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2015 Aetna Pharmacy Plan Drug List
Three Tier Open Individual Plan
www.aetna.com
©2014 Aetna Inc.
13.05.301.1 A (9/14)
Do you have questions?
Call the toll-free number on your member ID card. Or visit
www.aetna.com/formulary for the most up-to-date information.
Dear Member:
What pharmacy benefits plan do I have?
To help you know how drugs are covered by your plan, we
are pleased to provide you with a copy of our 2015 Aetna
Pharmacy Plan Drug List.
You are enrolled in the Aetna Three Tier Open
Individual plan.
This guide provides helpful information about your pharmacy
benefits plan. You may want to take this guide with you when
you see your doctor to talk about what is covered under your
plan and what you can expect to pay for your medicine.
Many commonly prescribed drugs are listed in this guide. Please
remember this is not a complete list of drugs covered under your
plan. Because thousands of drugs are included in your pharmacy
benefits plan, we only list the most commonly prescribed ones.
Here’s what that means to you:
Think of tier as a level. Three Tier means you could pay three
different amounts, depending on the drug you take.
A formulary is a list of generic and brand-name drugs that your
health plan covers. An open formulary means your plan covers
most prescription drugs. But it may not cover some others.
What can I expect to pay?
With this health benefits and health insurance plan, the amount
you pay depends on the drug your doctor prescribes. It’s either
a flat fee or a percent of the prescription’s price.
What you pay falls into one of these tiers or levels:
Tier One: Generics – You pay the lowest cost for drugs in
this level. Your plan may include an additional benefit where
some Tier 1 drugs would be provided at an even lower cost to
you. These are considered Value Drugs/Tier 1a and include
generics and some over-the-counter brand and generic
products. These would be available at the lowest cost share
indicated in your plan materials.
Tier Two: Preferred Brands – You pay a slightly higher cost
for drugs in this level.
Tier Three: Non-Preferred Brands – You pay the highest cost
for drugs in this level.
To find your exact costs
Check your Plan Design and Benefits summary. This should be
in your enrollment kit.
Your pharmacy benefits plan may include a program that
encourages you to choose a generic drug over a brand-name
drug, in order to help reduce what you pay. This means that
if you fill a brand-name drug when a generic is available, that
in addition to your standard copay or coinsurance, you must
also pay the difference in cost between the brand-name and
generic drug.
For a summary of your pharmacy benefits plan, including
out-of-pocket costs, visit www.aetna.com and log in to Aetna
Navigator. Or call the toll-free number on your member ID card.
www.aetna.com/formulary
Where can I find more formulary information?
Why is the formulary subject to change?
You and your doctor can search for a drug, find out if it’s covered
and see what tier it falls under. You can also see if there are
alternatives that cost less. Make sure your doctor knows that
you pay more for two and three tier drugs. He or she can
consider this before writing a prescription.
We may add or remove drugs for certain reasons. We might
also move a drug from one coverage tier to another.
Take these steps:
1.Visit www.aetna.com/formulary. You arrive at a page that
says “Medication Search.”
2.This is where you can learn more about the types of
drug coverage reviews your drug requires; things like
precertification, step therapy or quantity limits. You will
arrive at a menu page where you can view various drug lists,
including your Aetna Pharmacy Plan Drug List and more.
How is the formulary developed?
Aetna’s Pharmacy and Therapeutics (P&T) Committee meets
regularly to review new drugs and new information about
drugs that are already on the market. It reviews available
information concerning safety, effectiveness and current use
in therapy. The P&T Committee reviews scientific evidence,
including relevant findings of federal government agencies,
pharmaceutical manufacturers, medical professional
associations, national commissions and peer-reviewed journals.
Our P&T Committee includes licensed pharmacists and doctors,
including those who are currently in practice and others who are
Aetna employees. All committee members must tell us if they
are in a situation that can create a conflict of interest or if they
have a financial stake that might affect their decisions.
Once the P&T Committee completes its clinical review, we
also consider overall value (including cost and manufacturer
rebate arrangements) and other factors before adding or
removing a drug from the formulary. Aetna Pharmacy Plan
Drug List shows you recent changes to the guide. For example,
it could show what drugs started requiring coverage reviews like
precertification, step therapy or quantity limits. Or which drugs
no longer do. The P&T Committee can make recommendations
to change the tier level of a drug or to place it on our Formulary
Exclusions List, designating it as a drug that is no longer covered.
Here are some reasons why:
•As brand-name drugs lose their patents and generic versions
become available, the brand-name may be covered at a higher
out-of-pocket cost while the generic may be covered at a lower
out-of-pocket cost.
•The Food and Drug Administration (FDA) approves many
new drugs throughout the year.
•Drugs can be withdrawn from the market or may become
available without a prescription.
Our website, www.aetna.com/formulary, reflects the most
up-to-date formulary information – so please visit it often.
Why do some drugs require prior authorization
or precertification?
This drug coverage review encourages appropriate and costeffective use of prescription drugs by allowing coverage only
when certain conditions are met.
Reasons for precertification include:
•Compliance with dosing guidelines
•Avoiding duplicate therapies
•Helping health care providers check that a drug is being
used based on generally accepted medical criteria
The precertification program is based upon current medical
findings, FDA-approved manufacturer labeling information,
and cost and manufacturer rebate arrangements.
If your plan requires precertification, you will find a list of drugs
that are subject to precertification with this guide. Please keep
the following in mind:
•Your doctor must contact Aetna to request approval of
coverage for these drugs.
•If we approve the request, we will notify your doctor. The
drug will then be covered at the applicable out-of-pocket
cost under your plan. You will also be notified of approvals
where the state requires notification to members.
If the request is denied, you and your doctor will be notified.
You can still purchase the drug, but for the full price.
www.aetna.com/formulary
Why do some drugs have quantity limits?
Saving on prescriptions
This drug coverage review limits coverage of quantities for
certain drugs. These limits help your doctor and pharmacist
check that your prescribed drug is used correctly and safely.
Here are some other tips to pay less out of pocket for your
prescription drugs:
We use medical guidelines and FDA-approved recommendations
from drug makers to set these coverage limits. The quantity limit
program includes:
•Dose Efficiency Edits – Limit coverage of prescriptions to one
dose per day for drugs that are approved for once-daily dosing.
•Maximum Daily Dose – A message is sent to the pharmacy
if a prescription is less than the minimum or higher than the
maximum allowed dose.
•Quantity Limits Over Time – Limit coverage of prescriptions
to a specific number of units in a defined amount of time.
What is step therapy?
This drug coverage review promotes the appropriate use
of equally effective but lower-cost drugs first. Prerequisite
drugs are FDA-approved and treat the same condition as
the corresponding step therapy drugs.
What is therapeutic duplication?
Therapeutic duplication means that two or more drugs of
the same type are prescribed at the same time. This can occur
when two doctors prescribe similar drugs or when your doctor
switches from one drug to another drug in the same class
without cancelling the first prescription.
It is rare that you should ever need two drugs from the same
class to treat a medical condition. Since serious side effects
may occur, we help bring such duplications to your pharmacist’s
and doctor’s attention.
Learn more about drug coverage reviews
If you have a medical need for a drug that requires precertification,
quantity limits or step therapy, your doctor can ask for a medical
exception. The list of drugs requiring precertification, quantity
limits or step therapy is subject to change. Find the most
up-to-date information at www.aetna.com/formulary.
You may be able to save with generic drugs
Generic drugs are approved by the U.S. Food and Drug
Administration (FDA) and proven to be just as safe and effective
as brand-name drugs. They contain the same active ingredients
in the same amounts as the brand-name products. The
difference is that generics may be a different color, shape or size.
When appropriate, your doctor may decide to prescribe, or allow
substitution with, a generic drug. Please talk to your doctor to
find out if a generic is right for you.
•Ask your doctor to consider prescribing generic drugs
instead of brand-name drugs.
•Ask your doctor to consider prescribing drugs that are
on the Aetna Pharmacy Plan Drug List.
•Check to see if your plan includes our mail-order pharmacy
service. Depending upon your plan, mail order may save you
money. See Aetna Rx Home Delivery® in this guide for details.
•Remind your doctor to check your plan to make sure you
get maximum coverage.
What is Aetna Rx Home Delivery?
Check your plan documents to see if your plan includes
our Aetna Rx Home Delivery mail-order pharmacy. It fills
prescriptions for maintenance medicine. This type of medicine
is used regularly, to treat conditions like arthritis, asthma,
diabetes or high cholesterol. If you need this type of drug, you
can get up to a 90-day supply, or the maximum supply allowed
by your plan, and free delivery right to your mailbox.
You also get:
•Quick, confidential service
•Free standard shipping
•Pharmacists who check all prescriptions for accuracy
and can answer questions any time
It’s easy and fast to order – choose one of these ways:
1. Mail – Get a new prescription from your doctor. Mail
your new prescription to Aetna Rx Home Delivery with
a completed order form. You can access the form online.
Visit www.aetna.com and log in to Aetna Navigator,
your secure member website. Or you can go right to
www.aetnanavigator.com. Once logged in, click the
link to “Aetna Pharmacy”.
2. F
ax – Give your doctor the Aetna Rx Home Delivery fax
number: 1-877-270-3317. Your doctor can fax in the
prescription. Make sure your doctor includes your member
ID number, your date of birth and your mailing address on
the fax cover sheet. Only a doctor may fax a prescription.
3. Phone – To help make it easy to get started, you can also
choose to use our Aetna Rx Courtesy Start SM program. Call
the toll-free number on your member ID card. Ask us to reach
out to your doctor. We can request a new 90-day prescription
on your behalf. Your doctor may need you to schedule a visit
before he or she will write you a new prescription. After we
reach out to your doctor, please allow time (up to 7 days) for
us to receive a reply. To help this process move quickly, please
alert your doctor to expect our call.
If your prescription is for a controlled medicine, a written
prescription from your doctor may be needed.
Generally, if your order is complete, you will receive your
medicine within 10-14 days from when Aetna Rx Home Delivery
receives your order. You can request expedited delivery for an
additional charge.
www.aetna.com/formulary
What is Aetna Specialty Pharmacy?
Aetna Specialty Pharmacy is Aetna’s in-house specialty
pharmacy. It can fill your prescription specialty medicine.
These types of drugs may be injected, infused or taken by
mouth. Specialty medicine often needs special storage and
handling. It must be delivered quickly. And a nurse or pharmacist
should monitor you during your treatment. Use Aetna Specialty
Pharmacy to get this medicine sent right to your mailbox.
You also get:
•Free delivery that is reliable, secure and sent anywhere
you choose
•Extra help when you need it – like injection training and
side effect monitoring
•Proactive outreach to confirm your refills
•Free standard supplies
•Nurses and pharmacists who can help you 24 hours a day,
every day
It’s easy and fast to order – choose one of these ways:
•Fax – Your doctor may fax your prescription to
1-866-FAX-ASRX (1-866-329-2779).
•Mail – You or your doctor may mail your prescription order to:
Aetna Specialty Pharmacy, 503 Sunport Lane, Orlando, FL 32809.
If you mail in your own prescription, please send it along with
a completed Patient Profile Form. To access this form, visit
www.AetnaSpecialtyRx.com and click “Specialty pharmacy:
How to enroll.”
•Phone – Your doctor may also call and speak to one
of our registered pharmacists at 1-866-782-ASRX
(1-866-782-2779) during normal business hours of
8 a.m. until 7 p.m. ET.
To transfer an existing prescription order to be filled by
Aetna Specialty Pharmacy, call toll-free at 1-866-353-1892.
www.aetna.com/formulary
Need more information?
Visit www.aetna.com/formulary or call the
appropriate toll-free number on your member ID card.
Please note that if your prescription drug benefits plan changes, the information herein may no longer apply.
A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law
to be otherwise. Some drugs on the Preferred Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That
means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug.
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 Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In
Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Aetna Pharmacy
Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary
of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment.
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features
and availability may vary by location and are subject to change.
SP – Drugs listed are managed by our Aetna’s Specialty Health Care Management SM nurse team. Members receive the support of this team throughout the entire
course of therapy. This team employs a “split fill” dispensing provision. This means that half of a one month’s supply of medicine is filled at a time. Split fill
dispensing allows the nurse team to offer more support, including more follow up to monitor response to treatment and potential reactions or side-effects. This
helps prevent wasted medicine and saves members money if their medicine or dose changes between fills. This list is not all-inclusive and is subject to change.
Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a
member pays the pharmacy for covered prescriptions. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com.
The drugs on the Preferred Drug List, Formulary Exclusions, Precertification, Quantity Limit and Step Therapy Lists are subject to change. The quantity limits and
step therapy drug coverage review programs are not available in all service areas. For example, step therapy programs do not apply to fully-insured members in
Indiana. Step therapy does not apply to fully-insured members in New Jersey. However, these programs are available to self-funded plans.
In accordance with state law, commercial fully-insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving
coverage for medications that are added or removed from the Preferred Drug List, Precertification, Quantity Limits or Step-Therapy Lists during the plan year will
continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service
utilization review.” It is not “verification” as defined by Texas law.
In accordance with state law, fully-insured Commercial California HMO members (except Federal Employee Health Benefit Plan members) who are receiving
coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered, for as long as the treating
physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical
condition. In accordance with state law, fully-insured Commercial Connecticut PPO members (except Federal Employee Health Benefit Plan members) who are
receiving coverage for medications that are added to the Precertification or Step-therapy Lists will continue to have those medications covered for as long as the
treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall
preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this
section be construed to prohibit generic drug substitutions.
This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan
documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are
subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide
care or guarantee access to health services. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com.
www.aetna.com
©2014 Aetna Inc.
13.05.301.1 A (9/14)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
Contents
of
Table
Table of Contents
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* ............................................................................................................................................................................ 3
*AMEBICIDES* ....................................................................................................................................................................................................................................................................................................................... 5
*AMINOGLYCOSIDES* ................................................................................................................................................................................................................................................................................................ 5
*ANALGESICS - ANTI-INFLAMMATORY* ......................................................................................................................................................................................................................................... 6
*ANALGESICS - NONNARCOTIC* ................................................................................................................................................................................................................................................................. 8
*ANALGESICS - OPIOID* ........................................................................................................................................................................................................................................................................................... 9
*ANDROGENS-ANABOLIC* ............................................................................................................................................................................................................................................................................... 11
*ANORECTAL AGENTS* ......................................................................................................................................................................................................................................................................................... 12
*ANTHELMINTICS* ....................................................................................................................................................................................................................................................................................................... 12
*ANTIANGINAL AGENTS* ................................................................................................................................................................................................................................................................................... 12
*ANTIANXIETY AGENTS* ................................................................................................................................................................................................................................................................................... 13
*ANTIARRHYTHMICS* ............................................................................................................................................................................................................................................................................................ 13
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* .......................................................................................................................................................................................... 14
*ANTICOAGULANTS* ................................................................................................................................................................................................................................................................................................ 16
*ANTICONVULSANTS* ............................................................................................................................................................................................................................................................................................ 17
*ANTIDEPRESSANTS* ............................................................................................................................................................................................................................................................................................... 20
*ANTIDIABETICS* .......................................................................................................................................................................................................................................................................................................... 22
*ANTIDIARRHEALS* ................................................................................................................................................................................................................................................................................................... 26
*ANTIDOTES* ....................................................................................................................................................................................................................................................................................................................... 27
*ANTIEMETICS* ................................................................................................................................................................................................................................................................................................................ 27
*ANTIFUNGALS* .............................................................................................................................................................................................................................................................................................................. 27
*ANTIHISTAMINES* ..................................................................................................................................................................................................................................................................................................... 28
*ANTIHYPERLIPIDEMICS* .................................................................................................................................................................................................................................................................................. 30
*ANTIHYPERTENSIVES* ........................................................................................................................................................................................................................................................................................ 32
*ANTI-INFECTIVE AGENTS - MISC.* ..................................................................................................................................................................................................................................................... 36
*ANTIMALARIALS* ...................................................................................................................................................................................................................................................................................................... 37
*ANTIMYASTHENIC/CHOLINERGIC AGENTS* ...................................................................................................................................................................................................................... 37
*ANTIMYCOBACTERIAL AGENTS* ........................................................................................................................................................................................................................................................ 37
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* ................................................................................................................................................................................................ 38
*ANTIPARKINSON AGENTS* ........................................................................................................................................................................................................................................................................... 41
*ANTIPSYCHOTICS/ANTIMANIC AGENTS* ................................................................................................................................................................................................................................ 43
*ANTIVIRALS* ..................................................................................................................................................................................................................................................................................................................... 45
*ASSORTED CLASSES* ............................................................................................................................................................................................................................................................................................ 47
*BETA BLOCKERS* ....................................................................................................................................................................................................................................................................................................... 49
*CALCIUM CHANNEL BLOCKERS* ........................................................................................................................................................................................................................................................ 50
*CARDIOTONICS* ........................................................................................................................................................................................................................................................................................................... 51
*CARDIOVASCULAR AGENTS - MISC.* ............................................................................................................................................................................................................................................ 51
*CEPHALOSPORINS* ................................................................................................................................................................................................................................................................................................... 53
*CHEMICALS* ...................................................................................................................................................................................................................................................................................................................... 53
*CONTRACEPTIVES* .................................................................................................................................................................................................................................................................................................. 53
*CORTICOSTEROIDS* ................................................................................................................................................................................................................................................................................................ 58
*COUGH/COLD/ALLERGY* ................................................................................................................................................................................................................................................................................ 58
*DERMATOLOGICALS* ........................................................................................................................................................................................................................................................................................... 60
*DIAGNOSTIC PRODUCTS* ................................................................................................................................................................................................................................................................................ 68
*DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* ...................................................................................................................................................................... 69
*DIGESTIVE AIDS* ......................................................................................................................................................................................................................................................................................................... 70
*DIURETICS* .......................................................................................................................................................................................................................................................................................................................... 71
*ENDOCRINE AND METABOLIC AGENTS - MISC.* .......................................................................................................................................................................................................... 72
*ESTROGENS* ...................................................................................................................................................................................................................................................................................................................... 76
*FLUOROQUINOLONES* ....................................................................................................................................................................................................................................................................................... 77
*GASTROINTESTINAL AGENTS - MISC.* ........................................................................................................................................................................................................................................ 78
*GENITOURINARY AGENTS - MISCELLANEOUS* ............................................................................................................................................................................................................. 79
*GOUT AGENTS* .............................................................................................................................................................................................................................................................................................................. 80
*HEMATOLOGICAL AGENTS - MISC.* ................................................................................................................................................................................................................................................ 81
*HEMATOPOIETIC AGENTS* ........................................................................................................................................................................................................................................................................... 82
1
Contents
of
Table
*HEMOSTATICS* .............................................................................................................................................................................................................................................................................................................. 83
*HYPNOTICS* ....................................................................................................................................................................................................................................................................................................................... 83
*LAXATIVES* ....................................................................................................................................................................................................................................................................................................................... 84
*MACROLIDES* .................................................................................................................................................................................................................................................................................................................. 85
*MEDICAL DEVICES* ................................................................................................................................................................................................................................................................................................. 85
*MIGRAINE PRODUCTS* ....................................................................................................................................................................................................................................................................................... 87
*MINERALS & ELECTROLYTES* ................................................................................................................................................................................................................................................................ 88
*MOUTH/THROAT/DENTAL AGENTS* ............................................................................................................................................................................................................................................... 89
*MULTIVITAMINS* ....................................................................................................................................................................................................................................................................................................... 89
*MUSCULOSKELETAL THERAPY AGENTS* .............................................................................................................................................................................................................................. 91
*NASAL AGENTS - SYSTEMIC AND TOPICAL* ...................................................................................................................................................................................................................... 91
*NEUROMUSCULAR AGENTS* ..................................................................................................................................................................................................................................................................... 92
*OPHTHALMIC AGENTS* ..................................................................................................................................................................................................................................................................................... 92
*OTIC AGENTS* ................................................................................................................................................................................................................................................................................................................. 96
*OXYTOCICS* ....................................................................................................................................................................................................................................................................................................................... 97
*PASSIVE IMMUNIZING AGENTS* .......................................................................................................................................................................................................................................................... 97
*PENICILLINS* .................................................................................................................................................................................................................................................................................................................... 97
*PHARMACEUTICAL ADJUVANTS* ...................................................................................................................................................................................................................................................... 98
*PROGESTINS* .................................................................................................................................................................................................................................................................................................................... 98
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* ............................................................................................................................................................ 98
*RESPIRATORY AGENTS - MISC.* ........................................................................................................................................................................................................................................................ 102
*SULFONAMIDES* ...................................................................................................................................................................................................................................................................................................... 102
*TETRACYCLINES* ................................................................................................................................................................................................................................................................................................... 102
*THYROID AGENTS* ................................................................................................................................................................................................................................................................................................ 103
*ULCER DRUGS* ........................................................................................................................................................................................................................................................................................................... 104
*URINARY ANTI-INFECTIVES* ................................................................................................................................................................................................................................................................. 106
*URINARY ANTISPASMODICS* ................................................................................................................................................................................................................................................................ 107
*VACCINES* ........................................................................................................................................................................................................................................................................................................................ 108
*VAGINAL PRODUCTS* ....................................................................................................................................................................................................................................................................................... 108
*VASOPRESSORS* ....................................................................................................................................................................................................................................................................................................... 109
*VITAMINS* ......................................................................................................................................................................................................................................................................................................................... 109
2
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
lowercase italics = Generic drugs
UPPERCASE = Brand name drugs
Drug Name
Drug Status
=
=
=
=
CE = Copay Exception
LA = Limited Access Covered in Listed States
NC = Not Covered Unless
Noted Otherwise
Tier 1 = Preferred Generic
Tier 2 = Preferred Brand
Tier 3 = Non Preferred Drugs
Drug Status
Drug Details
# = Brand-name drug expected to become
available generically in the near future
AL = Age Limit
Copay Note = 3 Copays Required
DS = Not available as 90 day supply
N1 = Step Therapy Not Applicable in NJ
N2 = Covered in NJ, IN
N3 = Covered in listed states
N4 = Covered at noted tier in DE
PA = Prior Authorization Applies
QL = Quantity Limit Applies
SF = Split Fill Applies
ST = Step Therapy Applies
Drug Details
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANO
REXIANTS*
*AMPHETAMINES**-*AMPHETAMINE
MIXTURES***
ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG,
20 MG, 30 MG, 5 MG, 7.5 MG
Tier 3
QL
ADDERALL XR
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL; AL
amphetamine-dextroamphet er
Tier 1
PA; QL
amphetamine-dextroamphetamine oral tablet 10 mg, 12.5
mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg
Tier 1
QL
DESOXYN
Tier 3
DS; QL
DEXEDRINE ORAL CAPSULE EXTENDED RELEASE
24 HOUR
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
dextroamphetamine sulfate oral solution
Tier 1
QL
dextroamphetamine sulfate oral tablet
Tier 1
PA; DS; QL
dextroamphetamine sulfate er
Tier 1
DS; QL
methamphetamine hcl
Tier 1
QL
PROCENTRA
Tier 3
PA; N1 (Step Therapy Not Applicable in
NJ); QL
VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50
MG, 60 MG, 70 MG
Tier 2
DS; QL; AL
ZENZEDI ORAL TABLET 10 MG, 5 MG
Tier 1
DS; QL
*AMPHETAMINES**-*AMPHETAMINES***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
3
Drug Name
Drug Status
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30
MG, 7.5 MG
NC
Drug Details
N2 (Covered in NJ, IN)
*ANALEPTICS**-*ANALEPTICS***
CAFCIT ORAL
Tier 3
*ANOREXIANTS
NON-AMPHETAMINE**-*ANOREXIANT
COMBINATIONS***
QSYMIA
LA
SD; DS; N1 (Please refer to your health
plan documents regarding coverage of
and any limitations or exclusions that may
apply.); N3 (Covered in DC)
*ANOREXIANTS
NON-AMPHETAMINE**-*ANOREXIANTS
NON-AMPHETAMINE***
ADIPEX-P ORAL TABLET
benzphetamine hcl
DIDREX
Tier 3
LA
N3 (Covered in DC)
Tier 3
diethylpropion hcl oral
LA
N3 (Covered in DC)
diethylpropion hcl er
LA
N3 (Covered in DC)
phendimetrazine tartrate
LA
N3 (Covered in DC)
phendimetrazine tartrate er
LA
N3 (Covered in DC)
phentermine hcl oral
LA
N3 (Covered in DC)
REGIMEX
LA
N3 (Covered in DC)
SUPRENZA
LA
N3 (Covered in DC)
*ANTI-OBESITY AGENTS**-*LIPASE
INHIBITORS***
ALLI
XENICAL
Tier 3
LA
N3 (Covered in DC)
*ANTI-OBESITY AGENTS**-*SEROTONIN 2C
RECEPTOR AGONISTS***
BELVIQ
NC
*ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER (ADHD) AGENTS**-*ADHD AGENT SELECTIVE ALPHA ADRENERGIC AGONISTS***
clonidine hcl er
Tier 1
PA; QL
INTUNIV
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); #; QL
KAPVAY ORAL TABLET EXTENDED RELEASE 12
HR*
Tier 3
PA; N1 (Step Therapy not Applicable in
NJ); QL
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
Tier 3
ST; DS; N1 (Step Therapy Not
Applicable In NJ); QL; AL
*ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER (ADHD) AGENTS**-*ADHD AGENT SELECTIVE NOREPINEPHRINE REUPTAKE
INHIBITOR***
STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG,
25 MG, 40 MG, 60 MG, 80 MG
*STIMULANTS - MISC.**-*STIMULANTS MISC.***
CONCERTA ORAL TABLET EXTENDEDRELEASE* 18
MG, 27 MG, 36 MG, 54 MG
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
4
Drug Name
Drug Status
Drug Details
DAYTRANA
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable In NJ); #; QL; AL
dexmethylphenidate hcl
Tier 1
DS; QL
dexmethylphenidate hcl er oral capsule extended release 24
hour 15 mg, 30 mg, 40 mg
Tier 1
DS; QL; AL
FOCALIN
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
FOCALIN XR ORAL CAPSULE EXTENDED RELEASE
24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35
MG, 40 MG, 5 MG
Tier 3
ST; DS; N1 (Step Therapy Not
Applicable In NJ); #; QL; AL
METADATE CD ORAL CAPSULE EXTENDED
RELEASE* 10 MG, 20 MG, 30 MG, 40 MG, 50 MG
Tier 3
ST; DS; N1 (Step Therapy not Applicable
in NJ); QL
METADATE CD ORAL CAPSULE EXTENDED
RELEASE* 60 MG
Tier 3
ST; DS; N1 (Step Therapy not Applicable
in NJ); QL; AL
METADATE ER
Tier 1
DS; QL
METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML
Tier 3
QL
METHYLIN ORAL TABLET CHEWABLE
Tier 3
PA; ST; N1 (Step Therapy not Applicable
in NJ); QL
methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml
Tier 1
QL
methylphenidate hcl oral tablet
Tier 1
DS; QL
methylphenidate hcl er oral tablet extendedrelease* 18 mg,
27 mg, 36 mg, 54 mg
Tier 1
DS; QL; AL
methylphenidate hcl er (cd)
Tier 1
DS; QL; AL
methylphenidate hcl er (la)
Tier 1
QL
modafinil
Tier 1
PA; DS; QL
NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50
MG
Tier 3
PA; DS; QL
PROVIGIL
Tier 3
PA; DS; QL
QUILLIVANT XR
Tier 3
PA; DS; N1 (Step Therapy Not
Applicable in NJ); QL
RITALIN
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
RITALIN LA ORAL CAPSULE EXTENDED RELEASE
24 HOUR 10 MG, 20 MG, 30 MG, 40 MG
Tier 3
ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL; AL
RITALIN SR
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
Tier 2
DS
BETHKIS
Tier 3
DS
neomycin sulfate oral
Tier 1
DS
paromomycin sulfate oral
Tier 1
DS
TOBI
Tier 3
SD; DS; QL
TOBI PODHALER
Tier 3
PA; SD; DS; QL
tobramycin inhalation
Tier 1
SD; DS; QL
*AMEBICIDES*
*AMEBICIDES**-*AMEBICIDES***
YODOXIN
*AMINOGLYCOSIDES*
*AMINOGLYCOSIDES**-*AMINOGLYCOSIDES***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
5
Drug Name
Drug Status
Drug Details
*ANALGESICS - ANTI-INFLAMMATORY*
*ANTIRHEUMATIC - ENZYME
INHIBITORS**-*ANTIRHEUMATIC - JANUS
KINASE (JAK) INHIBITORS***
XELJANZ
Tier 3
PA; SD; DS; QL
*ANTIRHEUMATIC
ANTIMETABOLITES**-*ANTIRHEUMATIC
ANTIMETABOLITES***
OTREXUP
NC
N2 (Covered in NJ, IN)
*ANTI-TNF-ALPHA - MONOCLONAL
ANTIBODIES**-*ANTI-TNF-ALPHA MONOCLONAL ANTIBODIES***
HUMIRA SUBCUTANEOUS* KIT
Tier 2
PA; SD; DS; QL
HUMIRA PEN
Tier 2
PA; SD; DS; QL
HUMIRA PEN-CROHNS STARTER
Tier 2
SD; DS
HUMIRA PEN-PSORIASIS STARTER
Tier 2
SD; DS; QL
*GOLD COMPOUNDS**-*GOLD COMPOUNDS***
RIDAURA
Tier 2
*INTERLEUKIN-1 BLOCKERS**-*INTERLEUKIN-1
BLOCKERS***
ARCALYST
Tier 3
PA; SD; DS
Tier 3
PA; SD; DS; QL
Tier 3
PA; SD; DS; QL
Tier 3
#; QL
*INTERLEUKIN-1BETA
BLOCKERS**-*INTERLEUKIN-1BETA
BLOCKERS***
ILARIS
*INTERLEUKIN-6 RECEPTOR
INHIBITORS**-*INTERLEUKIN-6 RECEPTOR
INHIBITORS***
ACTEMRA SUBCUTANEOUS*
*NONSTEROIDAL ANTI-INFLAMMATORY
AGENTS (NSAIDS)**-*CYCLOOXYGENASE 2
(COX-2) INHIBITORS***
CELEBREX
*NONSTEROIDAL ANTI-INFLAMMATORY
AGENTS (NSAIDS)**-*NONSTEROIDAL
ANTI-INFLAMMATORY AGENT
COMBINATIONS***
ARTHROTEC
Tier 3
diclofenac-misoprostol
Tier 3
DUEXIS
NC
N2 (Covered in NJ, IN)
IC 400
NC
N2 (Covered in NJ, IN)
IC 800
NC
N2 (Covered in NJ, IN)
VIMOVO
NC
N2 (Covered in NJ, IN)
*NONSTEROIDAL ANTI-INFLAMMATORY
AGENTS (NSAIDS)**-*NONSTEROIDAL
ANTI-INFLAMMATORY AGENTS (NSAIDS)***
ANAPROX
Tier 3
ANAPROX DS
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
6
Drug Name
Drug Status
CATAFLAM
Tier 3
DAYPRO
Tier 3
diclofenac potassium
Tier 1
diclofenac sodium oral tablet delayed release 25 mg, 50 mg
Tier 1
diclofenac sodium oral tablet delayed release 75 mg
Tier 1
diclofenac sodium er
Tier 1
EC-NAPROSYN
Tier 3
etodolac oral
Tier 1
etodolac er
Tier 1
FELDENE
Tier 3
fenoprofen calcium oral tablet
Tier 1
flurbiprofen oral
Tier 1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1
IBUPROFEN COMFORT PAC
NC
INDOCIN ORAL
Tier 2
INDOCIN SUPPOSITORY
Tier 3
indomethacin oral
Tier 1
indomethacin er
Tier 1
ketoprofen oral
Tier 1
ketoprofen er
Tier 1
ketorolac tromethamine oral
Tier 1
meclofenamate sodium oral
Tier 1
meloxicam oral suspension
Tier 1
meloxicam oral tablet
Tier 1
MELOXICAM COMFORT PAC
NC
MOBIC
Tier 3
nabumetone oral
Tier 1
NALFON ORAL CAPSULE 400 MG
Tier 2
NAPRELAN ORAL TABLET EXTENDED RELEASE 24
HR* 375 MG, 500 MG, 750 MG
Tier 3
NAPROSYN
Tier 3
naproxen oral suspension
Tier 1
naproxen oral tablet
Tier 1
NAPROXEN COMFORT PAC
NC
naproxen sodium oral tablet 275 mg
Tier 1
naproxen sodium oral tablet 550 mg
Tier 1
oxaprozin
Tier 1
piroxicam oral capsule 10 mg
Tier 1
piroxicam oral capsule 20 mg
Tier 3
PONSTEL
Tier 3
Drug Details
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
N2 (Covered in NJ, IN)
DS
Drug Note (Lowest Generic Copay
Applies)
N2 (Covered in NJ, IN)
Drug Note (Lowest Generic Copay
Applies)
N2 (Covered in NJ, IN)
Drug Note (Lowest Generic Copay
Applies)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
7
Drug Name
Drug Status
SPRIX
Tier 3
sulindac oral
Tier 1
tolmetin sodium
Tier 1
VOLTAREN-XR
Tier 3
ZIPSOR
ZORVOLEX
NC
Drug Details
DS; QL
N2 (Covered in NJ, IN)
Tier 3
*PHOSPHODIESTERASE 4 (PDE4)
INHIBITORS**-*PHOSPHODIESTERASE 4 (PDE4)
INHIBITORS***
OTEZLA ORAL 10 & 20 & 30 MG
Tier 3
PA; SD; DS; QL
OTEZLA ORAL TABLET
Tier 3
PA; SD; DS; QL
ARAVA
Tier 3
QL
leflunomide oral
Tier 1
DS; QL
Tier 2
PA; SD; DS; QL
*PYRIMIDINE SYNTHESIS
INHIBITORS**-*PYRIMIDINE SYNTHESIS
INHIBITORS***
*SOLUBLE TUMOR NECROSIS FACTOR
RECEPTOR AGENTS**-*SOLUBLE TUMOR
NECROSIS FACTOR RECEPTOR AGENTS***
ENBREL SUBCUTANEOUS* KIT
*ANALGESICS - NONNARCOTIC*
*ANALGESIC
COMBINATIONS**-*ANALGESICS-SEDATIVES***
butalbital-acetaminophen
Tier 1
butalbital-apap-caffeine oral capsule 50-300-40 mg
Tier 1
DS
butalbital-apap-caffeine oral tablet 50-325-40 mg
Tier 1
DS
butalbital-asa-caffeine
Tier 1
DS
FIORINAL
Tier 3
DS
*ANALGESICS OTHER**-*ANALGESICS
OTHER***
TYLENOL ORAL TABLET
Tier 3
*SALICYLATES**-*SALICYLATE
COMBINATIONS***
choline-mag trisalicylate
Tier 1
*SALICYLATES**-*SALICYLATES***
ANACIN ORAL TABLET DELAYED RELEASE
CE
ARTHRITIS PAIN REGIMEN EX ST
CE
aspirin low dose oral tablet delayed release
CE
baby aspirin
CE
BAYER ADVANCED ASPIRIN EX ST
CE
BAYER ADVANCED ASPIRIN REG ST
CE
BAYER ASPIRIN REGIMEN
CE
diflunisal oral
Tier 1
ECOTRIN
CE
eq aspirin low dose
CE
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
8
Drug Name
Drug Status
HALFPRIN ORAL TABLET DELAYED RELEASE 162
MG
CE
ra aspirin ec oral tablet delayed release 325 mg
CE
salsalate oral
Drug Details
Tier 1
*ANALGESICS - OPIOID*
*OPIOID AGONISTS**-*OPIOID AGONISTS***
ABSTRAL
Tier 3
PA; DS
ACTIQ
Tier 3
PA; DS; QL
AVINZA ORAL CAPSULE EXTENDED RELEASE 24
HOUR 120 MG
Tier 3
PA; ST; SD; DS; N1 (Step Therapy Not
Applicable in NJ); QL
AVINZA ORAL CAPSULE EXTENDED RELEASE 24
HOUR 30 MG, 45 MG, 60 MG, 75 MG, 90 MG
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
codeine sulfate oral solution 30 mg/5ml
Tier 1
DS
codeine sulfate oral tablet
Tier 1
DS
CONZIP
NC
N2 (Covered in NJ, IN)
DEMEROL ORAL
Tier 3
DS
DILAUDID ORAL TABLET
Tier 3
DS
DOLOPHINE
Tier 3
DS
DURAGESIC-100
Tier 3
PA; DS; QL
DURAGESIC-12
Tier 3
PA; DS; QL
DURAGESIC-25
Tier 3
PA; DS; QL
DURAGESIC-50
Tier 3
PA; DS; QL
DURAGESIC-75
Tier 3
PA; DS; QL
EXALGO
Tier 3
PA; DS; QL
fentanyl
Tier 3
DS; QL
fentanyl citrate buccal
Tier 3
PA; DS; QL
FENTORA
Tier 3
PA; DS; QL
hydromorphone hcl oral liquid†
Tier 3
DS
hydromorphone hcl oral tablet
Tier 1
DS
KADIAN ORAL CAPSULE EXTENDED RELEASE 24
HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG,
50 MG, 60 MG, 80 MG
Tier 3
PA; DS; N1 (Step Therapy Not
Applicable in NJ); QL
LAZANDA
Tier 3
PA; DS; QL
meperidine hcl oral tablet
Tier 1
DS
meperitab oral tablet 50 mg
Tier 1
DS
methadone hcl oral tablet
Tier 1
DS
methadone hcl oral tablet soluble
Tier 1
DS
METHADOSE ORAL TABLET
Tier 1
DS
morphine sulfate oral solution 10 mg/5ml
Tier 1
DS
morphine sulfate oral tablet 15 mg
Tier 1
DS
morphine sulfate er
Tier 1
DS
morphine sulfate er beads
Tier 1
MS CONTIN
Tier 3
DS
NUCYNTA
Tier 3
ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
9
Drug Name
Drug Status
Drug Details
NUCYNTA ER
Tier 3
PA; DS; N1 (Step Therapy Not
Applicable in NJ); QL
OPANA ORAL
Tier 3
ST; DS; N1 (Step Therapy Not
Applicable in NJ)
OPANA ER ORAL 10 MG, 15 MG, 20 MG, 30 MG, 40
MG, 5 MG, 7.5 MG
Tier 2
QL
oxycodone hcl oral capsule
Tier 1
DS
oxycodone hcl oral tablet
Tier 1
DS
OXYCONTIN
Tier 3
PA; DS; N1 (Step Therapy Not
Applicable in NJ); QL
oxymorphone hcl
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
oxymorphone hcl er
Tier 1
QL
SUBSYS
Tier 3
PA; DS; QL
tramadol hcl oral
Tier 1
DS
tramadol hcl er oral capsule extended release 24 hour
Tier 1
N2 (Covered in NJ, IN)
tramadol hcl er oral tablet extended release 24 hr*
Tier 1
DS
ULTRAM
Tier 3
DS
ULTRAM ER
Tier 3
DS
ZOHYDRO ER
Tier 3
PA; DS; QL
acetaminophen-codeine oral solution
Tier 1
DS
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg,
300-60 mg
Tier 1
DS
acetaminophen-codeine #2
Tier 1
DS
acetaminophen-codeine #3
Tier 1
DS
acetaminophen-codeine #4
Tier 1
DS
butalbital-apap-caff-cod
Tier 1
DS
FIORINAL/CODEINE #3
Tier 3
DS
TYLENOL WITH CODEINE #3
Tier 3
DS
TYLENOL WITH CODEINE #4
Tier 3
DS
*OPIOID COMBINATIONS**-*CODEINE
COMBINATIONS***
*OPIOID COMBINATIONS**-*DIHYDROCODEINE
COMBINATIONS***
SYNALGOS-DC
Tier 3
*OPIOID COMBINATIONS**-*HYDROCODONE
COMBINATIONS***
hydrocodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1
DS
hydrocodone-acetaminophen oral tablet 5-300 mg, 7.5-300
mg
Tier 3
DS
hydrocodone-ibuprofen oral tablet 7.5-200 mg
Tier 1
DS
VICOPROFEN
Tier 3
DS
XODOL
Tier 3
DS
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
10
Drug Name
Drug Status
Drug Details
*OPIOID COMBINATIONS**-*OPIOID
COMBINATIONS***
PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG,
5-325 MG, 7.5-325 MG
Tier 3
DS
PERCODAN
Tier 3
DS
PRIMLEV
Tier 3
DS
XARTEMIS XR
Tier 3
ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
tramadol-acetaminophen
Tier 1
QL
ULTRACET
Tier 3
QL
buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg
Tier 1
PA; DS; QL
buprenorphine hcl-naloxone hcl
Tier 1
PA; DS; QL
butorphanol tartrate nasal
Tier 3
DS; QL
BUTRANS TRANSDERMAL PATCH WEEKLY 10
MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR
Tier 2
DS; QL
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG,
4-1 MG, 8-2 MG
Tier 3
PA; DS; QL
ZUBSOLV
Tier 3
PA; DS; N1 (Step Therapy not applicable
in NJ); QL
*OPIOID COMBINATIONS**-*TRAMADOL
COMBINATIONS***
*OPIOID PARTIAL AGONISTS**-*OPIOID
PARTIAL AGONISTS***
*ANDROGENS-ANABOLIC*
*ANABOLIC STEROIDS**-*ANABOLIC
STEROIDS***
ANADROL-50
Tier 3
OXANDRIN
Tier 3
*ANDROGENS**-*ANDROGENS***
ANDRODERM TRANSDERMAL PATCH 24 HR 2
MG/24HR, 4 MG/24HR
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); N2 (Covered in
NJ,IN); #; QL
ANDROGEL
Tier 2
PA; DS; QL
ANDROGEL PUMP TRANSDERMAL 12.5 MG/ACT
(1%)
Tier 2
PA; DS; #; QL
ANDROGEL PUMP TRANSDERMAL 20.25 MG/ACT
(1.62%)
Tier 2
PA; DS; QL
ANDROID
Tier 2
DS
ANDROXY
Tier 1
AXIRON
Tier 3
danazol oral
Tier 1
FORTESTA
Tier 3
PA; N1 (Step Therapy Not Applicable in
NJ); N2 (Covered in NJ,IN); QL
STRIANT
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); N2 (Covered in
NJ,IN); QL
PA; DS; N1 (Step Therapy Not
Applicable in NJ); N2 (Covered in
NJ,IN); QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
11
Drug Name
Drug Status
Drug Details
TESTIM
Tier 2
PA; DS; QL
VOGELXO
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); N2 (Covered in
NJ,IN); QL
VOGELXO PUMP
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); N2 (Covered in
NJ,IN); QL
*ANORECTAL AGENTS*
*INTRARECTAL STEROIDS**-*INTRARECTAL
STEROIDS***
CORTIFOAM
Tier 2
*RECTAL COMBINATIONS**-*RECTAL
ANESTHETIC/STEROIDS***
ANALPRAM-HC
Tier 3
lidocaine-hydrocortisone ace cream
Tier 1
lidocaine-hydrocortisone ace kit 3-0.5 %, 3-1 %
Tier 1
PROCTOFOAM HC
Tier 3
*RECTAL STEROIDS**-*RECTAL STEROIDS***
ANUSOL-HC CREAM
Tier 3
hydrocortisone cream
Tier 1
PROCTOCORT CREAM
Tier 3
PROCTOZONE-HC
Tier 1
*VASODILATING AGENTS**-*NITRATE
VASODILATING AGENTS***
RECTIV
Tier 3
QL
*ANTHELMINTICS*
*ANTHELMINTICS**-*ANTHELMINTICS***
ALBENZA
Tier 3
BILTRICIDE
Tier 2
DS
STROMECTOL
Tier 3
DS
Tier 2
QL
*ANTIANGINAL AGENTS*
*ANTIANGINALS-OTHER**-*ANTIANGINALS-OT
HER***
RANEXA
*NITRATES**-*NITRATES***
DILATRATE-SR
Tier 2
IMDUR
Tier 3
ISORDIL TITRADOSE ORAL TABLET 40 MG
Tier 2
ISORDIL TITRADOSE ORAL TABLET 5 MG
Tier 3
isosorbide dinitrate oral
Tier 1
isosorbide dinitrate er
Tier 1
isosorbide mononitrate oral tablet 10 mg, 20 mg
Tier 1
isosorbide mononitrate er
Tier 1
MINITRAN
Tier 2
NITRO-BID
Tier 1
NITRO-DUR
Tier 2
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
12
Drug Name
Drug Status
NITRO-TIME
Tier 1
nitroglycerin transdermal
Tier 1
nitroglycerin er
Tier 1
NITROLINGUAL
Tier 3
NITROMIST
Tier 3
NITROSTAT
Tier 2
Drug Details
QL
*ANTIANXIETY AGENTS*
*ANTIANXIETY AGENTS MISC.**-*ANTIANXIETY AGENTS - MISC.***
buspirone hcl oral tablet 10 mg, 5 mg
Tier 1
buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg
Tier 1
hydroxyzine hcl oral syrup
Tier 1
hydroxyzine hcl oral tablet
Tier 1
hydroxyzine pamoate oral capsule 25 mg, 50 mg
Tier 1
VISTARIL
Tier 3
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
*BENZODIAZEPINES**-*BENZODIAZEPINES***
alprazolam oral tablet
Tier 1
DS; AL
alprazolam oral tablet dispersible
Tier 3
DS; AL
alprazolam er
Tier 1
DS; QL; AL
alprazolam xr
Tier 1
DS; QL; AL
ATIVAN ORAL
Tier 3
SD; DS
chlordiazepoxide hcl
Tier 1
DS; AL
clorazepate dipotassium
Tier 1
DS
diazepam oral tablet
Tier 1
DS
lorazepam oral tablet
Tier 1
DS
oxazepam
Tier 1
DS; AL
TRANXENE-T
Tier 3
DS
VALIUM
Tier 3
DS
XANAX
Tier 3
DS; AL
XANAX XR
Tier 3
DS; QL; AL
*ANTIARRHYTHMICS*
*ANTIARRHYTHMICS TYPE
I-A**-*ANTIARRHYTHMICS TYPE I-A***
disopyramide phosphate oral
Tier 1
NORPACE
Tier 3
NORPACE CR
Tier 2
quinidine gluconate er
Tier 1
quinidine sulfate oral
Tier 1
quinidine sulfate er
Tier 1
*ANTIARRHYTHMICS TYPE
I-B**-*ANTIARRHYTHMICS TYPE I-B***
mexiletine hcl oral
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
13
Drug Name
Drug Status
Drug Details
*ANTIARRHYTHMICS TYPE
I-C**-*ANTIARRHYTHMICS TYPE I-C***
flecainide acetate
Tier 1
propafenone hcl
Tier 1
propafenone hcl er
Tier 1
RYTHMOL
Tier 3
RYTHMOL SR
Tier 3
QL
QL
*ANTIARRHYTHMICS TYPE
III**-*ANTIARRHYTHMICS TYPE III***
amiodarone hcl oral
Tier 1
CORDARONE
Tier 3
MULTAQ
Tier 3
TIKOSYN
Tier 2
QL
*ANTIASTHMATIC AND BRONCHODILATOR
AGENTS*
*ANTI-INFLAMMATORY
AGENTS**-*ANTI-INFLAMMATORY AGENTS***
cromolyn sodium inhalation
Tier 1
*BRONCHODILATORS ANTICHOLINERGICS**-*BRONCHODILATORS ANTICHOLINERGICS***
ATROVENT HFA
Tier 2
QL
ipratropium bromide inhalation
Tier 1
SPIRIVA HANDIHALER
Tier 2
QL
TUDORZA PRESSAIR
Tier 3
PA; N1 (Step Therapy Not Applicable in
NJ); QL
*LEUKOTRIENE
MODULATORS**-*5-LIPOXYGENASE
INHIBITORS***
ZYFLO CR
Tier 3
*LEUKOTRIENE
MODULATORS**-*LEUKOTRIENE RECEPTOR
ANTAGONISTS***
ACCOLATE
Tier 3
montelukast sodium oral tablet
Tier 1
QL
montelukast sodium oral tablet chewable
Tier 1
QL
SINGULAIR ORAL PACKET
Tier 3
QL
SINGULAIR ORAL TABLET
Tier 3
QL
SINGULAIR ORAL TABLET CHEWABLE
Tier 3
QL
zafirlukast
Tier 1
*SELECTIVE PHOSPHODIESTERASE 4 (PDE4)
INHIBITORS**-*SELECTIVE
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***
DALIRESP
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
14
Tier 3
QL
Drug Name
Drug Status
Drug Details
*STEROID INHALANTS**-*STEROID
INHALANTS***
AEROSPAN
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
ALVESCO
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
ASMANEX 120 METERED DOSES
Tier 2
ASMANEX 14 METERED DOSES
Tier 2
ASMANEX 30 METERED DOSES INHALATION
AEROSOL POWDER, BREATH ACTIVATED 110
MCG/INH, 220 MCG/INH
Tier 2
ASMANEX 60 METERED DOSES
Tier 2
ASMANEX 7 METERED DOSES
Tier 2
budesonide inhalation
Tier 1
PA; AL
FLOVENT DISKUS
Tier 3
PA; QL
FLOVENT HFA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
PULMICORT
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); AL
PULMICORT FLEXHALER
Tier 3
PA; N1 (Step Therapy Not Applicable in
NJ); QL
QVAR
Tier 2
*SYMPATHOMIMETICS**-*ADRENERGIC
COMBINATIONS***
ADVAIR DISKUS
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
ADVAIR HFA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
ANORO ELLIPTA
Tier 3
PA; QL
BREO ELLIPTA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
COMBIVENT RESPIMAT
Tier 2
QL
DULERA
Tier 2
QL
DUONEB
Tier 3
ipratropium-albuterol
Tier 1
SYMBICORT
Tier 2
QL
*SYMPATHOMIMETICS**-*BETA
ADRENERGICS***
albuterol sulfate inhalation
Tier 1
albuterol sulfate oral
Tier 1
albuterol sulfate er
Tier 1
ARCAPTA NEOHALER
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
BROVANA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable In NJ); QL
FORADIL AEROLIZER
Tier 2
QL
levalbuterol hcl inhalation
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
15
Drug Name
Drug Status
Drug Details
metaproterenol sulfate oral
Tier 1
PERFOROMIST
Tier 3
PA; N1 (Step Therapy Not Applicable in
NJ); QL
PROAIR HFA
Tier 2
QL
PROVENTIL HFA
Tier 3
PA; N1 (Step Therapy Not Applicable in
NJ); QL
SEREVENT DISKUS
Tier 2
QL
VENTOLIN HFA
Tier 2
QL
VOSPIRE ER
Tier 3
XOPENEX
Tier 3
XOPENEX CONCENTRATE
Tier 3
XOPENEX HFA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
Tier 1
DS
*SYMPATHOMIMETICS**-*MIXED
ADRENERGICS***
epinephrine hcl injection solution 1 mg/ml
*XANTHINES**-*XANTHINES***
ELIXOPHYLLIN
Tier 3
LUFYLLIN
Tier 3
THEO-24 ORAL CAPSULE EXTENDED RELEASE 24
HOUR 100 MG, 200 MG
Tier 2
THEO-24 ORAL CAPSULE EXTENDED RELEASE 24
HOUR 300 MG, 400 MG
Tier 2
THEOCHRON
Tier 1
theophylline oral solution
Tier 3
theophylline er
Tier 1
QL
*ANTICOAGULANTS*
*COUMARIN ANTICOAGULANTS**-*COUMARIN
ANTICOAGULANTS***
COUMADIN ORAL
Tier 3
warfarin sodium oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
ELIQUIS
Tier 2
QL
XARELTO ORAL TABLET 10 MG, 20 MG
Tier 2
QL
XARELTO ORAL TABLET 15 MG
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
Tier 1
DS; N4 (Tier 1 for DE)
*DIRECT FACTOR XA INHIBITORS**-*DIRECT
FACTOR XA INHIBITORS***
*HEPARINS AND HEPARINOID-LIKE
AGENTS**-*HEPARINS AND HEPARINOID-LIKE
AGENTS***
heparin sodium (porcine) injection solution 1000 unit/ml,
10000 unit/ml, 20000 unit/ml, 5000 unit/ml
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
16
Drug Name
Drug Status
Drug Details
*HEPARINS AND HEPARINOID-LIKE
AGENTS**-*LOW MOLECULAR WEIGHT
HEPARINS***
Tier 1
PA; Drug Note (Initial therapy of 21 days
will be covered to assure that therapy is
not delayed while the prior authorization
request is being reviewed.); DS; QL
Tier 3
PA; Drug Note (Initial therapy of 21 days
will be covered to assure that therapy is
not delayed while the prior authorization
request is being reviewed.); DS; QL
Tier 3
PA; Drug Note (Initial therapy of 21 days
will be covered to assure that therapy is
not delayed while the prior authorization
request is being reviewed.); DS; QL
Tier 3
PA; Drug Note (Initial therapy of 21 days
will be covered to assure that therapy is
not delayed while the prior authorization
request is being reviewed.); DS; QL
Tier 3
PA; Drug Note (Initial therapy of 21 days
will be covered to assure that therapy is
not delayed while the prior authorization
request is being reviewed.); DS; QL
Tier 3
PA; Drug Note (Initial therapy of 10 days
will be covered to assure that therapy is
not delayed while the prior authorization
request is being reviewed.)
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
Tier 3
PA; QL
clonazepam oral tablet
Tier 1
DS
clonazepam oral tablet dispersible
Tier 3
DS
DIASTAT PEDIATRIC
Tier 2
QL
KLONOPIN
Tier 3
DS
ONFI ORAL TABLET 10 MG, 20 MG
Tier 3
QL
enoxaparin sodium
FRAGMIN
LOVENOX
*HEPARINS AND HEPARINOID-LIKE
AGENTS**-*SYNTHETIC HEPARINOID-LIKE
AGENTS***
ARIXTRA
fondaparinux sodium
*THROMBIN INHIBITORS**-*THROMBIN
INHIBITORS - HIRUDIN TYPE***
IPRIVASK
*THROMBIN INHIBITORS**-*THROMBIN
INHIBITORS - SELECTIVE DIRECT &
REVERSIBLE***
PRADAXA
*ANTICONVULSANTS*
*AMPA GLUTAMATE RECEPTOR
ANTAGONISTS**-*AMPA GLUTAMATE
RECEPTOR ANTAGONISTS***
FYCOMPA
*ANTICONVULSANTS BENZODIAZEPINES**-*ANTICONVULSANTS BENZODIAZEPINES***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
17
Drug Name
Drug Status
Drug Details
*ANTICONVULSANTS MISC.**-*ANTICONVULSANTS - MISC.***
APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG,
800 MG
Tier 3
QL
BANZEL ORAL TABLET
Tier 3
QL
carbamazepine oral tablet
Tier 1
Drug Note (Lowest Generic Copay
Applies)
carbamazepine oral tablet chewable
Tier 1
carbamazepine er oral capsule extended release 12 hour
100 mg, 200 mg
Tier 1
carbamazepine er oral tablet extended release 12 hr*
Tier 1
CARBATROL
Tier 2
gabapentin oral capsule
Tier 1
gabapentin oral solution
Tier 1
gabapentin oral tablet
Tier 1
KEPPRA ORAL
Tier 3
KEPPRA XR ORAL TABLET EXTENDED RELEASE 24
HR* 500 MG, 750 MG
Tier 3
LAMICTAL ORAL TABLET
Tier 3
LAMICTAL ORAL TABLET CHEWABLE
Tier 3
LAMICTAL ODT ORAL KIT
Tier 3
LAMICTAL ODT ORAL TABLET DISPERSIBLE 100
MG, 200 MG, 25 MG, 50 MG
Tier 3
QL
LAMICTAL XR ORAL TABLET EXTENDED RELEASE
24 HR* 100 MG, 200 MG, 25 MG, 250 MG, 50 MG
Tier 3
QL
LAMICTAL XR ORAL TABLET EXTENDED RELEASE
24 HR* 300 MG
Tier 3
lamotrigine oral tablet
Tier 1
lamotrigine oral tablet chewable
Tier 3
lamotrigine er oral tablet extended release 24 hr* 100 mg,
200 mg, 25 mg, 50 mg
Tier 3
lamotrigine er oral tablet extended release 24 hr* 250 mg,
300 mg
Tier 3
levetiracetam oral tablet
Tier 1
levetiracetam er oral tablet extended release 24 hr* 500
mg, 750 mg
Tier 3
QL
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG,
225 MG, 25 MG, 300 MG, 50 MG, 75 MG
Tier 3
PA; DS; N1 (Step Therapy not Applicable
in NJ); QL
LYRICA ORAL SOLUTION
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
MYSOLINE
Tier 3
NEURONTIN ORAL CAPSULE
Tier 3
NEURONTIN ORAL SOLUTION
Tier 3
NEURONTIN ORAL TABLET
Tier 3
oxcarbazepine
Tier 1
OXTELLAR XR ORAL TABLET EXTENDED RELEASE
24 HR* 150 MG, 300 MG, 600 MG
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
18
QL
QL
QL
QL
QL
QL
QL
Drug Name
Drug Status
Drug Details
POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50
MG
Tier 3
primidone oral
Tier 1
TEGRETOL ORAL SUSPENSION
Tier 2
TEGRETOL ORAL TABLET
Tier 2
TEGRETOL-XR
Tier 2
TOPAMAX ORAL TABLET 100 MG, 25 MG, 50 MG
Tier 3
TOPAMAX SPRINKLE
Tier 3
QL
topiramate oral capsule sprinkle
Tier 1
QL
topiramate oral tablet
Tier 1
TRILEPTAL
Tier 3
TROKENDI XR ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG
Tier 3
QL
VIMPAT ORAL TABLET
Tier 3
QL
ZONEGRAN
Tier 3
zonisamide oral
Tier 1
QL
*CARBAMATES**-*CARBAMATES***
FELBATOL
Tier 3
*GABA MODULATORS**-*GABA
MODULATORS***
GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG
Tier 3
QL
SABRIL
Tier 3
PA; SD; DS; QL
*HYDANTOINS**-*HYDANTOINS***
DILANTIN ORAL CAPSULE 100 MG, 30 MG
Tier 2
DILANTIN ORAL SUSPENSION
Tier 2
DILANTIN INFATABS
Tier 2
PEGANONE
Tier 3
PHENYTEK
Tier 2
phenytoin oral tablet chewable
Tier 1
PHENYTOIN INFATABS
Tier 1
phenytoin sodium extended oral capsule 100 mg
Tier 2
phenytoin sodium extended oral capsule 200 mg, 300 mg
Tier 1
*SUCCINIMIDES**-*SUCCINIMIDES***
CELONTIN
Tier 2
ethosuximide oral
Tier 1
ZARONTIN
Tier 3
*VALPROIC ACID**-*VALPROIC ACID***
DEPAKENE
Tier 3
DEPAKOTE
Tier 3
DEPAKOTE ER
Tier 3
DEPAKOTE SPRINKLES
Tier 3
divalproex sodium
Tier 1
divalproex sodium er
Tier 1
STAVZOR
NC
N2 (Covered in NJ, IN)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
19
Drug Name
Drug Status
valproic acid oral
Drug Details
Tier 1
*ANTIDEPRESSANTS*
*ALPHA-2 RECEPTOR ANTAGONISTS
(TETRACYCLICS)**-*ALPHA-2 RECEPTOR
ANTAGONISTS (TETRACYCLICS)***
mirtazapine oral tablet
Tier 1
mirtazapine oral tablet dispersible
Tier 3
REMERON
Tier 3
REMERON SOLTAB
Tier 3
QL
QL
*ANTIDEPRESSANTS MISC.**-*ANTIDEPRESSANTS - MISC.***
APLENZIN
NC
N2 (Covered in NJ, IN)
BUDEPRION XL
Tier 1
QL
bupropion hcl oral
Tier 1
QL
bupropion hcl er (sr)
Tier 1
QL
bupropion hcl er (xl)
Tier 1
QL
FORFIVO XL
NC
N2 (Covered in NJ, IN)
maprotiline hcl
Tier 1
WELLBUTRIN
Tier 3
QL
WELLBUTRIN SR
Tier 3
QL
WELLBUTRIN XL
Tier 3
QL
EMSAM
Tier 3
QL
NARDIL
Tier 2
PARNATE
Tier 3
tranylcypromine sulfate
Tier 1
*MONOAMINE OXIDASE INHIBITORS
(MAOIS)**-*MONOAMINE OXIDASE INHIBITORS
(MAOIS)***
*SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRIS)**-*SELECTIVE SEROTONIN
REUPTAKE INHIBITORS (SSRIS)***
CELEXA
Tier 3
citalopram hydrobromide oral solution
Tier 1
citalopram hydrobromide oral tablet
Tier 1
escitalopram oxalate oral solution
Tier 1
escitalopram oxalate oral tablet
Tier 1
QL
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies); QL
fluoxetine hcl oral capsule delayed release
Tier 1
QL
fluoxetine hcl oral tablet 10 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies); QL
fluoxetine hcl oral tablet 20 mg
Tier 1
QL
fluoxetine hcl oral tablet 60 mg
Tier 3
QL
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg
Tier 1
QL
fluvoxamine maleate er
Tier 1
QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
20
QL
Drug Note (Lowest Generic Copay
Applies); QL
Drug Name
Drug Status
Drug Details
LEXAPRO ORAL SOLUTION
Tier 3
LEXAPRO ORAL TABLET
Tier 3
QL
LUVOX CR
Tier 3
QL
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies); QL
paroxetine hcl er
Tier 1
DS; QL
PAXIL ORAL SUSPENSION
Tier 3
QL
PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG
Tier 3
QL
PAXIL CR
Tier 3
QL
PEXEVA
NC
N2 (Covered in NJ, IN)
PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG
Tier 3
QL
PROZAC WEEKLY
Tier 3
QL
sertraline hcl oral concentrate
Tier 1
QL
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies); QL
ZOLOFT ORAL CONCENTRATE
Tier 3
QL
ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG
Tier 3
QL
BRINTELLIX
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable In NJ); QL
nefazodone hcl
Tier 3
OLEPTRO ORAL TABLET EXTENDED RELEASE 24
HR* 150 MG, 300 MG
Tier 3
trazodone hcl oral
Tier 1
VIIBRYD ORAL KIT
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
VIIBRYD ORAL TABLET
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
CYMBALTA ORAL CAPSULE DELAYED RELEASE
PARTICLES 20 MG, 30 MG, 60 MG
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable In NJ); QL
desvenlafaxine er
Tier 3
ST; N1 (Step Therapy Not Applicable In
NJ); QL
desvenlafaxine fumarate er
Tier 3
ST; N1 (Step Therapy Not Applicable In
NJ); QL
duloxetine hcl oral capsule delayed release particles 20 mg,
30 mg, 60 mg
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable In NJ); QL
EFFEXOR XR
Tier 3
QL
FETZIMA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable In NJ); QL
FETZIMA TITRATION
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable In NJ); QL
KHEDEZLA
Tier 3
PA; ST; N1 (Step Therapy not Applicable
in NJ); QL
*SEROTONIN MODULATORS**-*SEROTONIN
MODULATORS***
N1 (Step Therapy Not Applicable in NJ);
QL
*SEROTONIN-NOREPINEPHRINE REUPTAKE
INHIBITORS
(SNRIS)**-*SEROTONIN-NOREPINEPHRINE
REUPTAKE INHIBITORS (SNRIS)***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
21
Drug Name
Drug Status
Drug Details
PRISTIQ
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg,
75 mg
Tier 1
QL
venlafaxine hcl er oral capsule extended release 24 hour
150 mg, 37.5 mg, 75 mg
Tier 1
QL
venlafaxine hcl er oral tablet extended release 24 hr* 150
mg, 225 mg, 37.5 mg, 75 mg
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
amitriptyline hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg,
75 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
amitriptyline hcl oral tablet 150 mg
Tier 1
amoxapine
Tier 1
ANAFRANIL
Tier 3
clomipramine hcl oral
Tier 1
desipramine hcl oral
Tier 1
doxepin hcl oral
Tier 1
imipramine hcl oral
Tier 1
imipramine pamoate
Tier 3
NORPRAMIN ORAL TABLET 10 MG, 100 MG, 150 MG,
25 MG, 50 MG, 75 MG
Tier 3
nortriptyline hcl oral capsule 10 mg, 25 mg
Tier 1
nortriptyline hcl oral capsule 50 mg, 75 mg
Tier 1
PAMELOR
Tier 3
protriptyline hcl
Tier 1
SURMONTIL
Tier 3
TOFRANIL
Tier 3
TOFRANIL-PM
Tier 3
VIVACTIL
Tier 3
*TRICYCLIC AGENTS**-*TRICYCLIC AGENTS***
Drug Note (Lowest Generic Copay
Applies)
*ANTIDIABETICS*
*ALPHA-GLUCOSIDASE
INHIBITORS**-*ALPHA-GLUCOSIDASE
INHIBITORS***
acarbose
Tier 1
GLYSET
Tier 3
PRECOSE
Tier 3
*ANTIDIABETIC - AMYLIN
ANALOGS**-*ANTIDIABETIC - AMYLIN
ANALOGS***
SYMLINPEN 120
Tier 3
PA; QL
SYMLINPEN 60
Tier 3
PA; QL
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
*ANTIDIABETIC
COMBINATIONS**-*DIPEPTIDYL PEPTIDASE-4
INHIBITOR-BIGUANIDE COMBINATIONS***
JANUMET
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
22
Drug Name
Drug Status
Drug Details
JANUMET XR ORAL TABLET EXTENDED RELEASE
24 HR* 100-1000 MG, 50-1000 MG, 50-500 MG
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
JENTADUETO
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
KAZANO
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
KOMBIGLYZE XR ORAL TABLET EXTENDED
RELEASE 24 HR* 2.5-1000 MG, 5-1000 MG, 5-500 MG
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
Tier 3
QL
Tier 2
ST; N1 (Step Therapy Not Applicable in
NJ); QL
*ANTIDIABETIC COMBINATIONS**-*DPP-4
INHIBITOR-THIAZOLIDINEDIONE
COMBINATIONS***
OSENI
*ANTIDIABETIC
COMBINATIONS**-*MEGLITINIDE-BIGUANIDE
COMBINATIONS***
PRANDIMET
*ANTIDIABETIC
COMBINATIONS**-*SODIUM-GLUCOSE
CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE
COMB***
INVOKAMET
*ANTIDIABETIC
COMBINATIONS**-*SULFONYLUREA-BIGUANID
E COMBINATIONS***
glipizide-metformin hcl
Tier 1
GLUCOVANCE ORAL TABLET 2.5-500 MG, 5-500 MG
Tier 3
glyburide-metformin
Tier 1
*ANTIDIABETIC
COMBINATIONS**-*SULFONYLUREA-THIAZOLI
DINEDIONE COMBINATIONS***
AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 4-4
MG, 8-4 MG
Tier 3
PA; QL
DUETACT
Tier 3
QL
pioglitazone hcl-glimepiride
Tier 1
QL
ACTOPLUS MET
Tier 3
QL
ACTOPLUS MET XR ORAL TABLET EXTENDED
RELEASE 24 HR* 15-1000 MG, 30-1000 MG
Tier 2
QL
AVANDAMET ORAL TABLET 2-1000 MG, 2-500 MG,
4-500 MG
Tier 3
PA; QL
pioglitazone hcl-metformin hcl
Tier 1
QL
*ANTIDIABETIC
COMBINATIONS**-*THIAZOLIDINEDIONE-BIGU
ANIDE COMBINATIONS***
*BIGUANIDES**-*BIGUANIDES***
FORTAMET
Tier 3
GLUCOPHAGE
Tier 3
GLUCOPHAGE XR
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
23
Drug Name
Drug Status
Drug Details
GLUMETZA
Tier 3
metformin hcl oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
metformin hcl er oral tablet extended release 24 hr* 500 mg
Tier 3
Drug Note (Lowest Generic Copay
Applies)
metformin hcl er oral tablet extended release 24 hr* 750 mg
Tier 1
metformin hcl er (osm)
Tier 3
*DIABETIC OTHER**-*DIABETIC OTHER***
GLUCAGEN
Tier 3
QL
GLUCAGEN HYPOKIT
Tier 2
QL
GLUCAGON EMERGENCY
Tier 2
QL
PROGLYCEM
Tier 3
*DIABETIC OTHER**-*PROGESTERONE
RECEPTOR ANTAGONISTS***
KORLYM
Tier 3
PA; SD; DS; QL
JANUVIA
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
NESINA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
ONGLYZA
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
TRADJENTA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
Tier 3
QL
BYDUREON
Tier 2
ST; N1 (Step Therapy Not Applicable in
NJ); QL
BYDUREON SUBCUTANEOUS* 2 MG
Tier 2
ST; N1 (Step Therapy Not Applicable in
NJ); QL
BYETTA 10 MCG PEN
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
BYETTA 5 MCG PEN
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
TANZEUM
Tier 3
PA; QL
VICTOZA
Tier 3
PA; N1 (Step Therapy Not Applicable in
NJ); QL
ACTOS
Tier 3
QL
AVANDIA
Tier 3
PA; QL
pioglitazone hcl
Tier 1
QL
*DIPEPTIDYL PEPTIDASE-4 (DPP-4)
INHIBITORS**-*DIPEPTIDYL PEPTIDASE-4
(DPP-4) INHIBITORS***
*DOPAMINE RECEPTOR AGONISTS ANTIDIABETIC**-*DOPAMINE RECEPTOR
AGONISTS - ERGOT DERIVATIVES***
CYCLOSET
*INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR
AGONISTS)**-*INCRETIN MIMETIC AGENTS
(GLP-1 RECEPTOR AGONISTS)***
*INSULIN SENSITIZING
AGENTS**-*THIAZOLIDINEDIONES***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
24
Drug Name
Drug Status
Drug Details
*INSULIN**-*HUMAN INSULIN***
APIDRA
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
APIDRA SOLOSTAR
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
HUMALOG
Tier 2
HUMALOG SUBCUTANEOUS* 100 UNIT/ML
Tier 2
HUMALOG KWIKPEN
Tier 2
HUMALOG MIX 50/50
Tier 2
HUMALOG MIX 50/50 KWIKPEN
Tier 2
HUMALOG MIX 75/25
Tier 2
HUMALOG MIX 75/25 KWIKPEN
Tier 2
HUMULIN 70/30
Tier 2
HUMULIN 70/30 KWIKPEN
Tier 2
HUMULIN N
Tier 2
HUMULIN N KWIKPEN
Tier 2
HUMULIN R
Tier 2
HUMULIN R U-500 (CONCENTRATED)
Tier 2
LANTUS
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
LANTUS SOLOSTAR
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
LEVEMIR
Tier 2
LEVEMIR FLEXPEN
Tier 2
LEVEMIR FLEXTOUCH
Tier 2
NOVOLIN 70/30
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
NOVOLIN 70/30 RELION
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
NOVOLIN R
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
NOVOLIN R RELION
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
NOVOLOG
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
NOVOLOG FLEXPEN
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
NOVOLOG MIX 70/30
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
NOVOLOG MIX 70/30 FLEXPEN
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
*MEGLITINIDE ANALOGUES**-*MEGLITINIDE
ANALOGUES***
nateglinide
Tier 3
PRANDIN
Tier 3
repaglinide
Tier 3
STARLIX
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
25
Drug Name
Drug Status
Drug Details
*SODIUM-GLUCOSE CO-TRANSPORTER 2
(SGLT2) INHIBITORS**-*SODIUM-GLUCOSE
CO-TRANSPORTER 2 (SGLT2) INHIBITORS***
FARXIGA
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
INVOKANA
Tier 2
ST; N1 (Step Therapy Not Applicable in
NJ); QL
*SULFONYLUREAS**-*SULFONYLUREAS***
AMARYL
Tier 3
chlorpropamide oral tablet 100 mg
Tier 1
chlorpropamide oral tablet 250 mg
Tier 1
DIABETA
Tier 3
glimepiride
Tier 1
Drug Note (Lowest Generic Copay
Applies)
glipizide oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
glipizide er oral tablet extended release 24 hr* 10 mg, 5 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
glipizide er oral tablet extended release 24 hr* 2.5 mg
Tier 1
GLIPIZIDE XL
Tier 1
GLUCOTROL
Tier 3
GLUCOTROL XL
Tier 3
glyburide oral tablet 1.25 mg
Tier 1
glyburide oral tablet 2.5 mg, 5 mg
Tier 1
glyburide micronized oral tablet 1.5 mg
Tier 1
glyburide micronized oral tablet 3 mg, 6 mg
Tier 1
GLYNASE
Tier 3
tolazamide
Tier 1
tolbutamide
Tier 1
Drug Note (Lowest generic copay
applies)
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
*ANTIDIARRHEALS*
*ANTIDIARRHEAL - CHLORIDE CHANNEL
ANTAGONISTS**-*ANTIDIARRHEAL - CHLORIDE
CHANNEL ANTAGONISTS***
FULYZAQ
Tier 3
PA; QL
diphenatol
Tier 1
DS
diphenoxylate-atropine
Tier 1
DS
LOMOTIL
Tier 3
DS
MOTOFEN
Tier 3
opium
Tier 3
DS
opium tincture (paregoric)
Tier 3
DS
*ANTIPERISTALTIC
AGENTS**-*ANTIPERISTALTIC AGENTS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
26
Drug Name
Drug Status
Drug Details
EXJADE
Tier 2
PA; SD; DS
FERRIPROX
Tier 3
PA; SD; DS
naltrexone hcl oral
Tier 1
DS
REVIA
Tier 3
*ANTIDOTES*
*ANTIDOTES - CHELATING
AGENTS**-*ANTIDOTES - CHELATING
AGENTS***
*OPIOID ANTAGONISTS**-*OPIOID
ANTAGONISTS***
*ANTIEMETICS*
*5-HT3 RECEPTOR ANTAGONISTS**-*5-HT3
RECEPTOR ANTAGONISTS***
ANZEMET ORAL
Tier 3
DS; QL
ondansetron
Tier 1
DS; QL
ondansetron hcl oral solution
Tier 1
DS; QL
ondansetron hcl oral tablet 24 mg
Tier 3
DS; QL
ondansetron hcl oral tablet 4 mg, 8 mg
Tier 1
DS; QL
SANCUSO
Tier 3
QL
ZOFRAN ORAL SOLUTION
Tier 3
DS; QL
ZOFRAN ORAL TABLET
Tier 3
DS; QL
ZOFRAN ODT
Tier 3
DS; QL
ZUPLENZ
NC
N2 (Covered in NJ, IN)
*ANTIEMETICS ANTICHOLINERGIC**-*ANTIEMETICS ANTICHOLINERGIC***
TIGAN ORAL
Tier 3
TRANSDERM-SCOP
Tier 3
trimethobenzamide hcl oral
Tier 1
*ANTIEMETICS MISCELLANEOUS**-*ANTIEMETIC
COMBINATIONS***
DICLEGIS
Tier 3
QL
CESAMET
Tier 3
QL
dronabinol
Tier 3
PA; QL
MARINOL
Tier 3
PA; DS; QL
Tier 3
#; QL
ANCOBON
Tier 3
DS
GRIFULVIN V
Tier 2
DS
*ANTIEMETICS MISCELLANEOUS**-*ANTIEMETICS MISCELLANEOUS***
*SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR
ANTAGONISTS**-*SUBSTANCE P/NEUROKININ 1
(NK1) RECEPTOR ANTAGONISTS***
EMEND ORAL
*ANTIFUNGALS*
*ANTIFUNGALS**-*ANTIFUNGALS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
27
Drug Name
Drug Status
GRIS-PEG
Tier 2
DS
griseofulvin microsize oral suspension
Tier 1
DS
griseofulvin microsize oral tablet
Tier 1
DS
griseofulvin ultramicrosize
Tier 1
DS
LAMISIL ORAL PACKET 125 MG, 187.5 MG
Tier 3
DS; QL
LAMISIL ORAL TABLET
Tier 3
DS
nystatin oral tablet
Tier 1
DS
terbinafine hcl oral
Tier 1
DS
TERBINEX
NC
Drug Details
N2 (Covered in NJ, IN)
*IMIDAZOLE-RELATED
ANTIFUNGALS**-*IMIDAZOLES***
ketoconazole oral
Tier 1
DS; QL
*IMIDAZOLE-RELATED
ANTIFUNGALS**-*TRIAZOLES***
DIFLUCAN ORAL SUSPENSION RECONSTITUTED
Tier 3
DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG
Tier 3
DIFLUCAN ORAL TABLET 150 MG
Tier 3
QL
fluconazole oral suspension reconstituted
Tier 1
AL
fluconazole oral tablet 100 mg, 200 mg, 50 mg
Tier 1
fluconazole oral tablet 150 mg
Tier 1
QL
itraconazole oral
Tier 1
QL
NOXAFIL ORAL SUSPENSION
Tier 3
DS; QL
NOXAFIL ORAL TABLET DELAYED RELEASE
Tier 3
DS
ONMEL
NC
N2 (Covered in NJ, IN)
SPORANOX ORAL CAPSULE
Tier 3
QL
SPORANOX ORAL SOLUTION
Tier 2
DS
SPORANOX PULSEPAK
Tier 3
QL
VFEND ORAL SUSPENSION RECONSTITUTED
Tier 3
DS
VFEND ORAL TABLET
Tier 3
DS
voriconazole oral tablet
Tier 1
DS
*ANTIHISTAMINES*
*ANTIHISTAMINES ETHANOLAMINES**-*ANTIHISTAMINES ETHANOLAMINES***
clemastine fumarate oral tablet 2.68 mg
Tier 1
KARBINAL ER
Tier 3
*ANTIHISTAMINES NON-SEDATING**-*ANTIHISTAMINES NON-SEDATING***
ALAVERT ORAL TABLET
Tier 1
Drug Note (Lowest Generic Copay
Applies)
ALAVERT ORAL TABLET DISPERSIBLE
Tier 1
Drug Note (Requires doctors prescription)
ALLEGRA ALLERGY ORAL TABLET 180 MG, 60 MG
Tier 1
Drug Note (Requires doctors
prescription); QL
ALLEGRA ALLERGY CHILDRENS
Tier 1
Drug Note (Requires doctors prescription)
allergy oral tablet 10 mg
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
Drug Note (Requires doctors prescription)
28
Drug Name
Drug Status
Drug Details
allergy relief oral tablet 10 mg
Tier 1
Drug Note (Requires doctors prescription)
allergy relief oral tablet dispersible
Tier 1
Drug Note (Requires doctors prescription)
cetirizine hcl oral syrup 5 mg/5ml
Tier 1
Drug Note (Lowest Generic Copay
Applies)
cetirizine hcl oral tablet
Tier 1
Drug Note (Lowest Generic Copay
Applies)
cetirizine hcl oral tablet chewable
Tier 1
Drug Note (Requires doctors prescription)
childrens loratadine
Tier 1
Drug Note (Requires doctors prescription)
CLARINEX ORAL SYRUP
Tier 3
CLARINEX ORAL TABLET
Tier 3
QL
CLARITIN ORAL SYRUP
Tier 1
Drug Note (Lowest Generic Copay
Applies)
CLARITIN REDITABS
Tier 1
cvs allergy relief oral tablet 10 mg
Tier 1
Drug Note (Requires doctors prescription)
cvs allergy relief oral tablet dispersible
Tier 1
Drug Note (Requires doctors prescription)
cvs loratadine
Tier 1
Drug Note (Requires doctors prescription)
eq allergy relief oral tablet 10 mg
Tier 1
Drug Note (Requires doctors prescription)
eql allergy relief
Tier 1
Drug Note (Requires doctors prescription)
eql childrens loratadine
Tier 1
Drug Note (Requires doctors prescription)
gnp allergy relief oral tablet dispersible
Tier 1
Drug Note (Requires doctors prescription)
gnp loratadine
Tier 1
Drug Note (Requires doctors prescription)
gnp loratadine childrens
Tier 1
Drug Note (Requires doctors prescription)
hm allergy relief oral tablet 10 mg
Tier 1
Drug Note (Requires doctors prescription)
hm allergy relief oral tablet dispersible
Tier 1
Drug Note (Requires doctors prescription)
hm loratadine childrens
Tier 1
Drug Note (Requires doctors prescription)
kp cetirizine hcl
Tier 1
Drug Note (Requires doctors prescription)
kp loratadine
Tier 1
Drug Note (Requires doctors prescription)
levocetirizine dihydrochloride oral solution
Tier 3
levocetirizine dihydrochloride oral tablet
Tier 3
QL
loratadine oral syrup
Tier 1
Drug Note (Lowest Generic Copay
Applies)
loratadine oral tablet
Tier 1
Drug Note (Requires doctors prescription)
loratadine allergy relief
Tier 1
Drug Note (Requires doctors prescription)
loratadine childrens oral solution
Tier 1
Drug Note (Requires doctors prescription)
loratadine childrens oral syrup
Tier 1
Drug Note (Lowest Generic Copay
Applies)
loratadine hives relief
Tier 1
Drug Note (Requires doctors prescription)
meijer allergy relief oral tablet dispersible
Tier 1
Drug Note (Requires doctors prescription)
px allergy relief loratadine
Tier 1
Drug Note (Requires doctors prescription)
qc allergy relief
Tier 1
Drug Note (Requires doctors prescription)
qc loratadine allergy relief
Tier 1
Drug Note (Requires doctors prescription)
ra cetirizine
Tier 1
Drug Note (Requires doctors prescription)
ra cetirizine childrens
Tier 1
Drug Note (Requires doctors prescription)
ra loratadine oral syrup
Tier 1
Drug Note (Requires doctors prescription)
ra loratadine oral tablet
Tier 1
Drug Note (Requires doctors prescription)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
29
Drug Name
Drug Status
Drug Details
ra loratadine childrens
Tier 1
Drug Note (Requires doctors prescription)
sb loratadine oral tablet
Tier 1
Drug Note (Requires doctors prescription)
sb loratadine allergy relief
Tier 1
Drug Note (Requires doctors prescription)
sm allergy relief oral tablet dispersible
Tier 1
Drug Note (Requires doctors prescription)
sm allergy relief loratadine
Tier 1
Drug Note (Requires doctors prescription)
sm childrens loratadine
Tier 1
Drug Note (Requires doctors prescription)
sm loratadine oral syrup
Tier 1
Drug Note (Requires doctors prescription)
tgt allergy relief oral tablet 10 mg
Tier 1
Drug Note (Requires doctors prescription)
tgt allergy relief oral tablet dispersible
Tier 1
Drug Note (Requires doctors prescription)
tgt loratadine childrens
Tier 1
Drug Note (Requires doctors prescription)
th cetirizine hcl
Tier 1
Drug Note (Requires doctors prescription)
th loratadine oral tablet
Tier 1
Drug Note (Requires doctors prescription)
XYZAL
Tier 3
QL
ZYRTEC ALLERGY
Tier 1
*ANTIHISTAMINES PHENOTHIAZINES**-*ANTIHISTAMINES PHENOTHIAZINES***
promethazine hcl oral
Tier 1
*ANTIHISTAMINES PIPERIDINES**-*ANTIHISTAMINES PIPERIDINES***
cyproheptadine hcl oral
Tier 1
*ANTIHYPERLIPIDEMICS*
*ANTIHYPERLIPIDEMICS COMBINATIONS**-*INTEST CHOLEST ABSORP
INHIB-HMG COA REDUCTASE INHIB COMB***
LIPTRUZET ORAL TABLET 10-10 MG, 10-20 MG,
10-40 MG, 10-80 MG
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40
MG, 10-80 MG
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
LOVAZA
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
VASCEPA
Tier 2
QL
*ANTIHYPERLIPIDEMICS MISC.**-*ANTIHYPERLIPIDEMICS - MISC.***
*BILE ACID SEQUESTRANTS**-*BILE ACID
SEQUESTRANTS***
cholestyramine oral packet
Tier 1
COLESTID
Tier 3
colestipol hcl oral granules
Tier 1
colestipol hcl oral tablet
Tier 1
micronized colestipol hcl
Tier 1
PREVALITE
Tier 1
QUESTRAN
Tier 3
QUESTRAN LIGHT ORAL POWDER
Tier 3
WELCHOL ORAL PACKET
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
30
#; QL
Drug Name
Drug Status
WELCHOL ORAL TABLET
Drug Details
Tier 3
#
ANTARA ORAL CAPSULE 30 MG, 90 MG
Tier 3
QL
fenofibrate oral tablet 145 mg, 48 mg
Tier 3
QL
fenofibrate oral tablet 160 mg, 54 mg
Tier 1
QL
fenofibrate micronized oral capsule 130 mg, 43 mg
Tier 3
QL
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
Tier 1
QL
fenofibric acid oral capsule delayed release
Tier 1
QL
fenofibric acid oral tablet
Tier 1
FENOGLIDE
Tier 3
#; QL
FIBRICOR
Tier 3
QL
gemfibrozil oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
LIPOFEN
Tier 3
#; QL
LOFIBRA
Tier 3
QL
LOPID
Tier 3
TRICOR
Tier 3
QL
TRIGLIDE ORAL TABLET 160 MG
Tier 3
QL
TRILIPIX
Tier 3
QL
ADVICOR ORAL TABLET EXTENDED RELEASE 24
HR* 1000-20 MG, 1000-40 MG, 500-20 MG, 750-20 MG
Tier 3
QL
SIMCOR
Tier 3
QL
ALTOPREV
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
atorvastatin calcium oral
Tier 1
QL
CRESTOR
Tier 2
QL
fluvastatin sodium
Tier 1
QL
LESCOL
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
LESCOL XL
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
LIPITOR
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
LIVALO
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
lovastatin
Tier 1
Drug Note (Lowest Generic Copay
Applies); QL
MEVACOR
Tier 3
QL
PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG
Tier 3
QL
pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies); QL
*FIBRIC ACID DERIVATIVES**-*FIBRIC ACID
DERIVATIVES***
*HMG COA REDUCTASE INHIBITORS**-*HMG
COA REDUCTASE INHIBITOR COMBINATIONS***
*HMG COA REDUCTASE INHIBITORS**-*HMG
COA REDUCTASE INHIBITORS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
31
Drug Name
Drug Status
Drug Details
simvastatin oral
Tier 1
Drug Note (Lowest Generic Copay
Applies); QL
ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG,
80 MG
Tier 3
QL
Tier 2
QL
Tier 3
PA; SD; DS; QL
niacin er (antihyperlipidemic)
Tier 1
DS
NIASPAN
Tier 3
*INTESTINAL CHOLESTEROL ABSORPTION
INHIBITORS**-*INTESTINAL CHOLESTEROL
ABSORPTION INHIBITORS***
ZETIA
*MICROSOMAL TRIGLYCERIDE TRANSFER
PROTEIN (MTP) INHIBITORS**-*MICROSOMAL
TRIGLYCERIDE TRANSFER PROTEIN
INHIBITORS***
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG
*NICOTINIC ACID DERIVATIVES**-*NICOTINIC
ACID DERIVATIVES***
*ANTIHYPERTENSIVES*
*ACE INHIBITORS**-*ACE INHIBITORS***
ACCUPRIL
Tier 3
ACEON ORAL TABLET 4 MG, 8 MG
Tier 3
ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5
MG
Tier 3
benazepril hcl oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
captopril oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
enalapril maleate oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
EPANED
Tier 3
QL; AL
fosinopril sodium
Tier 1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
Tier 1
lisinopril oral tablet 30 mg, 40 mg
Tier 1
LOTENSIN ORAL TABLET 20 MG, 40 MG
Tier 3
MAVIK
Tier 3
moexipril hcl
Tier 1
perindopril erbumine oral tablet 2 mg, 8 mg
Tier 3
perindopril erbumine oral tablet 4 mg
Tier 3
PRINIVIL
Tier 3
quinapril hcl
Tier 1
ramipril
Tier 1
trandolapril
Tier 1
UNIVASC
Tier 3
VASOTEC
Tier 3
ZESTRIL
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
32
QL
Drug Note (Lowest Generic Copay
Applies)
QL
Drug Name
Drug Status
Drug Details
*AGENTS FOR
PHEOCHROMOCYTOMA**-*AGENTS FOR
PHEOCHROMOCYTOMA***
DEMSER
Tier 3
DIBENZYLINE
Tier 2
*ANGIOTENSIN II RECEPTOR
ANTAGONISTS**-*ANGIOTENSIN II RECEPTOR
ANTAGONISTS***
ATACAND
Tier 3
QL
AVAPRO
Tier 3
QL
BENICAR
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
candesartan cilexetil
Tier 1
QL
COZAAR
Tier 3
DIOVAN
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
EDARBI
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
eprosartan mesylate
Tier 3
QL
irbesartan
Tier 1
QL
losartan potassium
Tier 1
Drug Note (Lowest Generic Copay
Applies)
MICARDIS
Tier 3
QL
telmisartan
Tier 1
QL
TEVETEN ORAL TABLET 600 MG
Tier 3
QL
valsartan
Tier 1
*ANTIADRENERGIC
ANTIHYPERTENSIVES**-*ANTIADRENERGICS CENTRALLY ACTING***
CATAPRES
Tier 3
CATAPRES-TTS-1
Tier 3
QL
CATAPRES-TTS-2
Tier 3
QL
CATAPRES-TTS-3
Tier 3
QL
clonidine hcl oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.3
mg/24hr
Tier 3
QL
clonidine hcl transdermal patch weekly 0.2 mg/24hr
Tier 3
guanfacine hcl oral
Tier 1
methyldopa oral
Tier 1
TENEX
Tier 3
*ANTIADRENERGIC
ANTIHYPERTENSIVES**-*ANTIADRENERGICS PERIPHERALLY ACTING***
CARDURA
Tier 3
doxazosin mesylate
Tier 1
Drug Note (Lowest Generic Copay
Applies)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
33
Drug Name
Drug Status
Drug Details
MINIPRESS
Tier 3
prazosin hcl oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
terazosin hcl oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
*ANTIADRENERGIC
ANTIHYPERTENSIVES**-*RESERPINE***
reserpine oral
Tier 3
*ANTIHYPERTENSIVE COMBINATIONS**-*ACE
INHIBITOR & CALCIUM CHANNEL BLOCKER
COMBINATIONS***
amlodipine besy-benazepril hcl
Tier 3
QL
LOTREL
Tier 3
QL
TARKA
Tier 3
#
*ANTIHYPERTENSIVE COMBINATIONS**-*ACE
INHIBITORS & THIAZIDE/THIAZIDE-LIKE***
ACCURETIC
Tier 3
benazepril-hydrochlorothiazide
Tier 1
captopril-hydrochlorothiazide
Tier 1
enalapril-hydrochlorothiazide
Tier 1
fosinopril sodium-hctz
Tier 1
lisinopril-hydrochlorothiazide
Tier 1
moexipril-hydrochlorothiazide
Tier 1
quinapril-hydrochlorothiazide
Tier 1
UNIRETIC ORAL TABLET 15-12.5 MG
Tier 3
VASERETIC
Tier 3
ZESTORETIC
Tier 3
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
*ANTIHYPERTENSIVE
COMBINATIONS**-*ADRENOLYTICS-CENTRAL
& THIAZIDE/THIAZIDE-LIKE COMB***
CLORPRES
Tier 3
methyldopa-hydrochlorothiazide oral tablet 250-15 mg,
250-25 mg
Tier 1
*ANTIHYPERTENSIVE
COMBINATIONS**-*ANGIOTENSIN II RECEPTOR
ANTAG & CA CHANNEL BLOCKER COMB***
AZOR
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
EXFORGE
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); #; QL
telmisartan-amlodipine
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
TWYNSTA
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
34
Drug Name
Drug Status
Drug Details
*ANTIHYPERTENSIVE
COMBINATIONS**-*ANGIOTENSIN II RECEPTOR
ANTAG & THIAZIDE/THIAZIDE-LIKE***
ATACAND HCT
Tier 3
QL
AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG
Tier 3
QL
BENICAR HCT
Tier 3
SD; N1 (Step Therapy Not Applicable in
NJ); QL
candesartan cilexetil-hctz
Tier 1
QL
DIOVAN HCT
Tier 3
QL
EDARBYCLOR
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
HYZAAR
Tier 3
irbesartan-hydrochlorothiazide
Tier 1
QL
losartan potassium-hctz
Tier 1
Drug Note (Lowest Generic Copay
Applies)
MICARDIS HCT
Tier 3
QL
telmisartan-hctz
Tier 1
QL
TEVETEN HCT
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); #; QL
valsartan-hydrochlorothiazide
Tier 1
QL
EXFORGE HCT
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); #; QL
TRIBENZOR
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
atenolol-chlorthalidone
Tier 1
Drug Note (Lowest Generic Copay
Applies)
bisoprolol-hydrochlorothiazide
Tier 1
Drug Note (Lowest Generic Copay
Applies)
CORZIDE
Tier 3
DUTOPROL
Tier 3
LOPRESSOR HCT ORAL TABLET 50-25 MG
Tier 3
metoprolol-hydrochlorothiazide
Tier 1
propranolol-hctz
Tier 1
TENORETIC 100
Tier 3
TENORETIC 50
Tier 3
ZIAC
Tier 3
*ANTIHYPERTENSIVE
COMBINATIONS**-*ANGIOTENSIN II RECEPTOR
ANT-CA CHANNEL BLOCKER-THIAZIDES***
*ANTIHYPERTENSIVE COMBINATIONS**-*BETA
BLOCKER & DIURETIC COMBINATIONS***
*ANTIHYPERTENSIVE
COMBINATIONS**-*DIRECT RENIN INHIBITORS
& CALCIUM CHANNEL BLOCKER COMB***
TEKAMLO
Tier 3
QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
35
Drug Name
Drug Status
Drug Details
*ANTIHYPERTENSIVE
COMBINATIONS**-*DIRECT RENIN INHIBITORS
& THIAZIDE/THIAZIDE-LIKE COMB***
TEKTURNA HCT
Tier 3
QL
Tier 3
QL
Tier 3
PA; SD; DS; QL
Tier 3
QL
Tier 3
QL
*ANTIHYPERTENSIVE
COMBINATIONS**-*DIRECT RENIN
INHIBITORS-CA CHANNEL BLOCKER-THIAZIDE
COMB***
AMTURNIDE
*ANTIHYPERTENSIVES MISC.**-*ANTIHYPERTENSIVES - MISC.***
VECAMYL
*DIRECT RENIN INHIBITORS**-*DIRECT RENIN
INHIBITORS***
TEKTURNA
*SELECTIVE ALDOSTERONE RECEPTOR
ANTAGONISTS (SARAS)**-*SELECTIVE
ALDOSTERONE RECEPTOR ANTAGONISTS
(SARAS)***
INSPRA ORAL TABLET 25 MG, 50 MG
*VASODILATORS**-*VASODILATORS***
hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg
Tier 1
hydralazine hcl oral tablet 25 mg
Tier 1
minoxidil oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
*ANTI-INFECTIVE AGENTS - MISC.*
*ANTI-INFECTIVE AGENTS MISC.**-*ANTI-INFECTIVE AGENTS - MISC.***
CAYSTON
Tier 3
SD; DS; QL
FLAGYL
Tier 3
FLAGYL ER
Tier 3
metronidazole oral
Tier 1
DS
NEBUPENT
Tier 2
DS
TINDAMAX ORAL TABLET 250 MG, 500 MG
Tier 3
QL
trimethoprim oral
Tier 1
VANCOCIN HCL ORAL CAPSULE 125 MG, 250 MG
Tier 3
vancomycin hcl intravenous*
Tier 1
XIFAXAN ORAL TABLET 200 MG
Tier 3
DS; QL
XIFAXAN ORAL TABLET 550 MG
Tier 3
PA; DS; QL
BACTRIM
Tier 3
DS
BACTRIM DS
Tier 3
DS
smz-tmp ds
Tier 1
Drug Note (Lowest Generic Copay
Applies); DS
sulfamethoxazole-tmp ds
Tier 1
Drug Note (Lowest Generic Copay
Applies); DS
QL
*ANTI-INFECTIVE MISC. COMBINATIONS**-*ANTI-INFECTIVE MISC. COMBINATIONS***
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Drug Name
Drug Status
Drug Details
sulfamethoxazole-trimethoprim oral suspension 200-40
mg/5ml
Tier 1
Drug Note (Lowest Generic Copay
Applies); DS
sulfamethoxazole-trimethoprim oral tablet
Tier 1
Drug Note (Lowest Generic Copay
Applies); DS
ALINIA ORAL SUSPENSION RECONSTITUTED
Tier 3
QL
ALINIA ORAL TABLET
Tier 3
QL
atovaquone oral
Tier 1
QL
MEPRON
Tier 3
DS; QL
Tier 3
QL
*ANTIPROTOZOAL
AGENTS**-*ANTIPROTOZOAL AGENTS***
*KETOLIDES**-*KETOLIDES***
KETEK
*LEPROSTATICS**-*LEPROSTATICS***
dapsone oral
Tier 2
*LINCOSAMIDES**-*LINCOSAMIDES***
CLEOCIN ORAL
Tier 3
clindamycin hcl oral
Tier 1
DS
ZYVOX ORAL SUSPENSION RECONSTITUTED
Tier 2
DS; QL
ZYVOX ORAL TABLET
Tier 2
DS; #; QL
atovaquone-proguanil hcl
Tier 3
PA; DS; QL
COARTEM
Tier 2
PA; DS; QL
MALARONE
Tier 3
PA; QL
ARALEN
Tier 3
DS
chloroquine phosphate oral
Tier 1
DS
DARAPRIM
Tier 2
DS
hydroxychloroquine sulfate oral
Tier 1
DS
PLAQUENIL
Tier 3
DS
primaquine phosphate oral
Tier 3
DS
QUALAQUIN
Tier 3
PA; DS; QL
*OXAZOLIDINONES**-*OXAZOLIDINONES***
*ANTIMALARIALS*
*ANTIMALARIAL
COMBINATIONS**-*ANTIMALARIAL
COMBINATIONS***
*ANTIMALARIALS**-*ANTIMALARIALS***
*ANTIMYASTHENIC/CHOLINERGIC AGENTS*
*ANTIMYASTHENIC/CHOLINERGIC
AGENTS**-*ANTIMYASTHENIC/CHOLINERGIC
AGENTS***
MESTINON ORAL SYRUP
Tier 3
MESTINON ORAL TABLET
Tier 3
pyridostigmine bromide oral
Tier 1
*ANTIMYCOBACTERIAL AGENTS*
*ANTI TB COMBINATIONS**-*ANTI TB
COMBINATIONS***
RIFAMATE
Tier 3
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Drug Name
Drug Status
RIFATER
Drug Details
Tier 3
*ANTIMYCOBACTERIAL
AGENTS**-*ANTIMYCOBACTERIAL AGENTS***
ethambutol hcl oral
Tier 1
DS
isoniazid oral
Tier 1
DS
MYAMBUTOL ORAL TABLET 400 MG
Tier 3
DS
MYCOBUTIN
Tier 2
DS
PASER
Tier 3
PRIFTIN
Tier 3
pyrazinamide oral
Tier 1
rifabutin
Tier 1
RIFADIN
Tier 3
rifampin oral
Tier 1
DS
SIRTURO
Tier 3
PA; SD; DS; QL
TRECATOR
Tier 3
DS
*ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES*
*ALKYLATING AGENTS**-*ALKYLATING
AGENTS***
HEXALEN
Tier 2
SD; DS
MYLERAN
Tier 2
SD; DS
TEMODAR ORAL
Tier 3
PA; SD; DS
temozolomide
Tier 1
PA; SD; DS
ALKERAN ORAL
Tier 2
SD; DS
cyclophosphamide oral tablet
Tier 1
SD; DS
LEUKERAN
Tier 2
SD; DS
Tier 1
SD
capecitabine
Tier 1
PA; SD; DS
mercaptopurine oral
Tier 1
DS
methotrexate oral
Tier 1
DS
methotrexate sodium injection solution
Tier 1
DS
methotrexate sodium (pf)
Tier 1
PURINETHOL
Tier 3
TABLOID
Tier 2
XELODA
Tier 3
PA; SD
Tier 3
PA; SD; DS; QL
*ALKYLATING
AGENTS**-*IMIDAZOTETRAZINES***
*ALKYLATING AGENTS**-*NITROGEN
MUSTARDS***
*ALKYLATING AGENTS**-*NITROSOUREAS***
lomustine
*ANTIMETABOLITES**-*ANTIMETABOLITES***
*ANTINEOPLASTIC - HEDGEHOG PATHWAY
INHIBITORS**-*ANTINEOPLASTIC - HEDGEHOG
PATHWAY INHIBITORS***
ERIVEDGE
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Drug Name
Drug Status
Drug Details
*ANTINEOPLASTIC - HORMONAL AND RELATED
AGENTS**-*ANDROGEN BIOSYNTHESIS
INHIBITORS***
ZYTIGA
Tier 2
PA; SD; DS; QL
*ANTINEOPLASTIC - HORMONAL AND RELATED
AGENTS**-*ANTIADRENALS***
LYSODREN
Tier 2
*ANTINEOPLASTIC - HORMONAL AND RELATED
AGENTS**-*ANTIANDROGENS***
bicalutamide
Tier 1
QL
CASODEX
Tier 3
QL
flutamide
Tier 1
NILANDRON
Tier 2
XTANDI
Tier 3
PA; SD; DS; QL
*ANTINEOPLASTIC - HORMONAL AND RELATED
AGENTS**-*ANTIESTROGENS***
FARESTON
Tier 2
SOLTAMOX
Tier 3
tamoxifen citrate oral
CE
*ANTINEOPLASTIC - HORMONAL AND RELATED
AGENTS**-*AROMATASE INHIBITORS***
anastrozole oral
Tier 1
PA; DS
ARIMIDEX
Tier 3
PA; DS
AROMASIN
Tier 3
PA; DS; QL
exemestane
Tier 1
PA; DS; QL
FEMARA
Tier 3
PA
letrozole oral
Tier 1
PA
Tier 2
DS
Tier 3
PA
*ANTINEOPLASTIC - HORMONAL AND RELATED
AGENTS**-*ESTROGENS-ANTINEOPLASTIC***
EMCYT
*ANTINEOPLASTIC - HORMONAL AND RELATED
AGENTS**-*LHRH ANALOGS***
leuprolide acetate injection
*ANTINEOPLASTIC - HORMONAL AND RELATED
AGENTS**-*PROGESTINS-ANTINEOPLASTIC***
MEGACE ORAL
Tier 3
megestrol acetate oral tablet
Tier 1
*ANTINEOPLASTIC IMMUNOMODULATORS**-*ANTINEOPLASTIC IMMUNOMODULATORS***
POMALYST
Tier 3
PA; SD; DS; QL
TAFINLAR
Tier 3
PA; SD; DS; SF; QL
ZELBORAF
Tier 3
PA; SD; DS; SF; QL
*ANTINEOPLASTIC ENZYME
INHIBITORS**-*ANTINEOPLASTIC - BRAF
KINASE INHIBITORS***
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Drug Name
Drug Status
Drug Details
*ANTINEOPLASTIC ENZYME
INHIBITORS**-*ANTINEOPLASTIC - HISTONE
DEACETYLASE INHIBITORS***
ZOLINZA
Tier 3
PA; SD; DS; QL
Tier 3
PA; SD; DS; SF; QL
AFINITOR
Tier 3
PA; SD; DS; SF; QL
AFINITOR DISPERZ
Tier 3
PA; SD; DS; SF; QL
NEXAVAR
Tier 3
PA; SD; DS; SF; QL
STIVARGA
Tier 3
PA; SD; DS; QL
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG
Tier 2
PA; SD; DS; SF; QL
BOSULIF
Tier 3
PA; ST; SD; DS; N1 (Step Therapy Not
Applicable in NJ); QL
CAPRELSA ORAL TABLET 100 MG, 300 MG
Tier 3
PA; SD; DS; N4 (Tier 2 for DE); QL
COMETRIQ (100 MG DAILY DOSE)
Tier 3
PA; SD; DS; QL
COMETRIQ (140 MG DAILY DOSE)
Tier 3
PA; SD; DS; QL
COMETRIQ (60 MG DAILY DOSE)
Tier 3
PA; SD; DS; QL
GILOTRIF
Tier 3
PA; SD; DS; QL
GLEEVEC
Tier 2
PA; SD; DS; N4 (Tier 2 for DE)
ICLUSIG ORAL TABLET 15 MG, 45 MG
Tier 3
PA; ST; SD; DS; N1 (Step Therapy Not
Applicable in NJ); QL
IMBRUVICA
Tier 3
PA; SD; DS
INLYTA
Tier 3
PA; SD; DS; SF; QL
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50
MG, 70 MG, 80 MG
Tier 3
PA; ST; SD; DS; N1 (Step Therapy Not
Applicable in NJ); SF; QL
TARCEVA
Tier 2
PA; SD; DS; SF; QL
TASIGNA
Tier 3
PA; ST; SD; DS; N1 (Step Therapy Not
Applicable in NJ); QL
TYKERB
Tier 3
PA; SD; DS
VOTRIENT
Tier 3
PA; SD; DS; SF; QL
XALKORI
Tier 3
PA; SD; DS; QL
ZYKADIA
Tier 3
PA
Tier 3
PA; SD; DS; SF; QL
*ANTINEOPLASTIC ENZYME
INHIBITORS**-*ANTINEOPLASTIC - MEK
INHIBITORS***
MEKINIST ORAL TABLET 0.5 MG, 2 MG
*ANTINEOPLASTIC ENZYME
INHIBITORS**-*ANTINEOPLASTIC - MTOR
KINASE INHIBITORS***
*ANTINEOPLASTIC ENZYME
INHIBITORS**-*ANTINEOPLASTIC MULTIKINASE INHIBITORS***
*ANTINEOPLASTIC ENZYME
INHIBITORS**-*ANTINEOPLASTIC - TYROSINE
KINASE INHIBITORS***
*ANTINEOPLASTIC ENZYME
INHIBITORS**-*JANUS ASSOCIATED KINASE
(JAK) INHIBITORS***
JAKAFI
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
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Drug Name
Drug Status
Drug Details
*ANTINEOPLASTIC ENZYME
INHIBITORS**-*PHOSPHATIDYLINOSITOL
3-KINASE (PI3K) INHIBITORS***
ZYDELIG
Tier 3
PA
*ANTINEOPLASTICS
MISC.**-*ANTINEOPLASTICS INTERLEUKINS***
PROLEUKIN
NC
*ANTINEOPLASTICS
MISC.**-*ANTINEOPLASTICS MISC.***
ACTIMMUNE
Tier 2
PA; SD; DS
HYDREA
Tier 1
DS
hydroxyurea oral
Tier 1
DS
INTRON-A
Tier 2
PA; SD; DS
MATULANE
Tier 2
SD; DS
SYLATRON SUBCUTANEOUS* KIT 296 MCG, 4 X 296
MCG, 4 X 444 MCG, 444 MCG, 888 MCG
Tier 3
PA; SD; DS
Tier 1
SD; DS; N4 (Tier 1 for DE)
Tier 2
SD; DS
*ANTINEOPLASTICS MISC.**-*RETINOIDS***
tretinoin oral
*ANTINEOPLASTICS MISC.**-*SELECTIVE
RETINOID X RECEPTOR AGONISTS***
TARGRETIN ORAL
*CHEMOTHERAPY RESCUE/ANTIDOTE
AGENTS**-*FOLIC ACID ANTAGONISTS RESCUE
AGENTS***
leucovorin calcium oral
Tier 1
*MITOTIC INHIBITORS**-*MITOTIC
INHIBITORS***
etoposide oral
Tier 1
SD; DS
Tier 3
PA; SD; DS
*TOPOISOMERASE I
INHIBITORS**-*TOPOISOMERASE I
INHIBITORS***
HYCAMTIN ORAL
*ANTIPARKINSON AGENTS*
*ANTIPARKINSON
ADJUVANTS**-*DECARBOXYLASE
INHIBITORS***
carbidopa oral
Tier 3
LODOSYN
Tier 3
*ANTIPARKINSON
ANTICHOLINERGICS**-*ANTIPARKINSON
ANTICHOLINERGICS***
benztropine mesylate oral
Tier 1
trihexyphenidyl hcl oral elixir
Tier 1
trihexyphenidyl hcl oral tablet 2 mg
Tier 1
trihexyphenidyl hcl oral tablet 5 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
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Drug Name
Drug Status
Drug Details
*ANTIPARKINSON COMT
INHIBITORS**-*CENTRAL/PERIPHERAL COMT
INHIBITORS***
TASMAR
Tier 3
*ANTIPARKINSON COMT
INHIBITORS**-*PERIPHERAL COMT
INHIBITORS***
COMTAN
Tier 2
entacapone
Tier 2
*ANTIPARKINSON
DOPAMINERGICS**-*ANTIPARKINSON
DOPAMINERGICS***
amantadine hcl oral
Tier 1
bromocriptine mesylate oral
Tier 1
PARLODEL ORAL CAPSULE
Tier 3
*ANTIPARKINSON
DOPAMINERGICS**-*LEVODOPA
COMBINATIONS***
carbidopa-levodopa oral tablet
Tier 1
SINEMET
Tier 3
SINEMET CR
Tier 3
STALEVO 100
Tier 3
STALEVO 125
Tier 3
STALEVO 150
Tier 3
STALEVO 200
Tier 3
STALEVO 50
Tier 3
STALEVO 75
Tier 3
*ANTIPARKINSON
DOPAMINERGICS**-*NONERGOLINE DOPAMINE
RECEPTOR AGONISTS***
APOKYN
Tier 3
SD; DS
MIRAPEX
Tier 3
MIRAPEX ER
Tier 3
QL
NEUPRO
Tier 3
QL
pramipexole dihydrochloride
Tier 1
REQUIP
Tier 3
REQUIP XL ORAL TABLET EXTENDED RELEASE 24
HR* 12 MG, 2 MG, 4 MG, 6 MG, 8 MG
Tier 3
ropinirole hcl
Tier 1
ropinirole hcl er oral tablet extended release 24 hr* 12 mg,
2 mg, 4 mg, 6 mg, 8 mg
Tier 3
QL
AZILECT
Tier 3
QL
ELDEPRYL
Tier 3
selegiline hcl oral
Tier 1
QL
*ANTIPARKINSON MONOAMINE OXIDASE
INHIBITORS**-*ANTIPARKINSON MONOAMINE
OXIDASE INHIBITORS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
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Drug Name
Drug Status
ZELAPAR
Tier 3
Drug Details
QL
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*
*ANTIMANIC AGENTS**-*ANTIMANIC
AGENTS***
lithium carbonate oral
Tier 1
lithium carbonate er oral tablet extendedrelease* 450 mg
Tier 1
LITHOBID
Tier 3
*ANTIPSYCHOTICS - MISC.**-*ANTIPSYCHOTICS
- MISC.***
EQUETRO
Tier 3
GEODON ORAL
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60
MG, 80 MG
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
ziprasidone hcl
Tier 1
QL
FANAPT
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
FANAPT TITRATION PACK
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
INVEGA ORAL TABLET EXTENDED RELEASE 24
HR* 1.5 MG, 3 MG, 6 MG, 9 MG
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
RISPERDAL ORAL SOLUTION
Tier 3
RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2
MG, 3 MG, 4 MG
Tier 3
QL
RISPERDAL M-TAB ORAL TABLET DISPERSIBLE 0.5
MG, 1 MG, 2 MG, 3 MG, 4 MG
Tier 3
QL
risperidone oral solution
Tier 3
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4
mg
Tier 1
QL
risperidone oral tablet dispersible 0.25 mg, 3 mg
Tier 1
QL
risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg, 4 mg
Tier 1
ST; N1 (Step Therapy Not Applicable in
NJ); QL
RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE
0.5 MG, 1 MG, 2 MG, 4 MG
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE
3 MG
Tier 3
QL
*BENZISOXAZOLES**-*BENZISOXAZOLES***
*BUTYROPHENONES**-*BUTYROPHENONES***
haloperidol oral
Tier 1
haloperidol lactate oral
Tier 1
*DIBENZAPINES**-*DIBENZODIAZEPINES***
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg
Tier 1
DS; QL
clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg
Tier 1
QL
CLOZARIL ORAL TABLET 100 MG, 25 MG
Tier 3
QL
FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5
MG, 150 MG, 200 MG, 25 MG
Tier 3
#; QL
VERSACLOZ
Tier 3
N1 (Step Therapy Not Applicable in NJ)
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Drug Name
Drug Status
Drug Details
*DIBENZAPINES**-*DIBENZO-OXEPINO
PYRROLES***
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300
mg, 400 mg, 50 mg
Tier 1
QL
SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG,
300 MG, 400 MG, 50 MG
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
SEROQUEL XR ORAL TABLET EXTENDED RELEASE
24 HR* 150 MG, 200 MG, 300 MG, 50 MG
Tier 3
PA; N1 (Step Therapy not applicable in
NJ); QL
SEROQUEL XR ORAL TABLET EXTENDED RELEASE
24 HR* 400 MG
Tier 3
PA; ST; N1 (Step Therapy not applicable
in NJ); QL
SAPHRIS
*DIBENZAPINES**-*DIBENZOTHIAZEPINES***
*DIBENZAPINES**-*DIBENZOXAZEPINES***
loxapine succinate oral
Tier 1
*DIBENZAPINES**-*THIENBENZODIAZEPINES***
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg,
7.5 mg
Tier 1
QL
olanzapine oral tablet dispersible 15 mg, 20 mg, 5 mg
Tier 1
QL
ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20
MG, 5 MG
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
ZYPREXA ORAL TABLET 7.5 MG
Tier 3
QL
ZYPREXA ZYDIS
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
*PHENOTHIAZINES**-*PHENOTHIAZINES***
chlorpromazine hcl oral
Tier 1
COMPAZINE SUPPOSITORY
Tier 3
fluphenazine hcl oral concentrate
Tier 1
fluphenazine hcl oral tablet
Tier 1
perphenazine oral
Tier 1
prochlorperazine
Tier 1
prochlorperazine edisylate injection
Tier 1
prochlorperazine maleate oral
Tier 1
thioridazine hcl oral
Tier 1
trifluoperazine hcl oral
Tier 1
*QUINOLINONE DERIVATIVES**-*QUINOLINONE
DERIVATIVES***
ABILIFY INTRAMUSCULAR*
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
ABILIFY ORAL SOLUTION
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
ABILIFY ORAL TABLET
Tier 3
PA; ST; N1 (Step Therapy not applicable
in NJ); #; QL
ABILIFY DISCMELT
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); #; QL
*THIOXANTHENES**-*THIOXANTHENES***
thiothixene oral
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
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Tier 1
Drug Name
Drug Status
Drug Details
*ANTIVIRALS*
*ANTIRETROVIRALS**-*ANTIRETROVIRAL
COMBINATIONS***
abacavir-lamivudine-zidovudine
Tier 2
SD; DS
ATRIPLA
Tier 3
SD; DS
COMBIVIR
Tier 3
ST; SD; DS; N1 (Step Therapy Not
Applicable in NJ)
COMPLERA
Tier 3
SD; DS; QL
EPZICOM
Tier 3
SD; DS
KALETRA
Tier 2
SD; DS
lamivudine-zidovudine
Tier 2
SD
STRIBILD
Tier 3
PA; SD; DS; QL
TRIZIVIR
Tier 3
SD; DS
TRUVADA
Tier 2
PA; SD; DS
Tier 3
SD; DS; QL
Tier 3
SD; DS; #; N4 (Tier 2 for DE)
ISENTRESS ORAL TABLET
Tier 3
SD; DS; QL
ISENTRESS ORAL TABLET CHEWABLE
Tier 3
SD; DS
TIVICAY
Tier 3
SD; DS; QL
APTIVUS ORAL CAPSULE
Tier 2
SD; DS; QL
APTIVUS ORAL SOLUTION
Tier 2
SD; DS
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
Tier 3
SD; DS; N4 (Tier 2 for DE)
INVIRASE
Tier 3
SD; DS
LEXIVA
Tier 2
SD; DS
NORVIR
Tier 2
SD; DS
PREZISTA ORAL SUSPENSION
Tier 2
SD; DS; QL
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG,
800 MG
Tier 2
SD; DS; QL
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
Tier 2
SD; DS; QL
VIRACEPT ORAL TABLET
Tier 3
SD; DS
EDURANT
Tier 3
SD; DS; QL
INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG
Tier 3
SD; DS; QL
nevirapine
Tier 1
SD; DS; N4 (Tier 1 for DE)
nevirapine er
Tier 2
DS
RESCRIPTOR
Tier 3
SD; DS
*ANTIRETROVIRALS**-*ANTIRETROVIRALS CCR5 ANTAGONISTS (ENTRY INHIBITOR)***
SELZENTRY
*ANTIRETROVIRALS**-*ANTIRETROVIRALS FUSION INHIBITORS***
FUZEON SUBCUTANEOUS* SOLUTION
RECONSTITUTED
*ANTIRETROVIRALS**-*ANTIRETROVIRALS INTEGRASE INHIBITORS***
*ANTIRETROVIRALS**-*ANTIRETROVIRALS PROTEASE INHIBITORS***
*ANTIRETROVIRALS**-*ANTIRETROVIRALS RTI-NON-NUCLEOSIDE ANALOGUES***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
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Drug Name
Drug Status
Drug Details
SUSTIVA
Tier 3
SD; DS
VIRAMUNE
Tier 3
SD; DS
VIRAMUNE XR ORAL TABLET EXTENDED
RELEASE 24 HR* 100 MG, 400 MG
Tier 3
SD; DS; QL
abacavir sulfate
Tier 1
SD; DS
didanosine
Tier 1
SD; DS
VIDEX
Tier 2
SD
VIDEX EC
Tier 2
SD; DS
ZIAGEN
Tier 3
SD; DS
EMTRIVA
Tier 3
SD; DS; QL
EPIVIR
Tier 2
SD; DS
EPIVIR HBV
Tier 2
SD; DS
lamivudine oral tablet
Tier 1
SD; DS
RETROVIR ORAL CAPSULE
Tier 3
SD; DS
RETROVIR ORAL SYRUP
Tier 3
SD; DS
stavudine
Tier 1
SD; DS
ZERIT
Tier 3
SD; DS
zidovudine
Tier 1
SD; DS; N4 (Tier 1 for DE)
VIREAD ORAL POWDER
Tier 2
SD; DS
VIREAD ORAL TABLET
Tier 2
SD; DS; QL
Tier 2
PA; DS
adefovir dipivoxil
Tier 1
SD; DS; QL
BARACLUDE ORAL SOLUTION
Tier 3
SD; DS; #
BARACLUDE ORAL TABLET
Tier 3
SD; DS; #; QL
HEPSERA
Tier 3
SD; DS; QL
TYZEKA
Tier 3
SD; DS; QL
COPEGUS
Tier 2
PA; SD; DS
INCIVEK
Tier 3
PA; SD; DS; QL
*ANTIRETROVIRALS**-*ANTIRETROVIRALS RTI-NUCLEOSIDE ANALOGUES-PURINES***
*ANTIRETROVIRALS**-*ANTIRETROVIRALS RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES***
*ANTIRETROVIRALS**-*ANTIRETROVIRALS RTI-NUCLEOSIDE ANALOGUES-THYMIDINES***
*ANTIRETROVIRALS**-*ANTIRETROVIRALS RTI-NUCLEOTIDE ANALOGUES***
*CMV AGENTS**-*CMV AGENTS***
VALCYTE
*HEPATITIS AGENTS**-*HEPATITIS B
AGENTS***
*HEPATITIS AGENTS**-*HEPATITIS C
AGENTS***
MODERIBA ORAL TABLET
NC
N4 (Tier 1 for DE)
MODERIBA 1200 DOSE PACK
NC
N2 (Covered in NJ, IN)
MODERIBA 800 DOSE PACK
NC
N2 (Covered in NJ, IN)
OLYSIO
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
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Tier 3
PA; SD; DS
Drug Name
Drug Status
Drug Details
PEG-INTRON
NC
SD; N2 (Covered in NJ,IN)
PEG-INTRON REDIPEN
NC
SD; N2 (Covered in NJ,IN)
PEG-INTRON REDIPEN PAK 4
NC
SD; N2 (Covered in NJ,IN)
PEGASYS
Tier 2
PA; SD; DS
PEGASYS PROCLICK
Tier 2
PA
REBETOL ORAL CAPSULE
Tier 2
PA; SD; DS
REBETOL ORAL SOLUTION
Tier 2
PA; SD; DS; QL
RIBASPHERE ORAL CAPSULE
Tier 1
PA; SD; DS; N4 (Tier 1 for DE)
RIBASPHERE ORAL TABLET 200 MG
Tier 1
PA; SD; DS; N4 (Tier 1 for DE)
RIBASPHERE ORAL TABLET 400 MG, 600 MG
Tier 1
PA; SD; DS
RIBASPHERE RIBAPAK
NC
N2 (Covered in NJ, IN)
ribavirin oral
Tier 1
PA; SD; DS; N4 (Tier 1 for DE)
SOVALDI
Tier 3
PA; SD; DS
VICTRELIS
Tier 3
PA; SD; DS; QL
acyclovir oral capsule
Tier 1
Drug Note (Lowest Generic Copay
Applies)
acyclovir oral suspension
Tier 1
acyclovir oral tablet 400 mg
Tier 1
acyclovir oral tablet 800 mg
Tier 1
*HERPES AGENTS**-*HERPES AGENTS - PURINE
ANALOGUES***
SITAVIG
NC
Drug Note (Lowest Generic Copay
Applies)
N2 (Covered in NJ, IN)
valacyclovir hcl oral tablet 1 gm, 500 mg
Tier 1
DS; QL
VALTREX ORAL TABLET 1 GM, 500 MG
Tier 3
DS; QL
ZOVIRAX ORAL CAPSULE
Tier 3
ZOVIRAX ORAL SUSPENSION
Tier 3
ZOVIRAX ORAL TABLET
Tier 3
*HERPES AGENTS**-*HERPES AGENTS THYMIDINE ANALOGUES***
famciclovir oral
Tier 1
DS; QL
FAMVIR
Tier 3
QL
*INFLUENZA AGENTS**-*INFLUENZA
AGENTS***
FLUMADINE
Tier 3
rimantadine hcl
Tier 1
DS
RELENZA DISKHALER
Tier 3
#; QL
TAMIFLU ORAL CAPSULE
Tier 3
DS; QL
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6
MG/ML
Tier 3
DS; QL
*INFLUENZA AGENTS**-*NEURAMINIDASE
INHIBITORS***
*ASSORTED CLASSES*
*CHELATING AGENTS**-*CHELATING
AGENTS***
CUPRIMINE
Tier 2
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Drug Name
Drug Status
DEPEN TITRATABS
Tier 2
SYPRINE
Tier 3
Drug Details
*IMMUNOMODULATORS**-*ANTILEPROTICS***
THALOMID
Tier 2
PA; SD; DS; N4 (Tier 2 for DE)
Tier 3
PA; SD; DS; QL
cyclosporine oral capsule
Tier 1
SD; DS
cyclosporine modified
Tier 1
SD; DS
GENGRAF
Tier 1
SD; DS
NEORAL
Tier 2
SD; DS
SANDIMMUNE ORAL
Tier 3
SD; DS
CELLCEPT
Tier 2
SD; DS
mycophenolate mofetil oral capsule
Tier 1
SD; DS
mycophenolate mofetil oral tablet
Tier 1
SD; DS
mycophenolic acid
Tier 3
SD; DS
MYFORTIC
Tier 3
SD; DS
ASTAGRAF XL ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 0.5 MG, 1 MG
Tier 3
SD; QL
ASTAGRAF XL ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 5 MG
Tier 3
SD
HECORIA
Tier 3
SD; DS
PROGRAF ORAL
Tier 3
SD; DS
RAPAMUNE
Tier 2
SD; DS
sirolimus oral tablet 0.5 mg
Tier 1
SD; DS
tacrolimus oral
Tier 1
SD; DS
ZORTRESS
Tier 3
SD; DS
*IMMUNOMODULATORS**-*IMMUNOMODULAT
ORS FOR MYELODYSPLASTIC SYNDROMES***
REVLIMID
*IMMUNOSUPPRESSIVE
AGENTS**-*CYCLOSPORINE ANALOGS***
*IMMUNOSUPPRESSIVE AGENTS**-*INOSINE
MONOPHOSPHATE DEHYDROGENASE
INHIBITORS***
*IMMUNOSUPPRESSIVE
AGENTS**-*MACROLIDE
IMMUNOSUPPRESSANTS***
*IMMUNOSUPPRESSIVE AGENTS**-*PURINE
ANALOGS***
azathioprine oral
Tier 1
IMURAN
Tier 3
DS
*POTASSIUM REMOVING RESINS**-*POTASSIUM
REMOVING RESINS***
KAYEXALATE
Tier 3
KIONEX
Tier 1
sodium polystyrene sulfonate oral powder
Tier 1
sodium polystyrene sulfonate oral suspension
Tier 1
sodium polystyrene sulfonate suspension 30 gm/120ml
Tier 1
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DS
Drug Name
Drug Status
sodium polystyrene sulfonate suspension 50 gm/200ml
Tier 2
SPS
Tier 1
Drug Details
*BETA BLOCKERS*
*ALPHA-BETA BLOCKERS**-*ALPHA-BETA
BLOCKERS***
carvedilol
Tier 1
COREG
Tier 3
COREG CR
Tier 3
labetalol hcl oral
Tier 1
TRANDATE
Tier 3
Drug Note (Lowest Generic Copay
Applies)
QL
*BETA BLOCKERS CARDIO-SELECTIVE**-*BETA
BLOCKERS CARDIO-SELECTIVE***
acebutolol hcl oral
Tier 1
atenolol oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
bisoprolol fumarate
Tier 1
Drug Note (Lowest Generic Copay
Applies)
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5
MG
Tier 3
QL
metoprolol succinate er oral tablet extended release 24 hr*
100 mg, 200 mg, 25 mg, 50 mg
Tier 1
QL
metoprolol tartrate oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
SECTRAL
Tier 3
TENORMIN
Tier 3
TOPROL XL ORAL TABLET EXTENDED RELEASE 24
HR* 100 MG, 200 MG, 25 MG
Tier 3
QL
TOPROL XL ORAL TABLET EXTENDED RELEASE 24
HR* 50 MG
Tier 1
QL
ZEBETA
Tier 3
*BETA BLOCKERS NON-SELECTIVE**-*BETA
BLOCKERS NON-SELECTIVE***
BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG
Tier 3
BETAPACE AF
Tier 3
CORGARD
Tier 3
HEMANGEOL
INDERAL LA
Tier 3
INNOPRAN XL ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 120 MG, 80 MG
Tier 3
nadolol oral
Tier 1
pindolol
Tier 1
propranolol hcl oral solution
Tier 1
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg
Tier 1
propranolol hcl oral tablet 60 mg
Tier 1
propranolol hcl er
Tier 1
QL
Drug Note (Lowest Generic Copay
Applies)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
49
Drug Name
Drug Status
sotalol hcl oral tablet 120 mg, 80 mg
Tier 1
sotalol hcl oral tablet 160 mg, 240 mg
Tier 1
sotalol hcl (af) oral tablet 120 mg
Tier 1
sotalol hcl (af) oral tablet 160 mg, 80 mg
Tier 1
timolol maleate oral
Tier 1
Drug Details
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
*CALCIUM CHANNEL BLOCKERS*
*CALCIUM CHANNEL BLOCKERS**-*CALCIUM
CHANNEL BLOCKERS***
ADALAT CC ORAL TABLET EXTENDED RELEASE
24 HR* 30 MG, 60 MG, 90 MG
Tier 3
QL
AFEDITAB CR ORAL TABLET EXTENDED RELEASE
24 HR* 30 MG, 60 MG
Tier 1
QL
amlodipine besylate oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
CALAN
Tier 3
CALAN SR
Tier 3
CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG
Tier 3
CARDIZEM CD ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG,
360 MG
Tier 3
QL
CARDIZEM LA ORAL TABLET EXTENDED RELEASE
24 HR* 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420
MG
Tier 3
QL
CARTIA XT ORAL CAPSULE EXTENDED RELEASE
24 HOUR 120 MG, 180 MG, 240 MG, 300 MG
Tier 1
QL
diltiazem hcl oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
diltiazem hcl cd
Tier 1
QL
diltiazem hcl er oral capsule extended release 12 hour
Tier 1
diltiazem hcl er oral capsule extended release 24 hour 240
mg
Tier 1
QL
diltiazem hcl er beads oral capsule extended release 24
hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg
Tier 1
QL
diltiazem hcl er coated beads oral capsule extended release
24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg
Tier 1
QL
diltiazem hcl er coated beads oral tablet extended release
24 hr* 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
Tier 3
QL
felodipine er
Tier 1
QL
MATZIM LA ORAL TABLET EXTENDED RELEASE 24
HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
Tier 3
QL
nicardipine hcl oral
Tier 1
NIFEDICAL XL ORAL TABLET EXTENDED RELEASE
24 HR* 30 MG, 60 MG
Tier 1
nifedipine oral
Tier 1
nifedipine er oral tablet extended release 24 hr* 30 mg, 60
mg, 90 mg
Tier 1
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50
QL
QL
Drug Name
Drug Status
Drug Details
nifedipine er osmotic oral tablet extended release 24 hr* 30
mg, 60 mg, 90 mg
Tier 1
nimodipine oral
Tier 1
nisoldipine er oral tablet extended release 24 hr* 17 mg, 20
mg, 30 mg, 34 mg, 40 mg, 8.5 mg
Tier 1
nisoldipine er oral tablet extended release 24 hr* 25.5 mg
Tier 1
NORVASC
Tier 3
NYMALIZE
Tier 3
PROCARDIA
Tier 3
PROCARDIA XL ORAL TABLET EXTENDED
RELEASE 24 HR* 30 MG, 60 MG, 90 MG
Tier 3
QL
SULAR ORAL TABLET EXTENDED RELEASE 24 HR*
17 MG, 34 MG, 8.5 MG
Tier 3
QL
TAZTIA XT ORAL CAPSULE EXTENDED RELEASE
24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG
Tier 1
QL
TIAZAC ORAL CAPSULE EXTENDED RELEASE 24
HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420
MG
Tier 3
QL
verapamil hcl oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
verapamil hcl er oral capsule extended release 24 hour 100
mg, 200 mg, 300 mg
Tier 1
QL
verapamil hcl er oral capsule extended release 24 hour 120
mg, 180 mg, 240 mg, 360 mg
Tier 1
verapamil hcl er oral tablet extendedrelease* 120 mg
Tier 1
verapamil hcl er oral tablet extendedrelease* 180 mg, 240
mg
Tier 1
VERELAN
Tier 3
VERELAN PM ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 100 MG, 200 MG, 300 MG
Tier 3
QL
QL
PA
Drug Note (Lowest Generic Copay
Applies)
QL
*CARDIOTONICS*
*CARDIAC GLYCOSIDES**-*CARDIAC
GLYCOSIDES***
DIGOX
Tier 1
digoxin oral solution
Tier 1
digoxin oral tablet
Tier 1
LANOXIN ORAL TABLET 0.0625 MG, 187.5 MCG
Tier 3
LANOXIN ORAL TABLET 0.125 MG, 0.25 MG
Tier 1
LANOXIN PEDIATRIC
Tier 3
Drug Note (Lowest Generic Copay
Applies)
*CARDIOVASCULAR AGENTS - MISC.*
*CARDIOVASCULAR AGENTS MISC. COMBINATIONS**-*CALCIUM CHANNEL
BLOCKER & HMG COA REDUCTASE INHIBIT
COMB***
CADUET
NC
N2 (Covered in NJ, IN)
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Drug Name
Drug Status
Drug Details
*CARDIOVASCULAR AGENTS MISC. COMBINATIONS**-*NITRATE & VASODILATOR
COMBINATIONS***
BIDIL
Tier 3
*IMPOTENCE AGENTS**-*PROSTAGLANDIN IMPOTENCE AGENTS***
CAVERJECT
LA
DS; #; N3 (Covered in DC); QL
CAVERJECT IMPULSE
LA
DS; #; N3 (Covered in DC); QL
EDEX
LA
DS; N3 (Covered in DC); QL
MUSE
LA
N3 (Covered in DC); QL
CIALIS ORAL TABLET 10 MG, 20 MG, 5 MG
LA
N3 (Covered in DC, NY); QL
CIALIS ORAL TABLET 2.5 MG
LA
N2 (Covered in NJ, IN); N3 (Covered in
DC, NY)
LEVITRA ORAL TABLET 10 MG, 20 MG, 5 MG
LA
ST; DS; N1 (Step Therapy Not
Applicable in NJ); N3 (Covered in DC,
NY); QL
LEVITRA ORAL TABLET 2.5 MG
LA
ST; DS; N1 (Step Therapy Not
Applicable in NJ); N3 (Covered in DC);
QL
STAXYN
LA
ST; N1 (Step Therapy Not Applicable in
NJ); N3 (Covered in DC); QL
STENDRA
LA
ST; N1 (Step Therapy Not Applicable in
NJ); N3 (Covered in DC, NY); QL
VIAGRA
LA
ST; DS; N1 (Step Therapy Not
Applicable in NJ); N3 (Covered in DC,
NY); QL
*IMPOTENCE AGENTS**-*SELECTIVE CGMP
PHOSPHODIESTERASE TYPE 5 INHIBITORS***
*PERIPHERAL VASODILATORS**-*PERIPHERAL
VASODILATORS***
isoxsuprine hcl oral tablet 10 mg
Tier 3
isoxsuprine hcl oral tablet 20 mg
Tier 3
QL
ORENITRAM
Tier 3
PA; SD; DS
TYVASO
Tier 3
PA; SD; DS; QL
TYVASO REFILL
Tier 3
PA; SD; DS; QL
TYVASO STARTER
Tier 3
PA; SD; DS; QL
VENTAVIS
Tier 3
PA; SD; DS
LETAIRIS
Tier 2
PA; SD; DS
OPSUMIT
Tier 2
PA; SD
TRACLEER
Tier 2
PA; SD; DS; #
*PROSTAGLANDIN
VASODILATORS**-*PROSTAGLANDIN
VASODILATORS***
*PULMONARY HYPERTENSION - ENDOTHELIN
RECEPTOR ANTAGONISTS**-*PULMONARY
HYPERTENSION - ENDOTHELIN RECEPTOR
ANTAGONISTS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
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Drug Name
Drug Status
Drug Details
*PULMONARY HYPERTENSION PHOSPHODIESTERASE
INHIBITORS**-*PULMONARY HYPERTENSION PHOSPHODIESTERASE INHIBITORS***
ADCIRCA
Tier 2
PA; SD; DS; QL
REVATIO ORAL TABLET
Tier 3
PA; SD; DS; QL
sildenafil citrate oral
Tier 3
PA; SD; DS; N4 (Tier 1 for DE); QL
Tier 3
PA; SD; DS; QL
cefadroxil
Tier 1
DS
cephalexin oral capsule
Tier 1
DS
cephalexin oral tablet
Tier 1
DS
KEFLEX
Tier 3
DS
cefaclor
Tier 1
DS
cefaclor er
Tier 1
DS; QL
cefprozil
Tier 1
DS
CEFTIN
Tier 3
cefuroxime axetil oral tablet
Tier 1
*PULMONARY HYPERTENSION - SOL
GUANYLATE CYCLASE STIMULATOR**-*PULM
HYPERTEN-SOLUBLE GUANYLATE CYCLASE
STIMULATOR (SGC)***
ADEMPAS
*CEPHALOSPORINS*
*CEPHALOSPORINS - 1ST
GENERATION**-*CEPHALOSPORINS - 1ST
GENERATION***
*CEPHALOSPORINS - 2ND
GENERATION**-*CEPHALOSPORINS - 2ND
GENERATION***
DS
*CEPHALOSPORINS - 3RD
GENERATION**-*CEPHALOSPORINS - 3RD
GENERATION***
CEDAX
Tier 3
cefdinir
Tier 1
DS
SUPRAX ORAL SUSPENSION RECONSTITUTED 100
MG/5ML, 200 MG/5ML
Tier 3
QL
SUPRAX ORAL TABLET CHEWABLE
Tier 3
QL
*CHEMICALS*
*BULK CHEMICALS - C'S**-*BULK CHEMICALS CY'S***
cyclopentolate hcl powder
Tier 1
*CONTRACEPTIVES*
*COMBINATION CONTRACEPTIVES ORAL**-*BIPHASIC CONTRACEPTIVES ORAL***
AZURETTE
Tier 1
QL
KARIVA
Tier 1
QL
LO LOESTRIN FE
Tier 3
QL
MIRCETTE
Tier 3
QL
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Drug Name
Drug Status
NECON 10/11 (28)
PIMTREA
Tier 1
Drug Details
QL
CE
*COMBINATION CONTRACEPTIVES ORAL**-*COMBINATION CONTRACEPTIVES ORAL***
ALTAVERA
Tier 1
QL
alyacen 1/35
Tier 1
QL
APRI
Tier 1
QL
AVIANE
Tier 1
QL
BALZIVA
Tier 1
QL
BEYAZ
Tier 3
QL
BREVICON (28)
Tier 3
QL
briellyn
Tier 1
QL
CE
QL
CRYSELLE-28
Tier 1
QL
CYCLAFEM 1/35
Tier 1
QL
DASETTA 1/35
Tier 1
QL
CHATEAL
DELYLA
CE
DESOGEN
Tier 3
QL
desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg
Tier 1
QL
drospirenone-ethinyl estradiol
Tier 1
QL
CE
QL
Tier 1
QL
CE
QL
ESTARYLLA
Tier 1
QL
FALMINA
Tier 1
QL
FEMCON FE
Tier 3
QL
GENERESS FE
Tier 3
#; QL
GIANVI
Tier 1
QL
GILDAGIA
Tier 1
QL
GILDESS FE 1.5/30
Tier 1
QL
GILDESS FE 1/20
Tier 1
QL
JUNEL 1.5/30
Tier 1
QL
JUNEL 1/20
Tier 1
QL
JUNEL FE 1.5/30
Tier 1
QL
JUNEL FE 1/20
Tier 1
QL
KELNOR 1/35
CE
QL
Tier 1
QL
ELINEST
EMOQUETTE
ENSKYCE
KURVELO
LARIN 1.5/30
CE
LARIN 1/20
CE
LARIN FE 1.5/30
CE
LARIN FE 1/20
CE
LESSINA
Tier 1
QL
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg
Tier 1
QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
54
Drug Name
Drug Status
Drug Details
levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg
Tier 3
Copay Note (3 copays required); QL
LEVORA 0.15/30 (28)
Tier 1
QL
LOESTRIN 1.5/30 (21)
Tier 3
QL
LOESTRIN 1/20 (21)
Tier 3
QL
LOESTRIN FE 1.5/30
Tier 3
QL
LOESTRIN FE 1/20
Tier 3
QL
LORYNA
Tier 1
QL
LOW-OGESTREL
Tier 1
QL
LUTERA
Tier 1
QL
marlissa
Tier 1
QL
MICROGESTIN 1.5/30
Tier 1
QL
MICROGESTIN 1/20
Tier 1
QL
MICROGESTIN FE 1.5/30
Tier 1
QL
MICROGESTIN FE 1/20
Tier 1
QL
MINASTRIN 24 FE
Tier 3
QL
MODICON (28)
Tier 3
QL
MONO-LINYAH
Tier 1
QL
MONONESSA
Tier 1
QL
NECON 0.5/35 (28)
Tier 1
QL
NECON 1/35 (28)
Tier 1
QL
NECON 1/50 (28)
Tier 1
QL
norgestimate-eth estradiol
Tier 1
QL
norgestrel-ethinyl estradiol
CE
NORINYL 1+35 (28)
Tier 3
QL
NORINYL 1+50 (28)
Tier 3
QL
NORTREL 0.5/35 (28)
Tier 1
QL
NORTREL 1/35 (21)
Tier 1
QL
NORTREL 1/35 (28)
Tier 1
QL
OCELLA
Tier 1
QL
OGESTREL
Tier 3
QL
ORSYTHIA
Tier 1
QL
ORTHO-CEPT (28)
Tier 3
QL
ORTHO-CYCLEN (28)
Tier 3
QL
ORTHO-NOVUM 1/35 (28)
Tier 3
QL
OVCON-35 (28)
Tier 3
QL
PHILITH
Tier 1
QL
CE
QL
PORTIA-28
Tier 1
QL
PREVIFEM
Tier 1
QL
RECLIPSEN
Tier 1
QL
SPRINTEC 28
Tier 1
QL
SRONYX
Tier 1
QL
SYEDA
Tier 1
QL
PIRMELLA 1/35
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
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Drug Name
Drug Status
VESTURA
Tier 1
VYFEMLA
CE
WERA
CE
WYMZYA FE
CE
Drug Details
QL
QL
YASMIN 28
Tier 3
QL
YAZ
Tier 3
QL
ZARAH
Tier 1
QL
ZENCHENT
Tier 1
QL
ZEOSA
CE
ZOVIA 1/35E (28)
Tier 1
QL
ZOVIA 1/50E (28)
Tier 1
QL
Tier 1
QL
AMETHIA
Tier 1
Copay Note (3 copays required); QL
AMETHIA LO
Tier 1
Copay Note (3 copays required); QL
CAMRESE
Tier 1
Copay Note (3 copays required); QL
CAMRESE LO
Tier 1
Copay Note (3 copays required); QL
DAYSEE
Tier 1
Copay Note (3 copays required); QL
INTROVALE
Tier 1
Copay Note (3 copays required); QL
JOLESSA
Tier 1
Copay Note (3 copays required); QL
levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01
mg, 0.15-0.03 mg
Tier 1
Copay Note (3 copays required); QL
LOSEASONIQUE
Tier 3
Copay Note (3 copays required); QL
QUARTETTE
Tier 1
Copay Note (3 copays required); QL
QUASENSE
Tier 1
Copay Note (3 copays required); QL
SEASONIQUE
Tier 3
Copay Note (3 copays required); QL
Tier 3
QL
alyacen 7/7/7
Tier 1
QL
ARANELLE
Tier 1
QL
CE
QL
CYCLESSA
Tier 3
QL
DASETTA 7/7/7
Tier 1
QL
ENPRESSE-28
Tier 1
QL
ESTROSTEP FE
Tier 3
QL
CE
QL
*COMBINATION CONTRACEPTIVES ORAL**-*CONTINUOUS CONTRACEPTIVES ORAL***
AMETHYST
*COMBINATION CONTRACEPTIVES ORAL**-*EXTENDED-CYCLE CONTRACEPTIVES
- ORAL***
*COMBINATION CONTRACEPTIVES ORAL**-*FOUR PHASE CONTRACEPTIVES ORAL***
NATAZIA
*COMBINATION CONTRACEPTIVES ORAL**-*TRIPHASIC CONTRACEPTIVES ORAL***
CAZIANT
LEENA
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
56
Drug Name
Drug Status
LEVONEST
CE
NECON 7/7/7
NC
Drug Details
QL
norgestim-eth estrad triphasic
Tier 1
QL
NORTREL 7/7/7
Tier 1
QL
ORTHO TRI-CYCLEN (28)
Tier 3
QL
ORTHO TRI-CYCLEN LO
Tier 3
#; QL
ORTHO-NOVUM 7/7/7 (28)
Tier 3
QL
CE
QL
TRI-ESTARYLLA
Tier 1
QL
TRI-LEGEST FE
Tier 1
QL
TRI-LINYAH
Tier 1
QL
TRI-NORINYL (28)
Tier 3
QL
TRI-PREVIFEM
Tier 1
QL
TRI-SPRINTEC
Tier 1
QL
TRINESSA (28)
Tier 1
QL
TRIVORA (28)
Tier 1
QL
VELIVET
Tier 1
QL
Tier 3
QL
TILIA FE
*COMBINATION CONTRACEPTIVES TRANSDERMAL**-*COMBINATION
CONTRACEPTIVES - TRANSDERMAL***
ORTHO EVRA
XULANE
CE
*COMBINATION CONTRACEPTIVES VAGINAL**-*COMBINATION CONTRACEPTIVES
- VAGINAL***
NUVARING
Tier 2
QL
*COPPER CONTRACEPTIVES - IUD**-*COPPER
CONTRACEPTIVES - IUD***
PARAGARD INTRAUTERINE COPPER
CE
*EMERGENCY
CONTRACEPTIVES**-*EMERGENCY
CONTRACEPTIVES***
FALLBACK SOLO
CE
levonorgestrel oral tablet 0.75 mg
CE
NEXT CHOICE
CE
QL
NEXT CHOICE ONE DOSE
Tier 1
QL
PLAN B ONE-STEP
Tier 1
QL
*PROGESTIN CONTRACEPTIVES IMPLANTS**-*PROGESTIN CONTRACEPTIVES IMPLANTS***
IMPLANON
CE
NEXPLANON
CE
*PROGESTIN CONTRACEPTIVES INJECTABLE**-*PROGESTIN CONTRACEPTIVES
- INJECTABLE***
DEPO-PROVERA INTRAMUSCULAR* SUSPENSION
150 MG/ML
Tier 3
QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
57
Drug Name
Drug Status
DEPO-SUBQ PROVERA 104
medroxyprogesterone acetate intramuscular*
Drug Details
Tier 3
QL
CE
QL
*PROGESTIN CONTRACEPTIVES IUD**-*PROGESTIN CONTRACEPTIVES - IUD***
MIRENA
CE
*PROGESTIN CONTRACEPTIVES ORAL**-*PROGESTIN CONTRACEPTIVES ORAL***
ERRIN
Tier 1
QL
JENCYCLA
Tier 1
QL
JOLIVETTE
Tier 1
QL
LYZA
Tier 1
QL
NOR-QD
Tier 3
QL
NORA-BE
Tier 1
QL
norethindrone oral
Tier 1
QL
ORTHO MICRONOR
Tier 3
QL
*CORTICOSTEROIDS*
*GLUCOCORTICOSTEROIDS**-*GLUCOCORTIC
OSTEROIDS***
budesonide er
Tier 1
CORTEF
Tier 3
cortisone acetate oral
Tier 1
dexamethasone oral
Tier 1
ENTOCORT EC
Tier 3
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg
Tier 1
MEDROL
Tier 3
MEDROL (PAK)
Tier 3
methylprednisolone oral
Tier 1
methylprednisolone (pak)
Tier 1
ORAPRED ODT
Tier 3
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg
Tier 1
prednisone oral tablet 50 mg
Tier 1
prednisone (pak)
Tier 1
Drug Note (Lowest Generic Copay
Applies)
RAYOS
Tier 3
N1 (Step Therapy Not Applicable in NJ)
UCERIS ORAL
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
*MINERALOCORTICOIDS**-*MINERALOCORTIC
OIDS***
fludrocortisone acetate oral
Tier 1
*COUGH/COLD/ALLERGY*
*ANTITUSSIVES**-*ANTITUSSIVE NONNARCOTIC***
benzonatate
Tier 1
TESSALON PERLES
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
58
Drug Note (Lowest Generic Copay
Applies)
Drug Name
Drug Status
ZONATUSS
NC
Drug Details
N2 (Covered in NJ, IN)
*ANTITUSSIVES**-*ANTITUSSIVE - OPIOID***
hydrocodone-homatropine
Tier 1
DS
cheratussin ac oral syrup
Tier 1
DS
guaifenesin-codeine oral solution
Tier 1
DS
guaifenesin-codeine oral syrup
Tier 1
DS
Tier 1
Drug Note (Requires doctors prescription)
*COUGH/COLD/ALLERGY
COMBINATIONS**-*ANTITUSSIVE-EXPECTORAN
T***
*COUGH/COLD/ALLERGY
COMBINATIONS**-*DECONGESTANT &
ANTIHISTAMINE***
ALAVERT ALLERGY/SINUS
ALLEGRA-D ALLERGY & CONGESTION
NC
N2 (Covered in NJ, IN)
CLARINEX-D 12 HOUR
Tier 3
QL
CLARITIN-D 12 HOUR
Tier 1
DS
CLARITIN-D 24 HOUR
Tier 1
DS
promethazine vc
Tier 1
promethazine vc plain
Tier 1
SEMPREX-D
Tier 3
ZYRTEC-D ALLERGY & CONGESTION
Tier 1
*COUGH/COLD/ALLERGY
COMBINATIONS**-*NON-NARC
ANTITUSSIVE-ANTIHISTAMINE***
promethazine-dm
Tier 1
*COUGH/COLD/ALLERGY
COMBINATIONS**-*NON-NARC
ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE
***
BROMFED DM
Tier 3
DS
promethazine-codeine
Tier 1
DS
TUSSICAPS
Tier 3
QL
TUSSIONEX PENNKINETIC ER
Tier 3
DS; QL
VITUZ
Tier 3
QL
*COUGH/COLD/ALLERGY
COMBINATIONS**-*OPIOID
ANTITUSSIVE-ANTIHISTAMINE***
*COUGH/COLD/ALLERGY
COMBINATIONS**-*OPIOID
ANTITUSSIVE-DECONGESTANT***
REZIRA
Tier 3
*COUGH/COLD/ALLERGY
COMBINATIONS**-*OPIOID
ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE
***
promethazine vc/codeine
Tier 1
pseudoeph-chlorphen-hydrocod
Tier 3
ZUTRIPRO
Tier 3
DS
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
59
Drug Name
Drug Status
Drug Details
*MISC. RESPIRATORY INHALANTS**-*MISC.
RESPIRATORY INHALANTS***
NEBUSAL INHALATION NEBULIZATION SOLUTION
3%
Tier 1
sodium chloride inhalation nebulization solution 0.9 %, 10
%, 3 %
Tier 1
*MUCOLYTICS**-*MUCOLYTICS***
acetylcysteine inhalation
Tier 1
*DERMATOLOGICALS*
*ACNE PRODUCTS**-*ACNE ANTIBIOTICS***
ACZONE
Tier 3
CLEOCIN-T EXTERNAL 1 %
Tier 3
CLINDAGEL
Tier 3
clindamycin phosphate external lotion
Tier 1
DS
clindamycin phosphate external solution
Tier 1
DS
clindamycin phosphate external swab
Tier 3
DS
erythromycin external solution
Tier 1
EVOCLIN
Tier 3
KLARON
Tier 3
*ACNE PRODUCTS**-*ACNE COMBINATIONS***
ACANYA
NC
AVAR CLEANSER
Tier 1
AVAR-E EMOLLIENT
Tier 3
AVAR-E GREEN
Tier 3
BENZACLIN
Tier 3
BENZACLIN WITH PUMP
NC
BENZAMYCIN
Tier 3
BENZAMYCINPAK
Tier 3
benzoyl peroxide-erythromycin
Tier 1
bp 10-1
Tier 1
CLARIFOAM EF
Tier 2
CLINDACIN PAC
NC
clindamycin phos-benzoyl perox external 1-5 %
Tier 3
DUAC
Tier 3
EPIDUO
Tier 3
PLEXION
Tier 3
PLEXION CLEANSER EXTERNAL LIQUID†
Tier 3
PLEXION CLEANSING CLOTH EXTERNAL PAD
Tier 3
ROSANIL CLEANSER
Tier 3
sulfacetamide sod-sulfur wash external kit
NC
sulfacetamide sodium-sulfur external emulsion
Tier 1
sulfacetamide sodium-sulfur external liquid† 9-4.5 %
Tier 1
sulfacetamide sodium-sulfur external lotion 10-5 %
Tier 1
sulfacetamide sodium-sulfur external suspension 10-5 %
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
60
N2 (Covered in NJ, IN)
QL
N2 (Covered in NJ, IN)
N2 (Covered in NJ, IN)
QL
QL
N2 (Covered in NJ, IN)
Drug Name
Drug Status
sulfacetamide-sulfur in urea external 10-5 %
Drug Details
Tier 1
SUMADAN
NC
N2 (Covered in NJ, IN)
SUMADAN WASH
NC
N2 (Covered in NJ, IN)
SUMADAN XLT
NC
N2 (Covered in NJ, IN)
SUMAXIN CP
NC
N2 (Covered in NJ, IN)
VANOXIDE-HC
Tier 3
VELTIN
Tier 3
ZIANA
Tier 3
#
*ACNE PRODUCTS**-*ACNE PRODUCTS***
ABSORICA ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40
MG
NC
DS; N2 (Covered in NJ, IN); QL
adapalene external 0.1 %
Tier 3
adapalene external 0.3 %
Tier 3
adapalene external cream
Tier 3
AMNESTEEM
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
ATRALIN
Tier 3
#; QL
AVITA
Tier 3
QL
AVITA EXTERNAL 0.025 %
Tier 3
QL
AZELEX
Tier 2
CLARAVIS
Tier 1
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
DIFFERIN EXTERNAL 0.1 %, 0.3 %
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
DIFFERIN EXTERNAL CREAM
Tier 3
DIFFERIN EXTERNAL LOTION
Tier 3
FABIOR
Tier 3
MYORISAN
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
RETIN-A
Tier 3
QL
RETIN-A EXTERNAL 0.01 %, 0.025 %
Tier 3
QL
RETIN-A MICRO
Tier 3
QL
RETIN-A MICRO PUMP EXTERNAL 0.04 %, 0.1 %
Tier 3
QL
TRETIN-X EXTERNAL CREAM 0.0375 %
Tier 3
QL
TRETIN-X EXTERNAL KIT 0.025 % CREAM, 0.05 %
CREAM, 0.1 % CREAM
NC
ST; N1 (Step Therapy Not Applicable in
NJ)
N2 (Covered in NJ, IN)
tretinoin external 0.01 %
Tier 1
tretinoin external 0.025 %
Tier 1
QL
tretinoin external cream
Tier 1
QL
tretinoin microsphere
Tier 1
QL
tretinoin microsphere pump
Tier 1
QL
ZENATANE ORAL CAPSULE 10 MG, 20 MG, 40 MG
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
61
Drug Name
Drug Status
Drug Details
*AGENTS FOR EXTERNAL GENITAL AND
PERIANAL WARTS**-*AGENTS FOR EXTERNAL
GENITAL AND PERIANAL WARTS***
VEREGEN
Tier 3
*ANTIBIOTICS - TOPICAL**-*ANTIBIOTICS TOPICAL***
ALTABAX
Tier 3
BACTROBAN EXTERNAL CREAM
Tier 3
BACTROBAN EXTERNAL OINTMENT
Tier 3
gentamicin sulfate external
Tier 1
mupirocin external
Tier 1
mupirocin calcium
Tier 1
Drug Note (Lowest Generic Copay
Applies)
*ANTIFUNGALS - TOPICAL**-*ANTIFUNGALS TOPICAL COMBINATIONS***
DERMAZENE
Tier 3
hydrocortisone-iodoquinol
Tier 3
LOTRISONE
Tier 3
nystatin-triamcinolone
Tier 1
DS
*ANTIFUNGALS - TOPICAL**-*ANTIFUNGALS TOPICAL***
CICLODAN CREAM
NC
N2 (Covered in NJ, IN)
CICLODAN SOLUTION
NC
N2 (Covered in NJ, IN)
ciclopirox external 0.77 %
Tier 3
ciclopirox external shampoo
Tier 3
ciclopirox olamine external cream
Tier 1
CNL8 NAIL
NC
DS
DS
N2 (Covered in NJ, IN)
LOPROX EXTERNAL SHAMPOO
Tier 3
MENTAX
Tier 3
NAFTIN EXTERNAL 1 %, 2 %
Tier 3
NAFTIN EXTERNAL CREAM 1 %, 2 %
Tier 3
nystatin external cream
Tier 1
DS
nystatin external ointment
Tier 1
DS
PENLAC
Tier 3
*ANTIFUNGALS TOPICAL**-*IMIDAZOLE-RELATED
ANTIFUNGALS - TOPICAL***
clotrimazole external cream
Tier 1
clotrimazole af
Tier 1
clotrimazole anti-fungal
Tier 1
cvs clotrimazole
Tier 1
econazole nitrate external
Tier 1
ECOZA
NC
ERTACZO
Tier 3
EXELDERM
Tier 2
EXTINA
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
62
N2 (Covered in NJ, IN)
Drug Name
Drug Status
KETODAN EXTERNAL KIT
NC
kp clotrimazole
Tier 1
LUZU
Tier 3
OXISTAT
Tier 3
qc clotrimazole
Tier 1
ra clotrimazole
Tier 1
sm antifungal clotrimazole
Tier 1
tgt clotrimazole
Tier 1
th clotrimazole
Tier 1
XOLEGEL
Tier 3
Drug Details
N2 (Covered in NJ, IN)
*ANTI-INFLAMMATORY AGENTS TOPICAL**-*ANTI-INFLAMMATORY AGENTS TOPICAL***
FLECTOR
NC
N2 (Covered in NJ, IN)
PENNSAID TRANSDERMAL SOLUTION 1.5 %, 2 %
NC
N2 (Covered in NJ, IN)
VOLTAREN TRANSDERMAL
Tier 3
QL
Tier 3
PA; SD; DS; QL
*ANTINEOPLASTIC OR PREMALIGNANT LESION
AGENTS - TOPICAL**-*ANTINEOPLASTIC
ALKYLATING AGENTS - TOPICAL***
VALCHLOR
*ANTINEOPLASTIC OR PREMALIGNANT LESION
AGENTS - TOPICAL**-*ANTINEOPLASTIC
ANTIMETABOLITES - TOPICAL***
EFUDEX
Tier 3
FLUOROPLEX
Tier 3
fluorouracil external cream 5 %
Tier 1
fluorouracil external solution
Tier 1
*ANTINEOPLASTIC OR PREMALIGNANT LESION
AGENTS - TOPICAL**-*ANTINEOPLASTIC OR
PREMALIGNANT LESIONS - TOPICAL MISC.***
PICATO
Tier 2
DS; QL
*ANTINEOPLASTIC OR PREMALIGNANT LESION
AGENTS - TOPICAL**-*ANTINEOPLASTIC OR
PREMALIGNANT LESIONS - TOPICAL NSAID'S***
diclofenac sodium transdermal 3 %
Tier 1
SOLARAZE
Tier 3
*ANTINEOPLASTIC OR PREMALIGNANT LESION
AGENTS - TOPICAL**-*ANTINEOPLASTIC
RETINOIDS - TOPICAL***
PANRETIN
Tier 3
*ANTINEOPLASTIC OR PREMALIGNANT LESION
AGENTS - TOPICAL**-*PHOTODYNAMIC
THERAPY AGENTS - TOPICAL***
LEVULAN KERASTICK
Tier 3
*ANTINEOPLASTIC OR PREMALIGNANT LESION
AGENTS - TOPICAL**-*TOPICAL SELECTIVE
RETINOID X RECEPTOR AGONISTS***
TARGRETIN EXTERNAL
Tier 2
SD; DS
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
63
Drug Name
Drug Status
Drug Details
*ANTIPSORIATICS**-*ANTIPSORIATICS SYSTEMIC***
acitretin
Tier 1
methoxsalen rapid
Tier 1
OXSORALEN ULTRA
Tier 3
SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG
Tier 2
QL
QL
*ANTIPSORIATICS**-*ANTIPSORIATICS***
calcipotriene external cream
Tier 3
calcipotriene external ointment
Tier 3
calcipotriene external solution
Tier 3
CALCITRENE
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
calcitriol external
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
DOVONEX EXTERNAL CREAM
Tier 3
SORILUX
NC
TAZORAC EXTERNAL 0.05 %, 0.1 %
Tier 3
VECTICAL
Tier 3
ZITHRANOL
Tier 3
N2 (Covered in NJ, IN)
*ANTISEBORRHEIC
PRODUCTS**-*ANTISEBORRHEIC
COMBINATIONS***
selenium sulf-pyrithione-urea
SELRX
Tier 1
NC
N2 (Covered in NJ, IN)
*ANTISEBORRHEIC
PRODUCTS**-*ANTISEBORRHEIC PRODUCTS***
OVACE WASH
Tier 3
selenium sulfide external
Tier 1
SELSUN BLUE MEDICATED
NC
*ANTIVIRALS - TOPICAL**-*ANTIVIRALS TOPICAL***
ABREVA
Tier 1
acyclovir external
Tier 3
DENAVIR
Tier 3
ZOVIRAX EXTERNAL CREAM
Tier 3
ZOVIRAX EXTERNAL OINTMENT
Tier 3
Drug Note (Requires doctors
prescription); DS
DS
*BURN PRODUCTS**-*BURN PRODUCTS***
SILVADENE
Tier 3
silver sulfadiazine external
Tier 1
SULFAMYLON
Tier 3
*CORTICOSTEROIDS TOPICAL**-*CORTICOSTEROIDS - TOPICAL***
alclometasone dipropionate
Tier 1
betamethasone dipropionate aug external cream
Tier 1
betamethasone dipropionate aug external lotion
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
64
DS
Drug Name
Drug Status
betamethasone dipropionate aug external ointment
Tier 1
betamethasone valerate external cream
Tier 1
betamethasone valerate external lotion
Tier 1
betamethasone valerate external ointment
Tier 1
CAPEX
Tier 2
clobetasol propionate external cream
Tier 1
clobetasol propionate external ointment
Tier 1
clobetasol propionate e
Tier 1
CLOBEX
Tier 3
CLOBEX SPRAY
Tier 3
CLODERM
Tier 3
CLODERM PUMP
Tier 3
CORDRAN EXTERNAL TAPE
Tier 3
CUTIVATE EXTERNAL CREAM
Tier 3
CUTIVATE EXTERNAL LOTION
Tier 3
DERMA-SMOOTHE/FS BODY
Tier 2
DERMA-SMOOTHE/FS SCALP
Tier 2
DERMATOP
Tier 3
DESONATE
Tier 3
desonide external cream
Tier 1
desonide external ointment
Tier 1
DESOWEN EXTERNAL CREAM
Tier 3
DIPROLENE
Tier 3
DIPROLENE AF
Tier 3
ELOCON
Tier 3
fluocinolone acetonide body
Tier 1
fluocinolone acetonide scalp
Tier 1
fluocinonide external 0.05 %
Tier 1
fluocinonide external cream 0.05 %
Tier 1
fluocinonide external cream 0.1 %
Tier 1
fluocinonide external ointment
Tier 1
fluocinonide-e
Tier 1
fluticasone propionate external cream
Tier 1
fluticasone propionate external lotion
Tier 3
fluticasone propionate external ointment
Tier 1
halobetasol propionate
Tier 1
HALOG
Tier 3
hydrocortisone external cream 2.5 %
Tier 1
hydrocortisone external lotion 2.5 %
Tier 1
hydrocortisone external ointment 2.5 %
Tier 1
hydrocortisone butyr lipo base
Tier 1
hydrocortisone butyrate external
Tier 1
Drug Details
QL
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
65
Drug Name
Drug Status
hydrocortisone valerate
Tier 1
KENALOG EXTERNAL
Tier 3
LOCOID EXTERNAL CREAM
Tier 3
LOCOID EXTERNAL LOTION
Tier 3
LOCOID EXTERNAL OINTMENT
Tier 3
LOCOID LIPOCREAM
Tier 3
LUXIQ
Tier 3
mometasone furoate external
Tier 1
OLUX
Tier 3
OLUX-E
Tier 3
PANDEL
Tier 3
PEDIADERM HC
NC
SYNALAR
Tier 3
TEMOVATE EXTERNAL CREAM
Tier 3
TEMOVATE EXTERNAL OINTMENT
Tier 3
TOPICORT
Tier 3
TOPICORT EXTERNAL 0.05 %
Tier 3
TOPICORT SPRAY
NC
Drug Details
N2 (Covered in NJ, IN)
N2 (Covered in NJ, IN)
triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5
%
Tier 1
Drug Note (Lowest Generic Copay
Applies)
triamcinolone acetonide external ointment
Tier 1
Drug Note (Lowest Generic Copay
Applies)
ULTRAVATE
Tier 3
VANOS
Tier 3
VERDESO
Tier 3
WESTCORT
Tier 3
*CORTICOSTEROIDS TOPICAL**-*STEROID-LOCAL ANESTHETIC
COMBINATIONS***
hydrocortisone ace-pramoxine external
Tier 1
PRAMOSONE
Tier 3
*CORTICOSTEROIDS - TOPICAL**-*TOPICAL
STEROID COMBINATIONS***
calcipotriene-betameth diprop
Tier 3
SD
HALONATE
NC
N2 (Covered in NJ, IN)
HALONATE PAC
NC
N2 (Covered in NJ, IN)
SYNALAR (CREAM)
Tier 3
SYNALAR (OINTMENT)
Tier 3
SYNALAR TS
TACLONEX EXTERNAL OINTMENT
NC
N2 (Covered in NJ, IN)
Tier 3
ULTRAVATE X (CREAM)
NC
N2 (Covered in NJ, IN)
ULTRAVATE X (OINTMENT)
NC
N2 (Covered in NJ, IN)
*EMOLLIENTS**-*EMOLLIENTS***
HYLATOPIC
Tier 3
LAC-HYDRIN
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
66
Drug Name
Drug Status
Drug Details
*ENZYMES - TOPICAL**-*ENZYMES TOPICAL***
GRANULEX
Tier 3
SANTYL
Tier 3
*HAIR REDUCTION AGENTS**-*ORNITHINE
DECARBOXYLASE (ODC) INHIBITORS TOPICAL***
VANIQA
Tier 3
*IMMUNOMODULATING AGENTS TOPICAL**-*IMMUNOMODULATORS
IMIDAZOQUINOLINAMINES - TOPICAL***
ALDARA
Tier 3
QL
imiquimod external
Tier 1
QL
ZYCLARA
NC
PA; N2 (Covered in NJ, IN)
ZYCLARA PUMP
NC
PA; N2 (Covered in NJ, IN)
*IMMUNOSUPPRESSIVE AGENTS TOPICAL**-*MACROLIDE
IMMUNOSUPPRESSANTS - TOPICAL***
ELIDEL
Tier 3
PA; DS; QL
PROTOPIC
Tier 3
PA; DS; #; QL
*KERATOLYTIC/ANTIMITOTIC
AGENTS**-*KERATOLYTIC/ANTIMITOTIC
AGENTS***
CONDYLOX
Tier 3
CONDYLOX EXTERNAL 0.5 %
Tier 3
podocon
Tier 3
podofilox external
Tier 1
SALEX EXTERNAL SHAMPOO
Tier 3
*LOCAL ANESTHETICS - TOPICAL**-*LOCAL
ANESTHETICS - TOPICAL***
lidocaine external patch
Tier 1
LIDODERM
Tier 3
lidorx
Tier 3
QL
EMLA
Tier 3
DS
lidocaine-prilocaine external cream
Tier 1
DS
SYNERA
Tier 3
*LOCAL ANESTHETICS - TOPICAL**-*TOPICAL
ANESTHETIC COMBINATIONS***
*MISC. TOPICAL**-*ASTRINGENTS***
aluminum acetate external
Tier 1
XERAC AC
Tier 2
*MISC. TOPICAL**-*MISC. TOPICAL***
DRYSOL
Tier 3
*PIGMENTING-DEPIGMENTING
AGENTS**-*PIGMENTING AGENTS***
OXSORALEN
Tier 2
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
67
Drug Name
Drug Status
Drug Details
*ROSACEA AGENTS**-*ROSACEA AGENTS***
FINACEA
Tier 3
METROCREAM
Tier 3
METROGEL EXTERNAL 1 %
Tier 3
METROLOTION
Tier 3
metronidazole external 0.75 %
Tier 1
DS
metronidazole external 1 %
Tier 3
DS
metronidazole external cream
Tier 1
DS
metronidazole external lotion
Tier 1
DS
MIRVASO
Tier 3
NORITATE
Tier 3
ORACEA
NC
ROSADAN EXTERNAL 0.75 %
Tier 3
ROSADAN EXTERNAL CREAM
Tier 1
ROSADAN EXTERNAL KIT
NC
ST; N1 (Step Therapy Not Applicable in
NJ)
N2 (Covered in NJ, IN)
N2 (Covered in NJ, IN)
*SCABICIDES & PEDICULICIDES**-*SCABICIDES
& PEDICULICIDES***
cvs permethrin
Tier 1
DS
ELIMITE
Tier 3
EURAX
Tier 2
lindane external lotion
Tier 1
DS; QL
lindane external shampoo
Tier 2
DS; QL
NATROBA
Tier 3
OVIDE
Tier 3
QL
permethrin external cream
Tier 1
DS
permethrin external lotion
Tier 1
DS
ULESFIA
Tier 3
QL
*WOUND CARE PRODUCTS**-*WOUND CARE GROWTH FACTOR AGENTS***
REGRANEX
Tier 3
*DIAGNOSTIC PRODUCTS*
*DIAGNOSTIC TESTS**-*DIAGNOSTIC TESTS***
ACCU-CHEK AVIVA IN VITRO STRIP
Tier 3
PA; ST; N1 (Step Therapy not applicable
in NJ); N2 (Covered in NJ,IN); QL
ACCU-CHEK COMFORT CURVE IN VITRO STRIP
Tier 3
PA; ST; N1 (Step Therapy not applicable
in NJ); N2 (Covered in NJ,IN); QL
ACCU-CHEK SMARTVIEW
Tier 3
PA; ST; N1 (Step Therapy not applicable
in NJ); N2 (Covered in NJ,IN); QL
FREESTYLE INSULINX TEST
Tier 3
ST; N1 (Step Therapy Not Applicable In
NJ); QL
FREESTYLE LITE TEST
Tier 3
ST; N1 (Step Therapy Not Applicable In
NJ); QL
FREESTYLE TEST
Tier 3
ST; N1 (Step Therapy Not Applicable In
NJ); QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
68
Drug Name
Drug Status
Drug Details
NOVA MAX GLUCOSE TEST
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
ONETOUCH ULTRA BLUE
Tier 2
QL
ONETOUCH VERIO IN VITRO STRIP
Tier 2
QL
PRECISION XTRA BLOOD GLUCOSE
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
RA TRUETEST TEST
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
TRUETEST TEST
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
TRUETRACK TEST
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
*DIETARY PRODUCTS/DIETARY MANAGEMENT
PRODUCTS*
*DIETARY MANAGEMENT
PRODUCTS**-*DIETARY MANAGEMENT
PRODUCT COMBINATIONS***
APPTRIM
LA
N3 (Covered in TX)
APPTRIM-D
LA
N3 (Covered in TX)
AXONA
LA
N3 (Covered in TX)
CARDIOTEK RX
LA
N3 (Covered in TX)
CEREFOLIN
LA
N3 (Covered in TX)
CEREFOLIN NAC
LA
N3 (Covered in TX)
DEPLIN 15
LA
N3 (Covered in TX)
DEPLIN 7.5
LA
N3 (Covered in TX)
DERMANIC
Tier 3
ENLYTE
LA
N3 (Covered in TX)
FOLBEE AR
LA
N3 (Covered in TX)
FOLBIC
LA
N3 (Covered in TX)
FOLBIC RF
LA
N3 (Covered in TX)
FOLTANX
LA
N3 (Covered in TX)
FOLTANX RF
LA
N3 (Covered in TX)
FOLTX
LA
N3 (Covered in TX)
FOSTEUM
LA
N3 (Covered in TX)
FOSTEUM PLUS
LA
N3 (Covered in TX)
FOVEX
LA
N3 (Covered in TX)
GABADONE
LA
N3 (Covered in TX)
HYPERTENSA
LA
N3 (Covered in TX)
l-methyl-mc
LA
N3 (Covered in TX)
l-methyl-mc nac
LA
N3 (Covered in TX)
l-methylfolate ca me-cbl nac
LA
N3 (Covered in TX)
l-methylfolate formula 15
LA
N3 (Covered in TX)
l-methylfolate formula 7.5
LA
N3 (Covered in TX)
l-methylfolate forte
LA
N3 (Covered in TX)
l-methylfolate-algae-b12-b6
LA
N3 (Covered in TX)
l-methylfolate-b6-b12
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
LA
N3 (Covered in TX)
69
Drug Name
Drug Status
Drug Details
LIMBREL250
LA
N3 (Covered in TX)
LIMBREL500
LA
N3 (Covered in TX)
LIPICHOL 540
LA
N3 (Covered in TX)
LISTER-V
LA
N3 (Covered in TX)
LUKAID GLA
LA
N3 (Covered in TX)
MACUTEK
LA
N3 (Covered in TX)
METAFOLBIC
LA
N3 (Covered in TX)
METAFOLBIC PLUS
LA
N3 (Covered in TX)
METAFOLBIC PLUS RF
LA
N3 (Covered in TX)
METANX ORAL CAPSULE
LA
N3 (Covered in TX)
PERCURA
LA
N3 (Covered in TX)
PODIAPN
LA
N3 (Covered in TX)
PROTEOLIN ORAL TABLET
LA
N3 (Covered in TX)
PROTEOLIN DS
LA
N3 (Covered in TX)
PULMONA
LA
N3 (Covered in TX)
SENTRA AM
LA
N3 (Covered in TX)
SENTRA PM
LA
N3 (Covered in TX)
THERAMINE
LA
N3 (Covered in TX)
TOZAL
LA
N3 (Covered in TX)
TREPADONE
LA
N3 (Covered in TX)
VASCULERA
LA
N3 (Covered in TX)
VAYACOG
LA
N3 (Covered in TX)
VAYARIN
LA
N3 (Covered in TX)
VIRILEX
LA
N3 (Covered in TX)
virt-vite forte
LA
N3 (Covered in TX)
VITA-RESPA
LA
N3 (Covered in TX)
vp-gstn
LA
N3 (Covered in TX)
VSL#3 JUNIOR
LA
N3 (Covered in TX)
AVAILNEX
LA
N3 (Covered in TX)
ENTERAGAM
LA
N3 (Covered in TX)
l-methylfolate
LA
N3 (Covered in TX)
LIMBREL
LA
N3 (Covered in TX)
VASCAZEN
LA
N3 (Covered in TX)
*DIETARY MANAGEMENT
PRODUCTS**-*DIETARY MANAGEMENT
PRODUCTS***
*DIGESTIVE AIDS*
*DIGESTIVE ENZYMES**-*DIGESTIVE
ENZYMES***
CREON ORAL CAPSULE DELAYED RELEASE
PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT,
36000 UNIT, 6000 UNIT
Tier 2
PANCREAZE
Tier 3
PERTZYE
Tier 3
SUCRAID
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
70
SD; DS
Drug Name
Drug Status
ULTRESA
Tier 3
VIOKACE
Tier 3
ZENPEP ORAL CAPSULE DELAYED RELEASE
PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT,
25000 UNIT, 3000-10000 UNIT, 5000 UNIT
Tier 2
Drug Details
*DIURETICS*
*CARBONIC ANHYDRASE
INHIBITORS**-*CARBONIC ANHYDRASE
INHIBITORS***
acetazolamide oral
Tier 1
acetazolamide er
Tier 1
DIAMOX SEQUELS
Tier 3
methazolamide oral
Tier 1
NEPTAZANE
Tier 3
*DIURETIC COMBINATIONS**-*DIURETIC
COMBINATIONS***
ALDACTAZIDE
Tier 3
amiloride-hydrochlorothiazide
Tier 1
DYAZIDE
Tier 3
MAXZIDE
Tier 3
MAXZIDE-25
Tier 3
spironolactone-hctz
Tier 1
triamterene-hctz oral capsule 37.5-25 mg
Tier 1
triamterene-hctz oral capsule 50-25 mg
Tier 1
triamterene-hctz oral tablet
Tier 1
Drug Note (Lowest Generic Copay
Applies)
bumetanide oral tablet 0.5 mg, 1 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
bumetanide oral tablet 2 mg
Tier 1
DEMADEX
Tier 3
EDECRIN
Tier 3
furosemide oral tablet
Tier 1
LASIX
Tier 3
torsemide oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
*LOOP DIURETICS**-*LOOP DIURETICS***
Drug Note (Lowest Generic Copay
Applies)
*POTASSIUM SPARING
DIURETICS**-*POTASSIUM SPARING
DIURETICS***
ALDACTONE
Tier 3
amiloride hcl oral
Tier 1
DYRENIUM
Tier 3
spironolactone oral tablet 100 mg, 50 mg
Tier 1
spironolactone oral tablet 25 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
71
Drug Name
Drug Status
Drug Details
*THIAZIDES AND THIAZIDE-LIKE
DIURETICS**-*THIAZIDES AND THIAZIDE-LIKE
DIURETICS***
chlorothiazide oral
Tier 1
DS
chlorthalidone oral tablet 25 mg, 50 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
DIURIL
Tier 3
hydrochlorothiazide oral capsule
Tier 1
hydrochlorothiazide oral tablet 12.5 mg
Tier 1
hydrochlorothiazide oral tablet 25 mg, 50 mg
Tier 1
indapamide oral
Tier 1
metolazone
Tier 1
MICROZIDE
Tier 3
ZAROXOLYN
Tier 3
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
*ENDOCRINE AND METABOLIC AGENTS - MISC.*
*BONE DENSITY
REGULATORS**-*BISPHOSPHONATES***
ACTONEL ORAL TABLET 150 MG
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); #; QL
ACTONEL ORAL TABLET 30 MG, 35 MG, 5 MG
Tier 3
#; QL
alendronate sodium oral tablet 10 mg
Tier 1
alendronate sodium oral tablet 35 mg, 40 mg, 5 mg
Tier 1
QL
alendronate sodium oral tablet 70 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies); QL
ATELVIA
Tier 3
QL
BINOSTO
NC
N2 (Covered in NJ, IN)
BONIVA ORAL
Tier 3
QL
FOSAMAX ORAL TABLET 70 MG
Tier 3
QL
FOSAMAX PLUS D
Tier 3
QL
ibandronate sodium oral
Tier 3
QL
risedronate sodium
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
calcitonin (salmon)
Tier 1
DS
FORTICAL
Tier 1
MIACALCIN INJECTION
Tier 3
MIACALCIN NASAL
Tier 3
*BONE DENSITY
REGULATORS**-*CALCITONINS***
PA
*BONE DENSITY
REGULATORS**-*PARATHYROID HORMONE
AND DERIVATIVES***
FORTEO
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
72
Tier 3
PA; SD; DS
Drug Name
Drug Status
Drug Details
*FERTILITY REGULATORS**-*OVULATION
STIMULANTS-GONADOTROPINS***
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.); N3 (Covered in VA)
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.); N3 (Covered in VA)
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.); N3 (Covered in VA)
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.); N3 (Covered in VA)
GONAL-F RFF
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.); N3 (Covered in VA)
GONAL-F RFF PEN
LA
N3 (Covered in VA)
GONAL-F RFF REDIJECT
LA
N3 (Covered in VA)
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.); N3 (Covered in VA)
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.); N3 (Covered in VA)
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.); N3 (Covered in VA)
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.)
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.); N3 (Covered in VA)
LA
N3 (Covered in VA)
LA
DS; N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.);
N3 (Covered in VA)
BRAVELLE
chorionic gonadotropin intramuscular*
FOLLISTIM AQ
GONAL-F
MENOPUR
NOVAREL
OVIDREL
PREGNYL
REPRONEX
*FERTILITY REGULATORS**-*OVULATION
STIMULANTS-SYNTHETIC***
clomiphene citrate oral
SEROPHENE
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
73
Drug Name
Drug Status
Drug Details
*GNRH/LHRH ANTAGONISTS**-*GNRH/LHRH
ANTAGONISTS***
CETROTIDE SUBCUTANEOUS* KIT 0.25 MG
ganirelix acetate
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.)
LA
PA; SD; DS; N1 (Please refer to your
health plan documents regarding coverage
of and any limitations or exclusions that
may apply.)
*GROWTH HORMONE RECEPTOR
ANTAGONISTS**-*GROWTH HORMONE
RECEPTOR ANTAGONISTS***
SOMAVERT SUBCUTANEOUS* SOLUTION
RECONSTITUTED 10 MG, 15 MG, 20 MG
Tier 3
PA; SD; DS
Tier 3
PA; SD; DS
*GROWTH HORMONE RELEASING HORMONES
(GHRH)**-*GROWTH HORMONE RELEASING
HORMONES (GHRH)***
EGRIFTA SUBCUTANEOUS* SOLUTION
RECONSTITUTED 2 MG
*GROWTH HORMONES**-*GROWTH
HORMONES***
GENOTROPIN
NC
N2 (Covered in NJ, IN)
GENOTROPIN MINIQUICK
NC
N2 (Covered in NJ, IN)
HUMATROPE
NC
N2 (Covered in NJ, IN)
NORDITROPIN FLEXPRO SUBCUTANEOUS*
SOLUTION 10 MG/1.5ML, 15 MG/1.5ML
NC
N2 (Covered in NJ,IN)
NORDITROPIN FLEXPRO SUBCUTANEOUS*
SOLUTION 5 MG/1.5ML
NC
N2 (Not Covered in NJ,IN)
NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS*
SOLUTION 30 MG/3ML
NC
N2 (Covered in NJ,IN)
NUTROPIN AQ NUSPIN 10
NC
N2 (Covered in NJ,IN)
NUTROPIN AQ NUSPIN 20
NC
N2 (Not Covered in NJ,IN)
NUTROPIN AQ NUSPIN 5
NC
N2 (Covered in NJ,IN)
NUTROPIN AQ PEN
NC
N2 (Covered in NJ,IN)
SAIZEN
NC
N2 (Covered in NJ, IN)
SAIZEN CLICK.EASY
NC
N2 (Covered in NJ, IN)
SEROSTIM
NC
N2 (Covered in NJ, IN)
TEV-TROPIN
NC
N2 (Covered in NJ, IN)
ZORBTIVE
Tier 3
PA; SD; DS
*HORMONE RECEPTOR
MODULATORS**-*SELECTIVE ESTROGEN
RECEPTOR MODULATORS (SERMS)***
EVISTA
Tier 3
OSPHENA
Tier 3
raloxifene hcl
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
74
CE
QL
Drug Name
Drug Status
Drug Details
Tier 3
PA; SD; DS
*INSULIN-LIKE GROWTH FACTORS
(SOMATOMEDINS)**-*INSULIN-LIKE GROWTH
FACTORS (SOMATOMEDINS)***
INCRELEX
*LHRH/GNRH AGONIST ANALOG PITUITARY
SUPPRESSANTS**-*LHRH/GNRH AGONIST
ANALOG PITUITARY SUPPRESSANTS***
SYNAREL
Tier 2
*METABOLIC MODIFIERS**-*CALCIMIMETIC
AGENTS***
SENSIPAR
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
Tier 3
SD; DS
Tier 3
SD; DS
Tier 3
PA; SD; DS
*METABOLIC MODIFIERS**-*HEREDITARY
TYROSINEMIA TYPE 1 (HT-1) TREATMENT AGENTS***
ORFADIN
*METABOLIC MODIFIERS**-*HOMOCYSTINURIA
TREATMENT - AGENTS***
CYSTADANE
*METABOLIC
MODIFIERS**-*HYPERAMMONEMIA
TREATMENT - AGENTS***
CARBAGLU
*METABOLIC
MODIFIERS**-*HYPERPARATHYROID
TREATMENT - VITAMIN D ANALOGS***
calcitriol oral capsule
Tier 1
doxercalciferol oral
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
HECTOROL ORAL
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
paricalcitol oral
Tier 1
ROCALTROL
Tier 3
ZEMPLAR ORAL
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
KUVAN ORAL PACKET
Tier 3
PA
KUVAN ORAL TABLET SOLUBLE
Tier 3
PA; SD; DS
BUPHENYL
Tier 3
PA; SD; DS
RAVICTI
Tier 3
PA; SD; DS; QL
sodium phenylbutyrate oral
Tier 3
PA; SD; DS
*METABOLIC
MODIFIERS**-*PHENYLKETONURIA
TREATMENT - AGENTS***
*METABOLIC MODIFIERS**-*UREA CYCLE
DISORDER - AGENTS***
*POSTERIOR PITUITARY
HORMONES**-*VASOPRESSIN***
DDAVP NASAL
Tier 3
DDAVP ORAL
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
75
Drug Name
Drug Status
DDAVP RHINAL TUBE
Tier 3
desmopressin ace rhinal tube
Tier 1
desmopressin ace spray refrig
Tier 1
desmopressin acetate oral
Tier 1
desmopressin acetate spray
Tier 1
STIMATE
Tier 2
Drug Details
PA; SD
*PROLACTIN INHIBITORS**-*DOPAMINE
RECEPTOR AGONISTS***
cabergoline
Tier 1
*SOMATOSTATIC AGENTS**-*SOMATOSTATIC
AGENTS***
octreotide acetate
Tier 1
PA; SD; DS
SIGNIFOR
Tier 3
PA; SD; DS; QL
SOMATULINE DEPOT
Tier 3
PA; SD; DS
Tier 3
PA; SD; DS; QL
*VASOPRESSIN RECEPTOR
ANTAGONISTS**-*SELECTIVE VASOPRESSIN
V2-RECEPTOR ANTAGONISTS***
SAMSCA ORAL TABLET 15 MG, 30 MG
*ESTROGENS*
*ESTROGEN COMBINATIONS**-*ESTROGEN &
ANDROGEN***
COVARYX
Tier 1
COVARYX HS
Tier 1
EEMT
Tier 1
EEMT HS
Tier 1
est estrogens-methyltest
Tier 1
est estrogens-methyltest ds
Tier 1
est estrogens-methyltest hs
Tier 1
methyltest-est estrogens
Tier 1
methyltest-est estrogens hs
Tier 1
*ESTROGEN COMBINATIONS**-*ESTROGEN &
PROGESTIN***
ACTIVELLA
Tier 3
QL
ANGELIQ
Tier 3
QL
CLIMARA PRO
Tier 3
#; QL
COMBIPATCH
Tier 3
#; QL
estradiol-norethindrone acet
Tier 1
QL
FEMHRT LOW DOSE
Tier 3
QL
JINTELI
Tier 1
MIMVEY
Tier 1
QL
PREFEST
Tier 3
QL
PREMPHASE
Tier 2
PREMPRO
Tier 2
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
76
Drug Name
Drug Status
Drug Details
*ESTROGEN
COMBINATIONS**-*ESTROGEN-SELECTIVE
ESTROGEN RECEPTOR MODULATOR COMB***
DUAVEE
Tier 2
QL
ALORA
Tier 3
QL
CENESTIN ORAL TABLET 0.45 MG, 0.625 MG, 0.9 MG
Tier 3
QL
CLIMARA
Tier 3
QL
DIVIGEL
Tier 3
ELESTRIN
Tier 3
QL
ENJUVIA
Tier 3
QL
ESTRACE ORAL
Tier 3
estradiol oral
Tier 1
Drug Note (Lowest generic copay
applies)
estradiol transdermal patch weekly
Tier 1
QL
ESTROGEL
Tier 3
QL
estropipate oral tablet 0.75 mg, 1.5 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
estropipate oral tablet 3 mg
Tier 1
EVAMIST
Tier 3
MENEST
Tier 3
MENOSTAR
Tier 3
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625
MG, 0.9 MG, 1.25 MG
Tier 2
VIVELLE-DOT TRANSDERMAL PATCH BIWEEKLY
0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075
MG/24HR, 0.1 MG/24HR
Tier 3
QL
AVELOX ORAL
Tier 3
DS; QL
CIPRO ORAL SUSPENSION RECONSTITUTED
Tier 3
DS
CIPRO ORAL TABLET 250 MG, 500 MG
Tier 3
DS
CIPRO XR ORAL TABLET EXTENDED RELEASE 24
HR* 1000 MG, 500 MG
Tier 3
QL
ciprofloxacin hcl oral
Tier 1
DS
FACTIVE
Tier 3
DS; #; QL
LEVAQUIN ORAL SOLUTION
Tier 3
DS; QL
LEVAQUIN ORAL TABLET
Tier 3
DS; QL
levofloxacin oral solution
Tier 1
DS; QL
levofloxacin oral tablet
Tier 1
DS; QL
moxifloxacin hcl oral
Tier 1
DS; QL
NOROXIN
Tier 3
DS; QL
ofloxacin oral tablet 400 mg
Tier 1
DS; QL
*ESTROGENS**-*ESTROGENS***
QL
QL
*FLUOROQUINOLONES*
*FLUOROQUINOLONES**-*FLUOROQUINOLONE
S***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
77
Drug Name
Drug Status
Drug Details
*GASTROINTESTINAL AGENTS - MISC.*
*GALLSTONE SOLUBILIZING
AGENTS**-*GALLSTONE SOLUBILIZING
AGENTS***
ACTIGALL
Tier 3
CHENODAL
Tier 3
URSO 250
Tier 3
URSO FORTE
Tier 3
ursodiol oral capsule
Tier 1
ursodiol oral tablet
Tier 3
PA; SD; DS
*GASTROINTESTINAL CHLORIDE CHANNEL
ACTIVATORS**-*GASTROINTESTINAL
CHLORIDE CHANNEL ACTIVATORS***
AMITIZA
Tier 2
ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
*GASTROINTESTINAL
STIMULANTS**-*GASTROINTESTINAL
STIMULANTS***
metoclopramide hcl injection
Tier 1
metoclopramide hcl oral solution 5 mg/5ml
Tier 1
Drug Note (Lowest Generic Copay
Applies)
metoclopramide hcl oral tablet 10 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
metoclopramide hcl oral tablet 5 mg
Tier 1
METOZOLV ODT ORAL TABLET DISPERSIBLE 5 MG
REGLAN ORAL
NC
N2 (Covered in NJ, IN)
Tier 3
*INFLAMMATORY BOWEL
AGENTS**-*INFLAMMATORY BOWEL
AGENTS***
APRISO
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
ASACOL HD
Tier 2
#; QL
AZULFIDINE
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
AZULFIDINE EN-TABS
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
balsalazide disodium
Tier 1
QL
CANASA
Tier 2
QL
COLAZAL
Tier 3
QL
DELZICOL
Tier 2
QL
DIPENTUM
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
GIAZO
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
LIALDA
Tier 2
QL
mesalamine enema
Tier 1
PENTASA ORAL CAPSULE EXTENDED RELEASE*
250 MG, 500 MG
Tier 2
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
78
QL
Drug Name
Drug Status
Drug Details
sulfasalazine oral
Tier 1
QL
SULFAZINE
Tier 1
QL
SULFAZINE EC
Tier 1
QL
CIMZIA
Tier 3
PA; SD; DS; N4 (Tier 2 for DE); QL
CIMZIA PREFILLED
Tier 3
PA; SD; DS; N4 (Tier 2 for DE); QL
CIMZIA STARTER KIT
Tier 3
PA; SD; DS; N4 (Tier 2 for DE); QL
Tier 1
Drug Note (Lowest Generic Copay
Applies)
Tier 3
ST; N1 (Step Therapy not Applicable in
NJ); QL
Tier 2
DS
*INFLAMMATORY BOWEL AGENTS**-*TUMOR
NECROSIS FACTOR ALPHA BLOCKERS***
*INTESTINAL ACIDIFIERS**-*INTESTINAL
ACIDIFIERS***
lactulose encephalopathy
*IRRITABLE BOWEL SYNDROME (IBS)
AGENTS**-*IBS AGENT - GUANYLATE
CYCLASE-C (GC-C) AGONISTS***
LINZESS
*IRRITABLE BOWEL SYNDROME (IBS)
AGENTS**-*IBS AGENT - SELECTIVE 5-HT3
RECEPTOR ANTAGONISTS***
LOTRONEX
*PERIPHERAL OPIOID RECEPTOR
ANTAGONISTS**-*PERIPHERAL OPIOID
RECEPTOR ANTAGONISTS***
RELISTOR
Tier 3
*PHOSPHATE BINDER AGENTS**-*PHOSPHATE
BINDER AGENTS***
calcium acetate oral capsule
Tier 1
calcium acetate (phos binder)
Tier 1
ELIPHOS
Tier 1
FOSRENOL
Tier 3
PHOSLO
Tier 3
RENAGEL
Tier 3
RENVELA
Tier 3
sevelamer carbonate
Tier 1
VELPHORO
Tier 3
#
*SHORT BOWEL SYNDROME (SBS)
AGENTS**-*GLUCAGON-LIKE PEPTIDE-2 (GLP-2)
ANALOGS***
GATTEX
Tier 3
PA; SD; N4 (Tier 2 for DE); QL
*GENITOURINARY AGENTS - MISCELLANEOUS*
*ALKALINIZERS**-*CITRATES***
citric acid-sodium citrate
Tier 1
CYTRA-3
Tier 1
cytra-k
Tier 1
potassium citrate er
Tier 1
SHOHLS MODIFIED
Tier 3
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79
Drug Name
Drug Status
tricitrates
Tier 1
UROCIT-K 10
Tier 3
UROCIT-K 15
Tier 3
UROCIT-K 5
Tier 3
Drug Details
*CYSTINOSIS AGENTS**-*CYSTINOSIS
AGENTS***
CYSTAGON
Tier 2
PA; SD; DS
PROCYSBI ORAL CAPSULE DELAYED RELEASE 25
MG, 75 MG
Tier 3
PA; SD; DS; QL
*GENITOURINARY
IRRIGANTS**-*GENITOURINARY IRRIGANTS***
acetic acid irrigation
Tier 1
*INTERSTITIAL CYSTITIS
AGENTS**-*INTERSTITIAL CYSTITIS AGENTS***
ELMIRON
Tier 2
*PROSTATIC HYPERTROPHY
AGENTS**-*5-ALPHA REDUCTASE
INHIBITORS***
AVODART
Tier 3
finasteride oral tablet 5 mg
Tier 1
PROSCAR
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); #; QL
*PROSTATIC HYPERTROPHY AGENTS**-*ALPHA
1-ADRENOCEPTOR ANTAGONISTS***
alfuzosin hcl er
Tier 1
QL
CARDURA XL
Tier 3
QL
FLOMAX
Tier 3
RAPAFLO
Tier 3
QL
tamsulosin hcl
Tier 1
Drug Note (Lowest Generic Copay
Applies)
UROXATRAL
Tier 3
QL
Tier 3
#; QL
*PROSTATIC HYPERTROPHY
AGENTS**-*PROSTATIC HYPERTROPHY AGENT
COMBINATIONS***
JALYN
*URINARY ANALGESICS**-*URINARY
ANALGESICS***
PHENAZO ORAL TABLET 200 MG
Tier 1
phenazopyridine hcl oral tablet 100 mg
Tier 1
phenazopyridine hcl oral tablet 200 mg
Tier 1
*GOUT AGENTS*
*GOUT AGENT COMBINATIONS**-*GOUT AGENT
COMBINATIONS***
colchicine-probenecid
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80
Tier 1
Drug Note (Lowest Generic Copay
Applies)
Drug Name
Drug Status
Drug Details
*GOUT AGENTS**-*GOUT AGENTS***
allopurinol oral
Tier 1
Drug Note (Lowest Generic Copay
Applies)
COLCRYS
Tier 3
DS; QL
ULORIC
Tier 3
QL
ZYLOPRIM
Tier 3
*URICOSURICS**-*URICOSURICS***
probenecid oral
Tier 1
*HEMATOLOGICAL AGENTS - MISC.*
*BRADYKININ B2 RECEPTOR
ANTAGONISTS**-*BRADYKININ B2 RECEPTOR
ANTAGONISTS***
FIRAZYR
Tier 3
PA; SD; DS; QL
BERINERT
Tier 3
PA; SD; DS; N4 (Tier 2 for DE)
CINRYZE
Tier 3
PA; SD; DS
*COMPLEMENT INHIBITORS**-*C1
INHIBITORS***
*HEMATORHEOLOGIC
AGENTS**-*HEMATORHEOLOGIC AGENTS***
pentoxifylline er
Tier 1
*PLATELET AGGREGATION
INHIBITORS**-*CYCLOPENTYLTRIAZOLOPYRI
MIDINE (CPTP) DERIVATIVES***
BRILINTA
Tier 2
QL
*PLATELET AGGREGATION
INHIBITORS**-*PHOSPHODIESTERASE III
INHIBITORS***
cilostazol
Tier 1
PLETAL
Tier 3
*PLATELET AGGREGATION
INHIBITORS**-*PLATELET AGGREGATION
INHIBITOR COMBINATIONS***
AGGRENOX
Tier 2
#
*PLATELET AGGREGATION
INHIBITORS**-*PLATELET AGGREGATION
INHIBITORS***
dipyridamole oral
Tier 1
PERSANTINE
Tier 3
*PLATELET AGGREGATION
INHIBITORS**-*PROTEASE-ACTIVATED
RECEPTOR-1 (PAR-1) ANTAGONISTS***
ZONTIVITY
Tier 3
*PLATELET AGGREGATION
INHIBITORS**-*QUINAZOLINE AGENTS***
AGRYLIN
Tier 3
anagrelide hcl
Tier 1
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81
Drug Name
Drug Status
Drug Details
*PLATELET AGGREGATION
INHIBITORS**-*THIENOPYRIDINE
DERIVATIVES***
clopidogrel bisulfate
Tier 1
QL
EFFIENT
Tier 3
QL
PLAVIX
Tier 3
QL
ticlopidine hcl
Tier 1
*HEMATOPOIETIC AGENTS*
*AGENTS FOR GAUCHER DISEASE**-*AGENTS
FOR GAUCHER DISEASE***
ZAVESCA
Tier 3
PA; SD; DS; #; QL
*COBALAMINS**-*COBALAMINS***
cyanocobalamin injection
Tier 3
*FOLIC ACID/FOLATES**-*FOLIC
ACID/FOLATES***
cvs folic acid oral tablet 400 mcg
Tier 1
eql folic acid
Tier 1
folic acid oral capsule 20 mg
Tier 1
folic acid oral tablet 1 mg
CE
folic acid oral tablet 400 mcg
Tier 1
gnp folic acid
Tier 1
hm folic acid
Tier 1
kp folic acid
CE
px folic acid
Tier 1
ra folic acid oral tablet 400 mcg
Tier 1
sm folic acid
Tier 1
th folic acid
CE
Drug Note (Lowest Generic Copay
Applies)
*HEMATOPOIETIC GROWTH
FACTORS**-*ERYTHROPOIESIS-STIMULATING
AGENTS (ESAS)***
ARANESP (ALBUMIN FREE) INJECTION SOLUTION
100 MCG/0.5ML, 100 MCG/ML, 150 MCG/0.3ML, 150
MCG/0.75ML
Tier 2
ARANESP (ALBUMIN FREE) INJECTION SOLUTION
200 MCG/0.4ML, 200 MCG/ML, 25 MCG/0.42ML, 25
MCG/ML, 300 MCG/0.6ML, 300 MCG/ML, 40
MCG/0.4ML, 40 MCG/ML, 500 MCG/ML, 60
MCG/0.3ML, 60 MCG/ML
PA; SD; DS
PA; SD; DS
EPOGEN
Tier 3
PA; SD; DS
PROCRIT
Tier 2
PA; SD; DS
GRANIX
Tier 3
PA; SD; DS
NEULASTA
Tier 3
PA; SD; DS
NEUPOGEN
Tier 2
PA; SD; DS
*HEMATOPOIETIC GROWTH
FACTORS**-*GRANULOCYTE
COLONY-STIMULATING FACTORS (G-CSF)***
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82
Drug Name
Drug Status
Drug Details
Tier 2
PA; SD; DS
Tier 3
PA; SD; DS; QL
*HEMATOPOIETIC GROWTH
FACTORS**-*GRANULOCYTE/MACROPHAGE
COLONY-STIMULATING FACTOR(GM-CSF)***
LEUKINE INTRAVENOUS*
*HEMATOPOIETIC GROWTH
FACTORS**-*THROMBOPOIETIN (TPO)
RECEPTOR AGONISTS***
PROMACTA
*HEMATOPOIETIC MIXTURES**-*IRON
COMBINATIONS***
FERIVAFA
Tier 3
ICAR-C PLUS
Tier 3
*IRON**-*IRON***
BPROTECTED PEDIA IRON
CE
FER-IN-SOL
CE
*HEMOSTATICS*
*HEMOSTATICS - SYSTEMIC**-*HEMOSTATICS SYSTEMIC***
aminocaproic acid oral
Tier 1
LYSTEDA
Tier 3
QL
BUTISOL SODIUM
Tier 3
DS
phenobarbital oral
Tier 1
DS
*HYPNOTICS*
*BARBITURATE HYPNOTICS**-*BARBITURATE
HYPNOTICS***
*HYPNOTICS - TRICYCLIC
AGENTS**-*HYPNOTICS - TRICYCLIC
AGENTS***
SILENOR
NC
N2 (Covered in NJ, IN); AL
*NON-BARBITURATE
HYPNOTICS**-*BENZODIAZEPINE
HYPNOTICS***
DORAL
Tier 3
DS
estazolam
Tier 1
DS; AL
flurazepam hcl
Tier 1
DS; AL
HALCION
Tier 3
DS; AL
RESTORIL ORAL CAPSULE 15 MG, 30 MG
Tier 3
DS; AL
RESTORIL ORAL CAPSULE 22.5 MG, 7.5 MG
Tier 3
DS; QL; AL
temazepam oral capsule 15 mg, 30 mg
Tier 1
DS; AL
temazepam oral capsule 22.5 mg, 7.5 mg
Tier 3
DS; QL; AL
triazolam
Tier 1
DS; AL
AMBIEN
Tier 3
DS; QL; AL
AMBIEN CR
Tier 3
PA; DS; QL; AL
*NON-BARBITURATE
HYPNOTICS**-*NON-BENZODIAZEPINE GABA-RECEPTOR MODULATORS***
EDLUAR
NC
N2 (Covered in NJ, IN); AL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
83
Drug Name
Drug Status
eszopiclone
Tier 3
INTERMEZZO
NC
Drug Details
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL; AL
N2 (Covered in NJ, IN); AL
LUNESTA
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL; AL
SONATA
Tier 3
QL
zolpidem tartrate oral tablet 10 mg
Tier 3
DS; QL; AL
zolpidem tartrate oral tablet 5 mg
Tier 1
DS; QL; AL
zolpidem tartrate er
Tier 3
PA; DS; QL; AL
ZOLPIMIST
NC
N2 (Covered in NJ, IN)
*SELECTIVE MELATONIN RECEPTOR
AGONISTS**-*SELECTIVE MELATONIN
RECEPTOR AGONISTS***
HETLIOZ
Tier 3
PA; SD; DS
ROZEREM
Tier 3
QL; AL
COLYTE WITH FLAVOR PACKS ORAL SOLUTION
RECONSTITUTED 227.1 GM, 240 GM
Tier 3
QL
GOLYTELY ORAL SOLUTION RECONSTITUTED 236
GM
Tier 3
DS; QL
MOVIPREP
Tier 3
NULYTELY WITH FLAVOR PACKS
Tier 3
peg 3350-kcl-na bicarb-nacl
Tier 1
peg 3350/electrolytes
Tier 3
QL
peg-3350/electrolytes
Tier 1
DS; QL
TRILYTE
Tier 1
*LAXATIVES*
*LAXATIVE COMBINATIONS**-*BOWEL
EVACUANT COMBINATIONS***
*LAXATIVES - MISCELLANEOUS**-*LAXATIVES MISCELLANEOUS***
gavilax oral packet
CE
KRISTALOSE
Tier 3
lactulose oral solution 10 gm/15ml
Tier 1
lactulose oral solution 20 gm/30ml
Tier 1
MIRALAX ORAL PACKET
Tier 1
peg 3350
Tier 1
polyethylene glycol 3350 oral
Tier 1
sb polyethylene glycol 3350
Tier 1
*SALINE LAXATIVES**-*SALINE LAXATIVE
MIXTURES***
OSMOPREP
saline laxative oral solution 2.7-7.2 gm/15ml
Tier 3
CE
*STIMULANT LAXATIVES**-*STIMULANT
LAXATIVES***
fematrol
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
84
CE
Drug Note (Lowest Generic Copay
Applies)
Drug Name
Drug Status
Drug Details
*MACROLIDES*
*AZITHROMYCIN**-*AZITHROMYCIN***
azithromycin oral suspension reconstituted
Tier 1
DS; QL
azithromycin oral tablet 250 mg, 500 mg
Tier 1
DS; QL
ZITHROMAX ORAL SUSPENSION RECONSTITUTED
Tier 3
DS; QL
ZITHROMAX ORAL TABLET 500 MG, 600 MG
Tier 3
DS; QL
ZITHROMAX TRI-PAK
Tier 3
DS; QL
ZMAX
Tier 3
DS; QL
BIAXIN ORAL SUSPENSION RECONSTITUTED
Tier 3
DS; QL
BIAXIN ORAL TABLET
Tier 3
DS; QL
BIAXIN XL
Tier 3
DS; QL
BIAXIN XL PAC
Tier 3
DS; QL
clarithromycin oral suspension reconstituted 125 mg/5ml
Tier 1
DS
clarithromycin oral suspension reconstituted 250 mg/5ml
Tier 1
DS; QL
clarithromycin oral tablet
Tier 1
DS
clarithromycin er
Tier 1
DS; QL
E.E.S. 400
Tier 1
DS
E.E.S. GRANULES
Tier 2
DS
ERY-TAB
Tier 1
DS
ERYTHROCIN STEARATE
Tier 1
DS
erythromycin base oral tablet
Tier 1
DS
erythromycin ethylsuccinate oral
Tier 1
DS
erythromycin stearate oral
Tier 1
DS
PCE
Tier 3
DS
Tier 3
DS; QL
*CLARITHROMYCIN**-*CLARITHROMYCIN***
*ERYTHROMYCINS**-*ERYTHROMYCINS***
*FIDAXOMICIN**-*FIDAXOMICIN***
DIFICID
*MEDICAL DEVICES*
*CONTRACEPTIVES**-*CERVICAL CAPS***
FEMCAP
CE
*CONTRACEPTIVES**-*CONDOMS - FEMALE***
FC2 FEMALE CONDOM
CE
*CONTRACEPTIVES**-*DIAPHRAGMS***
ORTHO DIAPHRAGM ALL-FLEX
CE
WIDE-SEAL DIAPHRAGM 60
CE
WIDE-SEAL DIAPHRAGM 65
CE
WIDE-SEAL DIAPHRAGM 70
CE
WIDE-SEAL DIAPHRAGM 75
CE
WIDE-SEAL DIAPHRAGM 80
CE
WIDE-SEAL DIAPHRAGM 85
CE
WIDE-SEAL DIAPHRAGM 90
CE
WIDE-SEAL DIAPHRAGM 95
CE
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
85
Drug Name
Drug Status
Drug Details
*DIABETIC SUPPLIES**-*GLUCOSE
MONITORING TEST SUPPLIES***
ACCU-CHEK COMPACT PLUS CARE
NC
N2 (Covered in NJ,IN)
ADVOCATE BLOOD GLUCOSE MONITOR
NC
N2 (Covered in NJ,IN)
ADVOCATE BLOOD GLUCOSE SYSTEM
NC
N2 (Covered in NJ,IN)
ONETOUCH VERIO IQ SYSTEM
Tier 2
*GI-GU OSTOMY & IRRIGATION
SUPPLIES**-*IRRIGATION-TYPE SYRINGES***
BD CATHETER TIP SYRINGE
Tier 2
*MISC. DEVICES**-*MISC. DEVICES***
ORTHO ALL-FLEX FITTING SET
CE
*PARENTERAL THERAPY SUPPLIES**-*NEEDLES
& SYRINGES***
BD AUTOSHIELD
Tier 2
BD ECLIPSE SYRINGE 23G X 1" 3 ML, 25G X 5/8" 3
ML, 27G X 1/2" 1 ML, 30G X 1/2" 1 ML
Tier 2
BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1
ML, 26G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5
ML, 29G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, U-100 1 ML
Tier 2
BD INSULIN SYRINGE HALF-UNIT
Tier 2
BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.3
ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML
Tier 2
BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 ML,
30G X 1/2" 0.3 ML, 31G X 15/64" 0.3 ML, 31G X 5/16"
0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
Tier 2
BD INTEGRA INSULIN SYRINGE
Tier 2
BD INTEGRA SYRINGE 21G X 1-1/2" 3 ML, 22G X
1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 5/8"
1 ML, 25G X 5/8" 3 ML
Tier 2
BD LUER-LOK SYRINGE 18G X 1-1/2" 3 ML, 20G X 1"
1 ML, 20G X 1" 10 ML, 20G X 1" 3 ML, 20G X 1" 5 ML,
20G X 1-1/2" 10 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 5
ML, 21G X 1" 10 ML, 21G X 1" 3 ML, 21G X 1" 5 ML,
21G X 1-1/2" 10 ML, 21G X 1-1/2" 3 ML, 21G X 1-1/2" 5
ML, 21G X 1-1/4" 3 ML, 22G X 1" 10 ML, 22G X 1" 3
ML, 22G X 1" 5 ML, 22G X 1-1/2" 10 ML, 22G X 1-1/2" 3
ML, 22G X 1-1/2" 5 ML, 23G X 1" 3 ML, 23G X 1" 5 ML,
23G X 1-1/2" 3 ML, 23G X 1-1/4" 10 ML, 23G X 1-1/4" 3
ML, 23G X 1-1/4" 5 ML, 24G X 1" 3 ML, 25G X 1" 3 ML,
25G X 1-1/2" 3 ML, 25G X 5/8" 3 ML, 26G X 5/8" 3 ML,
2G X 1-1/4" 3 ML
Tier 2
BD PEN NEEDLE MINI U/F
Tier 2
BD PEN NEEDLE SHORT U/F
Tier 2
BD PEN NEEDLE ULTRAFINE
Tier 2
BD SAFETY-LOK INSULIN SYRINGE
Tier 2
BD SAFETYGLIDE INSULIN SYRINGE
Tier 2
BD SAFETYGLIDE NEEDLE
Tier 2
BD SAFETYGLIDE SHIELDED NEEDLE 21G X 1-1/2" ,
22G X 1-1/2" , 22G X 1-1/2" 10 ML, 23G X 1" , 25G X 1"
Tier 2
BD SAFETYGLIDE SYRINGE/NEEDLE
Tier 2
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
86
QL
Drug Name
Drug Status
BD SYRINGE 20 ML , 60 ML
Tier 2
BD SYRINGE 50-60 ML
Tier 2
BD SYRINGE DUAL CANNULA
Tier 2
BD SYRINGE LUER SLIP TIP 3 ML , 5 ML
Tier 2
BD SYRINGE LUER-LOK 1 ML , 20 ML
Tier 2
BD SYRINGE SLIP TIP 1 ML , 3 ML
Tier 2
BD SYRINGE/NEEDLE 22G X 1-1/2" 3 ML, 25G X 5/8"
1 ML
Tier 2
BD SYRINGE/NEEDLE SLIP TIP 26G X 5/8" 1 ML
Tier 2
GLASPAK TB SYRINGE
Tier 2
SAFETY-GLIDE SYRINGE
Tier 2
syringe disposable 10 ml , 3 ml , 5 ml , 60 ml
Tier 2
syringe disposable 50-60ml
Tier 2
Drug Details
*RESPIRATORY THERAPY
SUPPLIES**-*SPACER/AEROSOL-HOLDING
CHAMBERS & SUPPLIES***
AEROCHAMBER MV
Tier 2
MICROCHAMBER
Tier 2
QL
*MIGRAINE PRODUCTS*
*MIGRAINE COMBINATIONS**-*ERGOT
COMBINATIONS***
CAFERGOT
Tier 2
DS
Tier 1
DS
*MIGRAINE COMBINATIONS**-*MIGRAINE
COMBINATIONS***
isometheptene-apap-dichloral
*MIGRAINE COMBINATIONS**-*SELECTIVE
SEROTONIN AGONIST-NSAID COMBINATIONS***
TREXIMET
NC
N2 (Covered in NJ, IN)
NC
N2 (Covered in NJ, IN)
*MIGRAINE PRODUCTS - NSAIDS**-*MIGRAINE
PRODUCTS - NSAIDS***
CAMBIA
*MIGRAINE PRODUCTS**-*MIGRAINE
PRODUCTS***
D.H.E. 45
Tier 3
QL
dihydroergotamine mesylate injection
Tier 3
QL
dihydroergotamine mesylate nasal
Tier 1
DS; QL
MIGRANAL
Tier 3
QL
*SEROTONIN AGONISTS**-*SELECTIVE
SEROTONIN AGONISTS 5-HT(1)***
ALSUMA
NC
N2 (Covered in NJ, IN)
AMERGE
Tier 3
DS; QL
AXERT
Tier 3
ST; DS; N1 (Step Therapy Not
Applicable in NJ); #; QL
FROVA
Tier 3
ST; DS; N1 (Step Therapy Not
Applicable in NJ); #; QL
IMITREX NASAL
Tier 3
DS; QL
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
87
Drug Name
Drug Status
Drug Details
IMITREX ORAL
Tier 3
DS; QL
IMITREX SUBCUTANEOUS*
Tier 3
DS; QL
IMITREX STATDOSE REFILL SUBCUTANEOUS* 4
MG/0.5ML, 6 MG/0.5ML
Tier 3
DS; QL
MAXALT
Tier 3
DS; QL
MAXALT-MLT
Tier 3
DS; QL
naratriptan hcl
Tier 1
DS; QL
RELPAX
Tier 3
DS; N1 (Step Therapy Not Applicable in
NJ); QL
rizatriptan benzoate
Tier 1
DS; QL
sumatriptan nasal
Tier 1
DS; QL
sumatriptan succinate oral
Tier 1
DS; QL
sumatriptan succinate subcutaneous* , 4 mg/0.5ml, 6
mg/0.5ml
Tier 1
DS; QL
sumatriptan succinate refill
Tier 1
DS; QL
SUMAVEL DOSEPRO SUBCUTANEOUS* 6 MG/0.5ML
NC
DS; N2 (Covered in NJ, IN)
zolmitriptan oral
Tier 1
DS; QL
ZOMIG NASAL
Tier 3
DS; N1 (Step Therapy Not Applicable in
NJ); QL
ZOMIG ORAL
Tier 3
DS; QL
ZOMIG ZMT
Tier 3
DS; QL
*MINERALS & ELECTROLYTES*
*FLUORIDE**-*FLUORIDE COMBINATIONS***
FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25
(F)-236.79 MG, 0.5 (F)-236.79 MG
CE
*FLUORIDE**-*FLUORIDE***
EPIFLUR
CE
FLUORABON
CE
FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F)
MG/DROP
CE
LURIDE ORAL SOLUTION
CE
LURIDE ORAL TABLET CHEWABLE 1.1 (0.5 F) MG
CE
sodiphluor
CE
sodium fluoride oral solution
CE
sodium fluoride oral tablet
Tier 1
sodium fluoride oral tablet chewable
Tier 1
*IODINE PRODUCTS**-*IODINE PRODUCTS***
SSKI
Tier 2
*PHOSPHATE**-*PHOSPHATE***
K-PHOS-NEUTRAL
Tier 3
*POTASSIUM**-*POTASSIUM***
potassium chloride oral liquid† 20 meq/15ml (10%)
Tier 1
Drug Note (Lowest Generic Copay
Applies)
potassium chloride crys er oral tablet extendedrelease* 10
meq
Tier 1
Drug Note (Lowest Generic Copay
Applies)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
88
Drug Name
Drug Status
potassium chloride er oral capsule extended release* 10
meq
Tier 1
potassium chloride er oral capsule extended release* 8 meq
Tier 1
potassium chloride er oral tablet extendedrelease* 10 meq,
8 meq
Tier 1
potassium chloride er oral tablet extendedrelease* 20 meq
Tier 1
Drug Details
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
*SODIUM**-*SODIUM***
sodium chloride injection solution 0.9 %
Tier 1
*MOUTH/THROAT/DENTAL AGENTS*
*ANESTHETICS TOPICAL
ORAL**-*ANESTHETICS TOPICAL ORAL***
lidocaine viscous
Tier 1
*ANTI-INFECTIVES THROAT**-*ANTI-INFECTIVES - THROAT***
clotrimazole mouth/throat
Tier 1
nystatin mouth/throat
Tier 1
ORAVIG
Tier 3
DS; QL
*ANTISEPTICS MOUTH/THROAT**-*ANTISEPTICS MOUTH/THROAT***
PERIOGARD
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
*STEROIDS - MOUTH/THROAT**-*STEROIDS MOUTH/THROAT***
ORALONE
*THROAT PRODUCTS - MISC.**-*DRY MOUTH
AGENTS AND ARTIFICIAL SALIVA***
CAPHOSOL
Tier 3
*THROAT PRODUCTS - MISC.**-*PROTECTANTS MOUTH/THROAT***
GELCLAIR
Tier 3
*THROAT PRODUCTS - MISC.**-*SALIVA
STIMULANTS***
EVOXAC
Tier 2
SALAGEN
Tier 3
QL
*MULTIVITAMINS*
*B-COMPLEX W/ FOLIC ACID**-*B-COMPLEX W/
C & FOLIC ACID***
virt-caps
Tier 3
*MULTIPLE VITAMINS W/
MINERALS**-*MULTIPLE VITAMINS W/
MINERALS***
NICADAN
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
89
Drug Name
Drug Status
*PED MV W/ FLUORIDE**-*PED MV W/
FLUORIDE***
POLY-VI-FLOR ORAL TABLET CHEWABLE
Tier 2
QUFLORA PEDIATRIC ORAL TABLET CHEWABLE
Tier 3
*PED MV W/ FLUORIDE**-*PED VITAMINS ACD &
FA W/ FLUORIDE***
TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML
Tier 2
TRI-VI-FLOR ORAL SUSPENSION 0.5 MG/ML
Tier 3
*PRENATAL VITAMINS**-*PRENATAL MV & MIN
W/FE-FA***
CITRANATAL B-CALM
Tier 3
CITRANATAL RX
Tier 3
cvs prenatal
Tier 1
MYNATAL
Tier 1
NEEVO DHA ORAL CAPSULE 27-1.13 MG
Tier 3
NESTABS
Tier 3
O-CAL PRENATAL
Tier 3
OBTREX
Tier 3
pnv fe fum/docusate/folic acid
Tier 3
prenatabs fa
Tier 3
PRENATABS RX
Tier 3
prenatal oral tablet 27-0.8 mg
Tier 1
prenatal vitamins oral tablet 0.8 mg
Tier 1
prenatal/iron
Tier 1
PRENATE ELITE ORAL TABLET 26-0.6-0.4 MG
Tier 3
PRENATE ESSENTIAL ORAL CAPSULE 29-0.6-0.4-340
MG
Tier 3
TRICARE PRENATAL DHA ONE
Tier 3
TRINATE
Tier 1
VINATE DHA RF
Tier 3
VITAPEARL
Tier 3
VIVA DHA
Tier 3
*PRENATAL VITAMINS**-*PRENATAL MV & MIN
W/FE-FA-DHA***
CITRANATAL 90 DHA
Tier 3
CITRANATAL ASSURE
Tier 3
CITRANATAL DHA
Tier 3
CITRANATAL HARMONY ORAL CAPSULE 27-1-260
MG
Tier 3
levomefolate dha
Tier 3
PREFERAOB ONE
Tier 3
PRENATE DHA ORAL CAPSULE 28-0.6-0.4-300 MG
Tier 3
PREQUE 10 ORAL TABLET 15-25-0.5-50 MG
Tier 3
SELECT-OB+DHA
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
90
Drug Details
Drug Name
Drug Status
Drug Details
*VITAMIN MIXTURES**-*NIACINAMIDE W/
ZINC-COPPER & FOLIC ACID***
NICOMIDE ORAL TABLET 750-25-1.5-0.5 MG
Tier 3
*MUSCULOSKELETAL THERAPY AGENTS*
*CENTRAL MUSCLE RELAXANTS**-*CENTRAL
MUSCLE RELAXANTS***
AMRIX
NC
baclofen oral tablet 10 mg
Tier 1
baclofen oral tablet 20 mg
Tier 1
carisoprodol oral tablet 350 mg
Tier 1
chlorzoxazone oral
Tier 1
CYCLOBENZAPRINE COMFORT PAC
NC
N2 (Covered in NJ, IN)
Drug Note (Lowest Generic Copay
Applies)
DS
N2 (Covered in NJ, IN)
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies); DS
cyclobenzaprine hcl oral tablet 7.5 mg
Tier 1
DS
LIORESAL
Tier 3
LORZONE ORAL TABLET 375 MG, 750 MG
NC
metaxalone
Tier 3
methocarbamol oral
Tier 1
orphenadrine citrate er
Tier 1
PARAFON FORTE DSC
Tier 3
ROBAXIN ORAL
Tier 3
SKELAXIN
Tier 3
SOMA
tizanidine hcl oral tablet
ZANAFLEX
NC
N2 (Covered in NJ, IN)
QL
QL
N2 (Covered in NJ, IN)
Tier 1
NC
N2 (Covered in NJ, IN)
*DIRECT MUSCLE RELAXANTS**-*DIRECT
MUSCLE RELAXANTS***
DANTRIUM ORAL CAPSULE 25 MG, 50 MG
Tier 3
dantrolene sodium oral
Tier 1
*MUSCLE RELAXANT
COMBINATIONS**-*MUSCLE RELAXANT
COMBINATIONS***
carisoprodol-aspirin
Tier 1
DS
*MUSCLE RELAXANT
COMBINATIONS**-*MUSCLE
RELAXANT-LINIMENTS COMBINATIONS***
TIZANIDINE COMFORT PAC
NC
N2 (Covered in NJ, IN)
NC
N2 (Covered in NJ, IN)
*NASAL AGENTS - SYSTEMIC AND TOPICAL*
*NASAL AGENT
COMBINATIONS**-*ANTIHISTAMINE-STEROID**
*
DYMISTA
*NASAL ANTIALLERGY**-*NASAL
ANTIHISTAMINES***
ASTEPRO
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
91
Drug Name
Drug Status
azelastine hcl nasal solution 0.15 %
Tier 3
azelastine hcl nasal solution 137 mcg/spray
Tier 1
PATANASE
Tier 3
Drug Details
*NASAL ANTICHOLINERGICS**-*NASAL
ANTICHOLINERGICS***
ATROVENT
Tier 3
QL
ipratropium bromide nasal
Tier 1
QL
*NASAL ANTI-INFECTIVES**-*NASAL
ANTIBIOTICS***
BACTROBAN NASAL
Tier 3
*NASAL STEROIDS**-*NASAL STEROIDS***
BECONASE AQ
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
FLONASE
Tier 3
ST; N1 (Step Therapy Not Applicable In
NJ)
flunisolide nasal solution 25 mcg/act (0.025%)
Tier 1
fluticasone propionate nasal
Tier 1
NASACORT ALLERGY 24HR
Tier 1
Drug Note (Requires doctors prescription)
NASONEX
Tier 2
QL
OMNARIS
Tier 3
QNASL
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
RHINOCORT AQUA
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
VERAMYST
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
ZETONNA
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ)
*SYMPATHOMIMETIC
DECONGESTANTS**-*TOPICAL
DECONGESTANTS***
ADRENALIN NASAL
Tier 2
*NEUROMUSCULAR AGENTS*
*ALS AGENTS**-*BENZATHIAZOLES***
RILUTEK
Tier 3
PA
riluzole
Tier 1
PA
*OPHTHALMIC AGENTS*
*ARTIFICIAL TEARS AND
LUBRICANTS**-*ARTIFICIAL TEAR INSERTS***
LACRISERT
Tier 3
*BETA-BLOCKERS OPHTHALMIC**-*BETA-BLOCKERS OPHTHALMIC COMBINATIONS***
COMBIGAN
Tier 3
COSOPT
Tier 3
COSOPT PF
Tier 3
dorzolamide hcl-timolol mal
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
92
Drug Name
Drug Status
Drug Details
*BETA-BLOCKERS OPHTHALMIC**-*BETA-BLOCKERS OPHTHALMIC***
BETAGAN
Tier 3
betaxolol hcl ophthalmic
Tier 1
BETIMOL OPHTHALMIC SOLUTION 0.5 %
Tier 2
BETOPTIC-S
Tier 2
carteolol hcl
Tier 1
levobunolol hcl
Tier 1
metipranolol
Tier 1
timolol maleate ophthalmic
Tier 1
TIMOPTIC
Tier 3
TIMOPTIC-XE
Tier 3
*CYCLOPLEGIC MYDRIATICS**-*CYCLOPLEGIC
MYDRIATIC COMBINATIONS***
CYCLOMYDRIL
Tier 3
*CYCLOPLEGIC MYDRIATICS**-*CYCLOPLEGIC
MYDRIATICS***
atropine sulfate ophthalmic
Tier 1
CYCLOGYL
Tier 3
cyclopentolate hcl ophthalmic
Tier 1
ISOPTO ATROPINE
Tier 3
ISOPTO HYOSCINE
Tier 3
*MIOTICS**-*MIOTICS - CHOLINESTERASE
INHIBITORS***
PHOSPHOLINE IODIDE
Tier 2
*MIOTICS**-*MIOTICS - DIRECT ACTING***
ISOPTO CARBACHOL OPHTHALMIC SOLUTION 1.5
%
Tier 3
ISOPTO CARPINE
Tier 3
pilocarpine hcl ophthalmic
Tier 1
*OPHTHALMIC ADRENERGIC
AGENTS**-*ALPHA ADRENERGIC AGONIST &
CARBONIC ANHYDRASE INHIB COMB***
SIMBRINZA
Tier 3
QL
*OPHTHALMIC ADRENERGIC
AGENTS**-*OPHTHALMIC SELECTIVE ALPHA
ADRENERGIC AGONISTS***
ALPHAGAN P
Tier 3
apraclonidine hcl
Tier 1
brimonidine tartrate ophthalmic solution 0.2 %
Tier 1
IOPIDINE
Tier 3
*OPHTHALMIC
ANTI-INFECTIVES**-*OPHTHALMIC
ANTIBIOTICS***
AZASITE
Tier 3
bacitracin ophthalmic
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
93
Drug Name
Drug Status
Drug Details
BESIVANCE
Tier 3
CILOXAN OPHTHALMIC OINTMENT
Tier 2
CILOXAN OPHTHALMIC SOLUTION
Tier 3
GARAMYCIN OPHTHALMIC SOLUTION
Tier 3
gatifloxacin
Tier 3
gentamicin sulfate ophthalmic
Tier 1
ILOTYCIN
Tier 3
levofloxacin ophthalmic
Tier 1
MOXEZA
Tier 3
OCUFLOX
Tier 3
ofloxacin ophthalmic
Tier 1
TOBREX
Tier 3
VIGAMOX
Tier 3
DS
ZYMAXID
Tier 3
QL
DS
DS
*OPHTHALMIC
ANTI-INFECTIVES**-*OPHTHALMIC
ANTIFUNGAL***
NATACYN
Tier 3
*OPHTHALMIC
ANTI-INFECTIVES**-*OPHTHALMIC
ANTI-INFECTIVE COMBINATIONS***
bacitracin-polymyxin b ophthalmic
Tier 1
NEOSPORIN
Tier 3
polymyxin b-trimethoprim
Tier 1
POLYTRIM
Tier 3
*OPHTHALMIC
ANTI-INFECTIVES**-*OPHTHALMIC
ANTIVIRALS***
trifluridine ophthalmic
Tier 1
VIROPTIC
Tier 3
ZIRGAN
Tier 3
QL
*OPHTHALMIC
ANTI-INFECTIVES**-*OPHTHALMIC
SULFONAMIDES***
BLEPH-10
Tier 3
sulfacetamide sodium ophthalmic
Tier 1
*OPHTHALMIC
IMMUNOMODULATORS**-*OPHTHALMIC
IMMUNOMODULATORS***
RESTASIS
Tier 3
*OPHTHALMIC STEROIDS**-*OPHTHALMIC
STEROID COMBINATIONS***
BLEPHAMIDE
Tier 2
BLEPHAMIDE S.O.P.
Tier 2
MAXITROL
Tier 3
neomycin-polymyxin-dexameth ophthalmic ointment
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
94
QL
Drug Name
Drug Status
neomycin-polymyxin-dexameth ophthalmic suspension
3.5-10000-0.1
Tier 1
PRED-G
Tier 3
PRED-G S.O.P.
Tier 3
sulfacetamide-prednisolone ophthalmic solution
Tier 1
sulfacetamide-prednisolone ophthalmic suspension
Tier 2
TOBRADEX
Tier 3
TOBRADEX ST
Tier 3
ZYLET
Tier 3
Drug Details
*OPHTHALMIC STEROIDS**-*OPHTHALMIC
STEROIDS***
ALREX
Tier 3
dexamethasone sodium phosphate ophthalmic
Tier 1
DUREZOL
Tier 3
fluorometholone ophthalmic
Tier 1
FML
Tier 2
FML FORTE
Tier 2
FML LIQUIFILM
Tier 3
LOTEMAX
Tier 3
LOTEMAX OPHTHALMIC 0.5 %
Tier 3
PRED FORTE
Tier 3
PRED MILD
Tier 3
prednisolone acetate ophthalmic
Tier 1
prednisolone sodium phosphate ophthalmic
Tier 1
VEXOL
Tier 2
*OPHTHALMICS - MISC.**-*OPHTHALMIC
ANTIALLERGIC***
ALAWAY
Tier 1
Drug Note (Lowest Generic Copay
Applies)
ALAWAY CHILDRENS ALLERGY
Tier 1
Drug Note (Lowest Generic Copay
Applies)
ALOCRIL
Tier 3
ALOMIDE
Tier 3
BEPREVE
Tier 3
cromolyn sodium ophthalmic
Tier 1
ELESTAT
Tier 3
LASTACAFT
Tier 3
OPTIVAR
Tier 3
PATADAY
Tier 3
PATANOL
Tier 3
ZADITOR
Tier 1
QL
QL
#
*OPHTHALMICS - MISC.**-*OPHTHALMIC
CARBONIC ANHYDRASE INHIBITORS***
AZOPT
Tier 2
dorzolamide hcl
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
95
Drug Name
Drug Status
TRUSOPT
Tier 3
Drug Details
*OPHTHALMICS - MISC.**-*OPHTHALMIC
NONSTEROIDAL ANTI-INFLAMMATORY
AGENTS***
ACULAR
Tier 3
ACULAR LS
Tier 3
ACUVAIL
Tier 3
diclofenac sodium ophthalmic
Tier 1
flurbiprofen sodium
Tier 1
ketorolac tromethamine ophthalmic
Tier 3
NEVANAC
Tier 3
OCUFEN
Tier 3
PROLENSA
Tier 3
QL
Tier 3
PA; SD; DS; QL
latanoprost ophthalmic
Tier 1
QL
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
Tier 3
PA; N1 (Step Therapy Not Applicable in
NJ); #; QL
RESCULA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
TRAVATAN Z
Tier 2
QL
travoprost
Tier 3
PA
XALATAN
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
ZIOPTAN
Tier 3
PA; N1 (Step Therapy Not Applicable in
NJ); QL
QL
*OPHTHALMICS - MISC.**-*OPHTHALMICS CYSTINOSIS AGENTS**
CYSTARAN
*PROSTAGLANDINS OPHTHALMIC**-*PROSTAGLANDINS OPHTHALMIC***
*OTIC AGENTS*
*OTIC AGENTS - MISCELLANEOUS**-*OTIC
AGENTS - MISCELLANEOUS***
acetic acid otic
Tier 1
acetic acid-aluminum acetate
Tier 1
*OTIC ANTI-INFECTIVES**-*OTIC
ANTI-INFECTIVES***
CETRAXAL
Tier 3
ofloxacin otic
Tier 1
DS
*OTIC COMBINATIONS**-*OTIC ANALGESIC
COMBINATIONS***
antipyrine-benzocaine
Tier 1
*OTIC COMBINATIONS**-*OTIC
STEROID-ANTI-INFECTIVE COMBINATIONS***
CIPRO HC
Tier 3
CIPRODEX
Tier 2
COLY-MYCIN S
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
96
#
Drug Name
Drug Status
CORTISPORIN OTIC
Tier 3
CORTISPORIN-TC
Tier 3
Drug Details
*OTIC STEROIDS**-*OTIC STEROIDS***
ACETASOL HC
Tier 1
hydrocortisone-acetic acid
Tier 1
VOSOL HC
Tier 3
*OXYTOCICS*
*ABORTIFACIENTS/AGENTS FOR CERVICAL
RIPENING**-*ABORTIFACIENTS/CERVICAL
RIPENING - PROSTAGLANDINS***
CERVIDIL
Tier 3
PREPIDIL
Tier 3
*OXYTOCICS**-*OXYTOCICS***
methylergonovine maleate oral
Tier 1
*PASSIVE IMMUNIZING AGENTS*
*IMMUNE SERUMS**-*IMMUNE SERUMS***
GAMMAGARD
Tier 3
PA; SD; DS
GAMMAKED
Tier 3
PA; SD; DS
GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10
GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML
Tier 3
PA; SD; DS; N4 (Tier 2 for DE)
HIZENTRA
Tier 2
PA; SD; DS
HIZENTRA 20%
Tier 2
PA; SD; DS
HYPERRHO S/D
Tier 3
DS; QL
RHOGAM ULTRA-FILTERED PLUS
Tier 3
QL
WINRHO SDF
Tier 3
DS; QL
amoxicillin
Tier 1
DS
ampicillin oral capsule 250 mg, 500 mg
Tier 1
DS
ampicillin oral suspension reconstituted
Tier 1
DS
Tier 1
DS
amoxicillin-pot clavulanate oral
Tier 1
DS
AUGMENTIN ORAL SUSPENSION RECONSTITUTED
125-31.25 MG/5ML
Tier 2
AUGMENTIN ORAL SUSPENSION RECONSTITUTED
250-62.5 MG/5ML
Tier 3
AUGMENTIN ORAL TABLET
Tier 3
AUGMENTIN XR
Tier 3
QL
Tier 1
DS
*PENICILLINS*
*AMINOPENICILLINS**-*AMINOPENICILLINS***
*NATURAL PENICILLINS**-*NATURAL
PENICILLINS***
penicillin v potassium
*PENICILLIN COMBINATIONS**-*PENICILLIN
COMBINATIONS***
*PENICILLINASE-RESISTANT
PENICILLINS**-*PENICILLINASE-RESISTANT
PENICILLINS***
dicloxacillin sodium
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
97
Drug Name
Drug Status
Drug Details
*PHARMACEUTICAL ADJUVANTS*
*SEMI SOLID VEHICLES**-*SEMI SOLID
VEHICLES***
polyethylene glycol 3350 powder
Tier 1
*PROGESTINS*
*PROGESTINS**-*PROGESTINS***
AYGESTIN
Tier 3
medroxyprogesterone acetate oral
Tier 1
MEGACE ES
Tier 3
PROMETRIUM
Tier 2
PROVERA
Tier 3
Drug Note (Lowest generic copay
applies)
QL
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS - MISC.*
*AGENTS FOR CHEMICAL
DEPENDENCY**-*ALCOHOL DETERRENTS***
acamprosate calcium
Tier 3
ANTABUSE
Tier 3
CAMPRAL
Tier 3
disulfiram oral
Tier 1
QL
QL
*ANTI-CATAPLECTIC
AGENTS**-*ANTI-CATAPLECTIC AGENTS***
XYREM
Tier 3
PA; SD; DS
ARICEPT ORAL TABLET 10 MG
Tier 3
AL
ARICEPT ORAL TABLET 23 MG, 5 MG
Tier 3
QL; AL
ARICEPT ODT ORAL TABLET DISPERSIBLE 10 MG
Tier 3
AL
donepezil hcl oral tablet 10 mg
Tier 1
AL
donepezil hcl oral tablet 23 mg
Tier 3
QL; AL
donepezil hcl oral tablet 5 mg
Tier 1
QL; AL
donepezil hcl oral tablet dispersible
Tier 1
AL
EXELON ORAL CAPSULE
Tier 3
QL
EXELON TRANSDERMAL PATCH 24 HR 13.3
MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR
Tier 3
QL
galantamine hydrobromide
Tier 3
galantamine hydrobromide er
Tier 3
QL; AL
RAZADYNE ORAL TABLET
Tier 3
AL
RAZADYNE ER
Tier 3
QL; AL
NAMENDA ORAL SOLUTION
Tier 2
#; AL
NAMENDA XR
Tier 2
ST; N1 (Step Therapy Not Applicable in
NJ); #; QL; AL
*ANTIDEMENTIA
AGENTS**-*CHOLINOMIMETICS - ACHE
INHIBITORS***
*ANTIDEMENTIA
AGENTS**-*N-METHYL-D-ASPARTATE (NMDA)
RECEPTOR ANTAGONISTS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
98
Drug Name
Drug Status
NAMENDA XR TITRATION PACK
Tier 2
Drug Details
ST; N1 (Step Therapy Not Applicable in
NJ); #; QL; AL
*COMBINATION
PSYCHOTHERAPEUTICS**-*BENZODIAZEPINES
& TRICYCLIC AGENTS***
chlordiazepoxide-amitriptyline
Tier 3
*COMBINATION
PSYCHOTHERAPEUTICS**-*PHENOTHIAZINES &
TRICYCLIC AGENTS***
perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg,
4-25 mg
Tier 1
*COMBINATION
PSYCHOTHERAPEUTICS**-*THIENBENZODIAZE
PINES & SSRIS***
SYMBYAX
Tier 3
QL
SAVELLA
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
SAVELLA TITRATION PACK
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
Tier 2
PA; SD; DS; #; QL
AUBAGIO ORAL TABLET 14 MG
Tier 3
PA; SD; DS; QL
AUBAGIO ORAL TABLET 7 MG
Tier 3
PA; DS; QL
AVONEX
Tier 3
PA; SD; DS; QL
AVONEX PEN
Tier 3
PA; SD; DS; QL
AVONEX PREFILLED
Tier 3
PA; SD; DS; QL
BETASERON
Tier 3
PA; SD; DS; QL
EXTAVIA
Tier 3
PA; SD; DS; N4 (Tier 2 for DE); QL
REBIF SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML
Tier 2
PA; SD; DS; QL
REBIF SUBCUTANEOUS* SOLUTION 44 MCG/0.5ML
Tier 2
PA; SD; DS
REBIF REBIDOSE
Tier 2
PA; SD; DS; QL
REBIF REBIDOSE TITRATION PACK
Tier 2
PA; SD; DS; QL
REBIF TITRATION PACK
Tier 2
PA; SD; DS; QL
TECFIDERA
Tier 3
PA; SD; DS; QL
TECFIDERA ORAL 120 & 240 MG
Tier 3
PA; SD; DS; QL
*FIBROMYALGIA AGENTS**-*FIBROMYALGIA
AGENT - SNRIS***
*MOVEMENT DISORDER DRUG
THERAPY**-*MOVEMENT DISORDER DRUG
THERAPY***
XENAZINE ORAL TABLET 12.5 MG, 25 MG
*MULTIPLE SCLEROSIS AGENTS**-*MS AGENTS
- PYRIMIDINE SYNTHESIS INHIBITORS***
*MULTIPLE SCLEROSIS AGENTS**-*MULTIPLE
SCLEROSIS AGENTS - INTERFERONS***
*MULTIPLE SCLEROSIS AGENTS**-*MULTIPLE
SCLEROSIS AGENTS - NRF2 PATHWAY
ACTIVATORS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
99
Drug Name
Drug Status
Drug Details
*MULTIPLE SCLEROSIS AGENTS**-*MULTIPLE
SCLEROSIS AGENTS - POTASSIUM CHANNEL
BLOCKERS***
AMPYRA
Tier 3
PA; SD; DS; QL
COPAXONE SUBCUTANEOUS* 40 MG/ML
Tier 2
PA; DS
COPAXONE SUBCUTANEOUS* KIT
Tier 2
PA; SD; DS; #
Tier 3
PA; SD; DS; QL
GRALISE ORAL TABLET 300 MG, 600 MG
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
GRALISE STARTER
Tier 3
PA; ST; N1 (Step Therapy Not
Applicable in NJ); QL
fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies); QL
SARAFEM ORAL TABLET 10 MG, 20 MG
Tier 1
QL
Tier 3
QL
*MULTIPLE SCLEROSIS AGENTS**-*MULTIPLE
SCLEROSIS AGENTS***
*MULTIPLE SCLEROSIS
AGENTS**-*SPHINGOSINE 1-PHOSPHATE (S1P)
RECEPTOR MODULATORS***
GILENYA
*POSTHERPETIC NEURALGIA (PHN)
AGENTS**-*POSTHERPETIC NEURALGIA (PHN)
AGENTS***
*PREMENSTRUAL DYSPHORIC DISORDER
(PMDD) AGENTS**-*PREMENSTRUAL
DYSPHORIC DISORDER (PMDD) AGENTS SSRIS***
*PSEUDOBULBAR AFFECT (PBA)
AGENTS**-*PSEUDOBULBAR AFFECT AGENT
COMBINATIONS***
NUEDEXTA
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS - MISC.**-*PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.***
ergoloid mesylates oral
Tier 3
ORAP
Tier 3
*SMOKING DETERRENTS**-*SMOKING
DETERRENTS***
BUPROBAN
bupropion hcl er (smoking det)
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
Tier 1
CHANTIX
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
CHANTIX CONTINUING MONTH PAK
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
CHANTIX STARTING MONTH PAK
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
100
Drug Name
Drug Status
Drug Details
cvs nicotine
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
eq nicotine transdermal patch 24 hr 14 mg/24hr, 21
mg/24hr
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
eql nicotine
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
hm nicotine
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
NICODERM CQ
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
NICORELIEF MOUTH/THROAT GUM
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
NICORETTE
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
NICORETTE MINI
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
NICORETTE STARTER KIT
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
nicotine transdermal patch 24 hr
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
nicotine step 1
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
nicotine step 2
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
nicotine step 3
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
NICOTROL
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
NICOTROL NS
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
ra nicotine transdermal
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
sm nicotine transdermal
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
101
Drug Name
Drug Status
Drug Details
tgt nicotine step one
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
tgt nicotine step three
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
tgt nicotine step two
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
ZYBAN
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
NC
N2 (Covered in NJ, IN)
*VASOMOTOR SYMPTOM
AGENTS**-*VASOMOTOR SYMPTOM AGENTS SSRIS***
BRISDELLE
*RESPIRATORY AGENTS - MISC.*
*CYSTIC FIBROSIS AGENTS**-*CFTR
POTENTIATORS***
KALYDECO
Tier 3
PA; SD; DS; QL
Tier 2
PA; SD; DS; QL
*CYSTIC FIBROSIS AGENTS**-*HYDROLYTIC
ENZYMES***
PULMOZYME
*SULFONAMIDES*
*SULFONAMIDES**-*SULFONAMIDES***
sulfadiazine oral
Tier 3
sulfisoxizole
Tier 1
*TETRACYCLINES*
*TETRACYCLINE
COMBINATIONS**-*TETRACYCLINE
COMBINATIONS***
AVIDOXY DK
NC
N2 (Covered in NJ, IN)
ADOXA ORAL CAPSULE
NC
N2 (Covered in NJ, IN)
ADOXA ORAL TABLET
NC
N2 (Covered in NJ, IN)
ADOXA PAK 1/100
NC
N2 (Covered in NJ, IN)
ADOXA PAK 1/150
NC
N2 (Covered in NJ, IN)
ADOXA PAK 2/100
NC
N2 (Covered in NJ, IN)
*TETRACYCLINES**-*TETRACYCLINES***
avidoxy
DORYX ORAL TABLET DELAYED RELEASE 150 MG,
200 MG
Tier 1
NC
N2 (Covered in NJ, IN)
doxycycline hyclate oral capsule
Tier 1
Drug Note (Lowest Generic Copay
Applies)
doxycycline hyclate oral tablet 100 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
doxycycline hyclate oral tablet 20 mg
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
doxycycline hyclate oral tablet delayed release
NC
N2 (Covered in NJ,IN)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
102
Drug Name
doxycycline monohydrate oral capsule 100 mg, 150 mg
Drug Status
NC
doxycycline monohydrate oral capsule 50 mg
Tier 1
doxycycline monohydrate oral capsule 75 mg
NC
doxycycline monohydrate oral suspension reconstituted
Tier 1
doxycycline monohydrate oral tablet 100 mg
Tier 1
Drug Details
N2 (Covered in NJ,IN)
doxycycline monohydrate oral tablet 50 mg, 75 mg
NC
N2 (Covered in NJ,IN)
MINOCIN COMBINATION
NC
N2 (Covered in NJ, IN)
MINOCIN ORAL CAPSULE 100 MG, 50 MG
Tier 3
minocycline hcl oral capsule
NC
DS; N2 (Covered in NJ, IN)
minocycline hcl oral tablet
NC
N2 (Covered in NJ, IN)
minocycline hcl er
NC
N2 (Covered in NJ, IN)
MONODOX ORAL CAPSULE 100 MG
Tier 3
MONODOX ORAL CAPSULE 75 MG
NC
DS; N2 (Covered in NJ, IN)
MORGIDOX COMBINATION
NC
N2 (Covered in NJ, IN)
OCUDOX
NC
N2 (Covered in NJ, IN)
SOLODYN ORAL TABLET EXTENDED RELEASE 24
HR* 105 MG, 115 MG, 55 MG, 65 MG, 80 MG
NC
N2 (Covered in NJ, IN)
tetracycline hcl oral
Tier 1
VIBRAMYCIN ORAL CAPSULE
Tier 3
VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED
Tier 3
VIBRAMYCIN ORAL SYRUP
Tier 3
DS
Drug Note (Lowest Generic Copay
Applies)
*THYROID AGENTS*
*ANTITHYROID AGENTS**-*ANTITHYROID
AGENTS***
methimazole oral
Tier 1
propylthiouracil oral
Tier 1
TAPAZOLE
Tier 3
*THYROID HORMONES**-*THYROID
HORMONES***
ARMOUR THYROID
Tier 2
CYTOMEL
Tier 3
levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125
mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
Tier 1
levothyroxine sodium oral tablet 300 mcg
Tier 1
LEVOXYL
Tier 1
liothyronine sodium oral
Tier 1
NATURE-THROID
Tier 1
np thyroid oral tablet 30 mg
Tier 1
SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125
MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300
MCG, 50 MCG, 75 MCG, 88 MCG
Tier 2
SYNTHROID ORAL TABLET 137 MCG
Tier 1
THYROLAR-1
Tier 3
Drug Note (Lowest Generic Copay
Applies)
THYROLAR-1/2
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
103
Drug Name
Drug Status
THYROLAR-1/4
Tier 3
THYROLAR-2
Tier 3
THYROLAR-3
Tier 3
TIROSINT
Tier 3
UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125
MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300
MCG, 50 MCG, 75 MCG, 88 MCG
Tier 1
Drug Details
QL
*ULCER DRUGS*
*ANTISPASMODICS**-*ANTICHOLINERGIC
COMBINATIONS***
chlordiazepoxide-clidinium
Tier 1
LIBRAX
Tier 3
DS
*ANTISPASMODICS**-*ANTISPASMODICS***
BENTYL ORAL CAPSULE
Tier 3
BENTYL ORAL TABLET
Tier 3
dicyclomine hcl oral capsule
Tier 1
Drug Note (Lowest Generic Copay
Applies)
dicyclomine hcl oral tablet
Tier 1
Drug Note (Lowest Generic Copay
Applies)
*ANTISPASMODICS**-*BELLADONNA
ALKALOIDS***
ANASPAZ
Tier 3
hyoscyamine sulfate oral tablet
Tier 1
hyoscyamine sulfate oral tablet dispersible
Tier 1
LEVSIN ORAL
Tier 3
*ANTISPASMODICS**-*QUATERNARY
ANTICHOLINERGICS***
CUVPOSA
Tier 3
PAMINE
Tier 3
PAMINE FORTE
Tier 3
propantheline bromide oral
Tier 1
ROBINUL ORAL
Tier 3
ROBINUL-FORTE
Tier 3
*H-2 ANTAGONISTS**-*H-2 ANTAGONISTS***
cimetidine oral tablet 200 mg, 300 mg, 400 mg
Tier 1
cimetidine oral tablet 800 mg
Tier 1
cimetidine 200
Tier 1
cimetidine hcl oral
Tier 1
cvs heartburn relief
Tier 1
famotidine oral tablet 10 mg
Tier 1
famotidine oral tablet 20 mg, 40 mg
Tier 1
gnp heartburn relief
Tier 1
hm famotidine
Tier 1
nizatidine
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
104
Drug Note (Lowest Generic Copay
Applies)
Drug Note (Lowest Generic Copay
Applies)
Drug Name
Drug Status
PEPCID
Tier 3
px acid reducer max st oral tablet 20 mg
Tier 1
ranitidine hcl oral capsule
Tier 1
ranitidine hcl oral tablet 150 mg, 300 mg
Tier 1
th famotidine 10
Tier 1
ZANTAC ORAL TABLET
Tier 3
ZANTAC 150 MAXIMUM STRENGTH
Tier 3
Drug Details
Drug Note (Lowest Generic Copay
Applies)
*MISC. ANTI-ULCER**-*MISC. ANTI-ULCER***
CARAFATE ORAL SUSPENSION
Tier 2
CARAFATE ORAL TABLET
Tier 3
sucralfate oral tablet
Tier 1
*PROTON PUMP INHIBITORS**-*PROTON PUMP
INHIBITORS***
ACIPHEX
Tier 3
PA; QL
cvs omeprazole oral tablet delayed release
Tier 1
Drug Note (Requires doctors prescription)
DEXILANT
Tier 3
PA; QL
eq lansoprazole
NC
eq omeprazole
Tier 1
Drug Note (Requires doctors prescription)
eql omeprazole
Tier 1
Drug Note (Requires doctors prescription)
esomeprazole strontium oral capsule delayed release 49.3
mg
NC
N2 (Covered in NJ, IN)
FIRST-LANSOPRAZOLE
Tier 2
FIRST-OMEPRAZOLE
Tier 2
gnp omeprazole
Tier 1
Drug Note (Requires doctors prescription)
hm omeprazole
Tier 1
Drug Note (Requires doctors prescription)
kls omeprazole
Tier 1
Drug Note (Requires doctors prescription)
lansoprazole oral capsule delayed release
NC
N2 (Covered in NJ, IN)
NEXIUM ORAL CAPSULE DELAYED RELEASE
Tier 2
#; QL
NEXIUM ORAL PACKET 10 MG, 2.5 MG, 5 MG
Tier 2
#
NEXIUM ORAL PACKET 20 MG, 40 MG
Tier 2
#; QL
omeprazole oral capsule delayed release 10 mg, 40 mg
Tier 1
omeprazole oral capsule delayed release 20 mg
Tier 1
Drug Note (Lowest Generic Copay
Applies)
omeprazole oral tablet delayed release
Tier 1
Drug Note (Requires doctors prescription)
omeprazole magnesium
Tier 1
Drug Note (Lowest Generic Copay
Applies)
pantoprazole sodium oral
Tier 1
PREVACID ORAL CAPSULE DELAYED RELEASE 15
MG
NC
PA; N2 (Covered in NJ, IN); QL; AL
PREVACID ORAL CAPSULE DELAYED RELEASE 30
MG
NC
N2 (Covered in NJ, IN)
PREVACID 24HR
Tier 1
Drug Note (Requires doctors
prescription); QL
PREVACID SOLUTAB
Tier 3
PA; QL; AL
PRILOSEC ORAL CAPSULE DELAYED RELEASE
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
105
Drug Name
Drug Status
PRILOSEC ORAL PACKET
NC
Drug Details
N2 (Covered in NJ, IN)
Drug Note (Lowest Generic Copay
Applies)
PRILOSEC OTC
Tier 1
PROTONIX ORAL
Tier 3
px omeprazole
Tier 1
Drug Note (Requires doctors prescription)
ra omeprazole
Tier 1
Drug Note (Requires doctors prescription)
rabeprazole sodium
Tier 3
PA; QL
sb omeprazole
Tier 1
Drug Note (Requires doctors prescription)
sm omeprazole
Tier 1
Drug Note (Requires doctors prescription)
sw omeprazole
Tier 1
Drug Note (Requires doctors prescription)
tgt omeprazole
Tier 1
Drug Note (Requires doctors prescription)
*ULCER DRUGS - PROSTAGLANDINS**-*ULCER
DRUGS - PROSTAGLANDINS***
CYTOTEC
Tier 3
misoprostol oral
Tier 1
*ULCER THERAPY COMBINATIONS**-*PROTON
PUMP INHIBITOR-ANTACID COMBINATIONS***
ZEGERID ORAL CAPSULE 20-1100 MG
NC
N2 (Not Covered in NJ,IN)
ZEGERID ORAL CAPSULE 40-1100 MG
NC
N2 (Covered in NJ, IN)
ZEGERID ORAL PACKET
NC
N2 (Covered in NJ, IN)
ZEGERID OTC
Tier 1
N2 (Covered in NJ, IN); QL
*ULCER THERAPY COMBINATIONS**-*ULCER
ANTI-INFECTIVE W/ BISMUTH
COMBINATIONS***
PYLERA
Tier 3
*ULCER THERAPY COMBINATIONS**-*ULCER
ANTI-INFECTIVE W/ PROTON PUMP
INHIBITORS***
amoxicill-clarithro-lansopraz
OMECLAMOX-PAK
PREVPAC
Tier 3
NC
N2 (Covered in NJ, IN)
Tier 3
*URINARY ANTI-INFECTIVES*
*URINARY ANTI-INFECTIVES**-*URINARY
ANTI-INFECTIVES***
FURADANTIN
Tier 3
HIPREX
Tier 3
MACROBID
Tier 3
MACRODANTIN
Tier 3
methenamine hippurate
Tier 1
methenamine mandelate oral
Tier 1
nitrofurantoin
Tier 1
DS
nitrofurantoin macrocrystal oral
Tier 1
DS
nitrofurantoin monohyd macro
Tier 1
DS
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
106
DS
Drug Name
Drug Status
Drug Details
*URINARY ANTISPASMODICS*
*URINARY ANTISPASMODIC ANTIMUSCARINICS
(ANTICHOLINERGIC)**-*URINARY
ANTISPASMODIC - ANTIMUSCARINIC
(ANTICHOLINERGIC)***
DETROL LA
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
oxybutynin chloride oral tablet
Tier 1
Drug Note (Lowest Generic Copay
Applies); DS
OXYTROL
NC
N2 (Covered in NJ, IN); #
OXYTROL FOR WOMEN
Tier 1
Drug Note (Requires doctors
prescription); QL
SANCTURA XR
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
tolterodine tartrate er
Tier 1
QL
VESICARE
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
Tier 2
N1 (Step Therapy Not Applicable in NJ);
QL
*URINARY ANTISPASMODICS - BETA-3
ADRENERGIC AGONISTS**-*URINARY
ANTISPASMODICS - BETA-3 ADRENERGIC
AGONISTS***
MYRBETRIQ
*URINARY ANTISPASMODICS - CHOLINERGIC
AGONISTS**-*URINARY ANTISPASMODICS CHOLINERGIC AGONISTS***
bethanechol chloride oral tablet 25 mg
Tier 1
*URINARY ANTISPASMODICS**-*URINARY
ANTISPASMODICS***
bethanechol chloride oral tablet 10 mg, 5 mg, 50 mg
Tier 1
DETROL ORAL TABLET 1 MG, 2 MG
Tier 3
DITROPAN XL ORAL TABLET EXTENDED RELEASE
24 HR* 10 MG, 15 MG, 5 MG
Tier 3
ST; N1 (Step Therapy Not Applicable In
NJ); QL
ENABLEX
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
flavoxate hcl
Tier 1
GELNIQUE TRANSDERMAL 10 %, 3 (28) % (MG/ACT)
Tier 3
oxybutynin chloride oral syrup
Tier 1
oxybutynin chloride er
Tier 1
tolterodine tartrate
Tier 1
TOVIAZ
Tier 3
N1 (Step Therapy Not Applicable in NJ);
QL
trospium chloride
Tier 1
QL
trospium chloride er
Tier 1
QL
URECHOLINE
Tier 3
ST; N1 (Step Therapy Not Applicable in
NJ); QL
DS
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
107
Drug Name
Drug Status
Drug Details
*VACCINES*
*VIRAL VACCINES**-*VIRAL VACCINES***
AFLURIA
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
AFLURIA PRESERVATIVE FREE
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLUARIX
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLUARIX QUADRIVALENT
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLUBLOK
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLULAVAL
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLULAVAL QUADRIVALENT INTRAMUSCULAR*
SUSPENSION
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLUVIRIN
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLUVIRIN PRESERVATIVE FREE
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLUZONE
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLUZONE PEDIATRIC PF
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
FLUZONE QUADRIVALENT INTRAMUSCULAR*
SUSPENSION 0.25 ML, 0.5 ML
LA
N1 (Please refer to your health plan
documents regarding coverage of and any
limitations or exclusions that may apply.)
*VAGINAL PRODUCTS*
*MISCELLANEOUS VAGINAL
PRODUCTS**-*MISCELLANEOUS VAGINAL
COMBINATIONS***
FEM PH
Tier 3
RELAGARD
Tier 3
*SPERMICIDES**-*SPERMICIDES***
TODAY SPONGE
CE
VCF VAGINAL CONTRACEPTIVE
CE
*VAGINAL
ANTI-INFECTIVES**-*IMIDAZOLE-RELATED
ANTIFUNGALS***
clotrimazole vaginal cream 1 %
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
108
Tier 1
Drug Name
Drug Status
GYNAZOLE-1
Tier 3
miconazole 3 vaginal suppository
Tier 3
ra clotrimazole 7
Tier 1
sm clotrimazole vaginal
Tier 1
TERAZOL 3 VAGINAL CREAM
Tier 3
TERAZOL 7
Tier 3
terconazole
Tier 1
Drug Details
QL
*VAGINAL ANTI-INFECTIVES**-*VAGINAL
ANTI-INFECTIVES***
AVC VAGINAL
Tier 3
CLEOCIN VAGINAL CREAM
Tier 3
CLEOCIN VAGINAL SUPPOSITORY
Tier 2
clindamycin phosphate vaginal
Tier 1
CLINDESSE
Tier 3
METROGEL-VAGINAL
Tier 3
metronidazole vaginal
Tier 1
VANDAZOLE
Tier 1
DS
*VAGINAL ESTROGENS**-*VAGINAL
ESTROGENS***
ESTRACE VAGINAL
Tier 3
ESTRING
Tier 3
FEMRING
Tier 3
PREMARIN VAGINAL
Tier 2
VAGIFEM
Tier 3
#; QL
*VAGINAL PROGESTINS**-*VAGINAL
PROGESTINS***
CRINONE VAGINAL 4 %
Tier 3
*VASOPRESSORS*
*ANAPHYLAXIS THERAPY
AGENTS**-*ANAPHYLAXIS THERAPY
AGENTS***
ADRENACLICK
Tier 3
PA; ST; DS; N1 (Step Therapy Not
Applicable in NJ); QL
ADRENALIN INJECTION SOLUTION 1 MG/ML
Tier 3
DS
AUVI-Q INJECTION 0.15 MG/0.15ML, 0.3 MG/0.3ML
Tier 2
DS; QL
epinephrine injection 0.15 mg/0.15ml, 0.3 mg/0.3ml
Tier 1
DS; QL
EPIPEN 2-PAK
Tier 2
DS; QL
EPIPEN JR 2-PAK
Tier 2
DS; QL
*VASOPRESSORS**-*VASOPRESSORS***
midodrine hcl
Tier 3
*VITAMINS*
*OIL SOLUBLE VITAMINS**-*VITAMIN D***
BPROTECTED PEDIA D-VITE
CE
CALCIFEROL
Tier 1
d 400 oral tablet
CE
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
109
Drug Name
Drug Status
D-VI-SOL
CE
d3-1000 oral tablet
CE
gnp vitamin d oral tablet chewable
CE
vitamin d-3 oral capsule
CE
Drug Details
*OIL SOLUBLE VITAMINS**-*VITAMIN K***
MEPHYTON
Tier 2
*WATER SOLUBLE VITAMINS**-*VITAMIN
B-3***
gnp niacin tr
Tier 1
DS
hm niacin
Tier 1
DS
niacin er
Tier 1
DS
sm niacin cr
Tier 1
DS
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
110
abacavir sulfate ............................................................. 46 ADDERALL XR ............................................................ 3
abacavir-lamivudine-zidovudine
adefovir dipivoxil ......................................................... 46
......................................................................................................... 45
ADEMPAS ........................................................................ 53
ABILIFY .............................................................................. 44 ADIPEX-P ............................................................................. 4
ABILIFY DISCMELT
ADOXA ............................................................................. 102
......................................................................................................... 44
ADOXA PAK 1/100 ............................................. 102
ABREVA ............................................................................. 64 ADOXA PAK 1/150 ............................................. 102
ABSORICA ...................................................................... 61
ADOXA PAK 2/100 ............................................. 102
ABSTRAL ............................................................................. 9 ADRENACLICK ..................................................... 109
acamprosate calcium
ADRENALIN ................................................................. 92
......................................................................................................... 98
ADVAIR DISKUS .................................................... 15
ACANYA ........................................................................... 60
ADVAIR HFA ............................................................... 15
acarbose ................................................................................ 22 ADVICOR .......................................................................... 31
ACCOLATE .................................................................... 14
ADVOCATE BLOOD GLUCOSE
ACCU-CHEK AVIVA
MONITOR ......................................................................... 86
......................................................................................................... 68
ADVOCATE BLOOD GLUCOSE
ACCU-CHEK COMFORT CURVE
SYSTEM .............................................................................. 86
......................................................................................................... 68
AEROCHAMBER MV
ACCU-CHEK COMPACT PLUS CARE
......................................................................................................... 87
......................................................................................................... 86
AEROSPAN ..................................................................... 15
ACCU-CHEK SMARTVIEW
AFEDITAB CR ............................................................ 50
......................................................................................................... 68
AFINITOR ......................................................................... 40
ACCUPRIL ....................................................................... 32 AFINITOR DISPERZ
ACCURETIC .................................................................. 34 ......................................................................................................... 40
acebutolol hcl .................................................................. 49 AFLURIA ........................................................................ 108
ACEON ................................................................................. 32 AFLURIA PRESERVATIVE FREE
acetaminophen-codeine
...................................................................................................... 108
......................................................................................................... 10
AGGRENOX ................................................................... 81
acetaminophen-codeine #2
AGRYLIN .......................................................................... 81
......................................................................................................... 10
ALAVERT ......................................................................... 28
acetaminophen-codeine #3
ALAVERT ALLERGY/SINUS
......................................................................................................... 10
......................................................................................................... 59
acetaminophen-codeine #4
ALAWAY .......................................................................... 95
......................................................................................................... 10
ALAWAY CHILDRENS ALLERGY
ACETASOL HC .......................................................... 97
......................................................................................................... 95
acetazolamide ................................................................. 71
ALBENZA ......................................................................... 12
acetazolamide er .......................................................... 71
albuterol sulfate ............................................................ 15
acetic acid ........................................................................... 80 albuterol sulfate er ..................................................... 15
acetic acid-aluminum acetate
alclometasone dipropionate
......................................................................................................... 96
......................................................................................................... 64
acetylcysteine ................................................................... 60 ALDACTAZIDE ......................................................... 71
ACIPHEX ........................................................................ 105 ALDACTONE ............................................................... 71
acitretin ................................................................................. 64
ALDARA ............................................................................ 67
ACTEMRA ........................................................................... 6 alendronate sodium ................................................... 72
ACTIGALL ....................................................................... 78 alfuzosin hcl er ............................................................... 80
ACTIMMUNE ............................................................... 41 ALINIA ................................................................................. 37
ACTIQ ....................................................................................... 9 ALKERAN ........................................................................ 38
ACTIVELLA ................................................................... 76 ALLEGRA ALLERGY
ACTONEL ......................................................................... 72 ......................................................................................................... 28
ACTOPLUS MET ...................................................... 23 ALLEGRA ALLERGY CHILDRENS
ACTOPLUS MET XR
......................................................................................................... 28
......................................................................................................... 23
ALLEGRA-D ALLERGY &
ACTOS .................................................................................. 24 CONGESTION ............................................................. 59
ACULAR ............................................................................. 96 allergy ..................................................................................... 28
ACULAR LS ................................................................... 96 allergy relief ..................................................................... 29
ACUVAIL .......................................................................... 96 ALLI ............................................................................................ 4
acyclovir ............................................................................... 47 allopurinol .......................................................................... 81
ACZONE ............................................................................. 60 ALOCRIL ........................................................................... 95
ADALAT CC .................................................................. 50 ALOMIDE ......................................................................... 95
adapalene ............................................................................ 61
ALORA ................................................................................. 77
ADCIRCA .......................................................................... 53 ALPHAGAN P .............................................................. 93
2015
Aetna Pharmacy
Plan Drug List - Three
Tier
Open Individual
Plan
ADDERALL
.......................................................................
3
alprazolam
..........................................................................
13
Index
Index
Index
Index
alprazolam er .................................................................. 13
alprazolam xr .................................................................. 13
ALREX .................................................................................. 95
ALSUMA ............................................................................ 87
ALTABAX ........................................................................ 62
ALTACE .............................................................................. 32
ALTAVERA .................................................................... 54
ALTOPREV ..................................................................... 31
aluminum acetate ........................................................ 67
ALVESCO ......................................................................... 15
alyacen 1/35 ...................................................................... 54
alyacen 7/7/7 .................................................................... 56
amantadine hcl ............................................................... 42
AMARYL ........................................................................... 26
AMBIEN .............................................................................. 83
AMBIEN CR ................................................................... 83
AMERGE ............................................................................ 87
AMETHIA ......................................................................... 56
AMETHIA LO ............................................................... 56
AMETHYST .................................................................... 56
amiloride hcl .................................................................... 71
amiloride-hydrochlorothiazide
......................................................................................................... 71
aminocaproic acid ...................................................... 83
amiodarone hcl .............................................................. 14
AMITIZA ............................................................................ 78
amitriptyline hcl ............................................................ 22
amlodipine besy-benazepril hcl
......................................................................................................... 34
amlodipine besylate .................................................. 50
AMNESTEEM .............................................................. 61
amoxapine ........................................................................... 22
amoxicill-clarithro-lansopraz
...................................................................................................... 106
amoxicillin .......................................................................... 97
amoxicillin-pot clavulanate
......................................................................................................... 97
amphetamine-dextroamphet er
............................................................................................................ 3
amphetamine-dextroamphetamine
............................................................................................................ 3
ampicillin ............................................................................. 97
AMPYRA ........................................................................ 100
AMRIX .................................................................................. 91
AMTURNIDE ................................................................ 36
ANACIN ................................................................................. 8
ANADROL-50 .............................................................. 11
ANAFRANIL ................................................................. 22
anagrelide hcl ................................................................. 81
ANALPRAM-HC ....................................................... 12
ANAPROX ........................................................................... 6
ANAPROX DS ................................................................. 6
ANASPAZ ...................................................................... 104
anastrozole ......................................................................... 39
ANCOBON ....................................................................... 27
ANDRODERM ............................................................. 11
ANDROGEL ................................................................... 11
ANDROGEL PUMP
......................................................................................................... 11
ANDROID ......................................................................... 11
ANDROXY ....................................................................... 11
ANGELIQ .......................................................................... 76
111
Index
Index
Index
ANORO ELLIPTA .................................................... 15 ATROVENT .................................................................... 92
ANTABUSE .................................................................... 98
ATROVENT HFA ..................................................... 14
ANTARA ............................................................................ 31
AUBAGIO ......................................................................... 99
antipyrine-benzocaine
AUGMENTIN ................................................................ 97
......................................................................................................... 96
AUGMENTIN XR ..................................................... 97
ANUSOL-HC ................................................................. 12
AUVI-Q ............................................................................. 109
ANZEMET ........................................................................ 27 AVAILNEX ...................................................................... 70
APIDRA ............................................................................... 25 AVALIDE .......................................................................... 35
APIDRA SOLOSTAR
AVANDAMET ............................................................. 23
......................................................................................................... 25
AVANDARYL .............................................................. 23
APLENZIN ....................................................................... 20
AVANDIA ......................................................................... 24
APOKYN ............................................................................ 42
AVAPRO ............................................................................. 33
APPTRIM ........................................................................... 69 AVAR CLEANSER ................................................. 60
APPTRIM-D .................................................................... 69 AVAR-E EMOLLIENT
apraclonidine hcl ......................................................... 93 ......................................................................................................... 60
APRI ......................................................................................... 54 AVAR-E GREEN ....................................................... 60
APRISO ................................................................................ 78
AVC VAGINAL ....................................................... 109
APTIOM .............................................................................. 18
AVELOX ............................................................................. 77
APTIVUS ............................................................................ 45 AVIANE .............................................................................. 54
ARALEN ............................................................................. 37 avidoxy ................................................................................ 102
ARANELLE ..................................................................... 56 AVIDOXY DK .......................................................... 102
ARANESP (ALBUMIN FREE)
AVINZA .................................................................................. 9
......................................................................................................... 82
AVITA ................................................................................... 61
ARAVA .................................................................................... 8 AVODART ....................................................................... 80
ARCALYST ........................................................................ 6 AVONEX ............................................................................ 99
ARCAPTA NEOHALER
AVONEX PEN .............................................................. 99
......................................................................................................... 15
AVONEX PREFILLED
ARICEPT ............................................................................ 98 ......................................................................................................... 99
ARICEPT ODT ............................................................. 98 AXERT .................................................................................. 87
ARIMIDEX ....................................................................... 39 AXIRON .............................................................................. 11
ARIXTRA .......................................................................... 17
AXONA ................................................................................ 69
ARMOUR THYROID
AYGESTIN ....................................................................... 98
...................................................................................................... 103
AZASITE ............................................................................ 93
AROMASIN .................................................................... 39
azathioprine ...................................................................... 48
ARTHRITIS PAIN REGIMEN EX ST
azelastine hcl ................................................................... 92
............................................................................................................ 8
AZELEX .............................................................................. 61
ARTHROTEC ................................................................... 6
AZILECT ............................................................................ 42
ASACOL HD .................................................................. 78 azithromycin ..................................................................... 85
ASMANEX 120 METERED DOSES
AZOPT .................................................................................. 95
......................................................................................................... 15
AZOR ...................................................................................... 34
ASMANEX 14 METERED DOSES
AZULFIDINE ................................................................ 78
......................................................................................................... 15
AZULFIDINE EN-TABS
ASMANEX 30 METERED DOSES
......................................................................................................... 78
......................................................................................................... 15
AZURETTE ...................................................................... 53
ASMANEX 60 METERED DOSES
baby aspirin .......................................................................... 8
......................................................................................................... 15
bacitracin ............................................................................. 93
ASMANEX 7 METERED DOSES
bacitracin-polymyxin b
......................................................................................................... 15
......................................................................................................... 94
aspirin low dose ............................................................... 8
baclofen ................................................................................. 91
ASTAGRAF XL .......................................................... 48
BACTRIM .......................................................................... 36
ASTEPRO .......................................................................... 91
BACTRIM DS ............................................................... 36
ATACAND ....................................................................... 33
BACTROBAN ............................................................... 62
ATACAND HCT ........................................................ 35
BACTROBAN NASAL
ATELVIA ........................................................................... 72 ......................................................................................................... 92
atenolol .................................................................................. 49 balsalazide disodium
atenolol-chlorthalidone
......................................................................................................... 78
......................................................................................................... 35
BALZIVA ........................................................................... 54
ATIVAN .............................................................................. 13
BANZEL .............................................................................. 18
atorvastatin calcium ................................................. 31 BARACLUDE ............................................................... 46
atovaquone ......................................................................... 37 BAYER ADVANCED ASPIRIN EX ST
atovaquone-proguanil hcl
............................................................................................................ 8
......................................................................................................... 37
BAYER ADVANCED ASPIRIN REG ST
ATRALIN ........................................................................... 61 ............................................................................................................ 8
ATRIPLA
45 Tier
BAYER
REGIMEN
2015 Aetna............................................................................
Pharmacy Plan Drug List - Three
OpenASPIRIN
Individual
Plan
atropine sulfate .............................................................. 93 ............................................................................................................ 8
112
BD AUTOSHIELD ................................................... 86
BD CATHETER TIP SYRINGE
......................................................................................................... 86
BD ECLIPSE SYRINGE
......................................................................................................... 86
BD INSULIN SYRINGE
......................................................................................................... 86
BD INSULIN SYRINGE HALF-UNIT
......................................................................................................... 86
BD INSULIN SYRINGE MICROFINE
......................................................................................................... 86
BD INSULIN SYRINGE ULTRAFINE
......................................................................................................... 86
BD INTEGRA INSULIN SYRINGE
......................................................................................................... 86
BD INTEGRA SYRINGE
......................................................................................................... 86
BD LUER-LOK SYRINGE
......................................................................................................... 86
BD PEN NEEDLE MINI U/F
......................................................................................................... 86
BD PEN NEEDLE SHORT U/F
......................................................................................................... 86
BD PEN NEEDLE ULTRAFINE
......................................................................................................... 86
BD SAFETYGLIDE INSULIN
SYRINGE ........................................................................... 86
BD SAFETYGLIDE NEEDLE
......................................................................................................... 86
BD SAFETYGLIDE SHIELDED
NEEDLE .............................................................................. 86
BD SAFETYGLIDE
SYRINGE/NEEDLE
......................................................................................................... 86
BD SAFETY-LOK INSULIN SYRINGE
......................................................................................................... 86
BD SYRINGE ................................................................ 87
BD SYRINGE 50-60 ML
......................................................................................................... 87
BD SYRINGE DUAL CANNULA
......................................................................................................... 87
BD SYRINGE LUER SLIP TIP
......................................................................................................... 87
BD SYRINGE LUER-LOK
......................................................................................................... 87
BD SYRINGE SLIP TIP
......................................................................................................... 87
BD SYRINGE/NEEDLE
......................................................................................................... 87
BD SYRINGE/NEEDLE SLIP TIP
......................................................................................................... 87
BECONASE AQ ......................................................... 92
BELVIQ ................................................................................... 4
benazepril hcl .................................................................. 32
benazepril-hydrochlorothiazide
......................................................................................................... 34
BENICAR ........................................................................... 33
BENICAR HCT ............................................................ 35
BENTYL .......................................................................... 104
BENZACLIN .................................................................. 60
BENZACLIN WITH PUMP
......................................................................................................... 60
BENZAMYCIN ............................................................ 60
BENZAMYCINPAK
......................................................................................................... 60
Index
Index
Index
benzonatate ........................................................................ 58 BUPROBAN ................................................................ 100
benzoyl peroxide-erythromycin
bupropion hcl .................................................................. 20
......................................................................................................... 60
bupropion hcl er (smoking det)
benzphetamine hcl ......................................................... 4
...................................................................................................... 100
benztropine mesylate
bupropion hcl er (sr)
......................................................................................................... 41
......................................................................................................... 20
BEPREVE .......................................................................... 95
bupropion hcl er (xl) ................................................ 20
BERINERT ....................................................................... 81
buspirone hcl ................................................................... 13
BESIVANCE ................................................................... 94 butalbital-acetaminophen
BETAGAN ........................................................................ 93 ............................................................................................................ 8
betamethasone dipropionate aug
butalbital-apap-caff-cod
............................................................................................... 64, 65
......................................................................................................... 10
betamethasone valerate
butalbital-apap-caffeine
......................................................................................................... 65
............................................................................................................ 8
BETAPACE ..................................................................... 49
butalbital-asa-caffeine
BETAPACE AF ........................................................... 49
............................................................................................................ 8
BETASERON ................................................................. 99 BUTISOL SODIUM
......................................................................................................... 83
betaxolol hcl ..................................................................... 93
butorphanol tartrate ................................................. 11
bethanechol chloride
...................................................................................................... 107
BUTRANS ......................................................................... 11
BETHKIS ............................................................................... 5 BYDUREON ................................................................... 24
BETIMOL .......................................................................... 93
BYETTA 10 MCG PEN
BETOPTIC-S .................................................................. 93 ......................................................................................................... 24
BEYAZ .................................................................................. 54 BYETTA 5 MCG PEN
BIAXIN ................................................................................. 85 ......................................................................................................... 24
BIAXIN XL ...................................................................... 85 BYSTOLIC ....................................................................... 49
BIAXIN XL PAC ....................................................... 85
cabergoline ........................................................................ 76
bicalutamide ..................................................................... 39 CADUET ............................................................................. 51
CAFCIT .................................................................................... 4
BIDIL ...................................................................................... 52
BILTRICIDE ................................................................... 12 CAFERGOT ..................................................................... 87
BINOSTO ........................................................................... 72 CALAN ................................................................................. 50
bisoprolol fumarate ................................................... 49 CALAN SR ....................................................................... 50
bisoprolol-hydrochlorothiazide
CALCIFEROL ........................................................... 109
......................................................................................................... 35
calcipotriene ..................................................................... 64
BLEPH-10 .......................................................................... 94 calcipotriene-betameth diprop
BLEPHAMIDE ............................................................. 94 ......................................................................................................... 66
BLEPHAMIDE S.O.P.
calcitonin (salmon) .................................................... 72
......................................................................................................... 94
CALCITRENE .............................................................. 64
BONIVA .............................................................................. 72 calcitriol ............................................................................... 64
BOSULIF ............................................................................ 40 calcium acetate .............................................................. 79
calcium acetate (phos binder)
bp 10-1 ................................................................................... 60
......................................................................................................... 79
BPROTECTED PEDIA D-VITE
CAMBIA ............................................................................. 87
...................................................................................................... 109
BPROTECTED PEDIA IRON
CAMPRAL ........................................................................ 98
......................................................................................................... 83
CAMRESE ........................................................................ 56
BRAVELLE ..................................................................... 73 CAMRESE LO .............................................................. 56
BREO ELLIPTA ......................................................... 15
CANASA ............................................................................. 78
BREVICON (28) ......................................................... 54 candesartan cilexetil ................................................ 33
briellyn ................................................................................... 54
candesartan cilexetil-hctz
BRILINTA ......................................................................... 81 ......................................................................................................... 35
brimonidine tartrate ................................................. 93
capecitabine ...................................................................... 38
BRINTELLIX ................................................................. 21 CAPEX .................................................................................. 65
BRISDELLE ................................................................. 102 CAPHOSOL ..................................................................... 89
CAPRELSA ...................................................................... 40
BROMFED DM ........................................................... 59
bromocriptine mesylate
captopril ............................................................................... 32
......................................................................................................... 42
captopril-hydrochlorothiazide
BROVANA ....................................................................... 15 ......................................................................................................... 34
BUDEPRION XL ....................................................... 20
CARAFATE ................................................................. 105
budesonide .......................................................................... 15 CARBAGLU ................................................................... 75
budesonide er .................................................................. 58
carbamazepine ............................................................... 18
bumetanide ......................................................................... 71 carbamazepine er ........................................................ 18
BUPHENYL .................................................................... 75
CARBATROL ................................................................ 18
buprenorphine hcl ....................................................... 11 carbidopa ............................................................................. 41
carbidopa-levodopa
42
buprenorphine
hcl-naloxone
hcl List - Three Tier
2015 Aetna Pharmacy
Plan Drug
Open Individual..................................................
Plan
CARDIOTEK RX ....................................................... 69
......................................................................................................... 11
CARDIZEM ..................................................................... 50
CARDIZEM CD .......................................................... 50
CARDIZEM LA ........................................................... 50
CARDURA ....................................................................... 33
CARDURA XL ............................................................. 80
carisoprodol ..................................................................... 91
carisoprodol-aspirin ................................................ 91
carteolol hcl ...................................................................... 93
CARTIA XT ..................................................................... 50
carvedilol ............................................................................. 49
CASODEX ........................................................................ 39
CATAFLAM ....................................................................... 7
CATAPRES ...................................................................... 33
CATAPRES-TTS-1 .................................................. 33
CATAPRES-TTS-2 .................................................. 33
CATAPRES-TTS-3 .................................................. 33
CAVERJECT .................................................................. 52
CAVERJECT IMPULSE
......................................................................................................... 52
CAYSTON ........................................................................ 36
CAZIANT ........................................................................... 56
CEDAX ................................................................................. 53
cefaclor .................................................................................. 53
cefaclor er ........................................................................... 53
cefadroxil ............................................................................. 53
cefdinir ................................................................................... 53
cefprozil ................................................................................. 53
CEFTIN ................................................................................. 53
cefuroxime axetil .......................................................... 53
CELEBREX ......................................................................... 6
CELEXA .............................................................................. 20
CELLCEPT ....................................................................... 48
CELONTIN ....................................................................... 19
CENESTIN ........................................................................ 77
cephalexin ........................................................................... 53
CEREFOLIN ................................................................... 69
CEREFOLIN NAC .................................................... 69
CERVIDIL ......................................................................... 97
CESAMET ......................................................................... 27
cetirizine hcl ..................................................................... 29
CETRAXAL .................................................................... 96
CETROTIDE ................................................................... 74
CHANTIX ....................................................................... 100
CHANTIX CONTINUING MONTH
PAK ....................................................................................... 100
CHANTIX STARTING MONTH PAK
...................................................................................................... 100
CHATEAL ......................................................................... 54
CHENODAL ................................................................... 78
cheratussin ac ................................................................. 59
childrens loratadine .................................................. 29
chlordiazepoxide hcl ................................................ 13
chlordiazepoxide-amitriptyline
......................................................................................................... 99
chlordiazepoxide-clidinium
...................................................................................................... 104
chloroquine phosphate
......................................................................................................... 37
chlorothiazide ................................................................. 72
chlorpromazine hcl .................................................... 44
chlorpropamide ............................................................. 26
chlorthalidone ................................................................. 72
chlorzoxazone ................................................................. 91
cholestyramine ............................................................... 30
113
............................................................................................................
chorionic gonadotropin
Index
Index
Index
choline-mag trisalicylate
clindamycin phos-benzoyl perox
8
.........................................................................................................
60
clindamycin phosphate
73 ......................................................................................................... 60
CIALIS .................................................................................. 52
CLINDESSE ................................................................. 109
CICLODAN CREAM
clobetasol propionate
......................................................................................................... 62
......................................................................................................... 65
CICLODAN SOLUTION
clobetasol propionate e
......................................................................................................... 62
......................................................................................................... 65
ciclopirox ............................................................................. 62 CLOBEX ............................................................................. 65
ciclopirox olamine ...................................................... 62 CLOBEX SPRAY ...................................................... 65
cilostazol .............................................................................. 81
CLODERM ....................................................................... 65
CILOXAN .......................................................................... 94 CLODERM PUMP .................................................... 65
cimetidine ......................................................................... 104 clomiphene citrate ...................................................... 73
cimetidine 200 ............................................................. 104
clomipramine hcl ......................................................... 22
cimetidine hcl ............................................................... 104 clonazepam ........................................................................ 17
CIMZIA ................................................................................ 79
clonidine hcl ..................................................................... 33
CIMZIA PREFILLED
clonidine hcl er ................................................................. 4
......................................................................................................... 79
clopidogrel bisulfate ................................................. 82
CIMZIA STARTER KIT
clorazepate dipotassium
......................................................................................................... 79
......................................................................................................... 13
CINRYZE ........................................................................... 81 CLORPRES ...................................................................... 34
CIPRO .................................................................................... 77
clotrimazole ....................................................................... 62
CIPRO HC ......................................................................... 96
clotrimazole af ................................................................ 62
CIPRO XR ......................................................................... 77
clotrimazole anti-fungal
CIPRODEX ....................................................................... 96 ......................................................................................................... 62
ciprofloxacin hcl ........................................................... 77 clozapine .............................................................................. 43
citalopram hydrobromide
CLOZARIL ....................................................................... 43
......................................................................................................... 20
CNL8 NAIL ...................................................................... 62
CITRANATAL 90 DHA
COARTEM ....................................................................... 37
......................................................................................................... 90
codeine sulfate ................................................................... 9
CITRANATAL ASSURE
COLAZAL ......................................................................... 78
......................................................................................................... 90
colchicine-probenecid
CITRANATAL B-CALM
......................................................................................................... 80
......................................................................................................... 90
COLCRYS ......................................................................... 81
CITRANATAL DHA
COLESTID ........................................................................ 30
......................................................................................................... 90
colestipol hcl .................................................................... 30
CITRANATAL HARMONY
COLY-MYCIN S ........................................................ 96
......................................................................................................... 90
COLYTE WITH FLAVOR PACKS
CITRANATAL RX .................................................. 90
......................................................................................................... 84
citric acid-sodium citrate
COMBIGAN .................................................................... 92
......................................................................................................... 79
COMBIPATCH ............................................................ 76
CLARAVIS ....................................................................... 61 COMBIVENT RESPIMAT
CLARIFOAM EF ....................................................... 60
......................................................................................................... 15
CLARINEX ...................................................................... 29
COMBIVIR ....................................................................... 45
CLARINEX-D 12 HOUR
COMETRIQ (100 MG DAILY DOSE)
......................................................................................................... 59
......................................................................................................... 40
clarithromycin ................................................................ 85
COMETRIQ (140 MG DAILY DOSE)
clarithromycin er ......................................................... 85 ......................................................................................................... 40
CLARITIN ......................................................................... 29 COMETRIQ (60 MG DAILY DOSE)
CLARITIN REDITABS
......................................................................................................... 40
......................................................................................................... 29
COMPAZINE ................................................................. 44
CLARITIN-D 12 HOUR
COMPLERA .................................................................... 45
......................................................................................................... 59
COMTAN ........................................................................... 42
CLARITIN-D 24 HOUR
CONCERTA ....................................................................... 4
......................................................................................................... 59
CONDYLOX ................................................................... 67
clemastine fumarate .................................................. 28 CONZIP ................................................................................... 9
CLEOCIN ........................................................................... 37 COPAXONE ................................................................ 100
CLEOCIN-T ..................................................................... 60 COPEGUS .......................................................................... 46
CLIMARA ......................................................................... 77
CORDARONE .............................................................. 14
CLIMARA PRO ........................................................... 76 CORDRAN ....................................................................... 65
CLINDACIN PAC ..................................................... 60 COREG ................................................................................. 49
CLINDAGEL .................................................................. 60 COREG CR ....................................................................... 49
clindamycin
hcl ..............................................................
37 Tier
CORGARD
.......................................................................
49
2015 Aetna Pharmacy
Plan Drug List - Three
Open Individual
Plan
CORTEF .............................................................................. 58
114
.........................................................................................................
CORTIFOAM ................................................................. 12
cortisone acetate .......................................................... 58
CORTISPORIN ............................................................ 97
CORTISPORIN-TC ................................................. 97
CORZIDE ........................................................................... 35
COSOPT .............................................................................. 92
COSOPT PF ..................................................................... 92
COUMADIN ................................................................... 16
COVARYX ....................................................................... 76
COVARYX HS ............................................................. 76
COZAAR ............................................................................. 33
CREON ................................................................................. 70
CRESTOR .......................................................................... 31
CRINONE ....................................................................... 109
CRIXIVAN ....................................................................... 45
cromolyn sodium .......................................................... 14
CRYSELLE-28 ............................................................. 54
CUPRIMINE ................................................................... 47
CUTIVATE ....................................................................... 65
CUVPOSA ..................................................................... 104
cvs allergy relief ........................................................... 29
cvs clotrimazole ............................................................ 62
cvs folic acid ..................................................................... 82
cvs heartburn relief ................................................ 104
cvs loratadine .................................................................. 29
cvs nicotine ..................................................................... 101
cvs omeprazole ........................................................... 105
cvs permethrin ................................................................ 68
cvs prenatal ....................................................................... 90
cyanocobalamin ............................................................ 82
CYCLAFEM 1/35 ...................................................... 54
CYCLESSA ...................................................................... 56
CYCLOBENZAPRINE COMFORT PAC
......................................................................................................... 91
cyclobenzaprine hcl .................................................. 91
CYCLOGYL .................................................................... 93
CYCLOMYDRIL ....................................................... 93
cyclopentolate hcl ....................................................... 53
cyclophosphamide ...................................................... 38
CYCLOSET ..................................................................... 24
cyclosporine ...................................................................... 48
cyclosporine modified
......................................................................................................... 48
CYMBALTA ................................................................... 21
cyproheptadine hcl ..................................................... 30
CYSTADANE ................................................................ 75
CYSTAGON .................................................................... 80
CYSTARAN .................................................................... 96
CYTOMEL .................................................................... 103
CYTOTEC ...................................................................... 106
CYTRA-3 ............................................................................ 79
cytra-k ..................................................................................... 79
d 400 ...................................................................................... 109
D.H.E. 45 ............................................................................. 87
d3-1000 .............................................................................. 110
DALIRESP ........................................................................ 14
danazol ................................................................................... 11
DANTRIUM .................................................................... 91
dantrolene sodium ...................................................... 91
dapsone .................................................................................. 37
DARAPRIM ..................................................................... 37
DASETTA 1/35 ............................................................ 54
DASETTA 7/7/7 .......................................................... 56
DAYPRO ................................................................................ 7
DAYSEE .............................................................................. 56
Index
Index
Index
DAYTRANA ...................................................................... 5 DIAMOX SEQUELS
DDAVP ................................................................................. 75 ......................................................................................................... 71
DIASTAT PEDIATRIC
DDAVP RHINAL TUBE
......................................................................................................... 17
......................................................................................................... 76
DELYLA ............................................................................. 54
diazepam .............................................................................. 13
DELZICOL ....................................................................... 78
DIBENZYLINE ............................................................ 33
DEMADEX ....................................................................... 71 DICLEGIS .......................................................................... 27
DEMEROL ........................................................................... 9 diclofenac potassium
DEMSER ............................................................................. 33 ............................................................................................................ 7
DENAVIR .......................................................................... 64 diclofenac sodium ........................................................... 7
DEPAKENE ..................................................................... 19 diclofenac sodium er ................................................... 7
DEPAKOTE ..................................................................... 19 diclofenac-misoprostol
DEPAKOTE ER ........................................................... 19 ............................................................................................................ 6
dicloxacillin sodium ........................................ 97, 98
DEPAKOTE SPRINKLES
dicyclomine hcl ........................................................... 104
......................................................................................................... 19
didanosine ........................................................................... 46
DEPEN TITRATABS
......................................................................................................... 48
DIDREX .................................................................................. 4
DEPLIN 15 ........................................................................ 69 diethylpropion hcl .......................................................... 4
DEPLIN 7.5 ...................................................................... 69
diethylpropion hcl er
DEPO-PROVERA ..................................................... 57
............................................................................................................ 4
DEPO-SUBQ PROVERA 104
DIFFERIN .......................................................................... 61
......................................................................................................... 58
DIFICID ................................................................................ 85
DERMANIC .................................................................... 69
DIFLUCAN ...................................................................... 28
DERMA-SMOOTHE/FS BODY
diflunisal .................................................................................. 8
......................................................................................................... 65
DIGOX .................................................................................. 51
DERMA-SMOOTHE/FS SCALP
digoxin .................................................................................... 51
......................................................................................................... 65
dihydroergotamine mesylate
DERMATOP ................................................................... 65
......................................................................................................... 87
DERMAZENE ............................................................... 62 DILANTIN ........................................................................ 19
desipramine hcl ............................................................. 22
DILANTIN INFATABS
desmopressin ace rhinal tube
......................................................................................................... 19
......................................................................................................... 76
DILATRATE-SR ........................................................ 12
desmopressin ace spray refrig
DILAUDID ........................................................................... 9
......................................................................................................... 76
diltiazem hcl ...................................................................... 50
desmopressin acetate
diltiazem hcl cd .............................................................. 50
......................................................................................................... 76
diltiazem hcl er .............................................................. 50
desmopressin acetate spray
diltiazem hcl er beads
......................................................................................................... 76
......................................................................................................... 50
DESOGEN ......................................................................... 54 diltiazem hcl er coated beads
desogestrel-ethinyl estradiol
......................................................................................................... 50
......................................................................................................... 54
DIOVAN .............................................................................. 33
DESONATE ..................................................................... 65 DIOVAN HCT ............................................................... 35
desonide ................................................................................ 65
DIPENTUM ...................................................................... 78
DESOWEN ....................................................................... 65
diphenatol ........................................................................... 26
DESOXYN ........................................................................... 3
diphenoxylate-atropine
desvenlafaxine er ......................................................... 21 ......................................................................................................... 26
desvenlafaxine fumarate er
DIPROLENE ................................................................... 65
......................................................................................................... 21
DIPROLENE AF ......................................................... 65
DETROL .......................................................................... 107
dipyridamole .................................................................... 81
DETROL LA ................................................................ 107 disopyramide phosphate
dexamethasone ............................................................... 58 ......................................................................................................... 13
dexamethasone sodium phosphate
disulfiram ............................................................................. 98
......................................................................................................... 95
DITROPAN XL ........................................................ 107
DEXEDRINE ..................................................................... 3 DIURIL ................................................................................. 72
DEXILANT ................................................................... 105 divalproex sodium ....................................................... 19
dexmethylphenidate hcl
divalproex sodium er
............................................................................................................ 5
......................................................................................................... 19
dexmethylphenidate hcl er
DIVIGEL ............................................................................. 77
............................................................................................................ 5
DOLOPHINE ..................................................................... 9
dextroamphetamine sulfate
donepezil hcl ..................................................................... 98
............................................................................................................ 3
DORAL ................................................................................. 83
dextroamphetamine sulfate er
DORYX ............................................................................. 102
............................................................................................................ 3
dorzolamide hcl ............................................................. 95
DIABETA
26 Tier
dorzolamide
hcl-timolol
mal
2015 Aetna...........................................................................
Pharmacy Plan Drug List - Three
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Plan
......................................................................................................... 92
DOVONEX ....................................................................... 64
doxazosin mesylate .................................................... 33
doxepin hcl ......................................................................... 22
doxercalciferol ............................................................... 75
doxycycline hyclate ................................................ 102
doxycycline monohydrate
...................................................................................................... 103
dronabinol .......................................................................... 27
drospirenone-ethinyl estradiol
......................................................................................................... 54
DRYSOL ............................................................................. 67
DUAC ..................................................................................... 60
DUAVEE ............................................................................. 77
DUETACT ......................................................................... 23
DUEXIS ................................................................................... 6
DULERA ............................................................................. 15
duloxetine hcl .................................................................. 21
DUONEB ............................................................................ 15
DURAGESIC-100 ......................................................... 9
DURAGESIC-12 ............................................................ 9
DURAGESIC-25 ............................................................ 9
DURAGESIC-50 ............................................................ 9
DURAGESIC-75 ............................................................ 9
DUREZOL ......................................................................... 95
DUTOPROL .................................................................... 35
D-VI-SOL ........................................................................ 110
DYAZIDE .......................................................................... 71
DYMISTA .......................................................................... 91
DYRENIUM .................................................................... 71
E.E.S. 400 ........................................................................... 85
E.E.S. GRANULES .................................................. 85
EC-NAPROSYN ............................................................. 7
econazole nitrate .......................................................... 62
ECOTRIN .............................................................................. 8
ECOZA .................................................................................. 62
EDARBI ............................................................................... 33
EDARBYCLOR ........................................................... 35
EDECRIN ........................................................................... 71
EDEX ...................................................................................... 52
EDLUAR ............................................................................. 83
EDURANT ........................................................................ 45
EEMT ...................................................................................... 76
EEMT HS ............................................................................ 76
EFFEXOR XR ............................................................... 21
EFFIENT ............................................................................. 82
EFUDEX .............................................................................. 63
EGRIFTA ............................................................................ 74
ELDEPRYL ...................................................................... 42
ELESTAT ........................................................................... 95
ELESTRIN ........................................................................ 77
ELIDEL ................................................................................. 67
ELIMITE ............................................................................. 68
ELINEST ............................................................................. 54
ELIPHOS ............................................................................. 79
ELIQUIS .............................................................................. 16
ELIXOPHYLLIN ....................................................... 16
ELMIRON .......................................................................... 80
ELOCON ............................................................................. 65
EMCYT ................................................................................. 39
EMEND ................................................................................ 27
EMLA ..................................................................................... 67
EMOQUETTE ............................................................... 54
EMSAM ............................................................................... 20
EMTRIVA .......................................................................... 46
ENABLEX ...................................................................... 107
115
Index
Index
Index
enalapril maleate ......................................................... 32 ESTRING ........................................................................ 109
enalapril-hydrochlorothiazide
ESTROGEL ...................................................................... 77
......................................................................................................... 34
estropipate .......................................................................... 77
ENBREL ................................................................................. 8
ESTROSTEP FE .......................................................... 56
ENJUVIA ............................................................................ 77 eszopiclone ......................................................................... 84
ENLYTE .............................................................................. 69 ethambutol hcl ................................................................ 38
enoxaparin sodium ..................................................... 17 ethosuximide ..................................................................... 19
ENPRESSE-28 .............................................................. 56
etodolac .................................................................................... 7
ENSKYCE ......................................................................... 54
etodolac er ............................................................................. 7
entacapone ......................................................................... 42
etoposide .............................................................................. 41
ENTERAGAM .............................................................. 70 EURAX ................................................................................. 68
ENTOCORT EC .......................................................... 58
EVAMIST .......................................................................... 77
EPANED .............................................................................. 32 EVISTA ................................................................................ 74
EPIDUO ................................................................................ 60 EVOCLIN ........................................................................... 60
EPIFLUR ............................................................................. 88 EVOXAC ............................................................................ 89
epinephrine ..................................................................... 109 EXALGO ................................................................................ 9
epinephrine hcl .............................................................. 16
EXELDERM .................................................................... 62
EPIPEN 2-PAK ......................................................... 109
EXELON ............................................................................. 98
EPIPEN JR 2-PAK ................................................. 109 exemestane ......................................................................... 39
EPIVIR .................................................................................. 46
EXFORGE ......................................................................... 34
EPIVIR HBV ................................................................... 46 EXFORGE HCT .......................................................... 35
EPOGEN .............................................................................. 82 EXJADE ............................................................................... 27
eprosartan mesylate .................................................. 33 EXTAVIA .......................................................................... 99
EPZICOM ........................................................................... 45 EXTINA ............................................................................... 62
eq allergy relief ............................................................. 29
FABIOR ............................................................................... 61
eq aspirin low dose ....................................................... 8
FACTIVE ............................................................................ 77
eq lansoprazole .......................................................... 105
FALLBACK SOLO .................................................. 57
eq nicotine ....................................................................... 101
FALMINA .......................................................................... 54
eq omeprazole .............................................................. 105 famciclovir .......................................................................... 47
eql allergy relief ............................................................ 29 famotidine ........................................................................ 104
eql childrens loratadine
FAMVIR .............................................................................. 47
......................................................................................................... 29
FANAPT .............................................................................. 43
eql folic acid ..................................................................... 82 FANAPT TITRATION PACK
eql nicotine ..................................................................... 101
......................................................................................................... 43
eql omeprazole ............................................................ 105 FARESTON ..................................................................... 39
EQUETRO ......................................................................... 43 FARXIGA .......................................................................... 26
ergoloid mesylates .................................................. 100
FAZACLO ......................................................................... 43
ERIVEDGE ....................................................................... 38 FC2 FEMALE CONDOM
ERRIN .................................................................................... 58 ......................................................................................................... 85
ERTACZO ......................................................................... 62
FELBATOL ...................................................................... 19
ERY-TAB ........................................................................... 85 FELDENE .............................................................................. 7
ERYTHROCIN STEARATE
felodipine er ...................................................................... 50
......................................................................................................... 85
FEM PH ............................................................................. 108
erythromycin .................................................................... 60
FEMARA ............................................................................ 39
erythromycin base ....................................................... 85 fematrol ................................................................................. 84
erythromycin ethylsuccinate
FEMCAP ............................................................................. 85
......................................................................................................... 85
FEMCON FE ................................................................... 54
erythromycin stearate
FEMHRT LOW DOSE
......................................................................................................... 85
......................................................................................................... 76
escitalopram oxalate
FEMRING ....................................................................... 109
......................................................................................................... 20
fenofibrate ........................................................................... 31
esomeprazole strontium
fenofibrate micronized
...................................................................................................... 105
......................................................................................................... 31
est estrogens-methyltest
fenofibric acid ................................................................. 31
......................................................................................................... 76
FENOGLIDE ................................................................... 31
est estrogens-methyltest ds
fenoprofen calcium ........................................................ 7
......................................................................................................... 76
fentanyl ...................................................................................... 9
est estrogens-methyltest hs
fentanyl citrate ................................................................... 9
......................................................................................................... 76
FENTORA ............................................................................. 9
ESTARYLLA ................................................................. 54 FER-IN-SOL .................................................................... 83
estazolam ............................................................................. 83
FERIVAFA ....................................................................... 83
ESTRACE .......................................................................... 77
FERRIPROX ................................................................... 27
estradiol ................................................................................ 77
FETZIMA ........................................................................... 21
estradiol-norethindrone
acetDrug List - Three Tier
FETZIMA
TITRATION
2015 Aetna Pharmacy Plan
Open Individual
Plan
......................................................................................................... 76
......................................................................................................... 21
116
FIBRICOR ......................................................................... 31
FINACEA ........................................................................... 68
finasteride ........................................................................... 80
FIORINAL ............................................................................ 8
FIORINAL/CODEINE #3
......................................................................................................... 10
FIRAZYR ........................................................................... 81
FIRST-LANSOPRAZOLE
...................................................................................................... 105
FIRST-OMEPRAZOLE
...................................................................................................... 105
FLAGYL .............................................................................. 36
FLAGYL ER ................................................................... 36
flavoxate hcl .................................................................. 107
flecainide acetate ......................................................... 14
FLECTOR .......................................................................... 63
FLOMAX ............................................................................ 80
FLONASE .......................................................................... 92
FLOVENT DISKUS
......................................................................................................... 15
FLOVENT HFA ........................................................... 15
FLUARIX ........................................................................ 108
FLUARIX QUADRIVALENT
...................................................................................................... 108
FLUBLOK ...................................................................... 108
fluconazole ......................................................................... 28
fludrocortisone acetate
......................................................................................................... 58
FLULAVAL ................................................................. 108
FLULAVAL QUADRIVALENT
...................................................................................................... 108
FLUMADINE ................................................................. 47
flunisolide ............................................................................ 92
fluocinolone acetonide body
......................................................................................................... 65
fluocinolone acetonide scalp
......................................................................................................... 65
fluocinonide ....................................................................... 65
fluocinonide-e ................................................................. 65
FLUORABON ............................................................... 88
FLUOR-A-DAY .......................................................... 88
fluorometholone ............................................................ 95
FLUOROPLEX ............................................................. 63
fluorouracil ........................................................................ 63
fluoxetine hcl .................................................................... 20
fluoxetine hcl (pmdd)
...................................................................................................... 100
fluphenazine hcl ............................................................ 44
FLURA-DROPS .......................................................... 88
flurazepam hcl ................................................................ 83
flurbiprofen ........................................................................... 7
flurbiprofen sodium ................................................... 96
flutamide ............................................................................... 39
fluticasone propionate
......................................................................................................... 65
fluvastatin sodium ....................................................... 31
FLUVIRIN ...................................................................... 108
FLUVIRIN PRESERVATIVE FREE
...................................................................................................... 108
fluvoxamine maleate ................................................. 20
fluvoxamine maleate er
......................................................................................................... 20
FLUZONE ...................................................................... 108
FLUZONE PEDIATRIC PF
...................................................................................................... 108
GENGRAF ........................................................................ 48
108 GENOTROPIN ............................................................. 74
FML .......................................................................................... 95
GENOTROPIN MINIQUICK
FML FORTE ................................................................... 95
......................................................................................................... 74
FML LIQUIFILM ....................................................... 95 gentamicin sulfate ....................................................... 62
FOCALIN .............................................................................. 5
GEODON ............................................................................ 43
FOCALIN XR ................................................................... 5
GIANVI ................................................................................ 54
FOLBEE AR .................................................................... 69 GIAZO ................................................................................... 78
FOLBIC ................................................................................ 69
GILDAGIA ....................................................................... 54
FOLBIC RF ...................................................................... 69
GILDESS FE 1.5/30 ................................................. 54
folic acid ............................................................................... 82 GILDESS FE 1/20 ...................................................... 54
FOLLISTIM AQ .......................................................... 73 GILENYA ....................................................................... 100
FOLTANX ......................................................................... 69 GILOTRIF .......................................................................... 40
FOLTANX RF ............................................................... 69 GLASPAK TB SYRINGE
FOLTX .................................................................................. 69
......................................................................................................... 87
fondaparinux sodium
GLEEVEC .......................................................................... 40
......................................................................................................... 17
glimepiride ......................................................................... 26
FORADIL AEROLIZER
glipizide ................................................................................. 26
......................................................................................................... 15
glipizide er .......................................................................... 26
FORFIVO XL ................................................................. 20 GLIPIZIDE XL ............................................................. 26
FORTAMET .................................................................... 23 glipizide-metformin hcl
FORTEO .............................................................................. 72 ......................................................................................................... 23
FORTESTA ...................................................................... 11
GLUCAGEN ................................................................... 24
FORTICAL ....................................................................... 72
GLUCAGEN HYPOKIT
FOSAMAX ....................................................................... 72
......................................................................................................... 24
GLUCAGON EMERGENCY
FOSAMAX PLUS D
......................................................................................................... 24
......................................................................................................... 72
fosinopril sodium ......................................................... 32 GLUCOPHAGE ........................................................... 23
fosinopril sodium-hctz
GLUCOPHAGE XR
......................................................................................................... 34
......................................................................................................... 23
FOSRENOL ..................................................................... 79
GLUCOTROL ................................................................ 26
FOSTEUM ......................................................................... 69 GLUCOTROL XL ..................................................... 26
FOSTEUM PLUS ....................................................... 69 GLUCOVANCE .......................................................... 23
FOVEX .................................................................................. 69 GLUMETZA ................................................................... 24
FRAGMIN ......................................................................... 17
glyburide .............................................................................. 26
FREESTYLE INSULINX TEST
glyburide micronized
......................................................................................................... 68
......................................................................................................... 26
FREESTYLE LITE TEST
glyburide-metformin ................................................. 23
......................................................................................................... 68
GLYNASE ......................................................................... 26
FREESTYLE TEST ................................................. 68
GLYSET .............................................................................. 22
FROVA ................................................................................. 87
gnp allergy relief .......................................................... 29
FULYZAQ ......................................................................... 26 gnp folic acid ................................................................... 82
FURADANTIN ......................................................... 106
gnp heartburn relief ............................................... 104
furosemide .......................................................................... 71
gnp loratadine ................................................................ 29
FUZEON .............................................................................. 45 gnp loratadine childrens
FYCOMPA ........................................................................ 17 ......................................................................................................... 29
GABADONE ................................................................... 69 gnp niacin tr .................................................................. 110
gabapentin .......................................................................... 18 gnp omeprazole .......................................................... 105
GABITRIL ......................................................................... 19 gnp vitamin d ................................................................ 110
GOLYTELY .................................................................... 84
galantamine hydrobromide
......................................................................................................... 98
GONAL-F ........................................................................... 73
galantamine hydrobromide er
GONAL-F RFF ............................................................. 73
......................................................................................................... 98
GONAL-F RFF PEN
GAMMAGARD ........................................................... 97 ......................................................................................................... 73
GAMMAKED ................................................................ 97 GONAL-F RFF REDIJECT
GAMUNEX-C ............................................................... 97
......................................................................................................... 73
ganirelix acetate ........................................................... 74 GRALISE ........................................................................ 100
GARAMYCIN ............................................................... 94 GRALISE STARTER
gatifloxacin ........................................................................ 94 ...................................................................................................... 100
GATTEX ............................................................................. 79
GRANIX .............................................................................. 82
gavilax .................................................................................... 84
GRANULEX ................................................................... 67
GELCLAIR ....................................................................... 89 GRIFULVIN V .............................................................. 27
GELNIQUE ................................................................... 107 griseofulvin microsize
.........................................................................................................
28
gemfibrozil
31 Tier
2015 Aetna ..........................................................................
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GENERESS FE ............................................................. 54
Index
Index
Index
FLUZONE QUADRIVALENT
griseofulvin ultramicrosize
......................................................................................................
.........................................................................................................
28
GRIS-PEG .......................................................................... 28
guaifenesin-codeine .................................................. 59
guanfacine hcl ................................................................. 33
GYNAZOLE-1 ........................................................... 109
HALCION .......................................................................... 83
HALFPRIN ........................................................................... 9
halobetasol propionate
......................................................................................................... 65
HALOG ................................................................................. 65
HALONATE .................................................................... 66
HALONATE PAC ..................................................... 66
haloperidol ......................................................................... 43
haloperidol lactate ..................................................... 43
HECORIA .......................................................................... 48
HECTOROL .................................................................... 75
HEMANGEOL .............................................................. 49
heparin sodium (porcine)
......................................................................................................... 16
HEPSERA .......................................................................... 46
HETLIOZ ............................................................................ 84
HEXALEN ........................................................................ 38
HIPREX ............................................................................. 106
HIZENTRA ....................................................................... 97
HIZENTRA 20% ......................................................... 97
hm allergy relief ............................................................ 29
hm famotidine .............................................................. 104
hm folic acid ..................................................................... 82
hm loratadine childrens
......................................................................................................... 29
hm niacin .......................................................................... 110
hm nicotine ..................................................................... 101
hm omeprazole ............................................................ 105
HUMALOG ...................................................................... 25
HUMALOG KWIKPEN
......................................................................................................... 25
HUMALOG MIX 50/50
......................................................................................................... 25
HUMALOG MIX 50/50 KWIKPEN
......................................................................................................... 25
HUMALOG MIX 75/25
......................................................................................................... 25
HUMALOG MIX 75/25 KWIKPEN
......................................................................................................... 25
HUMATROPE .............................................................. 74
HUMIRA ................................................................................ 6
HUMIRA PEN .................................................................. 6
HUMIRA PEN-CROHNS STARTER
............................................................................................................ 6
HUMIRA PEN-PSORIASIS STARTER
............................................................................................................ 6
HUMULIN 70/30 ........................................................ 25
HUMULIN 70/30 KWIKPEN
......................................................................................................... 25
HUMULIN N .................................................................. 25
HUMULIN N KWIKPEN
......................................................................................................... 25
HUMULIN R .................................................................. 25
HUMULIN R U-500
(CONCENTRATED)
......................................................................................................... 25
HYCAMTIN .................................................................... 41
hydralazine hcl ............................................................... 36
HYDREA ............................................................................ 41
117
Index
Index
Index
hydrochlorothiazide .................................................. 72 INTROVALE .................................................................. 56
hydrocodone-acetaminophen
INTUNIV ................................................................................ 4
......................................................................................................... 10
INVEGA .............................................................................. 43
hydrocodone-homatropine
INVIRASE ......................................................................... 45
......................................................................................................... 59
INVOKAMET ................................................................ 23
hydrocodone-ibuprofen
INVOKANA .................................................................... 26
......................................................................................................... 10
IOPIDINE ........................................................................... 93
hydrocortisone ................................................................ 12 ipratropium bromide
hydrocortisone ace-pramoxine
......................................................................................................... 14
......................................................................................................... 66
ipratropium-albuterol
hydrocortisone butyr lipo base
......................................................................................................... 15
......................................................................................................... 65
IPRIVASK ......................................................................... 17
hydrocortisone butyrate
irbesartan ............................................................................ 33
......................................................................................................... 65
irbesartan-hydrochlorothiazide
hydrocortisone valerate
......................................................................................................... 35
......................................................................................................... 66
ISENTRESS ..................................................................... 45
hydrocortisone-acetic acid
isometheptene-apap-dichloral
......................................................................................................... 97
......................................................................................................... 87
hydrocortisone-iodoquinol
isoniazid ................................................................................ 38
......................................................................................................... 62
ISOPTO ATROPINE
hydromorphone hcl ....................................................... 9 ......................................................................................................... 93
hydroxychloroquine sulfate
ISOPTO CARBACHOL
......................................................................................................... 37
......................................................................................................... 93
hydroxyurea ...................................................................... 41
ISOPTO CARPINE .................................................. 93
hydroxyzine hcl .............................................................. 13 ISOPTO HYOSCINE
hydroxyzine pamoate
......................................................................................................... 93
......................................................................................................... 13
ISORDIL TITRADOSE
HYLATOPIC .................................................................. 66
......................................................................................................... 12
hyoscyamine sulfate ............................................... 104 isosorbide dinitrate .................................................... 12
HYPERRHO S/D ........................................................ 97 isosorbide dinitrate er
HYPERTENSA ............................................................. 69 ......................................................................................................... 12
HYZAAR ............................................................................ 35
isosorbide mononitrate
ibandronate sodium .................................................. 72
......................................................................................................... 12
ibuprofen ................................................................................. 7
isosorbide mononitrate er
IBUPROFEN COMFORT PAC
......................................................................................................... 12
............................................................................................................ 7
isoxsuprine hcl ............................................................... 52
IC 400 ......................................................................................... 6 itraconazole ....................................................................... 28
IC 800 ......................................................................................... 6 JAKAFI ................................................................................. 40
ICAR-C PLUS ............................................................... 83
JALYN ................................................................................... 80
ICLUSIG .............................................................................. 40 JANUMET ......................................................................... 22
ILARIS ...................................................................................... 6 JANUMET XR .............................................................. 23
ILOTYCIN ........................................................................ 94
JANUVIA ........................................................................... 24
IMBRUVICA .................................................................. 40 JENCYCLA ...................................................................... 58
IMDUR .................................................................................. 12 JENTADUETO ............................................................. 23
imipramine hcl ............................................................... 22
JINTELI ................................................................................ 76
imipramine pamoate ................................................. 22 JOLESSA ............................................................................ 56
imiquimod ........................................................................... 67
JOLIVETTE ..................................................................... 58
IMITREX .................................................................. 87, 88
JUNEL 1.5/30 ................................................................. 54
IMITREX STATDOSE REFILL
JUNEL 1/20 ...................................................................... 54
......................................................................................................... 88
JUNEL FE 1.5/30 ........................................................ 54
IMPLANON ..................................................................... 57 JUNEL FE 1/20 ............................................................. 54
IMURAN ............................................................................. 48 JUXTAPID ........................................................................ 32
INCIVEK ............................................................................. 46 KADIAN ................................................................................. 9
INCRELEX ....................................................................... 75 KALETRA ......................................................................... 45
indapamide ........................................................................ 72
KALYDECO ................................................................ 102
INDERAL LA ................................................................ 49 KAPVAY ................................................................................ 4
INDOCIN ............................................................................... 7 KARBINAL ER ........................................................... 28
indomethacin ....................................................................... 7 KARIVA .............................................................................. 53
indomethacin er ................................................................ 7 KAYEXALATE ........................................................... 48
INLYTA ............................................................................... 40 KAZANO ............................................................................ 23
INNOPRAN XL ........................................................... 49 KEFLEX .............................................................................. 53
INSPRA ................................................................................ 36
KELNOR 1/35 ............................................................... 54
INTELENCE ................................................................... 45
KENALOG ........................................................................ 66
INTERMEZZO
.............................................................
84
KEPPRA
18
2015 Aetna Pharmacy
Plan Drug List - Three
Tier
Open..............................................................................
Individual Plan
INTRON-A ........................................................................ 41 KEPPRA XR ................................................................... 18
118
KETEK .................................................................................. 37
ketoconazole ..................................................................... 28
KETODAN ........................................................................ 63
ketoprofen ............................................................................... 7
ketoprofen er ........................................................................ 7
ketorolac tromethamine
............................................................................................................ 7
KHEDEZLA .................................................................... 21
KIONEX .............................................................................. 48
KLARON ............................................................................ 60
KLONOPIN ...................................................................... 17
kls omeprazole ............................................................ 105
KOMBIGLYZE XR ................................................. 23
KORLYM ........................................................................... 24
kp cetirizine hcl ............................................................. 29
kp clotrimazole ............................................................... 63
kp folic acid ....................................................................... 82
kp loratadine .................................................................... 29
K-PHOS-NEUTRAL
......................................................................................................... 88
KRISTALOSE ............................................................... 84
KURVELO ........................................................................ 54
KUVAN ................................................................................ 75
labetalol hcl ...................................................................... 49
LAC-HYDRIN .............................................................. 66
LACRISERT .................................................................... 92
lactulose ................................................................................ 84
lactulose encephalopathy
......................................................................................................... 79
LAMICTAL ...................................................................... 18
LAMICTAL ODT ...................................................... 18
LAMICTAL XR ........................................................... 18
LAMISIL ............................................................................. 28
lamivudine .......................................................................... 46
lamivudine-zidovudine
......................................................................................................... 45
lamotrigine ......................................................................... 18
lamotrigine er .................................................................. 18
LANOXIN .......................................................................... 51
LANOXIN PEDIATRIC
......................................................................................................... 51
lansoprazole .................................................................. 105
LANTUS .............................................................................. 25
LANTUS SOLOSTAR
......................................................................................................... 25
LARIN 1.5/30 ................................................................. 54
LARIN 1/20 ...................................................................... 54
LARIN FE 1.5/30 ........................................................ 54
LARIN FE 1/20 ............................................................. 54
LASIX .................................................................................... 71
LASTACAFT ................................................................. 95
latanoprost ......................................................................... 96
LATUDA ............................................................................. 43
LAZANDA ........................................................................... 9
LEENA .................................................................................. 56
leflunomide ............................................................................ 8
LESCOL ............................................................................... 31
LESCOL XL .................................................................... 31
LESSINA ............................................................................. 54
LETAIRIS .......................................................................... 52
letrozole ................................................................................. 39
leucovorin calcium ..................................................... 41
LEUKERAN .................................................................... 38
LEUKINE ........................................................................... 83
leuprolide acetate ........................................................ 39
Index
Index
Index
levalbuterol hcl .............................................................. 15 l-methylfolate formula 7.5
LEVAQUIN ...................................................................... 77 ......................................................................................................... 69
l-methylfolate forte ..................................................... 69
LEVEMIR .......................................................................... 25
LEVEMIR FLEXPEN
l-methylfolate-algae-b12-b6
......................................................................................................... 25
......................................................................................................... 69
LEVEMIR FLEXTOUCH
l-methylfolate-b6-b12
......................................................................................................... 25
......................................................................................................... 69
levetiracetam .................................................................... 18 l-methyl-mc ........................................................................ 69
levetiracetam er ............................................................ 18
l-methyl-mc nac ............................................................. 69
LEVITRA ........................................................................... 52
LO LOESTRIN FE .................................................... 53
levobunolol hcl ............................................................... 93 LOCOID ............................................................................... 66
levocetirizine dihydrochloride
LOCOID LIPOCREAM
......................................................................................................... 29
......................................................................................................... 66
levofloxacin ....................................................................... 77
LODOSYN ........................................................................ 41
levomefolate dha .......................................................... 90
LOESTRIN 1.5/30 (21)
LEVONEST ...................................................................... 57 ......................................................................................................... 55
LOESTRIN 1/20 (21)
levonorgest-eth estrad 91-day
......................................................................................................... 55
......................................................................................................... 56
levonorgestrel ................................................................. 57
LOESTRIN FE 1.5/30
levonorgestrel-ethinyl estrad
......................................................................................................... 55
............................................................................................... 54, 55
LOESTRIN FE 1/20 ................................................. 55
LEVORA 0.15/30 (28)
LOFIBRA ........................................................................... 31
......................................................................................................... 55
LOMOTIL .......................................................................... 26
levothyroxine sodium
lomustine .............................................................................. 38
...................................................................................................... 103
LOPID .................................................................................... 31
LEVOXYL ..................................................................... 103 LOPRESSOR HCT ................................................... 35
LEVSIN ............................................................................. 104 LOPROX ............................................................................. 62
LEVULAN KERASTICK
loratadine ............................................................................ 29
......................................................................................................... 63
loratadine allergy relief
LEXAPRO ......................................................................... 21
......................................................................................................... 29
LEXIVA ............................................................................... 45 loratadine childrens .................................................. 29
LIALDA ............................................................................... 78 loratadine hives relief
LIBRAX ............................................................................ 104 ......................................................................................................... 29
lidocaine ............................................................................... 67 lorazepam ............................................................................ 13
lidocaine viscous .......................................................... 89 LORYNA ............................................................................ 55
lidocaine-hydrocortisone ace
LORZONE ......................................................................... 91
......................................................................................................... 12
losartan potassium ..................................................... 33
lidocaine-prilocaine .................................................. 67 losartan potassium-hctz
LIDODERM ..................................................................... 67 ......................................................................................................... 35
lidorx ........................................................................................ 67 LOSEASONIQUE ..................................................... 56
LIMBREL ........................................................................... 70 LOTEMAX ....................................................................... 95
LIMBREL250 ................................................................. 70 LOTENSIN ....................................................................... 32
LIMBREL500 ................................................................. 70 LOTREL .............................................................................. 34
lindane .................................................................................... 68 LOTRISONE ................................................................... 62
LINZESS ............................................................................. 79
LOTRONEX .................................................................... 79
LIORESAL ........................................................................ 91 lovastatin .............................................................................. 31
liothyronine sodium ............................................... 103 LOVAZA ............................................................................. 30
LIPICHOL 540 .............................................................. 70 LOVENOX ........................................................................ 17
LIPITOR .............................................................................. 31
LOW-OGESTREL .................................................... 55
LIPOFEN ............................................................................. 31 loxapine succinate ...................................................... 44
LIPTRUZET .................................................................... 30
LUFYLLIN ....................................................................... 16
LUKAID GLA ............................................................... 70
lisinopril ............................................................................... 32
lisinopril-hydrochlorothiazide
LUMIGAN ........................................................................ 96
......................................................................................................... 34
LUNESTA .......................................................................... 84
LISTER-V .......................................................................... 70
LURIDE ................................................................................ 88
lithium carbonate ........................................................ 43
LUTERA .............................................................................. 55
lithium carbonate er ................................................. 43 LUVOX CR ...................................................................... 21
LITHOBID ........................................................................ 43
LUXIQ ................................................................................... 66
LIVALO ............................................................................... 31 LUZU ...................................................................................... 63
l-methylfolate ................................................................... 70 LYRICA ............................................................................... 18
l-methylfolate ca me-cbl nac
LYSODREN .................................................................... 39
......................................................................................................... 69
LYSTEDA .......................................................................... 83
l-methylfolate formula 15
LYZA ...................................................................................... 58
.........................................................................................................
69 Tier
MACROBID
.................................................................
106
2015 Aetna Pharmacy Plan Drug List - Three
Open Individual
Plan
MACRODANTIN ................................................... 106
MACUTEK ....................................................................... 70
MALARONE .................................................................. 37
maprotiline hcl ............................................................... 20
MARINOL ......................................................................... 27
marlissa ................................................................................. 55
MATULANE ................................................................... 41
MATZIM LA .................................................................. 50
MAVIK ................................................................................. 32
MAXALT ........................................................................... 88
MAXALT-MLT ........................................................... 88
MAXITROL ..................................................................... 94
MAXZIDE ......................................................................... 71
MAXZIDE-25 ................................................................ 71
meclofenamate sodium
............................................................................................................ 7
MEDROL ............................................................................ 58
MEDROL (PAK) ........................................................ 58
medroxyprogesterone acetate
......................................................................................................... 58
MEGACE ES .................................................................. 98
MEGACE ORAL ........................................................ 39
megestrol acetate ......................................................... 39
meijer allergy relief ................................................... 29
MEKINIST ........................................................................ 40
meloxicam .............................................................................. 7
MELOXICAM COMFORT PAC
............................................................................................................ 7
MENEST ............................................................................. 77
MENOPUR ....................................................................... 73
MENOSTAR ................................................................... 77
MENTAX ........................................................................... 62
meperidine hcl ................................................................... 9
meperitab ................................................................................ 9
MEPHYTON ................................................................ 110
MEPRON ............................................................................ 37
mercaptopurine ............................................................. 38
mesalamine ........................................................................ 78
MESTINON ...................................................................... 37
METADATE CD ............................................................ 5
METADATE ER ............................................................ 5
METAFOLBIC ............................................................. 70
METAFOLBIC PLUS
......................................................................................................... 70
METAFOLBIC PLUS RF
......................................................................................................... 70
METANX ........................................................................... 70
metaproterenol sulfate
......................................................................................................... 16
metaxalone ......................................................................... 91
metformin hcl ................................................................... 24
metformin hcl er ............................................................ 24
metformin hcl er (osm)
......................................................................................................... 24
methadone hcl .................................................................... 9
METHADOSE .................................................................. 9
methamphetamine hcl
............................................................................................................ 3
methazolamide ................................................................ 71
methenamine hippurate
...................................................................................................... 106
methenamine mandelate
...................................................................................................... 106
methimazole ................................................................... 103
methocarbamol .............................................................. 91
methotrexate ..................................................................... 38
119
Index
Index
Index
methotrexate sodium ................................................ 38
minocycline hcl er ................................................... 103
methotrexate sodium (pf)
minoxidil ............................................................................... 36
......................................................................................................... 38
MIRALAX ......................................................................... 84
methoxsalen rapid ....................................................... 64 MIRAPEX .......................................................................... 42
methyldopa ......................................................................... 33 MIRAPEX ER ................................................................ 42
methyldopa-hydrochlorothiazide
MIRCETTE ....................................................................... 53
......................................................................................................... 34
MIRENA .............................................................................. 58
methylergonovine maleate
mirtazapine ........................................................................ 20
......................................................................................................... 97
MIRVASO ......................................................................... 68
METHYLIN ........................................................................ 5
misoprostol ..................................................................... 106
methylphenidate hcl ..................................................... 5
MOBIC ..................................................................................... 7
methylphenidate hcl er
modafinil .................................................................................. 5
............................................................................................................ 5
MODERIBA .................................................................... 46
methylphenidate hcl er (cd)
MODERIBA 1200 DOSE PACK
............................................................................................................ 5
......................................................................................................... 46
methylphenidate hcl er (la)
MODERIBA 800 DOSE PACK
............................................................................................................ 5
......................................................................................................... 46
methylprednisolone ................................................... 58
MODICON (28) ........................................................... 55
methylprednisolone (pak)
moexipril hcl ..................................................................... 32
......................................................................................................... 58
moexipril-hydrochlorothiazide
methyltest-est estrogens
......................................................................................................... 34
......................................................................................................... 76
mometasone furoate .................................................. 66
methyltest-est estrogens hs
MONODOX .................................................................. 103
......................................................................................................... 76
MONO-LINYAH ........................................................ 55
metipranolol ..................................................................... 93
MONONESSA .............................................................. 55
metoclopramide hcl ................................................... 78 montelukast sodium ................................................... 14
metolazone .......................................................................... 72 MORGIDOX ................................................................ 103
metoprolol succinate er
morphine sulfate .............................................................. 9
......................................................................................................... 49
morphine sulfate er ....................................................... 9
metoprolol tartrate ..................................................... 49 morphine sulfate er beads
metoprolol-hydrochlorothiazide
............................................................................................................ 9
......................................................................................................... 35
MOTOFEN ........................................................................ 26
METOZOLV ODT .................................................... 78 MOVIPREP ...................................................................... 84
METROCREAM ......................................................... 68 MOXEZA ........................................................................... 94
METROGEL .................................................................... 68 moxifloxacin hcl ............................................................ 77
METROGEL-VAGINAL
MS CONTIN ....................................................................... 9
...................................................................................................... 109
MULTAQ ........................................................................... 14
METROLOTION ........................................................ 68 mupirocin ............................................................................. 62
metronidazole .................................................................. 36 mupirocin calcium ...................................................... 62
MEVACOR ....................................................................... 31 MUSE ..................................................................................... 52
mexiletine hcl ................................................................... 13 MYAMBUTOL ............................................................ 38
MIACALCIN .................................................................. 72
MYCOBUTIN ................................................................ 38
MICARDIS ....................................................................... 33
mycophenolate mofetil
MICARDIS HCT ........................................................ 35
......................................................................................................... 48
miconazole 3 ................................................................. 109
mycophenolic acid ...................................................... 48
MICROCHAMBER ................................................. 87 MYFORTIC ..................................................................... 48
MICROGESTIN 1.5/30
MYLERAN ....................................................................... 38
......................................................................................................... 55
MYNATAL ....................................................................... 90
MICROGESTIN 1/20
MYORISAN .................................................................... 61
......................................................................................................... 55
MYRBETRIQ ............................................................. 107
MICROGESTIN FE 1.5/30
MYSOLINE ...................................................................... 18
......................................................................................................... 55
nabumetone ........................................................................... 7
MICROGESTIN FE 1/20
nadolol .................................................................................... 49
......................................................................................................... 55
NAFTIN ................................................................................ 62
micronized colestipol hcl
NALFON ................................................................................ 7
......................................................................................................... 30
naltrexone hcl .................................................................. 27
MICROZIDE ................................................................... 72 NAMENDA ...................................................................... 98
midodrine hcl ............................................................... 109
NAMENDA XR ........................................................... 98
MIGRANAL .................................................................... 87 NAMENDA XR TITRATION PACK
MIMVEY ............................................................................ 76
......................................................................................................... 99
MINASTRIN 24 FE ................................................. 55 NAPRELAN ........................................................................ 7
MINIPRESS ..................................................................... 34 NAPROSYN ....................................................................... 7
MINITRAN ....................................................................... 12 naproxen .................................................................................. 7
MINOCIN
NAPROXEN
COMFORT
2015 Aetna.......................................................................
Pharmacy Plan Drug List -103
Three Tier
Open Individual
Plan PAC
minocycline hcl ........................................................... 103 ............................................................................................................ 7
120
naproxen sodium ............................................................. 7
naratriptan hcl ............................................................... 88
NARDIL ............................................................................... 20
NASACORT ALLERGY 24HR
......................................................................................................... 92
NASONEX ........................................................................ 92
NATACYN ....................................................................... 94
NATAZIA .......................................................................... 56
nateglinide .......................................................................... 25
NATROBA ........................................................................ 68
NATURE-THROID .............................................. 103
NEBUPENT ..................................................................... 36
NEBUSAL ......................................................................... 60
NECON 0.5/35 (28) .................................................. 55
NECON 1/35 (28) ....................................................... 55
NECON 1/50 (28) ....................................................... 55
NECON 10/11 (28) ................................................... 54
NECON 7/7/7 .................................................................. 57
NEEVO DHA ................................................................. 90
nefazodone hcl ................................................................ 21
neomycin sulfate .............................................................. 5
neomycin-polymyxin-dexameth
............................................................................................... 94, 95
NEORAL ............................................................................. 48
NEOSPORIN ................................................................... 94
NEPTAZANE ................................................................. 71
NESINA ................................................................................ 24
NESTABS .......................................................................... 90
NEULASTA ..................................................................... 82
NEUPOGEN .................................................................... 82
NEUPRO ............................................................................. 42
NEURONTIN ................................................................. 18
NEVANAC ....................................................................... 96
nevirapine ........................................................................... 45
nevirapine er .................................................................... 45
NEXAVAR ....................................................................... 40
NEXIUM .......................................................................... 105
NEXPLANON ............................................................... 57
NEXT CHOICE ............................................................ 57
NEXT CHOICE ONE DOSE
......................................................................................................... 57
niacin er ............................................................................. 110
niacin er (antihyperlipidemic)
......................................................................................................... 32
NIASPAN ........................................................................... 32
NICADAN ......................................................................... 89
nicardipine hcl ............................................................... 50
NICODERM CQ ...................................................... 101
NICOMIDE ....................................................................... 91
NICORELIEF .............................................................. 101
NICORETTE ................................................................ 101
NICORETTE MINI ............................................... 101
NICORETTE STARTER KIT
...................................................................................................... 101
nicotine ............................................................................... 101
nicotine step 1 .............................................................. 101
nicotine step 2 .............................................................. 101
nicotine step 3 .............................................................. 101
NICOTROL ................................................................... 101
NICOTROL NS ......................................................... 101
NIFEDICAL XL .......................................................... 50
nifedipine ............................................................................. 50
nifedipine er ...................................................................... 50
nifedipine er osmotic
......................................................................................................... 51
Index
Index
Index
NILANDRON ................................................................ 39
NOXAFIL ........................................................................... 28
nimodipine .......................................................................... 51 np thyroid ......................................................................... 103
nisoldipine er ................................................................... 51 NUCYNTA ........................................................................... 9
NITRO-BID ...................................................................... 12 NUCYNTA ER ............................................................. 10
NITRO-DUR ................................................................... 12
NUEDEXTA ................................................................ 100
nitrofurantoin ............................................................... 106 NULYTELY WITH FLAVOR PACKS
nitrofurantoin macrocrystal
......................................................................................................... 84
...................................................................................................... 106
NUTROPIN AQ NUSPIN 10
nitrofurantoin monohyd macro
......................................................................................................... 74
...................................................................................................... 106
NUTROPIN AQ NUSPIN 20
nitroglycerin ..................................................................... 13 ......................................................................................................... 74
nitroglycerin er .............................................................. 13 NUTROPIN AQ NUSPIN 5
NITROLINGUAL ...................................................... 13 ......................................................................................................... 74
NITROMIST .................................................................... 13 NUTROPIN AQ PEN
NITROSTAT ................................................................... 13 ......................................................................................................... 74
NITRO-TIME ................................................................. 13 NUVARING .................................................................... 57
NUVIGIL ................................................................................ 5
nizatidine .......................................................................... 104
NORA-BE .......................................................................... 58
NYMALIZE ..................................................................... 51
NORDITROPIN FLEXPRO
nystatin ................................................................................... 28
......................................................................................................... 74
nystatin-triamcinolone
NORDITROPIN NORDIFLEX PEN
......................................................................................................... 62
......................................................................................................... 74
OBTREX ............................................................................. 90
norethindrone .................................................................. 58 O-CAL PRENATAL
norgestimate-eth estradiol
......................................................................................................... 90
......................................................................................................... 55
OCELLA .............................................................................. 55
norgestim-eth estrad triphasic
octreotide acetate ........................................................ 76
......................................................................................................... 57
OCUDOX ........................................................................ 103
norgestrel-ethinyl estradiol
OCUFEN ............................................................................. 96
......................................................................................................... 55
OCUFLOX ........................................................................ 94
NORINYL 1+35 (28)
ofloxacin ............................................................................... 77
......................................................................................................... 55
OGESTREL ...................................................................... 55
NORINYL 1+50 (28)
olanzapine ........................................................................... 44
......................................................................................................... 55
OLEPTRO .......................................................................... 21
NORITATE ....................................................................... 68 OLUX ..................................................................................... 66
NOROXIN ......................................................................... 77
OLUX-E ............................................................................... 66
NORPACE ......................................................................... 13 OLYSIO ................................................................................ 46
NORPACE CR .............................................................. 13
OMECLAMOX-PAK
NORPRAMIN ................................................................ 22 ...................................................................................................... 106
NOR-QD .............................................................................. 58 omeprazole ...................................................................... 105
NORTREL 0.5/35 (28)
omeprazole magnesium
......................................................................................................... 55
...................................................................................................... 105
NORTREL 1/35 (21)
OMNARIS ......................................................................... 92
......................................................................................................... 55
ondansetron ....................................................................... 27
NORTREL 1/35 (28)
ondansetron hcl ............................................................. 27
......................................................................................................... 55
ONETOUCH ULTRA BLUE
NORTREL 7/7/7 .......................................................... 57 ......................................................................................................... 69
nortriptyline hcl ............................................................ 22
ONETOUCH VERIO
NORVASC ........................................................................ 51 ......................................................................................................... 69
NORVIR .............................................................................. 45
ONETOUCH VERIO IQ SYSTEM
NOVA MAX GLUCOSE TEST
......................................................................................................... 86
......................................................................................................... 69
ONFI ........................................................................................ 17
NOVAREL ........................................................................ 73 ONGLYZA ........................................................................ 24
NOVOLIN 70/30 ......................................................... 25 ONMEL ................................................................................ 28
NOVOLIN 70/30 RELION
OPANA ................................................................................. 10
......................................................................................................... 25
OPANA ER ....................................................................... 10
NOVOLIN R ................................................................... 25
opium ....................................................................................... 26
NOVOLIN R RELION
opium tincture (paregoric)
......................................................................................................... 25
......................................................................................................... 26
NOVOLOG ....................................................................... 25 OPSUMIT ........................................................................... 52
NOVOLOG FLEXPEN
OPTIVAR ........................................................................... 95
......................................................................................................... 25
ORACEA ............................................................................. 68
NOVOLOG MIX 70/30
ORALONE ........................................................................ 89
......................................................................................................... 25
ORAP ................................................................................... 100
NOVOLOG
MIX 70/30
FLEXPEN
ORAPRED
ODT .........................................................
58
2015 Aetna Pharmacy
Plan
Drug List - Three Tier
Open Individual
Plan
......................................................................................................... 25
ORAVIG .............................................................................. 89
ORENITRAM ................................................................ 52
ORFADIN .......................................................................... 75
orphenadrine citrate er
......................................................................................................... 91
ORSYTHIA ...................................................................... 55
ORTHO ALL-FLEX FITTING SET
......................................................................................................... 86
ORTHO DIAPHRAGM ALL-FLEX
......................................................................................................... 85
ORTHO EVRA ............................................................. 57
ORTHO MICRONOR
......................................................................................................... 58
ORTHO TRI-CYCLEN (28)
......................................................................................................... 57
ORTHO TRI-CYCLEN LO
......................................................................................................... 57
ORTHO-CEPT (28) .................................................. 55
ORTHO-CYCLEN (28)
......................................................................................................... 55
ORTHO-NOVUM 1/35 (28)
......................................................................................................... 55
ORTHO-NOVUM 7/7/7 (28)
......................................................................................................... 57
OSENI .................................................................................... 23
OSMOPREP ..................................................................... 84
OSPHENA ......................................................................... 74
OTEZLA ................................................................................. 8
OTREXUP ............................................................................. 6
OVACE WASH ............................................................ 64
OVCON-35 (28) ........................................................... 55
OVIDE ................................................................................... 68
OVIDREL ........................................................................... 73
OXANDRIN .................................................................... 11
oxaprozin ................................................................................. 7
oxazepam ............................................................................. 13
oxcarbazepine ................................................................. 18
OXISTAT ........................................................................... 63
OXSORALEN ................................................................ 67
OXSORALEN ULTRA
......................................................................................................... 64
OXTELLAR XR .......................................................... 18
oxybutynin chloride ............................................... 107
oxybutynin chloride er
...................................................................................................... 107
oxycodone hcl .................................................................. 10
OXYCONTIN ................................................................ 10
oxymorphone hcl .......................................................... 10
oxymorphone hcl er ................................................... 10
OXYTROL ..................................................................... 107
OXYTROL FOR WOMEN
...................................................................................................... 107
PAMELOR ........................................................................ 22
PAMINE ........................................................................... 104
PAMINE FORTE .................................................... 104
PANCREAZE ................................................................. 70
PANDEL .............................................................................. 66
PANRETIN ....................................................................... 63
pantoprazole sodium
...................................................................................................... 105
PARAFON FORTE DSC
......................................................................................................... 91
PARAGARD INTRAUTERINE
COPPER ............................................................................... 57
paricalcitol ......................................................................... 75
PARLODEL ..................................................................... 42
121
Index
Index
Index
PARNATE ......................................................................... 20
PHOSLO .............................................................................. 79
paromomycin sulfate
PHOSPHOLINE IODIDE
............................................................................................................ 5
......................................................................................................... 93
paroxetine hcl .................................................................. 21 PICATO ................................................................................ 63
paroxetine hcl er .......................................................... 21
pilocarpine hcl ............................................................... 93
PASER ................................................................................... 38
PIMTREA ........................................................................... 54
PATADAY ........................................................................ 95 pindolol .................................................................................. 49
PATANASE ..................................................................... 92 pioglitazone hcl ............................................................. 24
PATANOL ......................................................................... 95 pioglitazone hcl-glimepiride
PAXIL .................................................................................... 21
......................................................................................................... 23
PAXIL CR .......................................................................... 21 pioglitazone hcl-metformin hcl
PCE ............................................................................................ 85 ......................................................................................................... 23
PEDIADERM HC ...................................................... 66 PIRMELLA 1/35 ......................................................... 55
piroxicam ................................................................................ 7
peg 3350 ............................................................................... 84
PLAN B ONE-STEP
peg 3350/electrolytes
......................................................................................................... 57
......................................................................................................... 84
peg 3350-kcl-na bicarb-nacl
PLAQUENIL ................................................................... 37
......................................................................................................... 84
PLAVIX ................................................................................ 82
peg-3350/electrolytes
PLETAL ............................................................................... 81
......................................................................................................... 84
PLEXION ........................................................................... 60
PEGANONE .................................................................... 19 PLEXION CLEANSER
PEGASYS .......................................................................... 47
......................................................................................................... 60
PEGASYS PROCLICK
PLEXION CLEANSING CLOTH
......................................................................................................... 47
......................................................................................................... 60
PEG-INTRON ................................................................ 47 pnv fe fum/docusate/folic acid
PEG-INTRON REDIPEN
......................................................................................................... 90
......................................................................................................... 47
PODIAPN ........................................................................... 70
PEG-INTRON REDIPEN PAK 4
podocon ................................................................................. 67
......................................................................................................... 47
podofilox ............................................................................... 67
penicillin v potassium
polyethylene glycol 3350
......................................................................................................... 97
......................................................................................................... 84
PENLAC .............................................................................. 62 polymyxin b-trimethoprim
PENNSAID ....................................................................... 63 ......................................................................................................... 94
PENTASA .......................................................................... 78 POLYTRIM ...................................................................... 94
pentoxifylline er ............................................................ 81
POLY-VI-FLOR .......................................................... 90
PEPCID .............................................................................. 105 POMALYST .................................................................... 39
PERCOCET ...................................................................... 11 PONSTEL .............................................................................. 7
PERCODAN .................................................................... 11 PORTIA-28 ....................................................................... 55
PERCURA ......................................................................... 70
potassium chloride ..................................................... 88
PERFOROMIST .......................................................... 16 potassium chloride crys er
......................................................................................................... 88
perindopril erbumine
potassium chloride er
......................................................................................................... 32
PERIOGARD .................................................................. 89 ......................................................................................................... 89
permethrin .......................................................................... 68
potassium citrate er ................................................... 79
perphenazine .................................................................... 44 POTIGA ................................................................................ 19
perphenazine-amitriptyline
PRADAXA ........................................................................ 17
......................................................................................................... 99
pramipexole dihydrochloride
PERSANTINE ............................................................... 81
......................................................................................................... 42
PERTZYE ........................................................................... 70 PRAMOSONE ............................................................... 66
PEXEVA .............................................................................. 21 PRANDIMET ................................................................. 23
PHENAZO ......................................................................... 80 PRANDIN .......................................................................... 25
phenazopyridine hcl .................................................. 80 PRAVACHOL ............................................................... 31
pravastatin sodium ..................................................... 31
phendimetrazine tartrate
prazosin hcl ....................................................................... 34
............................................................................................................ 4
phendimetrazine tartrate er
PRECISION XTRA BLOOD GLUCOSE
............................................................................................................ 4
......................................................................................................... 69
phenobarbital .................................................................. 83 PRECOSE ........................................................................... 22
phentermine hcl ................................................................ 4 PRED FORTE ................................................................ 95
PHENYTEK ..................................................................... 19 PRED MILD .................................................................... 95
phenytoin .............................................................................. 19 PRED-G ................................................................................ 95
PHENYTOIN INFATABS
PRED-G S.O.P. ............................................................. 95
......................................................................................................... 19
prednisolone acetate ................................................ 95
phenytoin sodium extended
prednisolone sodium phosphate
.........................................................................................................
19 Tier
.........................................................................................................
95
2015 Aetna Pharmacy Plan Drug List - Three
Open Individual Plan
PHILITH .............................................................................. 55 prednisone .......................................................................... 58
122
prednisone (pak) ........................................................... 58
PREFERAOB ONE .................................................. 90
PREFEST ............................................................................ 76
PREGNYL ......................................................................... 73
PREMARIN ..................................................................... 77
PREMPHASE ................................................................. 76
PREMPRO ......................................................................... 76
prenatabs fa ...................................................................... 90
PRENATABS RX ...................................................... 90
prenatal ................................................................................. 90
prenatal vitamins ......................................................... 90
prenatal/iron .................................................................... 90
PRENATE DHA .......................................................... 90
PRENATE ELITE ...................................................... 90
PRENATE ESSENTIAL
......................................................................................................... 90
PREPIDIL ........................................................................... 97
PREQUE 10 ...................................................................... 90
PREVACID ................................................................... 105
PREVACID 24HR .................................................. 105
PREVACID SOLUTAB
...................................................................................................... 105
PREVALITE .................................................................... 30
PREVIFEM ....................................................................... 55
PREVPAC ....................................................................... 106
PREZISTA ......................................................................... 45
PRIFTIN ............................................................................... 38
PRILOSEC ........................................................ 105, 106
PRILOSEC OTC ...................................................... 106
primaquine phosphate
......................................................................................................... 37
primidone ............................................................................. 19
PRIMLEV ........................................................................... 11
PRINIVIL ........................................................................... 32
PRISTIQ ............................................................................... 22
PROAIR HFA ................................................................ 16
probenecid .......................................................................... 81
PROCARDIA ................................................................. 51
PROCARDIA XL ....................................................... 51
PROCENTRA .................................................................... 3
prochlorperazine .......................................................... 44
prochlorperazine edisylate
......................................................................................................... 44
prochlorperazine maleate
......................................................................................................... 44
PROCRIT ............................................................................ 82
PROCTOCORT ............................................................ 12
PROCTOFOAM HC
......................................................................................................... 12
PROCTOZONE-HC ................................................ 12
PROCYSBI ....................................................................... 80
PROGLYCEM ............................................................... 24
PROGRAF ......................................................................... 48
PROLENSA ..................................................................... 96
PROLEUKIN .................................................................. 41
PROMACTA ................................................................... 83
promethazine hcl .......................................................... 30
promethazine vc ............................................................ 59
promethazine vc plain
......................................................................................................... 59
promethazine vc/codeine
......................................................................................................... 59
promethazine-codeine
......................................................................................................... 59
promethazine-dm ......................................................... 59
Index
Index
Index
PROMETRIUM ........................................................... 98
ra cetirizine childrens
propafenone hcl ............................................................ 14
......................................................................................................... 29
ra clotrimazole ............................................................... 63
propafenone hcl er ..................................................... 14
propantheline bromide
ra clotrimazole 7 ....................................................... 109
...................................................................................................... 104
ra folic acid ....................................................................... 82
propranolol hcl .............................................................. 49 ra loratadine ..................................................................... 29
propranolol hcl er ....................................................... 49 ra loratadine childrens
propranolol-hctz ........................................................... 35 ......................................................................................................... 30
propylthiouracil ......................................................... 103 ra nicotine ........................................................................ 101
PROSCAR .......................................................................... 80 ra omeprazole .............................................................. 106
PROTEOLIN ................................................................... 70 RA TRUETEST TEST
PROTEOLIN DS ......................................................... 70 ......................................................................................................... 69
PROTONIX ................................................................... 106 rabeprazole sodium ............................................... 106
PROTOPIC ........................................................................ 67 raloxifene hcl ................................................................... 74
ramipril .................................................................................. 32
protriptyline hcl ............................................................ 22
PROVENTIL HFA .................................................... 16 RANEXA ............................................................................ 12
PROVERA ......................................................................... 98 ranitidine hcl ................................................................ 105
PROVIGIL ............................................................................ 5
RAPAFLO .......................................................................... 80
PROZAC .............................................................................. 21 RAPAMUNE ................................................................... 48
PROZAC WEEKLY
RAVICTI ............................................................................. 75
......................................................................................................... 21
RAYOS ................................................................................. 58
pseudoeph-chlorphen-hydrocod
RAZADYNE ................................................................... 98
......................................................................................................... 59
RAZADYNE ER ......................................................... 98
PULMICORT ................................................................. 15
REBETOL .......................................................................... 47
PULMICORT FLEXHALER
REBIF ..................................................................................... 99
......................................................................................................... 15
REBIF REBIDOSE ................................................... 99
PULMONA ....................................................................... 70 REBIF REBIDOSE TITRATION PACK
PULMOZYME .......................................................... 102
......................................................................................................... 99
PURINETHOL .............................................................. 38 REBIF TITRATION PACK
px acid reducer max st
......................................................................................................... 99
...................................................................................................... 105
RECLIPSEN .................................................................... 55
px allergy relief loratadine
RECTIV ................................................................................ 12
......................................................................................................... 29
REGIMEX ............................................................................. 4
px folic acid ....................................................................... 82 REGLAN ............................................................................. 78
px omeprazole .............................................................. 106 REGRANEX .................................................................... 68
PYLERA ........................................................................... 106 RELAGARD ................................................................ 108
pyrazinamide .................................................................... 38 RELENZA DISKHALER
pyridostigmine bromide
......................................................................................................... 47
......................................................................................................... 37
RELISTOR ........................................................................ 79
qc allergy relief ............................................................. 29
RELPAX .............................................................................. 88
qc clotrimazole ............................................................... 63 REMERON ....................................................................... 20
qc loratadine allergy relief
REMERON SOLTAB
......................................................................................................... 29
......................................................................................................... 20
QNASL .................................................................................. 92 RENAGEL ......................................................................... 79
QSYMIA ................................................................................. 4 RENVELA ......................................................................... 79
QUALAQUIN ................................................................ 37 repaglinide ......................................................................... 25
QUARTETTE ................................................................. 56 REPRONEX ..................................................................... 73
QUASENSE ..................................................................... 56 REQUIP ................................................................................ 42
QUESTRAN .................................................................... 30
REQUIP XL ..................................................................... 42
QUESTRAN LIGHT
RESCRIPTOR ................................................................ 45
......................................................................................................... 30
RESCULA .......................................................................... 96
quetiapine fumarate .................................................. 44 reserpine ............................................................................... 34
QUFLORA PEDIATRIC
RESTASIS ......................................................................... 94
......................................................................................................... 90
RESTORIL ........................................................................ 83
QUILLIVANT XR ........................................................ 5 RETIN-A ............................................................................. 61
quinapril hcl ..................................................................... 32
RETIN-A MICRO ...................................................... 61
quinapril-hydrochlorothiazide
RETIN-A MICRO PUMP
......................................................................................................... 34
......................................................................................................... 61
quinidine gluconate er
RETROVIR ....................................................................... 46
......................................................................................................... 13
REVATIO ........................................................................... 53
quinidine sulfate ........................................................... 13
REVIA .................................................................................... 27
quinidine sulfate er .................................................... 13 REVLIMID ....................................................................... 48
QVAR ..................................................................................... 15 REYATAZ ......................................................................... 45
ra
aspirin
.........................................................................
9 Tier
REZIRA
59
2015
AetnaecPharmacy
Plan Drug List - Three
Open................................................................................
Individual Plan
ra cetirizine ........................................................................ 29
RHINOCORT AQUA
.........................................................................................................
92
RHOGAM ULTRA-FILTERED PLUS
97
RIBASPHERE ............................................................... 47
RIBASPHERE RIBAPAK
......................................................................................................... 47
ribavirin ................................................................................ 47
RIDAURA ............................................................................. 6
rifabutin ................................................................................. 38
RIFADIN ............................................................................. 38
RIFAMATE ...................................................................... 37
rifampin ................................................................................. 38
RIFATER ............................................................................ 38
RILUTEK ........................................................................... 92
riluzole .................................................................................... 92
rimantadine hcl .............................................................. 47
risedronate sodium .................................................... 72
RISPERDAL .................................................................... 43
RISPERDAL M-TAB
......................................................................................................... 43
risperidone ......................................................................... 43
RISPERIDONE M-TAB
......................................................................................................... 43
RITALIN ................................................................................. 5
RITALIN LA ...................................................................... 5
RITALIN SR ....................................................................... 5
rizatriptan benzoate .................................................. 88
ROBAXIN .......................................................................... 91
ROBINUL ....................................................................... 104
ROBINUL-FORTE ................................................ 104
ROCALTROL ................................................................ 75
ropinirole hcl ................................................................... 42
ropinirole hcl er ............................................................ 42
ROSADAN ........................................................................ 68
ROSANIL CLEANSER
......................................................................................................... 60
ROZEREM ........................................................................ 84
RYTHMOL ....................................................................... 14
RYTHMOL SR ............................................................. 14
SABRIL ................................................................................ 19
SAFETY-GLIDE SYRINGE
......................................................................................................... 87
SAIZEN ................................................................................ 74
SAIZEN CLICK.EASY
......................................................................................................... 74
SALAGEN ......................................................................... 89
SALEX .................................................................................. 67
saline laxative ................................................................. 84
salsalate .................................................................................... 9
SAMSCA ............................................................................. 76
SANCTURA XR ...................................................... 107
SANCUSO ......................................................................... 27
SANDIMMUNE .......................................................... 48
SANTYL .............................................................................. 67
SAPHRIS ............................................................................. 44
SARAFEM ..................................................................... 100
SAVELLA .......................................................................... 99
SAVELLA TITRATION PACK
......................................................................................................... 99
sb loratadine ..................................................................... 30
sb loratadine allergy relief
......................................................................................................... 30
sb omeprazole .............................................................. 106
.........................................................................................................
123
SOLODYN ..................................................................... 103
84 SOLTAMOX ................................................................... 39
SEASONIQUE .............................................................. 56 SOMA ..................................................................................... 91
SECTRAL .......................................................................... 49
SOMATULINE DEPOT
SELECT-OB+DHA .................................................. 90 ......................................................................................................... 76
selegiline hcl ..................................................................... 42 SOMAVERT ................................................................... 74
selenium sulfide ............................................................. 64 SONATA ............................................................................. 84
selenium sulf-pyrithione-urea
SORIATANE .................................................................. 64
......................................................................................................... 64
SORILUX ........................................................................... 64
SELRX ................................................................................... 64 sotalol hcl ............................................................................ 50
SELSUN BLUE MEDICATED
sotalol hcl (af) ................................................................. 50
......................................................................................................... 64
SOVALDI ........................................................................... 47
SELZENTRY .................................................................. 45 SPIRIVA HANDIHALER
SEMPREX-D .................................................................. 59 ......................................................................................................... 14
SENSIPAR ........................................................................ 75
spironolactone ................................................................ 71
SENTRA AM .................................................................. 70 spironolactone-hctz ................................................... 71
SENTRA PM ................................................................... 70 SPORANOX .................................................................... 28
SEREVENT DISKUS
SPORANOX PULSEPAK
......................................................................................................... 16
......................................................................................................... 28
SEROPHENE ................................................................. 73
SPRINTEC 28 ................................................................ 55
SEROQUEL ..................................................................... 44 SPRIX ........................................................................................ 8
SEROQUEL XR .......................................................... 44
SPRYCEL ........................................................................... 40
SEROSTIM ....................................................................... 74 SPS ............................................................................................. 49
sertraline hcl .................................................................... 21
SRONYX ............................................................................. 55
sevelamer carbonate ................................................ 79
SSKI ......................................................................................... 88
SHOHLS MODIFIED
STALEVO 100 .............................................................. 42
......................................................................................................... 79
STALEVO 125 .............................................................. 42
SIGNIFOR ......................................................................... 76
STALEVO 150 .............................................................. 42
sildenafil citrate ............................................................ 53 STALEVO 200 .............................................................. 42
SILENOR ............................................................................ 83 STALEVO 50 ................................................................. 42
SILVADENE ................................................................... 64 STALEVO 75 ................................................................. 42
silver sulfadiazine ....................................................... 64
STARLIX ............................................................................ 25
SIMBRINZA ................................................................... 93
stavudine .............................................................................. 46
SIMCOR .............................................................................. 31
STAVZOR ......................................................................... 19
simvastatin .......................................................................... 32 STAXYN ............................................................................. 52
SINEMET ........................................................................... 42 STENDRA ......................................................................... 52
SINEMET CR ................................................................ 42
STIMATE ........................................................................... 76
SINGULAIR .................................................................... 14 STIVARGA ...................................................................... 40
sirolimus ............................................................................... 48 STRATTERA ..................................................................... 4
SIRTURO ........................................................................... 38
STRIANT ............................................................................ 11
SITAVIG ............................................................................. 47
STRIBILD .......................................................................... 45
SKELAXIN ....................................................................... 91 STROMECTOL ........................................................... 12
sm allergy relief ............................................................ 30
SUBOXONE .................................................................... 11
sm allergy relief loratadine
SUBSYS ............................................................................... 10
......................................................................................................... 30
SUCRAID ........................................................................... 70
sm antifungal clotrimazole
sucralfate .......................................................................... 105
......................................................................................................... 63
SULAR .................................................................................. 51
sm childrens loratadine
sulfacetamide sodium
......................................................................................................... 30
......................................................................................................... 94
sm clotrimazole vaginal
sulfacetamide sodium-sulfur
...................................................................................................... 109
......................................................................................................... 60
sm folic acid ...................................................................... 82 sulfacetamide sod-sulfur wash
sm loratadine ................................................................... 30 ......................................................................................................... 60
sm niacin cr .................................................................... 110 sulfacetamide-prednisolone
sm nicotine ...................................................................... 101 ......................................................................................................... 95
sm omeprazole ............................................................ 106
sulfacetamide-sulfur in urea
smz-tmp ds .......................................................................... 36 ......................................................................................................... 61
sodiphluor ........................................................................... 88 sulfadiazine .................................................................... 102
sodium chloride ............................................................. 60 sulfamethoxazole-tmp ds
sodium fluoride .............................................................. 88 ......................................................................................................... 36
sodium phenylbutyrate
sulfamethoxazole-trimethoprim
......................................................................................................... 75
......................................................................................................... 37
sodium polystyrene sulfonate
SULFAMYLON .......................................................... 64
...............................................................................................
48,- Three
49 Tier
sulfasalazine
.....................................................................
79
2015 Aetna Pharmacy Plan Drug List
Open Individual
Plan
SOLARAZE ..................................................................... 63 SULFAZINE .................................................................... 79
124
.........................................................................................................
Index
Index
Index
sb polyethylene glycol 3350
SULFAZINE EC ......................................................... 79
sulfisoxizole .................................................................... 102
sulindac ..................................................................................... 8
SUMADAN ...................................................................... 61
SUMADAN WASH ................................................. 61
SUMADAN XLT ........................................................ 61
sumatriptan ........................................................................ 88
sumatriptan succinate
......................................................................................................... 88
sumatriptan succinate refill
......................................................................................................... 88
SUMAVEL DOSEPRO
......................................................................................................... 88
SUMAXIN CP ............................................................... 61
SUPRAX .............................................................................. 53
SUPRENZA ......................................................................... 4
SURMONTIL ................................................................. 22
SUSTIVA ............................................................................ 46
SUTENT .............................................................................. 40
sw omeprazole ............................................................. 106
SYEDA .................................................................................. 55
SYLATRON .................................................................... 41
SYMBICORT ................................................................. 15
SYMBYAX ....................................................................... 99
SYMLINPEN 120 ...................................................... 22
SYMLINPEN 60 ......................................................... 22
SYNALAR ........................................................................ 66
SYNALAR (CREAM)
......................................................................................................... 66
SYNALAR (OINTMENT)
......................................................................................................... 66
SYNALAR TS ............................................................... 66
SYNALGOS-DC ......................................................... 10
SYNAREL ......................................................................... 75
SYNERA ............................................................................. 67
SYNTHROID .............................................................. 103
SYPRINE ............................................................................ 48
syringe disposable ...................................................... 87
syringe disposable 50-60ml
......................................................................................................... 87
TABLOID ........................................................................... 38
TACLONEX .................................................................... 66
tacrolimus ........................................................................... 48
TAFINLAR ....................................................................... 39
TAMIFLU .......................................................................... 47
tamoxifen citrate ........................................................... 39
tamsulosin hcl ................................................................. 80
TANZEUM ....................................................................... 24
TAPAZOLE .................................................................. 103
TARCEVA ........................................................................ 40
TARGRETIN .................................................................. 41
TARKA ................................................................................. 34
TASIGNA ........................................................................... 40
TASMAR ............................................................................ 42
TAZORAC ........................................................................ 64
TAZTIA XT ..................................................................... 51
TECFIDERA ................................................................... 99
TEGRETOL ...................................................................... 19
TEGRETOL-XR .......................................................... 19
TEKAMLO ....................................................................... 35
TEKTURNA .................................................................... 36
TEKTURNA HCT ..................................................... 36
telmisartan .......................................................................... 33
telmisartan-amlodipine
......................................................................................................... 34
Index
Index
Index
telmisartan-hctz ............................................................. 35 TOBRADEX .................................................................... 95
temazepam .......................................................................... 83 TOBRADEX ST .......................................................... 95
TEMODAR ....................................................................... 38 tobramycin ............................................................................. 5
TEMOVATE ................................................................... 66
TOBREX ............................................................................. 94
temozolomide ................................................................... 38 TODAY SPONGE .................................................. 108
TENEX .................................................................................. 33 TOFRANIL ....................................................................... 22
TENORETIC 100 ....................................................... 35
TOFRANIL-PM ........................................................... 22
TENORETIC 50 ........................................................... 35 tolazamide ........................................................................... 26
TENORMIN ..................................................................... 49 tolbutamide ........................................................................ 26
TERAZOL 3 ................................................................. 109
tolmetin sodium ................................................................ 8
TERAZOL 7 ................................................................. 109
tolterodine tartrate ................................................. 107
terazosin hcl ...................................................................... 34 tolterodine tartrate er
terbinafine hcl ................................................................. 28 ...................................................................................................... 107
TERBINEX ....................................................................... 28 TOPAMAX ....................................................................... 19
terconazole ...................................................................... 109 TOPAMAX SPRINKLE
TESSALON PERLES
......................................................................................................... 19
......................................................................................................... 58
TOPICORT ....................................................................... 66
TESTIM ................................................................................ 12 TOPICORT SPRAY ................................................ 66
tetracycline hcl ........................................................... 103
topiramate ........................................................................... 19
TEVETEN .......................................................................... 33 TOPROL XL ................................................................... 49
TEVETEN HCT ........................................................... 35 torsemide .............................................................................. 71
TEV-TROPIN ................................................................. 74 TOVIAZ ............................................................................ 107
tgt allergy relief ............................................................. 30 TOZAL .................................................................................. 70
tgt clotrimazole .............................................................. 63 TRACLEER ..................................................................... 52
tgt loratadine childrens
TRADJENTA ................................................................. 24
......................................................................................................... 30
tramadol hcl ...................................................................... 10
tgt nicotine step one ............................................... 102 tramadol hcl er .............................................................. 10
tgt nicotine step three
tramadol-acetaminophen
...................................................................................................... 102
......................................................................................................... 11
tgt nicotine step two ............................................... 102 TRANDATE .................................................................... 49
tgt omeprazole ............................................................. 106 trandolapril ....................................................................... 32
th cetirizine hcl .............................................................. 30
TRANSDERM-SCOP
th clotrimazole ................................................................ 63 ......................................................................................................... 27
th famotidine 10 ......................................................... 105 TRANXENE-T .............................................................. 13
th folic acid ........................................................................ 82 tranylcypromine sulfate
......................................................................................................... 20
th loratadine ..................................................................... 30
TRAVATAN Z .............................................................. 96
THALOMID .................................................................... 48
THEO-24 ............................................................................. 16
travoprost ............................................................................ 96
THEOCHRON ............................................................... 16 trazodone hcl ................................................................... 21
theophylline ....................................................................... 16 TRECATOR ..................................................................... 38
theophylline er ................................................................ 16 TREPADONE ................................................................ 70
THERAMINE ................................................................. 70 tretinoin ................................................................................. 41
thioridazine hcl .............................................................. 44 tretinoin microsphere
thiothixene .......................................................................... 44
......................................................................................................... 61
THYROLAR-1 ........................................................... 103 tretinoin microsphere pump
THYROLAR-1/2 ...................................................... 103 ......................................................................................................... 61
THYROLAR-1/4 ...................................................... 104 TRETIN-X ......................................................................... 61
THYROLAR-2 ........................................................... 104 TREXIMET ...................................................................... 87
THYROLAR-3 ........................................................... 104 triamcinolone acetonide
TIAZAC ................................................................................ 51 ......................................................................................................... 66
ticlopidine hcl .................................................................. 82 triamterene-hctz ............................................................ 71
TIGAN ................................................................................... 27
triazolam .............................................................................. 83
TIKOSYN ........................................................................... 14 TRIBENZOR ................................................................... 35
TILIA FE ............................................................................. 57 TRICARE PRENATAL DHA ONE
timolol maleate .............................................................. 50
......................................................................................................... 90
tricitrates .............................................................................. 80
TIMOPTIC ........................................................................ 93
TRICOR ............................................................................... 31
TIMOPTIC-XE ............................................................. 93
TINDAMAX .................................................................... 36 TRI-ESTARYLLA .................................................... 57
trifluoperazine hcl ...................................................... 44
TIROSINT ...................................................................... 104
TIVICAY ............................................................................. 45 trifluridine ........................................................................... 94
TRIGLIDE ......................................................................... 31
TIZANIDINE COMFORT PAC
......................................................................................................... 91
trihexyphenidyl hcl ..................................................... 41
tizanidine hcl .................................................................... 91 TRI-LEGEST FE ......................................................... 57
TOBI
............................................................................................
5 Tier
TRILEPTAL
....................................................................
19
2015 Aetna
Pharmacy Plan Drug List - Three
Open Individual
Plan
TOBI PODHALER ....................................................... 5 TRI-LINYAH ................................................................. 57
TRILIPIX ............................................................................ 31
TRILYTE ............................................................................ 84
trimethobenzamide hcl
......................................................................................................... 27
trimethoprim ..................................................................... 36
TRINATE ........................................................................... 90
TRINESSA (28) ........................................................... 57
TRI-NORINYL (28) ................................................ 57
TRI-PREVIFEM .......................................................... 57
TRI-SPRINTEC ........................................................... 57
TRI-VI-FLOR ................................................................. 90
TRIVORA (28) .............................................................. 57
TRIZIVIR ........................................................................... 45
TROKENDI XR ........................................................... 19
trospium chloride ..................................................... 107
trospium chloride er .............................................. 107
TRUETEST TEST ..................................................... 69
TRUETRACK TEST
......................................................................................................... 69
TRUSOPT .......................................................................... 96
TRUVADA ....................................................................... 45
TUDORZA PRESSAIR
......................................................................................................... 14
TUSSICAPS ..................................................................... 59
TUSSIONEX PENNKINETIC ER
......................................................................................................... 59
TWYNSTA ....................................................................... 34
TYKERB ............................................................................. 40
TYLENOL ............................................................................. 8
TYLENOL WITH CODEINE #3
......................................................................................................... 10
TYLENOL WITH CODEINE #4
......................................................................................................... 10
TYVASO ............................................................................. 52
TYVASO REFILL ..................................................... 52
TYVASO STARTER
......................................................................................................... 52
TYZEKA ............................................................................. 46
UCERIS ................................................................................ 58
ULESFIA ............................................................................. 68
ULORIC ............................................................................... 81
ULTRACET ..................................................................... 11
ULTRAM ............................................................................ 10
ULTRAM ER .................................................................. 10
ULTRAVATE ................................................................ 66
ULTRAVATE X (CREAM)
......................................................................................................... 66
ULTRAVATE X (OINTMENT)
......................................................................................................... 66
ULTRESA .......................................................................... 71
UNIRETIC ......................................................................... 34
UNITHROID ................................................................ 104
UNIVASC .......................................................................... 32
URECHOLINE .......................................................... 107
UROCIT-K 10 ................................................................ 80
UROCIT-K 15 ................................................................ 80
UROCIT-K 5 ................................................................... 80
UROXATRAL ............................................................... 80
URSO 250 .......................................................................... 78
URSO FORTE ............................................................... 78
ursodiol .................................................................................. 78
VAGIFEM ...................................................................... 109
valacyclovir hcl ............................................................. 47
VALCHLOR .................................................................... 63
VALCYTE ......................................................................... 46
125
Index
Index
Index
VALIUM ............................................................................. 13
VITAPEARL ................................................................... 90
valproic acid ..................................................................... 20 VITA-RESPA ................................................................. 70
valsartan ............................................................................... 33 VITUZ .................................................................................... 59
valsartan-hydrochlorothiazide
VIVA DHA ....................................................................... 90
......................................................................................................... 35
VIVACTIL ........................................................................ 22
VALTREX ......................................................................... 47 VIVELLE-DOT ............................................................ 77
VANCOCIN HCL ...................................................... 36 VOGELXO ........................................................................ 12
vancomycin hcl .............................................................. 36
VOGELXO PUMP .................................................... 12
VANDAZOLE ............................................................ 109 VOLTAREN .................................................................... 63
VANIQA .............................................................................. 67 VOLTAREN-XR ............................................................ 8
VANOS ................................................................................. 66 voriconazole ...................................................................... 28
VANOXIDE-HC ......................................................... 61
VOSOL HC ....................................................................... 97
VASCAZEN .................................................................... 70
VOSPIRE ER .................................................................. 16
VASCEPA .......................................................................... 30 VOTRIENT ....................................................................... 40
VASCULERA ................................................................ 70 vp-gstn .................................................................................... 70
VASERETIC ................................................................... 34
VSL#3 JUNIOR ........................................................... 70
VASOTEC ......................................................................... 32
VYFEMLA ........................................................................ 56
VAYACOG ....................................................................... 70 VYTORIN .......................................................................... 30
VAYARIN ......................................................................... 70
VYVANSE ........................................................................... 3
VCF VAGINAL CONTRACEPTIVE
warfarin sodium ............................................................ 16
...................................................................................................... 108
WELCHOL ............................................................. 30, 31
VECAMYL ....................................................................... 36 WELLBUTRIN ............................................................. 20
VECTICAL ....................................................................... 64 WELLBUTRIN SR ................................................... 20
VELIVET ............................................................................ 57 WELLBUTRIN XL .................................................. 20
VELPHORO .................................................................... 79
WERA .................................................................................... 56
VELTIN ................................................................................ 61 WESTCORT .................................................................... 66
venlafaxine hcl ............................................................... 22
WIDE-SEAL DIAPHRAGM 60
venlafaxine hcl er ........................................................ 22
......................................................................................................... 85
VENTAVIS ....................................................................... 52 WIDE-SEAL DIAPHRAGM 65
VENTOLIN HFA ....................................................... 16
......................................................................................................... 85
VERAMYST ................................................................... 92
WIDE-SEAL DIAPHRAGM 70
verapamil hcl ................................................................... 51 ......................................................................................................... 85
verapamil hcl er ............................................................ 51 WIDE-SEAL DIAPHRAGM 75
VERDESO ......................................................................... 66
......................................................................................................... 85
VEREGEN ......................................................................... 62 WIDE-SEAL DIAPHRAGM 80
VERELAN ......................................................................... 51 ......................................................................................................... 85
VERELAN PM .............................................................. 51 WIDE-SEAL DIAPHRAGM 85
VERSACLOZ ................................................................. 43 ......................................................................................................... 85
VESICARE .................................................................... 107 WIDE-SEAL DIAPHRAGM 90
VESTURA ......................................................................... 56
......................................................................................................... 85
VEXOL ................................................................................. 95
WIDE-SEAL DIAPHRAGM 95
VFEND .................................................................................. 28 ......................................................................................................... 85
VIAGRA .............................................................................. 52 WINRHO SDF ............................................................... 97
VIBRAMYCIN .......................................................... 103 WYMZYA FE ................................................................ 56
VICOPROFEN .............................................................. 10 XALATAN ........................................................................ 96
VICTOZA ........................................................................... 24 XALKORI .......................................................................... 40
VICTRELIS ...................................................................... 47 XANAX ................................................................................ 13
XANAX XR ..................................................................... 13
VIDEX ................................................................................... 46
VIDEX EC ......................................................................... 46 XARELTO ......................................................................... 16
VIGAMOX ........................................................................ 94 XARTEMIS XR ........................................................... 11
VIIBRYD ............................................................................ 21
XELJANZ .............................................................................. 6
VIMOVO ................................................................................ 6 XELODA ............................................................................. 38
VIMPAT .............................................................................. 19
XENAZINE ...................................................................... 99
VINATE DHA RF ..................................................... 90
XENICAL .............................................................................. 4
VIOKACE .......................................................................... 71 XERAC AC ...................................................................... 67
XIFAXAN .......................................................................... 36
VIRACEPT ....................................................................... 45
VIRAMUNE .................................................................... 46 XODOL ................................................................................. 10
VIRAMUNE XR ......................................................... 46 XOLEGEL ......................................................................... 63
VIREAD ............................................................................... 46 XOPENEX ......................................................................... 16
XOPENEX CONCENTRATE
VIRILEX ............................................................................. 70
......................................................................................................... 16
VIROPTIC ......................................................................... 94
virt-caps ................................................................................ 89
XOPENEX HFA .......................................................... 16
virt-vite forte ..................................................................... 70 XTANDI .............................................................................. 39
VISTARIL
13 Tier
XULANE
57
2015 Aetna ..........................................................................
Pharmacy Plan Drug List - Three
Open .............................................................................
Individual Plan
vitamin d-3 ...................................................................... 110 XYREM ................................................................................ 98
126
XYZAL ................................................................................. 30
YASMIN 28 ..................................................................... 56
YAZ .......................................................................................... 56
YODOXIN ............................................................................ 5
ZADITOR ........................................................................... 95
zafirlukast ............................................................................ 14
ZANAFLEX ..................................................................... 91
ZANTAC .......................................................................... 105
ZANTAC 150 MAXIMUM STRENGTH
...................................................................................................... 105
ZARAH ................................................................................. 56
ZARONTIN ...................................................................... 19
ZAROXOLYN .............................................................. 72
ZAVESCA ......................................................................... 82
ZEBETA .............................................................................. 49
ZEGERID ........................................................................ 106
ZEGERID OTC ......................................................... 106
ZELAPAR .......................................................................... 43
ZELBORAF ..................................................................... 39
ZEMPLAR ......................................................................... 75
ZENATANE .................................................................... 61
ZENCHENT ..................................................................... 56
ZENPEP ............................................................................... 71
ZENZEDI ........................................................................ 3, 4
ZEOSA .................................................................................. 56
ZERIT ..................................................................................... 46
ZESTORETIC ................................................................ 34
ZESTRIL ............................................................................. 32
ZETIA ..................................................................................... 32
ZETONNA ........................................................................ 92
ZIAC ........................................................................................ 35
ZIAGEN ............................................................................... 46
ZIANA ................................................................................... 61
zidovudine ........................................................................... 46
ZIOPTAN ........................................................................... 96
ziprasidone hcl ............................................................... 43
ZIPSOR .................................................................................... 8
ZIRGAN ............................................................................... 94
ZITHRANOL .................................................................. 64
ZITHROMAX ................................................................ 85
ZITHROMAX TRI-PAK
......................................................................................................... 85
ZMAX .................................................................................... 85
ZOCOR ................................................................................. 32
ZOFRAN ............................................................................. 27
ZOFRAN ODT .............................................................. 27
ZOHYDRO ER ............................................................. 10
ZOLINZA ........................................................................... 40
zolmitriptan ....................................................................... 88
ZOLOFT .............................................................................. 21
zolpidem tartrate .......................................................... 84
zolpidem tartrate er ................................................... 84
ZOLPIMIST ..................................................................... 84
ZOMIG .................................................................................. 88
ZOMIG ZMT .................................................................. 88
ZONATUSS ..................................................................... 59
ZONEGRAN ................................................................... 19
zonisamide .......................................................................... 19
ZONTIVITY .................................................................... 81
ZORBTIVE ....................................................................... 74
ZORTRESS ....................................................................... 48
ZORVOLEX ....................................................................... 8
ZOVIA 1/35E (28) ..................................................... 56
ZOVIA 1/50E (28) ..................................................... 56
ZOVIRAX .......................................................................... 47
Index
ZUBSOLV ......................................................................... 11
ZUPLENZ .......................................................................... 27
ZUTRIPRO ....................................................................... 59
ZYBAN .............................................................................. 102
ZYCLARA ........................................................................ 67
ZYCLARA PUMP ..................................................... 67
ZYDELIG ........................................................................... 41
ZYFLO CR ........................................................................ 14
ZYKADIA .......................................................................... 40
ZYLET ................................................................................... 95
ZYLOPRIM ...................................................................... 81
ZYMAXID ........................................................................ 94
ZYPREXA ......................................................................... 44
ZYPREXA ZYDIS .................................................... 44
ZYRTEC ALLERGY
......................................................................................................... 30
ZYRTEC-D ALLERGY &
CONGESTION ............................................................. 59
ZYTIGA ............................................................................... 39
ZYVOX ................................................................................. 37
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
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Z0: An Optimizing Distributed Zero-Knowledge Compiler

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