Drug coverage reviews. Drugs requiring prior authorization Aetna Premier plan

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1 Drug coverage reviews Drugs requiring prior authorization Aetna Premier plan

2 The drugs on this list require prior authorization (also called preauthorization) under the Aetna Premier plan. If you have a medical need for a prior authorization drug, your doctor can ask for a medical exception. Drugs requiring prior authorization for Premier Plan effective July 1, 2019 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ADZENYS amphetamine sulfate APTENSIO XR armodafinil clonidine er COTEMPLA XR-ODT DAYTRANA DESOXYN dextroamphetamine sulfate solution DYANAVEL XR EVEKEO* guanfacine er INTUNIV KAPVAY methamphetamine modafinil MYDAYIS NUVIGIL PROCENTRA PROVIGIL QUILLICHEW ER QUILLIVANT XR AMINOGLYCOSIDES ARIKAYCE Key * Not covered for plans with formulary exclusions. For plans without formulary exclusions, you will pay the nonpreferred copay with prior authorization approval. UPPERCASE Brand-name medicine lowercase italics Generic medicine Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna Health Assurance Pennsylvania Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company. In Maryland by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT Each insurer has sole financial responsibility for its own products. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

3 ANALGESICS - ANTI-INFLAMMATORY ACTEMRA ARCALYST ENBREL HUMIRA ILARIS KEVZARA KINERET OLUMIANT ORENCIA ANALGESICS - NARCOTIC ABSTRAL acetaminophen/caffeine/ dihydrocodeine capsule acetaminophen/codeine ACTIQ APADAZ* ARYMO ER ascomp/codeine BELBUCA benzhydrocodone/acetaminophen buprenorphine patch butalbital/acetaminophen/caffeine/ codeine butalbital/aspirin/caffeine/codeine butorphanol tartrate BUTRANS codeine sulfate CONZIP* DILAUDID DOLOPHINE DURAGESIC DVORAH* EMBEDA endocet fentanyl FENTORA OTEZLA SIMPONI SIMPONI ARIA TIVORBEX* VIVLODEX* XELJANZ XELJANZ XR ZORVOLEX* FIORICET/CODEINE FIORINAL/CODEINE #3 hydrocodone/acetaminophen hydrocodone/ibuprofen hydromorphone hydromorphone er HYSINGLA ER IBUDONE KADIAN LAZANDA* levorphanol tartrate lorcet LORTAB meperidine methadone METHADOSE methadose MORPHABOND ER morphine sulfate morphine sulfate er MS CONTIN NALOCET* NORCO NUCYNTA NUCYNTA ER

4 ANALGESICS NARCOTIC (continued) OPANA OXAYDO oxycodone oxycodone er oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen OXYCONTIN oxymorphone oxymorphone er pentazocine/naloxone PERCOCET PRIMLEV* ROXICODONE ANDROGEN-ANABOLIC ANDRODERM* ANDROGEL* FORTESTA* NATESTO* STRIANT* ANORECTAL UCERIS foam ANTHELMINTIC BENZNIDAZOLE ANTIASTHMATIC AIRDUO RESPICLICK ARCAPTA NEOHALER BEVESPI AEROSPHERE BROVANA CINQAIR DALIRESP DUPIXENT LONHALA MAGNAIR ROXYBOND SUBSYS* tramadol tramadol er capsules* tramadol er tablets tramadol/acetaminophen TREZIX TYLENOL/CODEINE #3 TYLENOL/CODEINE #4 ULTRACET ULTRAM vicodin XTAMPZA ER ZOHYDRO ER TESTIM* testosterone VOGELXO* XYOSTED NUCALA PERFOROMIST PULMICORT SEEBRI NEOHALER TUDORZA PRESSAIR UTIBRON NEOHALER XOLAIR YUPELRI

5 ANTICOAGULANTS BEVYXXA ANTICONVULSANT BRIVIACT DIACOMIT EPIDIOLEX ANTIDEPRESSANTS DESVENLAFAXINE ER desvenlafaxine er FETZIMA ANTIDIABETIC ADLYXIN* AFREZZA BYDUREON BYETTA FORTAMET* GLUMETZA* KORLYM ANTIDIARRHEALS MYTESI ANTIDOTES deferasirox EVZIO* EXJADE ANTIEMETICS AKYNZEO BONJESTA DICLEGIS ANTIHISTAMINES carbinoxamine 6 mg tablet* phenadoz promethazine ryvent* SABRIL vigabatrin vigadrone KHEDEZLA PRISTIQ* TRINTELLIX metformin er (generic FORTAMET and generic GLUMETZA)* OZEMPIC SYMLINPEN TRULICITY VICTOZA FERRIPROX JADENU dronabinol MARINOL SYNDROS promethazine promethegan

6 ANTIHYPERLIPIDEMIC FLOLIPID* JUXTAPID KYNAMRO ANTIHYPERTENSIVE EPANED QBRELIS ANTIMYASTHENIC AGENTS FIRDAPSE ANTIMYCOBACTERIAL AGENTS SIRTURO ANTINEOPLASTICS abiraterone acetate ACTIMMUNE AFINITOR ALECENSA ALUNBRIG BALVERSA bexarotene BOSULIF BRAFTOVI CABOMETYX CALQUENCE capecitabine CAPRELSA COMETRIQ COPIKTRA COTELLIC DAURISMO ELIGARD ERIVEDGE ERLEADA erlotinib FARYDAK FASLODEX FIRMAGON GILOTRIF GLEEVEC* PRALUENT REPATHA VECAMYL GLEOSTINE HYCAMTIN IBRANCE ICLUSIG IDHIFA imatinib mesylate IMBRUVICA INLYTA INTRON A IRESSA JAKAFI KISQALI KISQALI FEMARA LENVIMA leuprolide acetate LONSURF LORBRENA LUPRON DEPOT LYNPARZA MEKINIST MEKTOVI NERLYNX NEXAVAR NINLARO ODOMZO POMALYST

7 ANTINEOPLASTICS (continued) PURIXAN RUBRACA RYDAPT SPRYCEL STIVARGA SUTENT SYLATRON TAFINLAR TAGRISSO TALZENNA TARCEVA TARGRETIN* TASIGNA TEMODAR* temozolomide TIBSOVO TRELSTAR MIXJECT TYKERB ANTIPARKINSONIAN DUOPA GOCOVRI* INBRIJA ANTIPSYCHOTICS ANTIVIRAL CLOZARIL FAZACLO GEODON INVEGA NUPLAZID RISPERDAL DAKLINZA DELSTRIGO EPCLUSA VENCLEXTA VERZENIO VITRAKVI VIZIMPRO VOTRIENT XALKORI XATMEP XELODA* XOSPATA XTANDI YONSA ZEJULA ZELBORAF ZOLINZA ZYDELIG ZYKADIA ZYTIGA OSMOLEX ER* XADAGO* SAPHRIS SEROQUEL VERSACLOZ VRAYLAR ZYPREXA FUZEON GENVOYA HARVONI

8 ANTIVIRAL (continued) ledipasvir/sofosbuvir* MAVYRET PEGASYS PEGINTRON PREVYMIS sofosbuvir/velpatasvir* SOVALDI STRIBILD BETA BLOCKERS HEMANGEOL CORTICOSTEROIDS budesonide er EMFLAZA* COUGH/COLD/ALLERGY CODITUSSIN AC hydrocodone bitartrate/guaifenesin DERMATOLOGICAL ABSORICA ALTRENO* amnesteem ATRALIN* avita claravis COSENTYX diclofenac* DUPIXENT ELIDEL EUCRISA* ILUMYA isotretinoin lidocaine patch LIDODERM* MIRVASO* Myorisan SYMTUZA VALCYTE valganciclovir VEMLIDY VIEKIRA PAK VOSEVI ZEPATIER TAPERDEX* UCERIS tablets TUSSICAPS TUXARIN ER pimecrolimus PROTOPIC* QBREXZA REGRANEX RETIN-A RETIN-A MICRO retinoic acid SILIQ STELARA tacrolimus ointment TALTZ tazarotene TAZORAC TREMFYA tretinoin topical VALCHLOR zenatane

9 DIURETICS CAROSPIR* FLUOROQUINOLONES GOUT BAXDELA KRYSTEXXA HEMATOPOIETIC AGENTS HYPNOTICS ARANESP ALBUMIN FREE CERDELGA CEREZYME DOPTELET ELELYSO ENDARI EPOGEN FULPHILA GRANIX LEUKINE miglustat MIRCERA MULPLETA eszopiclone HETLIOZ MIGRAINE PRODUCTS AIMOVIG AJOVY MISCELLANEOUS BENLYSTA CUPRIMINE D-PENAMINE DEPEN TITRATABS LOKELMA MISCELLANEOUS ANTI-INFECTIVES IMPAVIDO KEVEYIS NEULASTA NEUPOGEN NIVESTYM NPLATE PROCRIT PROMACTA RETACRIT SIKLOS UDENYCA VPRIV ZARXIO ZAVESCA LUNESTA EMGALITY REVLIMID SYPRINE THALOMID trientine VELTASSA XIFAXAN 550 mg

10 MISCELLANEOUS CARDIOVASCULAR ADCIRCA ADEMPAS alyq ambrisentan bosentan CORLANOR ENTRESTO epoprostenol FLOLAN LETAIRIS OPSUMIT MISCELLANEOUS ENDOCRINE ALDURAZYME BUPHENYL CARBAGLU cinacalcet CYSTADANE ELAPRASE FABRAZYME FORTEO GENOTROPIN H.P. ACTHAR HUMATROPE INCRELEX JYNARQUE KANUMA KUVAN LUMIZYME LUPANETA PACK LUPRON DEPOT-PED MYALEPT NAGLAZYME NATPARA NITYR NOCDURNA NOCTIVA ORENITRAM REMODULIN REVATIO sildenafil tadalafil TRACLEER treprostinil TYVASO UPTRAVI VELETRI VENTAVIS NORDITROPIN FLEXPRO NUTROPIN AQ NUSPIN octreotide acetate OMNITROPE ORFADIN ORILISSA PALYNZIQ PROLIA RAVICTI RAYALDEE SAIZEN SAMSCA SANDOSTATIN SANDOSTATIN LAR DEPOT SENSIPAR SEROSTIM SIGNIFOR SIGNIFOR LAR sodium phenylbutyrate SOMATULINE DEPOT SOMAVERT STIMATE STRENSIQ SYNAREL

11 MISCELLANEOUS ENDOCRINE (continued) TRIPTODUR TYMLOS VIMIZIM XGEVA MISCELLANEOUS GENITOURINARY PRODUCTS finasteride PROCYSBI MISCELLANEOUS GI alosetron CHOLBAM CIMZIA ENTYVIO GATTEX INFLECTRA LOTRONEX MOTEGRITY MISCELLANEOUS HEMATOLOGICAL ADVATE ADYNOVATE AFSTYLA ALPHANATE ALPHANINE SD ALPROLIX aspirin/omeprazole er BENEFIX BERINERT CABLIVI CINRYZE COAGADEX CORIFACT EFFIENT ELOCTATE FEIBA XURIDEN ZOMACTON ZORBTIVE PROSCAR THIOLA OCALIVA RELISTOR REMICADE RENFLEXIS STELARA SYMPROIC VIBERZI XERMELO FIBRYGA FIRAZYR HAEGARDA HELIXATE FS HEMLIBRA HEMOFIL M HUMATE-P IDELVION IXINITY JIVI KALBITOR KCENTRA KOATE KOATE-DVI KOGENATE FS KOVALTRY

12 MISCELLANEOUS HEMATOLOGICAL (continued) MONOCLATE-P RIXUBIS MONONINE RUCONEST NOVOEIGHT SOLIRIS NOVOSEVEN RT TAKHZYRO NUWIQ TAVALISSE OBIZUR TRETTEN prasugrel VONVENDI PROFILNINE WILATE PROFILNINE SD XYNTHA REBINYN XYNTHA SOLOFUSE RECOMBINATE YOSPRALA* RIASTAP ZONTIVITY MISCELLANEOUS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS AMPYRA* LEMTRADA AUBAGIO MAVENCLAD* AUSTEDO MAYZENT* AVONEX NUEDEXTA BETASERON paroxetine 7.5 mg capsule BRISDELLE PLEGRIDY COPAXONE REBIF dalfampridine er TECFIDERA EXTAVIA TEGSEDI GILENYA tetrabenazine glatiramer acetate TYSABRI glatopa XENAZINE HORIZANT XYREM INGREZZA MISCELLANEOUS RESPIRATORY ARALAST NP ORKAMBI ESBRIET PROLASTIN-C GLASSIA PULMOZYME KALYDECO SYMDEKO OFEV ZEMAIRA

13 MUSCULOSKELETAL THERAPY AGENTS DUROLANE EUFLEXXA GEL-ONE GELSYN-3 GENVISC 850 HYALGAN HYMOVIS NEUROMUSCULAR AGENTS BOTOX DYSPORT RILUTEK OPHTHALMIC CYSTARAN EYLEA JETREA LUCENTIS PASSIVE IMMUNIZING AGENTS PRESSORS PROGESTINS BIVIGAM CARIMUNE NANOFILTERED CUVITRU FLEBOGAMMA DIF GAMMAGARD GAMMAKED GAMMAPLEX AUVI-Q* hydroxyprogesterone caproate MAKENA oil* SYSTEMIC AND TOPICAL NASAL PRODUCTS XHANCE* TETRACYCLINES NUZYRA MONOVISC ORTHOVISC SUPARTZ FX SYNVISC TRIVISC VISCO-3 riluzole TIGLUTIK XEOMIN MACUGEN OXERVATE VISUDYNE XELPROS GAMUNEX-C HIZENTRA HYQVIA OCTAGAM PANZYGA PRIVIGEN SYNAGIS NORTHERA MAKENA solution auto-injector

14 ULCER DRUGS chlordiazepoxide/clidinium bromide* GLYCATE* glycopyrrolate* LIBRAX*

15 Please remember that this is not a complete list of medications covered under your plan. Because there are thousands of medications included in your pharmacy benefit, we only list the most common ones. Certain drugs such as those for smoking cessation or vitamins may not be covered by your particular pharmacy plan. Diabetic supplies may be covered under your medical plan. Specific prescription benefits plan design may not cover certain categories or may be subject to additional charges or restrictions, regardless of their appearance in this document. This is not an inclusive list. Void where prohibited by law. If you have any questions about your pharmacy benefits, please visit the website that s on your member ID card and log in to your member website. If you don t have access to our website, call the Member Services number on your ID card. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna may receive rebates from certain drug manufacturers. Generally, such rebates do not directly reduce the amount a member pays the pharmacy for covered prescriptions. Information is believed to be accurate as of the production date; however, it is subject to change. Policy forms issued in Missouri include: AL HGrpPol 01R5, HI HGrpAG 05, HO HGrpPol 04. Policy forms issued in Oklahoma include: HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23, GR-29N. ta Aetna Inc. aetna.com B (06/19)