrene Sulfonate)
SPS (Sodium Polystyrene Sulfonate)
*Beta Blockers*
*Alpha-Beta Blockers**-*Alpha-Beta Blockers*** Carvedilol QLL (60 per 30 days)
Labetalol HCl
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Beta Blockers Cardio-Selective**-*Beta Blockers Cardio-Selective*** Acebutolol HCl
Atenolol
Betaxolol HCl
Bisoprolol Fumarate
Metoprolol Succinate ER QLL (60 per 30 days)
Metoprolol Tartrate
*Beta Blockers Non-Selective**-*Beta Blockers Non-Selective*** Nadolol
Pindolol
Propranolol HCl
Propranolol HCl ER
SORINE (Sotalol HCl)
Sotalol HCl (AF)
Timolol Maleate
*Calcium Channel Blockers*
*Calcium Channel Blockers**-*Calcium Channel Blockers*** AFEDITAB CR
AmLODIPine Besylate QLL (30 per 30 days)
CARTIA XT (Diltiazem CD)
Diltiazem HCl QLL (120 per 30 days)
Diltiazem HCl ER QLL (60 per 30 days)
Diltiazem HCl ER Beads QLL (60 per 30 days)
Diltiazem HCl ER Coated Beads ORAL CAPSULE EXTENDED RELEASE 24 HOUR
QLL (60 per 30 days)
Diltiazem HCl ER Coated Beads ORAL TABLET EXTENDED RELEASE 24 HR*
Dilt-XR
Felodipine ER
Isradipine
MATZIM LA QLL (60 per 30 days)
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements NiCARdipine HCl
NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG
NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG
QLL (30 per 30 days)
NIFEDICAL XL QLL (30 per 30 days)
NIFEdipine
NIFEdipine ER ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 90 MG
QLL (30 per 30 days)
NIFEdipine ER Osmotic ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG
NIFEdipine ER Osmotic ORAL TABLET EXTENDED RELEASE 24 HR* 90 MG
QLL (30 per 30 days)
NiMODipine
Nisoldipine ER ORAL TABLET EXTENDED RELEASE 24 HR* 17 MG, 25.5 MG, 34 MG, 8.5 MG
Nisoldipine ER ORAL TABLET EXTENDED RELEASE 24 HR* 20 MG, 30 MG, 40 MG
QLL (30 per 30 days)
TAZTIA XT
Verapamil HCl QLL (120 per 30 days)
Verapamil HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR
QLL (30 per 30 days)
Verapamil HCl ER ORAL TABLET EXTENDEDRELEASE* QLL (60 per 30 days)
*Cardiotonics*
*Cardiac Glycosides**-*Cardiac Glycosides*** DIGITEK (Digoxin)
DIGOX (Digoxin)
LANOXIN
*Cardiovascular Agents - Misc.*
*Cardiovascular Agents Misc. - Combinations**-*Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** Amlodipine-Atorvastatin
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Pulmonary Hypertension - Phosphodiesterase Inhibitors**-*Pulmonary Hypertension - Phosphodiesterase Inhibitors*** ADCIRCA PA; QLL (60 per 30 days)
Sildenafil Citrate PA; QLL (90 per 30 days)
*Cephalosporins*
*Cephalosporins - 1St Generation**-*Cephalosporins - 1St Generation*** Cefadroxil
Cephalexin
*Cephalosporins - 2Nd Generation**-*Cephalosporins - 2Nd Generation*** Cefaclor
Cefprozil
CEFTIN
Cefuroxime Axetil
*Cephalosporins - 3Rd Generation**-*Cephalosporins - 3Rd Generation*** Cefdinir
Cefpodoxime Proxetil
CefTRIAXone Sodium QLL (2 Max Qty Per Fill Retail)
SUPRAX ORAL SUSPENSION RECONSTITUTED
SUPRAX ORAL TABLET CHEWABLE QLL (1 Max Qty Per Fill Retail)
*Contraceptives*
*Combination Contraceptives - Oral**-*Biphasic Contraceptives - Oral*** AZURETTE (Desogestrel-Ethinyl Estradiol)
KARIVA (Desogestrel-Ethinyl Estradiol)
KIMIDESS (Desogestrel-Ethinyl Estradiol)
NECON 10/11 (28)
PIMTREA (Desogestrel-Ethinyl Estradiol)
Viorele
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Combination Contraceptives - Oral**-*Combination Contraceptives - Oral*** ALTAVERA (Levonorgestrel-Ethinyl Estrad)
APRI (Desogestrel-Ethinyl Estradiol)
AUBRA (Levonorgestrel-Ethinyl Estrad)
AVIANE (Levonorgestrel-Ethinyl Estrad)
BALZIVA (Briellyn)
CHATEAL (Levonorgestrel-Ethinyl Estrad)
CRYSELLE-28
CYCLAFEM 1/35 (Alyacen 1/35)
CYRED (Desogestrel-Ethinyl Estradiol)
DASETTA 1/35 (Alyacen 1/35)
DELYLA (Levonorgestrel-Ethinyl Estrad)
ELINEST
EMOQUETTE (Desogestrel-Ethinyl Estradiol)
ENSKYCE (Desogestrel-Ethinyl Estradiol)
ESTARYLLA (Norgestimate-Eth Estradiol)
FALMINA (Levonorgestrel-Ethinyl Estrad)
GIANVI (Drospirenone-Ethinyl Estradiol)
GILDAGIA (Briellyn)
GILDESS 1.5/30
GILDESS 1/20 (Norethindrone Acet-Ethinyl Est)
GILDESS FE 1.5/30
GILDESS FE 1/20 (Norethin Ace-Eth Estrad-FE)
JUNEL 1.5/30
JUNEL 1/20 (Norethindrone Acet-Ethinyl Est)
JUNEL FE 1.5/30
JUNEL FE 1/20 (Norethin Ace-Eth Estrad-FE)
KELNOR 1/35
KURVELO (Levonorgestrel-Ethinyl Estrad)
LARIN 1.5/30
LARIN 1/20 (Norethindrone Acet-Ethinyl Est)
LARIN FE 1.5/30
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements LARIN FE 1/20 (Norethin Ace-Eth Estrad-FE)
LESSINA (Levonorgestrel-Ethinyl Estrad)
LEVORA 0.15/30 (28) (Levonorgestrel-Ethinyl Estrad)
LORYNA (Drospirenone-Ethinyl Estradiol)
LOW-OGESTREL
LUTERA (Levonorgestrel-Ethinyl Estrad)
Marlissa
MICROGESTIN 1.5/30
MICROGESTIN 1/20 (Norethindrone Acet-Ethinyl Est)
MICROGESTIN FE 1.5/30
MICROGESTIN FE 1/20 (Norethin Ace-Eth Estrad-FE)
MONO-LINYAH (Norgestimate-Eth Estradiol)
MONONESSA (Norgestimate-Eth Estradiol)
NECON 0.5/35 (28)
NECON 1/35 (28) (Alyacen 1/35)
NECON 1/50 (28)
NIKKI (Drospirenone-Ethinyl Estradiol)
NORTREL 0.5/35 (28)
NORTREL 1/35 (21) (Alyacen 1/35)
NORTREL 1/35 (28) (Alyacen 1/35)
OCELLA (Drospirenone-Ethinyl Estradiol)
OGESTREL
ORSYTHIA (Levonorgestrel-Ethinyl Estrad)
PHILITH (Briellyn)
PIRMELLA 1/35 (Alyacen 1/35)
PORTIA-28 (Levonorgestrel-Ethinyl Estrad)
PREVIFEM (Norgestimate-Eth Estradiol)
RECLIPSEN (Desogestrel-Ethinyl Estradiol)
SOLIA (Desogestrel-Ethinyl Estradiol)
SPRINTEC 28 (Norgestimate-Eth Estradiol)
SRONYX (Levonorgestrel-Ethinyl Estrad)
SYEDA (Drospirenone-Ethinyl Estradiol)
TARINA FE 1/20 (Norethin Ace-Eth Estrad-FE)
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements VESTURA (Drospirenone-Ethinyl Estradiol)
VYFEMLA (Briellyn)
WERA
ZARAH (Drospirenone-Ethinyl Estradiol)
ZENCHENT (Briellyn)
ZOVIA 1/35E (28)
ZOVIA 1/50E (28)
*Combination Contraceptives - Oral**-*Continuous Contraceptives - Oral*** AMETHYST (Levonorgestrel-Ethinyl Estrad)
*Combination Contraceptives - Oral**-*Extended-Cycle Contraceptives - Oral*** AMETHIA (Levonorgest-Eth Estrad 91-Day)
AMETHIA LO (Levonorgest-Eth Estrad 91-Day)
ASHLYNA (Levonorgest-Eth Estrad 91-Day)
CAMRESE (Levonorgest-Eth Estrad 91-Day)
DAYSEE (Levonorgest-Eth Estrad 91-Day)
INTROVALE (Levonorgest-Eth Estrad 91-Day)
JOLESSA (Levonorgest-Eth Estrad 91-Day)
QUASENSE (Levonorgest-Eth Estrad 91-Day)
SETLAKIN (Levonorgest-Eth Estrad 91-Day)
*Combination Contraceptives - Oral**-*Triphasic Contraceptives - Oral*** ARANELLE
CAZIANT
CESIA
CYCLAFEM 7/7/7 (Alyacen 7/7/7)
DASETTA 7/7/7 (Alyacen 7/7/7)
ENPRESSE-28
LEENA
LEVONEST
MYZILRA
NECON 7/7/7 (Alyacen 7/7/7)
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements NORTREL 7/7/7 (Alyacen 7/7/7)
PIRMELLA 7/7/7 (Alyacen 7/7/7)
TILIA FE
TRI-ESTARYLLA (Norgestim-Eth Estrad Triphasic)
TRI-LEGEST FE
TRI-LINYAH (Norgestim-Eth Estrad Triphasic)
TRINESSA (28) (Norgestim-Eth Estrad Triphasic)
TRI-PREVIFEM (Norgestim-Eth Estrad Triphasic)
TRI-SPRINTEC (Norgestim-Eth Estrad Triphasic)
TRIVORA (28)
VELIVET
*Combination Contraceptives - Transdermal**-*Combination Contraceptives - Transdermal*** XULANE QLL (3 per 28 days)
*Combination Contraceptives - Vaginal**-*Combination Contraceptives - Vaginal*** NUVARING QLL (1 per 30 days)
*Emergency Contraceptives**-*Emergency Contraceptives*** ELLA
MY WAY QLL (3 per 1 Years)
NEXT CHOICE ONE DOSE (Levonorgestrel)
*Progestin Contraceptives - Implants**-*Progestin Contraceptives - Implants*** NEXPLANON QLL (1 per 3 Yearss)
*Progestin Contraceptives - Injectable**-*Progestin Contraceptives - Injectable*** MedroxyPROGESTERone Acetate QLL (1 per 90 days)
*Progestin Contraceptives - Iud**-*Progestin Contraceptives - Iud*** MIRENA QLL (1 per 5 Yearss)
SKYLA QLL (1 per 3 Yearss)
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Progestin Contraceptives - Oral**-*Progestin Contraceptives - Oral*** CAMILA (Norethindrone)
DEBLITANE (Norethindrone)
ERRIN (Norethindrone)
HEATHER (Norethindrone)
JENCYCLA (Norethindrone)
JOLIVETTE (Norethindrone)
LYZA (Norethindrone)
NORA-BE (Norethindrone)
NORLYROC (Norethindrone)
SHAROBEL (Norethindrone)
*Corticosteroids*
*Glucocorticosteroids**-*Glucocorticosteroids*** Cortisone Acetate
DELTASONE (PredniSONE)
Dexamethasone
Hydrocortisone
MethylPREDNISolone
MethylPREDNISolone (Pak)
PrednisoLONE
PrednisoLONE Sodium Phosphate
PredniSONE
PredniSONE (Pak)
*Mineralocorticoids**-*Mineralocorticoids*** Fludrocortisone Acetate
*Cough/Cold/Allergy*
*Antitussives**-*Antitussive - Nonnarcotic*** Benzonatate
*Antitussives**-*Antitussive - Opioid*** Hydromet
TUSSIGON (Hydrocodone-Homatropine)
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Cough/Cold/Allergy Combinations**-*Antitussive-Expectorants-Decongestant*** Biotuss
*Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine*** Entre-B
Promethazine VC Plain
Promethazine-Phenylephrine
*Cough/Cold/Allergy Combinations**-*Non-Narc Antitussive-Antihistamine*** Promethazine-DM
*Cough/Cold/Allergy Combinations**-*Non-Narc Antitussive-Decongestant-Antihistamine*** Phenylephrine-Chlorphen-DM
TGQ 50PSE/3BRM/30DM
*Cough/Cold/Allergy Combinations**-*Opioid Antitussive-Antihistamine*** Promethazine-Codeine
*Cough/Cold/Allergy Combinations**-*Opioid Antitussive-Decongestant-Antihistamine*** Phenyleph-Promethazine-Cod
Promethazine VC/Codeine
*Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants*** HYPERSAL
NEBUSAL (Sodium Chloride)
PULMOSAL (Sodium Chloride)
Sodium Chloride
*Mucolytics**-*Mucolytics*** Acetylcysteine
*Dermatologicals*
*Acne Products**-*Acne Antibiotics*** CLINDACIN ETZ (Clindamycin Phosphate)
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements CLINDACIN-P (Clindamycin Phosphate)
CLINDAMAX (Clindamycin Phosphate)
Clindamycin Phosphate
Ery
Erythromycin
Sulfacetamide Sodium
Sulfacetamide Sodium (Acne)
*Acne Products**-*Acne Combinations*** AVAR CLEANSER (Sulfacetamide Sodium-Sulfur)
Benzoyl Peroxide-Erythromycin
BP Cleansing Wash
CERISA WASH (BP 10-1)
Clindamycin Phos-Benzoyl Perox
NEUAC (Clindamycin Phos-Benzoyl Perox)
PRASCION (Sulfacetamide Sodium-Sulfur)
PRASCION FC (Sulfacetamide Sodium-Sulfur)
ROSANIL CLEANSER (Sulfacetamide Sodium-Sulfur)
ROSULA (Sulfacetamide Sodium-Sulfur)
Sulfacetamide Sodium-Sulfur
*Acne Products**-*Acne Products*** Acne Medication 5
Adapalene
AMNESTEEM
AVITA QLL (20 per 30 days)
BENZEPRO CREAMY WASH (BP Wash)
BENZIQ WASH (BP Wash)
Benzoyl Peroxide
Benzoyl Peroxide Wash
BP Foaming Wash
BP Wash
CLARAVIS
CLEARPLEX X (Benzoyl Peroxide)
MYORISAN
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements OSCION CLEANSER (Benzoyl Peroxide Cleanser)
PR BENZOYL PEROXIDE WASH (BP Wash)
Tretinoin EXTERNAL 0.01 % QLL (20 per 30 days)
Tretinoin EXTERNAL 0.025 %
Tretinoin EXTERNAL CREAM 0.025 %
Tretinoin EXTERNAL CREAM 0.05 %, 0.1 % QLL (20 per 30 days)
ZENATANE
*Antibiotics - Topical**-*Antibiotics - Topical*** Gentamicin Sulfate
Mupirocin
Mupirocin Calcium
*Antifungals - Topical**-*Antifungals - Topical Combinations*** Clotrimazole-Betamethasone
DERMAZENE (Hydrocortisone-Iodoquinol)
Nystatin-Triamcinolone
*Antifungals - Topical**-*Antifungals - Topical*** CICLODAN (Ciclopirox)
Ciclopirox Olamine
Ciclopirox-Vitamin E
NYAMYC (Nystatin)
Nystatin
NYSTOP (Nystatin)
*Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** Clotrimazole
Clotrimazole Anti-Fungal
Econazole Nitrate
Ketoconazole
KP Clotrimazole
*Antineoplastic Or Premalignant Lesion Agents -Topical**-*Antineoplastic Antimetabolites - Topical*** FLUOROPLEX
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Fluorouracil
*Antineoplastic Or Premalignant Lesion Agents -Topical**-*Topical Selective Retinoid X Receptor Agonists*** TARGRETIN
*Antipsoriatics**-*Antipsoriatics - Systemic*** Methoxsalen Rapid
*Antipsoriatics**-*Antipsoriatics*** Calcipotriene
CALCITRENE (Calcipotriene)
VECTICAL (Calcitriol)
*Antiseborrheic Products**-*Antiseborrheic Combinations*** Selenium Sulfide
Selenium Sulf-Pyrithione-Urea
*Antiseborrheic Products**-*Antiseborrheic Products*** SEB-PREV WASH (Sulfacetamide Sodium)
Selenium Sulfide
*Antivirals - Topical**-*Antivirals - Topical*** Acyclovir
ZOVIRAX
*Burn Products**-*Burn Products*** SSD (Silver Sulfadiazine)
*Cauterizing Agents**-*Cauterizing Agent Combinations*** ARZOL SILVER NIT APPLICATORS (Grafco Silver Nit Applicator)
*Corticosteroids - Topical**-*Corticosteroids -Topical*** Ala Cort
Alclometasone Dipropionate
AlphaTrex
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Amcinonide
Betamethasone Dipropionate
Betamethasone Dipropionate Aug
Betamethasone Valerate
Clobetasol Propionate E
CLODAN (Clobetasol Propionate)
CORMAX SCALP APPLICATION (Clobetasol Propionate)
Desonide
Desoximetasone
Diflorasone Diacetate
Fluocinolone Acetonide
Fluocinonide
Fluocinonide-E
Fluticasone Propionate
Halobetasol Propionate
Hydrocortisone
Hydrocortisone Acetate
Hydrocortisone Butyr Lipo Base
Hydrocortisone Butyrate
Hydrocortisone Micronized
Hydrocortisone Valerate
LOKARA (Desonide)
Mometasone Furoate
Prednicarbate
PROCTOZONE-HC (Hydrocortisone)
Scalacort
Triamcinolone Acetonide
TRIDERM (Triamcinolone Acetonide)
*Emollients**-*Emollients*** Ammonium Lactate
LACLOTION (Ammonium Lactate)
NEOSALUS
TROPAZONE
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Enzymes - Topical**-*Enzymes - Topical*** SANTYL
*Immunomodulating Agents - Topical**-*Immunomodulators Imidazoquinolinamines -Topical*** Imiquimod
*Immunosuppressive Agents - Topical**-*Macrolide Immunosuppressants - Topical*** ELIDEL ST; QLL (30 per 30 days)
*Keratolytic/Antimitotic Agents**-*Keratolytic/Antimitotic Agents*** CONDYLOX
Podofilox
SALACYN (Salicylic Acid)
*Local Anesthetics - Topical**-*Local Anesthetics -Topical*** GLYDO (Lidocaine HCl)
Lidocaine EXTERNAL OINTMENT
Lidocaine EXTERNAL PATCH QLL (90 per 30 days)
Lidocaine HCl
Lidopin
Premium Lidocaine
*Local Anesthetics - Topical**-*Topical Anesthetic Combinations*** Lidocaine-Prilocaine
LIVIXIL PAK (Lidocaine-Prilocaine)
RELADOR PAK (Lidocaine-Prilocaine)
RELADOR PAK PLUS (Lidocaine-Prilocaine)
*Misc. Topical**-*Skin Cleansers*** Essentra Wipes 9x9"
*Rosacea Agents**-*Rosacea Agents*** ROSADAN (MetroNIDAZOLE)
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Scabicides & Pediculicides**-*Scabicides & Pediculicides*** ACTICIN (Permethrin)
Lindane
Malathion
ULESFIA
*Digestive Aids*
*Digestive Enzymes**-*Digestive Enzymes*** CREON
PANCREAZE
Pancrelipase (Lip-Prot-Amyl)
ZENPEP
*Diuretics*
*Carbonic Anhydrase Inhibitors**-*Carbonic Anhydrase Inhibitors*** AcetaZOLAMIDE
AcetaZOLAMIDE ER
Methazolamide
*Diuretic Combinations**-*Diuretic Combinations*** Amiloride-Hydrochlorothiazide
Spironolactone-HCTZ
Triamterene-HCTZ
*Loop Diuretics**-*Loop Diuretics*** Bumetanide
Furosemide
Torsemide
*Potassium Sparing Diuretics**-*Potassium Sparing Diuretics*** AMILoride HCl
Spironolactone
*Thiazides And Thiazide-Like Diuretics**-*Thiazides And Thiazide-Like Diuretics*** Chlorothiazide
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Chlorthalidone
Hydrochlorothiazide
Indapamide
Methyclothiazide
Metolazone
*Endocrine And Metabolic Agents - Misc.*
*Bone Density Regulators**-*Bisphosphonates*** Alendronate Sodium ORAL SOLUTION
Alendronate Sodium ORAL TABLET 10 MG, 40 MG, 5 MG QLL (30 per 30 days)
Alendronate Sodium ORAL TABLET 35 MG, 70 MG QLL (4 per 30 days)
Etidronate Disodium
Ibandronate Sodium
*Bone Density Regulators**-*Calcitonins*** Calcitonin (Salmon)
*Growth Hormones**-*Growth Hormones*** OMNITROPE PA
*Hormone Receptor Modulators**-*Selective Estrogen Receptor Modulators (Serms)*** Raloxifene HCl QLL (30 per 30 days)
*Metabolic Modifiers**-*Calcimimetic Agents*** SENSIPAR
*Metabolic Modifiers**-*Hyperparathyroid Treatment - Vitamin D Analogs*** Calcitriol
Paricalcitol
*Posterior Pituitary Hormones**-*Vasopressin*** Desmopressin Ace Rhinal Tube QLL (1 per 30 days)
Desmopressin Ace Spray Refrig QLL (1 per 30 days)
Desmopressin Acetate QLL (90 per 30 days)
Desmopressin Acetate Spray QLL (1 per 30 days)
*Prolactin Inhibitors**-*Dopamine Receptor Agonists*** Cabergoline
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Somatostatic Agents**-*Somatostatic Agents*** SOMATULINE DEPOT PA
*Estrogens*
*Estrogen Combinations**-*Estrogen & Progestin*** CLIMARA PRO
COMBIPATCH
JINTELI (Norethindrone-Eth Estradiol)
LOPREEZA (Estradiol-Norethindrone Acet)
MIMVEY (Estradiol-Norethindrone Acet)
MIMVEY LO (Estradiol-Norethindrone Acet)
Norethindrone-Eth Estradiol
PREFEST
PREMPHASE
PREMPRO
*Estrogens**-*Estrogens*** Estradiol ORAL
Estradiol TRANSDERMAL PATCH BIWEEKLY
Estradiol TRANSDERMAL PATCH WEEKLY QLL (4 per 30 days)
MENEST
ORTHO-EST 0.625 (Estropipate)
ORTHO-EST 1.25 (Estropipate)
PREMARIN
*Fluoroquinolones*
*Fluoroquinolones**-*Fluoroquinolones*** Ciprofloxacin HCl QLL (28 per 30 days)
Ciprofloxacin-Ciproflox HCl ER QLL (3 Max Qty Per Fill Retail)
Levofloxacin
Ofloxacin
*Gastrointestinal Agents - Misc.*
*Gallstone Solubilizing Agents**-*Gallstone Solubilizing Agents*** Ursodiol
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Gastrointestinal Chloride Channel Activators**-*Gastrointestinal Chloride Channel Activators*** AMITIZA QLL (60 per 30 days)
*Gastrointestinal Stimulants**-*Gastrointestinal Stimulants*** Metoclopramide HCl
*Inflammatory Bowel Agents**-*Inflammatory Bowel Agents*** ASACOL HD
Balsalazide Disodium
CANASA
DELZICOL
DIPENTUM
Mesalamine
PENTASA
SULFAZINE (SulfaSALAzine)
SULFAZINE EC (SulfaSALAzine)
*Inflammatory Bowel Agents**-*Tumor Necrosis Factor Alpha Blockers*** REMICADE PA
*Phosphate Binder Agents**-*Phosphate Binder Agents*** Calcium Acetate
RENVELA
*Genitourinary Agents - Miscellaneous*
*Acidifiers**-*Phosphates*** K-PHOS NO 2
*Alkalinizers**-*Citrates*** Citric Acid-Sodium Citrate
Cytra-2
CYTRA-3
Cytra-K
Pot & Sod Cit-Cit Ac
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Potassium Citrate ER
Potassium Citrate-Citric Acid
Sod Citrate-Citric Acid
TARON-CRYSTALS (Cytra K Crystals)
Tricitrates
Virtrate-2
Virtrate-3
Virtrate-K
*Genitourinary Irrigants**-*Genitourinary Irrigants*** ARGYLE STERILE SALINE (Sodium Chloride)
CURITY STERILE SALINE (Sodium Chloride)
*Interstitial Cystitis Agents**-*Interstitial Cystitis Agents*** ELMIRON
*Prostatic Hypertrophy Agents**-*5-Alpha Reductase Inhibitors*** Finasteride
*Prostatic Hypertrophy Agents**-*Alpha 1-Adrenoceptor Antagonists*** Alfuzosin HCl ER
Tamsulosin HCl QLL (60 per 30 days)
*Urinary Analgesics**-*Urinary Analgesics*** PHENAZO (Phenazopyridine HCl)
Phenazopyridine HCl
*Gout Agents*
*Gout Agent Combinations**-*Gout Agent Combinations*** Colchicine-Probenecid
*Gout Agents**-*Gout Agents*** Allopurinol
Colchicine
ULORIC ST
*Uricosurics**-*Uricosurics***
Updated: 10/01/2015 P a g e | 4 3
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Probenecid
*Hematological Agents - Misc.*
*Hematorheologic Agents**-*Hematorheologic Agents*** Pentoxifylline ER
*Platelet Aggregation Inhibitors**-*Phosphodiesterase Iii Inhibitors*** Cilostazol
*Platelet Aggregation Inhibitors**-*Platelet Aggregation Inhibitors*** Dipyridamole
*Platelet Aggregation Inhibitors**-*Quinazoline Agents*** Anagrelide HCl
*Platelet Aggregation Inhibitors**-*Thienopyridine Derivatives*** Clopidogrel Bisulfate QLL (30 per 30 days)
*Hematopoietic Agents*
*Agents For Sickle Cell Anemia**-*Cytotoxic Agents*** DROXIA
*Cobalamins**-*Cobalamins*** Cyanocobalamin
*Folic Acid/Folates**-*Folic Acid/Folates*** Folic Acid
*Hematopoietic Growth Factors**-*Erythropoiesis-Stimulating Agents (Esas)*** ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 60 MCG/0.3ML
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 500 MCG/ML, 60 MCG/ML
PA
EPOGEN PA
Updated: 10/01/2015 P a g e | 4 4
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
PROCRIT INJECTION SOLUTION 40000 UNIT/ML PA
*Hematopoietic Growth Factors**-*Granulocyte Colony-Stimulating Factors (G-Csf)*** NEULASTA PA
NEULASTA DELIVERY KIT
NEUPOGEN PA
*Hematopoietic Growth Factors**-*Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)*** LEUKINE PA
*Hematopoietic Growth Factors**-*Thrombopoietin (Tpo) Receptor Agonists*** PROMACTA PA
*Hematopoietic Mixtures**-*Folic Acid/Folate Combinations*** FA-Vitamin B-6-Vitamin B-12
Folplex 2.2
*Hematopoietic Mixtures**-*Iron Combinations*** FE C PLUS
ICAR-C PLUS
*Stem Cell Mobilizers**-*Cxcr4 Receptor Antagonist*** MOZOBIL
*Laxatives*
*Laxative Combinations**-*Bowel Evacuant Combinations*** GAVILYTE-C (PEG 3350/Electrolytes)
GAVILYTE-G (PEG-3350/Electrolytes)
GAVILYTE-N WITH FLAVOR PACK (PEG 3350-KCl-Na Bicarb-NaCl)
TRILYTE (PEG 3350-KCl-Na Bicarb-NaCl)
*Laxatives - Miscellaneous**-*Laxatives - Miscellaneous***
Updated: 10/01/2015 P a g e | 4 5
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Constulose
Lactulose
PEGYLAX (Polyethylene Glycol 3350)
*Macrolides*
*Azithromycin**-*Azithromycin*** Azithromycin ORAL PACKET
Azithromycin ORAL SUSPENSION RECONSTITUTED
Azithromycin ORAL TABLET 250 MG QLL (12 per 30 days)
Azithromycin ORAL TABLET 500 MG
Azithromycin ORAL TABLET 600 MG QLL (8 per 30 days)
*Clarithromycin**-*Clarithromycin*** Clarithromycin ER QLL (14 per 30 days)
Clarithromycin ORAL SUSPENSION RECONSTITUTED
Clarithromycin ORAL TABLET QLL (28 per 30 days)
*Erythromycins**-*Erythromycins*** E.E.S. 400 (Erythromycin Ethylsuccinate)
E.E.S. GRANULES
ERYPED 200
ERYPED 400
ERYTHROCIN STEARATE
Erythromycin Base
*Medical Devices*
*Contraceptives**-*Cervical Caps*** FEMCAP
PRENTIF CAVITY-RIM CERV CAP
PRENTIF FITTING SET
*Contraceptives**-*Diaphragms*** OMNIFLEX DIAPHRAGM
ORTHO DIAPHRAGM COIL
ORTHO DIAPHRAGM FLAT
WIDE-SEAL DIAPHRAGM 60
WIDE-SEAL DIAPHRAGM 65
WIDE-SEAL DIAPHRAGM 70
Updated: 10/01/2015 P a g e | 4 6
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements WIDE-SEAL DIAPHRAGM 75
WIDE-SEAL DIAPHRAGM 80
WIDE-SEAL DIAPHRAGM 85
WIDE-SEAL DIAPHRAGM 90
WIDE-SEAL DIAPHRAGM 95
*Misc. Devices**-*Applicators,Cotton Balls,Etc*** ALCOH-GLOVE CONTOURED WIPE (Alcohol Wipes)
*Parenteral Therapy Supplies**-*Needles & Syringes*** ASSURE ID INSULIN SAFETY SYR
BD ECLIPSE SYRINGE
BD INSULIN SYRINGE ULTRAFINE
MAGELLAN INSULIN SAFETY SYR
MONOJECT INSULIN SYRINGE
MONOJECT MAGELLAN SYRINGE
MONOJECT SAFETY SYRINGE/SHIELD
MONOJECT SYRINGE
MONOJECT ULTRA COMFORT SYRINGE
ULTICARE INSULIN SAFETY SYR
*Respiratory Therapy Supplies**-*Nebulizers*** Nebulizer
Nebulizer Compressor
Nebulizer Updraft-Style
*Respiratory Therapy Supplies**-*Peak Flow Meters*** TRUZONE PEAK FLOW METER QLL (1 per 1 Year)
*Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MINI CHAMBER (Valved Holding Chamber)
AEROCHAMBER MV (Valved Holding Chamber)
AEROCHAMBER PLUS FLO-VU (Valved Holding Chamber)
AEROCHAMBER PLUS FLO-VU LARGE (Valved Holding Chamber)
AEROCHAMBER PLUS FLO-VU MEDIUM (Valved Holding Chamber)
Updated: 10/01/2015 P a g e | 4 7
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements AEROCHAMBER PLUS FLO-VU SMALL (Valved Holding Chamber)
AEROCHAMBER PLUS FLO-VU W/MASK (Valved Holding Chamber)
AEROCHAMBER PLUS FLOW VU (Valved Holding Chamber)
AEROCHAMBER W/FLOWSIGNAL (Valved Holding Chamber)
AEROCHAMBER Z-STAT PLUS (Valved Holding Chamber)
AEROCHAMBER Z-STAT PLUS CHAMBR (Valved Holding Chamber)
AEROCHAMBER Z-STAT PLUS/LARGE (Valved Holding Chamber)
AEROCHAMBER Z-STAT PLUS/MEDIUM (Valved Holding Chamber)
AEROCHAMBER Z-STAT PLUS/SMALL (Valved Holding Chamber)
AEROVENT PLUS (Valved Holding Chamber)
BREATHERITE (Valved Holding Chamber)
BREATHERITE COLL SPACER ADULT (Valved Holding Chamber)
BREATHERITE COLL SPACER CHILD (Valved Holding Chamber)
BREATHERITE COLL SPACER INFANT (Valved Holding Chamber)
BREATHERITE RIGID SPACER/MASK (Valved Holding Chamber)
BREATHERITE SPACER NEONATE (Valved Holding Chamber)
BREATHERITE SPACER SMALL CHILD (Valved Holding Chamber)
BREATHERITE/LARGE MASK (Valved Holding Chamber)
BREATHERITE/MEDIUM MASK (Valved Holding Chamber)
BREATHERITE/SMALL MASK (Valved Holding Chamber)
EASIVENT (Valved Holding Chamber)
EASIVENT MASK LARGE (Valved Holding Chamber)
EASIVENT MASK MEDIUM (Valved Holding Chamber)
EASIVENT MASK SMALL (Valved Holding Chamber)
E-Z SPACER (Valved Holding Chamber)
Updated: 10/01/2015 P a g e | 4 8
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements E-Z SPACER THE BODY GUARDS PK (Valved Holding Chamber)
FLEXICHAMBER (Valved Holding Chamber)
INSPIRACHAMBER/MEDIUM (Valved Holding Chamber)
INSPIRACHAMBER/MOUTHPIECE (Valved Holding Chamber)
INSPIRACHAMBER/SMALL (Valved Holding Chamber)
INSPIREASE QLL (1 per 1 Year)
LITEAIRE (Valved Holding Chamber)
MICROCHAMBER (Valved Holding Chamber)
MICROSPACER (Valved Holding Chamber)
OPTICHAMBER ADVANTAGE (Valved Holding Chamber)
OPTICHAMBER ADVANTAGE-LG MASK (Valved Holding Chamber)
OPTICHAMBER ADVANTAGE-MED MASK (Valved Holding Chamber)
OPTICHAMBER ADVANTAGE-SM MASK (Valved Holding Chamber)
OPTICHAMBER DIAMOND (Valved Holding Chamber)
OPTICHAMBER DIAMOND-LG MASK (Valved Holding Chamber)
OPTICHAMBER DIAMOND-MD MASK (Valved Holding Chamber)
OPTICHAMBER DIAMOND-SM MASK (Valved Holding Chamber)
OPTIHALER (Valved Holding Chamber)
POCKET CHAMBER (Valved Holding Chamber)
POCKET SPACER (Valved Holding Chamber)
RITEFLO (Valved Holding Chamber)
VORTEX VALVED HOLDING CHAMBER (Valved Holding Chamber)
WATCHHALER (Valved Holding Chamber)
*Migraine Products*
*Migraine Combinations**-*Ergot Combinations*** CAFERGOT
MIGERGOT
*Migraine Products**-*Migraine Products***
Updated: 10/01/2015 P a g e | 4 9
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Dihydroergotamine Mesylate QLL (8 per 30 days)
ERGOMAR
*Serotonin Agonists**-*Selective Serotonin Agonists 5-Ht(1)*** ALSUMA (SUMAtriptan Succinate) QLL (4 per 30 days)
Naratriptan HCl
RELPAX QLL (6 per 30 days)
Rizatriptan Benzoate ORAL TABLET QLL (12 per 30 days)
Rizatriptan Benzoate ORAL TABLET DISPERSIBLE
SUMAtriptan QLL (6 per 30 days)
SUMAtriptan Succinate ORAL QLL (9 per 30 days)
SUMAtriptan Succinate Refill QLL (4 per 30 days)
SUMAtriptan Succinate SUBCUTANEOUS* QLL (4 per 30 days)
*Minerals & Electrolytes*
*Bicarbonates**-*Bicarbonates*** Sodium Bicarbonate
*Fluoride**-*Fluoride Combinations*** FLUOR-A-DAY
*Fluoride**-*Fluoride*** FLUORABON
FLUOR-A-DAY (Fluoritab)
FLURA-DROPS (Fluoritab)
KARIDIUM (Fluoritab)
LUDENT (Fluoritab)
NAFRINSE (Fluoritab)
NAFRINSE DROPS (Fluoritab)
Sodium Fluoride
*Phosphate**-*Phosphate*** K-PHOS
PHOSPHA 250 NEUTRAL (Virt-Phos 250 Neutral)
*Potassium**-*Potassium Combinations*** Effervescent Pot Chloride
Pot Bicarb-Pot Chloride
Updated: 10/01/2015 P a g e | 5 0
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Potassium**-*Potassium*** EFFER-K (K-Effervescent)
KLOR-CON (Potassium Chloride ER)
KLOR-CON 10 (Potassium Chloride ER)
KLOR-CON M10 (Potassium Chloride Crys ER)
KLOR-CON M15
KLOR-CON M20 (Potassium Chloride Crys ER)
KLOR-CON SPRINKLE (Potassium Chloride ER)
KLOR-CON/EF (K-Effervescent)
K-PRIME (K-Effervescent)
K-SOL (Potassium Chloride)
K-Vescent
Potassium Bicarbonate
*Mouth/Throat/Dental Agents*
*Anesthetics Topical Oral**-*Anesthetics Topical Oral*** Lidocaine HCl
Lidocaine Viscous
*Anti-Infectives - Throat**-*Anti-Infectives - Throat*** Clotrimazole
Nystatin
*Antiseptics - Mouth/Throat**-*Antiseptics - Mouth/Throat*** PAROEX (Chlorhexidine Gluconate)
PERIOGARD (Chlorhexidine Gluconate)
*Dental Products**-*Dental Products - Combinations*** FLUORIDEX SENSITIVITY RELIEF
*Dental Products**-*Fluoride Dental Products*** CAVAREST (SF)
CAVIRINSE (Neutral Sodium Fluoride)
CONTROLRX (SF 5000 Plus)
DENTA 5000 PLUS (SF 5000 Plus)
DENTAGEL (SF)
Updated: 10/01/2015 P a g e | 5 1
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements FLUORIDEX DAILY DEFENSE (SF)
FLUORIDEX ENHANCED WHITENING (SF)
KARIGEL (SF)
KARIGEL-N (SF)
NEUTRAGARD ADVANCED (SF)
PHOS-FLUR (SF)
*Steroids - Mouth/Throat**-*Steroids -Mouth/Throat*** ORALONE (Triamcinolone Acetonide)
*Throat Products - Misc.**-*Saliva Stimulants*** Pilocarpine HCl
*Multivitamins*
*Multiple Vitamins W/ Minerals**-*Multiple Vitamins W/ Minerals*** Biocel
CORVITE FREE (B-Plex Plus)
LYSIPLEX PLUS (B-Plex Plus)
NUTRIFAC ZX (B-Plex Plus)
VIC-FORTE (V-C Forte)
Vit B3-AzelAc-Turm-FA-B6-Zn-CU
VITA S FORTE (B-Plex Plus)
VITACEL (B-Plex Plus)
Vita-Min
*Ped Multi Vitamins W/Fl & Fe**-*Ped Multi Vitamins W/Fl & Fe*** Multi-Vit/Fluoride/Iron
Multi-Vitamin/Fluoride/Iron
*Ped Multi Vitamins W/Fl & Fe**-*Ped Vitamins Acd Fluoride & Iron*** Tri-Vit/Fluoride/Iron
*Ped Mv W/ Fluoride**-*Ped Mv W/ Fluoride*** Multi Vitamin/Fluoride
Multi-Vit/Fluoride
Updated: 10/01/2015 P a g e | 5 2
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Multivitamin/Fluoride
Multi-Vitamins/Fluoride
MVC-FLUORIDE (Multivitamins/Fluoride)
QUFLORA PEDIATRIC (Multi-Vitamin/Fluoride)
*Ped Mv W/ Fluoride**-*Ped Vitamins Acd W/ Fluoride*** Triple-Vitamin/Fluoride
Tri-Vit/Fluoride
Tri-Vitamin/Fluoride
Vitamins ACD-Fluoride
*Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa*** BP MultiNatal Plus
CompleteNate
CONCEPT DHA (Virt-C DHA)
Dothelle DHA
INATAL ADVANCE (Ultra Tabs)
INATAL GT (Ultra Tabs)
INATAL ULTRA (Ultra Tabs)
M-VIT (Prenatal Plus)
Mynatal Plus
NIVA-PLUS (Prenatal Plus)
O-CAL FA (Prenatal Plus)
PNV Folic Acid + Iron
PNV Prenatal Plus Multivitamin
PNV-Select
Prenatabs FA
PRENATABS RX
Prenatal
Prenatal 19
Prenatal Low Iron
PRENATAL-U (PNV-VP-U)
PrePLUS
SELECT-OB
Updated: 10/01/2015 P a g e | 5 3
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Se-Natal 19
TARON-C DHA (Virt-C DHA)
TriAdvance
TRICARE (Prenatal Plus)
TRINATE
VINATE AZ EXTRA
VINATE CALCIUM
VINATE II
VINATE M
VINATE ONE (Trinatal Rx 1)
VITAFOL-OB (Mynatal-Z)
Vol-Plus
*Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa-Dha*** Folcal DHA
PNV-DHA
SELECT-OB+DHA
VEMAVITE-PRX 2 (PNV-DHA+Docusate)
*Prenatal Vitamins**-*Prenatal Vitamins*** BP FoliNatal Plus B
*Specialty Vitamins Products**-*Specialty Vitamins Products*** Urosex
*Musculoskeletal Therapy Agents*
*Central Muscle Relaxants**-*Central Muscle Relaxants*** Baclofen
Carisoprodol QLL (120 per 30 days)
Chlorzoxazone
Cyclobenzaprine HCl QLL (120 per 30 days)
Metaxalone QLL (120 per 30 days)
Methocarbamol QLL (120 per 30 days)
TiZANidine HCl
Updated: 10/01/2015 P a g e | 5 4
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Direct Muscle Relaxants**-*Direct Muscle Relaxants*** Dantrolene Sodium
*Muscle Relaxant Combinations**-*Muscle Relaxant Combinations*** Carisoprodol-Aspirin
Carisoprodol-Aspirin-Codeine
*Nasal Agents - Systemic And Topical*
*Nasal Antiallergy**-*Nasal Antihistamines*** Azelastine HCl NASAL SOLUTION 0.1 % QLL (60 per 30 days)
Azelastine HCl NASAL SOLUTION 0.15 %
*Nasal Anticholinergics**-*Nasal Anticholinergics*** Ipratropium Bromide
*Nasal Steroids**-*Nasal Steroids*** Flunisolide ST
Fluticasone Propionate ST
NASONEX QLL (2 per 30 days)
Triamcinolone Acetonide
*Sympathomimetic Decongestants**-*Systemic Decongestants*** Pseudoephedrine HCl
*Neuromuscular Agents*
*Als Agents**-*Benzathiazoles*** Riluzole
*Ophthalmic Agents*
*Artificial Tears And Lubricants**-*Artificial Tears And Lubricants*** Polyvinyl Alcohol
*Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic Combinations*** COMBIGAN
Dorzolamide HCl-Timolol Mal
Updated: 10/01/2015 P a g e | 5 5
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Beta-Blockers - Ophthalmic**-*Beta-Blockers - Ophthalmic*** Betaxolol HCl
BETOPTIC-S
Carteolol HCl
Levobunolol HCl
Metipranolol
Timolol Maleate
*Cycloplegic Mydriatics**-*Cycloplegic Mydriatics*** Atropine Sulfate
Cyclopentolate HCl
HOMATROPAIRE (Homatropine HBr)
Tropicamide
*Miotics**-*Miotics - Direct Acting*** Pilocarpine HCl
*Ophthalmic Adrenergic Agents**-*Ophthalmic Selective Alpha Adrenergic Agonists*** Brimonidine Tartrate
*Ophthalmic Anti-Infectives**-*Ophthalmic Antibiotics*** Bacitracin
CILOXAN
Ciprofloxacin HCl
Gatifloxacin
GENTAK (Gentamicin Sulfate)
Gentamicin Sulfate
ILOTYCIN (Erythromycin)
Levofloxacin
Ofloxacin
Tobramycin
TOBREX
VIGAMOX
Updated: 10/01/2015 P a g e | 5 6
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Ophthalmic Anti-Infectives**-*Ophthalmic Anti-Infective Combinations*** Bacitracin-Polymyxin B
Neomycin-Polymyxin-Gramicidin
NEO-POLYCIN (Neomycin-Bacitracin Zn-Polymyx)
POLYCIN (AK-Poly-Bac)
Polymyxin B-Trimethoprim
*Ophthalmic Anti-Infectives**-*Ophthalmic Antivirals*** Trifluridine
*Ophthalmic Anti-Infectives**-*Ophthalmic Sulfonamides*** Sulfacetamide Sodium
*Ophthalmic Decongestants**-*Ophthalmic Decongestants*** ALTAFRIN (Phenylephrine HCl)
Naphazoline HCl
*Ophthalmic Steroids**-*Ophthalmic Steroid Combinations*** Neomycin-Polymyxin-Dexameth
Neomycin-Polymyxin-HC
NEO-POLYCIN HC (Bacitra-Neomycin-Polymyxin-HC)
Sulfacetamide-Prednisolone
TOBRADEX
Tobramycin-Dexamethasone
*Ophthalmic Steroids**-*Ophthalmic Steroids*** Dexamethasone Sodium Phosphate
Fluorometholone
FML FORTE
PRED MILD
PrednisoLONE Acetate
PrednisoLONE Sodium Phosphate
*Ophthalmics - Misc.**-*Ophthalmic Antiallergic***
Updated: 10/01/2015 P a g e | 5 7
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Azelastine HCl
Cromolyn Sodium
Epinastine HCl
Ketotifen Fumarate
PATANOL
*Ophthalmics - Misc.**-*Ophthalmic Carbonic Anhydrase Inhibitors*** AZOPT
Dorzolamide HCl
*Ophthalmics - Misc.**-*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** Diclofenac Sodium
Flurbiprofen Sodium
Ketorolac Tromethamine
*Prostaglandins - Ophthalmic**-*Prostaglandins - Ophthalmic*** Bimatoprost
Latanoprost
LUMIGAN
Travoprost
*Otic Agents*
*Otic Agents - Miscellaneous**-*Otic Agents -Miscellaneous*** Acetic Acid
Acetic Acid-Aluminum Acetate
*Otic Anti-Infectives**-*Otic Anti-Infectives*** Ofloxacin
*Otic Combinations**-*Otic Analgesic Combinations*** Antipyrine-Benzocaine
CORTIC-ND (Exotic-HC)
CYOTIC (Exotic-HC)
Oto-End 10
Otomax-HC
Updated: 10/01/2015 P a g e | 5 8
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Otic Combinations**-*Otic Steroid-Anti-Infective Combinations*** CIPRO HC
CIPRODEX
Neomycin-Polymyxin-HC
*Otic Steroids**-*Otic Steroids*** ACETASOL HC (Hydrocortisone-Acetic Acid)
*Oxytocics*
*Oxytocics**-*Oxytocics*** Methylergonovine Maleate
*Passive Immunizing Agents*
*Immune Serums**-*Immune Serums*** HEPAGAM B
HYPERHEP B S/D
HYPERRHO S/D
MICRHOGAM ULTRA-FILTERED PLUS
NABI-HB
RHOGAM ULTRA-FILTERED PLUS
RHOPHYLAC
*Monoclonal Antibodies**-*Antiviral Monoclonal Antibodies*** SYNAGIS PA
*Penicillins*
*Aminopenicillins**-*Aminopenicillins*** Amoxicillin
Ampicillin
*Natural Penicillins**-*Natural Penicillins*** Penicillin V Potassium
*Penicillin Combinations**-*Penicillin Combinations*** Amoxicillin-Pot Clavulanate ER QLL (28 per 30 days)
Amoxicillin-Pot Clavulanate ORAL SUSPENSION RECONSTITUTED
Amoxicillin-Pot Clavulanate ORAL TABLET QLL (28 per 30 days)
Updated: 10/01/2015 P a g e | 5 9
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Amoxicillin-Pot Clavulanate ORAL TABLET CHEWABLE QLL (28 per 30 days)
*Penicillinase-Resistant Penicillins**-*Penicillinase-Resistant Penicillins*** Dicloxacillin Sodium
*Pharmaceutical Adjuvants*
*Antimicrobial Agents**-*Antimicrobial Agents*** Benzyl Alcohol
*Pharmaceutical Excipients**-*Pharmaceutical Excipients*** Lactose Monohydrate
Xanthan Gum
*Progestins*
*Progestins**-*Progestins*** MedroxyPROGESTERone Acetate
MEGACE ES
Norethindrone Acetate
Progesterone
Progesterone Micronized
*Psychotherapeutic And Neurological Agents - Misc.*
*Antidementia Agents**-*Cholinomimetics - Ache Inhibitors*** Donepezil HCl QLL (30 per 30 days)
EXELON
Galantamine Hydrobromide QLL (60 per 30 days)
Galantamine Hydrobromide ER QLL (30 per 30 days)
Rivastigmine Tartrate QLL (60 per 30 days)
*Antidementia Agents**-*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** NAMENDA
NAMENDA TITRATION PAK
*Fibromyalgia Agents**-*Fibromyalgia Agent - Snris*** SAVELLA ST
SAVELLA TITRATION PACK ST
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*Multiple Sclerosis Agents**-*Multiple Sclerosis Agents - Interferons*** AVONEX PA
AVONEX PEN
AVONEX PREFILLED PA
BETASERON
EXTAVIA PA
REBIF PA
REBIF REBIDOSE
REBIF REBIDOSE TITRATION PACK PA
REBIF TITRATION PACK
*Multiple Sclerosis Agents**-*Multiple Sclerosis Agents*** COPAXONE PA
*Smoking Deterrents**-*Smoking Deterrents*** BUPROBAN (BuPROPion HCl ER (Smoking Det))
CHANTIX
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
Nicotine
NICOTROL
NICOTROL NS
*Sulfonamides*
*Sulfonamides**-*Sulfonamides*** SulfADIAZINE
*Tetracyclines*
*Tetracyclines**-*Tetracyclines*** Avidoxy
Demeclocycline HCl
Doxycycline Hyclate
Doxycycline Monohydrate
Minocycline HCl
Minocycline HCl ER
Updated: 10/01/2015 P a g e | 6 1
AETNA BETTER HEALTH® Formulary Guide
Drug Requirements MORGIDOX (Doxycycline Hyclate)
Tetracycline HCl
*Thyroid Agents*
*Antithyroid Agents**-*Antithyroid Agents*** Methimazole
Propylthiouracil
*Thyroid Hormones**-*Thyroid Hormones*** ARMOUR THYROID
LEVOXYL (Levothyroxine Sodium)
Liothyronine Sodium
NATURE-THROID
NP Thyroid
UNITHROID (Levothyroxine Sodium)
UNITHROID DIRECT (Levothyroxine Sodium)
WESTHROID
WP THYROID
*Ulcer Drugs*
*Antispasmodics**-*Antispasmodics*** Dicyclomine HCl
*Antispasmodics**-*Belladonna Alkaloids*** Ed-Spaz
HYOMAX-SL (Hyoscyamine Sulfate)
Hyoscyamine Sulfate
Hyosyne
NULEV (Hyoscyamine Sulfate)
Oscimin
Oscimin SR
SYMAX FASTABS (Hyoscyamine Sulfate)
SYMAX-SL (Hyoscyamine Sulfate)
SYMAX-SR (Hyoscyamine Sulfate ER)
*Antispasmodics**-*Quaternary Anticholinergics*** Glycopyrrolate
Propantheline Bromide
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements
*H-2 Antagonists**-*H-2 Antagonists*** Cimetidine
Cimetidine HCl
Famotidine
Nizatidine
Ranitidine HCl
*Misc. Anti-Ulcer**-*Misc. Anti-Ulcer*** Sucralfate
*Proton Pump Inhibitors**-*Proton Pump Inhibitors*** FIRST-LANSOPRAZOLE
FIRST-OMEPRAZOLE
Lansoprazole QLL (30 per 30 days)
Omeprazole ORAL CAPSULE DELAYED RELEASE 10 MG QLL (30 per 30 days)
Omeprazole ORAL CAPSULE DELAYED RELEASE 20 MG QLL (120 per 30 days)
Omeprazole ORAL CAPSULE DELAYED RELEASE 40 MG QLL (270 per 30 days)
OMEPRAZOLE+SYRSPEND SF ALKA
Pantoprazole Sodium QLL (30 per 30 days)
PREVACID SOLUTAB
*Ulcer Drugs - Prostaglandins**-*Ulcer Drugs - Prostaglandins*** Misoprostol
*Urinary Anti-Infectives*
*Urinary Anti-Infectives**-*Urinary Anti-Infectives*** MACRODANTIN
Methenamine Hippurate
Methenamine Mandelate
Nitrofurantoin
Nitrofurantoin Macrocrystal
Nitrofurantoin Monohyd Macro
*Urinary Antispasmodics*
*Urinary Antispasmodic - Antimuscarinics (Anticholinergic)**-*Urinary Antispasmodic -Antimuscarinic (Anticholinergic)***
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements Oxybutynin Chloride
Oxybutynin Chloride ER
Tolterodine Tartrate
Trospium Chloride QLL (60 per 30 days)
Trospium Chloride ER QLL (30 per 30 days)
*Urinary Antispasmodics - Cholinergic Agonists**-*Urinary Antispasmodics - Cholinergic Agonists*** Bethanechol Chloride
*Urinary Antispasmodics - Direct Muscle Relaxants**-*Urinary Antispasmodics - Direct Muscle Relaxants*** FlavoxATE HCl
*Vaccines*
*Bacterial Vaccines**-*Bacterial Vaccines*** PNEUMOVAX 23
*Vaginal Products*
*Vaginal Anti-Infectives**-*Imidazole-Related Antifungals*** Miconazole 3
ZAZOLE (Terconazole)
*Vaginal Anti-Infectives**-*Vaginal Anti-Infectives*** CLEOCIN
Clindamycin Phosphate
VANDAZOLE (MetroNIDAZOLE)
*Vaginal Estrogens**-*Vaginal Estrogens*** ESTRACE
ESTRING QLL (1 per 30 days)
FEMRING QLL (1 per 30 days)
PREMARIN
VAGIFEM
*Vasopressors*
*Anaphylaxis Therapy Agents**-*Anaphylaxis Therapy Agents*** AUVI-Q (EPINEPHrine)
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AETNA BETTER HEALTH® Formulary Guide
Drug Requirements EPIPEN 2-PAK (EPINEPHrine)
EPIPEN JR 2-PAK
*Vasopressors**-*Vasopressors*** Midodrine HCl
*Vitamins*
*Oil Soluble Vitamins**-*Vitamin D*** Ergocalciferol
Vitamin D (Ergocalciferol)
*Oil Soluble Vitamins**-*Vitamin K*** MEPHYTON
*Water Soluble Vitamins**-*Vitamin B-3*** Niacin ER
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