Drug coverage reviews. Drugs requiring prior authorization Aetna Value/Value Plus plans

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1 Drug coverage reviews Drugs requiring prior authorization Aetna Value/Value Plus plans

2 The drugs on this list require prior authorization (also called preauthorization) under the Aetna Value and Value Plus plans. If you have a medical need for a preauthorization drug, your doctor can ask for a medical exception. January 1, 2019 Drugs requiring prior authorization Value and Value Plus plans ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ADZENYS ER guanfacine er ADZENYS XR-ODT INTUNIV APTENSIO XR KAPVAY armodafinil methamphetamine hcl clonidine hcl er COTEMPLA XR-ODT DAYTRANA DESOXYN dextroamphetamine sulfate solution DYANAVEL XR EVEKEO ANALGESICS - ANTI-INFLAMMATORY ACTEMRA ARCALYST ENBREL HUMIRA ILARIS KEVZARA KINERET OLUMIANT ORENCIA modafinil MYDAYIS NUVIGIL PROCENTRA PROVIGIL QUILLICHEW ER QUILLIVANT XR OTEZLA SIMPONI SIMPONI ARIA TIVORBEX* VIVLODEX* XELJANZ XELJANZ XR ZORVOLEX* Key * Not covered for plans with formulary exclusions. For plans without this program, you will pay the non-preferred 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 - NARCOTIC ABSTRAL acetaminophen/caffeine/dihydrocodeine tablet acetaminophen/caffeine/dihydrocodeine bitartrate capsule* acetaminophen/codeine ACTIQ ARYMO ER ascomp/codeine BELBUCA BUNAVAIL buprenorphine buprenorphine hcl buprenorphine hcl/naloxone hcl butalbital/acetaminophen/caffeine/codeine butalbital/aspirin/caffeine/codeine butorphanol tartrate BUTRANS codeine sulfate CONZIP* DILAUDID DOLOPHINE DURAGESIC EMBEDA endocet EXALGO fentanyl fentanyl citrate oral transmucosal FENTORA FIORICET/CODEINE FIORINAL/CODEINE #3 hydrocodone bitartrate/acetaminophen hydrocodone/ibuprofen hydromorphone hcl hydromorphone hcl er HYSINGLA ER IBUDONE ibudone KADIAN LAZANDA* levorphanol tartrate lorcet lorcet hd lorcet plus LORTAB meperidine hcl methadone hcl methadone hcl intensol METHADOSE methadose METHADOSE SUGAR-FREE MORPHABOND ER morphine sulfate morphine sulfate er MS CONTIN NALOCET* NORCO NUCYNTA NUCYNTA ER OPANA OPANA ER (CRUSH RESISTANT) OXAYDO oxycodone hcl oxycodone hcl er oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen OXYCONTIN oxymorphone hcl oxymorphone hcl er panlor* pentazocine/naloxone hcl PERCOCET PRIMLEV* ROXICODONE ROXYBOND SUBOXONE SUBSYS* tramadol hcl tramadol hcl er tablets tramadol hcl er capsules* tramadol hcl/acetaminophen TREZIX TYLENOL/CODEINE #3

4 ANALGESICS NARCOTIC (continued) TYLENOL/CODEINE #4 ULTRACET ULTRAM verdrocet ANDROGEN-ANABOLIC ANDRODERM* ANDROGEL 1.62% ANDROGEL PUMP ANDROGEL 1%* FORTESTA* NATESTO* STRIANT* ANORECTAL UCERIS foam ANTHELMINTIC BENZNIDAZOLE ANTIANXIETY AGENTS alprazolam alprazolam er ALPRAZOLAM INTENSOL alprazolam odt alprazolam xr chlordiazepoxide hcl ANTIASTHMATIC AIRDUO RESPICLICK ALVESCO ARCAPTA NEOHALER ARMONAIR RESPICLICK BEVESPI AEROSPHERE BROVANA budesonide suspension CINQAIR ANTICOAGULANTS BEVYXXA ANTICONVULSANT BRIVIACT DALIRESP LONHALA MAGNAIR SABRIL vicodin vicodin es ZOHYDRO ER ZUBSOLV TESTIM* testosterone testosterone pump testosterone topical solution VOGELXO PUMP* VOGELXO* clorazepate dipotassium oxazepam TRANXENE T XANAX XR* XANAX* NUCALA PERFOROMIST PULMICORT PULMICORT FLEXHALER SEEBRI NEOHALER STRIVERDI RESPIMAT TUDORZA PRESSAIR UTIBRON NEOHALER XOLAIR vigabatrin vigadrone

5 ANTIDEPRESSANTS DESVENLAFAXINE ER desvenlafaxine er FETZIMA FETZIMA TITRATION PACK ANTIDIABETIC ADLYXIN STARTER PACK* ADLYXIN* AFREZZA BYDUREON BCISE* BYDUREON PEN* BYDUREON* BYETTA* FORTAMET* ANTIDIARRHEALS MYTESI ANTIDOTES EVZIO* EXJADE FERRIPROX ANTIEMETICS AKYNZEO BONJESTA DICLEGIS ANTIHISTAMINES carbinoxamine 6mg tablet* ANTIHYPERLIPIDEMIC JUXTAPID KYNAMRO ANTIHYPERTENSIVE BYVALSON EPANED ANTIMYCOBACTERIAL AGENTS SIRTURO KHEDEZLA PRISTIQ TRINTELLIX GLUMETZA* KORLYM metformin hcl er (generic FORTAMET and generic GLUMETZA)* OZEMPIC* SYMLINPEN TRULICITY VICTOZA JADENU JADENU SPRINKLE dronabinol MARINOL SYNDROS ryvent* PRALUENT REPATHA QBRELIS VECAMYL

6 ANTINEOPLASTICS ACTIMMUNE AFINITOR ALECENSA ALUNBRIG bexarotene BOSULIF BRAFTOVI CABOMETYX CALQUENCE capecitabine CAPRELSA COMETRIQ COTELLIC ELIGARD ERIVEDGE ERLEADA FARYDAK FASLODEX FIRMAGON GILOTRIF GLEEVEC* GLEOSTINE HYCAMTIN IBRANCE ICLUSIG IDHIFA imatinib mesylate IMBRUVICA INLYTA INTRON A IRESSA JAKAFI KISQALI KISQALI FEMARA LENVIMA leuprolide acetate LONSURF LUPRON DEPOT LYNPARZA MEKINIST MEKTOVI NERLYNX NEXAVAR NINLARO ODOMZO POMALYST PURIXAN RUBRACA RYDAPT SPRYCEL STIVARGA SUTENT SYLATRON TAFINLAR TAGRISSO TARCEVA TARGRETIN capsule TASIGNA TEMODAR* temozolomide TIBSOVO TRELSTAR MIXJECT TYKERB VENCLEXTA VERZENIO VOTRIENT XALKORI XATMEP XELODA* XTANDI YONSA ZEJULA ZELBORAF ZOLINZA ZYDELIG ZYKADIA

7 ANTIPARKINSONIAN DUOPA GOCOVRI* ANTIPSYCHOTICS CLOZARIL FAZACLO GEODON INVEGA NUPLAZID REXULTI RISPERDAL ANTIVIRAL BIKTARVY DAKLINZA EPCLUSA FUZEON GENVOYA HARVONI MAVYRET PEGASYS PEGASYS PROCLICK PEGINTRON PREVYMIS BETA BLOCKERS BYSTOLIC CORTICOSTEROIDS EMFLAZA* DERMATOLOGICAL ABSORICA* amnesteem ATRALIN* avita claravis COSENTYX COSENTYX SENSOREADY PEN diclofenac* DUPIXENT ELIDEL* EUCRISA* isotretinoin JUBLIA* KERYDIN lidocaine patch OSMOLEX ER* XADAGO* SAPHRIS SEROQUEL VERSACLOZ VRAYLAR ZYPREXA ZYPREXA ZYDIS SOVALDI STRIBILD SYMTUZA TECHNIVIE VALCYTE valganciclovir hydrochlorde VEMLIDY VIEKIRA PAK VIEKIRA XR VOSEVI ZEPATIER HEMANGEOL TAPERDEX 12-DAY* LIDODERM MIRVASO* myorisan PENLAC NAIL LACQUER PROTOPIC* REGRANEX RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP retinoic acid retinoic acid-all trans SILIQ STELARA SILIQ STELARA

8 DERMATOLOGICAL (continued) tacrolimus ointment TALTZ tazarotene TAZORAC TREMFYA tretinoin cream/gel DIURETICS CAROSPIR* FLUOROQUINOLONES BAXDELA GOUT DUZALLO KRYSTEXXA HEMATOPOIETIC AGENTS ARANESP ALBUMIN FREE CERDELGA CEREZYME DOPTELET ELELYSO ENDARI EPOGEN FULPHILA GRANIX LEUKINE miglustat MIRCERA HYPNOTICS AMBIEN AMBIEN CR BELSOMRA DORAL EDLUAR* estazolam eszopiclone flurazepam hcl HALCION HETLIOZ INTERMEZZO* LUNESTA tretinoin (all-trans retinoic acid) tretinoin microsphere tretinoin microsphere pump VALCHLOR zenatane KEVEYIS ZURAMPIC NEULASTA NEULASTA ONPRO KIT NEUPOGEN NPLATE PROCRIT PROMACTA RETACRIT SIKLOS VPRIV ZARXIO ZAVESCA quazepam RESTORIL SILENOR* SONATA temazepam triazolam zaleplon zolpidem tartrate zolpidem tartrate er zolpidem tartrate sublingual* ZOLPIMIST*

9 MIGRAINE PRODUCTS AIMOVIG MISCELLANEOUS BENLYSTA CUPRIMINE DEPEN TITRATABS REVLIMID MISCELLANEOUS ANTI-INFECTIVES IMPAVIDO MISCELLANEOUS CARDIOVASCULAR ADCIRCA ADEMPAS CORLANOR ENTRESTO epoprostenol FLOLAN LETAIRIS OPSUMIT ORENITRAM MISCELLANEOUS ENDOCRINE ALDURAZYME BRAVELLE BUPHENYL CARBAGLU CETROTIDE chorionic gonadotropin CYSTADANE ELAPRASE FABRAZYME FOLLISTIM AQ FORTEO GANIRELIX ACETATE GENOTROPIN GONAL-F MENOPUR MYALEPT NAGLAZYME NATPARA NITYR NOCTIVA NORDITROPIN FLEXPRO novarel CAMBIA* SYPRINE THALOMID trientine hcl VELTASSA XIFAXAN 550mg REMODULIN REVATIO sildenafil citrate tadalafil TRACLEER TYVASO UPTRAVI VELETRI VENTAVIS NUTROPIN AQ NUSPIN octreotide acetate OMNITROPE ORFADIN OVIDREL PALYNZIQ pregnyl w/diluent benzyl alcohol/nacl PROLIA RAVICTI RAYALDEE SAIZEN SAMSCA SANDOSTATIN SANDOSTATIN LAR DEPOT SENSIPAR SEROSTIM SIGNIFOR SIGNIFOR LAR sodium phenylbutyrate SOMATULINE DEPOT SOMAVERT STIMATE

10 MISCELLANEOUS ENDOCRINE (continued STRENSIQ SYNAREL TRIPTODUR TYMLOS VIMIZIM MISCELLANEOUS GASTROINTESTINAL alosetron hcl CHENODAL CHOLBAM CIMZIA ENTYVIO GATTEX INFLECTRA LOTRONEX MISCELLANEOUS HEMATOLOGICAL ADVATE ADYNOVATE AFSTYLA ALPHANATE ALPHANINE SD ALPROLIX BEBULIN BENEFIX BERINERT CINRYZE COAGADEX CORIFACT EFFIENT ELOCTATE FEIBA FIBRYGA FIRAZYR HAEGARDA HELIXATE FS HEMLIBRA HEMOFIL M HUMATE-P IDELVION IXINITY JIVI KALBITOR KCENTRA KOATE XGEVA XURIDEN ZOMACTON ZORBTIVE OCALIVA RELISTOR REMICADE RENFLEXIS STELARA SYMPROIC VIBERZI XERMELO KOATE-DVI KOGENATE FS KOGENATE FS BIO-SET KOVALTRY MONOCLATE-P MONONINE NOVOEIGHT NOVOSEVEN RT NUWIQ OBIZUR prasugrel PROFILNINE PROFILNINE SD REBINYN RECOMBINATE RIASTAP RIXUBIS RUCONEST SOLIRIS TAVALISSE TRETTEN VONVENDI WILATE XYNTHA XYNTHA SOLOFUSE YOSPRALA* ZONTIVITY

11 MISCELLANEOUS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS AMPYRA ARICEPT AUBAGIO AUSTEDO AVONEX AVONEX PEN BETASERON BRISDELLE COPAXONE* donepezil hcl donepezil hcl odt EXELON EXTAVIA galantamine hydrobromide galantamine hydrobromide er GILENYA glatiramer acetate glatopa HORIZANT INGREZZA LEMTRADA memantine hcl memantine hcl er MISCELLANEOUS RESPIRATORY ARALAST NP ESBRIET GLASSIA KALYDECO OFEV MISCELLANEOUS GENITOURINARY PRODUCTS CYSTAGON finasteride PROCYSBI MUSCULOSKELETAL THERAPY AGENTS DUROLANE EUFLEXXA GEL-ONE GELSYN-3 GENVISC 850 HYALGAN HYMOVIS memantine hcl titration pak NAMENDA NAMENDA TITRATION PAK NAMENDA XR NAMENDA XR TITRATION PACK NAMZARIC NUEDEXTA paroxetine 7.5mg capsule PLEGRIDY RAZADYNE RAZADYNE ER REBIF REBIF REBIDOSE REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK rivastigmine tartrate rivastigmine transdermal system TECFIDERA TECFIDERA STARTER PACK tetrabenazine TYSABRI XENAZINE XYREM ORKAMBI tablet PROLASTIN-C PULMOZYME SYMDEKO ZEMAIRA PROSCAR THIOLA MONOVISC ORTHOVISC SUPARTZ FX SYNVISC SYNVISC ONE VISCO-3

12 NEUROMUSCULAR AGENTS BOTOX DYSPORT RILUTEK OPHTHALMIC bimatoprost CYSTARAN EYLEA JETREA LUCENTIS LUMIGAN PASSIVE IMMUNIZING AGENTS BIVIGAM CARIMUNE NANOFILTERED CUVITRU FLEBOGAMMA DIF GAMMAGARD GAMMAKED GAMMAPLEX PRESSORS AUVI-Q* PROGESTINS hydroxyprogesterone caproate MAKENA SYSTEMIC AND TOPICAL NASAL PRODUCTS XHANCE* ULCER DRUGS ACIPHEX ACIPHEX SPRINKLE chlordiazepoxide hcl/clidinium bromide* DEXILANT* GLYCATE* lansoprazole dispersible tablet riluzole XEOMIN MACUGEN VISUDYNE VYZULTA XALATAN ZIOPTAN GAMUNEX-C HIZENTRA HYQVIA OCTAGAM PRIVIGEN SYNAGIS NORTHERA MAKENA* LIBRAX* omeprazole/sodium bicarbonate packet* PREVACID SOLUTAB PRILOSEC* ZEGERID*

13 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. If you have any questions about your pharmacy benefits, please visit aetna.com 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. To check coverage and copay information for a specific medicine, visit aetna.com and log in to your member website. For more details, please call the toll-free number on your member ID card. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Products that are not represented on this list may be subject to plan-specific copayment or coinsurance. Void where prohibited by law. 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. Aetna may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. Information is believed to be accurate as of the production date; however, it is subject to change. For questions, please call the tollfree number on your member ID card. Policy forms issued in Missouri include: AL HGrpPol 01R5, HI HGrpAG 01, HO HGrpPol 01. 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 (07/18) aetna.com