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2015 Aetna Pharmacy Plan Drug List
Three Tier Open Commercial
(Fully Insured)
www.aetna.com
©2014 Aetna Inc.
05.05.303.1 M (9/14)
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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 Commercial Three Tier
Open Formulary for fully insured plans.
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.
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
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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
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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
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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
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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.
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2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
Contents
of
Table
Table of Contents
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* ..................................................................................................................................... 3
*ALTERNATIVE MEDICINES* ......................................................................................................................................................................................................................................................... 5
*AMEBICIDES* ............................................................................................................................................................................................................................................................................................................. 5
*AMINOGLYCOSIDES* ................................................................................................................................................................................................................................................................................. 5
*ANALGESICS - ANTI-INFLAMMATORY* .............................................................................................................................................................................................................. 6
*ANALGESICS - NONNARCOTIC* ........................................................................................................................................................................................................................................... 8
*ANALGESICS - OPIOID* .......................................................................................................................................................................................................................................................................... 9
*ANDROGENS-ANABOLIC* ............................................................................................................................................................................................................................................................. 12
*ANORECTAL AGENTS* ........................................................................................................................................................................................................................................................................ 13
*ANTHELMINTICS* ......................................................................................................................................................................................................................................................................................... 14
*ANTIANGINAL AGENTS* ................................................................................................................................................................................................................................................................. 14
*ANTIANXIETY AGENTS* .................................................................................................................................................................................................................................................................. 14
*ANTIARRHYTHMICS* ............................................................................................................................................................................................................................................................................. 15
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* ....................................................................................................................................................... 15
*ANTICOAGULANTS* ................................................................................................................................................................................................................................................................................. 17
*ANTICONVULSANTS* ............................................................................................................................................................................................................................................................................ 18
*ANTIDEPRESSANTS* ................................................................................................................................................................................................................................................................................ 20
*ANTIDIABETICS* ............................................................................................................................................................................................................................................................................................. 23
*ANTIDIARRHEALS* .................................................................................................................................................................................................................................................................................... 28
*ANTIDOTES* ............................................................................................................................................................................................................................................................................................................. 28
*ANTIEMETICS* ..................................................................................................................................................................................................................................................................................................... 28
*ANTIFUNGALS* .................................................................................................................................................................................................................................................................................................. 29
*ANTIHISTAMINES* ...................................................................................................................................................................................................................................................................................... 30
*ANTIHYPERLIPIDEMICS* ................................................................................................................................................................................................................................................................ 31
*ANTIHYPERTENSIVES* ....................................................................................................................................................................................................................................................................... 33
*ANTI-INFECTIVE AGENTS - MISC.* ............................................................................................................................................................................................................................. 37
*ANTIMALARIALS* ........................................................................................................................................................................................................................................................................................ 38
*ANTIMYASTHENIC/CHOLINERGIC AGENTS* ........................................................................................................................................................................................ 38
*ANTIMYCOBACTERIAL AGENTS* ................................................................................................................................................................................................................................ 38
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* ............................................................................................................................................................. 39
*ANTIPARKINSON AGENTS* ....................................................................................................................................................................................................................................................... 42
*ANTIPSYCHOTICS/ANTIMANIC AGENTS* .................................................................................................................................................................................................... 43
*ANTISEPTICS & DISINFECTANTS* ................................................................................................................................................................................................................................ 46
*ANTIVIRALS* .......................................................................................................................................................................................................................................................................................................... 46
*ASSORTED CLASSES* ............................................................................................................................................................................................................................................................................ 49
*BETA BLOCKERS* ......................................................................................................................................................................................................................................................................................... 50
*BIOLOGICALS MISC* ............................................................................................................................................................................................................................................................................... 51
*CALCIUM CHANNEL BLOCKERS* ................................................................................................................................................................................................................................. 51
*CARDIOTONICS* .............................................................................................................................................................................................................................................................................................. 52
*CARDIOVASCULAR AGENTS - MISC.* .................................................................................................................................................................................................................. 52
*CEPHALOSPORINS* .................................................................................................................................................................................................................................................................................... 53
*CONTRACEPTIVES* .................................................................................................................................................................................................................................................................................... 54
*CORTICOSTEROIDS* ................................................................................................................................................................................................................................................................................ 58
*COUGH/COLD/ALLERGY* .............................................................................................................................................................................................................................................................. 59
*DERMATOLOGICALS* ........................................................................................................................................................................................................................................................................... 61
*DIAGNOSTIC PRODUCTS* ............................................................................................................................................................................................................................................................. 72
1
Contents
of
Table
*DIGESTIVE AIDS* ........................................................................................................................................................................................................................................................................................... 81
*DIURETICS* ................................................................................................................................................................................................................................................................................................................ 81
*ENDOCRINE AND METABOLIC AGENTS - MISC.* .......................................................................................................................................................................... 82
*ESTROGENS* ............................................................................................................................................................................................................................................................................................................ 86
*FLUOROQUINOLONES* ...................................................................................................................................................................................................................................................................... 87
*GASTROINTESTINAL AGENTS - MISC.* ............................................................................................................................................................................................................. 87
*GENERAL ANESTHETICS* ............................................................................................................................................................................................................................................................. 89
*GENITOURINARY AGENTS - MISCELLANEOUS* ............................................................................................................................................................................. 89
*GOUT AGENTS* .................................................................................................................................................................................................................................................................................................. 91
*HEMATOLOGICAL AGENTS - MISC.* ....................................................................................................................................................................................................................... 91
*HEMATOPOIETIC AGENTS* ....................................................................................................................................................................................................................................................... 93
*HEMOSTATICS* .................................................................................................................................................................................................................................................................................................. 95
*HYPNOTICS* ............................................................................................................................................................................................................................................................................................................. 95
*LAXATIVES* ............................................................................................................................................................................................................................................................................................................. 97
*MACROLIDES* ...................................................................................................................................................................................................................................................................................................... 97
*MEDICAL DEVICES* .................................................................................................................................................................................................................................................................................. 98
*MIGRAINE PRODUCTS* .................................................................................................................................................................................................................................................................. 120
*MINERALS & ELECTROLYTES* ...................................................................................................................................................................................................................................... 121
*MOUTH/THROAT/DENTAL AGENTS* .................................................................................................................................................................................................................. 123
*MULTIVITAMINS* ..................................................................................................................................................................................................................................................................................... 124
*MUSCULOSKELETAL THERAPY AGENTS* .............................................................................................................................................................................................. 130
*NASAL AGENTS - SYSTEMIC AND TOPICAL* .................................................................................................................................................................................... 131
*NEUROMUSCULAR AGENTS* ............................................................................................................................................................................................................................................ 131
*OPHTHALMIC AGENTS* ................................................................................................................................................................................................................................................................ 132
*OTIC AGENTS* .................................................................................................................................................................................................................................................................................................. 137
*OXYTOCICS* ........................................................................................................................................................................................................................................................................................................ 138
*PASSIVE IMMUNIZING AGENTS* ................................................................................................................................................................................................................................ 139
*PENICILLINS* ..................................................................................................................................................................................................................................................................................................... 140
*PHARMACEUTICAL ADJUVANTS* ........................................................................................................................................................................................................................... 140
*PROGESTINS* ..................................................................................................................................................................................................................................................................................................... 140
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* .............................................................................................................. 140
*RESPIRATORY AGENTS - MISC.* ................................................................................................................................................................................................................................. 143
*TETRACYCLINES* ..................................................................................................................................................................................................................................................................................... 143
*THYROID AGENTS* ................................................................................................................................................................................................................................................................................ 144
*ULCER DRUGS* .............................................................................................................................................................................................................................................................................................. 145
*URINARY ANTI-INFECTIVES* ............................................................................................................................................................................................................................................ 147
*URINARY ANTISPASMODICS* .......................................................................................................................................................................................................................................... 147
*VAGINAL PRODUCTS* ...................................................................................................................................................................................................................................................................... 148
*VASOPRESSORS* ......................................................................................................................................................................................................................................................................................... 149
*VITAMINS* ............................................................................................................................................................................................................................................................................................................... 149
2
Drug Name
2015 Aetna Pharmacy Plan Drug List - Three
Tier Open Commercial Fully Insured
Drug
Status
NC = Not
Covered
NC = Not
Covered
NF = Non
Formulary
Tier 1 =
Generic
Tier 2 =
Preferred
Brand
lowercase italics =
Tier 3 =
Generic drugs
Non
UPPERCASE = Brand Preferred
name drugs
Brand
Drug Name
Drug
Status
Drug Details
#=
Brand-name
drug expected
to become
available
generically in
the near future
LGC = Lowest
Generic Copay
Applies
N1 = Step
Therapy not
applied in NJ
PA = Prior
Authorization
Required
QL = Quantity
Limit Applies
SF = Split Fill
Applies
ST = Step
Therapy
Applies
Drug Details
*ADHD/ANTI-NARC
OLEPSY/ANTI-OBES
ITY/ANOREXIANTS
*
*AMPHETAMINES**
-*AMPHETAMINE
MIXTURES***
ADDERALL ORAL
TABLET 10 MG, 30
MG
Tier 3
PA; ST; N1;
QL (2 tab per 1
Day)
ADDERALL ORAL
TABLET 12.5 MG, 15
MG, 5 MG, 7.5 MG
Drug
Status
Drug Details
Tier 3
PA; ST; N1;
QL (2 tablets
per 1 day)
ADDERALL ORAL
TABLET 20 MG
Tier 3
PA; ST; N1;
QL (3 tab per 1
Day)
ADDERALL XR
Tier 3
PA; ST; N1;
QL (1 caps per
1 Day)
amphetamine-dextroam
phet er
Tier 1
QL (1 caps per
1 Day)
amphetamine-dextroam
phetamine oral tablet 10
mg, 12.5 mg, 15 mg, 30
mg, 5 mg, 7.5 mg
Tier 1
QL (2 tab per 1
Day)
amphetamine-dextroam
phetamine oral tablet 20
mg
Tier 1
QL (3 tab per 1
Day)
Tier 3
PA; ST; N1;
QL (4 tab per 1
Day)
DEXEDRINE ORAL
CAPSULE
EXTENDED
RELEASE 24 HOUR
Tier 3
PA; ST; N1;
QL (3 caps per
1 Day)
dextroamphetamine
sulfate oral solution
Tier 1
QL (40 ml per
1 Day)
dextroamphetamine
sulfate oral tablet
Tier 1
PA; QL (4 tab
per 1 Day)
dextroamphetamine
sulfate er
Tier 1
QL (3 caps per
1 Day)
methamphetamine hcl
Tier 1
QL (4 tab per 1
Day)
PROCENTRA
Tier 3
PA; ST; N1;
QL (40 ml per
1 Day)
VYVANSE
Tier 2
QL (1 caps per
1 Day)
ZENZEDI ORAL
TABLET 10 MG, 5 MG
Tier 1
PA; QL (4 tab
per 1 Day)
*AMPHETAMINES**
-*AMPHETAMINES*
**
DESOXYN
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
3
Drug Name
Drug Details
Drug Name
Tier 3
PA; ST; QL (4
tablets per 1
day)
STRATTERA ORAL
CAPSULE 100 MG, 80
MG
ZENZEDI ORAL
TABLET 2.5 MG, 7.5
MG
Tier 3
PA; ST; N1;
QL (4 tab per 1
Day)
*STIMULANTS MISC.**-*STIMULA
NTS - MISC.***
ZENZEDI ORAL
TABLET 20 MG, 30
MG
Tier 3
PA; ST; N1;
QL (4 tablets
per 1 day)
ZENZEDI ORAL
TABLET 15 MG
Drug
Status
*ANALEPTICS**-*A
NALEPTICS***
CAFCIT ORAL
caffeine citrate oral
Tier 3
Tier 1
*ATTENTION-DEFI
CIT/HYPERACTIVIT
Y DISORDER
(ADHD)
AGENTS**-*ADHD
AGENT SELECTIVE ALPHA
ADRENERGIC
AGONISTS***
Drug
Status
Drug Details
Tier 2
QL (1 caps per
1 Day)
CONCERTA ORAL
TABLET
EXTENDEDRELEASE
* 18 MG, 27 MG, 54
MG
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
CONCERTA ORAL
TABLET
EXTENDEDRELEASE
* 36 MG
Tier 3
PA; ST; N1;
QL (2 tab per 1
Day)
DAYTRANA
Tier 3
PA; ST; N1; #;
QL (1 patch per
1 Day)
dexmethylphenidate hcl
Tier 1
QL (2 tab per 1
Day)
dexmethylphenidate hcl
er
Tier 1
QL (1 caps per
1 Day)
FOCALIN
Tier 3
PA; ST; N1;
QL (2 tab per 1
Day)
Tier 1
PA; QL (4
tablets per 1
day)
INTUNIV
Tier 3
PA; ST; N1; #;
QL (1 tablet per
1 day)
FOCALIN XR
Tier 3
PA; ST; N1; #;
QL (1 caps per
1 Day)
KAPVAY ORAL
TABLET EXTENDED
RELEASE 12 HR*
Tier 3
PA; ST; N1;
QL (1 tablet per
1 day)
METADATE CD
Tier 3
PA; ST; N1;
QL (1 caps per
1 Day)
METADATE ER
Tier 1
QL (3 tab per 1
Day)
METHYLIN ORAL
SOLUTION 10
MG/5ML
Tier 3
PA; ST; N1;
QL (30 ml per
1 Day)
METHYLIN ORAL
SOLUTION 5 MG/5ML
Tier 3
PA; ST; N1;
QL (60 ml per
1 Day)
METHYLIN ORAL
TABLET
Tier 1
QL (3 tab per 1
Day)
Tier 3
PA; ST; N1;
QL (6 tab per 1
Day)
clonidine hcl er
*ATTENTION-DEFI
CIT/HYPERACTIVIT
Y DISORDER
(ADHD)
AGENTS**-*ADHD
AGENT SELECTIVE
NOREPINEPHRINE
REUPTAKE
INHIBITOR***
STRATTERA ORAL
CAPSULE 10 MG, 18
MG, 25 MG, 40 MG, 60
MG
Tier 2
QL (2 caps per
1 Day)
METHYLIN ORAL
TABLET CHEWABLE
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
4
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
METHYLIN ER
Tier 1
QL (3 tab per 1
Day)
RITALIN
Tier 3
methylphenidate hcl
oral solution 10 mg/5ml
Tier 1
QL (30 ml per
1 Day)
PA; ST; N1;
QL (3 tablets
per 1 day)
methylphenidate hcl
oral solution 5 mg/5ml
Tier 1
QL (60 ml per
1 Day)
Tier 3
methylphenidate hcl
oral tablet
QL (3 tab per 1
Day)
PA; ST; N1;
QL (1 caps per
1 Day)
Tier 1
RITALIN LA ORAL
CAPSULE
EXTENDED
RELEASE 24 HOUR
10 MG, 20 MG, 40 MG
Tier 3
PA; ST; N1;
QL (2 caps per
1 Day)
Tier 3
PA; ST; N1;
QL (3 tablets
per 1 day)
RITALIN LA ORAL
CAPSULE
EXTENDED
RELEASE 24 HOUR
30 MG
methylphenidate hcl er
oral tablet
extendedrelease* 18 mg,
27 mg, 54 mg
Tier 1
QL (1 tab per 1
Day)
methylphenidate hcl er
oral tablet
extendedrelease* 20 mg
Tier 1
QL (3 tab per 1
Day)
RITALIN SR
methylphenidate hcl er
oral tablet
extendedrelease* 36 mg
Tier 1
QL (2 tab per 1
Day)
*ALTERNATIVE
MEDICINES*
methylphenidate hcl er
(cd)
Tier 1
QL (1 caps per
1 Day)
methylphenidate hcl er
(la) oral capsule
extended release 24
hour 20 mg, 40 mg
Tier 1
QL (1 caps per
1 Day)
methylphenidate hcl er
(la) oral capsule
extended release 24
hour 30 mg
Tier 1
modafinil
Tier 1
PA; QL (2 tab
per 1 Day)
*AMINOGLYCOSID
ES*
NUVIGIL ORAL
TABLET 150 MG, 250
MG
Tier 3
PA; QL (1 tab
per 1 Day)
*AMINOGLYCOSID
ES**-*AMINOGLYC
OSIDES***
Tier 3
PA; QL (1
tablet per 1
day)
NUVIGIL ORAL
TABLET 50 MG
Tier 3
PA; QL (2 tab
per 1 Day)
PROVIGIL
Tier 3
PA; QL (2 tab
per 1 day)
Tier 3
PA; ST; N1;
QL (12 ML per
1 day)
NUVIGIL ORAL
TABLET 200 MG
QUILLIVANT XR
Drug Details
*ALTERNATIVE
MEDICINE C'S**-*ALTERNATI
VE MEDICINE CO'S***
QUINZYME
Tier 3
*AMEBICIDES*
QL (2 caps per
1 Day)
*AMEBICIDES**-*A
MEBICIDES***
YODOXIN
Tier 3
BETHKIS
Tier 3
neo-fradin
Tier 3
neomycin sulfate oral
Tier 1
paromomycin sulfate
oral
Tier 1
TOBI
Tier 3
TOBI PODHALER
Tier 2
tobramycin inhalation
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
5
Drug Name
Drug
Status
Drug Details
*ANALGESICS ANTI-INFLAMMAT
ORY*
Drug Details
Tier 3
PA
Tier 3
PA
Tier 2
PA
Tier 3
PA
CELEBREX ORAL
CAPSULE 100 MG,
400 MG, 50 MG
Tier 3
PA; #; QL (2
caps per 1 Day)
CELEBREX ORAL
CAPSULE 200 MG
Tier 3
PA; #; QL (1
caps per 1 Day)
ARCALYST
Tier 3
PA; QL (2 tab
per 1 Day)
*ANTIRHEUMATIC
ANTIMETABOLITES
**-*ANTIRHEUMAT
IC
ANTIMETABOLITES
***
*INTERLEUKIN-1
RECEPTOR
ANTAGONIST
(IL-1RA)**-*INTERL
EUKIN-1
RECEPTOR
ANTAGONIST
(IL-1RA)***
KINERET
OTREXUP
Tier 3
RHEUMATREX
Tier 3
*ANTI-TNF-ALPHA MONOCLONAL
ANTIBODIES**-*AN
TI-TNF-ALPHA MONOCLONAL
ANTIBODIES***
PA; ST; N1
*INTERLEUKIN-1BE
TA
BLOCKERS**-*INTE
RLEUKIN-1BETA
BLOCKERS***
ILARIS
*INTERLEUKIN-6
RECEPTOR
INHIBITORS**-*INT
ERLEUKIN-6
RECEPTOR
INHIBITORS***
HUMIRA
Tier 2
HUMIRA PEN
Tier 2
HUMIRA
PEN-CROHNS
STARTER
Tier 2
HUMIRA
PEN-PSORIASIS
STARTER
Tier 2
SIMPONI
Tier 3
SIMPONI ARIA
Tier 3
*GOLD
COMPOUNDS**-*G
OLD
COMPOUNDS***
RIDAURA
Drug
Status
*INTERLEUKIN-1
BLOCKERS**-*INTE
RLEUKIN-1
BLOCKERS***
*ANTIRHEUMATIC ENZYME
INHIBITORS**-*AN
TIRHEUMATIC JANUS KINASE
(JAK)
INHIBITORS***
XELJANZ
Drug Name
ACTEMRA
SUBCUTANEOUS*
*NONSTEROIDAL
ANTI-INFLAMMAT
ORY AGENTS
(NSAIDS)**-*CYCLO
OXYGENASE 2
(COX-2)
INHIBITORS***
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
6
Drug Name
Drug
Status
Drug Details
*NONSTEROIDAL
ANTI-INFLAMMAT
ORY AGENTS
(NSAIDS)**-*NONST
EROIDAL
ANTI-INFLAMMAT
ORY AGENT
COMBINATIONS***
ARTHROTEC
Tier 3
diclofenac-misoprostol
Tier 1
DUEXIS
Tier 3
VIMOVO
Tier 2
ST; N1; QL (3
tab per 1 Day)
ST; N1; QL (2
tab per 1 Day)
*NONSTEROIDAL
ANTI-INFLAMMAT
ORY AGENTS
(NSAIDS)**-*NONST
EROIDAL
ANTI-INFLAMMAT
ORY AGENTS
(NSAIDS)***
Drug Name
Drug
Status
Drug Details
INDOCIN
SUPPOSITORY
Tier 3
indomethacin oral
Tier 1
indomethacin er
Tier 1
ketoprofen oral
Tier 1
ketorolac tromethamine
oral
Tier 1
QL (20 tab per
30 Days)
mefenamic acid oral
Tier 1
QL (30 caps
per 30 Days)
meloxicam oral tablet
Tier 1
LGC
MELOXICAM
COMFORT PAC
Tier 3
MOBIC
Tier 3
nabumetone oral
Tier 3
NALFON ORAL
CAPSULE 400 MG
Tier 3
NAPRELAN ORAL
TABLET EXTENDED
RELEASE 24 HR* 375
MG, 500 MG, 750 MG
Tier 3
ANAPROX
Tier 3
NAPROSYN
Tier 3
ANAPROX DS
Tier 3
Tier 1
CATAFLAM
Tier 3
naproxen oral
suspension
DAYPRO
Tier 3
naproxen oral tablet
Tier 1
diclofenac potassium
Tier 1
naproxen dr
Tier 1
diclofenac sodium oral
tablet delayed release
25 mg, 50 mg
Tier 1
Tier 1
naproxen sodium oral
tablet 275 mg
Tier 1
diclofenac sodium oral
tablet delayed release
75 mg
naproxen sodium oral
tablet 550 mg
Tier 1
oxaprozin
Tier 3
piroxicam oral
Tier 1
diclofenac sodium er
Tier 3
PONSTEL
Tier 3
QL (30 caps
per 30 Days)
SPRIX
Tier 3
QL (5 days
maximum per 1
fill)
sulindac oral
Tier 1
tolmetin sodium oral
capsule
Tier 3
VOLTAREN-XR
Tier 3
EC-NAPROSYN
Tier 3
etodolac oral
Tier 1
etodolac er
Tier 3
FELDENE
Tier 3
flurbiprofen oral
Tier 1
ibuprofen oral tablet
400 mg, 600 mg, 800 mg
Tier 1
INDOCIN ORAL
Tier 3
LGC
LGC
LGC
LGC
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
7
Drug Name
Drug
Status
ZIPSOR
Tier 3
ZORVOLEX
Tier 3
Drug Details
PA; ST; N1
*PHOSPHODIESTER
ASE 4 (PDE4)
INHIBITORS**-*PH
OSPHODIESTERASE
4 (PDE4)
INHIBITORS***
OTEZLA
Tier 3
OTEZLA ORAL 10 &
20 & 30 MG
Tier 3
*PYRIMIDINE
SYNTHESIS
INHIBITORS**-*PY
RIMIDINE
SYNTHESIS
INHIBITORS***
leflunomide oral
Tier 1
PA
*SELECTIVE
COSTIMULATION
MODULATORS**-*S
ELECTIVE
COSTIMULATION
MODULATORS***
ORENCIA
SUBCUTANEOUS*
Tier 3
*SOLUBLE TUMOR
NECROSIS FACTOR
RECEPTOR
AGENTS**-*SOLUB
LE TUMOR
NECROSIS FACTOR
RECEPTOR
AGENTS***
PA
Drug Name
Drug
Status
ED-FLEX
Tier 1
*ANALGESIC
COMBINATIONS**-*
ANALGESICS-SEDA
TIVES***
alagesic
Tier 1
ALAGESIC LQ
Tier 3
anolor 300
Tier 1
BUPAP ORAL
TABLET 50-300 MG
Tier 3
butalbital-acetaminophe
n
Tier 1
butalbital-apap-caffeine
oral capsule
Tier 1
butalbital-apap-caffeine
oral tablet 50-325-40
mg
Tier 1
butalbital-asa-caffeine
Tier 1
CAPACET
Tier 1
EQUAGESIC
Tier 3
ESGIC ORAL
TABLET
Tier 3
FIORICET
Tier 3
FIORINAL
Tier 3
margesic
Tier 1
marten-tab
Tier 1
ORBIVAN CF
Tier 3
repan
Tier 1
TENCON ORAL
TABLET 50-325 MG
Tier 1
Tier 1
ENBREL
Tier 2
ENBREL SURECLICK
Tier 2
ZEBUTAL ORAL
CAPSULE 50-325-40
MG
be-flex plus
Tier 1
*ANALGESICS-PEPT
IDE CHANNEL
BLOCKERS**-*SEL
ECTIVE N-TYPE
NEURONAL
CALCIUM
CHANNEL
BLOCKERS***
duraxin
Tier 1
*ANALGESICS NONNARCOTIC*
*ANALGESIC
COMBINATIONS**-*
ANALGESIC
COMBINATIONS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
8
Drug Details
Drug Name
Drug
Status
PRIALT
Tier 3
Drug Name
Drug
Status
*SALICYLATES**-*
SALICYLATE
COMBINATIONS***
DURAGESIC-25
Tier 3
PA; QL (2
patches per 3
Days)
choline & mag
trisalicylate oral tablet
1000 mg
DURAGESIC-50
Tier 3
PA; QL (2
patches per 3
Days)
DURAGESIC-75
Tier 3
PA; QL (2
patches per 3
Days)
EXALGO ORAL 12
MG, 8 MG
Tier 3
ST; N1; QL (2
EA per 1 Day)
EXALGO ORAL 16
MG
Tier 3
ST; N1; QL (4
EA per 1 Day)
EXALGO ORAL 32
MG
Tier 3
ST; N1; QL (2
tablets per 1
day)
fentanyl
Tier 1
QL (20 patch
per 30 Days)
fentanyl citrate buccal
Tier 1
PA; QL (15
lollipops per 30
days)
FENTORA
Tier 3
PA; ST; N1;
QL (15 tab per
30 Days)
hydromorphone hcl oral
Tier 1
choline-mag
trisalicylate
Drug Details
Tier 1
Tier 1
*SALICYLATES**-*
SALICYLATES***
diflunisal oral
Tier 1
MST 600
Tier 3
salsalate oral
Tier 1
*ANALGESICS OPIOID*
*OPIOID
AGONISTS**-*OPIO
ID AGONISTS***
ABSTRAL
ACTIQ BUCCAL
LOLLIPOP 1200 MCG,
1600 MCG, 400 MCG,
600 MCG, 800 MCG
Tier 3
PA; ST; N1;
QL (15 tab per
30 Days)
Tier 3
PA; ST; N1;
QL (15
lollipops per 30
days)
AVINZA
Tier 3
PA; ST; N1;
QL (2 capsules
per 1 day)
CONZIP
Tier 3
QL (1 caps per
1 Day)
DEMEROL ORAL
Tier 3
DILAUDID ORAL
Tier 3
DOLOPHINE ORAL
TABLET 5 MG
Tier 3
QL (180 tab per
30 Days)
DURAGESIC-100
Tier 3
PA; QL (2
patches per 3
Days)
DURAGESIC-12
Tier 3
PA; QL (2
patches per 3
Days)
Drug Details
KADIAN ORAL
CAPSULE
EXTENDED
RELEASE 24 HOUR
10 MG, 100 MG, 20
MG, 200 MG, 30 MG,
50 MG, 60 MG
Tier 3
PA; ST; N1;
QL (2 capsules
per 1 Day)
KADIAN ORAL
CAPSULE
EXTENDED
RELEASE 24 HOUR
130 MG, 150 MG, 40
MG, 70 MG, 80 MG
Tier 3
PA; ST; N1;
QL (2 capsules
per 1 day)
LAZANDA
Tier 3
PA; ST; N1;
QL (4 bottle
per 30 Days)
meperidine hcl oral
tablet
Tier 1
meperitab
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
9
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
Drug Details
NUCYNTA
Tier 3
ST; N1; QL (6
tablets per 1
Day)
methadone hcl oral
concentrate
Tier 1
methadone hcl oral
solution
Tier 1
methadone hcl oral
tablet
QL (180 tab per
30 Days)
NUCYNTA ER
Tier 3
Tier 1
PA; ST; N1;
QL (2 tablets
per 1 Day)
methadone hcl oral
tablet soluble
QL (180 tab per
30 Days)
OPANA ORAL
Tier 3
ST; N1
Tier 1
METHADONE HCL
INTENSOL
Tier 1
Tier 2
QL (4 tablets
per 1 day)
METHADOSE ORAL
CONCENTRATE
OPANA ER ORAL 10
MG, 15 MG, 20 MG, 30
MG, 40 MG, 5 MG, 7.5
MG
Tier 3
OXECTA
Tier 3
METHADOSE ORAL
TABLET
QL (180 tab per
30 Days)
oxycodone hcl oral
Tier 1
Tier 1
METHADOSE ORAL
TABLET SOLUBLE
QL (180 tab per
30 Days)
OXYCONTIN
Tier 3
Tier 1
METHADOSE
SUGAR-FREE
oxymorphone hcl
Tier 1
Tier 3
oxymorphone hcl er
Tier 1
morphine sulfate
injection
Tier 1
Tier 3
morphine sulfate
intravenous* solution 1
mg/ml, 150 mg/30ml, 25
mg/ml, 50 mg/ml
ROXICODONE ORAL
TABLET
Tier 1
SUBSYS
SUBLINGUAL
LIQUID† 100 MCG
Tier 3
PA; ST; N1;
QL (15 ml per
30 Days)
morphine sulfate oral
solution
Tier 1
SUBSYS
SUBLINGUAL
LIQUID† 1200 (600 X
2) MCG, 1600 (800 X
2) MCG
Tier 3
PA; ST; N1;
QL (8 pack per
30 Days)
SUBSYS
SUBLINGUAL
LIQUID† 200 MCG,
400 MCG, 600 MCG,
800 MCG
Tier 3
PA; ST; N1;
QL (15 pack
per 30 Days)
tramadol hcl oral
Tier 1
tramadol hcl er oral
tablet extended release
24 hr*
Tier 1
QL (60 tab per
30 Days)
tramadol hcl er
(biphasic)
Tier 1
QL (60 tab per
30 Days)
ULTRAM
Tier 3
ULTRAM ER
Tier 3
morphine sulfate
(concentrate)
Tier 1
morphine sulfate (pf)
injection
Tier 1
morphine sulfate (pf)
intravenous* solution
10 mg/ml, 15 mg/ml, 2
mg/ml, 4 mg/ml, 8
mg/ml
Tier 1
morphine sulfate er oral
capsule extended
release 24 hour
Tier 1
QL (60 caps
per 30 Days)
morphine sulfate er oral
tablet extendedrelease*
Tier 1
QL (120 tab per
30 Days)
MS CONTIN
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
10
PA; ST; N1;
QL (4 tablets
per 1 day)
QL (120 tab per
30 Days)
QL (60 tab per
30 Days)
Drug Name
Drug
Status
ZOHYDRO ER
Tier 3
*OPIOID
COMBINATIONS**-*
CODEINE
COMBINATIONS***
Drug Details
Drug Name
Drug
Status
hydrocodone-acetamino
phen oral solution
2.5-108 mg/5ml, 5-217
mg/10ml, 7.5-325
mg/15ml
Tier 1
hydrocodone-acetamino
phen oral tablet 10-300
mg, 10-325 mg, 5-300
mg, 5-325 mg, 7.5-300
mg, 7.5-325 mg
Tier 1
hydrocodone-ibuprofen
Tier 1
acetaminophen-codeine
Tier 1
acetaminophen-codeine
#2
Tier 1
acetaminophen-codeine
#3
Tier 1
acetaminophen-codeine
#4
Tier 1
IBUDONE ORAL
TABLET 10-200 MG
Tier 3
ASCOMP-CODEINE
Tier 1
butalbital
compound/codeine
Tier 1
Tier 1
IBUDONE ORAL
TABLET 5-200 MG
LORCET
Tier 1
butalbital-apap-caff-cod
Tier 1
LORCET HD
Tier 1
butalbital-asa-caff-code
ine
Tier 1
Tier 3
CAPITAL/CODEINE
Tier 2
LORTAB ORAL
ELIXIR 10-300
MG/15ML
FIORICET/CODEINE
ORAL CAPSULE
50-300-40-30 MG
Tier 3
LORTAB ORAL
TABLET 10-325 MG,
5-325 MG, 7.5-325 MG
Tier 1
FIORINAL/CODEINE
#3
Tier 3
NORCO
Tier 3
TYLENOL WITH
CODEINE #3
Tier 1
Tier 3
REPREXAIN ORAL
TABLET 10-200 MG
TYLENOL WITH
CODEINE #4
Tier 3
REPREXAIN ORAL
TABLET 2.5-200 MG,
5-200 MG
Tier 3
VICODIN ORAL
TABLET 5-300 MG
Tier 1
VICODIN ES ORAL
TABLET 7.5-300 MG
Tier 1
VICODIN HP ORAL
TABLET 10-300 MG
Tier 1
VICOPROFEN
Tier 3
XODOL
Tier 3
ZAMICET
Tier 3
ZOLVIT
Tier 3
*OPIOID
COMBINATIONS**-*
DIHYDROCODEINE
COMBINATIONS***
SYNALGOS-DC
Tier 3
*OPIOID
COMBINATIONS**-*
HYDROCODONE
COMBINATIONS***
HYCET
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
11
Drug Name
Drug
Status
Drug Details
*OPIOID
COMBINATIONS**-*
OPIOID
COMBINATIONS***
ENDOCET ORAL
TABLET 10-325 MG,
5-325 MG, 7.5-325 MG
Tier 1
ENDODAN
Tier 1
oxycodone-acetaminoph
en oral tablet 10-325
mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg
Tier 1
oxycodone-aspirin oral
tablet 4.8355-325 mg
Tier 1
oxycodone-ibuprofen
Tier 1
PERCOCET ORAL
TABLET 10-325 MG,
2.5-325 MG, 5-325 MG,
7.5-325 MG
Tier 3
PERCODAN
Tier 3
PRIMLEV
Tier 3
ROXICET ORAL
SOLUTION
Tier 2
ROXICET ORAL
TABLET 5-325 MG
Tier 1
XARTEMIS XR
Tier 3
QL (28 tab per
30 Days)
Drug Details
Tier 1
PA; QL (8 tab
per 30 Days)
buprenorphine
hcl-naloxone hcl
Tier 1
PA; QL (90 tab
per 30 Days)
butorphanol tartrate
nasal
Tier 1
QL (2 bottle
per 30 Days)
BUTRANS
TRANSDERMAL
PATCH WEEKLY 10
MCG/HR, 15 MCG/HR,
20 MCG/HR, 5
MCG/HR
Tier 2
QL (1 patch per
7 Days)
SUBOXONE
SUBLINGUAL FILM
12-3 MG
Tier 3
PA; QL (2 pack
per 1 Day)
Tier 3
PA; QL (90
pack per 30
Days)
SUBOXONE
SUBLINGUAL
TABLET
SUBLINGUAL
Tier 3
PA; QL (90
tablets per 30
days)
ZUBSOLV
Tier 3
PA; N1; QL
(90 tab per 30
Days)
*ANDROGENS-ANA
BOLIC*
*ANABOLIC
STEROIDS**-*ANAB
OLIC STEROIDS***
tramadol-acetaminophe
n
Tier 1
ULTRACET
Tier 3
*OPIOID PARTIAL
AGONISTS**-*OPIO
ID PARTIAL
AGONISTS***
ANADROL-50
Tier 3
OXANDRIN
Tier 3
oxandrolone oral
Tier 1
*ANDROGENS**-*A
NDROGENS***
Tier 1
PA; QL (24 tab
per 30 Days)
ANDROGEL
TRANSDERMAL
20.25 MG/1.25GM
(1.62%)
ANDROGEL
TRANSDERMAL 25
MG/2.5GM
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
12
Drug
Status
buprenorphine hcl
sublingual tablet
sublingual 8 mg
SUBOXONE
SUBLINGUAL FILM
2-0.5 MG, 4-1 MG, 8-2
MG
*OPIOID
COMBINATIONS**-*
TRAMADOL
COMBINATIONS***
buprenorphine hcl
sublingual tablet
sublingual 2 mg
Drug Name
Tier 2
PA; QL (30
packs per 30
days)
Tier 2
PA; #; QL (30
pack per 30
Days)
Drug Name
Drug Details
Drug Name
Drug
Status
Tier 2
PA; QL (60
packs per 30
days)
VOGELXO PUMP
Tier 3
ANDROGEL
TRANSDERMAL 50
MG/5GM
Tier 2
PA; #; QL (60
packs per 30
days)
ANDROGEL PUMP
TRANSDERMAL 12.5
MG/ACT (1%)
Tier 2
PA; #; QL (4
pumps per 30
days)
ANDROGEL PUMP
TRANSDERMAL
20.25 MG/ACT (1.62%)
Tier 2
PA; QL (2
pumps per 30
days)
ANDROID
Tier 2
ANDROXY
Tier 1
ANDROGEL
TRANSDERMAL 40.5
MG/2.5GM (1.62%)
Drug
Status
*INTRARECTAL
STEROIDS**-*INTR
ARECTAL
STEROIDS***
COLOCORT
Tier 1
CORTENEMA
Tier 3
CORTIFOAM
Tier 3
hydrocortisone enema
Tier 1
PA; ST; N1;
QL (6 ML per
1 day)
*RECTAL
COMBINATIONS**-*
RECTAL
ANESTHETIC/STER
OIDS***
Tier 3
danazol oral
Tier 1
DEPO-TESTOSTERO
NE
Tier 3
QL (4 ML per
1 fill)
ANALPRAM-HC
LOTION
Tier 3
Tier 1
Tier 3
PA; ST; N1;
QL (4 GM per
1 day)
hc pram
FORTESTA
hydrocortisone
ace-pramoxine cream
Tier 1
LIDAZONE HC
Tier 1
lidocaine-hydrocortison
e ace cream
Tier 1
lidocaine-hydrocortison
e ace kit 3-0.5 %, 3-1 %,
3-2.5 %
Tier 1
Tier 2
Tier 3
PA; ST; N1;
QL (2 buccals
per 1 day)
TESTIM
Tier 2
PA; QL (10
GM per 1 Day)
testosterone
transdermal 12.5 mg/act
(1%)
Tier 3
PA; ST; N1;
QL (4 pumps
per 30 days)
LIDOCORT
Tier 1
pramcort
Tier 1
PROCORT
Tier 3
Tier 3
PA; ST; N1;
QL (60 packets
per 30 days)
PROCTOFOAM HC
Tier 3
STRIANT
testosterone
transdermal 50 mg/5gm
testosterone cypionate
intramuscular*
Tier 1
TESTRED
Tier 3
VOGELXO
Tier 3
QL (4 ML per
1 fill)
PA; ST; N1;
QL (60 packets
per 30 days)
PA; ST; N1;
QL (4 pumps
per 30 days)
*ANORECTAL
AGENTS*
AXIRON
methitest
Drug Details
*RECTAL
STEROIDS**-*RECT
AL STEROIDS***
anucort-hc
Tier 1
ANUSOL-HC CREAM
Tier 3
grx hicort 25
Tier 1
hemorrhoidal-hc
suppository
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
13
Drug Name
Drug
Status
HEMRIL-30
Tier 1
hydrocortisone acetate
suppository
Drug Details
Drug Name
Drug
Status
Tier 1
Tier 1
isosorbide dinitrate oral
tablet 10 mg, 20 mg, 5
mg
PROCTO-PAK
Tier 1
isosorbide dinitrate er
Tier 1
PROCTOCARE-HC
Tier 1
isosorbide mononitrate
Tier 1
PROCTOCREAM HC
Tier 1
Tier 1
PROCTOSOL HC
Tier 1
isosorbide mononitrate
er
PROCTOZONE-HC
Tier 1
MINITRAN
Tier 1
rectacort-hc
Tier 1
NITRO-BID
Tier 3
NITRO-DUR
Tier 3
NITRO-TIME
Tier 1
nitroglycerin
transdermal
Tier 1
nitroglycerin
translingual solution
Tier 1
nitroglycerin er
Tier 1
NITROLINGUAL
Tier 3
NITROMIST
Tier 3
Tier 2
*VASODILATING
AGENTS**-*NITRAT
E VASODILATING
AGENTS***
RECTIV
Tier 3
*ANTHELMINTICS*
*ANTHELMINTICS*
*-*ANTHELMINTIC
S***
ALBENZA
Tier 3
NITROSTAT
BILTRICIDE
Tier 3
STROMECTOL
Tier 3
*ANTIANXIETY
AGENTS*
*ANTIANGINAL
AGENTS*
*ANTIANXIETY
AGENTS MISC.**-*ANTIANXI
ETY AGENTS MISC.***
*ANTIANGINALS-O
THER**-*ANTIANGI
NALS-OTHER***
RANEXA ORAL
TABLET EXTENDED
RELEASE 12 HR*
1000 MG
Tier 2
RANEXA ORAL
TABLET EXTENDED
RELEASE 12 HR* 500
MG
Tier 2
*NITRATES**-*NIT
RATES***
DILATRATE-SR
Tier 3
IMDUR
Tier 3
ISOCHRON
Tier 1
isoditrate er
Tier 1
ISORDIL TITRADOSE
Tier 3
ST; N1; QL (2
tab per 1 Day)
ST; N1; QL (3
tab per 1 Day)
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
solution
Tier 1
hydroxyzine hcl oral
syrup
Tier 1
hydroxyzine hcl oral
tablet
Tier 1
hydroxyzine pamoate
oral capsule 25 mg, 50
mg
Tier 1
meprobamate
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
14
Drug Details
LGC
LGC
Drug Name
Drug
Status
VISTARIL
Tier 3
*BENZODIAZEPINE
S**-*BENZODIAZEP
INES***
Drug Details
Drug Name
Drug
Status
*ANTIARRHYTHMI
CS TYPE
I-B**-*ANTIARRHY
THMICS TYPE
I-B***
alprazolam oral
Tier 1
alprazolam er
Tier 1
ALPRAZOLAM
INTENSOL
Tier 3
alprazolam xr
Tier 1
ATIVAN ORAL
Tier 3
*ANTIARRHYTHMI
CS TYPE
I-C**-*ANTIARRHY
THMICS TYPE
I-C***
chlordiazepoxide hcl
Tier 1
flecainide acetate
Tier 1
clorazepate dipotassium
Tier 1
propafenone hcl
Tier 1
diazepam oral tablet
Tier 1
propafenone hcl er
Tier 1
DIAZEPAM
INTENSOL
RYTHMOL
Tier 3
Tier 3
RYTHMOL SR
Tier 3
lorazepam oral tablet
Tier 1
LORAZEPAM
INTENSOL
Tier 3
NIRAVAM ORAL
TABLET
DISPERSIBLE 0.25
MG
Tier 3
oxazepam
mexiletine hcl oral
Tier 1
*ANTIARRHYTHMI
CS TYPE
III**-*ANTIARRHYT
HMICS TYPE III***
amiodarone hcl oral
Tier 1
CORDARONE
Tier 3
MULTAQ
Tier 2
Tier 1
PACERONE
Tier 1
TRANXENE-T
Tier 3
TIKOSYN
Tier 3
VALIUM
Tier 3
XANAX
Tier 3
XANAX XR
Tier 3
*ANTIASTHMATIC
AND
BRONCHODILATOR
AGENTS*
*ANTIARRHYTHMI
CS*
Drug Details
*ANTIASTHMATIC MONOCLONAL
ANTIBODIES**-*AN
TI-IGE
MONOCLONAL
ANTIBODIES***
*ANTIARRHYTHMI
CS TYPE
I-A**-*ANTIARRHY
THMICS TYPE
I-A***
XOLAIR
disopyramide phosphate
oral
Tier 1
NORPACE
Tier 3
NORPACE CR
Tier 3
quinidine gluconate er
Tier 1
quinidine sulfate oral
Tier 1
Tier 2
PA
*ANTI-INFLAMMAT
ORY
AGENTS**-*ANTI-IN
FLAMMATORY
AGENTS***
cromolyn sodium
inhalation
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
15
Drug Name
Drug
Status
Drug Details
*ASTHMA AND
BRONCHODILATOR
AGENT
COMBINATIONS**-*
XANTHINE-EXPECT
ORANTS***
DIFIL-G FORTE
Tier 1
zafirlukast
Tier 1
QL (2 tab per 1
Day)
Tier 3
PA
AEROSPAN
Tier 3
ST; N1
ST; N1
DALIRESP
ATROVENT HFA
Tier 3
ipratropium bromide
inhalation
Tier 1
TUDORZA PRESSAIR
Drug
Status
Drug Details
*SELECTIVE
PHOSPHODIESTER
ASE 4 (PDE4)
INHIBITORS**-*SEL
ECTIVE
PHOSPHODIESTER
ASE 4 (PDE4)
INHIBITORS***
*BRONCHODILATO
RS ANTICHOLINERGIC
S**-*BRONCHODIL
ATORS ANTICHOLINERGIC
S***
SPIRIVA
HANDIHALER
Drug Name
*STEROID
INHALANTS**-*STE
ROID
INHALANTS***
ALVESCO
Tier 3
Tier 2
QL (1 box per
1 fill)
ASMANEX 120
METERED DOSES
Tier 2
Tier 3
PA; ST; N1;
QL (1 pack per
1 fill)
ASMANEX 14
METERED DOSES
Tier 2
ASMANEX 30
METERED DOSES
Tier 2
ASMANEX 60
METERED DOSES
Tier 2
*LEUKOTRIENE
MODULATORS**-*5
-LIPOXYGENASE
INHIBITORS***
ZYFLO
Tier 3
QL (4 tab per 1
Day)
ASMANEX 7
METERED DOSES
Tier 2
Tier 1
PA
Tier 3
QL (4 tab per 1
Day)
budesonide inhalation
ZYFLO CR
FLOVENT DISKUS
Tier 3
ST; N1
FLOVENT HFA
Tier 3
ST; N1
PULMICORT
Tier 3
PA; N1
PULMICORT
FLEXHALER
Tier 3
ST; N1
QVAR
Tier 2
*LEUKOTRIENE
MODULATORS**-*L
EUKOTRIENE
RECEPTOR
ANTAGONISTS***
ACCOLATE
Tier 3
QL (2 tab per 1
Day)
montelukast sodium oral
Tier 1
QL (1 pack per
1 Day)
montelukast sodium oral
Tier 1
QL (1 tab per 1
Day)
Tier 3
ST; N1; QL (1
tab per 1 Day)
SINGULAIR
*SYMPATHOMIMET
ICS**-*ADRENERGI
C
COMBINATIONS***
ADVAIR DISKUS
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
16
Tier 3
PA; ST; N1;
QL (1 disk per
1 fill)
Drug Name
Drug
Status
ADVAIR HFA
ANORO ELLIPTA
BREO ELLIPTA
Drug Details
Drug Name
Drug
Status
Tier 3
PA; ST; N1;
QL (1 inhaler
per 1 fill)
PROVENTIL HFA
Tier 3
ST; N1; QL (2
inhalers per 1
fill)
Tier 3
PA; ST; N1;
QL (2 aerosols
per 1 day)
SEREVENT DISKUS
Tier 2
QL (1 box per
1 fill)
terbutaline sulfate oral
Tier 1
VENTOLIN HFA
Tier 2
VOSPIRE ER
Tier 3
XOPENEX
Tier 3
XOPENEX
CONCENTRATE
Tier 3
Tier 3
COMBIVENT
RESPIMAT
Tier 2
DULERA
Tier 2
DUONEB
Tier 3
ipratropium-albuterol
Tier 1
SYMBICORT
Tier 2
PA; ST; N1;
QL (1 inhaler
per 30 days)
QL (1 inhaler
per 1 fill)
XOPENEX HFA
QL (1 unhaler
per 1 fill)
*SYMPATHOMIMET
ICS**-*BETA
ADRENERGICS***
albuterol sulfate
inhalation
Tier 1
albuterol sulfate oral
Tier 1
albuterol sulfate er
Tier 1
ARCAPTA
NEOHALER
BROVANA
Tier 3
Tier 3
FORADIL
AEROLIZER
Tier 2
levalbuterol hcl
inhalation
Tier 1
PA; ST; QL (1
capsule per 1
day)
PA; ST; N1;
QL (60 vials
(120ml) per 1
fill)
QL (2 capsules
per 1 day)
Tier 3
Drug Details
QL (2 inhalers
per 1 fill)
ST; N1; QL (2
inhalers per 1
fill)
*SYMPATHOMIMET
ICS**-*MIXED
ADRENERGICS***
epinephrine hcl
injection 0.1 mg/ml
Tier 1
epinephrine hcl
injection solution 1
mg/ml
Tier 1
*XANTHINES**-*XA
NTHINES***
ELIXOPHYLLIN
Tier 3
LUFYLLIN
Tier 3
THEO-24
Tier 3
THEOCHRON
Tier 1
theophylline oral
solution
Tier 1
theophylline er
Tier 1
*ANTICOAGULANT
S*
PERFOROMIST
Tier 3
PA; ST; N1;
QL (60 vials
(120ml) per 1
fill)
PROAIR HFA
Tier 2
QL (2 inhalers
per 1 fill)
*COUMARIN
ANTICOAGULANTS
**-*COUMARIN
ANTICOAGULANTS
***
COUMADIN ORAL
Tier 3
JANTOVEN
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
17
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
warfarin sodium oral
Tier 1
LGC
acd formula b
Tier 3
acd-a
Tier 3
ACD-A NOCLOT-50
Tier 3
anticoagulant cit dext
soln a
Tier 3
Tier 3
*DIRECT FACTOR
XA
INHIBITORS**-*DIR
ECT FACTOR XA
INHIBITORS***
ELIQUIS
Tier 2
QL (2 tab per 1
day)
ANTICOAGULANT
COMPOUND
XARELTO ORAL
TABLET 10 MG
Tier 2
QL (35 tab per
365 days)
XARELTO ORAL
TABLET 15 MG
Tier 2
QL (42 tab per
30 days)
*THROMBIN
INHIBITORS**-*TH
ROMBIN
INHIBITORS HIRUDIN TYPE***
XARELTO ORAL
TABLET 20 MG
Tier 2
QL (1 tab per 1
day)
IPRIVASK
PRADAXA
*HEPARINS AND
HEPARINOID-LIKE
AGENTS**-*LOW
MOLECULAR
WEIGHT
HEPARINS***
enoxaparin sodium
Tier 1
PA; QL (2
syringes per 1
day)
FRAGMIN
Tier 3
PA; QL (1 ML
per 1 day)
Tier 3
PA; QL (2
syringes per 1
day)
LOVENOX
*HEPARINS AND
HEPARINOID-LIKE
AGENTS**-*SYNTH
ETIC
HEPARINOID-LIKE
AGENTS***
Tier 3
PA; QL (1 ML
per 1 day)
fondaparinux sodium
Tier 3
PA; QL (1 ML
per 1 day)
*IN VITRO
ANTICOAGULANTS
**-*IN VITRO
ANTICOAGULANTS
***
acd formula a
Tier 3
PA
Tier 3
ST; N1; QL (2
caps per 1 day)
Tier 3
PA; QL (1 tab
per 1 Day)
*ANTICONVULSAN
TS*
*AMPA
GLUTAMATE
RECEPTOR
ANTAGONISTS**-*A
MPA GLUTAMATE
RECEPTOR
ANTAGONISTS***
*ANTICONVULSAN
TS BENZODIAZEPINES
**-*ANTICONVULS
ANTS BENZODIAZEPINES
***
clonazepam oral
Tier 1
DIASTAT ACUDIAL
Tier 3
DIASTAT PEDIATRIC
Tier 3
KLONOPIN
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
18
Tier 3
*THROMBIN
INHIBITORS**-*TH
ROMBIN
INHIBITORS SELECTIVE DIRECT
& REVERSIBLE***
FYCOMPA
ARIXTRA
Drug Details
Drug Name
ONFI ORAL
SUSPENSION
ONFI ORAL TABLET
10 MG, 20 MG
Drug
Status
Drug Details
Tier 3
PA
Tier 3
PA
*ANTICONVULSAN
TS MISC.**-*ANTICON
VULSANTS MISC.***
Drug Name
Drug
Status
MYSOLINE
Tier 3
NEURONTIN ORAL
CAPSULE
Tier 3
NEURONTIN ORAL
SOLUTION
Tier 3
NEURONTIN ORAL
TABLET
Tier 3
oxcarbazepine
Tier 1
OXTELLAR XR
Tier 3
POTIGA ORAL
TABLET 200 MG, 300
MG, 400 MG
Tier 3
PA; QL (3 tab
per 1 Day)
POTIGA ORAL
TABLET 50 MG
Tier 3
PA
APTIOM
Tier 3
BANZEL
Tier 3
carbamazepine oral
Tier 1
carbamazepine er
Tier 1
CARBATROL
Tier 3
EPITOL
Tier 1
LGC
primidone oral
Tier 1
gabapentin oral capsule
Tier 1
QL (6 caps per
1 Day)
TEGRETOL ORAL
SUSPENSION
Tier 3
gabapentin oral solution
Tier 1
TEGRETOL ORAL
TABLET
Tier 3
TEGRETOL-XR
Tier 3
PA
Drug Details
QL (6 caps per
1 Day)
QL (6 tab per 1
Day)
gabapentin oral tablet
Tier 1
QL (6 tab per 1
Day)
KEPPRA ORAL
Tier 3
ST; N1
TOPAMAX
Tier 3
ST; N1
KEPPRA XR
Tier 3
ST; N1
Tier 3
ST; N1
LAMICTAL
Tier 3
TOPAMAX
SPRINKLE
LAMICTAL ODT
Tier 3
TOPIRAGEN
Tier 1
LAMICTAL STARTER
Tier 3
topiramate oral
Tier 1
LAMICTAL XR
Tier 3
TRILEPTAL
Tier 3
lamotrigine oral
Tier 1
lamotrigine er
Tier 1
levetiracetam oral
Tier 1
Tier 3
ST; N1; QL (1
caps per 1 Day)
levetiracetam er
Tier 1
LYRICA ORAL
CAPSULE 100 MG,
150 MG, 200 MG, 25
MG, 50 MG, 75 MG
TROKENDI XR ORAL
CAPSULE
EXTENDED
RELEASE 24 HOUR
100 MG, 25 MG, 50
MG
Tier 3
TROKENDI XR ORAL
CAPSULE
EXTENDED
RELEASE 24 HOUR
200 MG
Tier 3
ST; N1; QL (2
caps per 1 Day)
VIMPAT ORAL
SOLUTION
Tier 3
PA; QL (40 ml
per 1 Day)
VIMPAT ORAL
TABLET 100 MG, 150
MG, 200 MG
Tier 3
PA; QL (2 tab
per 1 Day)
LYRICA ORAL
CAPSULE 225 MG,
300 MG
Tier 3
LYRICA ORAL
SOLUTION
Tier 3
ST; N1
PA; ST; N1;
QL (3 caps per
1 Day)
PA; ST; N1;
QL (2 caps per
1 Day)
PA; ST; N1;
QL (30 ML per
1 Day)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
19
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
Drug Details
PA; QL (6 tab
per 1 Day)
DEPAKOTE ER
Tier 3
ST; N1
Tier 3
ST; N1
VIMPAT ORAL
TABLET 50 MG
Tier 3
ZONEGRAN
Tier 3
DEPAKOTE
SPRINKLES
zonisamide
Tier 1
divalproex sodium
Tier 1
divalproex sodium er
Tier 1
*CARBAMATES**-*
CARBAMATES***
STAVZOR
Tier 3
felbamate
Tier 1
valproic acid oral
Tier 1
FELBATOL
Tier 3
*ANTIDEPRESSANT
S*
*GABA
MODULATORS**-*G
ABA
MODULATORS***
GABITRIL
Tier 3
PA
SABRIL ORAL
PACKET
Tier 3
SABRIL ORAL
TABLET
Tier 3
PA
tiagabine hcl
Tier 1
PA
*HYDANTOINS**-*H
YDANTOINS***
*ALPHA-2
RECEPTOR
ANTAGONISTS
(TETRACYCLICS)**
-*ALPHA-2
RECEPTOR
ANTAGONISTS
(TETRACYCLICS)**
*
mirtazapine oral tablet
15 mg, 30 mg, 45 mg
Tier 1
QL (1 tab per 1
Day)
mirtazapine oral tablet
dispersible
Tier 1
QL (1 tab per 1
Day)
REMERON
Tier 3
ST; N1; QL (1
tab per 1 Day)
Tier 3
ST; N1; QL (1
tab per 1 Day)
DILANTIN
Tier 3
DILANTIN INFATABS
Tier 3
PEGANONE
Tier 3
PHENYTEK ORAL
CAPSULE 300 MG
Tier 3
REMERON SOLTAB
phenytoin oral
Tier 1
PHENYTOIN
INFATABS
Tier 1
phenytoin sodium
extended
Tier 1
*ANTIDEPRESSANT
COMBINATIONS**-*
TRICYCLIC
AGENTS-NUTRITIO
NAL SUPPLEMENT
COMBINATIONS***
*SUCCINIMIDES**-*
SUCCINIMIDES***
SENTRAVIL PM-25
CELONTIN
Tier 3
ethosuximide oral
Tier 1
ZARONTIN
Tier 3
*ANTIDEPRESSANT
SMISC.**-*ANTIDEPR
ESSANTS - MISC.***
*VALPROIC
ACID**-*VALPROIC
ACID***
DEPAKENE
Tier 3
DEPAKOTE
Tier 3
APLENZIN
Tier 3
ST; QL (1
tablet per 1
day)
BUDEPRION SR
Tier 1
QL (6 tab per 1
day)
ST; N1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
20
Tier 3
Drug Name
Drug
Status
Drug Details
Drug Name
BUDEPRION XL
bupropion hcl oral
Tier 1
QL (1 tab per 1
Day)
Tier 1
Tier 1
QL (6 tab per 1
Day)
citalopram
hydrobromide oral
solution
Tier 1
bupropion hcl er (sr)
Tier 1
QL (2 tab per 1
Day)
citalopram
hydrobromide oral
tablet
LGC; QL (1 tab
per 1 Day)
bupropion hcl er (xl)
Tier 1
QL (1 tab per 1
Day)
escitalopram oxalate
oral solution
Tier 1
QL (20 ml per
1 Day)
FORFIVO XL
Tier 3
N1; QL (1 tab
per 1 Day)
escitalopram oxalate
oral tablet
Tier 1
QL (1 tab per 1
Day)
WELLBUTRIN
Tier 3
QL (6 tab per 1
day)
fluoxetine hcl oral
capsule 10 mg
Tier 1
LGC; QL (1
caps per 1 Day)
WELLBUTRIN SR
Tier 3
QL (2 tab per 1
Day)
fluoxetine hcl oral
capsule 20 mg
Tier 1
LGC; QL (4
caps per 1 Day)
WELLBUTRIN XL
Tier 3
QL (1 tab per 1
Day)
fluoxetine hcl oral
capsule 40 mg
Tier 1
LGC; QL (2
caps per 1 Day)
fluoxetine hcl oral
capsule delayed release
Tier 1
QL (1 caps per
7 Days)
fluoxetine hcl oral
solution
Tier 1
QL (10 ml per
1 Day)
fluoxetine hcl oral tablet
10 mg
Tier 1
LGC; QL (1 tab
per 1 Day)
fluoxetine hcl oral tablet
20 mg
Tier 1
QL (4 tab per 1
Day)
fluoxetine hcl oral tablet
60 mg
Tier 3
ST; N1; QL (1
tab per 1 Day)
fluvoxamine maleate
oral tablet 100 mg
Tier 1
QL (3 tab per 1
Day)
fluvoxamine maleate
oral tablet 25 mg, 50 mg
Tier 1
QL (1 tab per 1
Day)
fluvoxamine maleate er
Tier 1
QL (2 caps per
1 Day)
LEXAPRO ORAL
SOLUTION
Tier 3
QL (20 ml per
1 Day)
LEXAPRO ORAL
TABLET
Tier 3
QL (1 tab per 1
Day)
LUVOX CR
Tier 3
QL (2 caps per
1 Day)
paroxetine hcl oral
tablet 10 mg, 20 mg
Tier 1
LGC; QL (1 tab
per 1 Day)
paroxetine hcl oral
tablet 30 mg, 40 mg
Tier 1
LGC; QL (2 tab
per 1 Day)
*MONOAMINE
OXIDASE
INHIBITORS
(MAOIS)**-*MONOA
MINE OXIDASE
INHIBITORS
(MAOIS)***
EMSAM
Tier 3
MARPLAN
Tier 3
NARDIL
Tier 3
PARNATE
Tier 3
phenelzine sulfate oral
Tier 1
tranylcypromine sulfate
Tier 1
QL (1 patch per
1 Day)
*SELECTIVE
SEROTONIN
REUPTAKE
INHIBITORS
(SSRIS)**-*SELECTI
VE SEROTONIN
REUPTAKE
INHIBITORS
(SSRIS)***
CELEXA
Tier 3
N1; QL (1 tab
per 1 Day)
Drug
Status
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
21
Drug Name
Drug
Status
Drug Details
Drug Name
paroxetine hcl er
Tier 1
QL (2 tab per 1
Day)
Tier 3
QL (30 pen per
1 Day)
*SEROTONIN
MODULATORS**-*S
EROTONIN
MODULATORS***
PAXIL ORAL
SUSPENSION
Tier 3
QL (1 tab per 1
Day)
PAXIL ORAL
TABLET 30 MG, 40
MG
Tier 3
QL (2 tab per 1
Day)
PAXIL CR
Tier 3
ST; N1; QL (2
tab per 1 Day)
PEXEVA ORAL
TABLET 10 MG, 20
MG
Tier 3
ST; QL (1
tablet per 1
day)
PEXEVA ORAL
TABLET 30 MG, 40
MG
Tier 3
ST; QL (2
tablets per 1
day)
PROZAC ORAL
CAPSULE 10 MG
Tier 3
QL (1 caps per
1 Day)
PROZAC ORAL
CAPSULE 20 MG
Tier 3
QL (4 caps per
1 Day)
PROZAC ORAL
CAPSULE 40 MG
Tier 3
QL (2 caps per
1 Day)
PROZAC WEEKLY
Tier 3
QL (1 caps per
7 Days)
sertraline hcl oral
concentrate
Tier 1
QL (10 ml per
1 Day)
sertraline hcl oral tablet
100 mg
Tier 1
LGC; QL (2 tab
per 1 Day)
Drug
Status
Drug Details
BRINTELLIX
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
nefazodone hcl oral
tablet 250 mg
Tier 3
ST; N1
trazodone hcl oral
Tier 1
VIIBRYD
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
CYMBALTA ORAL
CAPSULE DELAYED
RELEASE
PARTICLES 20 MG,
30 MG
Tier 3
PA; ST; N1;
QL (2 caps per
1 Day)
CYMBALTA ORAL
CAPSULE DELAYED
RELEASE
PARTICLES 60 MG
Tier 3
PA; ST; N1;
QL (1 caps per
1 Day)
Tier 1
LGC; QL (1 tab
per 1 Day)
desvenlafaxine er
Tier 3
PA; ST; N1;
QL (1 tablet per
1 day)
sertraline hcl oral tablet
50 mg
Tier 1
LGC; QL (45
tab per 30
Days)
duloxetine hcl oral
capsule delayed release
particles 20 mg, 30 mg
Tier 3
PA; N1; QL (2
caps per 1 Day)
ZOLOFT ORAL
CONCENTRATE
Tier 3
QL (10 ml per
1 Day)
Tier 3
ZOLOFT ORAL
TABLET 100 MG
PA; N1; QL (1
caps per 1 Day)
Tier 3
duloxetine hcl oral
capsule delayed release
particles 60 mg
ZOLOFT ORAL
TABLET 25 MG
Tier 3
QL (1 tab per 1
Day)
Tier 3
ZOLOFT ORAL
TABLET 50 MG
QL (45 tab per
30 Days)
QL (2 caps per
1 Day)
Tier 3
EFFEXOR XR ORAL
CAPSULE
EXTENDED
RELEASE 24 HOUR
150 MG
PAXIL ORAL
TABLET 10 MG, 20
MG
sertraline hcl oral tablet
25 mg
QL (2 tab per 1
Day)
*SEROTONIN-NORE
PINEPHRINE
REUPTAKE
INHIBITORS
(SNRIS)**-*SEROTO
NIN-NOREPINEPHR
INE REUPTAKE
INHIBITORS
(SNRIS)***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
22
Drug Name
Drug
Status
Drug Details
amitriptyline hcl oral
tablet 10 mg, 100 mg,
25 mg, 50 mg, 75 mg
Tier 1
LGC
amitriptyline hcl oral
tablet 150 mg
Tier 1
Tier 3
PA; ST; N1;
QL (1 capsule
per 1 day)
ANAFRANIL
Tier 3
clomipramine hcl oral
Tier 1
desipramine hcl oral
Tier 1
FETZIMA TITRATION
Tier 3
PA; ST; N1;
QL (1 titration
pack per 28
days)
doxepin hcl oral capsule
10 mg, 100 mg, 150 mg,
25 mg, 50 mg
Tier 1
KHEDEZLA
Tier 3
PA; ST; N1;
QL (1 tablet per
1 day)
doxepin hcl oral
concentrate
Tier 1
imipramine hcl oral
Tier 1
PRISTIQ
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
imipramine pamoate
Tier 1
NORPRAMIN
Tier 3
venlafaxine hcl oral
tablet 100 mg, 25 mg
Tier 1
QL (3 tab per 1
Day)
nortriptyline hcl oral
capsule 10 mg, 25 mg
Tier 1
venlafaxine hcl oral
tablet 37.5 mg
Tier 1
QL (4 tab per 1
Day)
nortriptyline hcl oral
capsule 50 mg, 75 mg
Tier 1
venlafaxine hcl oral
tablet 50 mg
QL (6 tab per 1
Day)
PAMELOR
Tier 3
Tier 1
protriptyline hcl
Tier 1
venlafaxine hcl oral
tablet 75 mg
Tier 1
QL (5 tab per 1
Day)
SURMONTIL
Tier 3
TOFRANIL
Tier 3
venlafaxine hcl er oral
capsule extended
release 24 hour 150 mg
Tier 1
QL (2 caps per
1 Day)
TOFRANIL-PM
Tier 3
VIVACTIL
Tier 3
EFFEXOR XR ORAL
CAPSULE
EXTENDED
RELEASE 24 HOUR
37.5 MG, 75 MG
FETZIMA
Drug
Status
Tier 3
Drug Details
QL (1 caps per
1 Day)
Tier 1
QL (1 caps per
1 Day)
venlafaxine hcl er oral
tablet extended release
24 hr* 150 mg, 37.5 mg,
75 mg
Tier 3
QL (1 tablet per
1 day)
*TRICYCLIC
AGENTS**-*TRICYC
LIC AGENTS***
LGC
*ANTIDIABETICS*
venlafaxine hcl er oral
capsule extended
release 24 hour 37.5
mg, 75 mg
venlafaxine hcl er oral
tablet extended release
24 hr* 225 mg
Drug Name
Tier 3
ST; N1; QL (1
tablet per 1
Day)
*ALPHA-GLUCOSID
ASE
INHIBITORS**-*ALP
HA-GLUCOSIDASE
INHIBITORS***
acarbose
Tier 1
GLYSET
Tier 3
PRECOSE
Tier 3
*ANTIDIABETIC AMYLIN
ANALOGS**-*ANTI
DIABETIC AMYLIN
ANALOGS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
23
Drug Name
Drug
Status
Drug Details
Drug Name
SYMLINPEN 120
Tier 2
PA
SYMLINPEN 60
Tier 2
PA
*ANTIDIABETIC
COMBINATIONS**-*
SULFONYLUREA-BI
GUANIDE
COMBINATIONS***
*ANTIDIABETIC
COMBINATIONS**-*
DIPEPTIDYL
PEPTIDASE-4
INHIBITOR-BIGUAN
IDE
COMBINATIONS***
JANUMET
JANUMET XR ORAL
TABLET EXTENDED
RELEASE 24 HR*
100-1000 MG, 50-500
MG
JANUMET XR ORAL
TABLET EXTENDED
RELEASE 24 HR*
50-1000 MG
JENTADUETO
KAZANO
KOMBIGLYZE XR
Tier 2
ST; N1; QL (2
tablets per 1
day)
Tier 2
ST; N1; QL (1
tablet per 1
day)
Tier 1
GLUCOVANCE
Tier 3
glyburide-metformin
Tier 1
*ANTIDIABETIC
COMBINATIONS**-*
SULFONYLUREA-T
HIAZOLIDINEDION
E
COMBINATIONS***
AVANDARYL
Tier 3
PA
DUETACT
Tier 3
ST; N1
pioglitazone
hcl-glimepiride
Tier 1
Tier 2
Tier 3
PA; ST; N1;
QL (2 tablets
per 1 day)
ACTOPLUS MET
Tier 3
ST; N1
Tier 3
PA; ST; N1;
QL (2 tab per 1
Day)
ACTOPLUS MET XR
Tier 3
ST; N1
AVANDAMET
Tier 3
PA
Tier 2
ST; N1; QL (1
tablet per 1
day)
pioglitazone
hcl-metformin hcl
Tier 1
Tier 3
*ANTIDIABETIC
COMBINATIONS**-*
MEGLITINIDE-BIGU
ANIDE
COMBINATIONS***
PRANDIMET
glipizide-metformin hcl
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
*ANTIDIABETIC
COMBINATIONS**-*
THIAZOLIDINEDIO
NE-BIGUANIDE
COMBINATIONS***
*BIGUANIDES**-*BI
GUANIDES***
GLUCOPHAGE
Tier 3
GLUCOPHAGE XR
Tier 3
GLUMETZA
Tier 3
metformin hcl oral
Tier 1
LGC
metformin hcl er oral
tablet extended release
24 hr* 500 mg
Tier 1
LGC
metformin hcl er oral
tablet extended release
24 hr* 750 mg
Tier 1
metformin hcl er (osm)
Tier 1
RIOMET
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
24
Drug Details
ST; N1; QL (2
tablets per 1
day)
*ANTIDIABETIC
COMBINATIONS**-*
DPP-4
INHIBITOR-THIAZO
LIDINEDIONE
COMBINATIONS***
OSENI
Drug
Status
Drug Name
Drug
Status
*DIABETIC
OTHER**-*DIABETI
C OTHER COMBINATIONS***
Drug Details
Drug Name
walgreens glucose oral
tablet chewable 4-6
gm-mg
cvs glucose oral tablet
chewable 4-6 gm-mg
Tier 3
DEX4 ORAL TABLET
CHEWABLE 4-6
GM-MG
Tier 3
DEX4 NATURALS
Tier 3
DEX4 POUCH PACK
Drug
Status
Drug Details
Tier 3
*DIABETIC
OTHER**-*DIABETI
C OTHER***
BD GLUCOSE
Tier 3
cvs glucose oral 15
gm/38gm, 40 %
Tier 1
Tier 3
cvs glucose oral tablet
chewable 4 gm
Tier 3
drug mart glucose
Tier 3
cvs glucose bits
Tier 3
glucose oral tablet
chewable 4-6 gm-mg
Tier 3
cvs glucose shot oral
liquid† 15 gm/59ml
Tier 1
gnp glucose oral tablet
chewable 4-6 gm-mg
Tier 3
DEX4 ORAL TABLET
CHEWABLE 1 GM
Tier 3
hm glucose
Tier 3
Tier 1
hy-vee glucose
Tier 3
DEX4 GLUCOSE
ORAL 15 GM/38GM
kroger glucose oral
tablet chewable
Tier 3
DEX4 GLUCOSE
ORAL LIQUID†
Tier 3
leader glucose
Tier 3
Tier 3
longs glucose
Tier 3
DEX4 QUICK
DISSOLVE GLUCOSE
meijer glucose
Tier 3
GLUCAGEN
Tier 3
preferred plus glucose
Tier 3
GLUCAGEN
HYPOKIT
Tier 3
px glucose
Tier 3
ra glucose oral tablet
chewable
Tier 3
Tier 3
GLUCAGON
EMERGENCY
GLUCO BURST ORAL
40 %
Tier 1
RELION GLUCOSE
ORAL TABLET
CHEWABLE
Tier 3
glucose oral 40 %
Tier 1
sm glucose oral tablet
chewable 4-6 gm-mg
Tier 3
glucose oral tablet
chewable 4 gm
Tier 3
SMART SENSE
GLUCOSE
GLUTOSE 15
Tier 1
Tier 3
GLUTOSE 45
Tier 1
tgt glucose oral tablet
chewable 4-6 gm-mg
Tier 3
gnp glucose oral tablet
chewable 4 gm
Tier 3
up & up glucose
Tier 3
Tier 3
value plus glucose oral
tablet chewable
gnp quick dissolve
glucose
Tier 3
INSTA-GLUCOSE
ORAL 40 %
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
25
Drug Name
Drug
Status
leader quick dissolve
glucose
Tier 3
ms quick dissolve
glucose
Tier 3
PROGLYCEM
Tier 2
ra glucose oral 40 %
Tier 1
RELION GLUCOSE
ORAL 15 GM/38GM
Tier 1
RELION GLUCOSE
DRINK
Tier 1
sm glucose oral tablet
chewable 4 gm
Tier 3
ultilet glucose
Tier 3
value plus glucose oral
40 %
Tier 1
walgreens glucose oral
tablet chewable 4 gm
Tier 3
Drug Details
NESINA
ONGLYZA
TRADJENTA
Tier 3
CYCLOSET
PA; ST; N1;
QL (1 tablet per
1 day)
Tier 2
BYDUREON
SUBCUTANEOUS* 2
MG
Tier 2
ST; QL (4 pens
per 28 days)
BYDUREON
SUBCUTANEOUS*
SUSPENSION
RECONSTITUTED
Tier 2
ST; N1; QL (4
vials per 28
days)
BYETTA 10 MCG PEN
Tier 3
ST; N1; QL (1
pen per 30
days)
BYETTA 5 MCG PEN
Tier 3
ST; N1; QL (1
pen per 30
days)
Tier 2
ST; N1; QL (1
tablet per 1
day)
TANZEUM
Tier 3
PA; ST; N1;
QL (4 pens per
28 days)
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
VICTOZA
Tier 3
PA; ST; N1;
QL (3 pen per
30 days)
Tier 2
ST; N1; QL (1
tablet per 1
day)
ACTOS
Tier 3
ST; N1
AVANDIA
Tier 3
PA
Tier 3
PA; QL (4 tab
per 1 Day)
*INSULIN
SENSITIZING
AGENTS**-*THIAZ
OLIDINEDIONES***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
26
Drug Details
*INCRETIN
MIMETIC AGENTS
(GLP-1 RECEPTOR
AGONISTS)**-*INCR
ETIN MIMETIC
AGENTS (GLP-1
RECEPTOR
AGONISTS)***
*DIPEPTIDYL
PEPTIDASE-4
(DPP-4)
INHIBITORS**-*DIP
EPTIDYL
PEPTIDASE-4
(DPP-4)
INHIBITORS***
JANUVIA
Drug
Status
*DOPAMINE
RECEPTOR
AGONISTS ANTIDIABETIC**-*
DOPAMINE
RECEPTOR
AGONISTS - ERGOT
DERIVATIVES***
*DIABETIC
OTHER**-*PROGES
TERONE
RECEPTOR
ANTAGONISTS***
KORLYM
Drug Name
Drug Name
Drug
Status
pioglitazone hcl
Tier 1
*INSULIN**-*HUMA
N INSULIN***
APIDRA
Tier 3
APIDRA SOLOSTAR
Tier 3
HUMALOG
KWIKPEN
Tier 2
HUMALOG MIX 50/50
Tier 2
HUMALOG MIX 50/50
KWIKPEN
Tier 2
HUMALOG MIX 50/50
PEN
Tier 2
HUMALOG MIX 75/25
Tier 2
HUMALOG MIX 75/25
KWIKPEN
Drug Details
Drug Name
Drug
Status
Drug Details
PRANDIN
Tier 3
ST; N1
repaglinide
Tier 1
STARLIX
Tier 3
*SODIUM-GLUCOSE
CO-TRANSPORTER
2 (SGLT2)
INHIBITORS**-*SO
DIUM-GLUCOSE
CO-TRANSPORTER
2 (SGLT2)
INHIBITORS***
FARXIGA
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
Tier 2
INVOKANA
Tier 2
HUMALOG MIX 75/25
PEN
ST; N1; QL (1
tablet per 1
day)
Tier 2
HUMALOG PEN
Tier 2
*SULFONYLUREAS*
*-*SULFONYLUREA
S***
HUMULIN 70/30
KWIKPEN
Tier 2
AMARYL
Tier 3
HUMULIN 70/30 PEN
Tier 2
chlorpropamide oral
tablet 100 mg
Tier 1
HUMULIN N
KWIKPEN
Tier 2
DIABETA
Tier 3
HUMULIN N PEN
Tier 2
glimepiride
Tier 1
LGC
HUMULIN R U-500
(CONCENTRATED)
glipizide oral
Tier 1
LGC
Tier 2
LANTUS
Tier 2
glipizide er oral tablet
extended release 24 hr*
10 mg, 5 mg
Tier 1
LGC
LANTUS SOLOSTAR
Tier 2
LEVEMIR
Tier 2
Tier 1
LEVEMIR FLEXPEN
Tier 2
glipizide er oral tablet
extended release 24 hr*
2.5 mg
NOVOLOG
Tier 2
GLIPIZIDE XL
Tier 1
NOVOLOG FLEXPEN
Tier 2
GLUCOTROL
Tier 3
NOVOLOG MIX 70/30
Tier 2
GLUCOTROL XL
Tier 3
NOVOLOG MIX 70/30
FLEXPEN
Tier 2
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
*MEGLITINIDE
ANALOGUES**-*ME
GLITINIDE
ANALOGUES***
nateglinide
LGC
LGC
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
27
Drug Name
Drug
Status
Drug Details
glyburide micronized
oral tablet 3 mg, 6 mg
Tier 1
LGC
glycron oral tablet 1.5
mg, 3 mg, 6 mg
Tier 1
GLYNASE
Tier 3
tolazamide oral tablet
250 mg
Tier 1
Drug Name
Drug
Status
deferoxamine mesylate
Tier 1
DESFERAL
Tier 3
RADIOGARDASE
Tier 2
*OPIOID
ANTAGONISTS**-*O
PIOID
ANTAGONISTS***
*ANTIDIARRHEALS
*
DEPADE
Tier 1
EVZIO
Tier 3
*ANTIDIARRHEAL CHLORIDE
CHANNEL
ANTAGONISTS**-*A
NTIDIARRHEAL CHLORIDE
CHANNEL
ANTAGONISTS***
naltrexone hcl oral
Tier 1
REVIA
Tier 3
VIVITROL
Tier 3
FULYZAQ
Tier 3
diphenatol
Tier 1
diphenoxylate-atropine
oral tablet
Tier 1
lofene
Tier 1
LOMOTIL
Tier 3
LONOX
Tier 1
MOTOFEN
Tier 3
opium
Tier 1
*ANTIDOTES*
*ANTIDOTES CHELATING
AGENTS**-*ANTID
OTES - CHELATING
AGENTS***
CHEMET
Tier 2
EXJADE
Tier 3
FERRIPROX
Tier 3
PA; QL (2 tab
per 1 Day)
*5-HT3 RECEPTOR
ANTAGONISTS**-*5
-HT3 RECEPTOR
ANTAGONISTS***
ANZEMET ORAL
Tier 3
QL (5 tab per
30 Days)
granisetron hcl oral
Tier 1
QL (10 tab per
30 Days)
GRANISOL
Tier 3
QL (2 bottle
per 30 Days)
ondansetron
Tier 1
QL (12 tab per
30 Days)
ondansetron hcl oral
solution
Tier 1
QL (1 bottle
per 30 Days)
ondansetron hcl oral
tablet 24 mg
Tier 1
QL (5 tablets
per 30 days)
ondansetron hcl oral
tablet 4 mg, 8 mg
Tier 1
QL (12 tab per
30 Days)
SANCUSO
Tier 3
QL (1 patch per
21 Days)
ZOFRAN ORAL
SOLUTION
Tier 3
QL (1 bottle
per 30 Days)
ZOFRAN ORAL
TABLET
Tier 3
QL (12 tab per
30 Days)
ZOFRAN ODT
Tier 3
QL (12 tab per
30 Days)
ZUPLENZ
Tier 3
QL (12 pack
per 30 Days)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
28
PA
*ANTIEMETICS*
*ANTIPERISTALTIC
AGENTS**-*ANTIPE
RISTALTIC
AGENTS***
*ANTIDOTES**-*AN
TIDOTES***
Drug Details
Drug Name
Drug
Status
Drug Details
*ANTIEMETICS ANTICHOLINERGIC
**-*ANTIEMETICS ANTICHOLINERGIC
***
Drug Name
Drug
Status
bio-statin oral capsule
Tier 3
bio-statin oral powder
Tier 1
flucytosine oral
Tier 1
GRIFULVIN V
Tier 3
TIGAN ORAL
Tier 3
GRIS-PEG
Tier 3
TRANSDERM-SCOP
Tier 3
Tier 1
trimethobenzamide hcl
oral
griseofulvin microsize
oral
Tier 1
griseofulvin
ultramicrosize
Tier 1
LAMISIL
Tier 3
nystatin oral
Tier 1
terbinafine hcl oral
Tier 1
*ANTIEMETICS MISCELLANEOUS**
-*ANTIEMETIC
COMBINATIONS***
DICLEGIS
Tier 3
PA; ST; N1;
QL (4 tab per 1
Day)
*ANTIEMETICS MISCELLANEOUS**
-*ANTIEMETICS MISCELLANEOUS**
*
Tier 3
QL (20 caps
per 30 Days)
dronabinol
Tier 1
PA
MARINOL
Tier 3
PA
PA
PA
*IMIDAZOLE-RELA
TED
ANTIFUNGALS**-*I
MIDAZOLES***
ketoconazole oral
CESAMET
Drug Details
Tier 1
*IMIDAZOLE-RELA
TED
ANTIFUNGALS**-*T
RIAZOLES***
DIFLUCAN ORAL
SUSPENSION
RECONSTITUTED
Tier 3
PA
DIFLUCAN ORAL
TABLET 100 MG, 200
MG, 50 MG
Tier 3
PA
DIFLUCAN ORAL
TABLET 150 MG
Tier 3
QL (1 tab per
30 Days)
fluconazole oral
suspension reconstituted
Tier 1
PA
fluconazole oral tablet
100 mg, 200 mg, 50 mg
Tier 1
PA
fluconazole oral tablet
150 mg
Tier 1
QL (1 tab per
30 Days)
itraconazole oral
Tier 1
PA
NOXAFIL
Tier 3
ONMEL
Tier 3
PA
*ANTIFUNGALS*
SPORANOX
Tier 3
PA
*ANTIFUNGALS**-*
ANTIFUNGALS***
SPORANOX
PULSEPAK
Tier 3
PA
*SUBSTANCE
P/NEUROKININ 1
(NK1) RECEPTOR
ANTAGONISTS**-*S
UBSTANCE
P/NEUROKININ 1
(NK1) RECEPTOR
ANTAGONISTS***
EMEND ORAL
CAPSULE 125 MG, 40
MG
Tier 2
EMEND ORAL
CAPSULE 80 & 125
MG
Tier 2
#; QL (6 caps
per 30 Days)
Tier 2
#; QL (3 pack
per 30 Days)
EMEND ORAL
CAPSULE 80 MG
#; QL (5 caps
per 30 Days)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
29
Drug Name
Drug
Status
VFEND
Tier 3
voriconazole oral
Tier 1
Drug Details
*ANTIHISTAMINES*
*ANTIHISTAMINES
ALKYLAMINES**-*
ANTIHISTAMINES ALKYLAMINES***
Drug Name
Drug
Status
Drug Details
desloratadine
Tier 1
PA; QL (1 tab
per 1 Day)
kp cetirizine hcl oral
tablet 5 mg
Tier 1
LGC
levocetirizine
dihydrochloride oral
solution
Tier 1
PA; QL (10 ml
per 1 Day)
Tier 1
PA; QL (1 tab
per 1 Day)
ED CHLORPED ORAL
SUSPENSION
Tier 3
levocetirizine
dihydrochloride oral
tablet
ED-CHLOR-TAN
Tier 3
loratadine oral tablet
Tier 1
LGC
RESPA-BR
Tier 3
WAL-ITIN ORAL
SYRUP
Tier 1
LGC
XYZAL ORAL
SOLUTION
Tier 3
PA; QL (10 ml
per 1 Day)
XYZAL ORAL
TABLET
Tier 3
PA; QL (1 tab
per 1 Day)
PHENADOZ
Tier 1
PA
promethazine hcl oral
Tier 1
PA
promethazine hcl
suppository 12.5 mg, 25
mg
Tier 1
PA
PROMETHEGAN
SUPPOSITORY 12.5
MG, 25 MG
Tier 1
PA
PROMETHEGAN
SUPPOSITORY 50 MG
Tier 3
PA
*ANTIHISTAMINES
ETHANOLAMINES*
*-*ANTIHISTAMINE
SETHANOLAMINES*
**
ARBINOXA
Tier 1
carbinoxamine maleate
oral
Tier 1
clemastine fumarate
oral tablet 2.68 mg
Tier 1
DOXYTEX
Tier 3
KARBINAL ER
Tier 3
PALGIC ORAL
SOLUTION
Tier 3
*ANTIHISTAMINES
PHENOTHIAZINES*
*-*ANTIHISTAMINE
SPHENOTHIAZINES*
**
*ANTIHISTAMINES
NON-SEDATING**-*
ANTIHISTAMINES NON-SEDATING***
cetirizine hcl oral syrup
5 mg/5ml
Tier 1
LGC
CLARINEX ORAL
SYRUP
Tier 3
PA; QL (10 ml
per 1 Day)
CLARINEX ORAL
TABLET
Tier 3
PA; QL (1 tab
per 1 Day)
CLARINEX
REDITABS
Tier 3
PA; QL (1 tab
per 1 Day)
*ANTIHISTAMINES
PIPERIDINES**-*AN
TIHISTAMINES PIPERIDINES***
cyproheptadine hcl oral
*ANTIHYPERLIPID
EMICS*
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
30
Tier 1
Drug Name
Drug
Status
Drug Details
*ANTIHYPERLIPID
EMICS COMBINATIONS**-*
INTEST CHOLEST
ABSORP
INHIB-HMG COA
REDUCTASE INHIB
COMB***
LIPTRUZET
Tier 3
ST; N1; QL (1
tab per 1 day)
VYTORIN
Tier 3
ST; N1; QL (1
tab per 1 Day)
*ANTIHYPERLIPID
EMICS MISC.**-*ANTIHYP
ERLIPIDEMICS MISC.***
KYNAMRO
LOVAZA
Tier 3
PA; ST; N1;
QL (4 syringes
per 1 fill)
Tier 3
ST; N1; QL (4
capsules per 1
day)
omega-3-acid ethyl
esters
Tier 3
VASCEPA
Tier 2
*BILE ACID
SEQUESTRANTS**-*
BILE ACID
SEQUESTRANTS***
ST; N1; QL (4
capsules per 1
day)
Drug Name
Drug
Status
Drug Details
PREVALITE
Tier 1
QUESTRAN
Tier 3
QUESTRAN LIGHT
ORAL POWDER
Tier 3
WELCHOL
Tier 2
#
ANTARA
Tier 3
ST; N1
fenofibrate oral tablet
Tier 1
fenofibrate micronized
Tier 1
fenofibric acid oral
capsule delayed release
Tier 1
FENOGLIDE
Tier 3
ST; N1; #
FIBRICOR
Tier 3
ST; N1
gemfibrozil oral
Tier 1
LGC
LIPOFEN
Tier 3
ST; N1; #
LOFIBRA
Tier 3
ST; N1
LOPID
Tier 3
ST; N1
TRICOR
Tier 3
ST; N1
TRIGLIDE ORAL
TABLET 160 MG
Tier 3
ST; N1
TRILIPIX
Tier 3
ST; N1
*FIBRIC ACID
DERIVATIVES**-*FI
BRIC ACID
DERIVATIVES***
cholestyramine oral
Tier 1
cholestyramine light
Tier 1
*HMG COA
REDUCTASE
INHIBITORS**-*HM
G COA REDUCTASE
INHIBITOR
COMBINATIONS***
COLESTID ORAL
PACKET
Tier 3
ADVICOR
Tier 3
QL (2 tab per 1
Day)
COLESTID ORAL
TABLET
Tier 3
COLESTID
FLAVORED ORAL
PACKET
Tier 3
QL (2 tab per 1
Day)
Tier 3
SIMCOR ORAL
TABLET EXTENDED
RELEASE 24 HR*
1000-20 MG, 500-20
MG, 750-20 MG
colestipol hcl
Tier 1
SIMCOR ORAL
TABLET EXTENDED
RELEASE 24 HR*
1000-40 MG, 500-40
MG
Tier 3
QL (1 tab per 1
Day)
micronized colestipol
hcl
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
31
Drug Name
Drug
Status
Drug Details
Drug Name
ST; N1; QL (1
tab per 1 Day)
*INTESTINAL
CHOLESTEROL
ABSORPTION
INHIBITORS**-*INT
ESTINAL
CHOLESTEROL
ABSORPTION
INHIBITORS***
*HMG COA
REDUCTASE
INHIBITORS**-*HM
G COA REDUCTASE
INHIBITORS***
ALTOPREV ORAL
TABLET EXTENDED
RELEASE 24 HR* 20
MG, 60 MG
Tier 3
ALTOPREV ORAL
TABLET EXTENDED
RELEASE 24 HR* 40
MG
Tier 3
ST; N1; QL (2
tab per 1 Day)
atorvastatin calcium
Tier 1
QL (1 tab per 1
Day)
CRESTOR
Tier 2
QL (1 tab per 1
Day)
fluvastatin sodium
Tier 1
QL (2 caps per
1 Day)
LESCOL
Tier 3
ST; N1; QL (2
caps per 1 day)
LESCOL XL
Tier 3
ST; N1; QL (1
tab per 1 day)
LIPITOR
Tier 3
ST; N1; QL (1
tab per 1 day)
LIVALO
Tier 3
ST; N1; QL (1
tab per 1 day)
lovastatin
Tier 1
LGC; QL (2 tab
per 1 Day)
MEVACOR
Tier 3
QL (2 tab per 1
Day)
ZETIA
Drug
Status
Drug Details
Tier 2
QL (1 tab per 1
day)
Tier 3
PA; ST; N1;
QL (28
capsules per 1
fill)
Tier 3
PA; ST; N1;
QL (84
capsules per 1
fill)
Tier 3
PA; ST; N1;
QL (14
capsules per 1
fill)
*MICROSOMAL
TRIGLYCERIDE
TRANSFER
PROTEIN (MTP)
INHIBITORS**-*MI
CROSOMAL
TRIGLYCERIDE
TRANSFER
PROTEIN
INHIBITORS***
JUXTAPID ORAL
CAPSULE 10 MG
JUXTAPID ORAL
CAPSULE 20 MG
JUXTAPID ORAL
CAPSULE 5 MG
*NICOTINIC ACID
DERIVATIVES**-*NI
COTINIC ACID
DERIVATIVES***
PRAVACHOL ORAL
TABLET 20 MG, 40
MG, 80 MG
Tier 3
QL (1 tab per 1
Day)
pravastatin sodium
Tier 1
LGC; QL (1 tab
per 1 Day)
niacin er
(antihyperlipidemic)
Tier 1
simvastatin oral
Tier 1
LGC; QL (1 tab
per 1 Day)
NIACOR
Tier 3
ST; N1
NIASPAN
Tier 2
ST; N1
Tier 3
QL (1 tab per 1
Day)
*ANTIHYPERTENSI
VES*
ZOCOR
*ACE
INHIBITORS**-*AC
E INHIBITORS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
32
Drug Name
Drug
Status
ACCUPRIL
Tier 3
Drug Details
Drug Name
Drug
Status
Drug Details
ATACAND ORAL
TABLET 16 MG, 4
MG, 8 MG
Tier 3
PA; ST; N1;
QL (2 tab per 1
Day)
ATACAND ORAL
TABLET 32 MG
Tier 3
PA; ST; N1
AVAPRO ORAL
TABLET 150 MG, 75
MG
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
ACEON ORAL
TABLET 4 MG, 8 MG
Tier 3
ALTACE
Tier 3
benazepril hcl oral
Tier 1
LGC
captopril oral
Tier 1
LGC
enalapril maleate oral
Tier 1
LGC
EPANED
Tier 3
PA; ST; N1
Tier 3
PA; ST; N1
fosinopril sodium
Tier 1
AVAPRO ORAL
TABLET 300 MG
lisinopril oral tablet 10
mg, 2.5 mg, 20 mg, 5 mg
Tier 1
LGC
BENICAR ORAL
TABLET 20 MG, 5 MG
Tier 3
lisinopril oral tablet 30
mg, 40 mg
PA; ST; N1;
QL (1 tab per 1
Day)
Tier 1
Tier 3
PA; ST; N1
LOTENSIN
Tier 3
BENICAR ORAL
TABLET 40 MG
MAVIK
Tier 3
Tier 1
moexipril hcl
Tier 1
candesartan cilexetil
oral tablet 16 mg, 4 mg,
8 mg
QL (2 tab per 1
Day)
perindopril erbumine
Tier 1
Tier 1
PRINIVIL
Tier 3
candesartan cilexetil
oral tablet 32 mg
quinapril hcl
Tier 1
ramipril
Tier 1
COZAAR ORAL
TABLET 25 MG, 50
MG
Tier 3
PA; ST; N1;
QL (2 tab per 1
Day)
trandolapril
Tier 1
UNIVASC
Tier 3
Tier 3
VASOTEC
Tier 3
DIOVAN ORAL
TABLET 160 MG, 40
MG, 80 MG
PA; ST; N1;
QL (2 tab per 1
Day)
ZESTRIL
Tier 3
DIOVAN ORAL
TABLET 320 MG
Tier 3
PA; ST; N1
EDARBI
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
eprosartan mesylate
Tier 1
irbesartan oral tablet
150 mg, 75 mg
Tier 1
irbesartan oral tablet
300 mg
Tier 1
losartan potassium oral
tablet 100 mg
Tier 1
LGC
losartan potassium oral
tablet 25 mg, 50 mg
Tier 1
LGC; QL (2 tab
per 1 Day)
TEVETEN ORAL
TABLET 600 MG
Tier 3
PA; ST; N1
*AGENTS FOR
PHEOCHROMOCYT
OMA**-*AGENTS
FOR
PHEOCHROMOCYT
OMA***
DEMSER
Tier 3
DIBENZYLINE
Tier 2
*ANGIOTENSIN II
RECEPTOR
ANTAGONISTS**-*A
NGIOTENSIN II
RECEPTOR
ANTAGONISTS***
QL (1 tab per 1
Day)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
33
Drug Name
Drug
Status
Drug Details
*ANTIADRENERGIC
ANTIHYPERTENSIV
ES**-*ANTIADRENE
RGICS CENTRALLY
ACTING***
CATAPRES
Tier 3
CATAPRES-TTS-1
Tier 3
CATAPRES-TTS-2
Tier 3
CATAPRES-TTS-3
Tier 3
clonidine hcl oral
Tier 1
clonidine hcl
transdermal
Drug Name
Drug
Status
LOTREL ORAL
CAPSULE 10-40 MG,
5-40 MG
Tier 3
TARKA
Tier 3
Drug Details
#
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
ACE INHIBITORS &
THIAZIDE/THIAZID
E-LIKE***
ACCURETIC
Tier 3
Tier 1
benazepril-hydrochlorot
hiazide
Tier 1
LGC
guanfacine hcl oral
Tier 1
enalapril-hydrochloroth
iazide
Tier 1
LGC
methyldopa oral
Tier 1
fosinopril sodium-hctz
Tier 1
TENEX
Tier 3
lisinopril-hydrochloroth
iazide
Tier 1
LOTENSIN HCT
Tier 3
moexipril-hydrochloroth
iazide
Tier 1
PRINZIDE
Tier 3
Tier 1
LGC
quinapril-hydrochloroth
iazide
Tier 3
LGC
*ANTIADRENERGIC
ANTIHYPERTENSIV
ES**-*ANTIADRENE
RGICS PERIPHERALLY
ACTING***
CARDURA
Tier 3
doxazosin mesylate
Tier 1
MINIPRESS
Tier 3
prazosin hcl oral
Tier 1
LGC
UNIRETIC ORAL
TABLET 15-12.5 MG,
7.5-12.5 MG
terazosin hcl oral
Tier 1
LGC
VASERETIC
Tier 3
ZESTORETIC
Tier 3
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
ACE INHIBITOR &
CALCIUM
CHANNEL
BLOCKER
COMBINATIONS***
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
ADRENOLYTICS-CE
NTRAL &
THIAZIDE/THIAZID
E-LIKE COMB***
amlodipine
besy-benazepril hcl
Tier 1
LOTREL ORAL
CAPSULE 10-20 MG,
2.5-10 MG, 5-10 MG,
5-20 MG
Tier 3
CLORPRES
ST; N1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
34
Tier 3
LGC
Drug Name
Drug
Status
Drug Details
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
ANGIOTENSIN II
RECEPTOR ANTAG
& CA CHANNEL
BLOCKER COMB***
Drug Name
Drug
Status
Drug Details
DIOVAN HCT ORAL
TABLET 160-12.5 MG,
160-25 MG, 80-12.5
MG
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
DIOVAN HCT ORAL
TABLET 320-12.5 MG,
320-25 MG
Tier 3
PA; ST; N1
EDARBYCLOR
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
HYZAAR ORAL
TABLET 100-12.5 MG,
100-25 MG
Tier 3
PA; ST; N1
HYZAAR ORAL
TABLET 50-12.5 MG
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
irbesartan-hydrochlorot
hiazide oral tablet
150-12.5 mg
Tier 1
QL (1 tab per 1
Day)
PA; ST; N1;
QL (2 tab per 1
Day)
irbesartan-hydrochlorot
hiazide oral tablet
300-12.5 mg
Tier 1
Tier 3
PA; ST; N1
losartan potassium-hctz
oral tablet 100-12.5 mg,
100-25 mg
Tier 1
LGC
AVALIDE ORAL
TABLET 150-12.5 MG
losartan potassium-hctz
oral tablet 50-12.5 mg
Tier 1
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
LGC; QL (1 tab
per 1 Day)
TEVETEN HCT
Tier 3
PA; ST; N1; #
AVALIDE ORAL
TABLET 300-12.5 MG
Tier 3
Tier 1
QL (1 tab per 1
Day)
BENICAR HCT ORAL
TABLET 20-12.5 MG
Tier 3
valsartan-hydrochloroth
iazide oral tablet
160-12.5 mg, 160-25
mg, 80-12.5 mg
valsartan-hydrochloroth
iazide oral tablet
320-12.5 mg, 320-25 mg
Tier 1
AZOR
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
EXFORGE
Tier 2
#; QL (1 tab
per 1 Day)
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
ANGIOTENSIN II
RECEPTOR ANTAG
&
THIAZIDE/THIAZID
E-LIKE***
ATACAND HCT
ORAL TABLET
16-12.5 MG
ATACAND HCT
ORAL TABLET
32-12.5 MG, 32-25 MG
Tier 3
BENICAR HCT ORAL
TABLET 40-12.5 MG,
40-25 MG
Tier 3
candesartan
cilexetil-hctz oral tablet
16-12.5 mg
Tier 1
candesartan
cilexetil-hctz oral tablet
32-12.5 mg, 32-25 mg
Tier 1
PA; ST; N1
PA; ST; N1;
QL (1 tab per 1
Day)
PA; ST; N1
QL (2 tab per 1
Day)
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
ANGIOTENSIN II
RECEPTOR ANT-CA
CHANNEL
BLOCKER-THIAZID
ES***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
35
Drug Name
Drug
Status
EXFORGE HCT
Tier 2
TRIBENZOR
Tier 3
Drug Details
Drug Name
#; QL (1 tab
per 1 Day)
TEKTURNA HCT
ORAL TABLET
150-12.5 MG, 150-25
MG
Tier 3
TEKTURNA HCT
ORAL TABLET
300-12.5 MG, 300-25
MG
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
BETA BLOCKER &
DIURETIC
COMBINATIONS***
atenolol-chlorthalidone
Tier 1
LGC
bisoprolol-hydrochlorot
hiazide
Tier 1
LGC
CORZIDE
Tier 3
DUTOPROL
Tier 2
LOPRESSOR HCT
Tier 3
metoprolol-hydrochloro
thiazide
Tier 1
nadolol-bendroflumethi
azide
Tier 1
TENORETIC 100
Tier 3
TENORETIC 50
Tier 3
ZIAC
Tier 3
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
DIRECT RENIN
INHIBITORS &
THIAZIDE/THIAZID
E-LIKE COMB***
QL (1 tab per 1
Day)
Tier 3
QL (1 tab per 1
Day)
Tier 3
PA; ST; N1;
QL (10 tab per
1 Day)
Tier 3
QL (1 tab per 1
Day)
*ANTIHYPERTENSI
VES MISC.**-*ANTIHYP
ERTENSIVES MISC.***
VECAMYL
*DIRECT RENIN
INHIBITORS**-*DIR
ECT RENIN
INHIBITORS***
TEKTURNA
Tier 3
QL (1 tab per 1
Day)
*SELECTIVE
ALDOSTERONE
RECEPTOR
ANTAGONISTS
(SARAS)**-*SELECT
IVE ALDOSTERONE
RECEPTOR
ANTAGONISTS
(SARAS)***
eplerenone
Tier 1
INSPRA
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
36
Drug Details
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
DIRECT RENIN
INHIBITORS-CA
CHANNEL
BLOCKER-THIAZID
E COMB***
AMTURNIDE
*ANTIHYPERTENSI
VE
COMBINATIONS**-*
DIRECT RENIN
INHIBITORS &
CALCIUM
CHANNEL
BLOCKER COMB***
TEKAMLO
Drug
Status
Drug Name
Drug
Status
Drug Details
*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 Name
Drug
Status
Drug Details
*ANTI-INFECTIVE
MISC. COMBINATIONS**-*
ANTI-INFECTIVE
MISC. COMBINATIONS***
BACTRIM
Tier 3
BACTRIM DS
Tier 3
E.S.P.
Tier 1
*ANTI-INFECTIVE
AGENTS - MISC.*
erythromycin-sulfisoxaz
ole
Tier 1
*ANTI-INFECTIVE
AGENTS MISC.**-*ANTI-INFE
CTIVE AGENTS MISC.***
SEPTRA
Tier 3
SEPTRA DS
Tier 3
smz-tmp ds
Tier 1
sulfamethoxazole-tmp ds
Tier 1
sulfamethoxazole-trimet
hoprim oral suspension
Tier 1
Tier 1
Tier 1
LGC
CAYSTON
Tier 3
colistimethate sodium
injection
Tier 1
COLY-MYCIN M
Tier 3
sulfamethoxazole-trimet
hoprim oral tablet
FIRST-VANCOMYCI
N 25
Tier 3
SULFATRIM
PEDIATRIC
FIRST-VANCOMYCI
N 50
Tier 3
FLAGYL ORAL
TABLET
Tier 3
FLAGYL ER
Tier 3
metronidazole oral
tablet
Tier 1
NEBUPENT
Tier 2
PRIMSOL
Tier 3
TINDAMAX
Tier 3
tinidazole oral
Tier 1
trimethoprim oral
Tier 1
VANCOCIN HCL
Tier 3
vancomycin hcl oral
Tier 1
XIFAXAN ORAL
TABLET 200 MG
Tier 3
PA; QL (9 tab
per 30 Days)
XIFAXAN ORAL
TABLET 550 MG
Tier 3
PA; QL (2 tab
per 1 Day)
LGC
LGC
*ANTIPROTOZOAL
AGENTS**-*ANTIPR
OTOZOAL
AGENTS***
ALINIA
Tier 3
*KETOLIDES**-*KE
TOLIDES***
KETEK
Tier 3
*LINCOSAMIDES***LINCOSAMIDES***
CLEOCIN ORAL
CAPSULE 150 MG,
300 MG
Tier 3
CLEOCIN ORAL
SOLUTION
RECONSTITUTED
Tier 3
clindamycin hcl oral
Tier 1
clindamycin palmitate
hcl
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
37
Drug Name
Drug
Status
Drug Details
*OXAZOLIDINONES
**-*OXAZOLIDINON
ES***
SIVEXTRO ORAL
Tier 3
ZYVOX ORAL
SUSPENSION
RECONSTITUTED
Tier 2
ZYVOX ORAL
TABLET
Tier 2
PA; QL (6
tablets per 30
days)
#
*ANTIMALARIALS*
*ANTIMALARIAL
COMBINATIONS**-*
ANTIMALARIAL
COMBINATIONS***
Drug Name
Drug
Status
quinine sulfate oral
Tier 1
*ANTIMYASTHENIC
/CHOLINERGIC
AGENTS**-*ANTIM
YASTHENIC/CHOLI
NERGIC AGENTS***
MESTINON
Tier 2
pyridostigmine bromide
oral
Tier 1
*ANTIMYCOBACTE
RIAL AGENTS*
*ANTI TB
COMBINATIONS**-*
ANTI TB
COMBINATIONS***
Tier 1
PA
COARTEM
Tier 3
PA
RIFAMATE
Tier 3
MALARONE
Tier 3
PA
RIFATER
Tier 3
*ANTIMALARIALS*
*-*ANTIMALARIAL
S***
chloroquine phosphate
oral
DARAPRIM
Tier 3
QL (30 days
minimum per 1
fill)
Tier 1
QL (30 days
minimum per 1
fill)
Tier 3
QL (30 days
minimum per 1
fill)
*ANTIMYCOBACTE
RIAL
AGENTS**-*ANTIM
YCOBACTERIAL
AGENTS***
ethambutol hcl oral
Tier 1
isoniazid oral tablet
Tier 1
MYAMBUTOL
Tier 2
PASER
Tier 3
PRIFTIN
Tier 3
pyrazinamide oral
Tier 1
RIFADIN ORAL
Tier 3
rifampin oral
Tier 1
hydroxychloroquine
sulfate oral
Tier 1
QL (30 days
minimum per 1
fill)
mefloquine hcl
Tier 1
PA
SIRTURO
Tier 3
Tier 3
QL (30 days
minimum per 1
fill)
TRECATOR
Tier 3
Tier 3
QL (42 caps
per 365 Days)
PLAQUENIL
QUALAQUIN
*ANTINEOPLASTIC
S AND ADJUNCTIVE
THERAPIES*
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
38
QL (42 caps
per 365 Days)
*ANTIMYASTHENIC
/CHOLINERGIC
AGENTS*
atovaquone-proguanil
hcl oral tablet 250-100
mg
ARALEN
Drug Details
PA; ST; N1;
QL (68 tab per
30 Days)
Drug Name
Drug
Status
Drug Details
*ALKYLATING
AGENTS**-*ALKYL
ATING AGENTS***
HEXALEN
Tier 2
MYLERAN
Tier 2
temozolomide
Drug
Status
Drug Details
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*ANDRO
GEN BIOSYNTHESIS
INHIBITORS***
*ALKYLATING
AGENTS**-*IMIDAZ
OTETRAZINES***
TEMODAR ORAL
Drug Name
ZYTIGA
Tier 2
PA; QL (30
days maximum
per 1 fill)
Tier 1
PA; QL (30
days maximum
per 1 fill)
Tier 2
PA; QL (4 tab
per 1 Day)
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*ANTIAD
RENALS***
LYSODREN
Tier 3
ALKERAN ORAL
Tier 2
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*ANTIAN
DROGENS***
LEUKERAN
Tier 2
bicalutamide
Tier 1
PA
CASODEX
Tier 3
PA
flutamide
Tier 1
NILANDRON
Tier 2
*ALKYLATING
AGENTS**-*NITRO
GEN MUSTARDS***
*ANTIMETABOLITE
S**-*ANTIMETABO
LITES***
mercaptopurine oral
Tier 1
methotrexate oral
Tier 1
PURINETHOL
Tier 3
TABLOID
Tier 2
TREXALL
Tier 3
XELODA
Tier 3
XTANDI
PA; ST; N1;
QL (30 days
maximum per 1
fill)
*ANTINEOPLASTIC
- HEDGEHOG
PATHWAY
INHIBITORS**-*AN
TINEOPLASTIC HEDGEHOG
PATHWAY
INHIBITORS***
ERIVEDGE
Tier 3
PA; QL (30
days maximum
per 1 fill)
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*ANTIES
TROGENS***
FARESTON
Tier 3
SOLTAMOX
Tier 3
tamoxifen citrate oral
Tier 1
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*AROMA
TASE
INHIBITORS***
Tier 3
PA; QL (1 caps
per 1 Day)
anastrozole oral
Tier 1
PA
ARIMIDEX
Tier 3
PA; ST; N1
AROMASIN
Tier 3
PA
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
39
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
exemestane
Tier 1
PA
ZOLADEX
Tier 3
FEMARA
Tier 3
PA; ST; N1
letrozole oral
Tier 1
PA
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*PROGE
STINS-ANTINEOPLA
STIC***
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*ESTRO
GEN RECEPTOR
ANTAGONIST***
FASLODEX
Tier 2
megestrol acetate oral
Tier 1
Tier 3
PA; QL (30
days maximum
per 1 fill)
TAFINLAR
Tier 3
PA; SF; QL (30
days maximum
per 1 fill)
ZELBORAF
Tier 3
PA; SF; QL (8
tab per 1 Day)
Tier 3
PA; QL (30
days maximum
per 1 fill)
POMALYST
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*GONAD
OTROPIN
RELEASING
HORMONE (GNRH)
ANTAGONISTS***
FIRMAGON
Tier 3
*ANTINEOPLASTIC
IMMUNOMODULAT
ORS**-*ANTINEOPL
ASTIC IMMUNOMODULAT
ORS***
Tier 3
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*ESTRO
GENS-ANTINEOPLA
STIC***
EMCYT
MEGACE ORAL
*ANTINEOPLASTIC
ENZYME
INHIBITORS**-*AN
TINEOPLASTIC BRAF KINASE
INHIBITORS***
Tier 3
PA
*ANTINEOPLASTIC
- HORMONAL AND
RELATED
AGENTS**-*LHRH
ANALOGS***
ELIGARD
Tier 3
leuprolide acetate
injection
Tier 1
LUPRON DEPOT
Tier 2
TRELSTAR DEPOT
Tier 3
#
*ANTINEOPLASTIC
ENZYME
INHIBITORS**-*AN
TINEOPLASTIC HISTONE
DEACETYLASE
INHIBITORS***
TRELSTAR DEPOT
MIXJECT
Tier 3
#
ZOLINZA
TRELSTAR LA
Tier 3
#
TRELSTAR LA
MIXJECT
Tier 3
#
TRELSTAR MIXJECT
Tier 3
#
VANTAS
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
40
Drug Details
Drug Name
Drug
Status
Drug Details
*ANTINEOPLASTIC
ENZYME
INHIBITORS**-*AN
TINEOPLASTIC MEK
INHIBITORS***
MEKINIST
Tier 3
PA; SF; QL (30
days maximum
per 1 fill)
AFINITOR DISPERZ
Tier 3
Tier 3
PA; SF; QL (30
days maximum
per 1 fill)
PA; SF; QL (30
days maximum
per 1 fill)
*ANTINEOPLASTIC
ENZYME
INHIBITORS**-*AN
TINEOPLASTIC MULTIKINASE
INHIBITORS***
NEXAVAR
Tier 3
PA; SF; QL (30
days maximum
per 1 fill)
STIVARGA
Tier 3
PA
Tier 2
PA; SF; QL (30
days maximum
per 1 fill)
SUTENT ORAL
CAPSULE 12.5 MG, 25
MG, 50 MG
BOSULIF
Tier 3
PA; ST
CAPRELSA
Tier 3
PA; QL (30
days maximum
per 1 fill)
Drug Details
PA; QL (30
days maximum
per 1 fill)
COMETRIQ (140 MG
DAILY DOSE)
Tier 3
PA; QL (30
days maximum
per 1 fill)
COMETRIQ (60 MG
DAILY DOSE)
Tier 3
PA; QL (30
days maximum
per 1 fill)
GILOTRIF
Tier 3
PA; QL (30
days maximum
per 1 fill)
GLEEVEC
Tier 2
PA; QL (30
days maximum
per 1 fill)
Tier 3
PA; ST; QL
(30 days
maximum per 1
fill)
IMBRUVICA
Tier 3
PA; QL (30
days maximum
per 1 fill)
INLYTA
Tier 3
PA; SF; QL (30
days maximum
per 1 fill)
Tier 3
PA; ST; SF;
QL (30 days
maximum per 1
fill)
Tier 2
PA; SF; QL (30
days maximum
per 1 fill)
Tier 2
PA; ST; QL
(30 days
maximum per 1
fill)
TYKERB
Tier 3
PA; QL (30
days maximum
per 1 fill)
VOTRIENT
Tier 3
PA; SF; QL (30
days maximum
per 1 fill)
XALKORI
Tier 3
PA; QL (2 caps
per 1 Day)
ICLUSIG
SPRYCEL
TARCEVA
TASIGNA
*ANTINEOPLASTIC
ENZYME
INHIBITORS**-*AN
TINEOPLASTIC TYROSINE KINASE
INHIBITORS***
Drug
Status
Tier 3
COMETRIQ (100 MG
DAILY DOSE)
*ANTINEOPLASTIC
ENZYME
INHIBITORS**-*AN
TINEOPLASTIC MTOR KINASE
INHIBITORS***
AFINITOR
Drug Name
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
41
Drug Name
Drug
Status
Drug Details
*ANTINEOPLASTIC
ENZYME
INHIBITORS**-*JAN
US ASSOCIATED
KINASE (JAK)
INHIBITORS***
JAKAFI
leucovorin calcium oral
tablet 25 mg, 5 mg
Tier 3
PA; SF; QL (2
tab per 1 Day)
*ANTINEOPLASTIC
S
MISC.**-*ANTINEO
PLASTICS MISC.***
Tier 3
ALFERON N
Tier 3
hydroxyurea oral
Tier 1
INTRON-A
Tier 2
MATULANE
Tier 2
SYLATRON
SUBCUTANEOUS*
KIT 296 MCG, 4 X 296
MCG, 4 X 444 MCG,
444 MCG, 888 MCG
Tier 3
PA
*CHEMOTHERAPY
RESCUE/ANTIDOTE
AGENTS**-*FOLIC
ACID
ANTAGONISTS
RESCUE
AGENTS***
Tier 2
Tier 3
Tier 3
QL (30 days
maximum per 1
fill)
PA; QL (30
days maximum
per 1 fill)
benztropine mesylate
oral
Tier 1
LGC
QL (30 days
maximum per 1
fill)
trihexyphenidyl hcl oral
elixir
Tier 1
trihexyphenidyl hcl oral
tablet 2 mg
Tier 1
trihexyphenidyl hcl oral
tablet 5 mg
Tier 1
#
*ANTIPARKINSON
ANTICHOLINERGIC
S**-*ANTIPARKINS
ON
ANTICHOLINERGIC
S***
*ANTIPARKINSON
COMT
INHIBITORS**-*CE
NTRAL/PERIPHERA
L COMT
INHIBITORS***
TASMAR
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
42
Tier 1
*ANTIPARKINSON
AGENTS*
*ANTINEOPLASTIC
S
MISC.**-*SELECTIV
E RETINOID X
RECEPTOR
AGONISTS***
TARGRETIN ORAL
Drug Details
*TOPOISOMERASE
I
INHIBITORS**-*TO
POISOMERASE I
INHIBITORS***
HYCAMTIN ORAL
*ANTINEOPLASTIC
S
MISC.**-*RETINOID
S***
Tier 1
Drug
Status
*CHEMOTHERAPY
RESCUE/ANTIDOTE
AGENTS**-*URINA
RY TRACT
PROTECTIVE
AGENTS***
MESNEX ORAL
ACTIMMUNE
tretinoin oral
Drug Name
Tier 3
LGC
Drug Name
Drug
Status
*ANTIPARKINSON
COMT
INHIBITORS**-*PER
IPHERAL COMT
INHIBITORS***
Drug Details
Drug Name
Drug
Status
MIRAPEX
Tier 2
MIRAPEX ER
Tier 3
NEUPRO
Tier 3
Tier 1
COMTAN
Tier 3
pramipexole
dihydrochloride
entacapone
Tier 1
REQUIP
Tier 3
REQUIP XL
Tier 3
ropinirole hcl
Tier 1
ropinirole hcl er
Tier 1
*ANTIPARKINSON
DOPAMINERGICS**
-*ANTIPARKINSON
DOPAMINERGICS**
*
amantadine hcl oral
capsule
Tier 1
amantadine hcl oral
syrup
Tier 1
bromocriptine mesylate
oral
Tier 1
*ANTIPARKINSON
MONOAMINE
OXIDASE
INHIBITORS**-*AN
TIPARKINSON
MONOAMINE
OXIDASE
INHIBITORS***
PARLODEL
Tier 3
AZILECT
Tier 2
ELDEPRYL
Tier 3
selegiline hcl oral
Tier 1
ZELAPAR
Tier 3
*ANTIPARKINSON
DOPAMINERGICS**
-*LEVODOPA
COMBINATIONS***
ST; N1
ST; N1
*ANTIPSYCHOTICS/
ANTIMANIC
AGENTS*
carbidopa-levodopa
Tier 1
carbidopa-levodopa er
oral tablet
extendedrelease*
50-200 mg
Tier 1
*ANTIMANIC
AGENTS**-*ANTIM
ANIC AGENTS***
SINEMET
Tier 3
lithium carbonate oral
Tier 1
SINEMET CR
Tier 3
lithium carbonate er
Tier 1
STALEVO 100
Tier 3
LITHOBID
Tier 3
STALEVO 125
Tier 3
STALEVO 150
Tier 3
STALEVO 200
Tier 3
STALEVO 50
Tier 3
*ANTIPSYCHOTICS
MISC.**-*ANTIPSYC
HOTICS - MISC.***
STALEVO 75
Tier 3
*ANTIPARKINSON
DOPAMINERGICS**
-*NONERGOLINE
DOPAMINE
RECEPTOR
AGONISTS***
Drug Details
EQUETRO
Tier 3
GEODON ORAL
Tier 3
ST; N1; QL (2
caps per 1 Day)
LATUDA ORAL
TABLET 120 MG, 20
MG, 40 MG, 60 MG
Tier 2
ST; N1; QL (1
tab per 1 Day)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
43
Drug Name
Drug
Status
Drug Details
Drug Name
risperidone oral tablet
dispersible 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg
Tier 1
ST; N1; QL (2
tab per 1 Day)
risperidone oral tablet
dispersible 4 mg
Tier 1
ST; N1; QL (4
tab per 1 Day)
RISPERIDONE
M-TAB ORAL
TABLET
DISPERSIBLE 0.5 MG,
1 MG, 2 MG, 3 MG
Tier 1
ST; QL (2 tab
per 1 Day)
RISPERIDONE
M-TAB ORAL
TABLET
DISPERSIBLE 4 MG
Tier 1
ST; QL (4 tab
per 1 Day)
LATUDA ORAL
TABLET 80 MG
Tier 2
ST; N1; QL (2
tab per 1 Day)
ziprasidone hcl
Tier 1
QL (2 caps per
1 Day)
*BENZISOXAZOLES
**-*BENZISOXAZOL
ES***
Tier 3
ST; N1; QL (2
tab per 1 Day)
FANAPT TITRATION
PACK
Tier 3
ST; N1; QL (8
tab per 30
Days)
INVEGA ORAL
TABLET EXTENDED
RELEASE 24 HR* 1.5
MG, 3 MG, 6 MG
Tier 3
ST; N1; QL (2
tab per 1 Day)
INVEGA ORAL
TABLET EXTENDED
RELEASE 24 HR* 9
MG
Tier 3
ST; N1; QL (1
tab per 1 Day)
RISPERDAL ORAL
SOLUTION
Tier 3
ST; N1
RISPERDAL ORAL
TABLET 0.25 MG, 0.5
MG, 1 MG, 2 MG, 3
MG
Tier 3
ST; N1; QL (2
tab per 1 Day)
RISPERDAL ORAL
TABLET 4 MG
Tier 3
ST; N1; QL (4
tab per 1 Day)
RISPERDAL M-TAB
ORAL TABLET
DISPERSIBLE 0.5 MG,
1 MG, 2 MG, 3 MG
Tier 3
ST; N1; QL (2
tab per 1 Day)
RISPERDAL M-TAB
ORAL TABLET
DISPERSIBLE 4 MG
Tier 3
risperidone oral
solution
Tier 1
FANAPT
risperidone oral tablet
0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg
risperidone oral tablet 4
mg
ST; N1; QL (4
tab per 1 Day)
Drug Details
*BUTYROPHENONE
S**-*BUTYROPHEN
ONES***
haloperidol oral
Tier 1
haloperidol lactate oral
Tier 1
*DIBENZAPINES**-*
DIBENZODIAZEPIN
ES***
clozapine oral tablet
100 mg
Tier 1
QL (9 tab per 1
Day)
clozapine oral tablet
200 mg
Tier 1
QL (4 tablets
per 1 day)
clozapine oral tablet 25
mg, 50 mg
Tier 1
QL (3 tab per 1
Day)
CLOZARIL ORAL
TABLET 100 MG
Tier 3
QL (9 tab per 1
Day)
CLOZARIL ORAL
TABLET 25 MG
Tier 3
QL (3 tab per 1
Day)
FAZACLO ORAL
TABLET
DISPERSIBLE 100 MG
Tier 3
#; QL (9 tab
per 1 Day)
Tier 3
#; QL (1 tab
per 1 Day)
Tier 3
#; QL (6 tab
per 1 Day)
Tier 1
QL (2 tab per 1
Day)
FAZACLO ORAL
TABLET
DISPERSIBLE 12.5
MG
Tier 1
QL (4 tab per 1
Day)
FAZACLO ORAL
TABLET
DISPERSIBLE 150 MG
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
44
Drug
Status
Drug Name
Drug
Status
Drug Details
FAZACLO ORAL
TABLET
DISPERSIBLE 200 MG
Tier 3
#; QL (4 tab
per 1 Day)
FAZACLO ORAL
TABLET
DISPERSIBLE 25 MG
Tier 3
#; QL (3 tab
per 1 Day)
VERSACLOZ
Tier 3
ST; N1
*DIBENZAPINES**-*
DIBENZO-OXEPINO
PYRROLES***
SAPHRIS
Tier 3
ST; N1; QL (2
tab per 1 day)
*DIBENZAPINES**-*
DIBENZOTHIAZEPI
NES***
Drug Name
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR* 50
MG
Drug
Status
Tier 3
Drug Details
PA; ST; N1;
QL (6 tab per 1
Day)
*DIBENZAPINES**-*
DIBENZOXAZEPINE
S***
loxapine succinate oral
Tier 1
LOXITANE ORAL
CAPSULE 5 MG
Tier 3
*DIBENZAPINES**-*
THIENBENZODIAZE
PINES***
olanzapine oral tablet
10 mg, 15 mg, 20 mg, 5
mg, 7.5 mg
Tier 1
QL (1 tab per 1
Day)
olanzapine oral tablet
2.5 mg
Tier 1
QL (2 tab per 1
Day)
quetiapine fumarate
oral tablet 100 mg, 50
mg
Tier 1
QL (3 tab per 1
Day)
quetiapine fumarate
oral tablet 200 mg
Tier 1
QL (4 tab per 1
Day)
olanzapine oral tablet
dispersible
Tier 1
QL (1 tab per 1
Day)
quetiapine fumarate
oral tablet 25 mg
Tier 1
QL (6 tab per 1
Day)
Tier 3
quetiapine fumarate
oral tablet 300 mg, 400
mg
ST; N1; QL (1
tab per 1 Day)
Tier 1
ZYPREXA ORAL
TABLET 10 MG, 15
MG, 20 MG, 5 MG, 7.5
MG
Tier 3
SEROQUEL ORAL
TABLET 100 MG, 50
MG
ZYPREXA ORAL
TABLET 2.5 MG
ST; N1; QL (2
tab per 1 Day)
Tier 3
ST; N1; QL (3
tab per 1 Day)
ZYPREXA ZYDIS
Tier 3
ST; N1; QL (1
tab per 1 Day)
SEROQUEL ORAL
TABLET 200 MG
Tier 3
ST; N1; QL (4
tab per 1 Day)
SEROQUEL ORAL
TABLET 25 MG
Tier 3
ST; N1; QL (6
tab per 1 Day)
SEROQUEL ORAL
TABLET 300 MG, 400
MG
Tier 3
ST; N1; QL (2
tab per 1 Day)
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR* 150
MG, 200 MG
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR* 300
MG, 400 MG
Tier 3
Tier 3
QL (2 tab per 1
Day)
PA; ST; N1;
QL (1 tab per 1
Day)
PA; ST; N1;
QL (2 tab per 1
Day)
*PHENOTHIAZINES
**-*PHENOTHIAZIN
ES***
chlorpromazine hcl oral
Tier 1
COMPAZINE
SUPPOSITORY
Tier 1
COMPRO
Tier 1
fluphenazine hcl oral
tablet
Tier 1
perphenazine oral
Tier 1
prochlorperazine
Tier 1
prochlorperazine
maleate oral
Tier 1
thioridazine hcl oral
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
45
Drug Name
Drug
Status
trifluoperazine hcl oral
Tier 1
Drug Details
Drug
Status
Drug Details
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RAL
COMBINATIONS***
*QUINOLINONE
DERIVATIVES**-*Q
UINOLINONE
DERIVATIVES***
ABILIFY ORAL
SOLUTION
Drug Name
ATRIPLA
Tier 3
Tier 3
ST; N1; QL (30
ML per 1 day)
COMBIVIR
Tier 3
COMPLERA
Tier 3
ABILIFY ORAL
TABLET
Tier 3
PA; ST; N1; #;
QL (1 tablet per
1 day)
EPZICOM
Tier 3
KALETRA
Tier 2
Tier 1
Tier 3
#; QL (1 tab
per 1 Day)
lamivudine-zidovudine
ABILIFY DISCMELT
STRIBILD
Tier 3
PA
Tier 2
PA
Tier 3
QL (30 days
maximum per 1
fill)
TRUVADA
ABILIFY MAINTENA
*THIOXANTHENES*
*-*THIOXANTHENE
S***
thiothixene oral
Tier 1
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RALS - CCR5
ANTAGONISTS
(ENTRY
INHIBITOR)***
SELZENTRY
*ANTISEPTICS &
DISINFECTANTS*
Tier 3
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RALS - FUSION
INHIBITORS***
*ANTISEPTIC
COMBINATIONS**-*
ANTISEPTIC
COMBINATIONS***
BUCALSEP
EXTERNAL
SOLUTION
Tier 3
DURAPREP
Tier 3
*ANTISEPTICS &
DISINFECTANTS***ANTISEPTICS &
DISINFECTANTS***
FUZEON
SUBCUTANEOUS*
SOLUTION
RECONSTITUTED
Tier 3
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RALS - INTEGRASE
INHIBITORS***
ISENTRESS ORAL
TABLET
Tier 3
FORMA-RAY
Tier 3
FORMADON
Tier 1
ISENTRESS ORAL
TABLET CHEWABLE
Tier 3
FORMALAZ
Tier 1
TIVICAY
Tier 3
formaldehyde external
solution 10 %
Tier 1
KERR TRIPLE DYE
SWABS
Tier 3
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RALS - PROTEASE
INHIBITORS***
LAZERFORMALYDE
Tier 1
APTIVUS
*ANTIVIRALS*
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
46
ST; N1
Tier 2
#
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
CRIXIVAN ORAL
CAPSULE 200 MG,
400 MG
Tier 3
ZIAGEN ORAL
SOLUTION
Tier 3
INVIRASE
Tier 3
ZIAGEN ORAL
TABLET
Tier 3
LEXIVA
Tier 2
NORVIR
Tier 2
PREZISTA ORAL
SUSPENSION
Tier 2
PREZISTA ORAL
TABLET 150 MG, 600
MG, 75 MG, 800 MG
Tier 2
REYATAZ ORAL
CAPSULE 150 MG,
200 MG, 300 MG
VIRACEPT ORAL
TABLET
Tier 3
EPIVIR
Tier 2
Tier 2
EPIVIR HBV ORAL
SOLUTION
Tier 3
Tier 3
lamivudine oral tablet
150 mg, 300 mg
Tier 1
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RALS RTI-NUCLEOSIDE
ANALOGUES-THYM
IDINES***
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RALS RTI-NON-NUCLEOSI
DE ANALOGUES***
Tier 3
INTELENCE
Tier 3
nevirapine oral tablet
Tier 1
RESCRIPTOR
RETROVIR ORAL
CAPSULE
Tier 3
Tier 3
RETROVIR ORAL
SYRUP
Tier 3
SUSTIVA
Tier 3
stavudine
Tier 1
VIRAMUNE ORAL
SUSPENSION
Tier 3
ZERIT ORAL
CAPSULE
Tier 3
VIRAMUNE ORAL
TABLET
Tier 3
zidovudine
Tier 1
VIRAMUNE XR
Tier 3
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RALS RTI-NUCLEOSIDE
ANALOGUES-PURIN
ES***
ST; N1
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RALS RTI-NUCLEOSIDE
ANALOGUES-PYRI
MIDINES***
EMTRIVA
EDURANT
Drug Details
ST; N1
ST; N1
*ANTIRETROVIRAL
S**-*ANTIRETROVI
RALS RTI-NUCLEOTIDE
ANALOGUES***
VIREAD
Tier 2
abacavir sulfate
Tier 1
*CMV
AGENTS**-*CMV
AGENTS***
didanosine
Tier 1
cidofovir intravenous*
Tier 1
VIDEX
Tier 2
CYTOVENE
Tier 3
VIDEX EC
Tier 2
FOSCAVIR
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
47
Drug Name
Drug
Status
Drug Details
ganciclovir sodium
Tier 1
VALCYTE ORAL
SOLUTION
RECONSTITUTED
Tier 2
QL (1000 ml
per 30 Days)
VALCYTE ORAL
TABLET
Tier 2
QL (102 tab per
30 Days)
VISTIDE
Tier 3
*HEPATITIS
AGENTS**-*HEPATI
TIS B AGENTS***
adefovir dipivoxil
Tier 1
BARACLUDE
Tier 3
HEPSERA
Tier 3
TYZEKA
Tier 3
#
Drug
Status
RIBASPHERE ORAL
CAPSULE
Tier 2
RIBASPHERE ORAL
TABLET 200 MG
Tier 2
RIBASPHERE ORAL
TABLET 400 MG, 600
MG
Tier 3
RIBATAB
Tier 3
RIBATAB ORAL 400
& 600 MG
Tier 3
ribavirin oral
Tier 1
SOVALDI
Tier 3
PA
VICTRELIS
Tier 3
PA; QL (12
caps per 1 Day)
Tier 3
PA; QL (6 tab
per 1 Day)
acyclovir oral capsule
Tier 1
LGC
acyclovir oral
suspension
Tier 1
INCIVEK
Tier 2
MODERIBA ORAL
200 & 400 MG, 400 &
600 MG
Tier 3
acyclovir oral tablet 400
mg
Tier 1
MODERIBA ORAL
TABLET
Tier 2
acyclovir oral tablet 800
mg
Tier 1
MODERIBA 1200
DOSE PACK
valacyclovir hcl oral
Tier 1
Tier 3
VALTREX
Tier 3
MODERIBA 800
DOSE PACK
Tier 3
ZOVIRAX ORAL
CAPSULE
Tier 3
OLYSIO
Tier 3
PA; QL (1
capsule per 1
day)
ZOVIRAX ORAL
SUSPENSION
Tier 3
PEG-INTRON
Tier 2
PA
ZOVIRAX ORAL
TABLET 800 MG
Tier 3
PEG-INTRON
REDIPEN
Tier 2
PA
PEG-INTRON
REDIPEN PAK 4
Tier 2
PA
PEGASYS
Tier 2
PA
PEGASYS PROCLICK
Tier 2
PA
REBETOL
Tier 3
LGC
ST; N1
*HERPES
AGENTS**-*HERPE
S AGENTS THYMIDINE
ANALOGUES***
famciclovir oral tablet
125 mg, 250 mg
Tier 1
QL (60 tab per
30 Days)
famciclovir oral tablet
500 mg
Tier 1
QL (21 tab per
30 Days)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
48
Drug Details
*HERPES
AGENTS**-*HERPE
S AGENTS - PURINE
ANALOGUES***
*HEPATITIS
AGENTS**-*HEPATI
TIS C AGENTS***
COPEGUS
Drug Name
Drug Name
Drug
Status
Drug Details
FAMVIR ORAL
TABLET 125 MG, 250
MG
Tier 3
QL (60 tab per
30 Days)
FAMVIR ORAL
TABLET 500 MG
Tier 3
QL (21 tab per
30 Days)
*INFLUENZA
AGENTS**-*INFLUE
NZA AGENTS***
FLUMADINE
Tier 3
rimantadine hcl
Tier 1
TAMIFLU ORAL
CAPSULE 30 MG, 45
MG
TAMIFLU ORAL
CAPSULE 75 MG
TAMIFLU ORAL
SUSPENSION
RECONSTITUTED 6
MG/ML
Tier 3
#; QL (2 EA
per 365 Days)
Tier 3
QL (20 caps
per 365 Days)
Tier 3
Tier 3
Tier 3
*ASSORTED
CLASSES*
*CHELATING
AGENTS**-*CHELA
TING AGENTS***
CUPRIMINE
Tier 3
DEPEN TITRATABS
Tier 2
SYPRINE
Tier 3
*ENZYMES**-*ENZ
YMES***
XIAFLEX
Tier 2
Drug Details
*IMMUNOMODULA
TORS**-*ANTILEPR
OTICS***
THALOMID
REVLIMID
*RESPIRATORY
SYNCYTIAL VIRUS
(RSV)
AGENTS**-*RSV
AGENTS NUCLEOSIDE
ANALOGUES***
VIRAZOLE
Drug
Status
Tier 3
*IMMUNOMODULA
TORS**-*IMMUNO
MODULATORS FOR
MYELODYSPLASTI
C SYNDROMES***
*INFLUENZA
AGENTS**-*NEURA
MINIDASE
INHIBITORS***
RELENZA
DISKHALER
Drug Name
QL (2 pack per
365 Days)
QL (480 pen
per 365 Days)
Tier 3
PA
*IMMUNOSUPPRES
SIVE
AGENTS**-*CYCLO
SPORINE
ANALOGS***
cyclosporine
intravenous*
Tier 1
cyclosporine oral
capsule
Tier 1
cyclosporine modified
oral capsule 100 mg, 25
mg
Tier 1
cyclosporine modified
oral solution
Tier 1
GENGRAF
Tier 1
NEORAL
Tier 3
SANDIMMUNE
Tier 3
*IMMUNOSUPPRES
SIVE
AGENTS**-*IMMUN
E GLOBULIN
IMMUNOSUPPRESS
ANTS***
ATGAM
Tier 3
THYMOGLOBULIN
Tier 3
*IMMUNOSUPPRES
SIVE
AGENTS**-*INOSIN
E
MONOPHOSPHATE
DEHYDROGENASE
INHIBITORS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
49
Drug Name
Drug
Status
CELLCEPT
Tier 3
mycophenolate mofetil
Tier 1
mycophenolic acid
Tier 1
Drug Details
*IMMUNOSUPPRES
SIVE
AGENTS**-*MACRO
LIDE
IMMUNOSUPPRESS
ANTS***
Drug Name
Drug
Status
ARGYLE STERILE
WATER
Tier 1
lactated ringers
irrigation
Tier 1
PHYSIOLYTE
Tier 1
PHYSIOSOL
IRRIGATION
Tier 1
ringers irrigation
Tier 1
ASTAGRAF XL
Tier 3
sterile water for
irrigation
Tier 1
HECORIA
Tier 2
TIS-U-SOL
Tier 1
PROGRAF
Tier 3
RAPAMUNE ORAL
SOLUTION
Tier 3
RAPAMUNE ORAL
TABLET 1 MG, 2 MG
Tier 3
*POTASSIUM
REMOVING
RESINS**-*POTASSI
UM REMOVING
RESINS***
tacrolimus oral
Tier 1
kalexate
Tier 1
ZORTRESS
Tier 3
KAYEXALATE
Tier 3
KIONEX
Tier 1
sodium polystyrene
sulfonate oral
Tier 1
sodium polystyrene
sulfonate suspension
Tier 1
SPS
Tier 3
*IMMUNOSUPPRES
SIVE
AGENTS**-*MONOC
LONAL
ANTIBODIES***
SIMULECT
Tier 3
*IMMUNOSUPPRES
SIVE
AGENTS**-*PURINE
ANALOGS***
AZASAN
Tier 3
azathioprine oral
Tier 1
IMURAN
Tier 3
*IMMUNOSUPPRES
SIVE
AGENTS**-*SELECT
IVE T-CELL
COSTIMULATION
BLOCKERS***
NULOJIX
*IRRIGATION
SOLUTIONS**-*IRRI
GATION
SOLUTIONS***
#
*SYSTEMIC LUPUS
ERYTHEMATOSUS
AGENTS**-*B-LYMP
HOCYTE
STIMULATOR
(BLYS)-SPECIFIC
INHIBITORS***
BENLYSTA
Tier 3
PA
carvedilol
Tier 1
LGC
COREG
Tier 3
COREG CR
Tier 2
labetalol hcl oral
Tier 1
*BETA BLOCKERS*
*ALPHA-BETA
BLOCKERS**-*ALP
HA-BETA
BLOCKERS***
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
50
Drug Details
Drug Name
Drug
Status
TRANDATE
Tier 3
Drug Details
*BETA BLOCKERS
CARDIO-SELECTIV
E**-*BETA
BLOCKERS
CARDIO-SELECTIV
E***
acebutolol hcl oral
Tier 1
atenolol oral
Tier 1
betaxolol hcl oral
Tier 1
bisoprolol fumarate
Tier 1
BYSTOLIC
Tier 2
KERLONE
Tier 3
LOPRESSOR ORAL
Tier 3
metoprolol succinate er
Tier 3
metoprolol tartrate oral
Tier 1
SECTRAL
Tier 3
TENORMIN
Tier 3
TOPROL XL
Tier 3
ZEBETA
Tier 3
Drug Name
Drug
Status
Drug Details
sotalol hcl oral tablet
120 mg, 80 mg
Tier 1
LGC
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
LGC
*BIOLOGICALS
MISC*
LGC
*BIOLOGICALS
MISC**-*BIOLOGIC
ALS MISC***
ADAGEN
LGC
Tier 3
LGC
PA
*CALCIUM
CHANNEL
BLOCKERS*
*CALCIUM
CHANNEL
BLOCKERS**-*CAL
CIUM CHANNEL
BLOCKERS***
*BETA BLOCKERS
NON-SELECTIVE***BETA BLOCKERS
NON-SELECTIVE***
ADALAT CC
Tier 3
AFEDITAB CR
Tier 1
amlodipine besylate
oral
Tier 1
CALAN
Tier 3
CALAN SR
Tier 3
CARDENE SR ORAL
CAPSULE
EXTENDED
RELEASE 12 HOUR
30 MG, 60 MG
Tier 3
CARDIZEM ORAL
TABLET 120 MG, 30
MG, 60 MG
Tier 3
CARDIZEM CD
Tier 3
CARDIZEM LA
Tier 3
CARTIA XT
Tier 1
BETAPACE ORAL
TABLET 120 MG, 160
MG, 80 MG
Tier 3
BETAPACE AF
Tier 3
CORGARD
Tier 3
INDERAL LA
Tier 3
INDERAL XL
Tier 3
LEVATOL
Tier 3
nadolol oral
Tier 1
propranolol hcl oral
tablet 10 mg, 20 mg, 40
mg, 80 mg
Tier 1
propranolol hcl oral
tablet 60 mg
Tier 1
DILACOR XR
Tier 3
propranolol hcl er
Tier 1
dilt-cd
Tier 1
SORINE
Tier 1
dilt-xr
Tier 1
LGC
LGC
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
51
Drug Name
Drug
Status
Drug Details
Drug Name
diltiazem hcl oral
Tier 1
LGC
diltiazem hcl cd
Tier 1
Tier 1
diltiazem hcl er
Tier 1
verapamil hcl er oral
tablet extendedrelease*
180 mg, 240 mg
diltiazem hcl er beads
Tier 1
VERELAN
Tier 3
diltiazem hcl er coated
beads
VERELAN PM
Tier 3
Tier 1
*CARDIOTONICS*
diltzac
Tier 1
felodipine er
Tier 1
ISOPTIN SR
Tier 3
*CARDIAC
GLYCOSIDES**-*CA
RDIAC
GLYCOSIDES***
MATZIM LA
Tier 1
DIGOX
Tier 1
nicardipine hcl oral
Tier 1
digoxin oral tablet
Tier 1
NIFEDIAC CC
Tier 1
LANOXIN ORAL
Tier 3
NIFEDICAL XL
Tier 1
nifedipine oral
Tier 1
*CARDIOVASCULA
R AGENTS - MISC.*
nifedipine er
Tier 1
nifedipine er osmotic
Tier 1
nimodipine oral
Tier 1
nisoldipine er oral
tablet extended release
24 hr* 17 mg, 34 mg,
8.5 mg
Tier 1
NORVASC
Tier 3
ST; N1
NYMALIZE
Tier 3
PA; ST; N1;
QL (2520 ml
per 21 days)
PROCARDIA
Tier 3
CAVERJECT
Tier 3
PA; #
PROCARDIA XL
Tier 3
Tier 3
PA; #
SULAR ORAL
TABLET EXTENDED
RELEASE 24 HR* 17
MG, 34 MG, 8.5 MG
CAVERJECT
IMPULSE
EDEX
Tier 3
PA
Tier 3
MUSE
Tier 3
PA
TAZTIA XT
Tier 1
TIAZAC
Tier 3
verapamil hcl oral
Tier 1
verapamil hcl er oral
capsule extended
release 24 hour
epoprostenol sodium
Tier 1
PA
Tier 1
REMODULIN
Tier 3
PA
TYVASO
Tier 3
PA
verapamil hcl er oral
tablet extendedrelease*
120 mg
TYVASO REFILL
Tier 3
PA
Tier 1
TYVASO STARTER
Tier 3
PA
Drug Details
LGC
*CARDIOVASCULA
R AGENTS MISC. COMBINATIONS**-*
NITRATE &
VASODILATOR
COMBINATIONS***
BIDIL
LGC
LGC
Tier 3
*IMPOTENCE
AGENTS**-*PROST
AGLANDIN IMPOTENCE
AGENTS***
*PROSTAGLANDIN
VASODILATORS**-*
PROSTAGLANDIN
VASODILATORS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
52
Drug
Status
Drug Name
Drug
Status
Drug Details
VELETRI
Tier 3
PA
VENTAVIS
Tier 3
PA
ADEMPAS
Tier 3
Drug Details
PA; QL (3 tab
per 1 Day)
*CEPHALOSPORINS
- 1ST
GENERATION**-*C
EPHALOSPORINS 1ST
GENERATION***
Tier 2
PA
OPSUMIT
Tier 3
QL (1 tab per 1
Day)
TRACLEER
Tier 2
PA; #
*PULMONARY
HYPERTENSION PHOSPHODIESTER
ASE
INHIBITORS**-*PUL
MONARY
HYPERTENSION PHOSPHODIESTER
ASE INHIBITORS***
ADCIRCA
Tier 3
PA; QL (2 tab
per 1 Day)
REVATIO
INTRAVENOUS*
Tier 3
PA
REVATIO ORAL
TABLET
Tier 3
PA; QL (3 tab
per 1 Day)
sildenafil citrate oral
Tier 1
PA; QL (3 tab
per 1 Day)
*PULMONARY
HYPERTENSION SOL GUANYLATE
CYCLASE
STIMULATOR**-*P
ULM
HYPERTEN-SOLUB
LE GUANYLATE
CYCLASE
STIMULATOR
(SGC)***
Drug
Status
*CEPHALOSPORINS
*
*PULMONARY
HYPERTENSION ENDOTHELIN
RECEPTOR
ANTAGONISTS**-*P
ULMONARY
HYPERTENSION ENDOTHELIN
RECEPTOR
ANTAGONISTS***
LETAIRIS
Drug Name
cefadroxil
Tier 1
cephalexin oral capsule
Tier 1
cephalexin oral
suspension reconstituted
Tier 1
KEFLEX
Tier 3
*CEPHALOSPORINS
- 2ND
GENERATION**-*C
EPHALOSPORINS 2ND
GENERATION***
cefaclor oral capsule
Tier 1
cefprozil
Tier 1
CEFTIN ORAL
SUSPENSION
RECONSTITUTED 250
MG/5ML
Tier 3
CEFTIN ORAL
TABLET
Tier 3
cefuroxime axetil
Tier 1
*CEPHALOSPORINS
- 3RD
GENERATION**-*C
EPHALOSPORINS 3RD
GENERATION***
CEDAX
Tier 3
cefdinir
Tier 1
cefpodoxime proxetil
Tier 1
SPECTRACEF
Tier 3
SUPRAX
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
53
Drug Name
Drug
Status
Drug Details
*CONTRACEPTIVES
*
*COMBINATION
CONTRACEPTIVES
ORAL**-*BIPHASIC
CONTRACEPTIVES
- ORAL***
AZURETTE
Tier 1
PA; QL (2 tab
per 1 Day)
desogestrel-ethinyl
estradiol oral tablet
0.15-0.02/0.01 mg
(21/5)
Tier 1
PA; QL (2 tab
per 1 Day)
KARIVA
Tier 1
PA; QL (2 tab
per 1 Day)
Drug Name
Drug
Status
Drug Details
briellyn
Tier 1
PA; QL (2 tab
per 1 Day)
CHATEAL
Tier 1
PA; QL (2 tab
per 1 Day)
CRYSELLE-28
Tier 1
PA; QL (2 tab
per 1 Day)
CYCLAFEM 1/35
Tier 1
PA; QL (2 tab
per 1 Day)
DASETTA 1/35
Tier 1
PA; QL (2 tab
per 1 Day)
DESOGEN
Tier 3
desogestrel-ethinyl
estradiol oral tablet
0.15-30 mg-mcg
Tier 1
PA; QL (2 tab
per 1 Day)
Tier 1
PA; QL (2 tab
per 1 Day)
LO LOESTRIN FE
Tier 3
drospirenone-ethinyl
estradiol
MIRCETTE
Tier 3
ELINEST
Tier 1
PIMTREA
Tier 1
PA; QL (2 tab
per 1 Day)
PA; QL (2 tab
per 1 Day)
EMOQUETTE
Tier 1
viorele
Tier 1
PA; QL (2 tab
per 1 Day)
PA; QL (2 tab
per 1 Day)
ENSKYCE
Tier 1
PA; QL (2 tab
per 1 Day)
ESTARYLLA
Tier 1
PA; QL (2 tab
per 1 Day)
FALESSA
Tier 3
FALMINA
Tier 1
FEMCON FE
Tier 3
GENERESS FE
Tier 3
#
*COMBINATION
CONTRACEPTIVES
ORAL**-*COMBINA
TION
CONTRACEPTIVES
- ORAL***
PA; QL (2 tab
per 1 Day)
ALTAVERA
Tier 1
PA; QL (2 tab
per 1 Day)
alyacen 1/35
Tier 1
PA; QL (2 tab
per 1 Day)
GIANVI
Tier 1
PA; QL (2 tab
per 1 Day)
APRI
Tier 1
PA; QL (2 tab
per 1 Day)
GILDAGIA
Tier 1
PA; QL (2 tab
per 1 Day)
AUBRA
Tier 1
PA; QL (2 tab
per 1 Day)
GILDESS 1.5/30
Tier 1
PA; QL (2 tab
per 1 Day)
AVIANE
Tier 1
PA; QL (2 tab
per 1 Day)
GILDESS 1/20
Tier 1
PA; QL (2 tab
per 1 Day)
BALZIVA
Tier 1
PA; QL (2 tab
per 1 Day)
GILDESS FE 1.5/30
Tier 1
PA; QL (2 tab
per 1 Day)
BEYAZ
Tier 3
GILDESS FE 1/20
Tier 1
BREVICON (28)
Tier 3
PA; QL (2 tab
per 1 Day)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
54
Drug Name
Drug
Status
Drug Details
Drug Name
JUNEL 1.5/30
Tier 1
PA; QL (2 tab
per 1 Day)
MICROGESTIN FE
1.5/30
Tier 1
PA; QL (2 tab
per 1 Day)
JUNEL 1/20
Tier 1
PA; QL (2 tab
per 1 Day)
MICROGESTIN FE
1/20
Tier 1
PA; QL (2 tab
per 1 Day)
JUNEL FE 1.5/30
Tier 1
PA; QL (2 tab
per 1 Day)
MINASTRIN 24 FE
Tier 3
MODICON (28)
Tier 3
JUNEL FE 1/20
Tier 1
PA; QL (2 tab
per 1 Day)
MONO-LINYAH
Tier 1
PA; QL (2 tab
per 1 Day)
KELNOR 1/35
Tier 1
PA; QL (2 tab
per 1 Day)
MONONESSA
Tier 1
PA; QL (2 tab
per 1 Day)
KURVELO
Tier 1
PA; QL (2 tab
per 1 Day)
NECON 0.5/35 (28)
Tier 1
PA; QL (2 tab
per 1 Day)
LARIN 1/20
Tier 1
PA; QL (2 tab
per 1 Day)
NECON 1/35 (28)
Tier 1
PA; QL (2 tab
per 1 Day)
LARIN FE 1.5/30
Tier 1
PA; QL (2 tab
per 1 Day)
NECON 1/50 (28)
Tier 3
Tier 1
PA; QL (2 tab
per 1 Day)
norgestimate-eth
estradiol
Tier 1
NORINYL 1+35 (28)
Tier 3
LESSINA
Tier 1
PA; QL (2 tab
per 1 Day)
NORINYL 1+50 (28)
Tier 3
levonorgestrel-ethinyl
estrad
Tier 1
PA; QL (2 tab
per 1 Day)
NORTREL 0.5/35 (28)
Tier 1
PA; QL (2 tab
per 1 Day)
LEVORA 0.15/30 (28)
Tier 1
PA; QL (2 tab
per 1 Day)
NORTREL 1/35 (21)
Tier 1
PA; QL (2 tab
per 1 Day)
LOESTRIN 1.5/30 (21)
Tier 3
NORTREL 1/35 (28)
Tier 1
LOESTRIN 1/20 (21)
Tier 3
PA; QL (2 tab
per 1 Day)
LOESTRIN FE 1.5/30
Tier 3
OCELLA
Tier 1
PA; QL (2 tab
per 1 Day)
LOESTRIN FE 1/20
Tier 3
ORSYTHIA
Tier 1
PA; QL (2 tab
per 1 Day)
ORTHO-CEPT (28)
Tier 3
ORTHO-CYCLEN (28)
Tier 3
ORTHO-NOVUM 1/35
(28)
Tier 3
OVCON-35 (28)
Tier 3
PHILITH
Tier 1
PA; QL (2 tab
per 1 Day)
LARIN FE 1/20
LORYNA
Tier 1
PA; QL (2 tab
per 1 Day)
Drug
Status
Drug Details
PA; QL (2 tab
per 1 Day)
Tier 1
PA; QL (2 tab
per 1 Day)
Tier 1
PA; QL (2 tab
per 1 Day)
marlissa
Tier 1
PA; QL (2 tab
per 1 Day)
MICROGESTIN 1.5/30
Tier 1
PA; QL (2 tab
per 1 Day)
PIRMELLA 1/35
Tier 1
MICROGESTIN 1/20
Tier 1
PA; QL (2 tab
per 1 Day)
PA; QL (2 tab
per 1 Day)
PORTIA-28
Tier 1
PA; QL (2 tab
per 1 Day)
LOW-OGESTREL
LUTERA
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
55
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
PREVIFEM
Tier 1
PA; QL (2 tab
per 1 Day)
AMETHIA LO
Tier 1
PA; QL (2 tab
per 1 Day)
RECLIPSEN
Tier 1
PA; QL (2 tab
per 1 Day)
CAMRESE
Tier 1
PA; QL (2 tab
per 1 Day)
SAFYRAL
Tier 3
CAMRESE LO
Tier 1
PA; QL (2 tab
per 1 Day)
SOLIA
Tier 1
DAYSEE
Tier 1
PA; QL (2 tab
per 1 Day)
INTROVALE
Tier 1
PA; QL (2 tab
per 1 Day)
JOLESSA
Tier 1
PA; QL (2 tab
per 1 Day)
levonorgest-eth estrad
91-day
Tier 1
PA; QL (2 tab
per 1 Day)
SPRINTEC 28
SRONYX
SYEDA
Tier 1
Tier 1
Tier 1
PA; QL (2 tab
per 1 Day)
PA; QL (2 tab
per 1 Day)
PA; QL (2 tab
per 1 Day)
PA; QL (2 tab
per 1 Day)
Drug Details
VESTURA
Tier 1
PA; QL (2 tab
per 1 Day)
VYFEMLA
Tier 1
PA; QL (2 tab
per 1 Day)
LOSEASONIQUE
Tier 3
WERA
Tier 1
PA; QL (2 tab
per 1 Day)
PA; ST; N1;
QL (90 days
maximum per 1
fill)
QUARTETTE
Tier 3
ST; N1
WYMZYA FE
Tier 1
PA; QL (2 tab
per 1 Day)
QUASENSE
Tier 1
PA; QL (2 tab
per 1 Day)
YASMIN 28
Tier 3
YAZ
Tier 3
Tier 3
ZARAH
Tier 1
PA; ST; N1;
QL (90 days
maximum per 1
fill)
SEASONIQUE
PA; QL (2 tab
per 1 Day)
ZENCHENT
Tier 1
PA; QL (2 tab
per 1 Day)
ZENCHENT FE
Tier 1
PA; QL (2 tab
per 1 Day)
ZEOSA
Tier 1
PA; QL (2 tab
per 1 Day)
ZOVIA 1/35E (28)
Tier 1
PA; QL (2 tab
per 1 Day)
*COMBINATION
CONTRACEPTIVES
ORAL**-*EXTENDE
D-CYCLE
CONTRACEPTIVES
- ORAL***
AMETHIA
Tier 1
PA; QL (2 tab
per 1 Day)
*COMBINATION
CONTRACEPTIVES
- ORAL**-*FOUR
PHASE
CONTRACEPTIVES
- ORAL***
NATAZIA
*COMBINATION
CONTRACEPTIVES
ORAL**-*TRIPHASI
C
CONTRACEPTIVES
- ORAL***
alyacen 7/7/7
Tier 1
PA; QL (2 tab
per 1 Day)
ARANELLE
Tier 1
PA; QL (2 tab
per 1 Day)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
56
Tier 3
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
CAZIANT
Tier 1
PA; QL (2 tab
per 1 Day)
TRI-PREVIFEM
Tier 1
PA; QL (2 tab
per 1 Day)
CESIA
Tier 1
PA; QL (2 tab
per 1 Day)
TRI-SPRINTEC
Tier 1
PA; QL (2 tab
per 1 Day)
CYCLAFEM 7/7/7
Tier 1
PA; QL (2 tab
per 1 Day)
TRINESSA (28)
Tier 1
PA; QL (2 tab
per 1 Day)
CYCLESSA
Tier 3
TRIVORA (28)
Tier 1
PA; QL (2 tab
per 1 Day)
DASETTA 7/7/7
Tier 1
VELIVET
Tier 1
PA; QL (2 tab
per 1 Day)
PA; QL (2 tab
per 1 Day)
PA; QL (2 tab
per 1 Day)
ENPRESSE-28
Tier 1
ESTROSTEP FE
Tier 3
LEENA
Tier 1
PA; QL (2 tab
per 1 Day)
LEVONEST
Tier 1
PA; QL (2 tab
per 1 Day)
MYZILRA
Tier 1
PA; QL (2 tab
per 1 Day)
NECON 7/7/7
Tier 1
PA; QL (2 tab
per 1 Day)
norgestim-eth estrad
triphasic
Tier 1
PA; QL (2 tab
per 1 Day)
NORTREL 7/7/7
Tier 1
PA; QL (2 tab
per 1 Day)
ORTHO TRI-CYCLEN
(28)
Tier 3
ORTHO TRI-CYCLEN
LO
Tier 3
ORTHO-NOVUM 7/7/7
(28)
Tier 3
#
PIRMELLA 7/7/7
Tier 1
PA; QL (2 tab
per 1 Day)
TILIA FE
Tier 1
PA; QL (2 tab
per 1 Day)
TRI-ESTARYLLA
Tier 1
PA; QL (2 tab
per 1 Day)
TRI-LEGEST FE
Tier 1
PA; QL (2 tab
per 1 Day)
TRI-LINYAH
Tier 1
PA; QL (2 tab
per 1 Day)
TRI-NORINYL (28)
Tier 3
Drug Details
*COMBINATION
CONTRACEPTIVES
TRANSDERMAL**-*
COMBINATION
CONTRACEPTIVES
- TRANSDERMAL***
ORTHO EVRA
Tier 3
*COMBINATION
CONTRACEPTIVES
VAGINAL**-*COMB
INATION
CONTRACEPTIVES
- VAGINAL***
NUVARING
Tier 3
*COPPER
CONTRACEPTIVES
- IUD**-*COPPER
CONTRACEPTIVES
- IUD***
PARAGARD
INTRAUTERINE
COPPER
Tier 3
PA; QL (1 IUD
per 365 days)
IMPLANON
Tier 3
PA; QL (1 pack
per 365 Days)
NEXPLANON
Tier 3
PA; QL (1 pack
per 365 Days)
*PROGESTIN
CONTRACEPTIVES
- IMPLANTS**-*PRO
GESTIN
CONTRACEPTIVES
- IMPLANTS***
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57
Drug Name
Drug
Status
Drug Details
*PROGESTIN
CONTRACEPTIVES
INJECTABLE**-*PR
OGESTIN
CONTRACEPTIVES
- INJECTABLE***
DEPO-PROVERA
INTRAMUSCULAR*
SUSPENSION 150
MG/ML
Tier 3
DEPO-SUBQ
PROVERA 104
Tier 3
QL (8 syringe
per 365 Days)
medroxyprogesterone
acetate intramuscular*
Tier 1
PA; QL (5 vial
per 365 Days)
QL (5 vial per
365 Days)
SKYLA
Tier 3
Tier 3
LYZA
Tier 1
NOR-QD
Tier 3
NORA-BE
Tier 1
PA; QL (2 tab
per 1 Day)
norethindrone oral
Tier 1
PA; QL (2 tab
per 1 Day)
ORTHO MICRONOR
Tier 3
Tier 1
BAYCADRON
Tier 1
budesonide er
Tier 1
PA; #; QL (1
IUD per 365
days)
CORTEF
Tier 3
dexamethasone oral
elixir
Tier 1
PA; QL (1
Device per 365
days)
dexamethasone oral
tablet 0.5 mg, 0.75 mg,
1.5 mg, 4 mg, 6 mg
Tier 1
DEXAMETHASONE
INTENSOL
Tier 3
DEXPAK 10 DAY
Tier 3
DEXPAK 13 DAY
Tier 3
DEXPAK 6 DAY
Tier 3
ENTOCORT EC
Tier 3
FLO-PRED
Tier 3
hydrocortisone oral
Tier 1
MEDROL ORAL
TABLET 16 MG, 2
MG, 32 MG, 4 MG
Tier 3
MEDROL (PAK)
Tier 3
methylprednisolone oral
Tier 1
methylprednisolone
(pak)
Tier 1
Tier 1
ERRIN
Tier 1
PA; QL (2 tab
per 1 Day)
HEATHER
Tier 1
PA; QL (2 tab
per 1 Day)
JENCYCLA
Tier 1
PA; QL (2 tab
per 1 Day)
JOLIVETTE
Tier 1
PA; QL (2 tab
per 1 Day)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
58
PA; QL (2 tab
per 1 Day)
*GLUCOCORTICOS
TEROIDS**-*GLUC
OCORTICOSTEROI
DS***
ASMALPRED PLUS
PA; QL (2 tab
per 1 Day)
Drug Details
*CORTICOSTEROID
S*
Tier 1
*PROGESTIN
CONTRACEPTIVES
ORAL**-*PROGESTI
N
CONTRACEPTIVES
- ORAL***
CAMILA
Drug
Status
ASMALPRED
*PROGESTIN
CONTRACEPTIVES
IUD**-*PROGESTIN
CONTRACEPTIVES
- IUD***
MIRENA
Drug Name
QL (3 caps per
1 Day)
ST; N1; QL (3
caps per 1 Day)
Drug Name
Drug
Status
MILLIPRED
Drug Details
Drug Name
Drug
Status
Tier 3
hydromet
Tier 1
MILLIPRED DP
Tier 3
TUSSIGON
Tier 1
MILLIPRED DP
12-DAY
Tier 3
ORAPRED
Tier 3
ORAPRED ODT
Tier 3
PEDIAPRED
Tier 3
prednisolone oral
Tier 1
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
ANTITUSSIVE-EXPE
CTORANT DECONGEST-ANTIH
IST***
albatussin nn oral
liquid†
Tier 3
NEOTUSS-D ORAL
LIQUID† 30-2-30-200
MG/5ML
Tier 3
prednisolone sodium
phosphate oral solution
15 mg/5ml, 6.7 (5 base)
mg/5ml
Tier 1
prednisone oral tablet 1
mg, 10 mg, 2.5 mg, 20
mg, 5 mg
Tier 1
LGC
prednisone (pak)
Tier 1
LGC
PREDNISONE
INTENSOL
Tier 3
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
ANTITUSSIVE-EXPE
CTORANT***
PRELONE
Tier 3
cheratussin ac oral
syrup
Tier 1
RAYOS
Tier 3
ST; N1
gani-tuss nr
Tier 1
UCERIS
Tier 3
PA; QL (1 tab
per 1 Day)
guaiatussin ac
Tier 1
VERIPRED 20
Tier 3
guaifenesin ac
Tier 1
guaifenesin-codeine
oral solution
Tier 1
guaifenesin-codeine
oral syrup
Tier 1
guiatuss ac
Tier 1
*COUGH/COLD/ALL
ERGY*
iophen c-nr
Tier 1
m-clear wc
Tier 1
*ANTITUSSIVES**-*
ANTITUSSIVE NONNARCOTIC***
myci-gc
Tier 1
mytussin ac
Tier 1
nortuss-ex
Tier 3
relcof c
Tier 1
robafen ac
Tier 1
ROMILAR AC
Tier 1
virtussin a/c
Tier 1
*MINERALOCORTI
COIDS**-*MINERAL
OCORTICOIDS***
fludrocortisone acetate
oral
Tier 1
benzonatate
Tier 1
TESSALON PERLES
Tier 3
ZONATUSS
Tier 3
*ANTITUSSIVES**-*
ANTITUSSIVE OPIOID***
hydrocodone-homatropi
ne
Drug Details
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
59
Drug Name
Drug
Status
Drug Details
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
ANTITUSSIVE-EXPE
CTORANTS-ANTIHI
STAMINE***
TUSNEL ORAL
CAPSULE
Drug Name
Drug
Status
SEMPREX-D
Tier 3
Tier 3
GILPHEX TR
albatussin
Tier 3
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
DECONGESTANT-A
NTIHISTAMINE W/
EXPECTORANT***
cheratussin dac
Tier 1
DECON-G
EXACTUSS
Tier 3
GILTUSS
Tier 3
GILTUSS PED-C
Tier 3
GILTUSS TR
Tier 3
guaifenesin dac
Tier 1
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
NON-NARC
ANTITUSSIVE-ANTI
HISTAMINE***
mytussin dac
Tier 1
promethazine-dm
tgq 30pse/150gfn/15dm
Tier 3
tusnel ped-c
Tier 3
TUSSO-DMR
Tier 3
Z-COF I
Tier 3
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
NON-NARC
ANTITUSSIVE-DEC
ONGESTANT-ANTIH
ISTAMINE***
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
DECONGESTANT &
ANTIHISTAMINE***
Tier 3
Tier 3
Tier 1
BROMFED DM
Tier 1
CARBAPHEN 12
Tier 3
CARBAPHEN 12 PED
Tier 3
Tier 3
PA; QL (2 tab
per 1 Day)
DIMETANE DX
Tier 1
CLARINEX-D 24
HOUR
NEOTUSS PLUS
Tier 3
Tier 3
PA; QL (1 tab
per 1 Day)
PEDIATEX TDM
Tier 3
DECON-A ORAL
ELIXIR
Tier 3
Tier 1
RELHIST
Tier 3
pseudoeph-bromphen-d
m oral syrup 30-2-10
mg/5ml
RESCON-JR
Tier 3
tgq 30pse/3brm/15dm
Tier 3
RESCON-MX
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
60
PA; QL (4 caps
per 1 Day)
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
DECONGESTANT
W/
EXPECTORANT***
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
ANTITUSSIVE-EXPE
CTORANTS-DECON
GESTANT***
CLARINEX-D 12
HOUR
Drug Details
PA
Drug Name
Drug
Status
Drug Details
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
OPIOID
ANTITUSSIVE-ANTI
HISTAMINE***
hydrocod polst-cpm
polst er
Tier 1
promethazine-codeine
Tier 1
TUSSICAPS
Tier 3
TUSSIONEX
PENNKINETIC ER
Tier 3
VITUZ
Tier 3
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
OPIOID
ANTITUSSIVE-DEC
ONGESTANT***
PA
Drug Name
Drug
Status
NEBUSAL
INHALATION
NEBULIZATION
SOLUTION 6 %
Tier 3
PULMOSAL
Tier 1
sodium chloride
inhalation nebulization
solution 10 %, 3 %, 7 %
Tier 1
*MUCOLYTICS**-*
MUCOLYTICS***
acetylcysteine
inhalation
Tier 1
*DERMATOLOGICA
LS*
*ACNE
PRODUCTS**-*ACN
E ANTIBIOTICS***
ACZONE
Tier 3
AKNE-MYCIN
Tier 3
CLEOCIN-T
EXTERNAL 1 %
Tier 3
CLINDACIN ETZ
EXTERNAL SWAB
Tier 1
CLINDACIN-P
Tier 1
CLINDAGEL
Tier 3
CLINDAMAX
EXTERNAL 1 %
Tier 1
clindamycin phosphate
external , 1 %
Tier 1
*MISC.
RESPIRATORY
INHALANTS**-*MIS
C. RESPIRATORY
INHALANTS***
ery
Tier 1
ERYGEL
Tier 3
erythromycin external
pad
Tier 1
HYPERSAL
INHALATION
NEBULIZATION
SOLUTION 3.5 %
erythromycin external
solution
Tier 1
EVOCLIN
Tier 3
KLARON
Tier 3
sulfacetamide sodium
external suspension
Tier 1
sulfacetamide sodium
(acne)
Tier 1
REZIRA
Tier 3
*COUGH/COLD/ALL
ERGY
COMBINATIONS**-*
OPIOID
ANTITUSSIVE-DEC
ONGESTANT-ANTIH
ISTAMINE***
CPB WC
Tier 3
phenylhistine dh
Tier 3
TRICODE AR
Tier 3
NEBUSAL
INHALATION
NEBULIZATION
SOLUTION 3 %
Drug Details
Tier 3
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
61
Drug Name
Drug
Status
Drug Details
*ACNE
PRODUCTS**-*ACN
E
COMBINATIONS***
Drug
Status
ROSADERM
EXTERNAL
EMULSION
Tier 1
ROSANIL CLEANSER
Tier 1
se 10-5 ss
Tier 1
ACANYA
Tier 3
AVAR EXTERNAL
PAD
Tier 3
sss 10-5
Tier 1
AVAR CLEANSER
Tier 1
sulfacetamide sod-sulfur
wash external emulsion
Tier 1
AVAR LS
Tier 3
AVAR LS CLEANSER
Tier 3
Tier 1
AVAR-E EMOLLIENT
Tier 1
sulfacetamide
sodium-sulfur external
cream
AVAR-E GREEN
Tier 1
AVAR-E LS
Tier 3
sulfacetamide
sodium-sulfur external
emulsion
Tier 1
BENZAMYCIN
Tier 3
ST; N1
BENZAMYCINPAK
Tier 3
ST; N1
Tier 1
benzoyl
peroxide-erythromycin
sulfacetamide
sodium-sulfur external
foam
Tier 1
bp 10-1
Tier 1
Tier 1
bp cleansing wash
Tier 1
sulfacetamide
sodium-sulfur external
liquid†
CERISA WASH
Tier 1
Tier 1
CLARIS CLARIFYING
WASH
Tier 1
sulfacetamide
sodium-sulfur external
lotion
CLENIA
Tier 1
Tier 1
CLENIA FOAMING
WASH
Tier 1
sulfacetamide
sodium-sulfur external
pad
clindamycin
phos-benzoyl perox
Tier 1
Tier 1
sulfacetamide
sodium-sulfur external
suspension 8-4 %
DUAC
Tier 3
ST; N1
Tier 1
EPIDUO
Tier 2
PA
sulfacetamide-sulfur
wash
PLEXION
Tier 3
SULFACLEANSE 8/4
Tier 1
PLEXION CLEANSER
EXTERNAL LIQUID†
SUPHERA
Tier 1
Tier 3
topisulf
Tier 1
VANOXIDE-HC
Tier 3
virti-sulf
Tier 1
ZENCIA
Tier 1
PLEXION
CLEANSING CLOTH
EXTERNAL PAD
Tier 3
PRASCION
Tier 1
PRASCION FC
Tier 1
PRASCION RA
Tier 1
ST; N1
Drug Name
*ACNE
PRODUCTS**-*ACN
E PRODUCTS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
62
Drug Details
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
Drug Details
MYORISAN
Tier 3
NUOX
Tier 3
RETIN-A
Tier 3
PA; ST; N1
ABSORICA ORAL
CAPSULE 10 MG, 20
MG, 30 MG, 40 MG
Tier 3
PA; ST; QL (2
capsules per 1
day)
adapalene external 0.1
%
Tier 3
PA
adapalene external
cream
Tier 3
PA
RETIN-A EXTERNAL
0.01 %, 0.025 %
Tier 3
PA; ST; N1
AMNESTEEM
Tier 3
PA; ST; N1;
QL (2 capsules
per 1 day)
RETIN-A MICRO
Tier 2
PA
ATRALIN
Tier 3
PA; ST; N1; #
RETIN-A MICRO
PUMP EXTERNAL
0.04 %, 0.1 %
Tier 2
PA
AVITA
Tier 1
PA
RIAX
Tier 3
ST; N1
AVITA EXTERNAL
0.025 %
Tier 1
PA
SOTRET
Tier 1
PA
AZELEX
Tier 3
SULFOAM
Tier 3
BENZEPRO
Tier 1
TRETIN-X
EXTERNAL CREAM
Tier 3
PA; ST; N1
BENZEPRO SHORT
CONTACT
Tier 1
tretinoin external , 0.01
%, 0.025 %
Tier 1
PA
BENZIQ
Tier 3
tretinoin microsphere
Tier 1
PA
BENZIQ LS
Tier 3
benzoyl peroxide
external foam
Tier 1
PA
Tier 1
tretinoin microsphere
pump
benzoyl peroxide short
contact
Tier 3
Tier 1
zaclir cleansing external
lotion 8 %
bp foam
Tier 1
ZENATANE
Tier 3
bpo
Tier 3
bpo foaming cloths
Tier 3
CLARAVIS
Tier 1
PA; ST; N1;
QL (2 capsules
per 1 day)
DIFFERIN
EXTERNAL 0.1 %
Tier 3
PA; ST; N1
DIFFERIN
EXTERNAL 0.3 %
Tier 3
PA; ST
DIFFERIN
EXTERNAL CREAM
Tier 3
PA; ST; N1
DIFFERIN
EXTERNAL LOTION
Tier 3
PA; ST; N1
FABIOR
Tier 3
PA; ST; N1
PA; ST; N1;
QL (2 capsules
per 1 day)
PA; ST; N1;
QL (2 capsules
per 1 day)
*AGENTS FOR
EXTERNAL
GENITAL AND
PERIANAL
WARTS**-*AGENTS
FOR EXTERNAL
GENITAL AND
PERIANAL
WARTS***
VEREGEN
Tier 3
*ANTIBIOTICS TOPICAL**-*ANTIB
IOTIC STEROID
COMBINATIONS TOPICAL***
CORTISPORIN
EXTERNAL
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
63
Drug Name
Drug
Status
Drug Details
*ANTIBIOTICS TOPICAL**-*ANTIB
IOTICS TOPICAL***
Drug Name
Drug
Status
ciclopirox external 0.77
%
Tier 1
ciclopirox external
shampoo
Tier 1
ciclopirox external
solution
Tier 1
ciclopirox olamine
external
Tier 1
CNL8 NAIL
Tier 3
ALTABAX
Tier 3
BACTROBAN
Tier 3
CENTANY
Tier 3
gentamicin sulfate
external
Tier 1
mupirocin external
Tier 1
HALOTIN
Tier 3
mupirocin calcium
Tier 1
LOPROX EXTERNAL
0.77 %
Tier 3
NAFTIN
Tier 3
NAFTIN EXTERNAL
1 %, 2 %
Tier 3
LGC
*ANTIFUNGALS TOPICAL**-*ANTIF
UNGALS - TOPICAL
COMBINATIONS***
ala quin
Tier 3
NYAMYC
Tier 1
ALCORTIN A
Tier 3
nystatin external
Tier 1
ALOQUIN
Tier 3
NYSTOP
Tier 1
clotrimazole-betamethas
one
Tier 1
pedi-dri
Tier 1
DERMASORB AF
Tier 3
PENLAC
Tier 3
DERMAZENE
Tier 1
EXODERM
EXTERNAL LOTION
Tier 1
hydrocortisone-iodoqui
nol
Tier 1
LOTRISONE
Tier 1
Tier 3
nystatin-triamcinolone
Tier 1
baza antifungal
Tier 1
VERSICLEAR
Tier 1
Tier 1
VUSION
Tier 3
CARRINGTON
ANTIFUNGAL
VYTONE
Tier 3
econazole nitrate
external
Tier 1
ECOZA
Tier 3
ERTACZO
Tier 3
EXELDERM
Tier 3
EXTINA
Tier 3
JUBLIA
Tier 3
ketoconazole external
cream
Tier 1
*ANTIFUNGALS TOPICAL**-*ANTIF
UNGALS TOPICAL***
Tier 1
CICLODAN
EXTERNAL
SOLUTION
Tier 1
PA
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
64
PA
PA
*ANTIFUNGALS TOPICAL**-*IMIDA
ZOLE-RELATED
ANTIFUNGALS TOPICAL***
antifungal external
cream 2 %
CICLODAN
EXTERNAL CREAM
Drug Details
PA
Drug Name
Drug
Status
ketoconazole external
shampoo
Tier 1
KETODAN
EXTERNAL FOAM
Tier 1
kp miconazole nitrate
Tier 1
KURIC
Tier 1
LUZU
Tier 3
micaderm
Tier 1
MICATIN
Tier 3
miconazole nitrate
external cream
Tier 1
MICRO GUARD
EXTERNAL CREAM
Tier 1
NEOSPORIN AF
Tier 1
NIZORAL
Tier 3
NUZOLE
Tier 1
OXISTAT
Tier 3
podactin external cream
Tier 1
ra antifungal external
cream
Tier 1
REMEDY
ANTIFUNGAL
EXTERNAL CREAM
Tier 1
SECURA
ANTIFUNGAL
Tier 1
SECURA
ANTIFUNGAL
EXTRA THICK
Tier 1
sm antifungal
miconazole
Tier 1
SOOTHE & COOL
INZO ANTIFUNGAL
Tier 1
XOLEGEL
Tier 3
Drug Details
Tier 2
Drug
Status
Drug Details
PENNSAID
TRANSDERMAL
SOLUTION 1.5 %
Tier 3
ST; N1; QL (15
ml per 1 Day)
PENNSAID
TRANSDERMAL
SOLUTION 2 %
Tier 3
ST; N1; QL (4
ml per 1 Day)
VOLTAREN
TRANSDERMAL
Tier 2
ST; N1; QL (5
tubes per 30
days)
*ANTI-INFLAMMAT
ORY AGENTS TOPICAL**-*ANTI-I
NFLAMMATORY
COMBINATIONS TOPICAL***
aif #2 drug preparation
kit
Tier 3
*ANTINEOPLASTIC
OR
PREMALIGNANT
LESION AGENTS TOPICAL**-*ANTIN
EOPLASTIC
ALKYLATING
AGENTS TOPICAL***
VALCHLOR
Tier 3
PA
*ANTINEOPLASTIC
OR
PREMALIGNANT
LESION AGENTS TOPICAL**-*ANTIN
EOPLASTIC
ANTIMETABOLITES
- TOPICAL***
*ANTI-INFLAMMAT
ORY AGENTS TOPICAL**-*ANTI-I
NFLAMMATORY
AGENTS TOPICAL***
FLECTOR
Drug Name
CARAC
Tier 3
EFUDEX
Tier 3
FLUOROPLEX
Tier 3
fluorouracil external
Tier 1
QL (2 patch per
1 Day)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
65
Drug Name
Drug
Status
Drug Details
*ANTINEOPLASTIC
OR
PREMALIGNANT
LESION AGENTS TOPICAL**-*ANTIN
EOPLASTIC OR
PREMALIGNANT
LESIONS - TOPICAL
MISC.***
PICATO
Tier 2
Drug Details
QL (1 tube per
60 days)
TARGRETIN
EXTERNAL
Tier 2
*ANTIPRURITICS TOPICAL**-*ANTIP
RURITICS TOPICAL***
PRUDOXIN
Tier 3
ZONALON
Tier 3
*ANTIPSORIATICS*
*-*ANTIPSORIATIC
S - SYSTEMIC***
diclofenac sodium
transdermal 3 %
Tier 1
SOLARAZE
Tier 3
*ANTINEOPLASTIC
OR
PREMALIGNANT
LESION AGENTS TOPICAL**-*ANTIN
EOPLASTIC
RETINOIDS TOPICAL***
8-MOP
Tier 3
acitretin
Tier 1
OXSORALEN ULTRA
Tier 3
SORIATANE ORAL
CAPSULE 10 MG, 17.5
MG, 25 MG
Tier 2
*ANTIPSORIATICS*
*-*ANTIPSORIATIC
S***
Tier 2
*ANTINEOPLASTIC
OR
PREMALIGNANT
LESION AGENTS TOPICAL**-*PHOT
ODYNAMIC
THERAPY AGENTS TOPICAL***
LEVULAN
KERASTICK
Tier 3
METVIXIA
Tier 3
calcipotriene external
Tier 1
CALCITRENE
Tier 1
DOVONEX
EXTERNAL CREAM
Tier 3
DRITHO-CREME HP
Tier 3
SORILUX
Tier 3
ST; N1
TAZORAC
EXTERNAL 0.05 %,
0.1 %
Tier 2
PA
VECTICAL
Tier 3
ZITHRANOL
Tier 3
ZITHRANOL-RR
Tier 3
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66
Drug
Status
*ANTINEOPLASTIC
OR
PREMALIGNANT
LESION AGENTS TOPICAL**-*TOPIC
AL SELECTIVE
RETINOID X
RECEPTOR
AGONISTS***
*ANTINEOPLASTIC
OR
PREMALIGNANT
LESION AGENTS TOPICAL**-*ANTIN
EOPLASTIC OR
PREMALIGNANT
LESIONS - TOPICAL
NSAID'S***
PANRETIN
Drug Name
Drug Name
Drug
Status
*ANTISEBORRHEIC
PRODUCTS**-*ANTI
SEBORRHEIC
COMBINATIONS***
SELRX
Tier 3
sodium sulfacetamide
wash
Tier 3
*ANTISEBORRHEIC
PRODUCTS**-*ANTI
SEBORRHEIC
PRODUCTS***
MEXAR WASH
Tier 1
OVACE PLUS
EXTERNAL CREAM
Tier 3
OVACE PLUS
EXTERNAL
SHAMPOO
Tier 3
OVACE PLUS WASH
Tier 3
OVACE PLUS WASH
EXTERNAL 10 %
Tier 3
OVACE WASH
Tier 3
RE 10 WASH
Tier 1
SEB-PREV
Tier 3
SEB-PREV WASH
Tier 1
selenium sulfide
external
Tier 1
sodium sulfacetamide
Tier 1
sulfacetamide sodium
external 10 % (cleans)
Tier 1
sulfacetamide sodium
external liquid†
Tier 1
TERSI
Tier 3
*ANTIVIRALS TOPICAL**-*ANTIV
IRAL TOPICAL
COMBINATIONS***
XERESE
Tier 3
*ANTIVIRALS TOPICAL**-*ANTIV
IRALS TOPICAL***
acyclovir external
Drug Details
Drug Name
Drug
Status
DENAVIR
Tier 3
ZOVIRAX
EXTERNAL
Tier 3
Drug Details
*BURN
PRODUCTS**-*BUR
N PRODUCTS***
mafenide acetate
external
Tier 1
SILVADENE
Tier 3
silver sulfadiazine
external
Tier 1
SSD
Tier 1
SSD AF
Tier 1
SULFAMYLON
Tier 3
THERMAZENE
Tier 1
*CAUTERIZING
AGENTS**-*CAUTE
RIZING AGENT
COMBINATIONS***
grafco silver nit
applicator
Tier 1
*CAUTERIZING
AGENTS**-*CAUTE
RIZING AGENTS***
TRI-CHLOR
Tier 3
*CORTICOSTEROID
STOPICAL**-*CORTI
COSTEROIDS TOPICAL***
ACLOVATE
EXTERNAL CREAM
Tier 3
alclometasone
dipropionate
Tier 1
alphatrex
Tier 1
amcinonide external
cream
Tier 1
APEXICON
Tier 1
APEXICON E
Tier 3
BETA-VAL
Tier 1
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
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Drug Name
Drug
Status
betamethasone
dipropionate external
Tier 1
betamethasone
dipropionate aug
Tier 1
betamethasone
dipropionate aug
external 0.05 %
Tier 1
betamethasone valerate
external
Tier 1
CAPEX
Tier 3
clobetasol propionate
external , 0.05 %
Drug Details
Drug Name
Drug
Status
Drug Details
diflorasone diacetate
external ointment
Tier 1
DIPROLENE
Tier 3
DIPROLENE AF
Tier 3
ELOCON
Tier 3
fluocinolone acetonide
external
Tier 1
fluocinolone acetonide
body
Tier 1
Tier 1
fluocinolone acetonide
scalp
Tier 1
clobetasol propionate e
Tier 1
fluocinonide external
0.05 %
Tier 1
clobetasol propionate
emulsion
Tier 1
fluocinonide external
cream 0.05 %
Tier 1
CLOBEX
Tier 3
CLOBEX SPRAY
Tier 2
fluocinonide external
ointment
Tier 1
CORDRAN
EXTERNAL LOTION
Tier 3
fluocinonide external
solution
Tier 1
CORDRAN
EXTERNAL TAPE
Tier 3
fluocinonide-e
Tier 1
CORMAX
Tier 1
fluticasone propionate
external
Tier 1
CORMAX SCALP
APPLICATION
Tier 1
halobetasol propionate
Tier 1
HALOG
Tier 3
CUTIVATE
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
hydrocortisone valerate
Tier 1
isovate
Tier 1
KENALOG
EXTERNAL
Tier 3
LOCOID
Tier 3
ST; N1
LOCOID LIPOCREAM
Tier 3
ST; N1
DERMA-SMOOTHE/F
S BODY
DERMA-SMOOTHE/F
S SCALP
ST; N1
ST; N1
Tier 3
Tier 3
DERMATOP
EXTERNAL CREAM
Tier 3
DESONATE
Tier 3
desonide external
Tier 1
DESOWEN
Tier 3
desoximetasone external
0.05 %
Tier 1
desoximetasone external
cream 0.25 %
Tier 1
desoximetasone external
ointment 0.25 %
Tier 1
ST; N1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
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LGC
LGC
Drug Name
Drug
Status
Drug Details
Drug Name
LOKARA
Tier 1
LUXIQ
Tier 3
mometasone furoate
external
Tier 1
NUCORT
Tier 3
OLUX
Tier 3
ST; N1
OLUX-E
Tier 3
ST; N1
PANDEL
Tier 3
prednicarbate
Tier 1
scalacort
Tier 1
ST; N1
hydrocortisone
ace-pramoxine external
NOVACORT
Tier 3
PRAMOSONE
EXTERNAL CREAM
1-1 %
Tier 3
PRAMOSONE
EXTERNAL LOTION
Tier 3
Tier 3
Tier 1
PRAMOSONE
EXTERNAL
OINTMENT
SYNALAR
Tier 3
PRAMOSONE E
Tier 3
TEMOVATE
Tier 3
TEMOVATE
EXTERNAL 0.05 %
Tier 3
TEMOVATE E
Tier 3
*CORTICOSTEROID
STOPICAL**-*TOPIC
AL STEROID
COMBINATIONS***
TEXACORT
Tier 3
CORTALO
Tier 1
TOPICORT
Tier 3
TOPICORT
EXTERNAL 0.05 %
Tier 1
Tier 3
hydrocortisone
acetate-aloe external 2
%
TOPICORT SPRAY
Tier 3
TACLONEX
Tier 3
triamcinolone acetonide
external cream
U-CORT
Tier 1
Tier 1
triamcinolone acetonide
external lotion
Tier 1
triamcinolone acetonide
external ointment
Tier 1
TRIANEX
Tier 3
TRIDERM
Tier 1
ULTRAVATE
Tier 3
VERDESO
Tier 3
WESTCORT
Tier 3
*CORTICOSTEROID
STOPICAL**-*STERO
ID-LOCAL
ANESTHETIC
COMBINATIONS***
CORTANE-B
EXTERNAL
Tier 3
EPIFOAM
Tier 3
LGC
LGC
ST; N1
Drug
Status
Drug Details
*EMOLLIENT/KERA
TOLYTIC
AGENTS**-*EMOLL
IENT/KERATOLYTI
C AGENTS***
ALUVEA
Tier 3
CARMOL 40
EXTERNAL CREAM
Tier 1
CEM-UREA
Tier 3
CEROVEL
EXTERNAL 40 %
Tier 1
DERMASORB XM
Tier 3
GORDONS UREA
EXTERNAL
OINTMENT 40 %
Tier 3
KERAFOAM
Tier 3
KERAFOAM 42
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
69
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
urea hydrating
Tier 1
urea in zn undecyl-lactic
acid
Tier 1
KERALAC
EXTERNAL CREAM
47 %
Tier 3
re 40
Tier 1
urea nail external kit
Tier 3
re urea 40
Tier 1
urea nail external stick
Tier 3
REMEVEN
Tier 1
tl urea
Tier 1
*EMOLLIENTS**-*E
MOLLIENTS***
U-KERA E
Tier 1
hygel
Tier 1
UMECTA EXTERNAL
EMULSION
Tier 3
HYLIRA EXTERNAL
LOTION
Tier 3
urea external 40 %
Tier 1
lactic acid external
Tier 1
urea external cream 39
%, 40 %, 45 %, 50 %
Tier 1
sodium hyaluronate
external 0.2 %
Tier 1
urea external lotion 40
%, 45 %
Tier 1
urea external
suspension 40 %
Tier 1
urea nail external 45 %
*ENZYMES TOPICAL**-*ENZY
MES - TOPICAL***
OPTASE
Tier 3
Tier 1
REVINA
Tier 1
urea nail film
Tier 1
SANTYL
Tier 3
urea-c40
Tier 1
tbc
Tier 1
urea40
Tier 1
VASOLEX
Tier 1
UTOPIC
Tier 3
X-VIATE
Tier 1
X-VIATE EXTERNAL
40 %
Tier 1
*GLABELLAR
LINES (FROWN
LINES)
AGENTS**-*GLABE
LLAR LINES
(FROWN LINES)
AGENTS***
*EMOLLIENT/KERA
TOLYTIC
AGENTS**-*EMOLL
IENT/KERATOLYTI
C
COMBINATIONS***
BOTOX COSMETIC
LATRIX
Tier 1
re urea 50 external
emulsion
Tier 1
UMECTA PD
Tier 3
URAMAXIN
EXTERNAL FOAM
Tier 3
urea external emulsion
Tier 1
urea external
suspension 50 %
Tier 1
Tier 2
PA
ALDARA
Tier 3
QL (120 max
day supply per
365 days)
imiquimod external
Tier 1
QL (120 max
day supply per
365 days)
*IMMUNOMODULA
TING AGENTS TOPICAL**-*IMMU
NOMODULATORS
IMIDAZOQUINOLIN
AMINES TOPICAL***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
70
Drug Details
Drug Name
Drug
Status
ZYCLARA
ZYCLARA PUMP
EXTERNAL CREAM
2.5 %
ZYCLARA PUMP
EXTERNAL CREAM
3.75 %
Drug Details
Drug Name
Tier 3
PA; QL (56 EA
per 365 days)
salicylic acid external
foam
Tier 1
Tier 3
PA; QL (2
bottle per 365
days)
salicylic acid external
liquid† 27.5 %
Tier 1
salicylic acid external
lotion
Tier 1
Tier 3
PA; QL (56
packets per 30
days)
salicylic acid external
shampoo
Tier 1
salicylic acid wart
remover
Tier 1
*IMMUNOSUPPRES
SIVE AGENTS TOPICAL**-*MACR
OLIDE
IMMUNOSUPPRESS
ANTS - TOPICAL***
Drug
Status
ELIDEL
Tier 2
PA
*LOCAL
ANESTHETICS TOPICAL**-*LOCA
L ANESTHETICS TOPICAL***
PROTOPIC
Tier 2
PA; #
ANACAINE
Tier 3
lidocaine external
ointment
Tier 1
lidocaine external patch
Tier 1
lidocaine hcl external
cream
Tier 1
Tier 1
*KERATOLYTIC/AN
TIMITOTIC
AGENTS**-*KERAT
OLYTIC AND/OR
ANTIMITOTIC
COMBINATIONS***
bensal hp
Tier 3
GORDOFILM
Tier 3
lidocaine hcl external
solution
SALKERA
Tier 3
LIDODERM
Tier 3
SALVAX DUO PLUS
Tier 3
lidorx
Tier 3
QUTENZA
Tier 3
QUTENZA (2 PATCH)
Tier 3
XYLOCAINE
EXTERNAL
Tier 3
*KERATOLYTIC/AN
TIMITOTIC
AGENTS**-*KERAT
OLYTIC/ANTIMITO
TIC AGENTS***
ALICLEN
Tier 1
CONDYLOX
Tier 3
CONDYLOX
EXTERNAL 0.5 %
Tier 3
*LOCAL
ANESTHETICS TOPICAL**-*TOPIC
AL ANESTHETIC
COMBINATIONS***
podocon
Tier 3
EMLA
Tier 3
podofilox external
Tier 1
Tier 1
re sa
Tier 1
lidocaine-prilocaine
external cream
SALACYN
Tier 1
PLIAGLIS
Tier 3
salicylic acid external
cream
SYNERA
Tier 3
Tier 1
Drug Details
PA
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
71
Drug Name
Drug
Status
Drug Details
*LOCAL
ANESTHETICS TOPICAL**-*TOPIC
AL ANESTHETIC
GASSES***
GEBAUERS PAIN
EASE
GEBAUERS SPRAY
AND STRETCH
Tier 3
Tier 3
*MISC.
TOPICAL**-*ASTRI
NGENTS***
XERAC AC
Drug
Status
EURAX
Tier 3
lindane external
Tier 1
malathion external
Tier 1
NATROBA
Tier 3
OVIDE
Tier 3
permethrin external
cream
Tier 1
SKLICE
Tier 3
ULESFIA
Tier 3
*WOUND CARE
PRODUCTS**-*WOU
ND CARE GROWTH FACTOR
AGENTS***
Tier 3
*MISC.
TOPICAL**-*MISC.
TOPICAL***
HYPERCARE
Drug Name
REGRANEX
Tier 1
*WOUND CARE
PRODUCTS**-*WOU
ND CARE
COMBINATIONS***
FINACEA
Tier 3
REGENECARE
METROCREAM
Tier 3
METROGEL
EXTERNAL 1 %
Tier 3
METROLOTION
Tier 3
metronidazole external ,
0.75 %, 1 %
Tier 1
*WOUND CARE
PRODUCTS**-*WOU
ND
CLEANSERS/DECUB
ITUS ULCER
THERAPY***
MIRVASO
Tier 3
NORITATE
Tier 3
ORACEA
Tier 2
ROSADAN
EXTERNAL 0.75 %
*ROSACEA
AGENTS**-*ROSAC
EA AGENTS***
lavare wound wash
ST; N1
*DIAGNOSTIC
PRODUCTS*
PA
Tier 1
ROSADAN
EXTERNAL CREAM
*DIAGNOSTIC
BIOLOGICALS**-*M
ULTIPLE SKIN
TESTS***
Tier 1
T.R.U.E. TEST
VITAZOL
Tier 1
*DIAGNOSTIC
DRUGS**-*DIAGNO
STIC DRUGS***
*SCABICIDES &
PEDICULICIDES**-*
SCABICIDES &
PEDICULICIDES***
Tier 3
Tier 3
Tier 3
Tier 3
ARIDOL
Tier 3
METOPIRONE
Tier 3
ACTICIN
Tier 1
PROVOCHOLINE
Tier 3
ELIMITE
Tier 3
THYROGEN
Tier 2
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
72
Drug Details
Drug Name
Drug
Status
Drug Details
*DIAGNOSTIC
PRODUCTS,
MISC.**-*DIAGNOS
TIC PRODUCTS,
MISC.***
HYSKON
Drug Name
*DIAGNOSTIC
TESTS**-*DIAGNOS
TIC TESTS***
Drug Details
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ADVANCE
INTUITION TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ADVANCE
MICRO-DRAW TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACURA BLOOD
GLUCOSE TEST
Tier 3
Drug
Status
ACCU-CHEK ACTIVE
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACCU-CHEK
ADVANTAGE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACCU-CHEK AVIVA
IN VITRO STRIP
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ADVOCATE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACCU-CHEK AVIVA
PLUS IN VITRO
Tier 3
PA; ST; QL
(300 EA per 30
Days)
AGAMATRIX AMP
TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACCU-CHEK
COMFORT CURVE IN
VITRO STRIP
Tier 3
PA; ST; QL
(300 EA per 30
Days)
AGAMATRIX JAZZ
TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACCU-CHEK
COMPACT
Tier 3
PA; ST; QL
(300 EA per 30
Days)
AGAMATRIX
KEYNOTE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACCU-CHEK
COMPACT PLUS
Tier 3
PA; ST; QL
(300 EA per 30
Days)
AGAMATRIX
PRESTO TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACCU-CHEK
COMPACT TEST
DRUM
Tier 3
PA; ST; QL
(300 EA per 30
Days)
albertsons test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACCU-CHEK
SMARTVIEW
ALBUSTIX
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ASCENSIA
AUTODISC TEST
Tier 3
ACCUTREND
GLUCOSE
Tier 3
ASSURE 3 TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ACETEST
Tier 3
active-medicated spec
collect
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
ADVOCATE
REDI-CODE IN
VITRO
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ADVOCATE
REDI-CODE+ TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ASSURE 4 TEST
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
73
Drug Name
Drug
Status
ASSURE II
ASSURE II CHECK
ASSURE PLATINUM
ASSURE PRO TEST
AT LAST TEST
BAYER BREEZE 2
TEST
BAYER CONTOUR
NEXT TEST
BAYER CONTOUR
TEST
BD TEST
BG STAR TEST
BIOSCANNER
GLUCOSE TEST
bl test strip pack
blood glucose test
CAREONE BLOOD
GLUCOSE TEST
CARESENS N
GLUCOSE TEST
Drug Details
Drug Name
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CHEK-STIX
CONTROL
Tier 3
CHEMSTRIP K
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CHEMSTRIP MICRAL
Tier 3
Drug Details
CHOICE DM FORA
G20 TEST STRIPS
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CLEVER CHEK
AUTO-CODE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CLEVER CHEK
AUTO-CODE VOICE
IN VITRO
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CLEVER CHEK TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CLEVER CHOICE
AUTO-CODE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CLEVER CHOICE
MICRO TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CLINISTIX
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CLINITEST
Tier 3
Tier 3
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CONTROL AST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
CONTROL TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CVS ADVANCED
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
days)
PA; ST; QL
(300 EA per 30
Days)
cvs blood glucose test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
diabetic.com test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
DIASTIX
Tier 3
diatrue plus test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
74
Drug
Status
PA; ST; QL
(300 EA per 30
Days)
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
discount drug mart test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EASYMAX TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
drug emporium test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
easyplus blood glucose
test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
duane reade test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EASYPRO BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
DUO-CARE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EASYPRO PLUS IN
VITRO
Tier 3
PA; ST; QL
(300 EA per 30
Days)
easy check glucose test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ECLIPSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
easy plus blood glucose
test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
element compact test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
easy plus ii glucose test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ELEMENT PLUS
TEST
Tier 3
PA; ST; QL
(300 strips per
30 days)
EASY STEP TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ELEMENT TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
easy talk blood glucose
test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EMBRACE BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EASY TOUCH
HEALTHPRO TEST
Tier 3
PA; ST; QL
(300 EA per 30
days)
EMBRACE EVO
BLOOD GLUCOSE
TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EASY TOUCH TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EMBRACE PRO
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
easy trak blood glucose
test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ENVISION
AUTOCODE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EASYGLUCO IN
VITRO
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EQL TRUETEST TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EQL TRUETRACK
TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EASYMAX 15 TEST
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
75
Drug Name
Drug
Status
Drug Details
Drug Name
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA D15G BLOOD
GLUCOSE TEST
EVENCARE BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EVENCARE G2 TEST
Tier 3
EVENCARE G3 TEST
EVOLUTION
AUTOCODE IN
VITRO
Drug
Status
Drug Details
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA D15Z BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
FORA D20 BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA G20 BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA G30A BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EXACTECH R-S-G
TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA G71A BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EXACTECH TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA G90 BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
express med test strip
pack
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA GD20 TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EZ SMART BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA V10 BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EZ SMART PLUS
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA V12 BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FASTTAKE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA V20 BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FIFTY50 GLUCOSE
TEST 2.0
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA V22 BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA D10 BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORA V30A BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
FORACARE GD40
TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
EVENCARE + BLOOD
GLUCOSE TEST
FORA D15C BLOOD
GLUCOSE TEST
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
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Drug Name
Drug Details
Drug Name
Tier 3
PA; ST; QL
(300 EA per 30
Days)
GMATE BLOOD
GLUCOSE TEST
Tier 3
QL (300 EA
per 30 Days)
HEALTH ALLIANCE
Tier 3
FORACARE TEST N
GO TEST
QL (300 EA
per 30 Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
INFINITY BLOOD
GLUCOSE TEST
Tier 3
QL (300 EA
per 30 Days)
FREESTYLE
INSULINX TEST
Tier 3
PA; ST; N1;
QL (300 EA
per 30 days)
kerr drug test strip pack
Tier 3
QL (300 EA
per 30 Days)
KETOCARE
Tier 3
Tier 3
PA; ST; N1;
QL (300 EA
per 30 days)
KETOSTIX
Tier 3
kinray test
Tier 3
QL (300 EA
per 30 Days)
FORACARE
PREMIUM V10 TEST
FREESTYLE LITE
TEST
Drug
Status
Drug
Status
Drug Details
FREESTYLE TEST
Tier 3
PA; ST; N1;
QL (300 EA
per 30 days)
kroger blood glucose
test
Tier 3
QL (300 EA
per 30 Days)
ge100 blood glucose test
Tier 3
QL (300 EA
per 30 Days)
kroger premium glucose
test
Tier 3
QL (300 EA
per 30 Days)
Tier 3
PA; ST; QL
(300 EA per 30
days)
kroger test
Tier 3
QL (300 EA
per 30 Days)
LIBERTY NEXT
GENERATION TEST
Tier 3
QL (300 EA
per 30 Days)
liberty test
Tier 3
QL (300 EA
per 30 Days)
life medical test
Tier 3
QL (300 EA
per 30 Days)
long test
Tier 3
QL (300 EA
per 30 Days)
MAXIMA BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
meijer blood glucose
test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
meijer premium glucose
test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
meijer test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ght test
giant eagle pharm test
GLUCO PERFECT 3
TEST
GLUCOCARD 01
SENSOR
GLUCOCARD 01
TEST
Tier 3
Tier 3
Tier 3
Tier 3
QL (300 EA
per 30 Days)
QL (300 EA
per 30 Days)
QL (300 EA
per 30 Days)
QL (300 EA
per 30 Days)
GLUCOCARD
EXPRESSION TEST
Tier 3
QL (300 EA
per 30 Days)
GLUCOCARD VITAL
TEST
Tier 3
QL (300 EA
per 30 Days)
GLUCOCARD
X-SENSOR
Tier 3
QL (300 EA
per 30 Days)
GLUCOCOM TEST
Tier 3
QL (300 EA
per 30 Days)
GLUCOLAB TEST
Tier 3
QL (300 EA
per 30 Days)
GLUCONAVII
BLOOD GLUCOSE
TEST
Tier 3
QL (300 EA
per 30 Days)
GLUCOSTIX
Tier 3
QL (300 EA
per 30 Days)
MEIJER TRUETEST
TEST
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
77
Drug Name
Drug
Status
MEIJER TRUETRACK
TEST
Tier 3
MICRO-BUMINTEST
Tier 3
MICRODOT TEST
MYGLUCOHEALTH
TEST
NAVARRO BLOOD
GLUCOSE TEST
NEUTEK 2TEK TEST
NEXGEN TEST
NOVA MAX
GLUCOSE TEST
ON CALL EXPRESS
BLOOD GLUCOSE
ON CALL PLUS
BLOOD GLUCOSE
ON CALL VIVID
BLOOD GLUCOSE
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Drug Details
Drug Name
PA; ST; QL
(300 EA per 30
Days)
OPTUMRX BLOOD
GLUCOSE TEST
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
Drug
Status
Drug Details
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PHARMACIST
CHOICE AUTOCODE
Tier 3
PA; ST; QL
(300 EA per 30
Days)
POCKETCHEM EZ
TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PRECISION PCX
Tier 3
PA; ST; N1;
QL (300 EA
per 30 days)
PRECISION PCX
PLUS TEST
Tier 3
PA; ST; N1;
QL (300 EA
per 30 days)
PRECISION POINT OF
CARE TEST
Tier 3
PA; ST; N1;
QL (300 EA
per 30 days)
PRECISION QID TEST
Tier 3
PA; ST; N1;
QL (300 EA
per 30 days)
PRECISION
SOF-TACT TEST
Tier 3
PA; ST; N1;
QL (300 EA
per 30 days)
PRECISION XTRA
BLOOD GLUCOSE
Tier 3
PA; ST; N1;
QL (300 EA
per 30 days)
prestige smart system
test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
ONETOUCH TEST
Tier 2
QL (300 EA
per 30 Days)
PRESTIGE TEST
ONETOUCH ULTRA
BLUE
Tier 2
QL (300 EA
per 30 Days)
PRESTIGE VALUE
PACK
Tier 3
ONETOUCH VERIO
IN VITRO STRIP
Tier 2
QL (300 EA
per 30 Days)
PA; ST; QL
(300 EA per 30
Days)
PRODIGY
AUTOCODE BLOOD
GLUCOSE IN VITRO
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
OPTIUM TEST
OPTIUMEZ TEST
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
PRODIGY BLOOD
GLUCOSE TEST
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
78
Drug Name
Drug Details
Drug Name
Tier 3
PA; ST; QL
(300 EA per 30
Days)
REXALL BLOOD
GLUCOSE TEST
PRODIGY NO
CODING BLOOD
GLUC
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PRODIGY VOICE
BLOOD GLUCOSE IN
VITRO
Tier 3
PTS PANELS
GLUCOSE TEST
QUICKTEK TEST
PRODIGY EJECT
BLOOD GLUCOSE IN
VITRO
Drug
Status
Drug
Status
Drug Details
Tier 3
PA; ST; QL
(300 EA per 30
Days)
RIGHTEST GS100
BLOOD GLUCOSE
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
RIGHTEST GS300
BLOOD GLUCOSE
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
RIGHTEST GS550
BLOOD GLUCOSE
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
sentry test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
QUINTET AC BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
shoprite test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
QUINTET BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
SMART DIABETES
XPRES TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
RA TRUETEST TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
SMART SENSE
PREMIUM TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
REFUAH PLUS
BLOOD GLUCOSE
TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
SMART SENSE
VALUE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
RELION BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
SMARTEST BLOOD
GLUCOSE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
RELION
CONFIRM/MICRO
TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
SOLUS V2 TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
RELION KETONE
Tier 3
RELION PRIME TEST
RELION ULTIMA
TEST
REVEAL BLOOD
GLUCOSE TEST
Tier 3
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
Days)
SUPREME TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
SURE EDGE TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
SURE-TEST
EASYPLUS MINI
TEST
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
79
Drug Name
Drug Details
Drug Name
Tier 3
PA; ST; QL
(300 EA per 30
Days)
VOCAL POINT
BLOOD GLUCOSE
TEST
SURESTEP PRO TEST
Tier 3
PA; ST; QL
(300 EA per 30
Days)
SURESTEP TEST
Tier 3
TELCARE BLOOD
GLUCOSE TEST
tgt blood glucose test
SURECHEK BLOOD
GLUCOSE TEST
true care test strip pack
TRUE METRIX
BLOOD GLUCOSE
TEST
TRUETEST TEST
TRUETRACK TEST
ULTIMA TEST
ULTRATRAK PRO
TEST
ULTRATRAK
ULTIMATE TEST
UNISTRIP1 GENERIC
VICTORY AGM-4000
TEST
Drug
Status
Drug Details
Tier 3
PA; ST; QL
(300 EA per 30
Days)
WAVESENSE
PRESTO
Tier 3
PA; ST; QL
(300 EA per 30
Days)
PA; ST; QL
(300 EA per 30
Days)
winn dixie medic test
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
*DIAGNOSTIC
TESTS**-*MULTIPL
E URINE TESTS***
PA; ST; QL
(300 EA per 30
Days)
CHEMSTRIP 10 MD
Tier 3
Tier 3
CHEMSTRIP 10/SG
Tier 3
CHEMSTRIP 2 GP
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
Days)
CHEMSTRIP 5 OB
Tier 3
CHEMSTRIP 7
Tier 3
CHEMSTRIP 9
Tier 3
CHEMSTRIP UGK
Tier 3
COMBISTIX
Tier 3
CVS KETONE CARE
Tier 3
HEMA-COMBISTIX
Tier 3
KETO-DIASTIX
Tier 3
LABSTIX
Tier 3
MULTISTIX
Tier 3
MULTISTIX 10 SG
Tier 3
MULTISTIX 5
Tier 3
MULTISTIX 7
Tier 3
MULTISTIX 8
Tier 3
MULTISTIX 9
Tier 3
MULTISTIX 9 SG
Tier 3
URISTIX
Tier 3
URISTIX 4
Tier 3
Tier 3
PA; ST; QL
(300 EA per 30
days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
Tier 3
PA; ST; QL
(300 EA per 30
Days)
*RADIOGRAPHIC
CONTRAST
MEDIA**-*RADIOG
RAPHIC CONTRAST
MEDIA BARIUM***
BAR-TEST
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
80
Drug
Status
Tier 3
Drug Name
Drug
Status
DIGIBAR 190
Tier 3
E-Z-CAT DRY
Tier 3
E-Z-DISK
Tier 3
E-Z-DOSE
Tier 3
E-Z-HD
Tier 3
*RADIOGRAPHIC
CONTRAST
MEDIA**-*RADIOG
RAPHIC CONTRAST
MEDIA - IRON
OXIDE***
E-Z-PAQUE
Tier 3
GASTROMARK
E-Z-PASTE
Tier 3
*DIGESTIVE AIDS*
ENTERO VU
Tier 3
LIQUID E-Z-PAQUE
Tier 3
*DIGESTIVE
ENZYMES**-*DIGES
TIVE ENZYMES***
LIQUID POLIBAR
Tier 3
CREON
Tier 2
LIQUID POLIBAR
PLUS
Tier 3
PANCREAZE
Tier 3
MAXIBAR
Tier 3
PERTZYE
Tier 3
POLIBAR ACB
Tier 3
SUCRAID
Tier 3
READI-CAT
Tier 3
ULTRESA
Tier 3
ST; N1
READI-CAT 2
Tier 3
VIOKACE
Tier 3
ST; N1
SITZMARKS
Tier 3
ZENPEP
Tier 2
TAGITOL V
Tier 3
VARIBAR HONEY
Tier 3
VARIBAR NECTAR
Tier 3
VARIBAR PUDDING
Tier 3
VARIBAR THIN
HONEY
Tier 3
*CARBONIC
ANHYDRASE
INHIBITORS**-*CA
RBONIC
ANHYDRASE
INHIBITORS***
VARIBAR THIN
LIQUID
Tier 3
acetazolamide oral
tablet 250 mg
Tier 1
VOLUMEN
Tier 3
acetazolamide er
Tier 1
DIAMOX SEQUELS
Tier 3
methazolamide oral
Tier 1
NEPTAZANE
Tier 3
*RADIOGRAPHIC
CONTRAST
MEDIA**-*RADIOG
RAPHIC CONTRAST
MEDIA IODINATED***
CYSTO-CONRAY II
Tier 3
CYSTOGRAFIN-DILU
TE
Tier 3
GASTROGRAFIN
MD-GASTROVIEW
Drug Details
Drug Name
Drug
Status
Drug Details
Tier 3
ST; N1
*DIURETICS*
*DIURETIC
COMBINATIONS**-*
DIURETIC
COMBINATIONS***
ALDACTAZIDE
Tier 3
Tier 3
amiloride-hydrochlorot
hiazide
Tier 1
Tier 1
DYAZIDE
Tier 3
MAXZIDE
Tier 3
MAXZIDE-25
Tier 3
LGC
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
81
Drug Name
Drug
Status
spironolactone-hctz
Tier 1
triamterene-hctz oral
capsule 37.5-25 mg
Tier 1
triamterene-hctz oral
tablet
Tier 1
Drug Details
LGC
LGC
*LOOP
DIURETICS**-*LOO
P DIURETICS***
bumetanide oral tablet
0.5 mg, 1 mg
Tier 1
LGC
Drug Name
Drug
Status
chlorothiazide oral
tablet 500 mg
Tier 1
chlorthalidone oral
tablet 25 mg, 50 mg
Tier 1
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
Drug Details
LGC
LGC
LGC
bumetanide oral tablet 2
mg
Tier 1
indapamide oral
Tier 1
DEMADEX
Tier 3
metolazone
Tier 1
EDECRIN
Tier 3
MICROZIDE
Tier 3
furosemide oral solution
10 mg/ml, 40 mg/4ml
Tier 1
ZAROXOLYN
Tier 3
furosemide oral tablet
Tier 1
LASIX
Tier 3
torsemide oral
Tier 1
*BONE DENSITY
REGULATORS**-*BI
SPHOSPHONATES**
*
Tier 3
ACTONEL ORAL
TABLET 150 MG
Tier 3
ST; #; QL (1
tab per 30
Days)
ACTONEL ORAL
TABLET 30 MG, 5 MG
Tier 2
#
ACTONEL ORAL
TABLET 35 MG
Tier 2
#; QL (1 tab
per 7 Days)
alendronate sodium oral
tablet 10 mg, 5 mg
Tier 1
Tier 1
alendronate sodium oral
tablet 35 mg
Tier 1
QL (1 tab per 7
Days)
Tier 1
alendronate sodium oral
tablet 70 mg
Tier 1
LGC; QL (1 tab
per 7 Days)
ATELVIA
Tier 2
QL (1 tab per 7
Days)
BINOSTO
Tier 3
ST; N1; QL (1
tab per 7 Days)
BONIVA ORAL
Tier 3
ST; N1; QL (1
tab per 30
Days)
LGC
*OSMOTIC
DIURETICS**-*OSM
OTIC DIURETICS***
INTROL
*POTASSIUM
SPARING
DIURETICS**-*POT
ASSIUM SPARING
DIURETICS***
ALDACTONE
Tier 3
amiloride hcl oral
Tier 1
DYRENIUM
Tier 3
spironolactone oral
tablet 100 mg, 50 mg
spironolactone oral
tablet 25 mg
*THIAZIDES AND
THIAZIDE-LIKE
DIURETICS**-*THI
AZIDES AND
THIAZIDE-LIKE
DIURETICS***
LGC
*ENDOCRINE AND
METABOLIC
AGENTS - MISC.*
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
82
Drug Name
Drug
Status
Drug Details
Drug Name
*BONE DENSITY
REGULATORS**-*P
ARATHYROID
HORMONE AND
DERIVATIVES***
FOSAMAX ORAL
TABLET 70 MG
Tier 3
QL (1 tab per 7
Days)
FOSAMAX PLUS D
Tier 3
ST; N1; QL (1
tab per 7 Days)
ibandronate sodium
oral
Tier 1
QL (1 tab per
30 Days)
FORTEO
Drug
Status
Drug Details
Tier 3
PA
pamidronate disodium
intravenous* solution
30 mg/10ml, 90
mg/10ml
Tier 1
PA
pamidronate disodium
intravenous* solution
reconstituted
*BONE DENSITY
REGULATORS**-*R
ANK LIGAND
(RANKL)
INHIBITORS***
Tier 1
PA
PROLIA
Tier 3
PA
XGEVA
Tier 3
PA
Tier 2
PA
RECLAST
Tier 3
SKELID
Tier 3
PA; QL (1
bottle per 365
Days)
ACTHAR HP
zoledronic acid
intravenous*
concentrate
Tier 1
PA; QL (1 vial
per 21 Days)
zoledronic acid
intravenous* solution 5
mg/100ml
Tier 1
PA; QL (1
bottle per 365
Days)
ZOMETA
INTRAVENOUS*
CONCENTRATE
Tier 3
ZOMETA
INTRAVENOUS*
SOLUTION
Tier 3
PA; QL (1 vial
per 21 Days)
QL (1 vial per
365 Days)
*BONE DENSITY
REGULATORS**-*C
ALCITONINS***
calcitonin (salmon)
Tier 1
MIACALCIN
INJECTION
Tier 3
MIACALCIN NASAL
Tier 3
*BONE DENSITY
REGULATORS**-*C
ALCIUM
REGULATORS MISC.***
GANITE
*CORTICOTROPIN*
*-*CORTICOTROPI
N***
*FERTILITY
REGULATORS**-*O
VULATION
STIMULANTS-SYNT
HETIC***
CLOMID
Tier 3
clomiphene citrate oral
Tier 1
SEROPHENE
Tier 1
*GROWTH
HORMONE
RECEPTOR
ANTAGONISTS**-*G
ROWTH HORMONE
RECEPTOR
ANTAGONISTS***
SOMAVERT
PA
Tier 3
*GROWTH
HORMONES**-*GR
OWTH
HORMONES***
GENOTROPIN
Tier 3
PA
GENOTROPIN
MINIQUICK
Tier 3
PA
HUMATROPE
Tier 3
PA
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
83
Drug Name
Drug
Status
Drug Details
NORDITROPIN
SUBCUTANEOUS*
SOLUTION 15
MG/1.5ML
Tier 3
PA
NORDITROPIN
FLEXPRO
SUBCUTANEOUS*
SOLUTION 15
MG/1.5ML
Tier 3
PA
NORDITROPIN
NORDIFLEX PEN
SUBCUTANEOUS*
SOLUTION 15
MG/1.5ML, 30
MG/3ML
Tier 3
PA
NUTROPIN AQ
Tier 3
PA
NUTROPIN AQ
NUSPIN 10
Tier 3
PA
NUTROPIN AQ
NUSPIN 20
Tier 3
PA
NUTROPIN AQ
NUSPIN 5
Tier 3
PA
NUTROPIN AQ PEN
Tier 3
PA
Drug Name
LUPANETA PACK
SAIZEN
Tier 3
PA
SAIZEN CLICK.EASY
Tier 3
PA
SEROSTIM
Tier 3
PA
*METABOLIC
MODIFIERS**-*CAL
CIMIMETIC
AGENTS***
TEV-TROPIN
Tier 3
PA
SENSIPAR
ZORBTIVE
Tier 3
PA
*METABOLIC
MODIFIERS**-*CAR
NITINE
REPLENISHER AGENTS***
Tier 2
Tier 3
PA
LUPRON DEPOT-PED
Tier 2
SUPPRELIN LA
Tier 2
SYNAREL
Tier 3
Tier 3
CARNITOR ORAL
Tier 3
CARNITOR SF
Tier 3
levocarnitine oral
solution
Tier 1
levocarnitine oral tablet
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
84
PA
*LHRH/GNRH
AGONIST ANALOG
PITUITARY
SUPPRESSANTS**-*
LHRH/GNRH
AGONIST ANALOG
PITUITARY
SUPPRESSANTS***
Tier 2
EVISTA
Tier 2
*LHRH/GNRH
AGONIST ANALOG
PITUITARY
SUPPRESSANTS**-*
LHRH/GNRH
AGONIST ANALOG
COMBINATIONS***
OMNITROPE
SUBCUTANEOUS*
SOLUTION
RECONSTITUTED
*HORMONE
RECEPTOR
MODULATORS**-*S
ELECTIVE
ESTROGEN
RECEPTOR
MODULATORS
(SERMS)***
Drug Details
*INSULIN-LIKE
GROWTH FACTORS
(SOMATOMEDINS)*
*-*INSULIN-LIKE
GROWTH FACTORS
(SOMATOMEDINS)*
**
INCRELEX
PA
Drug
Status
Drug Name
Drug
Status
Drug Details
Drug Name
PA
*METABOLIC
MODIFIERS**-*MU
COPOLYSACCHARI
DOSIS II (MPS II) AGENTS***
*METABOLIC
MODIFIERS**-*FAB
RY DISEASE AGENTS***
FABRAZYME
Tier 2
ELAPRASE
*METABOLIC
MODIFIERS**-*HER
EDITARY
TYROSINEMIA
TYPE 1 (HT-1)
TREATMENT AGENTS***
ORFADIN
VIMIZIM
Tier 2
NAGLAZYME
Tier 2
PA
KUVAN
Tier 3
calcitriol oral
Tier 1
paricalcitol
Tier 1
ROCALTROL
Tier 3
ZEMPLAR
Tier 2
Tier 2
PA
Tier 2
*METABOLIC
MODIFIERS**-*URE
A CYCLE
DISORDER AGENTS***
AMMONUL
Tier 3
BUPHENYL
Tier 2
RAVICTI
Tier 3
sodium phenylbutyrate
oral
Tier 1
PA
*POSTERIOR
PITUITARY
HORMONES**-*VAS
OPRESSIN***
*METABOLIC
MODIFIERS**-*MU
COPOLYSACCHARI
DOSIS I (MPS I) AGENTS***
Tier 2
Tier 2
*METABOLIC
MODIFIERS**-*PHE
NYLKETONURIA
TREATMENT AGENTS***
*METABOLIC
MODIFIERS**-*HYP
ERPARATHYROID
TREATMENT VITAMIN D
ANALOGS***
ALDURAZYME
Tier 2
*METABOLIC
MODIFIERS**-*MU
COPOLYSACCHARI
DOSIS VI (MPS VI) AGENTS***
*METABOLIC
MODIFIERS**-*HYP
ERAMMONEMIA
TREATMENT AGENTS***
CARBAGLU
Drug Details
*METABOLIC
MODIFIERS**-*MU
COPOLYSACCHARI
DOSIS IV (MPS IV) AGENTS***
*METABOLIC
MODIFIERS**-*HO
MOCYSTINURIA
TREATMENT AGENTS***
CYSTADANE
Drug
Status
PA
DDAVP NASAL
Tier 3
PA
DDAVP ORAL
Tier 3
ST; N1
desmopressin ace rhinal
tube
Tier 1
PA
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
85
Drug Name
Drug
Status
Drug Details
desmopressin ace spray
refrig
Tier 1
PA
desmopressin acetate
oral
Tier 1
desmopressin acetate
spray
Tier 1
PA
MINIRIN
Tier 1
PA
STIMATE
Tier 3
PA
*PROLACTIN
INHIBITORS**-*DO
PAMINE RECEPTOR
AGONISTS***
cabergoline
Drug Name
Drug
Status
EEMT HS
Tier 1
ESSIAN
Tier 1
ESSIAN H.S.
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
Drug Details
*ESTROGEN
COMBINATIONS**-*
ESTROGEN &
PROGESTIN***
Tier 1
*SOMATOSTATIC
AGENTS**-*SOMAT
OSTATIC
AGENTS***
ACTIVELLA
Tier 3
QL (1 tablet per
1 day)
octreotide acetate
Tier 1
SANDOSTATIN
Tier 3
ANGELIQ
Tier 3
QL (1 tablet per
1 day)
SANDOSTATIN LAR
DEPOT
Tier 3
CLIMARA PRO
Tier 3
#; QL (1 patch
per 7 Days)
SIGNIFOR
Tier 3
COMBIPATCH
Tier 3
#; QL (8 patch
per 30 Days)
estradiol-norethindrone
acet
Tier 1
FEMHRT 1/5
Tier 3
QL (1 tablet per
1 day)
FEMHRT LOW DOSE
Tier 3
QL (1 tablet per
1 day)
JEVANTIQUE
Tier 1
MIMVEY
Tier 1
QL (1 tablet per
1 day)
PREFEST
Tier 3
QL (1 tablet per
1 day)
PREMPHASE
Tier 2
PREMPRO
Tier 2
SOMATULINE
DEPOT
PA; QL (10
Ampules per 30
days)
Tier 3
*VASOPRESSIN
RECEPTOR
ANTAGONISTS**-*S
ELECTIVE
VASOPRESSIN
V2-RECEPTOR
ANTAGONISTS***
SAMSCA
Tier 2
*ESTROGENS*
*ESTROGEN
COMBINATIONS**-*
ESTROGEN &
ANDROGEN***
COVARYX
Tier 1
COVARYX HS
Tier 1
EEMT
Tier 1
PA
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
86
Drug Name
Drug
Status
Drug Details
*ESTROGEN
COMBINATIONS**-*
ESTROGEN-SELECT
IVE ESTROGEN
RECEPTOR
MODULATOR
COMB***
DUAVEE
Tier 2
QL (1 tab per 1
Day)
*ESTROGENS**-*ES
TROGENS***
Drug Name
Drug
Status
Drug Details
MINIVELLE
Tier 3
ORTHO-EST 0.625
Tier 1
ORTHO-EST 1.25
Tier 1
PREMARIN ORAL
Tier 2
VIVELLE-DOT
Tier 3
QL (8 patch per
30 Days)
QL (8 patch per
30 Days)
*FLUOROQUINOLO
NES*
QL (8 patch per
30 Days)
*FLUOROQUINOLO
NES**-*FLUOROQU
INOLONES***
Tier 3
QL (1 tablet per
1 day)
CIPRO ORAL
SUSPENSION
RECONSTITUTED
Tier 3
PA
CLIMARA
Tier 3
QL (1 patch per
7 Days)
CIPRO ORAL
TABLET 250 MG, 500
MG
Tier 3
PA
DIVIGEL
Tier 3
CIPRO XR
Tier 3
PA
ELESTRIN
Tier 3
ciprofloxacin hcl oral
Tier 1
PA
ciprofloxacin-ciproflox
hcl er
Tier 1
PA
FACTIVE
Tier 3
PA; #
LEVAQUIN ORAL
Tier 3
PA
levofloxacin oral
Tier 1
PA
NOROXIN
Tier 3
PA
ofloxacin oral
Tier 1
PA
ALORA
CENESTIN ORAL
TABLET 0.3 MG, 0.45
MG, 0.625 MG, 0.9
MG, 1.25 MG
ENJUVIA
ESTRACE ORAL
Tier 3
Tier 3
QL (1 GM per
1 fill)
QL (1 tablet per
1 day)
Tier 3
ESTRADERM
Tier 3
QL (8 patch per
30 Days)
estradiol oral
Tier 1
LGC
estradiol transdermal
Tier 1
QL (1 patch per
7 Days)
ESTRASORB
Tier 3
#; QL (2
packets per 1
day)
ESTROGEL
Tier 3
QL (1 pump
per 1 fill)
estropipate oral tablet
0.75 mg, 1.5 mg
Tier 1
LGC
EVAMIST
Tier 3
QL (1 bottle
per 1 fill)
MENEST
MENOSTAR
Tier 3
Tier 3
QL (1 patch per
7 Days)
*GASTROINTESTIN
AL AGENTS MISC.*
*GALLSTONE
SOLUBILIZING
AGENTS**-*GALLS
TONE
SOLUBILIZING
AGENTS***
ACTIGALL
Tier 3
CHENODAL
Tier 3
URSO 250
Tier 3
URSO FORTE
Tier 3
ursodiol oral
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
87
Drug Name
Drug
Status
Drug Details
*GASTROINTESTIN
AL ANTIALLERGY
AGENTS**-*GASTR
OINTESTINAL
ANTIALLERGY
AGENTS***
cromolyn sodium oral
Tier 1
GASTROCROM
Tier 3
*GASTROINTESTIN
AL CHLORIDE
CHANNEL
ACTIVATORS**-*G
ASTROINTESTINAL
CHLORIDE
CHANNEL
ACTIVATORS***
AMITIZA
Tier 2
ST; N1; QL (2
capsules per 1
day)
Drug Name
Drug
Status
Drug Details
ASACOL HD
Tier 2
#; QL (6 tab
per 1 Day)
AZULFIDINE
Tier 3
ST; N1; QL (8
tab per 1 Day)
AZULFIDINE
EN-TABS
Tier 3
ST; N1; QL (8
tab per 1 Day)
balsalazide disodium
Tier 1
QL (9 caps per
1 Day)
CANASA
Tier 2
QL (1 EA per 1
Day)
COLAZAL
Tier 3
ST; N1; QL (9
caps per 1 Day)
DELZICOL
Tier 2
QL (12 caps
per 1 Day)
DIPENTUM
Tier 3
ST; N1; QL (4
caps per 1 Day)
GIAZO
Tier 3
*GASTROINTESTIN
AL
STIMULANTS**-*G
ASTROINTESTINAL
STIMULANTS***
PA; ST; N1;
QL (6 tab per 1
Day)
LIALDA
Tier 2
QL (4 tab per 1
Day)
mesalamine enema
Tier 1
metoclopramide hcl oral
solution 1 mg/ml, 10
mg/10ml
Tier 1
Tier 2
QL (16 caps
per 1 Day)
metoclopramide hcl oral
solution 5 mg/5ml
PENTASA ORAL
CAPSULE
EXTENDED
RELEASE* 250 MG
Tier 1
PENTASA ORAL
CAPSULE
EXTENDED
RELEASE* 500 MG
Tier 2
QL (8 caps per
1 Day)
SFROWASA
Tier 3
sulfasalazine oral
Tier 1
QL (8 tab per 1
Day)
SULFAZINE
Tier 1
QL (8 tab per 1
Day)
SULFAZINE EC
Tier 1
QL (8 tab per 1
Day)
Tier 1
LGC
metoclopramide hcl oral
tablet 10 mg
Tier 1
metoclopramide hcl oral
tablet 5 mg
Tier 1
METOZOLV ODT
ORAL TABLET
DISPERSIBLE 5 MG
Tier 3
REGLAN ORAL
Tier 3
LGC
LGC
*INFLAMMATORY
BOWEL
AGENTS**-*INFLA
MMATORY BOWEL
AGENTS***
APRISO
Tier 3
ST; N1; QL (4
caps per 1 day)
*INTESTINAL
ACIDIFIERS**-*INT
ESTINAL
ACIDIFIERS***
enulose
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
88
Drug Name
Drug
Status
generlac
Tier 1
lactulose
encephalopathy
Tier 1
Drug Details
*IRRITABLE
BOWEL SYNDROME
(IBS)
AGENTS**-*IBS
AGENT GUANYLATE
CYCLASE-C (GC-C)
AGONISTS***
LINZESS
Tier 3
ST; N1; QL (1
capsule per 1
day)
*IRRITABLE
BOWEL SYNDROME
(IBS)
AGENTS**-*IBS
AGENT SELECTIVE 5-HT3
RECEPTOR
ANTAGONISTS***
LOTRONEX
Tier 1
calcium acetate (phos
binder)
Tier 1
ELIPHOS
Tier 3
FOSRENOL
Tier 2
PHOSLO
Tier 3
PHOSLYRA
Tier 2
RENAGEL
Tier 3
RENVELA
Tier 2
VELPHORO
Tier 3
Drug Details
ST; N1
ST; N1; #
*SHORT BOWEL
SYNDROME (SBS)
AGENTS**-*GLUCA
GON-LIKE
PEPTIDE-2 (GLP-2)
ANALOGS***
Tier 3
PA
*GENERAL
ANESTHETICS*
Tier 3
Tier 2
RELISTOR
SUBCUTANEOUS*
SOLUTION 12
MG/0.6ML
Tier 2
RELISTOR
SUBCUTANEOUS*
SOLUTION 8
MG/0.4ML
Tier 2
*PHOSPHATE
BINDER
AGENTS**-*PHOSP
HATE BINDER
AGENTS***
Drug
Status
calcium acetate oral
capsule
GATTEX
PA
*PERIPHERAL
OPIOID RECEPTOR
ANTAGONISTS**-*P
ERIPHERAL OPIOID
RECEPTOR
ANTAGONISTS***
RELISTOR
SUBCUTANEOUS*
KIT
Drug Name
PA; QL (1 kit
per 30 Days)
PA; QL (10
vial per 30
Days)
PA; QL (11
syringe per 30
Days)
*VOLATILE
ANESTHETICS**-*V
OLATILE
ANESTHETICS***
FORANE
Tier 3
isoflurane
Tier 1
sevoflurane
Tier 1
SOJOURN
Tier 1
SUPRANE
Tier 3
TERRELL
Tier 1
ULTANE
Tier 3
*GENITOURINARY
AGENTS MISCELLANEOUS*
*ACIDIFIERS**-*PH
OSPHATES***
K-PHOS NO 2
Tier 3
*ALKALINIZERS***CITRATES***
citric acid-sodium
citrate
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
89
Drug Name
Drug
Status
CITROLITH
Tier 3
cytra k crystals
Drug Details
Drug Name
Drug
Status
Tier 1
Tier 1
CURITY STERILE
SALINE
cytra-2
Tier 1
glycine irrigation
Tier 1
CYTRA-3
Tier 3
glycine urologic
Tier 1
cytra-k
Tier 3
RENACIDIN
Tier 3
ORACIT
Tier 3
RESECTISOL
Tier 3
potassium citrate-citric
acid oral packet
Tier 1
Tier 1
potassium citrate-citric
acid oral solution
sodium chloride
irrigation solution 0.9
%
Tier 3
TARON-CRYSTALS
Tier 1
UROCIT-K 10
Tier 3
UROCIT-K 5
Tier 3
*INTERSTITIAL
CYSTITIS
AGENTS**-*INTERS
TITIAL CYSTITIS
AGENTS***
*CYSTINOSIS
AGENTS**-*CYSTIN
OSIS AGENTS***
CYSTAGON
PROCYSBI ORAL
CAPSULE DELAYED
RELEASE 25 MG
PROCYSBI ORAL
CAPSULE DELAYED
RELEASE 75 MG
Tier 2
PA; QL (3 caps
per 1 Day)
AVODART
Tier 2
PA; #
finasteride oral tablet 5
mg
Tier 1
PA
PROSCAR
Tier 3
PA
alfuzosin hcl er
Tier 1
PA
CARDURA XL
Tier 3
FLOMAX
Tier 3
PA; ST; N1
RAPAFLO
Tier 2
PA
tamsulosin hcl
Tier 1
PA; LGC
UROXATRAL
Tier 3
PA; ST; N1
ELMIRON
Tier 3
Tier 3
PA; ST; N1;
QL (4 caps per
1 Day)
Tier 3
PA; ST; N1;
QL (25 caps
per 1 Day)
*GENITOURINARY
IRRIGANTS**-*ANT
I-INFECTIVE
GENITOURINARY
IRRIGANTS***
*PROSTATIC
HYPERTROPHY
AGENTS**-*5-ALPH
A REDUCTASE
INHIBITORS***
*PROSTATIC
HYPERTROPHY
AGENTS**-*ALPHA
1-ADRENOCEPTOR
ANTAGONISTS***
neomycin-polymyxin b
gu
Tier 1
NEOSPORIN GU
IRRIGANT
Tier 3
*GENITOURINARY
IRRIGANTS**-*GEN
ITOURINARY
IRRIGANTS***
acetic acid irrigation
Tier 1
aminoacetic acid
Tier 1
ARGYLE STERILE
SALINE
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
90
Drug Details
Drug Name
Drug
Status
Drug Details
*PROSTATIC
HYPERTROPHY
AGENTS**-*PROST
ATIC
HYPERTROPHY
AGENT
COMBINATIONS***
JALYN
Drug Name
Drug
Status
Drug Details
ADVATE
Tier 2
PA
ALPHANATE/VWF
COMPLEX/HUMAN
INTRAVENOUS*
SOLUTION
RECONSTITUTED
1000 UNIT, 1500
UNIT, 250 UNIT, 500
UNIT
Tier 3
PA
ALPHANINE SD
INTRAVENOUS*
SOLUTION
RECONSTITUTED
1500 UNIT
Tier 3
PA
BEBULIN
Tier 3
PA
BEBULIN VH
Tier 3
PA
*HEMATOLOGICAL
AGENTS - MISC.*
*ANTIHEMOPHILIC
PRODUCTS**-*ANTI
HEMOPHILIC
PRODUCTS***
Tier 2
PA; #
*URINARY
ANALGESICS**-*UR
INARY
ANALGESICS***
PHENAZO ORAL
TABLET 200 MG
Tier 1
phenazopyridine hcl
oral tablet 100 mg
Tier 1
phenazopyridine hcl
oral tablet 200 mg
Tier 1
LGC
*URINARY STONE
AGENTS**-*URINA
RY STONE
AGENTS***
LITHOSTAT
Tier 3
BENEFIX
Tier 3
PA
THIOLA
Tier 3
CORIFACT
Tier 3
PA
*GOUT AGENTS*
FEIBA NF
Tier 2
PA
*GOUT AGENT
COMBINATIONS**-*
GOUT AGENT
COMBINATIONS***
FEIBA VH IMMUNO
Tier 2
PA
HELIXATE FS
Tier 3
PA
Tier 3
PA
allopurinol oral
Tier 1
COLCRYS
Tier 2
KRYSTEXXA
Tier 3
PA
HEMOFIL M
INTRAVENOUS*
SOLUTION
RECONSTITUTED
1000 UNIT, 1501-2000
UNIT, 1700 UNIT,
220-400 UNIT, 250
UNIT, 401-800 UNIT,
500 UNIT, 801-1500
UNIT
ULORIC
Tier 3
ST; N1
HUMATE-P
Tier 3
PA
ZYLOPRIM
Tier 3
KCENTRA
INTRAVENOUS* KIT
500 UNIT
Tier 3
PA
KOATE-DVI
Tier 3
PA
KOGENATE FS
Tier 3
PA
colchicine-probenecid
Tier 1
*GOUT
AGENTS**-*GOUT
AGENTS***
*URICOSURICS**-*
URICOSURICS***
probenecid oral
Tier 1
LGC
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
91
Drug Name
Drug
Status
Drug Details
KOGENATE FS
BIO-SET
Tier 3
PA
MONOCLATE-P
Tier 2
PA
MONONINE
INTRAVENOUS*
SOLUTION
RECONSTITUTED 250
UNIT
*HEMATORHEOLO
GIC
AGENTS**-*HEMAT
ORHEOLOGIC
AGENTS***
Tier 2
PA
pentopak
Tier 1
pentoxifylline er
Tier 1
NOVOSEVEN RT
Tier 2
PA
PROFILNINE SD
Tier 3
PA
RECOMBINATE
Tier 3
PA
*PLASMA
KALLIKREIN
INHIBITORS**-*PLA
SMA KALLIKREIN
INHIBITORS***
RIASTAP
Tier 2
PA
KALBITOR
rixubis
Tier 3
PA
TRETTEN
Tier 3
PA
WILATE
INTRAVENOUS*
SOLUTION
RECONSTITUTED
1000-1000 UNIT,
500-500 UNIT
Tier 3
PA
*PLATELET
AGGREGATION
INHIBITORS**-*CY
CLOPENTYLTRIAZ
OLOPYRIMIDINE
(CPTP)
DERIVATIVES***
XYNTHA
Tier 3
PA
XYNTHA SOLOFUSE
Tier 3
PA
BRILINTA
*BRADYKININ B2
RECEPTOR
ANTAGONISTS**-*B
RADYKININ B2
RECEPTOR
ANTAGONISTS***
FIRAZYR
Tier 2
PA
BERINERT
Tier 3
PA
CINRYZE
Tier 2
PA
*COMPLEMENT
INHIBITORS**-*C1
INHIBITORS***
*COMPLEMENT
INHIBITORS**-*CO
MPLEMENT
INHIBITORS***
SOLIRIS
Drug Name
PA
Tier 3
PA
Tier 3
QL (2 tab per 1
Day)
cilostazol
Tier 1
PLETAL
Tier 3
*PLATELET
AGGREGATION
INHIBITORS**-*PLA
TELET
AGGREGATION
INHIBITOR
COMBINATIONS***
Tier 2
*PLATELET
AGGREGATION
INHIBITORS**-*PLA
TELET
AGGREGATION
INHIBITORS***
dipyridamole oral
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
92
Drug Details
*PLATELET
AGGREGATION
INHIBITORS**-*PH
OSPHODIESTERASE
III INHIBITORS***
AGGRENOX
Tier 2
Drug
Status
Tier 1
#
Drug Name
Drug
Status
PERSANTINE
Tier 3
Drug Details
Tier 3
anagrelide hcl
Tier 1
clopidogrel bisulfate
Tier 1
EFFIENT
Tier 2
QL (1 tab per 1
Day)
PLAVIX
Tier 3
ST; N1
ticlopidine hcl
Tier 1
*HEMATOPOIETIC
AGENTS*
*AGENTS FOR
GAUCHER
DISEASE**-*AGENT
S FOR GAUCHER
DISEASE***
CEREZYME
Tier 2
PA
ELELYSO
Tier 3
PA
VPRIV
Tier 2
PA
ZAVESCA
Tier 3
PA; #
DROXIA
*FOLIC
ACID/FOLATES**-*
FOLIC
ACID/FOLATES***
Tier 1
LGC
ARANESP (ALBUMIN
FREE)
Tier 2
PA
OMONTYS
Tier 3
PA
PROCRIT INJECTION
SOLUTION 40000
UNIT/ML
Tier 2
PA
*HEMATOPOIETIC
GROWTH
FACTORS**-*GRAN
ULOCYTE
COLONY-STIMULA
TING FACTORS
(G-CSF)***
GRANIX
Tier 3
NEULASTA
Tier 2
NEUPOGEN
Tier 3
*HEMATOPOIETIC
GROWTH
FACTORS**-*GRAN
ULOCYTE/MACROP
HAGE
COLONY-STIMULA
TING
FACTOR(GM-CSF)**
*
LEUKINE
INTRAVENOUS*
Tier 3
*COBALAMINS**-*
COBALAMINS***
NASCOBAL
Drug Details
*HEMATOPOIETIC
GROWTH
FACTORS**-*ERYT
HROPOIESIS-STIMU
LATING AGENTS
(ESAS)***
*PLATELET
AGGREGATION
INHIBITORS**-*THI
ENOPYRIDINE
DERIVATIVES***
*AGENTS FOR
SICKLE CELL
ANEMIA**-*CYTOT
OXIC AGENTS***
Drug
Status
folic acid oral tablet 1
mg
*PLATELET
AGGREGATION
INHIBITORS**-*QUI
NAZOLINE
AGENTS***
AGRYLIN
Drug Name
Tier 3
Tier 3
*HEMATOPOIETIC
GROWTH
FACTORS**-*INTER
LEUKINS***
NEUMEGA
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
93
Drug Name
Drug
Status
Drug Details
*HEMATOPOIETIC
GROWTH
FACTORS**-*THRO
MBOPOIETIN (TPO)
RECEPTOR
AGONISTS***
NPLATE
Tier 3
PROMACTA
Tier 3
*HEMATOPOIETIC
MIXTURES**-*COB
ALAMIN
COMBINATIONS***
neurin-sl
Tier 3
*HEMATOPOIETIC
MIXTURES**-*FOLI
C ACID/FOLATE
COMBINATIONS***
PA
Drug Name
Drug
Status
ALBAFORT
INTRAMUSCULAR*
SOLUTION
Tier 3
CENTRATEX
Tier 3
CORVITA 150
Tier 1
ED CYTE F
Tier 3
FERIVA
Tier 3
FERIVAFA
Tier 3
ferocon
Tier 1
ferotrin
Tier 1
ferotrinsic
Tier 1
ferrex 150 forte
Tier 1
FERREX 150 FORTE
PLUS
Tier 3
Tier 3
AIRAVITE
Tier 1
FERRO-PLEX
HEMATINIC
ANIMI-3
Tier 3
FERROCITE PLUS
Tier 1
ANIMI-3/VITAMIN D
Tier 3
FERROGELS FORTE
Tier 1
bp vit 3
Tier 3
FERROTRIN
Tier 3
CENFOL
Tier 3
FOLIVANE-PLUS
Tier 3
DIVISTA
Tier 3
foltrin
Tier 1
fa-cyanocobalamin-pyri
doxine
FUSION PLUS
Tier 3
Tier 1
hematinic plus complex
Tier 1
fa-vitamin b-6-vitamin
b-12
Tier 1
hematinic plus
vit/minerals
Tier 1
fabb
Tier 1
HEMATOGEN FA
Tier 3
folbee
Tier 1
HEMATOGEN FORTE
Tier 1
FOLCAPS
Tier 1
HEMOCYTE PLUS
Tier 3
folplex 2.2
Tier 1
hemocyte-plus
Tier 1
NUFOL
Tier 1
IFEREX 150 FORTE
Tier 1
PRE-FOLIC
Tier 3
INTEGRA PLUS
Tier 3
tl gard rx
Tier 1
IROSPAN 24/6
Tier 3
virt-vite
Tier 1
martinic
Tier 1
MAXARON FORTE
Tier 3
MULTIGEN
Tier 3
MULTIGEN FOLIC
Tier 3
MULTIGEN PLUS
Tier 3
myferon 150 forte
Tier 1
*HEMATOPOIETIC
MIXTURES**-*IRON
COMBINATIONS***
active fe
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
94
Drug Details
Drug Name
Drug
Status
NEPHRON FA
Drug Name
Drug
Status
Tier 3
NULECIT
Tier 2
NOVAFERRUM
Tier 3
VENOFER
Tier 3
poly-iron 150 forte
Tier 1
*HEMOSTATICS*
polysaccharide iron
forte
Tier 1
PROTECTIRON
Tier 3
purefe plus
Tier 3
purevit dualfe plus
Tier 1
RE DUALVIT PLUS
Tier 1
se-tan plus
Tier 1
taron forte
Tier 3
tl icon
Tier 1
TRICON
Tier 1
trigels-f forte
Tier 1
*HEMATOPOIETIC
MIXTURES**-*IRON
W/ FOLIC ACID***
FOLIVANE-F
Tier 3
hematinic/folic acid
Tier 1
HEMOCYTE-F ORAL
TABLET
Tier 1
INTEGRA F
Drug Details
*HEMOSTATICS SYSTEMIC**-*HEM
OSTATICS SYSTEMIC***
AMICAR
Tier 3
aminocaproic acid oral
syrup
Tier 1
aminocaproic acid oral
tablet 500 mg
Tier 1
LYSTEDA
Tier 3
ST; N1; QL (30
tab per 30
Days)
tranexamic acid oral
Tier 1
QL (30 tab per
30 Days)
*HEMOSTATICS TOPICAL**-*HEMO
STATIC
COMBINATIONS TOPICAL***
ARTISS
Tier 3
Tier 3
EVICEL
Tier 3
PROFERRIN-FORTE
Tier 3
TISSEEL VH
Tier 3
TANDEM F
Tier 3
TISSEEL VHSD
Tier 3
BIFERARX
Tier 3
*HEMOSTATICS TOPICAL**-*HEMO
STATICS TOPICAL***
fe 90 plus
Tier 3
FERRALET 90
Tier 3
ferraplus 90
Tier 3
FERREX 28
Tier 3
hemetab
Tier 3
NATALVIRT FLT
Tier 3
*HEMATOPOIETIC
MIXTURES**-*IRON
-B12-FOLATE***
*IRON**-*IRON***
Drug Details
monsels ferric
subsulfate
Tier 3
*HYPNOTICS*
*BARBITURATE
HYPNOTICS**-*BAR
BITURATE
HYPNOTICS***
BUTISOL SODIUM
Tier 3
FERRLECIT
Tier 3
Tier 1
na ferric gluc cplx in
sucrose
phenobarbital oral
elixir
Tier 1
phenobarbital oral
solution
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
95
Drug Name
Drug
Status
phenobarbital oral
tablet 16.2 mg, 32.4 mg
Tier 1
SECONAL
Tier 3
Drug Details
*HYPNOTICS TRICYCLIC
AGENTS**-*HYPNO
TICS - TRICYCLIC
AGENTS***
SILENOR
Tier 3
ST; N1; QL (1
tab per 1 Day)
*NON-BARBITURAT
E
HYPNOTICS**-*BEN
ZODIAZEPINE
HYPNOTICS***
DORAL
Tier 3
estazolam
Tier 1
flurazepam hcl
Tier 1
HALCION
Tier 3
midazolam hcl oral
Tier 1
RESTORIL
Tier 3
temazepam
Tier 1
triazolam
Tier 1
*NON-BARBITURAT
E
HYPNOTICS**-*NO
N-BENZODIAZEPIN
EGABA-RECEPTOR
MODULATORS***
AMBIEN ORAL
TABLET 10 MG
Tier 3
ST; N1; QL (1
tab per 1 Day)
AMBIEN ORAL
TABLET 5 MG
Tier 3
ST; N1; QL (2
tab per 1 Day)
AMBIEN CR
Tier 3
ST; N1; QL (1
tab per 1 Day)
EDLUAR
Tier 3
Tier 3
eszopiclone
Drug Name
Drug Details
INTERMEZZO
SUBLINGUAL
TABLET
SUBLINGUAL 1.75
MG
Tier 3
ST; N1; QL (1
tab per 1 Day)
INTERMEZZO
SUBLINGUAL
TABLET
SUBLINGUAL 3.5 MG
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
LUNESTA
Tier 3
PA; ST; N1;
QL (1 tab per 1
day)
SONATA ORAL
CAPSULE 10 MG
Tier 3
ST; N1; QL (2
caps per 1 Day)
SONATA ORAL
CAPSULE 5 MG
Tier 3
ST; N1; QL (4
caps per 1 Day)
zaleplon oral capsule 10
mg
Tier 1
QL (2 caps per
1 Day)
zaleplon oral capsule 5
mg
Tier 1
QL (4 caps per
1 Day)
zolpidem tartrate oral
tablet 10 mg
Tier 1
QL (1 tab per 1
Day)
zolpidem tartrate oral
tablet 5 mg
Tier 1
QL (2 tab per 1
Day)
zolpidem tartrate er
Tier 1
QL (1 tab per 1
Day)
ZOLPIMIST
Tier 3
ST; N1; QL (1
bottle per 30
Days)
*SELECTIVE
MELATONIN
RECEPTOR
AGONISTS**-*SELE
CTIVE MELATONIN
RECEPTOR
AGONISTS***
HETLIOZ
Tier 3
ST; N1; QL (1
tab per 1 Day)
ROZEREM
Tier 3
PA; ST; N1;
QL (1 tablet per
1 day)
*LAXATIVES*
*LAXATIVE
COMBINATIONS**-*
BOWEL EVACUANT
COMBINATIONS***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
96
Drug
Status
ST; N1; QL (1
tab per 1 Day)
Drug Name
Drug
Status
COLYTE WITH
FLAVOR PACKS
ORAL SOLUTION
RECONSTITUTED
227.1 GM
Tier 3
GAVILYTE-C
Drug Details
Drug Name
Drug
Status
*AZITHROMYCIN**
-*AZITHROMYCIN*
**
azithromycin oral
suspension reconstituted
Tier 1
Tier 1
azithromycin oral tablet
Tier 1
GAVILYTE-G
Tier 1
ZITHROMAX ORAL
Tier 3
GAVILYTE-N WITH
FLAVOR PACK
Tier 1
ZITHROMAX
TRI-PAK
Tier 3
GOLYTELY
Tier 3
ZITHROMAX Z-PAK
Tier 3
MOVIPREP
Tier 2
ZMAX
Tier 3
NULYTELY WITH
FLAVOR PACKS
Tier 3
peg 3350-kcl-na
bicarb-nacl
Tier 1
*CLARITHROMYCI
N**-*CLARITHROM
YCIN***
peg 3350/electrolytes
BIAXIN
Tier 3
Tier 1
BIAXIN XL
Tier 3
peg-3350/electrolytes
Tier 1
BIAXIN XL PAC
Tier 3
PREPOPIK
Tier 3
clarithromycin oral
Tier 1
SUCLEAR
Tier 3
clarithromycin er
Tier 1
SUPREP BOWEL
PREP
Tier 3
TRILYTE
Tier 1
*ERYTHROMYCINS
**-*ERYTHROMYCI
NS***
*LAXATIVES MISCELLANEOUS**
-*LAXATIVES MISCELLANEOUS**
*
CLEARLAX ORAL
POWDER
Tier 1
constulose
Tier 1
KRISTALOSE
Tier 3
lactulose oral solution
10 gm/15ml
Tier 1
lactulose oral solution
20 gm/30ml
Tier 1
*SALINE
LAXATIVES**-*SAL
INE LAXATIVE
MIXTURES***
OSMOPREP
LGC
LGC
E.E.S. 400
Tier 3
E.E.S. GRANULES
Tier 3
ERY-TAB
Tier 3
ERYPED 200
Tier 3
ERYPED 400
Tier 3
ERYTHROCIN
STEARATE
Tier 3
erythromycin base oral
capsule delayed release
particles
Tier 1
PCE
Tier 3
*FIDAXOMICIN**-*
FIDAXOMICIN***
DIFICID
Tier 3
Drug Details
Tier 3
PA; QL (20 tab
per 30 Days)
*MEDICAL
DEVICES*
*MACROLIDES*
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
97
Drug Name
Drug
Status
Drug Details
*CONTRACEPTIVES
**-*CERVICAL
CAPS***
Drug Name
WIDE-SEAL
DIAPHRAGM 75
Drug
Status
Drug Details
Tier 3
PA; QL (1
diaphragm per
365 days)
FEMCAP
Tier 3
PA; QL (1
device per 365
days)
PRENTIF
CAVITY-RIM CERV
CAP
Tier 3
PA; QL (1 EA
per 365 Days)
WIDE-SEAL
DIAPHRAGM 85
Tier 3
PA; QL (1
device per 365
days)
WIDE-SEAL
DIAPHRAGM 90
Tier 3
PA; QL (1
diaphragm per
365 days)
WIDE-SEAL
DIAPHRAGM 95
Tier 3
PA; QL (1
diaphragm per
365 days)
PRENTIF FITTING
SET
*CONTRACEPTIVES
**-*CONDOMS FEMALE***
FC FEMALE
CONDOM
Tier 3
PA
FC2 FEMALE
CONDOM
Tier 3
PA
*CONTRACEPTIVES
**-*CONTRACEPTI
VE SPONGE***
TODAY SPONGE
Tier 3
PA; QL (10
devices per 30
days)
*CONTRACEPTIVES
**-*DIAPHRAGMS**
*
Tier 3
PA; QL (1
diaphragm per
365 days)
ORTHO DIAPHRAGM
COIL
Tier 3
PA; QL (1 kit
per 365 Days)
ORTHO DIAPHRAGM
FLAT
Tier 3
PA; QL (1 kit
per 365 Days)
Tier 3
PA; QL (1
diaphragm per
365 days)
OMNIFLEX
DIAPHRAGM
WIDE-SEAL
DIAPHRAGM 60
WIDE-SEAL
DIAPHRAGM 65
WIDE-SEAL
DIAPHRAGM 70
Tier 3
PA; QL (1
diaphragm per
365 days)
Tier 3
PA; QL (1
diaphragm per
365 days)
WIDE-SEAL
DIAPHRAGM 80
Tier 3
PA; QL (1
diaphragm per
365 days)
Tier 3
PA; QL (1
diaphragm per
365 days)
*DIABETIC
SUPPLIES**-*GLUC
OSE MONITORING
TEST SUPPLIES***
1st choice lancets super
thin
Tier 3
1st choice lancets thin
Tier 3
1st choice lancets ultra
thin
Tier 3
1st tier unilet
comfortouch
Tier 3
ACCU-CHEK ACTIVE
GLUCOSE CONT
Tier 3
ACCU-CHEK AVIVA
IN VITRO SOLUTION
Tier 3
ACCU-CHEK
COMFORT CURVE IN
VITRO SOLUTION
Tier 3
ACCU-CHEK
COMFORT CURVE
LINEAR
Tier 3
ACCU-CHEK
COMPACT BLUE
CONTROL
Tier 3
ACCU-CHEK
COMPACT PLUS
CONTROL
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
98
Drug Name
Drug
Status
ACCU-CHEK
FASTCLIX LANCET
Tier 3
ACCU-CHEK
FASTCLIX LANCETS
Tier 3
ACCU-CHEK
INSTANT CONTROL
Drug Details
Drug Name
Drug
Status
ADVANCE
MICRO-DRAW
NORMAL
Tier 3
Tier 3
Tier 3
ADVOCATE
CONTROL
SOLUTION
ACCU-CHEK
MULTICLIX LANCET
DEV
Tier 3
Tier 3
ADVOCATE
LANCETS
Tier 3
ACCU-CHEK
MULTICLIX
LANCETS
ADVOCATE
LANCING DEVICE
Tier 3
Tier 3
ACCU-CHEK SAFE-T
PRO LANCETS
ADVOCATE
RAPID-SAFE
LANCING
Tier 3
ADVOCATE
REDI-CODE+
CONTROL
Tier 3
ADVOCATE SAFETY
LANCETS
Tier 3
af lancets super thin
Tier 3
AGAMATRIX
CONTROL
Tier 3
AGAMATRIX
ULTRA-THIN
LANCETS
Tier 3
alternate site lancing
device
Tier 3
aqua lance adjustable
lancing
Tier 3
ASCENSIA
AUTODISC
CONTROL
Tier 3
Tier 3
ACCU-CHEK
SMARTVIEW
CONTROL
Tier 3
ACCU-CHEK SOFT
TOUCH LANCETS
Tier 3
ACCU-CHEK
SOFTCLIX LANCET
DEV
Tier 3
ACCU-CHEK
SOFTCLIX LANCETS
Tier 3
ACCUTREND
GLUCOSE CONTROL
Tier 3
acti-lance 28g
Tier 3
acti-lance lite lancets
28g
Tier 3
acti-lance special
lancets 17g
Tier 3
acti-lance universal 23g
Tier 3
ACURA CONTROL
Tier 3
ASCENSIA
AUTODISC
CONTROLS
adjustable lancing
device
Tier 3
ASSURE 3 CONTROL
Tier 3
ASSURE 4 CONTROL
LEVEL 1 & 2
Tier 3
assure comfort lancets
28g
Tier 3
assure comfort lancets
30g
Tier 3
ASSURE DOSE
CONTROL
Tier 3
ADVANCE
INTUITION
CONTROL
Tier 3
ADVANCE
MICRO-DRAW
CONTROL
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
99
Drug Name
ASSURE DOSE
NORM/HIGH
CONTROL
Drug
Status
Tier 3
ASSURE
HAEMOLANCE PLUS
HIGH
Tier 3
ASSURE
HAEMOLANCE PLUS
LOW
Tier 3
ASSURE
HAEMOLANCE PLUS
MICRO
Tier 3
ASSURE
HAEMOLANCE PLUS
NORMAL
Tier 3
Drug Details
Drug Name
Drug
Status
AUTOLET LANCING
DEVICE
Tier 3
AUTOLET LITE
CLINISAFE
Tier 3
AUTOLET LITE
STARTER PACK
Tier 3
AUTOLET MINI
Tier 3
AUTOLET
PLATFORMS
Tier 3
BAYER BREEZE 2
CONTROL
Tier 3
BAYER CONTOUR
Tier 3
BAYER CONTOUR
NEXT CONTROL
Tier 3
Tier 3
ASSURE
HAEMOLANCE PLUS
PED
Tier 3
BAYER MICROLET 2
LANCING DEVIC
ASSURE II CONTROL
Tier 3
BAYER MICROLET
LANCETS
Tier 3
ASSURE II CONTROL
LEVEL 1 & 2
Tier 3
BD LANCET DEVICE
Tier 3
ASSURE LANCE
LANCETS
Tier 3
Tier 3
BD LANCET
ULTRAFINE 30G
ASSURE LANCETS
Tier 3
BD LANCET
ULTRAFINE 33G
Tier 3
ASSURE PRO
CONTROL LEVEL 1 &
2
Tier 3
BD MICROTAINER
LANCETS
Tier 3
AT LAST CONTROL
Tier 3
BD ULTRA-FINE
LANCETS
Tier 3
AT LAST LANCETS
Tier 3
Tier 3
AURORA
HEALTHCARE
LANCETS
bullseye mini safety
lancets
Tier 3
BULLSEYE SAFETY
LANCETS
Tier 3
aurora lancet super thin
30g
Tier 3
CARDIOCOM
LANCING DEVICE
Tier 3
aurora lancet thin 23g
Tier 3
Tier 3
AUTO-LANCET
Tier 3
careone advanced
lancing dev
AUTO-LANCET MINI
Tier 3
careone lancet thin 23g
Tier 3
AUTOLET II
CLINISAFE
Tier 3
careone lancet ultra thin
28g
Tier 3
AUTOLET
IMPRESSION
Tier 3
CARESENS
CONTROL A
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
100
Drug Details
Drug Name
Drug
Status
CLEANLET LANCETS
28G
Tier 3
CLEVER CHEK
LANCETS
Tier 3
CLEVER CHOICE
GLUCOSE CONTROL
Tier 3
CLOSERCARE
Drug Details
Drug Name
Drug
Status
DRUG MART
LANCING DEVICE
Tier 3
DRUG MART
ON-THE-GO LANCET
30G
Tier 3
Tier 3
Tier 3
DRUG MART UNILET
LANCETS 28G
COAGUCHEK
LANCETS
Tier 3
DRUG MART UNILET
LANCETS 30G
Tier 3
comfort assured lancets
28g
Tier 3
duane reade lancet
altern site
Tier 3
comfort assured lancets
33g
Tier 3
duane reade lancet
super thin
Tier 3
comfort lancets
Tier 3
Tier 3
control
Tier 3
duane reade lancet ultra
thin
cvs lancets 21g
Tier 3
Tier 3
cvs lancets micro thin
33g
Tier 3
DUO-CARE
CONTROL
SOLUTION
cvs lancets original
Tier 3
E-Z JECT LANCET
MICRO-THIN 33G
Tier 3
cvs lancets thin
Tier 3
Tier 3
cvs lancets thin 26g
Tier 3
E-Z JECT LANCET
SUPER THIN 30G
cvs lancets ultra thin
30g
E-Z JECT LANCETS
Tier 3
Tier 3
Tier 3
cvs lancing device
Tier 3
E-Z JECT LANCETS
21G
cvs ultra thin lancets
Tier 3
Tier 3
DIASTAR EASY TEST
II LANCETS
E-Z JECT LANCETS
THIN 26G
Tier 3
easy check control
Tier 3
DIASTAR EASY TEST
LANCETS
easy comfort lancets
Tier 3
Tier 3
easy mini lancing device
Tier 3
diatrue control level 1
Tier 3
easy plus control
Tier 3
diatrue control level 2
Tier 3
easy plus ii control
Tier 3
diatrue control level 3
Tier 3
Tier 3
DROPLET LANCETS
ULTRA THIN 30G
EASY STEP
CONTROL
Tier 3
easy talk control
Tier 3
DROPLET LANCING
DEVICE
Tier 3
Tier 3
drug mart lancets thin
26g
EASY TOUCH
CONTROL HIGH &
LOW
Tier 3
easy touch lancets
Tier 3
drug mart lancets ultra
thin
Tier 3
EASY TOUCH
LANCETS 21G
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
101
Drug Name
Drug
Status
EASY TOUCH
LANCETS 23G
Tier 3
EASY TOUCH
LANCETS 26G
Tier 3
EASY TOUCH
LANCETS 28G
Drug Details
Drug Name
Drug
Status
EASYTEST II
LANCETS
Tier 3
EASYTEST LANCETS
Tier 3
ECLIPSE CONTROL
Tier 3
Tier 3
element compact control
2
Tier 3
EASY TOUCH
LANCETS 28G/TWIST
Tier 3
element compact control
3
Tier 3
EASY TOUCH
LANCETS 30G
Tier 3
ELEMENT CONTROL
Tier 3
EASY TOUCH
LANCETS 30G/TWIST
Tier 3
ELEMENT PLUS
CONTROL
Tier 3
EASY TOUCH
LANCETS 32G
EMBRACE CONTROL
Tier 3
Tier 3
ENVISION CONTROL
Tier 3
EASY TOUCH
LANCETS 32G/TWIST
eql color lancets 21g
Tier 3
Tier 3
Tier 3
EASY TOUCH
LANCETS 33G/TWIST
eql color lancets micro
33g
Tier 3
Tier 3
EASY TOUCH
LANCING DEVICE
eql super thin lancets
30g
Tier 3
eql thin lancets 26g
Tier 3
Tier 3
EASY TOUCH
SAFETY LANCETS
21G
Tier 3
EVENCARE
CONTROL
LOW/HIGH
EASY TOUCH
SAFETY LANCETS
23G
Tier 3
EVENCARE G2
LOW/HIGH
CONTROL
Tier 3
EASY TOUCH
SAFETY LANCETS
26G
Tier 3
EVENCARE G3
LOW/HIGH
CONTROL
Tier 3
EASY TOUCH
SAFETY LANCETS
28G
Tier 3
EVOLUTION
CONTROL
Tier 3
easy trak control
Tier 3
EZ SMART BLOOD
GLUCOSE LANCETS
Tier 3
EASY TWIST & CAP
LANCETS
Tier 3
EZ-LETS LANCETS
21G
Tier 3
EASYGLUCO
CONTROL
Tier 3
EZ-LETS LANCETS
23G
Tier 3
EASYMAX 15 LEVEL
1 CONTROL
Tier 3
EZ-LETS LANCETS
26G
Tier 3
EASYMAX 15 LEVEL
2 CONTROL
Tier 3
EZ-LETS LANCETS
28G
Tier 3
EASYMAX CONTROL
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
102
Drug Details
Drug Name
EZ-LETS LANCETS
30G
Drug
Status
Tier 3
Drug Details
Drug Name
Drug
Status
global lancing device
Tier 3
GLUCOCARD 01
CONTROL
Tier 3
GLUCOCARD
EXPRESSION
CONTROL
Tier 3
GLUCOCARD
X-SENSOR CONTROL
Tier 3
GLUCOCOM
CONTROL
Tier 3
GLUCOCOM
LANCETS 28G
Tier 3
FIFTY50 CONTROL
2.0
Tier 3
FIFTY50 LANCING
DEVICE
Tier 3
FIFTY50 SAFETY
SEAL LANCETS
Tier 3
FINE 30
Tier 3
FINGERSTIX
LANCETS
Tier 3
FORA CONTROL
Tier 3
FORA LANCETS
Tier 3
Tier 3
FORA LANCING
DEVICE
GLUCOCOM
LANCETS 30G
Tier 3
Tier 3
FORACARE GDH
CONTROL
GLUCOCOM
LANCETS 33G
Tier 3
Tier 3
freds pharmacy autolet
lancing
GLUCOLAB
CONTROL
Tier 3
freds pharmacy unilet
lanc 28g
Tier 3
Tier 3
GLUCOLET 2
AUTOMATIC
LANCING
freds pharmacy unilet
lanc 30g
glucose control
Tier 3
Tier 3
Tier 3
FREESTYLE
CONTROL
SOLUTION
GLUCOSOURCE
LANCET DEVICE
Tier 3
GLUCOSOURCE
LANCETS
Tier 3
FREESTYLE
LANCETS
Tier 3
GMATE CONTROL
LEVEL 2
Tier 3
gnp lancets
Tier 3
FREESTYLE
UNISTICK II
LANCETS
Tier 3
gnp lancets 21g
Tier 3
ge100 control
Tier 3
gnp lancets micro thin
33g
Tier 3
GENTLE-LET GP
LANCETS
Tier 3
gnp lancets super thin
30g
Tier 3
GENTLE-LET
LANCETS
Tier 3
gnp lancets thin
Tier 3
gnp lancets thin 26g
Tier 3
GENTLE-LET
PLATFORMS
Tier 3
gnp micro thin lancets
33g
Tier 3
global inject ease
lancets 28g
Tier 3
gnp super thin lancets
30g
Tier 3
global inject ease
lancets 30g
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
103
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
kroger lancets
Tier 3
kroger lancets 21g
Tier 3
H&H THINLET
LANCETS 26G
Tier 3
H&H THINLET
LANCETS 30G
Tier 3
kroger lancets micro
thin 33g
Tier 3
h-e-b incontrol adv
lancing
Tier 3
kroger lancets super
thin
Tier 3
h-e-b incontrol lancets
28g
Tier 3
kroger lancets thin
Tier 3
h-e-b incontrol lancets
30g
kroger lancets thin 26g
Tier 3
Tier 3
Tier 3
HAEMOLANCE
Tier 3
kroger lancets ultrathin
30g
HAEMOLANCE LOW
FLOW LANCETS
kroger lancing device
Tier 3
Tier 3
lady lite lancets
Tier 3
HAEMOLANCE PLUS
Tier 3
lancet device
Tier 3
HAEMOLANCE PLUS
HIGH FLOW
lancets
Tier 3
Tier 3
lancets 28g
Tier 3
HAEMOLANCE PLUS
LOW FLOW
Tier 3
lancets 30g
Tier 3
lancets micro thin 33g
Tier 3
HAEMOLANCE PLUS
MAX FLOW
Tier 3
lancets super thin 28g
Tier 3
HAEMOLANCE PLUS
PEDIATRIC FLOW
lancets thin
Tier 3
Tier 3
Tier 3
HEALTH CARE
LANCING DEVICE
LANCETS ULTRA
FINE
Tier 3
Tier 3
healthwise lancets 30g
Tier 3
LANCETS ULTRA
THIN
healthwise lancing pen
Tier 3
lancets ultra thin 30g
Tier 3
healthy accents lancing
device
lancing device
Tier 3
Tier 3
Tier 3
healthy accents unilet
lancets
leader advanced lancing
device
Tier 3
Tier 3
hm lancets micro thin
33g
LIBERTY GLUCOSE
CONTROL
Tier 3
Tier 3
hm lancets ultra thin
30g
LIBERTY GLUCOSE
CONTROL MID
Tier 3
Tier 3
HY-VEE LANCETS
Tier 3
LIBERTY MINI
LANCING DEVICE
hy-vee thin lancets
Tier 3
LIFESCAN UNISTIK 2
Tier 3
HYPOLANCE AST
LANCING
Tier 3
LIFESCAN UNISTIK
II LANCETS
Tier 3
INFINITY CONTROL
Tier 3
lite touch lancets
Tier 3
kinney lancets
Tier 3
LITE TOUCH
LANCING DEVICE
Tier 3
kinney thin lancets
Tier 3
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Drug Details
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
LITE TOUCH
LANCING PEN
Tier 3
MEDLANCE PLUS
EXTRA 21G
Tier 3
LITETOUCH
LANCETS
Tier 3
MEDLANCE PLUS
LANCETS
Tier 3
live better adv lancing
device
Tier 3
MEDLANCE PLUS
LITE 25G
Tier 3
live better lancet super
thin
Tier 3
MEDLANCE PLUS
SPECIAL 0.8MM
Tier 3
live better lancet ultra
thin
Tier 3
MEDLANCE PLUS
SUPERLITE 30G
Tier 3
longs lancets standard
Tier 3
Tier 3
longs lancets thin
Tier 3
MEDLANCE PLUS
UNIVERSAL 21G
longs lancets ultra thin
Tier 3
Tier 3
major comfort lancets
Tier 3
MEDLANCE
UNIVERSAL 21G
MAXIMA CONTROL
Tier 3
MEIJER LANCETS
Tier 3
medi-lance lancets
Tier 3
MEIJER LANCETS
THIN
Tier 3
medichoice safety lancet
Tier 3
MEIJER LANCETS
UNIVERSAL 21G
Tier 3
MEIJER LANCETS
UNIVERSAL 30G
Tier 3
MEIJER LANCETS
UNIVERSAL 33G
Tier 3
MEIJER SUPER THIN
LANCETS
Tier 3
medichoice safety lancet
extra
Tier 3
medichoice safety lancet
norm
Tier 3
medicine shoppe lancets
Tier 3
medicine shoppe lancets
thin
Tier 3
MEDISENSE
GLUCOSE KETONE
CONTR
Tier 3
MICRODOT
CONTROL
Tier 3
MEDISENSE
HI/MID/LOW
CONTROL
Tier 3
Tier 3
MICRODOT
CONTROL
HIGH/LOW
MICROLET LANCETS
Tier 3
MEDISENSE
HIGH/LOW
CONTROL
Tier 3
MICROTAINER
SAFETY FLOW
LANCET
Tier 3
MEDISENSE MID
CONTROL
Tier 3
mini lancing device
Tier 3
MEDISENSE THIN
LANCETS
Tier 3
MONOJECTOR END
CAPS
Tier 3
MEDLANCE EXTRA
21G
Tier 3
MONOJECTOR OPD
END CAPS
Tier 3
MEDLANCE LITE
25G
MONOLET LANCETS
Tier 3
Tier 3
MONOLET OPD
LANCETS
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
105
Drug Name
Drug
Status
MONOLETTOR
SAFETY LANCETS
Tier 3
multi-lancet device
Tier 3
MYGLUCOHEALTH
CONTROL
Tier 3
MYGLUCOHEALTH
LANCETS 30G
Tier 3
NETGROUP
LANCETS
Tier 3
NEUTEK 2TEK
CONTROL
Tier 3
NEXGEN CONTROL
Tier 3
NOVA MAX
CONTROL
Drug Details
Drug Name
Drug
Status
ONETOUCH DELICA
LANCETS 33G
Tier 3
ONETOUCH DELICA
LANCETS FINE
Tier 3
ONETOUCH DELICA
LANCING DEV
Tier 3
ONETOUCH
FINEPOINT LANCETS
Tier 3
ONETOUCH
LANCETS
Tier 3
ONETOUCH
SURESOFT LANCING
DEV
Tier 3
Tier 3
Tier 3
NOVA MAX PLUS
GLU/KET CONTROL
ONETOUCH ULTRA
CONTROL
Tier 3
NOVA SAFETY
LANCETS 23G
Tier 3
Tier 3
ONETOUCH
ULTRASOFT
LANCETS
NOVA SAFETY
LANCETS 28G
Tier 3
ONETOUCH VERIO
IN VITRO SOLUTION
Tier 3
NOVA SUREFLEX
LANCETS
Tier 3
OPTUMRX GLUCOSE
CONTROL
Tier 3
NOVA SUREFLEX
LANCING DEVICE
Tier 3
pc lancets super thin
30g
Tier 3
ON CALL EXPRESS
GLUCOSE CONTR
Tier 3
PENLET II BLOOD
SAMPLER
Tier 3
ON CALL LANCETS
Tier 3
PENLET II
REPLACEMENT CAP
Tier 3
ON CALL LANCING
DEVICE
Tier 3
PERFECT LANCETS
28G
Tier 3
ON CALL PLUS
GLUCOSE CONTROL
Tier 3
PERFECT LANCETS
30G
Tier 3
ON CALL PLUS
LANCETS
Tier 3
pharmacist choice
lancets
Tier 3
ON CALL PLUS
LANCING DEVICE
Tier 3
PHARMACY
COUNTER LANCETS
Tier 3
ON CALL VIVID
GLUCOSE CONTROL
Tier 3
POCKETCHEM EZ
CONTROL
Tier 3
ONETOUCH CLUB
LANCETS FINE PT
Tier 3
PRECISION
GLUCOSE CONTROL
Tier 3
ONETOUCH COMBO
PACK
Tier 3
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Drug Details
Drug Name
Drug
Status
PRECISION
GLUCOSE CONTROL
SOLN
Tier 3
PRECISION
GLUCOSE KETONE
CONTR
Tier 3
PRECISION
GLUCOSE/KETONE
CONTR
Tier 3
PRECISION THIN
LANCETS
Tier 3
PRECISION THINS GP
LANCETS
Tier 3
PRECISION ULTRA
LANCET
Tier 3
preferred plus lancets
colored
Tier 3
preferred plus lancets
thin
Tier 3
PRESTIGE GLUCOSE
CONTROL
Tier 3
PRODIGY CONTROL
SOLUTION
Tier 3
PRODIGY LANCETS
21G
Tier 3
PRODIGY LANCETS
26G
Tier 3
PRODIGY LANCETS
28G
Tier 3
PRODIGY LANCING
DEVICE
Tier 3
PRODIGY SAFETY
LANCETS 26G
Tier 3
PRODIGY TWIST TOP
LANCETS 28G
Tier 3
PSS SELECT GP
LANCETS
Tier 3
PSS SELECT
PLATFORMS
Tier 3
PSS SELECT SAFETY
LANCETS
Tier 3
Drug Details
Drug Name
Drug
Status
px advanced lancing
device
Tier 3
px lancet auto injector
Tier 3
px lancets
Tier 3
px lancets ultra thin
Tier 3
qc advanced lancing
device
Tier 3
qc lancets super thin
30g
Tier 3
qc lancets ultra thin
Tier 3
QUICKTEK
CONTROL
SOLUTION
Tier 3
QUINTET CONTROL
HIGH/NORMAL
Tier 3
RA E-ZJECT COLOR
LANCETS 33G
Tier 3
RA E-ZJECT
LANCETS 28G
Tier 3
RA E-ZJECT
LANCETS THIN 26G
Tier 3
RA E-ZJECT
LANCETS THIN 28G
Tier 3
RA E-ZJECT
LANCETS ULTRA
THIN
Tier 3
ra lancing device
Tier 3
reality lancets
Tier 3
reality trigger lancets
Tier 3
REFUAH PLUS
GLUCOSE CONTROL
Tier 3
RELION LANCETS
MICRO-THIN 33G
Tier 3
RELION LANCETS
STANDARD 21G
Tier 3
RELION LANCETS
THIN 26G
Tier 3
RELION LANCETS
ULTRA-THIN 30G
Tier 3
RELION LANCING
DEVICE
Tier 3
Drug Details
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Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
RELION ULTRA THIN
LANCETS 30G
Tier 3
SHOPKO AUTOLET
LANCING DEVICE
Tier 3
RELION ULTRA THIN
PLUS LANCETS
Tier 3
SHOPKO ON-THE-GO
LANCETS 30G
Tier 3
RENEW ADV
CARTRIDGE
REFILLS
Tier 3
SHOPKO UNILET
LANCETS 28G
Tier 3
RENEW ADVANCED
LANCING DEVICE
Tier 3
Tier 3
SHOPKO UNILET
LANCETS 30G
REXALL LANCETS
ULTRA THIN 30G
Tier 3
SIMPLE
DIAGNOSTICS
LANCING DEV
Tier 3
SINGLE-LET
Tier 3
sm lancets 21g
Tier 3
sm lancets 33g
Tier 3
RIGHTEST
ALTERNATE SITE
ADAPT
Tier 3
RIGHTEST GC300
CONTROL
Tier 3
Tier 3
RIGHTEST GD500
LANCING DEVICE
sm super thin lancets
30g
Tier 3
sm thin lancets 26g
Tier 3
RIGHTEST GL300
LANCETS
Tier 3
SMART DIABETES
VANTAGE LANCETS
Tier 3
SAFE-T-LANCE
Tier 3
Tier 3
SAFE-T-LANCE PLUS
Tier 3
SMART DIABETES
VANTAGE LANCING
safety lancet
21g/pressure act
Tier 3
SMART SENSE
COLOR LANCETS
33G
Tier 3
safety lancet
28g/pressure act
Tier 3
Tier 3
SAFETY LANCET
2MM
Tier 3
SMART SENSE
STANDARD
LANCETS
SAFETY LANCETS
Tier 3
Tier 3
SAFETY LANCETS
21G
SMART SENSE
SUPER THIN
LANCETS
Tier 3
Tier 3
safety lancets 28g
Tier 3
SMART SENSE THIN
LANCETS 26G
SAFETY LET
LANCETS
Tier 3
SMARTEST
CONTROL MEDIUM
Tier 3
SAFETY SEAL
LANCETS
Tier 3
SMARTEST
LANCETS 28G
Tier 3
sb lancets thin
Tier 3
Tier 3
sb lancets ultra thin
Tier 3
SOLARTEK
GLUCOSE CONTROL
select-lite device/lancets
Tier 3
SOLUS V2 CONTROL
Tier 3
select-lite lancing
device
Tier 3
SOLUS V2 LANCETS
28G
Tier 3
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Drug Details
Drug Name
Drug
Status
SOLUS V2 LANCING
DEVICE
Tier 3
SOLUS V2 TWIST
LANCETS 30G
Tier 3
STERILANCE PA
Drug Details
Drug Name
Drug
Status
SURESTEP PRO
NORMAL GLUCOSE
Tier 3
tai doc control
Tier 3
Tier 3
TECHLITE AST
LANCETS
Tier 3
STERILANCE TL
Tier 3
TECHLITE LANCETS
Tier 3
super thin lancets
Tier 3
Tier 3
supreme ii high/low
control
TECHLITE LANCETS
30G
Tier 3
Tier 3
sure comfort lancets 28g
Tier 3
TELCARE GLUCOSE
CONTROL
sure comfort lancets 30g
Tier 3
Tier 3
sure comfort lancing
pen
tgt advanced lancing
device
Tier 3
tgt lancet alternate site
Tier 3
SURE EDGE
GLUCOSE CONTROL
tgt lancet micro thin 33g
Tier 3
Tier 3
tgt lancet super thin 30g
Tier 3
SURE-LANCE FLAT
LANCETS
Tier 3
tgt lancet thin 23g
Tier 3
tgt lancet thin 26g
Tier 3
SURE-LANCE
LANCETS 26G
Tier 3
tgt lancet ultra thin 28g
Tier 3
SURE-LANCE THIN
LANCETS 28G
tgt lancet ultra thin 30g
Tier 3
Tier 3
tgt lancing device
Tier 3
SURE-LANCE ULTRA
THIN LANCETS
Tier 3
THINLETS GP
LANCETS
Tier 3
SURE-PEN
Tier 3
THINLETS LANCET
Tier 3
SURE-TEST
EASYPLUS
CONTROL
Tier 3
Tier 3
todays health lancing
device
Tier 3
SURE-TOUCH
LANCETS
UNIVERSAL
todays health thin
lancets 28g
Tier 3
todays health thin
lancets 30g
Tier 3
TRUECONTROL
GLUCOSE CONT LEV
0
Tier 3
Tier 3
SURECHEK
CONTROL
SOLUTION
Tier 3
SURELITE LANCETS
Tier 3
SURESTEP GLUCOSE
CONTROL
Tier 3
TRUECONTROL
GLUCOSE CONT LEV
1
SURESTEP PRO HIGH
GLUCOSE
Tier 3
TRUEDRAW
LANCING DEVICE
Tier 3
SURESTEP PRO LOW
GLUCOSE
Tier 3
TRUEPLUS LANCETS
26G
Tier 3
TRUEPLUS LANCETS
28G
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
109
Drug Name
Drug
Status
TRUEPLUS LANCETS
30G
Tier 3
TRUEPLUS LANCETS
33G
Tier 3
Drug Details
Drug Name
Drug
Status
ULTRA-THIN II
LANCETS
Tier 3
ULTRALANCE
Tier 3
ULTRATRAK PRO
CONTROL
Tier 3
ULTRATRAK
ULTIMATE
CONTROL
Tier 3
UNILET
COMFORTOUCH
LANCET
Tier 3
UNILET EXCELITE
Tier 3
UNILET EXCELITE II
Tier 3
UNILET G.P. LANCET
Tier 3
TRUEPLUS SAFETY
LANCETS 28G
Tier 3
TRUETEST
CONTROL LEVEL 1
Tier 3
TRUETEST
CONTROL LEVEL 2
Tier 3
TRUETEST
CONTROL LEVEL 3
Tier 3
TRUETRACK
GLUCOSE CONTROL
Tier 3
ULTI-LANCE
AUTO-ADJUST
DEVICE
Tier 3
UNILET G.P.
SUPERLITE LANCET
Tier 3
ULTI-LANCE
AUTOMATIC
Tier 3
UNILET GP 28
ULTRA THIN
Tier 3
ULTI-LANCE MINI
ADJUSTABLE
UNILET LANCET
Tier 3
Tier 3
Tier 3
ULTICARE THIN
LANCETS 28G
UNILET SUPERLITE
LANCET
Tier 3
UNISTIK 1
Tier 3
ULTICARE THIN
LANCETS 30G
UNISTIK 2
Tier 3
Tier 3
UNISTIK 2 COMFORT
Tier 3
ULTILET BASIC
LANCETS 30G
Tier 3
UNISTIK 2 EXTRA
Tier 3
ULTILET CLASSIC
LANCETS
Tier 3
Tier 3
UNISTIK 2
NEONATAL
UNISTIK 2 NORMAL
Tier 3
ULTILET LANCETS
Tier 3
UNISTIK 2 SUPER
Tier 3
ULTILET
OPERATING DEVICE
Tier 3
UNISTIK 3
Tier 3
ULTILET SAFETY
LANCETS 23G
UNISTIK 3 COMFORT
Tier 3
Tier 3
UNISTIK 3 EXTRA
Tier 3
UNISTIK 3 GENTLE
Tier 3
ULTILET
ULTI-LANCE ADJ
DEVICE
Tier 3
UNISTIK 3
NEONATAL
Tier 3
ultra thin lancets 28g
Tier 3
UNISTIK 3 NORMAL
Tier 3
ultra thin lancets 30g
Tier 3
Tier 3
ULTRA-THIN II
AUTO LANCET
UNISTIK CZT
COMFORT
Tier 3
UNISTIK CZT
NORMAL
Tier 3
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Drug Details
Drug Name
Drug
Status
UNISTRIP CONTROL
Tier 3
UNIVERSAL 1
LANCETS THIN 26G
Tier 3
UNIVERSAL 1
LANCETS ULTRA
THIN
Tier 3
value plus lancet
standard 21g
Tier 3
value plus lancets super
thin
Tier 3
value plus lancets thin
26g
Tier 3
value plus lancing
device
Tier 3
valumark lancet super
thin 30g
Tier 3
valumark lancet ultra
thin 28g
Tier 3
VICTORY CONTROL
LEVEL 1/2
Tier 3
VIDA MIA AUTOLET
LANCING DEV
Drug Details
Drug Name
Drug
Status
walgreens lancets super
thin
Tier 3
WALGREENS
LANCING DEVICE
Tier 3
WALGREENS THIN
LANCETS
Tier 3
WALGREENS ULTRA
THIN LANCETS
Tier 3
XPRES CONTROL
Tier 3
Drug Details
*MISC.
DEVICES**-*APPLI
CATORS,COTTON
BALLS,ETC***
ALCOH-GLOVE
CONTOURED WIPE
Tier 3
alcohol pads
Tier 3
alcohol prep
Tier 3
alcohol prep pad
Tier 3
alcohol preps pad
Tier 3
alcohol swabs
Tier 3
Tier 3
alcohol wipes
Tier 3
VIDA MIA UNILET
LANCETS 28G
Tier 3
BD SWAB SINGLE
USE REGULAR
Tier 3
VIDA MIA UNILET
LANCETS 30G
Tier 3
BD SWABS SINGLE
USE BUTTERFLY
Tier 3
VITALET PRO
LANCETS
Tier 3
CURITY ALCOHOL
PREPS
Tier 3
VITALET PRO PLUS
LANCETS
Tier 3
CURITY ALCOHOL
SWABS
Tier 3
VOCAL POINT
CONTROL
cvs alcohol prep swabs
Tier 3
Tier 3
cvs alcohol swabs
Tier 3
W&F LANCETS 26G
Tier 3
W&F LANCETS
COLORED 21G
Tier 3
Tier 3
EASY TOUCH
ALCOHOL PREP
MEDIUM
walgreens adv travel
lancets
Tier 3
FIFTY50 ALCOHOL
PREP
Tier 3
WALGREENS
LANCETS
global alcohol prep ease
Tier 3
Tier 3
gnp alcohol swabs
Tier 3
walgreens lancets micro
thin
Tier 3
healthwise alcohol prep
Tier 3
meijer alcohol swabs
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
111
Drug Name
Drug
Status
pharmacist choice
alcohol
Tier 3
qc alcohol swabs
Tier 3
ra alcohol swabs
Tier 3
reality swabs
Tier 3
RELION ALCOHOL
SWABS
Drug Details
Drug Name
Drug
Status
BD AUTOSHIELD
29G X 12MM
Tier 3
BD AUTOSHIELD
29G X 5MM , 29G X
8MM
Tier 2
Tier 3
BD AUTOSHIELD
DUO
Tier 2
sb alcohol prep
Tier 3
BD INSULIN SYR
ULTRAFINE II
Tier 3
SHOPKO ALCOHOL
SWABS
Tier 3
sm alcohol prep pad
Tier 3
sure comfort alcohol
prep
Tier 2
Tier 3
SURE-PREP
ALCOHOL PREP
Tier 3
BD INSULIN
SYRINGE 25G X 1" 1
ML, 25G X 5/8" 1 ML,
26G X 1/2" 1 ML,
27.5G X 5/8" 2 ML,
27G X 1/2" 1 ML, 29G
X 1/2" 2 ML
tgt alcohol swabs
Tier 3
ultilet alcohol swab
Tier 3
Tier 3
ultilet alcohol swabs
Tier 3
WEBCOL ALCOHOL
PREP LARGE
Tier 3
BD INSULIN
SYRINGE 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
WEBCOL ALCOHOL
PREP MEDIUM
Tier 3
BD INSULIN
SYRINGE HALF-UNIT
Tier 3
BD INSULIN
SYRINGE
MICROFINE 27G X
5/8" 1 ML, 28G X 1/2"
0.3 ML
Tier 2
BD INSULIN
SYRINGE
MICROFINE 28G X
1/2" 0.5 ML, 28G X
1/2" 1 ML
Tier 3
*PARENTERAL
THERAPY
SUPPLIES**-*NEED
LES & SYRINGES***
1st choice pen needles
Tier 3
1st tier unifine pentips
Tier 3
1st tier unifine pentips
plus
Tier 3
ADVOCATE INSULIN
PEN NEEDLES
Tier 3
Tier 2
ADVOCATE INSULIN
SYRINGE
BD INSULIN
SYRINGE U-40
Tier 3
ASSURE ID INSULIN
SAFETY SYR
Tier 3
aurora pen needles
Tier 3
Tier 3
aurora unifine pentips
Tier 3
AUTOJECT 2
Tier 3
BD INSULIN
SYRINGE
ULTRAFINE 29G X
1/2" 0.3 ML, 29G X
1/2" 0.5 ML, 29G X
1/2" 1 ML, 31G X 5/16"
0.3 ML, 31G X 5/16"
0.5 ML, 31G X 5/16" 1
ML
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
112
Drug Details
Drug Name
Drug
Status
BD INSULIN
SYRINGE
ULTRAFINE 30G X
1/2" 0.3 ML, 30G X
1/2" 1 ML, 31G X
15/64" 0.3 ML, 31G X
15/64" 0.5 ML, 31G X
15/64" 1 ML
Tier 2
BD INTEGRA
INSULIN SYRINGE
Drug Details
Drug Name
Drug
Status
COMFORT EZ
INSULIN SYRINGE
30G X 1/2" 0.3 ML,
30G X 1/2" 1 ML
Tier 2
COMFORT EZ PEN
NEEDLES
Tier 3
CORNWALL METAL
PIPETTING
Tier 3
Tier 3
Tier 2
BD INTEGRA
SYRINGE 25G X 1" 1
ML
cvs insulin syringe 30g x
1/2" 0.3 ml
Tier 2
drug mart unifine
pentips
Tier 3
BD PEN NEEDLE
MINI U/F
Tier 3
duane reade unifine
pentips
Tier 3
BD PEN NEEDLE
NANO U/F
Tier 3
easy comfort insulin
syringe 30g x 1/2" 1 ml
Tier 2
BD PEN NEEDLE
SHORT U/F
Tier 3
Tier 3
BD PEN NEEDLE
ULTRAFINE
easy comfort pen
needles 31g x 5 mm ,
31g x 8 mm
Tier 3
BD SAFETY-LOK
INSULIN SYRINGE
Tier 3
Tier 3
BD SAFETYGLIDE
INSULIN SYRINGE
Tier 3
EASY TOUCH
INSULIN SAFETY
SYR 29G X 1/2" 0.5
ML, 29G X 1/2" 1 ML,
30G X 5/16" 0.5 ML
EASY TOUCH
INSULIN SAFETY
SYR 30G X 1/2" 1 ML
Tier 2
EASY TOUCH
INSULIN SYRINGE
27G X 1/2" 1 ML, 30G
X 1/2" 0.3 ML, 30G X
1/2" 1 ML
Tier 2
EASY TOUCH
INSULIN SYRINGE
28G X 1/2" 0.5 ML,
28G X 1/2" 1 ML, 29G
X 1/2" 0.5 ML, 29G X
1/2" 1 ML, 30G X 5/16"
0.3 ML, 30G X 5/16"
0.5 ML, 30G X 5/16" 1
ML, 31G X 5/16" 0.3
ML, 31G X 5/16" 0.5
ML, 31G X 5/16" 1 ML
Tier 3
CAREONE
ULTIGUARD
INSULIN SYR
Tier 3
careone unifine pentips
Tier 3
careone unifine pentips
plus
Tier 3
clickfine pen needles
Tier 3
COMFORT EZ
INSULIN SYRINGE
28G X 1/2" 0.5 ML,
28G X 1/2" 1 ML, 29G
X 1/2" 0.3 ML, 29G X
1/2" 0.5 ML, 29G X
1/2" 1 ML, 30G X 5/16"
0.3 ML, 30G X 5/16"
0.5 ML, 30G X 5/16" 1
ML, 31G X 5/16" 0.3
ML, 31G X 5/16" 0.5
ML, 31G X 5/16" 1 ML
Tier 3
Drug Details
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Drug Name
EASY TOUCH PEN
NEEDLES 29G X
12MM , 31G X 5 MM ,
31G X 6 MM , 31G X 8
MM , 32G X 5 MM ,
32G X 6 MM
Drug
Status
Tier 3
Drug Details
Drug Name
Drug
Status
gnp clickfine pen
needles
Tier 3
h-e-b incontrol pen
needles
Tier 3
healthwise mini pen
needles
Tier 3
healthwise pen needles
Tier 3
healthwise short pen
needles
Tier 3
healthwise unifine
pentips
Tier 3
healthy accents unifine
pentip
Tier 3
HUMATROPEN FOR
12MG
Tier 3
Tier 3
elite-thin insulin syringe
28g x 5/16" 0.5 ml, 28g
x 5/16" 1 ml, 29g x
5/16" 0.5 ml, 29g x
5/16" 1 ml
Tier 3
eql short pen needle
Tier 3
eql ultra short pen
needle
Tier 3
exel pen needles 1/2"
Tier 3
EXEL PEN NEEDLES
1/3"
Tier 3
exel pen needles 1/4"
Tier 3
HUMATROPEN FOR
24MG
FIFTY50 PEN
NEEDLES
Tier 3
HUMATROPEN FOR
6MG
Tier 3
FIFTY50 SUPERIOR
COMFORT SYR
Tier 3
Tier 2
freds pharmacy unifine
pentip+
hy-vee insulin syringe
30g x 1/2" 0.3 ml, 30g x
1/2" 1 ml
Tier 3
inject-ease
Tier 3
freds pharmacy unifine
pentips
Tier 3
Tier 3
FREESTYLE
PRECISION INS SYR
INJECT-EASE
AUTOMATIC
INJECTOR
Tier 3
insupen pen needles
Tier 3
global ease inject pen
needles
INSUPEN SENSITIVE
Tier 3
Tier 3
INSUPEN ULTRAFIN
Tier 3
global inject ease
insulin syr 30g x 1/2"
0.3 ml, 30g x 1/2" 1 ml
Tier 2
J-TIP KIT W/VIAL
ADAPTERS
Tier 3
kmart valu insulin
syringe 29g
Tier 3
kmart valu insulin
syringe 30g
Tier 3
kroger pen needles
Tier 3
LEADER UNIFINE
PENTIPS
Tier 3
LEADER UNIFINE
PENTIPS PLUS
Tier 3
GLUCOPRO INSULIN
SYRINGE 30G X 1/2"
0.3 ML, 30G X 1/2" 1
ML
GLUCOPRO INSULIN
SYRINGE 30G X 5/16"
0.3 ML, 30G X 5/16"
0.5 ML, 30G X 5/16" 1
ML, 31G X 5/16" 0.3
ML, 31G X 5/16" 0.5
ML, 31G X 5/16" 1 ML
Tier 2
Tier 3
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Drug Details
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
LITE TOUCH PEN
NEEDLES
Tier 3
OMNITROPE PEN 5
INJ DEVICE
Tier 3
LITETOUCH INSULIN
SYRINGE
Tier 3
ORSINI INSULIN
SYRINGE
Tier 3
LITETOUCH PEN
NEEDLES
Tier 3
pc unifine pentips
Tier 3
pca injector
Tier 3
live better pen needles
Tier 3
pen needles
Tier 3
MAGELLAN INSULIN
SAFETY SYR
Tier 3
pen needles 1/2"
Tier 3
MAXI-COMFORT
INSULIN SYRINGE
pen needles 3/16"
Tier 3
Tier 3
pen needles 5/16"
Tier 3
medicine shoppe pen
needles
plastic adapter
Tier 3
Tier 3
meijer pen needles
Tier 3
Tier 3
MONOJECT INSULIN
SYRINGE 25G X 5/8"
1 ML, 27G X 1/2" 1 ML
PRECISION
SURE-DOSE
SYRINGE
Tier 2
PRECISION
SUREDOSE PLUS
SYR
Tier 3
preferred plus unifine
pentips
Tier 3
PRODIGY INSULIN
PEN NEEDLES
Tier 3
PRODIGY INSULIN
SYRINGE
Tier 3
PRODIGY MINI PEN
NEEDLES
Tier 3
PRODIGY SHORT
PEN NEEDLES
Tier 3
px extra short pen
needles
Tier 3
px insulin syringe 30g x
1/2" 0.3 ml, 30g x 1/2" 1
ml
Tier 2
px pen needle
Tier 3
px shortlength pen
needles
Tier 3
Tier 3
MONOJECT INSULIN
SYRINGE 28G X 1/2"
0.5 ML, 28G X 1/2" 1
ML, 29G X 1/2" 0.3
ML, 29G X 1/2" 0.5
ML, 29G X 1/2" 1 ML,
30G X 5/16" 0.3 ML,
30G X 5/16" 0.5 ML,
30G X 5/16" 1 ML, 31G
X 5/16" 1 ML, U-100 1
ML
Tier 3
MONOJECT ULTRA
COMFORT SYRINGE
Tier 3
MOORE MONO
INSULIN SYRINGE
Tier 3
NORDIPEN 5
INJECTION DEVICE
Tier 3
NORDIPEN
DELIVERY SYSTEM
Tier 3
NOVOFINE
Tier 3
NOVOFINE
AUTOCOVER
Tier 3
NOVOTWIST
Tier 3
qc insulin syringe 29g
0.3 ml, 29g 0.5 ml, 29g
1 ml, 30g 0.5 ml, 30g 1
ml
OMNITROPE PEN 10
INJ DEVICE
Tier 3
qc pen needles
Tier 3
qc unifine pentips
Tier 3
Drug Details
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115
Drug Name
Drug
Status
ra pen needles
Tier 3
RELI-ON INSULIN
SYRINGE
Tier 3
RELION INSULIN
SYRINGE
Tier 3
RELION MINI PEN
NEEDLES
Tier 3
RELION PEN
NEEDLES
Tier 3
RELION SHORT PEN
NEEDLES
Tier 3
SAFESNAP INSULIN
SYRINGE
Tier 3
SAFETY-GLIDE
SYRINGE
Tier 3
SHOPKO UNIFINE
PENTIPS
Tier 3
sure comfort insulin
syringe 30g x 1/2" 0.3
ml, 30g x 1/2" 1 ml
Tier 2
sure comfort pen
needles
Tier 3
SURE-FINE PEN
NEEDLES
Tier 3
SURE-JECT INSULIN
SYRINGE
Tier 3
TERUMO INSULIN
SYRINGE 27G X 1/2"
1 ML
Tier 2
TERUMO INSULIN
SYRINGE 28G X 1/2"
0.5 ML, 28G X 1/2" 1
ML, 29G X 1/2" 0.3
ML, 29G X 1/2" 0.5
ML, 29G X 1/2" 1 ML,
30G X 3/8" 0.3 ML,
30G X 3/8" 0.5 ML,
30G X 3/8" 1 ML
Tier 3
TERUMO
SURGUARD INSULIN
SYR
Tier 3
THINPRO INSULIN
SYRINGE
Tier 3
Drug Details
Drug Name
todays health mini pen
needles
Tier 3
todays health pen
needles
Tier 3
todays health short pen
needle
Tier 3
topcare clickfine pen
needles
Tier 3
TRUEPLUS INSULIN
SYRINGE
Tier 3
ULTICARE INSULIN
SAFETY SYR
Tier 3
ULTICARE INSULIN
SYRINGE 28G X 1/2"
0.5 ML, 28G X 1/2" 1
ML, 29G X 1/2" 0.3
ML, 29G X 1/2" 0.5
ML, 29G X 1/2" 1 ML,
30G X 5/16" 0.3 ML,
30G X 5/16" 0.5 ML,
30G X 5/16" 1 ML, 31G
X 5/16" 0.3 ML, 31G X
5/16" 0.5 ML, 31G X
5/16" 1 ML
Tier 3
ULTICARE INSULIN
SYRINGE 30G X 1/2"
0.3 ML, 30G X 1/2" 1
ML
Tier 2
ULTICARE MICRO
PEN NEEDLES
Tier 3
ULTICARE MINI PEN
NEEDLES
Tier 3
ULTICARE PEN
NEEDLES
Tier 3
ULTICARE SHORT
PEN NEEDLES
Tier 3
ULTILET INSULIN
SYRINGE
Tier 3
ULTILET INSULIN
SYRINGE SHORT 30G
X 5/16" 0.3 ML, 30G X
5/16" 0.5 ML, 30G X
5/16" 1 ML
Tier 3
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116
Drug
Status
Drug Details
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
ultra comfort insulin
syringe 30g x 1/2" 1 ml
Tier 2
MICROLIFE DIGITAL
PEAK FLOW
Tier 3
ULTRA-THIN II INS
SYR SHORT
Tier 3
MINI WRIGHT PEAK
FLOW METER
Tier 3
ULTRA-THIN II
INSULIN SYRINGE
Tier 3
PEAK AIR PEAK
FLOW METER
Tier 3
ULTRA-THIN II MINI
PEN NEEDLE
Tier 3
PERSONAL BEST
FULL RANGE
Tier 3
ULTRA-THIN II PEN
NEEDLE SHORT
Tier 3
PERSONAL BEST
LOW RANGE
Tier 3
ULTRA-THIN II PEN
NEEDLES
Tier 3
PIKO 1
Tier 3
UNIFINE PENTIPS
Tier 3
POCKET PEAK FLOW
METER
Tier 3
unifine pentips plus
Tier 3
Tier 3
V-R MONO INSULIN
SYRINGE
POCKETPEAK PEAK
FLOW METER
Tier 3
Tier 3
valumark pen needles
Tier 3
TRUZONE PEAK
FLOW METER
VANISHPOINT
INSULIN SYRINGE
29G X 1/2" 1 ML
Tier 3
VIDA MIA UNIFINE
PENTIPS
Tier 3
*RESPIRATORY
THERAPY
SUPPLIES**-*RESPI
RATORY THERAPY
SUPPLIES***
wegmans unifine pentips
plus
Tier 3
ACE AEROSOL
CLOUD ENHANCER
Tier 3
ACTIVITY POUCH
Tier 3
ADAPTER PED
DISPOSABLE
Tier 3
adult aerosol mask
Tier 3
adult mask
Tier 3
adult mask large
Tier 3
AEROTRACH PLUS
Tier 3
AIRS PEDIATRIC
AEROSOL MASK
Tier 3
*RESPIRATORY
THERAPY
SUPPLIES**-*PEAK
FLOW METERS***
AIRZONE PEAK
FLOW METER
Tier 3
ASSESS FULL
RANGE PEAK
METER
Tier 3
ASSESS LOW RANGE
PEAK METER
Tier 3
Tier 3
ASSESS PEAK FLOW
METER
ALL FLOW 1000 PFT
FILTER
Tier 3
Tier 3
ASTHMA CHECK
METER-ZONE
SYSTEM
BUBBLES THE FISH
II PEDI MASK
Tier 3
co monitor replacement
pieces
Tier 3
ASTHMAMENTOR
Tier 3
cone mask
Tier 3
earloop mask
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
117
Drug Name
Drug
Status
EFLOW SCF
AEROSOL HEAD
Tier 3
ELITE DC AUTO
ADAPTER
Tier 3
filter air pp
Tier 3
full kit nebulizer set
Drug Details
Drug Name
Drug
Status
PARI BABY
CONVERSION KIT
Tier 3
PARI ERAPID
NEBULIZER
HANDSET
Tier 3
Tier 3
Tier 3
HEALTHY LIVING
FILTERS
PARI EXPIRATORY
FILTER SET
Tier 3
PARI MASK SET
Tier 3
HEALTHY LIVING
MASKS
Tier 3
PARI SOFT PLASTIC
ADULT MASK
Tier 3
HEALTHY LIVING
REPLACEMENT KIT
Tier 3
PARI SOFT PLASTIC
PED MASK
Tier 3
inhaler companions
Tier 3
pediatric aerosol mask
Tier 3
pediatric mouthpiece
Tier 3
PFLEX
Tier 3
pillow mask/adult
Tier 3
pillow mask/child
Tier 3
pillow mask/pediatric
Tier 3
replacement air filter
Tier 3
replacement filters
Tier 3
SAMI THE SEAL
FILTERS
Tier 3
SIDESTREAM ADULT
FACE MASK
Tier 3
Tier 3
INNOSPIRE
REPLACEMENT
FILTER
Tier 3
KOKO PEAK PRO
MOUTHPIECE
Tier 3
LITETOUCH MASK
LARGE
Tier 3
LITETOUCH MASK
MEDIUM
Tier 3
LITETOUCH MASK
SMALL
Tier 3
MICROELITE
BATTERY
Tier 3
MICROELITE FILTER
REPLACEMENTS
Tier 3
SIDESTREAM
PEDIATRIC FACE
MASK
MINIELITE FILTER
REPLACEMENTS
Tier 3
SIDESTREAM PLS
ADULT FACE MASK
Tier 3
silicone mask/adult
Tier 3
silicone mask/infant
Tier 3
silicone mask/pediatric
Tier 3
MINIELITE
RECHARGEABLE
BATTERY
Tier 3
nebulizer air tube/plugs
Tier 3
THRESHOLD IMT
Tier 3
Tier 3
tubing/wing tip
Tier 3
WINDMILL TRAINER
Tier 3
nebulizer mask pediatric
nose clip
Tier 3
ONE FLOW TESTER
Tier 3
PARI ALTERA
NEBULIZER
HANDSET
Tier 3
*RESPIRATORY
THERAPY
SUPPLIES**-*SPACE
R/AEROSOL-HOLDI
NG CHAMBERS &
SUPPLIES***
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118
Drug Details
Drug Name
Drug
Status
AEROCHAMBER
MINI CHAMBER
Tier 3
AEROCHAMBER MV
Tier 3
AEROCHAMBER
PLUS
Tier 3
AEROCHAMBER
PLUS FLO-VU
Tier 3
AEROCHAMBER
PLUS FLO-VU
LARGE
Tier 3
AEROCHAMBER
PLUS FLO-VU
MEDIUM
Tier 3
AEROCHAMBER
PLUS FLO-VU
SMALL
Tier 3
Drug Details
Drug Name
Drug
Status
BREATHERITE COLL
SPACER ADULT
Tier 3
BREATHERITE COLL
SPACER CHILD
Tier 3
BREATHERITE COLL
SPACER INFANT
Tier 3
BREATHERITE RIGID
SPACER/MASK
Tier 3
BREATHERITE
SPACER NEONATE
Tier 3
BREATHERITE
SPACER SMALL
CHILD
Tier 3
BREATHERITE/LARG
E MASK
Tier 3
BREATHERITE/MEDI
UM MASK
Tier 3
BREATHERITE/SMAL
L MASK
Tier 3
AEROCHAMBER
PLUS FLO-VU
W/MASK
Tier 3
AEROCHAMBER
PLUS FLOW VU
Tier 3
E-Z SPACER
Tier 3
AEROCHAMBER
PLUS W/MASK
Tier 3
E-Z SPACER THE
BODY GUARDS PK
Tier 3
AEROCHAMBER
PLUS W/MASK
SMALL
EASIVENT
Tier 3
Tier 3
EASIVENT MASK
LARGE
Tier 3
AEROCHAMBER
W/FLOWSIGNAL
Tier 3
EASIVENT MASK
MEDIUM
Tier 3
AEROCHAMBER
Z-STAT PLUS
Tier 3
EASIVENT MASK
SMALL
Tier 3
INSPIREASE
Tier 3
INSPIREASE BAGS
Tier 3
INSPIREASE
MOUTHPIECE
Tier 3
INSPIREASE
RESERVOIR BAGS
Tier 3
LITEAIRE
Tier 3
MASK VORTEX
Tier 3
AEROCHAMBER
Z-STAT PLUS
CHAMBR
Tier 3
AEROCHAMBER
Z-STAT PLUS/LARGE
Tier 3
AEROCHAMBER
Z-STAT
PLUS/MEDIUM
Tier 3
AEROCHAMBER
Z-STAT PLUS/SMALL
Tier 3
MICROCHAMBER
Tier 3
ARIAL CHAMBER
Tier 3
MICROSPACER
Tier 3
BREATHERITE
Tier 3
NESSI SPACER WITH
MASK LARGE
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
119
Drug Name
NESSI SPACER WITH
MASK SM/MED
Drug
Status
Tier 3
NESSI SPACER WITH
MOUTHPIECE
Tier 3
OPTICHAMBER
ADVANTAGE
Tier 3
OPTICHAMBER
ADVANTAGE-LG
MASK
Tier 3
OPTICHAMBER
ADVANTAGE-MED
MASK
Tier 3
OPTICHAMBER
ADVANTAGE-SM
MASK
Tier 3
OPTICHAMBER
DIAMOND
Tier 3
OPTICHAMBER
DIAMOND-LG MASK
Tier 3
OPTICHAMBER
DIAMOND-MD MASK
Tier 3
OPTICHAMBER
DIAMOND-SM MASK
Tier 3
OPTICHAMBER
FACE MASK-LARGE
Tier 3
OPTICHAMBER
FACE
MASK-MEDIUM
Tier 3
OPTICHAMBER
FACE MASK-SMALL
Tier 3
OPTIHALER
Tier 3
PANDA MASK
LARGE
Tier 3
PANDA MASK
MEDIUM
Tier 3
PANDA MASK
SMALL
Tier 3
PEDIATRIC PANDA
MASK
Tier 3
POCKET CHAMBER
Tier 3
POCKET SPACER
Tier 3
RITEFLO
Tier 3
Drug Details
Drug Name
Drug
Status
valved holding chamber
Tier 3
VORTEX VALVED
HOLDING CHAMBER
Tier 3
WATCHHALER
Tier 3
*MIGRAINE
PRODUCTS*
*MIGRAINE
COMBINATIONS**-*
ERGOT
COMBINATIONS***
CAFERGOT
Tier 3
MIGERGOT
Tier 3
*MIGRAINE
COMBINATIONS**-*
MIGRAINE
COMBINATIONS***
EPIDRIN
Tier 1
isometheptene-apap-dic
hloral oral capsule
65-325-100 mg
Tier 1
migragesic ida
Tier 1
MIGRALAM
Tier 3
NODOLOR
Tier 1
PRODRIN ORAL
TABLET 325-65-20
MG
Tier 3
*MIGRAINE
COMBINATIONS**-*
SELECTIVE
SEROTONIN
AGONIST-NSAID
COMBINATIONS***
TREXIMET
Tier 3
ST; N1; QL (9
tablets per 30
days)
Tier 3
QL (9 pack per
30 Days)
*MIGRAINE
PRODUCTS NSAIDS**-*MIGRAI
NE PRODUCTS NSAIDS***
CAMBIA
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
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Drug Details
Drug Name
Drug
Status
Drug Details
*MIGRAINE
PRODUCTS**-*MIG
RAINE
PRODUCTS***
D.H.E. 45
Tier 3
dihydroergotamine
mesylate injection
Tier 1
ERGOMAR
Tier 3
MIGRAL
Tier 3
MIGRANAL
Tier 3
ST; N1; QL (1
box per 30
days)
*SEROTONIN
AGONISTS**-*SELE
CTIVE SEROTONIN
AGONISTS
5-HT(1)***
Drug Name
Drug
Status
rizatriptan benzoate
Tier 1
QL (12 Blisters
per 30 days)
sumatriptan succinate
oral
Tier 1
QL (9 tab per
30 Days)
sumatriptan succinate
subcutaneous* 4
mg/0.5ml, 6 mg/0.5ml
Tier 1
QL (10
cartridges per
30 days)
zolmitriptan oral
Tier 1
QL (6 tab per
30 Days)
ZOMIG NASAL
Tier 3
ST; N1; QL (6
bottles per 30
Days)
ZOMIG NASAL
Tier 3
ST; N1; QL (6
ml per 30
Days)
ZOMIG ORAL
Tier 3
QL (6 tab per
30 Days)
Tier 3
ST; N1; QL (6
tab per 30
Days)
Tier 3
QL (9 tab per
30 Days)
ZOMIG ZMT
AXERT
Tier 3
ST; N1; #; QL
(6 tab per 30
Days)
*MINERALS &
ELECTROLYTES*
FROVA
Tier 3
ST; N1; #; QL
(9 tab per 30
Days)
*CALCIUM**-*CAL
CIUM
COMBINATIONS***
IMITREX NASAL
Tier 3
QL (6 sprays
per 30 days)
CALCIFOL
Tier 3
calcium-folic acid plus d
Tier 3
IMITREX ORAL
Tier 3
QL (9 tab per
30 Days)
IMITREX
SUBCUTANEOUS*
Tier 3
QL (10 vial per
30 Days)
*FLUORIDE**-*FLU
ORIDE
COMBINATIONS***
IMITREX STATDOSE
SYSTEM
Tier 3
QL (10
cartridges per
30 days)
MAXALT
Tier 3
QL (12 tab per
30 Days)
Tier 3
QL (12 blisters
per 30 days)
Tier 1
QL (9 tab per
30 Days)
Tier 3
ST; N1; QL (6
tab per 30
Days)
AMERGE
MAXALT-MLT
naratriptan hcl
RELPAX
FLUOR-A-DAY ORAL
TABLET CHEWABLE
Drug Details
Tier 3
*FLUORIDE**-*FLU
ORIDE***
EPIFLUR
Tier 1
FLUOR-A-DAY ORAL
SOLUTION
Tier 1
FLUORABON
Tier 3
fluoritab
Tier 1
FLURA-DROPS ORAL
SOLUTION 0.275
(0.125 F) MG/DROP
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
121
Drug Name
Drug
Status
FLURA-DROPS ORAL
SOLUTION 0.55 (0.25
F) MG/DROP
Tier 3
KARIDIUM
Tier 1
LOZI-FLUR
Tier 3
LUDENT
Tier 1
NAFRINSE
Tier 1
NAFRINSE DROPS
Tier 1
renaf
Tier 1
sodiphluor
Tier 1
sodium fluoride oral
solution
Tier 1
sodium fluoride oral
tablet chewable 0.55
(0.25 f) mg
Tier 1
sodium fluoride oral
tablet chewable 1.1 (0.5
f) mg, 2.2 (1 f) mg
Tier 1
*IODINE
PRODUCTS**-*IODI
NE PRODUCTS***
SSKI
Tier 3
*PHOSPHATE**-*PH
OSPHATE***
K-PHOS
Tier 3
PHOSPHA 250
NEUTRAL
Tier 1
*POTASSIUM**-*PO
TASSIUM
COMBINATIONS***
EFFER-K ORAL
TABLET
EFFERVESCENT 10
MEQ, 20 MEQ
Tier 3
effervescent pot chloride
Tier 1
pot bicarb-pot chloride
Tier 1
*POTASSIUM**-*PO
TASSIUM***
EFFER-K ORAL
TABLET
EFFERVESCENT 25
MEQ
Tier 1
Drug Details
LGC
Drug Name
Drug
Status
EPIKLOR
Tier 1
k-effervescent
Tier 1
K-PRIME
Tier 1
k-vescent
Tier 1
KAON-CL-10
Tier 1
KLOR-CON ORAL
PACKET 20 MEQ
Tier 1
KLOR-CON ORAL
PACKET 25 MEQ
Tier 3
KLOR-CON ORAL
TABLET
EXTENDEDRELEASE
*
Tier 1
LGC
KLOR-CON 10
Tier 1
LGC
KLOR-CON M10
Tier 1
KLOR-CON M15
Tier 3
KLOR-CON M20
Tier 1
KLOR-CON/EF
Tier 1
MICRO-K
Tier 3
potassium bicarbonate
oral
Tier 1
potassium chloride oral
liquid† 20 meq/15ml
(10%)
Tier 1
potassium chloride oral
packet
Tier 1
potassium chloride oral
solution
Tier 1
LGC
potassium chloride crys
er oral tablet
extendedrelease* 10
meq
Tier 1
LGC
potassium chloride crys
er oral tablet
extendedrelease* 20
meq
Tier 1
potassium chloride er
oral capsule extended
release* 10 meq
Tier 1
potassium chloride er
oral capsule extended
release* 8 meq
Tier 1
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Drug Details
LGC
Drug Name
potassium chloride er
oral tablet
extendedrelease* 10
meq, 8 meq
Drug
Status
Drug Details
Tier 1
Tier 3
FLUORIDEX
SENSITIVITY RELIEF
DENTAL 1.1-5 %
Tier 3
FLUORIDEX
SENSITIVITY RELIEF
DENTAL PASTE
Tier 1
NAFRINSE DAILY
ACIDULATED
Tier 3
*MOUTH/THROAT/
DENTAL AGENTS*
*ANESTHETICS
TOPICAL
ORAL**-*ANESTHE
TICS TOPICAL
ORAL***
lidocaine hcl
mouth/throat
Tier 1
lidocaine viscous
Tier 1
LTA 360 KIT
Tier 3
clotrimazole
mouth/throat
Tier 1
nystatin mouth/throat
Tier 1
Tier 3
*ANTISEPTICS MOUTH/THROAT***ANTISEPTIC
COMBINATIONS MOUTH/THROAT**
*
DEBACTEROL
Tier 3
*ANTISEPTICS MOUTH/THROAT***ANTISEPTICS MOUTH/THROAT**
*
Drug Details
*DENTAL
PRODUCTS**-*FLU
ORIDE DENTAL
PRODUCTS***
*ANTI-INFECTIVES
THROAT**-*ANTI-I
NFECTIVES THROAT***
ORAVIG
Drug
Status
*DENTAL
PRODUCTS**-*DEN
TAL PRODUCTS COMBINATIONS***
*ZINC**-*ZINC***
GALZIN
Drug Name
QL (14 tab per
30 Days)
CAVAREST
Tier 1
CLINPRO 5000
Tier 1
CONTROLRX
Tier 1
DENTA 5000 PLUS
Tier 1
DENTAGEL
Tier 1
dentall 1100 plus
Tier 1
FLUORIDEX DAILY
DEFENSE
Tier 1
FLUORIDEX
ENHANCED
WHITENING
Tier 1
KARIGEL
Tier 1
KARIGEL-N
Tier 1
NAFRINSE
DAILY/NEUTRAL
Tier 3
NAFRINSE WEEKLY
Tier 3
NEUTRAGARD
ADVANCED
Tier 1
PERIO MED
Tier 1
PHOS-FLUR
Tier 1
PREVIDENT 5000
BOOSTER
Tier 3
Tier 3
Tier 1
chlorhexidine gluconate
mouth/throat
Tier 1
PERIDEX
Tier 3
PREVIDENT 5000
BOOSTER PLUS
PERIOGARD
Tier 1
sf
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Drug Name
Drug
Status
sf 5000 plus
Tier 1
stannous fluoride
mouth/throat
Tier 1
Drug Details
Drug Name
Drug
Status
SALAGEN
Tier 3
*MULTIVITAMINS*
*B-COMPLEX W/
FOLIC
ACID**-*B-COMPLE
X W/ C & FOLIC
ACID***
*STEROIDS MOUTH/THROAT***STEROIDS MOUTH/THROAT**
*
DIALYVITE
Tier 1
ORALONE
Tier 1
folbee plus
Tier 1
triamcinolone acetonide
mouth/throat
Tier 1
mynephrocaps
Tier 1
NEPHROCAPS
Tier 3
NEPHRONEX ORAL
TABLET
Tier 1
rena-vite rx
Tier 1
RENAL ORAL
CAPSULE
Tier 1
*THROAT
PRODUCTS MISC.**-*DRY
MOUTH AGENTS
AND ARTIFICIAL
SALIVA***
AQUORAL
Tier 3
RENALPREN
Tier 1
NEUTRASAL
Tier 3
reno caps
Tier 1
triphrocaps
Tier 1
virt-caps
Tier 1
virt-vite plus
Tier 1
vol-care rx
Tier 1
*THROAT
PRODUCTS MISC.**-*PROTECT
ANTS MOUTH/THROAT**
*
GELCLAIR
Tier 3
GELX
Tier 3
MUCOTROL
Tier 3
ORAFATE
Tier 3
ORAMAGICRX
Tier 3
PROTHELIAL
Tier 3
SALICEPT
MOUTH/THROAT
SUSPENSION
RECONSTITUTED
Tier 3
*B-COMPLEX W/
FOLIC
ACID**-*B-COMPLE
X W/ C-BIOTIN-D &
FOLIC ACID***
NEPHROCAPS QT
*B-COMPLEX W/
FOLIC
ACID**-*B-COMPLE
X W/
C-BIOTIN-D-ZINC &
FOLIC ACID***
VITAL-D RX
*THROAT
PRODUCTS MISC.**-*SALIVA
STIMULANTS***
cevimeline hcl
Tier 1
EVOXAC
Tier 3
*B-COMPLEX W/
FOLIC
ACID**-*B-COMPLE
X W/ C-BIOTIN-E &
FOLIC ACID***
pilocarpine hcl oral
Tier 1
RENATABS
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Tier 3
Tier 3
Tier 3
Drug Details
Drug Name
Drug
Status
*B-COMPLEX W/
FOLIC
ACID**-*B-COMPLE
X W/
C-BIOTIN-E-FOLIC
ACID & IRON***
RENATABS WITH
IRON
Drug Details
Drug Name
Drug
Status
*MULTIPLE
VITAMINS W/
CALCIUM**-*MULT
IPLE VITAMINS W/
CALCIUM***
advanced am/pm
Tier 3
Tier 3
*MULTIPLE
VITAMINS W/
MINERALS &
CALCIUM-FOLIC
ACID**-*MULTIPLE
VITAMINS W/
MINERALS &
CALCIUM-FOLIC
ACID***
DIALYVITE 3000
Tier 3
FOLGARD OS
Tier 3
DIALYVITE 5000
Tier 3
TL G-FOL OS
Tier 3
*B-COMPLEX W/
FOLIC
ACID**-*B-COMPLE
X W/
C-BIOTIN-E-MINER
ALS & FOLIC
ACID***
*B-COMPLEX W/
FOLIC
ACID**-*B-COMPLE
X W/
C-BIOTIN-MINERAL
S & FOLIC ACID***
FOLBEE PLUS CZ
*MULTIPLE
VITAMINS W/
MINERALS**-*MUL
TIPLE VITAMINS W/
MINERALS & FOLIC
ACID***
Tier 1
*B-COMPLEX W/
FOLIC
ACID**-*B-COMPLE
X W/ C-ZN & FOLIC
ACID***
CORVITA
Tier 1
DIALYVITE
SUPREME D
Tier 3
RENAX ORAL
TABLET 2.5 MG
Tier 3
DIALYVITE/ZINC
Tier 3
STROVITE FORTE
ORAL SYRUP
Tier 2
NEPHPLEX RX
Tier 3
SUPERVITE EC
Tier 3
SYNAGEX
Tier 3
SYNATEK
Tier 3
UDAMIN SP
Tier 3
*B-COMPLEX W/
FOLIC
ACID**-*B-COMPLE
X W/
LYSINE-MIN-FE &
FOLIC ACID***
NUTRIVIT
Drug Details
Tier 3
*IRON W/
VITAMINS**-*IRON
W/ VITAMINS***
APETIMAR/IRON
Tier 2
VITAFOL ORAL
SYRUP
Tier 2
*PED MULTI
VITAMINS W/FL &
FE**-*PED MULTI
VITAMINS W/FL &
FE***
ESCAVITE
Tier 3
ESCAVITE LQ
Tier 3
multi-vit/fluoride/iron
Tier 3
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125
Drug Name
Drug
Status
multi-vitamin/fluoride/ir
on
Tier 3
POLY-VI-FLOR/IRON
Tier 3
tl-fluorivite
Tier 3
*PED MULTI
VITAMINS W/FL &
FE**-*PED
VITAMINS ACD
FLUORIDE &
IRON***
Drug Details
Drug Name
Drug
Status
*PED MV W/
FLUORIDE**-*PED
VITAMINS ACD &
FA W/ FLUORIDE***
TRI-VI-FLOR
Tier 3
tri-vi-floro
Tier 3
*PED MV W/
FLUORIDE**-*PED
VITAMINS ACD W/
FLUORIDE***
MYKIDZ IRON FL
Tier 3
tri-vit/fluoride
Tier 1
tri-vit/fluoride/iron
Tier 3
tri-vitamin/fluoride
Tier 1
triple-vitamin/fluoride
Tier 1
vitamins acd-fluoride
Tier 1
*PED MV W/
FLUORIDE**-*PED
MV W/
FLUORIDE***
mult-vitamin/fluoride
Tier 1
multi vit/fl
Tier 1
multi vita-bets/fluoride
Tier 1
multi vitamin/fluoride
*PRENATAL
VITAMINS**-*PREN
ATAL MV & MIN
W/FE-FA***
Tier 3
Tier 1
ATABEX ORAL
TABLET
multi-vit/fluoride
Tier 1
ATABEX EC
Tier 3
multi-vitamin/fluoride
Tier 1
BAL-CARE DHA
Tier 3
multi-vitamins/fluoride
Tier 1
c-nate dha
Tier 3
multi-vits/fluoride
Tier 1
CAVAN-FOLATE OB
Tier 3
multiple
vitamins/fluoride
Tier 1
CITRANATAL
B-CALM
Tier 3
multivitamin/fluoride
Tier 1
CITRANATAL RX
Tier 3
multivitamins/fluoride
Tier 1
CO-NATAL FA
Tier 3
MVC-FLUORIDE
Tier 1
complete-rf prenatal
Tier 3
phluorivit
Tier 1
completenate
Tier 3
POLY-VI-FLOR
Tier 3
CONCEPT DHA
Tier 3
poly-vitamin/fluoride
Tier 1
CONCEPT OB
Tier 3
polyvitamin/fluoride
Tier 1
DUET DHA
Tier 3
DUET DHA 400
Tier 3
DUET DHA 400EC
Tier 3
DUET DHA 430
Tier 3
DUET DHA 430EC
Tier 3
QUFLORA
PEDIATRIC ORAL
TABLET CHEWABLE
Tier 1
re multivit with fluoride
Tier 1
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
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Drug Details
Drug Name
DUET DHA
BALANCED ORAL
25-1 & 267 MG, 27-1 &
380 MG, 27-1 & 430
MG
Drug
Status
Drug Details
Drug Name
Drug
Status
OB COMPLETE
PREMIER
Tier 3
Tier 3
OB COMPLETE/DHA
Tier 3
DUET DHA
COMPLETE
Tier 3
Tier 3
OB-NATAL ONE
ORAL CAPSULE 27-1
MG
DUET DHA EC
Tier 3
pnv fe
fum/docusate/folic acid
Tier 3
ELITE-OB
Tier 3
pnv-omega
Tier 3
ELITE-OB 400
Tier 3
pnv-select
Tier 3
FOLCAPS OMEGA 3
ORAL CAPSULE 27-1
MG
Tier 3
pnv-total
Tier 3
Tier 3
FOLIVANE-OB
Tier 3
PREFERA OB ORAL
TABLET 28-6-1 MG
hemenatal ob
Tier 3
Tier 3
hemenatal ob + dha
Tier 3
PREFERA OB + DHA
ORAL 28-6-1 & 203
MG
INATAL ADVANCE
Tier 3
prena1 pearl
Tier 3
INATAL GT
Tier 3
prenacare
Tier 3
INATAL ULTRA
Tier 3
Tier 3
LACTOCAL-F
Tier 3
prenaissance harmony
dha
MARNATAL-F
Tier 3
PRENATA
Tier 3
MYNATAL
Tier 3
prenatabs fa
Tier 3
MYNATAL
ADVANCE
PRENATABS RX
Tier 3
Tier 3
prenatal 19
Tier 3
NATACHEW
Tier 3
PRENATAL AD
Tier 3
natal-v rx
Tier 3
NATALVIT
Tier 3
Tier 3
NATELLE ONE
Tier 3
PRENATAL
MULTIVITAMIN-ULT
RA
NEEVO DHA ORAL
CAPSULE 27-1.13 MG
prenatal plus iron
Tier 3
Tier 3
PRENATAL-U
Tier 3
NESTABS
Tier 3
NESTABS DHA
Tier 3
Tier 3
nutri-tab ob + dha
Tier 3
PRENATE ELITE
ORAL TABLET
26-0.6-0.4 MG,
27-0.6-0.4 MG
O-CAL PRENATAL
Tier 3
OB COMPLETE
Tier 3
Tier 3
OB COMPLETE 400
Tier 3
PRENATE
ESSENTIAL ORAL
CAPSULE
28-0.6-0.4-340 MG
OB COMPLETE ONE
Tier 3
PROVIDA OB
Tier 3
OB COMPLETE
PETITE
Tier 3
purefe ob plus
Tier 3
RE DUALVIT OB
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
127
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
VINATE DHA RF
Tier 3
VINATE GT
Tier 3
re prenatal
multivitamin/iron
Tier 3
re-nata 29 ob
Tier 3
VINATE IC
Tier 3
relnate dha
Tier 3
VINATE II
Tier 3
se-natal 19
Tier 3
VINATE M
Tier 3
SELECT-OB ORAL
TABLET CHEWABLE
29-1 MG
Tier 3
vinate ultra
Tier 3
virt-bal dha
Tier 3
TANDEM DHA
Tier 3
virt-bal dha plus
Tier 3
TANDEM OB
Tier 3
virt-pn
Tier 3
TARON-BC
Tier 3
virt-pn plus
Tier 3
TARON-C DHA
Tier 3
VITA-PREN
Tier 3
tl-care dha
Tier 3
VITAFOL-NANO
Tier 3
TRI RX
Tier 3
VITAFOL-OB
Tier 3
tri-tabs dha
Tier 3
VITAFOL-PN
Tier 3
triadvance
Tier 3
VITAPEARL
Tier 3
TRICARE PRENATAL
COMPLEAT
VIVA DHA
Tier 3
Tier 3
vol-nate
Tier 3
TRICARE PRENATAL
DHA ONE
Tier 3
vol-tab rx
Tier 3
vp-heme ob
Tier 3
trinatal gt
Tier 3
vp-heme ob + dha
Tier 3
trinatal ultra
Tier 3
vp-pnv-dha
Tier 3
TRINATE
Tier 3
ZATEAN-PN
Tier 3
TRIVEEN-ONE
Tier 3
ZATEAN-PN PLUS
Tier 3
TRIVEEN-U
Tier 3
ultimatecare advantage
Tier 3
ultimatecare combo
Tier 3
ULTRA NATALCARE
Tier 3
*PRENATAL
VITAMINS**-*PREN
ATAL MV & MIN
W/FE-FA-CA-OMEG
A 3 FISH OIL***
ultra tabs
Tier 3
NESTABS ABC
Tier 3
ultra-natal
Tier 3
PR NATAL 400
Tier 3
v-natal dha
Tier 3
TRIVEEN-DUO DHA
Tier 3
vena-bal dha
Tier 3
venatal complete dha
Tier 3
venatal-fa
Tier 3
VINACAL
Tier 3
*PRENATAL
VITAMINS**-*PREN
ATAL MV & MIN
W/FE-FA-DHA***
VINACAL B
Tier 3
VINATE AZ EXTRA
VINATE CALCIUM
active ob
Tier 3
Tier 3
CITRANATAL 90
DHA
Tier 3
Tier 3
CITRANATAL DHA
Tier 3
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128
Drug Details
Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
prenaissance plus
Tier 3
prenaissance promise
Tier 3
prenatal+dha oral 27-1
& 250 mg
Tier 3
Tier 3
CITRANATAL
HARMONY
Tier 3
corenate-dha
Tier 3
CRNATAL
Tier 3
extra-virt plus dha
Tier 3
folcal dha
Tier 3
FOLIVANE-EC
CALCIUM DHA NF
PRENATE DHA ORAL
CAPSULE
28-0.6-0.4-300 MG
Tier 3
PRENATE ENHANCE
Tier 3
FOLIVANE-PRX DHA
NF
PRENATE MINI
Tier 3
Tier 3
PRENATE RESTORE
Tier 3
GESTICARE DHA
Tier 3
PRENEXA
Tier 3
infanate balance
Tier 3
PREQUE 10
Tier 3
KOLNATAL DHA
Tier 3
R-NATAL OB
Tier 3
l-methylfolate pnv dha
Tier 3
RE OB + DHA
Tier 3
levomefolate dha
Tier 3
reaphirm
Tier 3
MACNATAL CN DHA
Tier 3
SELECT-OB+DHA
Tier 3
NATALVIRT 90 DHA
Tier 3
TARON EC CALCIUM
Tier 3
NATALVIRT CA
Tier 3
TARON-PREX
Tier 3
NEEVO DHA ORAL
CAPSULE 27-1.13-0.4
MG
tl-assure one
Tier 3
Tier 3
tl-select
Tier 3
NEXA PLUS
Tier 3
tl-select dha
Tier 3
NEXA SELECT ORAL
CAPSULE 29-1.25-325
MG
TRIVEEN-PRX RNF
Tier 3
Tier 3
TRIVEEN-TEN
Tier 3
VEMAVITE-PRX 2
Tier 3
PAIRE OB
Tier 3
virt-pn dha
Tier 3
pnv ob+dha
Tier 3
virt-select
Tier 3
pnv-dha
Tier 3
VITAFOL ULTRA
Tier 3
pnv-dha+docusate
Tier 3
VITAFOL-OB+DHA
Tier 3
pnv-first
Tier 3
VITAFOL-ONE
Tier 3
PREFERAOB ONE
Tier 3
VITAFOL-PLUS
Tier 3
PREFOL-DHA
Tier 3
Tier 3
prena1 plus/quatrefolic
Tier 3
VITAMEDMD ONE
RX/QUATREFOLIC
prena1/quatrefolic oral
capsule
Tier 3
VITAMEDMD PLUS
RX/QUATREFOLIC
Tier 3
prenaissance
Tier 3
vp-ch plus
Tier 3
prenaissance 90 dha
Tier 3
vp-ch-pnv
Tier 3
prenaissance balance
Tier 3
vp-heme one
Tier 3
prenaissance dha
Tier 3
ZATEAN-CH
Tier 3
Drug Details
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
129
Drug Name
Drug
Status
ZATEAN-PN DHA
Tier 3
Drug Details
*PRENATAL
VITAMINS**-*PREN
ATAL MV &
MINERALS W/FA***
PRENATE
Tier 3
*PRENATAL
VITAMINS**-*PREN
ATAL VITAMINS***
Drug Name
Drug
Status
carisoprodol oral tablet
350 mg
Tier 1
chlorzoxazone oral
Tier 1
cyclobenzaprine hcl
oral tablet 10 mg, 5 mg
Tier 1
cyclobenzaprine hcl
oral tablet 7.5 mg
Tier 1
ed baclofen
Tier 1
FEXMID
Tier 3
LORZONE
Tier 3
metaxalone
Tier 1
B-NEXA
Tier 3
focalgin-b
Tier 3
prena1/quatrefolic oral
tablet chewable
Tier 3
methocarbamol oral
Tier 1
prenaissance next
Tier 3
orphenadrine citrate er
Tier 1
prenaissance next-b
Tier 3
Tier 3
PRENATE AM
Tier 3
PARAFON FORTE
DSC
VITAMEDMD
REDICHEW RX ORAL
TABLET CHEWABLE
0.6-0.4 MG
ROBAXIN ORAL
Tier 3
ROBAXIN-750
Tier 3
Tier 3
SKELAXIN
Tier 3
SOMA
Tier 3
vp-ggr-b6 prenatal
Tier 3
tizanidine hcl oral
Tier 1
zingiber
Tier 3
ZANAFLEX
Tier 3
*VITAMIN
MIXTURES**-*NIAC
INAMIDE W/
ZINC-COPPER &
FOLIC ACID***
NICOMIDE
*DIRECT MUSCLE
RELAXANTS**-*DIR
ECT MUSCLE
RELAXANTS***
Tier 3
*MUSCULOSKELET
AL THERAPY
AGENTS*
DANTRIUM ORAL
Tier 3
dantrolene sodium oral
Tier 1
*MUSCLE
RELAXANT
COMBINATIONS**-*
MUSCLE
RELAXANT
COMBINATIONS***
*CENTRAL
MUSCLE
RELAXANTS**-*CE
NTRAL MUSCLE
RELAXANTS***
carisoprodol-aspirin
Tier 1
AMRIX
Tier 3
ST; N1
Tier 1
baclofen oral tablet 10
mg
carisoprodol-aspirin-co
deine
Tier 1
LGC
baclofen oral tablet 20
mg
Tier 1
Tier 1
orphenadrine-aspirin-ca
ffeine oral tablet
25-385-30 mg
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
130
Drug Details
LGC
ST; N1
Drug Name
Drug
Status
Drug Details
*MUSCLE
RELAXANT
COMBINATIONS**-*
MUSCLE
RELAXANT-NUTRIT
IONAL
SUPPLEMENT
COMBINATIONS***
THERABENZAPRINE90-5
ipratropium bromide
nasal
BACTROBAN NASAL
Drug Details
Tier 1
Tier 3
ORTHOVISC
Tier 2
PA
SUPARTZ
Tier 3
PA
SYNVISC ONE
Tier 3
PA
*NASAL AGENTS SYSTEMIC AND
TOPICAL*
*NASAL AGENT
COMBINATIONS**-*
ANTIHISTAMINE-ST
EROID***
Tier 3
*NASAL
ANTIALLERGY**-*
NASAL
ANTIHISTAMINES**
*
ASTEPRO
Tier 3
azelastine hcl nasal
solution 0.15 %
Tier 3
azelastine hcl nasal
solution 137 mcg/spray
Tier 1
PATANASE
Tier 3
*NASAL
ANTICHOLINERGIC
S**-*NASAL
ANTICHOLINERGIC
S***
Tier 3
*NASAL
STEROIDS**-*NASA
L STEROIDS***
Tier 3
GEL-ONE
ATROVENT
Drug
Status
*NASAL
ANTI-INFECTIVES*
*-*NASAL
ANTIBIOTICS***
*VISCOSUPPLEMEN
TS**-*VISCOSUPPL
EMENTS***
DYMISTA
Drug Name
BECONASE AQ
Tier 3
ST; N1
budesonide nasal
Tier 3
FLONASE
Tier 3
flunisolide nasal
solution 25 mcg/act
(0.025%)
Tier 1
fluticasone propionate
nasal
Tier 1
NASONEX
Tier 2
OMNARIS
Tier 3
QNASL
Tier 3
ST; N1
RHINOCORT AQUA
Tier 3
ST; N1
triamcinolone acetonide
nasal
Tier 1
VERAMYST
Tier 3
ST; N1
ZETONNA
Tier 3
ST; N1
ST; N1
*SYMPATHOMIMET
IC
DECONGESTANTS*
*-*TOPICAL
DECONGESTANTS*
**
ADRENALIN NASAL
Tier 3
TYZINE
Tier 3
*NEUROMUSCULAR
AGENTS*
*ALS
AGENTS**-*BENZA
THIAZOLES***
Tier 3
RILUTEK
Tier 3
PA; ST; N1
riluzole
Tier 1
PA
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
131
Drug Name
Drug
Status
Drug Name
Drug
Status
*NEUROMUSCULAR
BLOCKING AGENT NEUROTOXINS**-*
NEUROMUSCULAR
BLOCKING AGENT NEUROTOXINS***
carteolol hcl
Tier 1
ISTALOL
Tier 3
levobunolol hcl
ophthalmic solution 0.5
%
Tier 1
BOTOX INJECTION
SOLUTION
RECONSTITUTED 100
UNIT
metipranolol
Tier 3
OPTIPRANOLOL
Tier 3
timolol maleate
ophthalmic
Tier 1
TIMOPTIC
Tier 3
TIMOPTIC OCUDOSE
Tier 3
TIMOPTIC-XE
Tier 3
Tier 2
Drug Details
PA
BOTOX INJECTION
SOLUTION
RECONSTITUTED 200
UNIT
Tier 2
DYSPORT
Tier 3
PA
XEOMIN
Tier 3
PA
*OPHTHALMIC
AGENTS*
*ARTIFICIAL
TEARS AND
LUBRICANTS**-*AR
TIFICIAL TEAR
INSERTS***
LACRISERT
*CYCLOPLEGIC
MYDRIATICS**-*CY
CLOPLEGIC
MYDRIATIC
COMBINATIONS***
CYCLOMYDRIL
Tier 3
*BETA-BLOCKERS OPHTHALMIC**-*B
ETA-BLOCKERS OPHTHALMIC
COMBINATIONS***
Tier 3
*CYCLOPLEGIC
MYDRIATICS**-*CY
CLOPLEGIC
MYDRIATICS***
AK-PENTOLATE
Tier 1
atropine sulfate
ophthalmic solution
Tier 1
atropine-care
Tier 1
CYCLOGYL
OPHTHALMIC
SOLUTION 0.5 %, 2 %
Tier 3
COMBIGAN
Tier 2
COSOPT
Tier 3
COSOPT PF
Tier 3
Tier 1
dorzolamide hcl-timolol
mal
cyclopentolate hcl
ophthalmic
Tier 1
cylate
Tier 1
HOMATROPAIRE
Tier 1
homatropine hbr
ophthalmic
Tier 1
Tier 3
*BETA-BLOCKERS OPHTHALMIC**-*B
ETA-BLOCKERS OPHTHALMIC***
BETAGAN
Tier 3
betaxolol hcl
ophthalmic
Tier 1
ISOPTO
HOMATROPINE
OPHTHALMIC
SOLUTION 2 %
BETIMOL
Tier 3
ISOPTO HYOSCINE
Tier 3
BETOPTIC-S
Tier 3
mydral
Tier 1
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Drug Details
Drug Name
Drug
Status
MYDRIACYL
tropicamide ophthalmic
Drug Name
Drug
Status
Tier 3
apraclonidine hcl
Tier 1
Tier 1
brimonidine tartrate
ophthalmic
Tier 1
IOPIDINE
Tier 3
*MIOTICS**-*MIOT
ICS CHOLINESTERASE
INHIBITORS***
PHOSPHOLINE
IODIDE
Tier 3
*MIOTICS**-*MIOT
ICS - DIRECT
ACTING***
ISOPTO
CARBACHOL
Tier 3
pilocarpine hcl
ophthalmic
Tier 1
PILOPINE HS
Tier 3
*OPHTHALMIC ANGIOGENESIS
INHIBITORS**-*VAS
CULAR
ENDOTHELIAL
GROWTH FACTOR
(VEGF)
ANTAGONISTS***
EYLEA
Tier 2
LUCENTIS
Tier 2
MACUGEN
Tier 3
*OPHTHALMIC
ADRENERGIC
AGENTS**-*ALPHA
ADRENERGIC
AGONIST &
CARBONIC
ANHYDRASE INHIB
COMB***
SIMBRINZA
Tier 3
*OPHTHALMIC
ADRENERGIC
AGENTS**-*OPHTH
ALMIC SELECTIVE
ALPHA
ADRENERGIC
AGONISTS***
ALPHAGAN P
Drug Details
Drug Details
*OPHTHALMIC
ANTI-INFECTIVES*
*-*OPHTHALMIC
ANTIBIOTICS***
QL (6 bottle
per 30 Days)
AZASITE
Tier 2
BESIVANCE
Tier 3
CILOXAN
OPHTHALMIC
OINTMENT
Tier 3
CILOXAN
OPHTHALMIC
SOLUTION
Tier 3
QL (1 ml per 1
Day)
ciprofloxacin hcl
ophthalmic
Tier 1
QL (1 ml per 1
Day)
erythromycin
ophthalmic
Tier 1
GARAMYCIN
OPHTHALMIC
OINTMENT
Tier 1
GARAMYCIN
OPHTHALMIC
SOLUTION
Tier 3
QL (9 bottle
per 30 Days)
gatifloxacin
Tier 1
QL (6 bottle
per 30 Days)
GENTAK
Tier 1
gentamicin sulfate
ophthalmic ointment
Tier 1
gentamicin sulfate
ophthalmic solution
Tier 1
QL (9 bottle
per 30 Days)
gentasol
Tier 1
QL (9 bottle
per 30 Days)
ILOTYCIN
Tier 1
levofloxacin ophthalmic
Tier 1
MITOSOL
Tier 3
MOXEZA
Tier 3
QL (5 bottle
per 30 Days)
Tier 2
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Drug Name
Drug
Status
Drug Details
Drug Name
OCUFLOX
Tier 3
QL (1 ml per 1
Day)
polymyxin
b-trimethoprim
Tier 1
QL (1 ml per 1
Day)
ofloxacin ophthalmic
Tier 1
QL (1 ml per 1
Day)
POLYTRIM
Tier 3
QL (1 ml per 1
Day)
romycin
Tier 1
triple antibiotic
ophthalmic
Tier 1
tobramycin ophthalmic
Tier 1
QL (3 bottle
per 30 Days)
tobrasol
Tier 1
QL (3 bottle
per 30 Days)
TOBREX
OPHTHALMIC
OINTMENT
Tier 3
Tier 3
QL (3 bottle
per 30 Days)
VIGAMOX
Tier 3
QL (5 bottle
per 30 Days)
ZYMAXID
Tier 3
QL (6 bottle
per 30 Days)
*OPHTHALMIC
ANTI-INFECTIVES*
*-*OPHTHALMIC
ANTIFUNGAL***
NATACYN
Tier 3
QL (1 pen per 1
Day)
ak-poly-bac
Tier 1
bacitracin-polymyxin b
ophthalmic
Tier 1
NEO-POLYCIN
Tier 1
neomycin-bacitracin
zn-polymyx
Tier 1
neomycin-polymyxin-gr
amicidin
trifluridine ophthalmic
Tier 1
QL (3 bottle
per 30 Days)
VIROPTIC
Tier 3
QL (3 bottle
per 30 Days)
ZIRGAN
Tier 3
*OPHTHALMIC
ANTI-INFECTIVES*
*-*OPHTHALMIC
SULFONAMIDES***
Tier 1
*OPHTHALMIC
DECONGESTANTS*
*-*OPHTHALMIC
DECONGESTANTS*
**
Tier 1
QL (1 ml per 1
Day)
NEOSPORIN
Tier 3
QL (1 ml per 1
Day)
POLYCIN
Tier 1
polycin b
Tier 1
ALTAFRIN
OPHTHALMIC
SOLUTION 10 %, 2.5
%
Tier 1
NEOFRIN
Tier 1
phenylephrine hcl
ophthalmic solution 10
%, 2.5 %
Tier 1
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Tier 3
*OPHTHALMIC
ANTI-INFECTIVES*
*-*OPHTHALMIC
ANTIVIRALS***
sulfacetamide sodium
ophthalmic solution
*OPHTHALMIC
ANTI-INFECTIVES*
*-*OPHTHALMIC
ANTI-INFECTIVE
COMBINATIONS***
Drug Details
*OPHTHALMIC
ANTI-INFECTIVES*
*-*OPHTHALMIC
ANTISEPTICS***
BETADINE
OPHTHALMIC PREP
TOBREX
OPHTHALMIC
SOLUTION
Drug
Status
QL (3 bottle
per 30 Days)
Drug Name
Drug
Status
Drug Details
*OPHTHALMIC
IMMUNOMODULAT
ORS**-*OPHTHALM
IC
IMMUNOMODULAT
ORS***
RESTASIS
Tier 2
*OPHTHALMIC
LOCAL
ANESTHETICS**-*O
PHTHALMIC
LOCAL
ANESTHETICS***
AKTEN
Tier 3
ALCAINE
Tier 3
ALTACAINE
Tier 1
parcaine
Tier 1
proparacaine hcl
ophthalmic
Tier 1
TETCAINE
Tier 1
tetracaine hcl
ophthalmic
Tier 1
TETRAVISC
Tier 1
TETRAVISC FORTE
Tier 1
*OPHTHALMIC
PHOTODYNAMIC
THERAPY
AGENTS**-*OPHTH
ALMIC
PHOTODYNAMIC
THERAPY
AGENTS***
VISUDYNE
Tier 3
*OPHTHALMIC
STEROIDS**-*OPHT
HALMIC STEROID
COMBINATIONS***
bacitra-neomycin-polym
yxin-hc
Tier 1
BLEPHAMIDE
Tier 3
BLEPHAMIDE S.O.P.
Tier 3
Drug Name
Drug
Status
Drug Details
MAXITROL
OPHTHALMIC
OINTMENT
Tier 3
MAXITROL
OPHTHALMIC
SUSPENSION
Tier 3
NEO-POLYCIN HC
Tier 1
neomycin-polymyxin-de
xameth ophthalmic
ointment
Tier 1
neomycin-polymyxin-de
xameth ophthalmic
suspension
3.5-10000-0.1
Tier 1
poly-dex ophthalmic
ointment
Tier 1
poly-dex ophthalmic
suspension
Tier 1
QL (15 pen per
30 Days)
PRED-G
Tier 3
QL (15 pen per
30 Days)
PRED-G S.O.P.
Tier 3
sulfacetamide-prednisol
one ophthalmic solution
Tier 1
TOBRADEX
OPHTHALMIC
OINTMENT
Tier 3
TOBRADEX
OPHTHALMIC
SUSPENSION
Tier 3
QL (1 pen per 1
Day)
TOBRADEX ST
Tier 3
QL (1 pen per 1
Day)
tobramycin-dexamethas
one
Tier 1
QL (1 pen per 1
Day)
ZYLET
Tier 3
QL (1 pen per 1
Day)
ALREX
Tier 2
QL (45 pen per
30 Days)
dexamethasone sodium
phosphate ophthalmic
Tier 1
QL (15 pen per
30 Days)
QL (15 pen per
30 Days)
*OPHTHALMIC
STEROIDS**-*OPHT
HALMIC
STEROIDS***
QL (1 pen per 1
Day)
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Drug Name
Drug
Status
Drug Details
DUREZOL
Tier 3
FLAREX
Tier 3
FLUOR-OP
Tier 1
QL (45 pen per
30 Days)
fluorometholone
ophthalmic
Tier 1
QL (45 pen per
30 Days)
FML
Tier 3
FML FORTE
Tier 3
QL (45 pen per
30 Days)
FML LIQUIFILM
Tier 3
QL (45 pen per
30 Days)
LOTEMAX
OPHTHALMIC 0.5 %
Tier 2
LOTEMAX
OPHTHALMIC
OINTMENT
Tier 3
LOTEMAX
OPHTHALMIC
SUSPENSION
Tier 2
MAXIDEX
Tier 3
*OPHTHALMICS MISC.**-*OPHTHAL
MIC
ANTIALLERGIC***
ALOMIDE
Tier 3
azelastine hcl
ophthalmic
Tier 1
BEPREVE
Tier 3
cromolyn sodium
ophthalmic
Tier 1
ELESTAT
Tier 3
EMADINE
Tier 3
epinastine hcl
Tier 1
LASTACAFT
Tier 3
OPTIVAR
Tier 3
QL (45 pen per
30 Days)
PATADAY
Tier 2
PATANOL
Tier 3
ST; N1; #
QL (45 pen per
30 Days)
ZADITOR
Tier 1
LGC
QL (45 pen per
30 Days)
OZURDEX
Tier 2
PRED FORTE
Tier 3
QL (45 pen per
30 Days)
PRED MILD
Tier 3
prednisolone acetate
ophthalmic
VEXOL
*OPHTHALMICS MISC.**-*OPHTHAL
MIC CARBONIC
ANHYDRASE
INHIBITORS***
AZOPT
Tier 2
QL (45 pen per
30 Days)
dorzolamide hcl
Tier 1
TRUSOPT
Tier 3
Tier 1
QL (45 pen per
30 Days)
Tier 3
QL (45 pen per
30 Days)
*OPHTHALMICS MISC.**-*OPHTHAL
MIC DIAGNOSTIC
PRODUCTS***
*OPHTHALMIC
SURGICAL
AIDS**-*OPHTHAL
MIC SURGICAL
AIDS***
Tier 3
Drug Details
Tier 3
Tier 3
ALTAFLUOR
Tier 1
BIO GLO
Tier 1
FLUCAINE
Tier 1
FLUOR-I-STRIPS A.T.
Tier 1
fluorescein-benoxinate
Tier 1
FLURA-SAFE
Tier 3
FLUROX
Tier 1
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Drug
Status
ALOCRIL
OMNIPRED
GELFILM
OPHTHALMIC
Drug Name
Drug Name
Drug
Status
FUL-GLO
OPHTHALMIC STRIP
0.6 MG
Tier 3
FUL-GLO
OPHTHALMIC STRIP
1 MG
Tier 1
PAREMYD
Tier 3
proparacaine-fluorescei
n
Tier 1
ROSE GLO
Drug Details
Drug
Status
Drug Details
CYSTARAN
Tier 3
PA
latanoprost
Tier 1
QL (3 ML per
1 fill)
LUMIGAN
OPHTHALMIC
SOLUTION 0.01 %
Tier 3
ST; N1; QL (3
ML per 30
days)
RESCULA
Tier 3
ST; N1; QL (1
bottle per 1 fill)
TRAVATAN Z
Tier 2
QL (90 days
maximum per 1
fill)
travoprost
Tier 3
ST; N1; QL (3
ML per 1 fill)
XALATAN
Tier 3
ST; N1; QL (3
ML per 1 fill)
ZIOPTAN
Tier 3
ST; N1; QL (1
unit per 1 day)
*PROSTAGLANDINS
OPHTHALMIC**-*P
ROSTAGLANDINS OPHTHALMIC***
Tier 3
*OPHTHALMICS MISC.**-*OPHTHAL
MIC ENZYMES***
JETREA
Drug Name
Tier 2
*OPHTHALMICS MISC.**-*OPHTHAL
MIC
NONSTEROIDAL
ANTI-INFLAMMAT
ORY AGENTS***
ACULAR
Tier 3
QL (1 ml per 1
Day)
ACULAR LS
Tier 3
QL (1 ml per 1
Day)
*OTIC AGENTS*
*OTIC AGENTS MISCELLANEOUS**
-*OTIC AGENTS MISCELLANEOUS**
*
ACUVAIL
Tier 3
QL (4 ml per 1
Day)
diclofenac sodium
ophthalmic
Tier 1
QL (6 bottle
per 30 Days)
Tier 1
Tier 1
QL (6 bottle
per 30 Days)
acetic acid otic
flurbiprofen sodium
CRESYLATE
Tier 3
ILEVRO
Tier 3
QL (15 pen per
30 Days)
ketorolac tromethamine
ophthalmic
Tier 1
QL (1 ml per 1
Day)
*OTIC
ANALGESICS**-*OT
IC ANALGESICS***
NEVANAC
Tier 3
QL (15 pen per
30 Days)
OCUFEN
Tier 3
QL (6 bottle
per 30 Days)
PROLENSA
Tier 3
*OPHTHALMICS MISC.**-*OPHTHAL
MICS - CYSTINOSIS
AGENTS**
pinnacaine otic
Tier 3
RE BENZOTIC
Tier 3
*OTIC
ANTI-INFECTIVES*
*-*OTIC
ANTI-INFECTIVES*
**
CETRAXAL
Tier 3
ofloxacin otic
Tier 1
QL (2 ml per 1
Day)
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Drug Name
Drug
Status
*OTIC
COMBINATIONS**-*
OTIC ANALGESIC
COMBINATIONS***
Drug Details
Drug Name
Drug
Status
Drug Details
antibiotic ear
Tier 1
QL (2 ml per 1
Day)
CIPRO HC
Tier 3
#; QL (2 pen
per 1 Day)
CIPRODEX
Tier 2
QL (45 pen per
30 Days)
COLY-MYCIN S
Tier 3
QL (1 pen per 1
Day)
CORTISPORIN OTIC
Tier 3
QL (2 ml per 1
Day)
CORTISPORIN-TC
Tier 3
QL (1 pen per 1
Day)
QL (2 pen per 1
Day)
a/b otic
Tier 1
AERO OTIC HC
Tier 1
antipyrine-benzocaine
Tier 1
AURALGAN OTIC
SOLUTION
Tier 3
aurax
Tier 1
AURODEX
Tier 1
AUROGUARD
Tier 1
auroto
Tier 1
cortomycin
Tier 1
CORTANE-B OTIC
Tier 3
CORTIC-ND
Tier 1
neomycin-polymyxin-hc
otic solution 1 %
Tier 1
CYOTIC
Tier 1
exotic-hc
Tier 1
Tier 1
QL (2 ml per 1
Day)
MYOXIN
Tier 3
neomycin-polymyxin-hc
otic solution
3.5-10000-1
otic care
Tier 1
neomycin-polymyxin-hc
otic suspension
Tier 1
QL (2 pen per 1
Day)
otic edge
Tier 3
oticin
Tier 1
OTICIN HC NR
Tier 3
*OTIC
STEROIDS**-*OTIC
STEROIDS***
OTIRX
Tier 1
ACETASOL HC
Tier 1
oto-end 10
Tier 1
DERMOTIC
Tier 3
otomar
Tier 1
Tier 1
otomax-hc
Tier 1
fluocinolone acetonide
otic
OTOZIN
Tier 3
hydrocortisone-acetic
acid
Tier 1
pramoxine-chloroxyleno
l
Tier 1
VOSOL HC
Tier 3
pramoxine-hc-chloroxyl
enol aq
Tier 1
re pramoxine-hc
Tier 1
zotane hc
Tier 1
*OTIC
COMBINATIONS**-*
OTIC
STEROID-ANTI-INF
ECTIVE
COMBINATIONS***
*OXYTOCICS*
*ABORTIFACIENTS/
AGENTS FOR
CERVICAL
RIPENING**-*ABOR
TIFACIENTS/CERVI
CAL RIPENING PROSTAGLANDINS*
**
CERVIDIL
Tier 3
PREPIDIL
Tier 3
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
138
Drug Name
Drug
Status
PROSTIN E2
Tier 3
Drug Details
Drug
Status
Drug Details
GAMUNEX
INTRAVENOUS*
SOLUTION 20
GM/200ML
Tier 3
PA
HEPAGAM B
Tier 2
*PASSIVE
IMMUNIZING
AGENTS*
HIZENTRA
Tier 3
PA
HIZENTRA 20%
Tier 3
PA
HYPERHEP B S/D
Tier 3
*IMMUNE
SERUMS**-*IMMUN
E SERUMS***
HYPERRHO S/D
Tier 3
HYPERTET S/D
Tier 2
PA
MICRHOGAM
ULTRA-FILTERED
PLUS
Tier 3
PA
NABI-HB
Tier 3
OCTAGAM
INTRAVENOUS*
SOLUTION 1
GM/20ML, 10
GM/200ML, 2.5
GM/50ML, 25
GM/500ML, 5
GM/100ML
Tier 3
PA
PRIVIGEN
INTRAVENOUS*
SOLUTION 20
GM/200ML, 40
GM/400ML
Tier 3
PA
RHOGAM
ULTRA-FILTERED
PLUS
Tier 3
RHOPHYLAC
Tier 2
*OXYTOCICS**-*OX
YTOCICS***
methylergonovine
maleate oral
Tier 1
CARIMUNE NF
Tier 3
CYTOGAM
Tier 2
FLEBOGAMMA
Tier 3
FLEBOGAMMA DIF
INTRAVENOUS*
SOLUTION 0.5
GM/10ML, 10
GM/200ML, 2.5
GM/50ML, 20
GM/200ML, 20
GM/400ML, 5
GM/100ML
Tier 3
PA
GAMASTAN S/D
Tier 3
PA
GAMMAGARD
INJECTION
SOLUTION 30
GM/300ML
Tier 3
GAMMAGARD S/D
INTRAVENOUS*
SOLUTION
RECONSTITUTED 10
GM, 2.5 GM, 5 GM
Tier 3
GAMMAGARD S/D
LESS IGA
Tier 3
GAMMAPLEX
INTRAVENOUS*
SOLUTION 10
GM/200ML, 2.5
GM/50ML, 5
GM/100ML
Tier 3
PA
PA
Drug Name
VARIZIG
Tier 3
WINRHO SDF
Tier 3
PA
PA
QL (30 days
maximum per 1
fill)
*MONOCLONAL
ANTIBODIES**-*AN
TIVIRAL
MONOCLONAL
ANTIBODIES***
SYNAGIS
Tier 2
PA
*PENICILLINS*
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
139
Drug Name
Drug
Status
*AMINOPENICILLI
NS**-*AMINOPENIC
ILLINS***
Tier 1
amoxicillin oral
suspension reconstituted
Tier 1
amoxicillin oral tablet
Tier 1
ampicillin oral capsule
Tier 1
MOXATAG
Tier 3
*NATURAL
PENICILLINS**-*NA
TURAL
PENICILLINS***
amoxicillin-pot
clavulanate er
Tier 1
Tier 1
AUGMENTIN ORAL
SUSPENSION
RECONSTITUTED
Tier 3
AUGMENTIN ORAL
TABLET 500-125 MG,
875-125 MG
Tier 3
AUGMENTIN ES-600
Tier 3
AUGMENTIN XR
Tier 3
*PENICILLINASE-R
ESISTANT
PENICILLINS**-*PE
NICILLINASE-RESIS
TANT
PENICILLINS***
dicloxacillin sodium
*PHARMACEUTICA
L ADJUVANTS*
Tier 1
Drug Details
Tier 3
*SEMI SOLID
VEHICLES**-*SEMI
SOLID
VEHICLES***
polyethylene glycol
3350 powder
Tier 1
LGC
*PROGESTINS*
*PROGESTINS**-*P
ROGESTINS***
AYGESTIN
Tier 3
MAKENA
Tier 3
PA; QL (5 vial
per 365 Days)
medroxyprogesterone
acetate oral
Tier 1
LGC
MEGACE ES
Tier 3
norethindrone acetate
oral
Tier 1
progesterone
intramuscular*
Tier 1
progesterone
micronized oral
Tier 1
PROMETRIUM
Tier 3
PROVERA
Tier 3
*PSYCHOTHERAPE
UTIC AND
NEUROLOGICAL
AGENTS - MISC.*
*AGENTS FOR
CHEMICAL
DEPENDENCY**-*A
LCOHOL
DETERRENTS***
acamprosate calcium
Tier 1
ANTABUSE
Tier 3
CAMPRAL
Tier 3
disulfiram oral
Tier 1
*LIQUID
VEHICLES**-*ORAL
VEHICLES***
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
140
Drug
Status
Tier 1
*PENICILLIN
COMBINATIONS**-*
PENICILLIN
COMBINATIONS***
amoxicillin-pot
clavulanate oral
Drug Name
PCCA ACACIA
SYRUP BASE
amoxicillin oral capsule
penicillin v potassium
Drug Details
Drug Name
Drug
Status
Drug Details
*ANTI-CATAPLECTI
C
AGENTS**-*ANTI-C
ATAPLECTIC
AGENTS***
XYREM
Drug
Status
Drug Details
*COMBINATION
PSYCHOTHERAPEU
TICS**-*THIENBEN
ZODIAZEPINES &
SSRIS***
Tier 3
PA; QL (18 ml
per 1 Day)
*ANTIDEMENTIA
AGENTS**-*CHOLI
NOMIMETICS ACHE
INHIBITORS***
ARICEPT
Tier 3
ST; N1
ARICEPT ODT
Tier 3
ST; N1
donepezil hcl
Tier 1
EXELON ORAL
CAPSULE
Tier 3
EXELON ORAL
SOLUTION
Tier 2
EXELON
TRANSDERMAL
Tier 2
galantamine
hydrobromide
Tier 1
galantamine
hydrobromide er
Tier 1
RAZADYNE
Tier 3
RAZADYNE ER
Tier 3
rivastigmine tartrate
Tier 1
Tier 2
olanzapine-fluoxetine
hcl
Tier 1
QL (1 caps per
1 Day)
SYMBYAX
Tier 3
QL (1 caps per
1 Day)
SAVELLA
Tier 3
PA; ST; N1;
QL (2 tab per 1
day)
SAVELLA
TITRATION PACK
Tier 2
PA; ST; QL
(55 EA per 30
Days)
XENAZINE ORAL
TABLET 12.5 MG
Tier 2
PA; #; QL (4
tab per 1 Day)
XENAZINE ORAL
TABLET 25 MG
Tier 2
PA; #; QL (2
tab per 1 Day)
Tier 3
PA; QL (1 tab
per 1 Day)
Tier 3
PA
*FIBROMYALGIA
AGENTS**-*FIBRO
MYALGIA AGENT SNRIS***
*MOVEMENT
DISORDER DRUG
THERAPY**-*MOVE
MENT DISORDER
DRUG THERAPY***
*MULTIPLE
SCLEROSIS
AGENTS**-*MS
AGENTS PYRIMIDINE
SYNTHESIS
INHIBITORS***
*ANTIDEMENTIA
AGENTS**-*N-MET
HYL-D-ASPARTATE
(NMDA) RECEPTOR
ANTAGONISTS***
NAMENDA
Drug Name
#
AUBAGIO
NAMENDA
TITRATION PAK
Tier 2
#
NAMENDA XR
Tier 2
#
NAMENDA XR
TITRATION PACK
Tier 2
#
*MULTIPLE
SCLEROSIS
AGENTS**-*MULTI
PLE SCLEROSIS
AGENTS INTERFERONS***
AVONEX
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141
Drug Name
Drug
Status
Drug Details
Drug Name
AVONEX PEN
Tier 3
PA
AVONEX PREFILLED
Tier 3
PA
Tier 3
BETASERON
Tier 3
PA
COPAXONE
SUBCUTANEOUS* 40
MG/ML
EXTAVIA
Tier 3
PA
Tier 2
PA; #
REBIF
Tier 2
PA
COPAXONE
SUBCUTANEOUS*
KIT
REBIF REBIDOSE
Tier 2
PA
REBIF REBIDOSE
TITRATION PACK
Tier 2
PA
REBIF TITRATION
PACK
Tier 2
PA
Tier 3
PA; QL (1 caps
per 1 Day)
Tier 3
PA; ST; N1;
QL (5 tab per 1
day)
GRALISE ORAL
TABLET 600 MG
Tier 3
PA; ST; N1;
QL (3 tab per 1
day)
GRALISE STARTER
Tier 3
PA; ST; QL (1
pack per 365
Days)
fluoxetine hcl (pmdd)
Tier 1
QL (14 caps
per 30 Days)
SARAFEM ORAL
TABLET 10 MG, 20
MG
Tier 3
QL (14 tab per
30 Days)
SELFEMRA
Tier 1
QL (14 caps
per 30 Days)
*MULTIPLE
SCLEROSIS
AGENTS**-*MULTI
PLE SCLEROSIS
AGENTS MONOCLONAL
ANTIBODIES***
TYSABRI
PA
*MULTIPLE
SCLEROSIS
AGENTS**-*MULTI
PLE SCLEROSIS
AGENTS - NRF2
PATHWAY
ACTIVATORS***
TECFIDERA
TECFIDERA ORAL
120 & 240 MG
Tier 3
PA; ST; N1
PA; ST; N1
*MULTIPLE
SCLEROSIS
AGENTS**-*MULTI
PLE SCLEROSIS
AGENTS POTASSIUM
CHANNEL
BLOCKERS***
AMPYRA
*MULTIPLE
SCLEROSIS
AGENTS**-*MULTI
PLE SCLEROSIS
AGENTS***
*POSTHERPETIC
NEURALGIA (PHN)
AGENTS**-*POSTH
ERPETIC
NEURALGIA (PHN)
AGENTS***
GRALISE ORAL
TABLET 300 MG
Tier 3
*PREMENSTRUAL
DYSPHORIC
DISORDER (PMDD)
AGENTS**-*PREME
NSTRUAL
DYSPHORIC
DISORDER (PMDD)
AGENTS - SSRIS***
Tier 3
PA; QL (2 tab
per 1 Day)
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Drug Details
*MULTIPLE
SCLEROSIS
AGENTS**-*SPHING
OSINE
1-PHOSPHATE (S1P)
RECEPTOR
MODULATORS***
GILENYA
Tier 3
Drug
Status
Drug Name
Drug
Status
Drug Details
*PSEUDOBULBAR
AFFECT (PBA)
AGENTS**-*PSEUD
OBULBAR AFFECT
AGENT
COMBINATIONS***
NUEDEXTA
Tier 3
PA; QL (2 caps
per 1 Day)
ZEMAIRA
Tier 3
PA
Tier 3
PA; QL (2 tab
per 1 Day)
Tier 2
PA
*CYSTIC FIBROSIS
AGENTS**-*HYDRO
LYTIC ENZYMES***
PULMOZYME
*PLEURAL
SCLEROSING
AGENTS**-*PLEUR
AL SCLEROSING
AGENTS***
Tier 3
Tier 3
PA; ST; N1;
QL (2 tab per 1
day)
*VASOMOTOR
SYMPTOM
AGENTS**-*VASOM
OTOR SYMPTOM
AGENTS - SSRIS***
BRISDELLE
Drug Details
KALYDECO
*RESTLESS LEG
SYNDROME (RLS)
AGENTS**-*RESTLE
SS LEG SYNDROME
(RLS) AGENTS***
HORIZANT
Drug
Status
*CYSTIC FIBROSIS
AGENTS**-*CFTR
POTENTIATORS***
*PSYCHOTHERAPE
UTIC AND
NEUROLOGICAL
AGENTS MISC.**-*PSYCHOT
HERAPEUTIC AND
NEUROLOGICAL
AGENTS - MISC.***
ORAP
Drug Name
SCLEROSOL
INTRAPLEURAL
Tier 3
STERILE TALC
POWDER
Tier 3
*RESPIRATORY
AGENTS MISC.**-*RESPIRAT
ORY AGENTS MISC.***
CUROSURF
Tier 3
INFASURF
Tier 3
*TETRACYCLINES*
Tier 3
ST; N1
*RESPIRATORY
AGENTS - MISC.*
*ALPHA-PROTEINA
SE INHIBITOR
(HUMAN)**-*ALPHA
-PROTEINASE
INHIBITOR
(HUMAN)***
*TETRACYCLINE
COMBINATIONS**-*
TETRACYCLINE
COMBINATIONS***
NICAZELDOXY 30
Tier 3
NICAZELDOXY 60
Tier 3
*TETRACYCLINES*
*-*TETRACYCLINE
S***
ADOXA
Tier 3
PA
ARALAST
Tier 3
PA
ADOXA PAK 1/100
Tier 3
PA
ARALAST NP
Tier 3
PA
ADOXA PAK 1/150
Tier 3
PA
GLASSIA
Tier 3
PA
ADOXA PAK 2/100
Tier 3
PA
PROLASTIN
Tier 3
PA
avidoxy
Tier 1
PA
PROLASTIN-C
Tier 3
PA
demeclocycline hcl oral
Tier 1
PA
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Drug Name
Drug
Status
Drug Details
Drug Name
Drug
Status
ARMOUR THYROID
ORAL TABLET 120
MG, 15 MG, 180 MG,
240 MG, 300 MG
Tier 3
CYTOMEL
Tier 3
LEVOTHROID
Tier 1
Tier 1
DORYX ORAL
TABLET DELAYED
RELEASE 150 MG,
200 MG
Tier 3
PA
doxycycline hyclate oral
capsule
Tier 1
PA; LGC
doxycycline hyclate oral
tablet 100 mg
Tier 1
PA; LGC
doxycycline hyclate oral
tablet 20 mg
Tier 1
PA
doxycycline hyclate oral
tablet delayed release
Tier 1
PA
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
doxycycline
monohydrate
Tier 1
PA
levothyroxine sodium
oral tablet 300 mcg
Tier 1
LEVOXYL
Tier 1
MINOCIN ORAL
CAPSULE 100 MG, 50
MG
Tier 3
PA
liothyronine sodium
oral
Tier 1
minocycline hcl oral
Tier 1
PA
NATURE-THROID
Tier 3
minocycline hcl er
Tier 1
PA
np thyroid
Tier 1
MONODOX ORAL
CAPSULE 100 MG, 75
MG
SYNTHROID
Tier 3
Tier 3
PA
THYROLAR-1
Tier 3
MORGIDOX ORAL
Tier 1
PA
THYROLAR-1/2
Tier 3
THYROLAR-1/4
Tier 3
THYROLAR-2
Tier 3
THYROLAR-3
Tier 3
TIROSINT
Tier 3
UNITHROID
Tier 1
UNITHROID DIRECT
Tier 1
WESTHROID
Tier 3
WESTHROID-P
Tier 3
Tier 3
SOLODYN ORAL
TABLET EXTENDED
RELEASE 24 HR* 105
MG, 115 MG, 55 MG,
65 MG, 80 MG
Tier 3
tetracycline hcl oral
Tier 1
LGC
VIBRAMYCIN
Tier 3
PA
*THYROID
AGENTS*
PA
methimazole oral
Tier 1
WP THYROID ORAL
TABLET 113.75 MG,
130 MG, 16.25 MG,
32.5 MG, 48.75 MG, 65
MG, 97.5 MG
propylthiouracil oral
Tier 1
*ULCER DRUGS*
TAPAZOLE
Tier 3
*ANTISPASMODICS
**-*ANTICHOLINER
GIC
COMBINATIONS***
*ANTITHYROID
AGENTS**-*ANTITH
YROID AGENTS***
*THYROID
HORMONES**-*TH
YROID
HORMONES***
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Drug Details
LGC
Drug Name
Drug
Status
clidinium-chlordiazepox
ide
Tier 1
DONNATAL
Tier 3
DONNATAL
EXTENTABS
Tier 3
GASTRINEX NF
Tier 3
re
chlordiazepoxide/clidini
um
Drug Details
*ANTISPASMODICS
**-*ANTISPASMODI
CS***
Tier 3
BENTYL ORAL
TABLET
Tier 3
dicyclomine hcl oral
capsule
Tier 1
dicyclomine hcl oral
tablet
Tier 1
*ANTISPASMODICS
**-*BELLADONNA
ALKALOIDS***
colidrops
Tier 1
ed-spaz
Tier 1
HYOMAX
Tier 1
HYOMAX-FT
Tier 1
HYOMAX-SL
Tier 1
HYOMAX-SR
Tier 1
Drug
Status
SYMAX-SL
Tier 1
SYMAX-SR
Tier 1
Drug Details
*ANTISPASMODICS
**-*QUATERNARY
ANTICHOLINERGIC
S***
Tier 1
BENTYL ORAL
CAPSULE
Drug Name
LGC
LGC
CANTIL
Tier 3
CUVPOSA
Tier 3
GLYCATE
Tier 3
glycopyrrolate oral
Tier 1
methscopolamine
bromide oral
Tier 1
PAMINE
Tier 3
PAMINE FORTE
Tier 3
ROBINUL ORAL
Tier 3
ROBINUL-FORTE
Tier 3
ST; N1
*H-2
ANTAGONISTS**-*H
-2 ANTAGONISTS***
acid reducer maximum
strength oral tablet 20
mg
Tier 1
AXID ORAL
CAPSULE 300 MG
Tier 3
AXID ORAL
SOLUTION
Tier 3
cimetidine oral tablet
300 mg, 400 mg
Tier 1
cimetidine oral tablet
800 mg
Tier 1
cimetidine hcl oral
Tier 1
hyoscyamine sulfate
oral
Tier 1
hyoscyamine sulfate
sublingual
Tier 1
famotidine oral
suspension reconstituted
Tier 1
hyoscyamine sulfate er
Tier 1
hyosyne
Tier 1
famotidine oral tablet
40 mg
Tier 1
NULEV
Tier 1
nizatidine
Tier 1
oscimin
Tier 1
oscimin sr
Tier 1
Tier 3
SYMAX DUOTAB
Tier 3
PEPCID ORAL
SUSPENSION
RECONSTITUTED
SYMAX FASTABS
Tier 1
PEPCID ORAL
TABLET 40 MG
Tier 3
LGC
LGC
LGC
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145
Drug Name
Drug
Status
ranitidine hcl oral
capsule 300 mg
Tier 1
ranitidine hcl oral syrup
Tier 1
ranitidine hcl oral tablet
300 mg
Tier 1
Drug Details
LGC
*MISC.
ANTI-ULCER**-*MI
SC. ANTI-ULCER***
CARAFATE
Tier 3
sucralfate oral tablet
Tier 1
*PROTON PUMP
INHIBITORS**-*PR
OTON PUMP
INHIBITORS***
ACIPHEX
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
ACIPHEX SPRINKLE
Tier 3
ST; N1; QL (1
caps per 1 Day)
DEXILANT
Tier 2
QL (1 caps per
1 Day)
esomeprazole strontium
oral capsule delayed
release 49.3 mg
Tier 3
PA; ST; N1;
QL (1 caps per
1 Day)
kp omeprazole
magnesium
Tier 1
LGC
lansoprazole oral
capsule delayed release
30 mg
Tier 1
QL (1 caps per
1 Day)
NEXIUM
Tier 2
#; QL (1 caps
per 1 Day)
omeprazole oral capsule
delayed release 10 mg,
40 mg
Tier 1
QL (1 caps per
1 Day)
omeprazole oral capsule
delayed release 20 mg
Tier 1
LGC; QL (1
caps per 1 Day)
pantoprazole sodium
oral
Tier 1
QL (1 tab per 1
Day)
Tier 3
PA; ST; N1;
QL (1 caps per
1 Day)
PREVACID ORAL
CAPSULE DELAYED
RELEASE 30 MG
Drug Name
Drug
Status
PREVACID SOLUTAB
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
PRILOSEC ORAL
CAPSULE DELAYED
RELEASE
Tier 3
PA; ST; N1;
QL (1 caps per
1 Day)
PRILOSEC ORAL
PACKET
Tier 3
PA; ST; N1;
QL (2 pack per
1 Day)
PRILOSEC OTC
Tier 1
LGC
PROTONIX ORAL
Tier 3
PA; ST; N1;
QL (1 pack per
1 Day)
PROTONIX ORAL
Tier 3
PA; ST; N1;
QL (1 tab per 1
Day)
rabeprazole sodium
Tier 1
QL (1 tab per 1
Day)
*ULCER DRUGS PROSTAGLANDINS*
*-*ULCER DRUGS PROSTAGLANDINS*
**
CYTOTEC
Tier 3
misoprostol oral
Tier 1
*ULCER THERAPY
COMBINATIONS**-*
PROTON PUMP
INHIBITOR-ANTACI
D
COMBINATIONS***
omeprazole-sodium
bicarbonate oral
capsule 40-1100 mg
Tier 1
QL (1 caps per
1 Day)
ZEGERID ORAL
CAPSULE 40-1100 MG
Tier 3
PA; ST; N1;
QL (1 caps per
1 Day)
Tier 3
PA; ST; N1;
QL (1 pack per
1 Day)
ZEGERID ORAL
PACKET
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Drug Details
Drug Name
Drug
Status
Drug Details
*ULCER THERAPY
COMBINATIONS**-*
ULCER
ANTI-INFECTIVE
W/ BISMUTH
COMBINATIONS***
PYLERA
Drug Name
Drug
Status
UTA
Tier 1
uticap
Tier 1
UTIRA-C
Tier 1
UTRONA-C
Tier 1
*URINARY
ANTI-INFECTIVES*
*-*URINARY
ANTI-INFECTIVES*
**
Tier 2
*ULCER THERAPY
COMBINATIONS**-*
ULCER
ANTI-INFECTIVE
W/ PROTON PUMP
INHIBITORS***
FURADANTIN
Tier 3
HIPREX
Tier 3
MACROBID
Tier 3
amoxicill-clarithro-lans
opraz
Tier 1
MACRODANTIN
Tier 3
OMECLAMOX-PAK
Tier 2
methenamine hippurate
Tier 1
PREVPAC
Tier 3
methenamine mandelate
oral tablet 1 gm
Tier 1
MONUROL
Tier 3
nitrofurantoin
Tier 1
nitrofurantoin
macrocrystal oral
Tier 1
nitrofurantoin monohyd
macro
Tier 1
UREX
Tier 3
*URINARY
ANTI-INFECTIVES*
*URINARY
ANTI-INFECTIVE
COMBINATIONS**-*
METHENAMINE
COMBOS***
UROQID #2
Tier 3
*URINARY
ANTI-INFECTIVE
COMBINATIONS**-*
URINARY
ANTISEPTIC-ANTIS
PASMODIC &/OR
ANALGESICS***
Drug Details
PA; ST; N1
*URINARY
ANTISPASMODICS*
HYOPHEN
Tier 1
phosenamine
Tier 1
PHOSPHASAL
Tier 1
ur n-c
Tier 1
URELLE
Tier 3
URIBEL
Tier 3
URIMAR-T
Tier 3
urin ds
*URINARY
ANTISPASMODIC ANTIMUSCARINICS
(ANTICHOLINERGI
C)**-*URINARY
ANTISPASMODIC ANTIMUSCARINIC
(ANTICHOLINERGI
C)***
DETROL LA
Tier 3
ST; N1; QL (1
capsule per 1
day)
Tier 1
LGC
Tier 1
oxybutynin chloride oral
tablet
URYL
Tier 1
OXYTROL
Tier 3
PA; ST
USTELL
Tier 1
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147
Drug Name
Drug
Status
SANCTURA
Tier 3
ST; N1; QL (2
tablets per 1
day)
Tier 1
QL (1 tablet per
1 day)
Tier 2
ST; N1; QL (1
tablet per 1
day)
tolterodine tartrate er
VESICARE
Drug Details
*URINARY
ANTISPASMODICS BETA-3
ADRENERGIC
AGONISTS**-*URIN
ARY
ANTISPASMODICS BETA-3
ADRENERGIC
AGONISTS***
MYRBETRIQ
Tier 2
ST; N1; QL (1
tablet per 1
day)
Tier 1
*URINARY
ANTISPASMODICS*
*-*URINARY
ANTISPASMODICS*
**
DITROPAN XL ORAL
TABLET EXTENDED
RELEASE 24 HR* 10
MG, 15 MG
DITROPAN XL ORAL
TABLET EXTENDED
RELEASE 24 HR* 5
MG
Drug
Status
oxybutynin chloride er
Tier 1
QL (2 tablets
per 1 day)
trospium chloride
Tier 1
QL (2 capsules
per 1 day)
trospium chloride er
Tier 1
QL (1 capsule
per 1 day)
*VAGINAL
PRODUCTS*
Tier 3
ST; N1; QL (2
tablets per 1
day)
Tier 3
ST; N1; QL (1
tablet per 1
day)
FEM PH
Tier 3
RELAGARD
Tier 3
*SPERMICIDES**-*S
PERMICIDES***
ENCARE VAGINAL
SUPPOSITORY
Tier 3
PA
GYNOL II
Tier 3
PA; QL (30
tubes per 3
days)
GYNOL II EXTRA
STRENGTH
Tier 3
PA
OPTIONS
CONCEPTROL
Tier 3
PA
OPTIONS GYNOL II
CONTRACEPTIVE
Tier 3
PA
SHUR-SEAL
CONTRACEPTIVE
Tier 3
PA
VCF VAGINAL
CONTRACEPTIVE
Tier 3
PA
*VAGINAL
ANTI-INFECTIVES*
*-*IMIDAZOLE-REL
ATED
ANTIFUNGALS***
GYNAZOLE-1
Tier 3
TERAZOL 3
Tier 3
TERAZOL 7
Tier 3
terconazole
Tier 1
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Drug Details
*MISCELLANEOUS
VAGINAL
PRODUCTS**-*MIS
CELLANEOUS
VAGINAL
COMBINATIONS***
*URINARY
ANTISPASMODICS CHOLINERGIC
AGONISTS**-*URIN
ARY
ANTISPASMODICS CHOLINERGIC
AGONISTS***
bethanechol chloride
oral tablet 25 mg
Drug Name
Drug Name
Drug
Status
ZAZOLE
Tier 1
Drug Details
*VAGINAL
ANTI-INFECTIVES*
*-*VAGINAL
ANTI-INFECTIVES*
**
Drug
Status
FIRST-PROGESTERO
NE VGS 50
Tier 3
PROCHIEVE
VAGINAL 4 %
Tier 2
Drug Details
*VASOPRESSORS*
AVC VAGINAL
Tier 3
CLEOCIN VAGINAL
Tier 3
clindamycin phosphate
vaginal
Tier 1
CLINDESSE
Tier 3
METROGEL-VAGINA
L
Tier 3
metronidazole vaginal
Tier 1
VANDAZOLE
Tier 1
*ANAPHYLAXIS
THERAPY
AGENTS**-*ANAPH
YLAXIS THERAPY
AGENTS***
*VAGINAL
ESTROGENS**-*VA
GINAL
ESTROGENS***
ESTRACE VAGINAL
Tier 3
ESTRING
Tier 3
FEMRING
Drug Name
Tier 3
PREMARIN
VAGINAL
Tier 2
VAGIFEM
Tier 3
*VAGINAL
PROGESTINS**-*VA
GINAL
PROGESTINS***
#; QL (1 ring
per 90 days)
ADRENACLICK
Tier 3
PA; ST; N1;
QL (2 doses per
1 fill)
AUVI-Q
Tier 2
QL (2 doses per
1 fill)
EPIPEN 2-PAK
Tier 2
N1; QL (2
doses per 1 fill)
EPIPEN JR
Tier 2
QL (2 doses per
1 fill)
EPIPEN JR 2-PAK
Tier 2
N1; #; QL (2
doses per 1 fill)
TWINJECT
Tier 3
QL (2 doses per
1 fill)
*VASOPRESSORS***VASOPRESSORS**
*
midodrine hcl
Tier 1
*VITAMINS*
*OIL SOLUBLE
VITAMINS**-*VITA
MIN D***
CRINONE
Tier 2
ENDOMETRIN
Tier 2
FIRST-PROGESTERO
NE VGS 100
DRISDOL ORAL
CAPSULE
Tier 3
Tier 3
ergocalciferol oral
capsule
Tier 1
FIRST-PROGESTERO
NE VGS 200
Tier 3
vitamin d
(ergocalciferol)
Tier 1
FIRST-PROGESTERO
NE VGS 25
Tier 3
FIRST-PROGESTERO
NE VGS 400
Tier 3
*OIL SOLUBLE
VITAMINS**-*VITA
MIN K***
MEPHYTON
Tier 2
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149
Drug Name
Drug
Status
Drug Details
*WATER SOLUBLE
VITAMINS**-*PABA
***
POTABA
Tier 3
*WATER SOLUBLE
VITAMINS**-*VITA
MIN B-3***
cvs niacin
Tier 1
ENDUR-ACIN
Tier 1
eql niacin
Tier 1
gnp niacin
Tier 1
gnp niacin tr
Tier 1
hm niacin
Tier 1
niacin oral tablet
Tier 1
niacin er oral capsule
extended release*
Tier 1
niacin er oral tablet
extendedrelease* 250
mg, 500 mg, 750 mg
Tier 1
niacin-50
Tier 1
px niacin
Tier 1
ra niacin
Tier 1
ra no flush niacin
Tier 1
SLO-NIACIN ORAL
TABLET
EXTENDEDRELEASE
* 250 MG
Tier 1
SLO-NIACIN ORAL
TABLET
EXTENDEDRELEASE
* 500 MG, 750 MG
Tier 3
sm niacin cr
Tier 1
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Index
Index
Index
Index
1st choice lancets super thin
ACCU-CHEK COMPACT PLUS
acetaminophen-codeine #4
CONTROL ................................................................. 98 ....................................................................................................... 11
1st choice lancets thin
ACCU-CHEK COMPACT TEST
ACETASOL HC
....................................................................................................... 98
DRUM .............................................................................. 73 ................................................................................................... 138
1st choice lancets ultra thin
ACCU-CHEK FASTCLIX
acetazolamide
....................................................................................................... 98
LANCET ....................................................................... 99 ....................................................................................................... 81
1st choice pen needles
ACCU-CHEK FASTCLIX
acetazolamide er
................................................................................................... 112
LANCETS .................................................................. 99 ....................................................................................................... 81
1st tier unifine pentips
ACCU-CHEK INSTANT
ACETEST ................................................................... 73
................................................................................................... 112
CONTROL ................................................................. 99 acetic acid ................................................. 90, 137
1st tier unifine pentips plus
ACCU-CHEK MULTICLIX
acetylcysteine
................................................................................................... 112
LANCET DEV
....................................................................................................... 61
1st tier unilet comfortouch
....................................................................................................... 99
acid reducer maximum strength
....................................................................................................... 98
ACCU-CHEK MULTICLIX
................................................................................................... 145
8-MOP .............................................................................. 66 LANCETS .................................................................. 99 ACIPHEX ................................................................ 146
a/b otic ........................................................................ 138 ACCU-CHEK SAFE-T PRO
ACIPHEX SPRINKLE
abacavir sulfate
LANCETS .................................................................. 99 ................................................................................................... 146
....................................................................................................... 47
ACCU-CHEK SMARTVIEW
acitretin ......................................................................... 66
ABILIFY ....................................................................... 46 ....................................................................................................... 73 ACLOVATE ........................................................... 67
ABILIFY DISCMELT
ACCU-CHEK SMARTVIEW
ACTEMRA ................................................................... 6
....................................................................................................... 46
CONTROL ................................................................. 99 ACTHAR HP
ABILIFY MAINTENA
ACCU-CHEK SOFT TOUCH
....................................................................................................... 83
....................................................................................................... 46
LANCETS .................................................................. 99 ACTICIN ...................................................................... 72
ABSORICA .............................................................. 63 ACCU-CHEK SOFTCLIX
ACTIGALL .............................................................. 87
ABSTRAL ...................................................................... 9 LANCET DEV
acti-lance 28g
....................................................................................................... 99
acamprosate calcium
....................................................................................................... 99
ACCU-CHEK SOFTCLIX
................................................................................................... 140
acti-lance lite lancets 28g
ACANYA .................................................................... 62 LANCETS .................................................................. 99 ....................................................................................................... 99
acarbose ....................................................................... 23 ACCUPRIL ............................................................... 33 acti-lance special lancets 17g
ACCOLATE ............................................................ 16 ACCURETIC
....................................................................................................... 99
ACCU-CHEK ACTIVE
....................................................................................................... 34
acti-lance universal 23g
....................................................................................................... 73
ACCUTREND GLUCOSE
....................................................................................................... 99
ACCU-CHEK ACTIVE
....................................................................................................... 73
ACTIMMUNE
GLUCOSE CONT
ACCUTREND GLUCOSE
....................................................................................................... 42
....................................................................................................... 98
CONTROL ................................................................. 99 ACTIQ .................................................................................. 9
ACCU-CHEK ADVANTAGE
acd formula a
active fe ......................................................................... 94
TEST ................................................................................... 73 ....................................................................................................... 18 active ob ................................................................... 128
ACCU-CHEK AVIVA
acd formula b
ACTIVELLA ......................................................... 86
........................................................................................... 73, 98
....................................................................................................... 18
active-medicated spec collect
ACCU-CHEK AVIVA PLUS
acd-a .................................................................................. 18 ....................................................................................................... 73
....................................................................................................... 73
ACD-A NOCLOT-50
ACTIVITY POUCH
....................................................................................................... 18
ACCU-CHEK COMFORT
................................................................................................... 117
CURVE ............................................................... 73, 98 ACE AEROSOL CLOUD
ACTONEL ................................................................. 82
ENHANCER ....................................................... 117 ACTOPLUS MET
ACCU-CHEK COMFORT
acebutolol hcl
CURVE LINEAR
....................................................................................................... 24
....................................................................................................... 51
....................................................................................................... 98
ACTOPLUS MET XR
ACEON ........................................................................... 33 ....................................................................................................... 24
ACCU-CHEK COMPACT
....................................................................................................... 73
acetaminophen-codeine
ACTOS ............................................................................ 26
....................................................................................................... 11
ACCU-CHEK COMPACT BLUE
ACULAR ................................................................. 137
CONTROL ................................................................. 98 acetaminophen-codeine #2
ACULAR LS ...................................................... 137
ACCU-CHEK COMPACT PLUS
....................................................................................................... 11
ACURA BLOOD GLUCOSE
....................................................................................................... 73
acetaminophen-codeine #3
TEST ................................................................................... 73
....................................................................................................... 11
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
.......................................................................................................
98
151
Index
Index
Index
ACURA CONTROL
ADVOCATE CONTROL
SOLUTION .............................................................. 99
ADVOCATE INSULIN PEN
NEEDLES ............................................................... 112
ADVOCATE INSULIN
SYRINGE ................................................................ 112
ADVOCATE LANCETS
....................................................................................................... 99
ADVOCATE LANCING DEVICE
....................................................................................................... 99
ADVOCATE RAPID-SAFE
LANCING .................................................................. 99
ADVOCATE REDI-CODE
....................................................................................................... 73
ADVOCATE REDI-CODE+
CONTROL ................................................................. 99
ADVOCATE REDI-CODE+
TEST ................................................................................... 73
ADVOCATE SAFETY
LANCETS .................................................................. 99
ADVOCATE TEST
....................................................................................................... 73
AERO OTIC HC
................................................................................................... 138
AEROCHAMBER MINI
CHAMBER ........................................................... 119
AEROCHAMBER MV
................................................................................................... 119
AEROCHAMBER PLUS
................................................................................................... 119
AEROCHAMBER PLUS
FLO-VU ..................................................................... 119
AEROCHAMBER PLUS
FLO-VU LARGE
................................................................................................... 119
AEROCHAMBER PLUS
FLO-VU MEDIUM
................................................................................................... 119
AEROCHAMBER PLUS
FLO-VU SMALL
................................................................................................... 119
AEROCHAMBER PLUS
FLO-VU W/MASK
................................................................................................... 119
AEROCHAMBER PLUS FLOW
VU ....................................................................................... 119
AEROCHAMBER PLUS
W/MASK ................................................................. 119
AEROCHAMBER PLUS
W/MASK SMALL
................................................................................................... 119
AEROCHAMBER
W/FLOWSIGNAL
................................................................................................... 119
AEROCHAMBER Z-STAT PLUS
................................................................................................... 119
AEROCHAMBER Z-STAT PLUS
CHAMBR ................................................................ 119
AEROCHAMBER Z-STAT
PLUS/LARGE
................................................................................................... 119
AEROCHAMBER Z-STAT
PLUS/MEDIUM
................................................................................................... 119
AEROCHAMBER Z-STAT
PLUS/SMALL
................................................................................................... 119
AEROSPAN ............................................................ 16
AEROTRACH PLUS
................................................................................................... 117
af lancets super thin
....................................................................................................... 99
AFEDITAB CR
....................................................................................................... 51
AFINITOR ................................................................. 41
AFINITOR DISPERZ
....................................................................................................... 41
AGAMATRIX AMP TEST
....................................................................................................... 73
AGAMATRIX CONTROL
....................................................................................................... 99
AGAMATRIX JAZZ TEST
....................................................................................................... 73
AGAMATRIX KEYNOTE TEST
....................................................................................................... 73
AGAMATRIX PRESTO TEST
....................................................................................................... 73
AGAMATRIX ULTRA-THIN
LANCETS .................................................................. 99
AGGRENOX ......................................................... 92
AGRYLIN .................................................................. 93
aif #2 drug preparation kit
....................................................................................................... 65
AIRAVITE ................................................................. 94
AIRS PEDIATRIC AEROSOL
MASK ........................................................................... 117
AIRZONE PEAK FLOW METER
................................................................................................... 117
AKNE-MYCIN
....................................................................................................... 61
AK-PENTOLATE
................................................................................................... 132
ak-poly-bac .......................................................... 134
AKTEN ....................................................................... 135
ala quin .......................................................................... 64
alagesic .............................................................................. 8
ALAGESIC LQ
........................................................................................................... 8
99
ACUVAIL .............................................................. 137
acyclovir ........................................................... 48, 67
ACZONE ...................................................................... 61
ADAGEN ..................................................................... 51
ADALAT CC
....................................................................................................... 51
adapalene ................................................................... 63
ADAPTER PED DISPOSABLE
................................................................................................... 117
ADCIRCA .................................................................. 53
ADDERALL ............................................................... 3
ADDERALL XR
........................................................................................................... 3
adefovir dipivoxil
....................................................................................................... 48
ADEMPAS ................................................................ 53
adjustable lancing device
....................................................................................................... 99
ADOXA ..................................................................... 143
ADOXA PAK 1/100
................................................................................................... 143
ADOXA PAK 1/150
................................................................................................... 143
ADOXA PAK 2/100
................................................................................................... 143
ADRENACLICK
................................................................................................... 149
ADRENALIN
................................................................................................... 131
adult aerosol mask
................................................................................................... 117
adult mask ............................................................. 117
adult mask large
................................................................................................... 117
ADVAIR DISKUS
....................................................................................................... 16
ADVAIR HFA
....................................................................................................... 17
ADVANCE INTUITION
CONTROL ................................................................. 99
ADVANCE INTUITION TEST
....................................................................................................... 73
ADVANCE MICRO-DRAW
CONTROL ................................................................. 99
ADVANCE MICRO-DRAW
NORMAL .................................................................... 99
ADVANCE MICRO-DRAW
TEST ................................................................................... 73
advanced am/pm
................................................................................................... 125
ADVATE ..................................................................... 91
ADVICOR .................................................................. 31
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
152
Index
Index
Index
ALBAFORT ............................................................ 94
albatussin ................................................................... 60
albatussin nn ......................................................... 59
ALBENZA ................................................................. 14
albertsons test
....................................................................................................... 73
ALBUSTIX ............................................................... 73
albuterol sulfate
....................................................................................................... 17
albuterol sulfate er
....................................................................................................... 17
ALCAINE ............................................................... 135
alclometasone dipropionate
....................................................................................................... 67
ALCOH-GLOVE CONTOURED
WIPE ............................................................................... 111
alcohol pads ....................................................... 111
alcohol prep ........................................................ 111
alcohol prep pad
................................................................................................... 111
alcohol preps
................................................................................................... 111
alcohol swabs
................................................................................................... 111
alcohol wipes
................................................................................................... 111
ALCORTIN A
....................................................................................................... 64
ALDACTAZIDE
....................................................................................................... 81
ALDACTONE
....................................................................................................... 82
ALDARA ..................................................................... 70
ALDURAZYME
....................................................................................................... 85
alendronate sodium
....................................................................................................... 82
ALFERON N .......................................................... 42
alfuzosin hcl er
....................................................................................................... 90
ALICLEN .................................................................... 71
ALINIA ........................................................................... 37
ALKERAN ................................................................ 39
ALL FLOW 1000 PFT FILTER
................................................................................................... 117
allopurinol ................................................................ 91
ALOCRIL ................................................................ 136
ALOMIDE ............................................................. 136
ALOQUIN .................................................................. 64
ALORA ........................................................................... 87
ALPHAGAN P
................................................................................................... 133
ALPHANATE/VWF
COMPLEX/HUMAN
amlodipine besy-benazepril hcl
.......................................................................................................
.......................................................................................................
91
ALPHANINE SD
91
alphatrex ...................................................................... 67
alprazolam ................................................................ 15
alprazolam er
....................................................................................................... 15
ALPRAZOLAM INTENSOL
....................................................................................................... 15
alprazolam xr
....................................................................................................... 15
ALREX ........................................................................ 135
ALTABAX ................................................................ 64
ALTACAINE
................................................................................................... 135
ALTACE ....................................................................... 33
ALTAFLUOR
................................................................................................... 136
ALTAFRIN ........................................................... 134
ALTAVERA ........................................................... 54
alternate site lancing device
....................................................................................................... 99
ALTOPREV ............................................................. 32
ALUVEA ..................................................................... 69
ALVESCO ................................................................. 16
alyacen 1/35 ........................................................... 54
alyacen 7/7/7
....................................................................................................... 56
amantadine hcl
....................................................................................................... 43
AMARYL .................................................................... 27
AMBIEN ....................................................................... 96
AMBIEN CR .......................................................... 96
amcinonide ............................................................... 67
AMERGE ................................................................. 121
AMETHIA ................................................................. 56
AMETHIA LO
....................................................................................................... 56
AMICAR ...................................................................... 95
amiloride hcl ......................................................... 82
amiloride-hydrochlorothiazide
....................................................................................................... 81
aminoacetic acid
....................................................................................................... 90
aminocaproic acid
....................................................................................................... 95
amiodarone hcl
....................................................................................................... 15
AMITIZA ..................................................................... 88
amitriptyline hcl
....................................................................................................... 23
.......................................................................................................
34
amlodipine besylate
51
AMMONUL ............................................................ 85
AMNESTEEM
....................................................................................................... 63
amoxicill-clarithro-lansopraz
................................................................................................... 147
amoxicillin ............................................................ 140
amoxicillin-pot clavulanate
................................................................................................... 140
amoxicillin-pot clavulanate er
................................................................................................... 140
amphetamine-dextroamphet er
........................................................................................................... 3
amphetamine-dextroamphetamine
........................................................................................................... 3
ampicillin ................................................................ 140
AMPYRA ................................................................ 142
AMRIX ........................................................................ 130
AMTURNIDE
....................................................................................................... 36
ANACAINE ............................................................. 71
ANADROL-50
....................................................................................................... 12
ANAFRANIL
....................................................................................................... 23
anagrelide hcl
....................................................................................................... 93
ANALPRAM-HC
....................................................................................................... 13
ANAPROX .................................................................... 7
ANAPROX DS
........................................................................................................... 7
anastrozole ............................................................... 39
ANDROGEL .............................................. 12, 13
ANDROGEL PUMP
....................................................................................................... 13
ANDROID ................................................................. 13
ANDROXY .............................................................. 13
ANGELIQ ................................................................... 86
ANIMI-3 ........................................................................ 94
ANIMI-3/VITAMIN D
....................................................................................................... 94
anolor 300 ..................................................................... 8
ANORO ELLIPTA
....................................................................................................... 17
ANTABUSE ........................................................ 140
ANTARA ..................................................................... 31
antibiotic ear
................................................................................................... 138
anticoagulant cit dext soln a
....................................................................................................... 18
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
153
Index
Index
Index
ANTICOAGULANT
COMPOUND
ARTHROTEC
ASSURE HAEMOLANCE PLUS
MICRO ........................................................................ 100
ASSURE HAEMOLANCE PLUS
NORMAL ................................................................ 100
ASSURE HAEMOLANCE PLUS
PED ................................................................................... 100
ASSURE ID INSULIN SAFETY
SYR ................................................................................... 112
ASSURE II ................................................................ 74
ASSURE II CHECK
....................................................................................................... 74
ASSURE II CONTROL
................................................................................................... 100
ASSURE II CONTROL LEVEL 1
& 2 ...................................................................................... 100
ASSURE LANCE LANCETS
................................................................................................... 100
ASSURE LANCETS
................................................................................................... 100
ASSURE PLATINUM
....................................................................................................... 74
ASSURE PRO CONTROL
LEVEL 1 & 2
................................................................................................... 100
ASSURE PRO TEST
....................................................................................................... 74
ASTAGRAF XL
....................................................................................................... 50
ASTEPRO ............................................................... 131
ASTHMA CHECK
METER-ZONE SYSTEM
................................................................................................... 117
ASTHMAMENTOR
................................................................................................... 117
AT LAST CONTROL
................................................................................................... 100
AT LAST LANCETS
................................................................................................... 100
AT LAST TEST
....................................................................................................... 74
ATABEX .................................................................. 126
ATABEX EC ...................................................... 126
ATACAND ............................................................... 33
ATACAND HCT
....................................................................................................... 35
ATELVIA .................................................................... 82
atenolol .......................................................................... 51
atenolol-chlorthalidone
....................................................................................................... 36
ATGAM ......................................................................... 49
ATIVAN ........................................................................ 15
atorvastatin calcium
....................................................................................................... 32
18
antifungal ................................................................... 64
antipyrine-benzocaine
................................................................................................... 138
anucort-hc ................................................................. 13
ANUSOL-HC
....................................................................................................... 13
ANZEMET ................................................................ 28
APETIMAR/IRON
................................................................................................... 125
APEXICON .............................................................. 67
APEXICON E
....................................................................................................... 67
APIDRA ......................................................................... 27
APIDRA SOLOSTAR
....................................................................................................... 27
APLENZIN ............................................................... 20
apraclonidine hcl
................................................................................................... 133
APRI .................................................................................... 54
APRISO .......................................................................... 88
APTIOM ........................................................................ 19
APTIVUS ..................................................................... 46
aqua lance adjustable lancing
....................................................................................................... 99
AQUORAL ........................................................... 124
ARALAST ............................................................. 143
ARALAST NP
................................................................................................... 143
ARALEN ...................................................................... 38
ARANELLE ............................................................ 56
ARANESP (ALBUMIN FREE)
....................................................................................................... 93
ARBINOXA ............................................................ 30
ARCALYST ................................................................ 6
ARCAPTA NEOHALER
....................................................................................................... 17
ARGYLE STERILE SALINE
....................................................................................................... 90
ARGYLE STERILE WATER
....................................................................................................... 50
ARIAL CHAMBER
................................................................................................... 119
ARICEPT ................................................................. 141
ARICEPT ODT
................................................................................................... 141
ARIDOL ........................................................................ 72
ARIMIDEX .............................................................. 39
ARIXTRA ................................................................... 18
ARMOUR THYROID
................................................................................................... 144
AROMASIN ............................................................ 39
.......................................................................................................
7
ARTISS ........................................................................... 95
ASACOL HD
....................................................................................................... 88
ASCENSIA AUTODISC
CONTROL ................................................................. 99
ASCENSIA AUTODISC
CONTROLS ............................................................ 99
ASCENSIA AUTODISC TEST
....................................................................................................... 73
ASCOMP-CODEINE
....................................................................................................... 11
ASMALPRED
....................................................................................................... 58
ASMALPRED PLUS
....................................................................................................... 58
ASMANEX 120 METERED
DOSES ............................................................................. 16
ASMANEX 14 METERED
DOSES ............................................................................. 16
ASMANEX 30 METERED
DOSES ............................................................................. 16
ASMANEX 60 METERED
DOSES ............................................................................. 16
ASMANEX 7 METERED DOSES
....................................................................................................... 16
ASSESS FULL RANGE PEAK
METER ....................................................................... 117
ASSESS LOW RANGE PEAK
METER ....................................................................... 117
ASSESS PEAK FLOW METER
................................................................................................... 117
ASSURE 3 CONTROL
....................................................................................................... 99
ASSURE 3 TEST
....................................................................................................... 73
ASSURE 4 CONTROL LEVEL 1
& 2 .......................................................................................... 99
ASSURE 4 TEST
....................................................................................................... 73
assure comfort lancets 28g
....................................................................................................... 99
assure comfort lancets 30g
....................................................................................................... 99
ASSURE DOSE CONTROL
....................................................................................................... 99
ASSURE DOSE NORM/HIGH
CONTROL ............................................................. 100
ASSURE HAEMOLANCE PLUS
HIGH .............................................................................. 100
ASSURE HAEMOLANCE PLUS
LOW ................................................................................ 100
...........................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
154
Index
Index
Index
atovaquone-proguanil hcl
AUTOLET PLATFORMS
bacitra-neomycin-polymyxin-hc
................................................................................................... 135
baclofen ..................................................................... 130
BACTRIM .................................................................. 37
BACTRIM DS
....................................................................................................... 37
BACTROBAN
....................................................................................................... 64
BACTROBAN NASAL
................................................................................................... 131
BAL-CARE DHA
................................................................................................... 126
balsalazide disodium
....................................................................................................... 88
BALZIVA ................................................................... 54
BANZEL ....................................................................... 19
BARACLUDE
....................................................................................................... 48
BAR-TEST ................................................................ 80
BAYCADRON
....................................................................................................... 58
BAYER BREEZE 2 CONTROL
................................................................................................... 100
BAYER BREEZE 2 TEST
....................................................................................................... 74
BAYER CONTOUR
................................................................................................... 100
BAYER CONTOUR NEXT
CONTROL ............................................................. 100
BAYER CONTOUR NEXT TEST
....................................................................................................... 74
BAYER CONTOUR TEST
....................................................................................................... 74
BAYER MICROLET 2
LANCING DEVIC
................................................................................................... 100
BAYER MICROLET LANCETS
................................................................................................... 100
baza antifungal
....................................................................................................... 64
BD AUTOSHIELD
................................................................................................... 112
BD AUTOSHIELD DUO
................................................................................................... 112
BD GLUCOSE
....................................................................................................... 25
BD INSULIN SYR ULTRAFINE
II ............................................................................................. 112
BD INSULIN SYRINGE
................................................................................................... 112
BD INSULIN SYRINGE
HALF-UNIT ........................................................ 112
BD INSULIN SYRINGE
MICROFINE ...................................................... 112
38
ATRALIN ................................................................... 63
ATRIPLA ..................................................................... 46
atropine sulfate
................................................................................................... 132
atropine-care
................................................................................................... 132
ATROVENT ....................................................... 131
ATROVENT HFA
....................................................................................................... 16
AUBAGIO ............................................................. 141
AUBRA .......................................................................... 54
AUGMENTIN
................................................................................................... 140
AUGMENTIN ES-600
................................................................................................... 140
AUGMENTIN XR
................................................................................................... 140
AURALGAN ..................................................... 138
aurax .............................................................................. 138
AURODEX ........................................................... 138
AUROGUARD
................................................................................................... 138
AURORA HEALTHCARE
LANCETS .............................................................. 100
aurora lancet super thin 30g
................................................................................................... 100
aurora lancet thin 23g
................................................................................................... 100
aurora pen needles
................................................................................................... 112
aurora unifine pentips
................................................................................................... 112
auroto ........................................................................... 138
AUTOJECT 2
................................................................................................... 112
AUTO-LANCET
................................................................................................... 100
AUTO-LANCET MINI
................................................................................................... 100
AUTOLET II CLINISAFE
................................................................................................... 100
AUTOLET IMPRESSION
................................................................................................... 100
AUTOLET LANCING DEVICE
................................................................................................... 100
AUTOLET LITE CLINISAFE
................................................................................................... 100
AUTOLET LITE STARTER
PACK ............................................................................. 100
AUTOLET MINI
................................................................................................... 100
.......................................................................................................
100
AUVI-Q ...................................................................... 149
AVALIDE ................................................................... 35
AVANDAMET
....................................................................................................... 24
AVANDARYL
....................................................................................................... 24
AVANDIA ................................................................. 26
AVAPRO ..................................................................... 33
AVAR ................................................................................ 62
AVAR CLEANSER
....................................................................................................... 62
AVAR LS .................................................................... 62
AVAR LS CLEANSER
....................................................................................................... 62
AVAR-E EMOLLIENT
....................................................................................................... 62
AVAR-E GREEN
....................................................................................................... 62
AVAR-E LS ............................................................. 62
AVC VAGINAL
................................................................................................... 149
AVIANE ........................................................................ 54
avidoxy ....................................................................... 143
AVINZA ............................................................................ 9
AVITA ............................................................................. 63
AVODART ............................................................... 90
AVONEX ................................................................. 141
AVONEX PEN
................................................................................................... 142
AVONEX PREFILLED
................................................................................................... 142
AXERT ........................................................................ 121
AXID .............................................................................. 145
AXIRON ....................................................................... 13
AYGESTIN .......................................................... 140
AZASAN ...................................................................... 50
AZASITE ................................................................. 133
azathioprine ............................................................ 50
azelastine hcl
................................................................................... 131, 136
AZELEX ....................................................................... 63
AZILECT ..................................................................... 43
azithromycin ........................................................... 97
AZOPT ......................................................................... 136
AZOR ................................................................................. 35
AZULFIDINE
....................................................................................................... 88
AZULFIDINE EN-TABS
....................................................................................................... 88
AZURETTE ............................................................. 54
bacitracin-polymyxin b
................................................................................................... 134
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
155
Index
Index
Index
BD INSULIN SYRINGE U-40
BENZAMYCIN
BINOSTO .................................................................... 82
BIO GLO .................................................................. 136
BIOSCANNER GLUCOSE TEST
....................................................................................................... 74
bio-statin ...................................................................... 29
bisoprolol fumarate
....................................................................................................... 51
bisoprolol-hydrochlorothiazide
....................................................................................................... 36
bl test strip pack
....................................................................................................... 74
BLEPHAMIDE
................................................................................................... 135
BLEPHAMIDE S.O.P.
................................................................................................... 135
blood glucose test
....................................................................................................... 74
B-NEXA .................................................................... 130
BONIVA ....................................................................... 82
BOSULIF ..................................................................... 41
BOTOX ....................................................................... 132
BOTOX COSMETIC
....................................................................................................... 70
bp 10-1 ............................................................................ 62
bp cleansing wash
....................................................................................................... 62
bp foam .......................................................................... 63
bp vit 3 ............................................................................ 94
bpo ........................................................................................ 63
bpo foaming cloths
....................................................................................................... 63
BREATHERITE
................................................................................................... 119
BREATHERITE COLL SPACER
ADULT ....................................................................... 119
BREATHERITE COLL SPACER
CHILD .......................................................................... 119
BREATHERITE COLL SPACER
INFANT ..................................................................... 119
BREATHERITE RIGID
SPACER/MASK
................................................................................................... 119
BREATHERITE SPACER
NEONATE ............................................................. 119
BREATHERITE SPACER
SMALL CHILD
................................................................................................... 119
BREATHERITE/LARGE MASK
................................................................................................... 119
BREATHERITE/MEDIUM
MASK ........................................................................... 119
BREATHERITE/SMALL MASK
................................................................................................... 119
112
BD INSULIN SYRINGE
ULTRAFINE ...................................... 112, 113
BD INTEGRA INSULIN
SYRINGE ................................................................ 113
BD INTEGRA SYRINGE
................................................................................................... 113
BD LANCET DEVICE
................................................................................................... 100
BD LANCET ULTRAFINE 30G
................................................................................................... 100
BD LANCET ULTRAFINE 33G
................................................................................................... 100
BD MICROTAINER LANCETS
................................................................................................... 100
BD PEN NEEDLE MINI U/F
................................................................................................... 113
BD PEN NEEDLE NANO U/F
................................................................................................... 113
BD PEN NEEDLE SHORT U/F
................................................................................................... 113
BD PEN NEEDLE ULTRAFINE
................................................................................................... 113
BD SAFETYGLIDE INSULIN
SYRINGE ................................................................ 113
BD SAFETY-LOK INSULIN
SYRINGE ................................................................ 113
BD SWAB SINGLE USE
REGULAR ............................................................. 111
BD SWABS SINGLE USE
BUTTERFLY
................................................................................................... 111
BD TEST ...................................................................... 74
BD ULTRA-FINE LANCETS
................................................................................................... 100
BEBULIN .................................................................... 91
BEBULIN VH
....................................................................................................... 91
BECONASE AQ
................................................................................................... 131
be-flex plus ................................................................... 8
benazepril hcl
....................................................................................................... 33
benazepril-hydrochlorothiazide
....................................................................................................... 34
BENEFIX ..................................................................... 91
BENICAR ................................................................... 33
BENICAR HCT
....................................................................................................... 35
BENLYSTA ............................................................. 50
bensal hp ..................................................................... 71
BENTYL ................................................................... 145
...................................................................................................
.......................................................................................................
62
BENZAMYCINPAK
62
BENZEPRO ............................................................. 63
BENZEPRO SHORT CONTACT
....................................................................................................... 63
BENZIQ ......................................................................... 63
BENZIQ LS .............................................................. 63
benzonatate .............................................................. 59
benzoyl peroxide
....................................................................................................... 63
benzoyl peroxide short contact
....................................................................................................... 63
benzoyl peroxide-erythromycin
....................................................................................................... 62
benztropine mesylate
....................................................................................................... 42
BEPREVE ............................................................... 136
BERINERT ............................................................... 92
BESIVANCE ..................................................... 133
BETADINE OPHTHALMIC
PREP ............................................................................... 134
BETAGAN ............................................................ 132
betamethasone dipropionate
....................................................................................................... 68
betamethasone dipropionate aug
....................................................................................................... 68
betamethasone valerate
....................................................................................................... 68
BETAPACE ............................................................. 51
BETAPACE AF
....................................................................................................... 51
BETASERON
................................................................................................... 142
BETA-VAL .............................................................. 67
betaxolol hcl ........................................... 51, 132
bethanechol chloride
................................................................................................... 148
BETHKIS ......................................................................... 5
BETIMOL ............................................................... 132
BETOPTIC-S
................................................................................................... 132
BEYAZ ............................................................................ 54
BG STAR TEST
....................................................................................................... 74
BIAXIN .......................................................................... 97
BIAXIN XL .............................................................. 97
BIAXIN XL PAC
....................................................................................................... 97
bicalutamide ........................................................... 39
BIDIL ................................................................................. 52
BIFERARX ............................................................... 95
BILTRICIDE .......................................................... 14
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
156
Index
Index
Index
BREO ELLIPTA
butalbital-asa-caff-codeine
CARAFATE ........................................................ 146
CARBAGLU .......................................................... 85
carbamazepine
....................................................................................................... 19
carbamazepine er
....................................................................................................... 19
CARBAPHEN 12
....................................................................................................... 60
CARBAPHEN 12 PED
....................................................................................................... 60
CARBATROL
....................................................................................................... 19
carbidopa-levodopa
....................................................................................................... 43
carbidopa-levodopa er
....................................................................................................... 43
carbinoxamine maleate
....................................................................................................... 30
CARDENE SR
....................................................................................................... 51
CARDIOCOM LANCING
DEVICE ..................................................................... 100
CARDIZEM ............................................................. 51
CARDIZEM CD
....................................................................................................... 51
CARDIZEM LA
....................................................................................................... 51
CARDURA ............................................................... 34
CARDURA XL
....................................................................................................... 90
careone advanced lancing dev
................................................................................................... 100
CAREONE BLOOD GLUCOSE
TEST ................................................................................... 74
careone lancet thin 23g
................................................................................................... 100
careone lancet ultra thin 28g
................................................................................................... 100
CAREONE ULTIGUARD
INSULIN SYR
................................................................................................... 113
careone unifine pentips
................................................................................................... 113
careone unifine pentips plus
................................................................................................... 113
CARESENS CONTROL A
................................................................................................... 100
CARESENS N GLUCOSE TEST
....................................................................................................... 74
CARIMUNE NF
................................................................................................... 139
carisoprodol ....................................................... 130
carisoprodol-aspirin
................................................................................................... 130
.......................................................................................................
17
BREVICON (28)
54
briellyn ........................................................................... 54
BRILINTA ................................................................. 92
brimonidine tartrate
................................................................................................... 133
BRINTELLIX
....................................................................................................... 22
BRISDELLE ....................................................... 143
BROMFED DM
....................................................................................................... 60
bromocriptine mesylate
....................................................................................................... 43
BROVANA ............................................................... 17
BUBBLES THE FISH II PEDI
MASK ........................................................................... 117
BUCALSEP ............................................................. 46
BUDEPRION SR
....................................................................................................... 20
BUDEPRION XL
....................................................................................................... 21
budesonide ................................................ 16, 131
budesonide er
....................................................................................................... 58
bullseye mini safety lancets
................................................................................................... 100
BULLSEYE SAFETY LANCETS
................................................................................................... 100
bumetanide ............................................................... 82
BUPAP ................................................................................ 8
BUPHENYL ............................................................ 85
buprenorphine hcl
....................................................................................................... 12
buprenorphine hcl-naloxone hcl
....................................................................................................... 12
bupropion hcl
....................................................................................................... 21
bupropion hcl er (sr)
....................................................................................................... 21
bupropion hcl er (xl)
....................................................................................................... 21
buspirone hcl
....................................................................................................... 14
butalbital compound/codeine
....................................................................................................... 11
butalbital-acetaminophen
........................................................................................................... 8
butalbital-apap-caff-cod
....................................................................................................... 11
butalbital-apap-caffeine
........................................................................................................... 8
.......................................................................................................
.......................................................................................................
11
butalbital-asa-caffeine
...........................................................................................................
8
BUTISOL SODIUM
.......................................................................................................
95
butorphanol tartrate
12
BUTRANS ................................................................. 12
BYDUREON .......................................................... 26
BYETTA 10 MCG PEN
....................................................................................................... 26
BYETTA 5 MCG PEN
....................................................................................................... 26
BYSTOLIC ............................................................... 51
cabergoline .............................................................. 86
CAFCIT .............................................................................. 4
CAFERGOT ........................................................ 120
caffeine citrate
........................................................................................................... 4
CALAN ........................................................................... 51
CALAN SR ............................................................... 51
CALCIFOL ........................................................... 121
calcipotriene .......................................................... 66
calcitonin (salmon)
....................................................................................................... 83
CALCITRENE
....................................................................................................... 66
calcitriol ....................................................................... 85
calcium acetate
....................................................................................................... 89
calcium acetate (phos binder)
....................................................................................................... 89
calcium-folic acid plus d
................................................................................................... 121
CAMBIA .................................................................. 120
CAMILA ....................................................................... 58
CAMPRAL ............................................................ 140
CAMRESE ................................................................ 56
CAMRESE LO
....................................................................................................... 56
CANASA ..................................................................... 88
candesartan cilexetil
....................................................................................................... 33
candesartan cilexetil-hctz
....................................................................................................... 35
CANTIL ..................................................................... 145
CAPACET ...................................................................... 8
CAPEX ............................................................................ 68
CAPITAL/CODEINE
....................................................................................................... 11
CAPRELSA ............................................................. 41
captopril ....................................................................... 33
CARAC ........................................................................... 65
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
157
Index
Index
Index
carisoprodol-aspirin-codeine
CERVIDIL ............................................................. 138
CESAMET ................................................................. 29
CESIA ............................................................................... 57
cetirizine hcl ........................................................... 30
CETRAXAL ........................................................ 137
cevimeline hcl
................................................................................................... 124
CHATEAL ................................................................. 54
CHEK-STIX CONTROL
....................................................................................................... 74
CHEMET ..................................................................... 28
CHEMSTRIP 10 MD
....................................................................................................... 80
CHEMSTRIP 10/SG
....................................................................................................... 80
CHEMSTRIP 2 GP
....................................................................................................... 80
CHEMSTRIP 5 OB
....................................................................................................... 80
CHEMSTRIP 7
....................................................................................................... 80
CHEMSTRIP 9
....................................................................................................... 80
CHEMSTRIP K
....................................................................................................... 74
CHEMSTRIP MICRAL
....................................................................................................... 74
CHEMSTRIP UGK
....................................................................................................... 80
CHENODAL .......................................................... 87
cheratussin ac
....................................................................................................... 59
cheratussin dac
....................................................................................................... 60
chlordiazepoxide hcl
....................................................................................................... 15
chlorhexidine gluconate
................................................................................................... 123
chloroquine phosphate
....................................................................................................... 38
chlorothiazide
....................................................................................................... 82
chlorpromazine hcl
....................................................................................................... 45
chlorpropamide
....................................................................................................... 27
chlorthalidone
....................................................................................................... 82
chlorzoxazone
................................................................................................... 130
CHOICE DM FORA G20 TEST
STRIPS ............................................................................ 74
cholestyramine
....................................................................................................... 31
cholestyramine light
130
CARMOL 40 .......................................................... 69
CARNITOR ............................................................. 84
CARNITOR SF
....................................................................................................... 84
CARRINGTON ANTIFUNGAL
....................................................................................................... 64
carteolol hcl ........................................................ 132
CARTIA XT ............................................................ 51
carvedilol .................................................................... 50
CASODEX ................................................................. 39
CATAFLAM .............................................................. 7
CATAPRES ............................................................. 34
CATAPRES-TTS-1
....................................................................................................... 34
CATAPRES-TTS-2
....................................................................................................... 34
CATAPRES-TTS-3
....................................................................................................... 34
CAVAN-FOLATE OB
................................................................................................... 126
CAVAREST ........................................................ 123
CAVERJECT
....................................................................................................... 52
CAVERJECT IMPULSE
....................................................................................................... 52
CAYSTON ................................................................. 37
CAZIANT ................................................................... 57
CEDAX ........................................................................... 53
cefaclor .......................................................................... 53
cefadroxil .................................................................... 53
cefdinir ........................................................................... 53
cefpodoxime proxetil
....................................................................................................... 53
cefprozil ........................................................................ 53
CEFTIN .......................................................................... 53
cefuroxime axetil
....................................................................................................... 53
CELEBREX ................................................................. 6
CELEXA ....................................................................... 21
CELLCEPT ............................................................... 50
CELONTIN .............................................................. 20
CEM-UREA ............................................................. 69
CENESTIN ................................................................ 87
CENFOL ....................................................................... 94
CENTANY ................................................................ 64
CENTRATEX
....................................................................................................... 94
cephalexin .................................................................. 53
CEREZYME ........................................................... 93
CERISA WASH
....................................................................................................... 62
CEROVEL ................................................................. 69
...................................................................................................
.......................................................................................................
...........................................................................................................
9
choline-mag trisalicylate
9
CICLODAN ............................................................. 64
ciclopirox .................................................................... 64
ciclopirox olamine
....................................................................................................... 64
cidofovir ....................................................................... 47
cilostazol ...................................................................... 92
CILOXAN .............................................................. 133
cimetidine ............................................................... 145
cimetidine hcl
................................................................................................... 145
CINRYZE .................................................................... 92
CIPRO ............................................................................... 87
CIPRO HC .............................................................. 138
CIPRO XR .................................................................. 87
CIPRODEX .......................................................... 138
ciprofloxacin hcl
....................................................................................... 87, 133
ciprofloxacin-ciproflox hcl er
....................................................................................................... 87
citalopram hydrobromide
....................................................................................................... 21
CITRANATAL 90 DHA
................................................................................................... 128
CITRANATAL B-CALM
................................................................................................... 126
CITRANATAL DHA
................................................................................................... 128
CITRANATAL HARMONY
................................................................................................... 129
CITRANATAL RX
................................................................................................... 126
citric acid-sodium citrate
....................................................................................................... 89
CITROLITH ............................................................ 90
CLARAVIS .............................................................. 63
CLARINEX .............................................................. 30
CLARINEX REDITABS
....................................................................................................... 30
CLARINEX-D 12 HOUR
....................................................................................................... 60
CLARINEX-D 24 HOUR
....................................................................................................... 60
CLARIS CLARIFYING WASH
....................................................................................................... 62
clarithromycin
....................................................................................................... 97
clarithromycin er
....................................................................................................... 97
...........................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
158
31
choline & mag trisalicylate
Index
Index
Index
CLEANLET LANCETS 28G
clobetasol propionate e
COMBIPATCH
101
CLEARLAX ............................................................ 97
clemastine fumarate
....................................................................................................... 30
CLENIA ......................................................................... 62
CLENIA FOAMING WASH
....................................................................................................... 62
CLEOCIN .................................................... 37, 149
CLEOCIN-T ............................................................ 61
CLEVER CHEK AUTO-CODE
TEST ................................................................................... 74
CLEVER CHEK AUTO-CODE
VOICE .............................................................................. 74
CLEVER CHEK LANCETS
................................................................................................... 101
CLEVER CHEK TEST
....................................................................................................... 74
CLEVER CHOICE AUTO-CODE
TEST ................................................................................... 74
CLEVER CHOICE GLUCOSE
CONTROL ............................................................. 101
CLEVER CHOICE MICRO TEST
....................................................................................................... 74
clickfine pen needles
................................................................................................... 113
clidinium-chlordiazepoxide
................................................................................................... 145
CLIMARA ................................................................. 87
CLIMARA PRO
....................................................................................................... 86
CLINDACIN ETZ
....................................................................................................... 61
CLINDACIN-P
....................................................................................................... 61
CLINDAGEL
....................................................................................................... 61
CLINDAMAX
....................................................................................................... 61
clindamycin hcl
....................................................................................................... 37
clindamycin palmitate hcl
....................................................................................................... 37
clindamycin phos-benzoyl perox
....................................................................................................... 62
clindamycin phosphate
....................................................................................... 61, 149
CLINDESSE ....................................................... 149
CLINISTIX ............................................................... 74
CLINITEST .............................................................. 74
CLINPRO 5000
................................................................................................... 123
clobetasol propionate
....................................................................................................... 68
...................................................................................................
.......................................................................................................
68
clobetasol propionate emulsion
68
CLOBEX ...................................................................... 68
CLOBEX SPRAY
....................................................................................................... 68
CLOMID ....................................................................... 83
clomiphene citrate
....................................................................................................... 83
clomipramine hcl
....................................................................................................... 23
clonazepam .............................................................. 18
clonidine hcl ........................................................... 34
clonidine hcl er
........................................................................................................... 4
clopidogrel bisulfate
....................................................................................................... 93
clorazepate dipotassium
....................................................................................................... 15
CLORPRES .............................................................. 34
CLOSERCARE
................................................................................................... 101
clotrimazole ........................................................ 123
clotrimazole-betamethasone
....................................................................................................... 64
clozapine ...................................................................... 44
CLOZARIL ............................................................... 44
c-nate dha .............................................................. 126
CNL8 NAIL ............................................................. 64
co monitor replacement pieces
................................................................................................... 117
COAGUCHEK LANCETS
................................................................................................... 101
COARTEM ............................................................... 38
COLAZAL ................................................................. 88
colchicine-probenecid
....................................................................................................... 91
COLCRYS ................................................................. 91
COLESTID ................................................................ 31
COLESTID FLAVORED
....................................................................................................... 31
colestipol hcl ......................................................... 31
colidrops .................................................................. 145
colistimethate sodium
....................................................................................................... 37
COLOCORT ........................................................... 13
COLY-MYCIN M
....................................................................................................... 37
COLY-MYCIN S
................................................................................................... 138
COLYTE WITH FLAVOR
PACKS ............................................................................ 97
COMBIGAN ....................................................... 132
.......................................................................................................
86
COMBISTIX .......................................................... 80
COMBIVENT RESPIMAT
....................................................................................................... 17
COMBIVIR .............................................................. 46
COMETRIQ (100 MG DAILY
DOSE) ............................................................................... 41
COMETRIQ (140 MG DAILY
DOSE) ............................................................................... 41
COMETRIQ (60 MG DAILY
DOSE) ............................................................................... 41
comfort assured lancets 28g
................................................................................................... 101
comfort assured lancets 33g
................................................................................................... 101
COMFORT EZ INSULIN
SYRINGE ................................................................ 113
COMFORT EZ PEN NEEDLES
................................................................................................... 113
comfort lancets
................................................................................................... 101
COMPAZINE
....................................................................................................... 45
COMPLERA ........................................................... 46
completenate ...................................................... 126
complete-rf prenatal
................................................................................................... 126
COMPRO .................................................................... 45
COMTAN .................................................................... 43
CO-NATAL FA
................................................................................................... 126
CONCEPT DHA
................................................................................................... 126
CONCEPT OB
................................................................................................... 126
CONCERTA ............................................................... 4
CONDYLOX ......................................................... 71
cone mask ............................................................... 117
constulose ................................................................... 97
control ......................................................................... 101
CONTROL AST
....................................................................................................... 74
CONTROL TEST
....................................................................................................... 74
CONTROLRX
................................................................................................... 123
CONZIP ............................................................................. 9
COPAXONE ....................................................... 142
COPEGUS .................................................................. 48
CORDARONE
....................................................................................................... 15
CORDRAN ............................................................... 68
COREG ........................................................................... 50
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
159
Index
Index
Index
COREG CR .............................................................. 50
corenate-dha ...................................................... 129
CORGARD ............................................................... 51
CORIFACT ............................................................... 91
CORMAX ................................................................... 68
CORMAX SCALP
APPLICATION
....................................................................................................... 68
CORNWALL METAL
PIPETTING .......................................................... 113
CORTALO ................................................................. 69
CORTANE-B
....................................................................................... 69, 138
CORTEF ........................................................................ 58
CORTENEMA
....................................................................................................... 13
CORTIC-ND ....................................................... 138
CORTIFOAM
....................................................................................................... 13
CORTISPORIN
....................................................................................... 63, 138
CORTISPORIN-TC
................................................................................................... 138
cortomycin ............................................................ 138
CORVITA ............................................................... 125
CORVITA 150
....................................................................................................... 94
CORZIDE .................................................................... 36
COSOPT .................................................................... 132
COSOPT PF ......................................................... 132
COUMADIN .......................................................... 17
COVARYX ............................................................... 86
COVARYX HS
....................................................................................................... 86
COZAAR ..................................................................... 33
CPB WC ........................................................................ 61
CREON ........................................................................... 81
CRESTOR .................................................................. 32
CRESYLATE
................................................................................................... 137
CRINONE ............................................................... 149
CRIXIVAN ............................................................... 47
CRNATAL ............................................................. 129
cromolyn sodium
........................................................................... 15, 88, 136
CRYSELLE-28
....................................................................................................... 54
CUPRIMINE .......................................................... 49
CURITY ALCOHOL PREPS
................................................................................................... 111
CURITY ALCOHOL SWABS
................................................................................................... 111
CURITY STERILE SALINE
....................................................................................................... 90
CUROSURF ........................................................ 143
CUTIVATE .............................................................. 68
CUVPOSA ............................................................. 145
CVS ADVANCED GLUCOSE
TEST ................................................................................... 74
cvs alcohol prep swabs
................................................................................................... 111
cvs alcohol swabs
................................................................................................... 111
cvs blood glucose test
....................................................................................................... 74
cvs glucose ................................................................ 25
cvs glucose bits
....................................................................................................... 25
cvs glucose shot
....................................................................................................... 25
cvs insulin syringe
................................................................................................... 113
CVS KETONE CARE
....................................................................................................... 80
cvs lancets 21g
................................................................................................... 101
cvs lancets micro thin 33g
................................................................................................... 101
cvs lancets original
................................................................................................... 101
cvs lancets thin
................................................................................................... 101
cvs lancets thin 26g
................................................................................................... 101
cvs lancets ultra thin 30g
................................................................................................... 101
cvs lancing device
................................................................................................... 101
cvs niacin ................................................................ 150
cvs ultra thin lancets
................................................................................................... 101
CYCLAFEM 1/35
....................................................................................................... 54
CYCLAFEM 7/7/7
....................................................................................................... 57
CYCLESSA ............................................................. 57
cyclobenzaprine hcl
................................................................................................... 130
CYCLOGYL ....................................................... 132
CYCLOMYDRIL
................................................................................................... 132
cyclopentolate hcl
................................................................................................... 132
CYCLOSET ............................................................. 26
cyclosporine ........................................................... 49
cyclosporine modified
....................................................................................................... 49
cylate ............................................................................. 132
CYMBALTA ......................................................... 22
CYOTIC ..................................................................... 138
cyproheptadine hcl
....................................................................................................... 30
CYSTADANE
....................................................................................................... 85
CYSTAGON ........................................................... 90
CYSTARAN ....................................................... 137
CYSTO-CONRAY II
....................................................................................................... 81
CYSTOGRAFIN-DILUTE
....................................................................................................... 81
CYTOGAM .......................................................... 139
CYTOMEL ............................................................ 144
CYTOTEC ............................................................. 146
CYTOVENE ........................................................... 47
cytra k crystals
....................................................................................................... 90
cytra-2 ............................................................................. 90
CYTRA-3 ..................................................................... 90
cytra-k .............................................................................. 90
D.H.E. 45 .................................................................. 121
DALIRESP ................................................................ 16
danazol ........................................................................... 13
DANTRIUM ....................................................... 130
dantrolene sodium
................................................................................................... 130
DARAPRIM ............................................................ 38
DASETTA 1/35
....................................................................................................... 54
DASETTA 7/7/7
....................................................................................................... 57
DAYPRO ......................................................................... 7
DAYSEE ....................................................................... 56
DAYTRANA ............................................................. 4
DDAVP ........................................................................... 85
DEBACTEROL
................................................................................................... 123
DECON-A .................................................................. 60
DECON-G .................................................................. 60
deferoxamine mesylate
....................................................................................................... 28
DELZICOL ............................................................... 88
DEMADEX .............................................................. 82
demeclocycline hcl
................................................................................................... 143
DEMEROL .................................................................... 9
DEMSER ...................................................................... 33
DENAVIR .................................................................. 67
DENTA 5000 PLUS
................................................................................................... 123
DENTAGEL ........................................................ 123
dentall 1100 plus
................................................................................................... 123
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
160
Index
Index
Index
DEPADE ....................................................................... 28
DEPAKENE ............................................................ 20
DEPAKOTE ............................................................ 20
DEPAKOTE ER
....................................................................................................... 20
DEPAKOTE SPRINKLES
....................................................................................................... 20
DEPEN TITRATABS
....................................................................................................... 49
DEPO-PROVERA
....................................................................................................... 58
DEPO-SUBQ PROVERA 104
....................................................................................................... 58
DEPO-TESTOSTERONE
....................................................................................................... 13
DERMA-SMOOTHE/FS BODY
....................................................................................................... 68
DERMA-SMOOTHE/FS SCALP
....................................................................................................... 68
DERMASORB AF
....................................................................................................... 64
DERMASORB XM
....................................................................................................... 69
DERMATOP .......................................................... 68
DERMAZENE
....................................................................................................... 64
DERMOTIC ......................................................... 138
DESFERAL .............................................................. 28
desipramine hcl
....................................................................................................... 23
desloratadine
....................................................................................................... 30
desmopressin ace rhinal tube
....................................................................................................... 85
desmopressin ace spray refrig
....................................................................................................... 86
desmopressin acetate
....................................................................................................... 86
desmopressin acetate spray
....................................................................................................... 86
DESOGEN ................................................................. 54
desogestrel-ethinyl estradiol
....................................................................................................... 54
DESONATE ............................................................ 68
desonide ........................................................................ 68
DESOWEN ............................................................... 68
desoximetasone
....................................................................................................... 68
DESOXYN .................................................................... 3
desvenlafaxine er
....................................................................................................... 22
DETROL LA ...................................................... 147
DEX4 .................................................................................. 25
DEX4 GLUCOSE
diatrue control level 1
.......................................................................................................
25
DEX4 NATURALS
.......................................................................................................
101
diatrue control level 2
25
DEX4 POUCH PACK
25
DEX4 QUICK DISSOLVE
GLUCOSE ................................................................. 25
dexamethasone
....................................................................................................... 58
DEXAMETHASONE INTENSOL
....................................................................................................... 58
dexamethasone sodium phosphate
................................................................................................... 135
DEXEDRINE
........................................................................................................... 3
DEXILANT .......................................................... 146
dexmethylphenidate hcl
........................................................................................................... 4
dexmethylphenidate hcl er
........................................................................................................... 4
DEXPAK 10 DAY
....................................................................................................... 58
DEXPAK 13 DAY
....................................................................................................... 58
DEXPAK 6 DAY
....................................................................................................... 58
dextroamphetamine sulfate
........................................................................................................... 3
dextroamphetamine sulfate er
........................................................................................................... 3
DIABETA ................................................................... 27
diabetic.com test
....................................................................................................... 74
DIALYVITE ....................................................... 124
DIALYVITE 3000
................................................................................................... 125
DIALYVITE 5000
................................................................................................... 125
DIALYVITE SUPREME D
................................................................................................... 125
DIALYVITE/ZINC
................................................................................................... 125
DIAMOX SEQUELS
....................................................................................................... 81
DIASTAR EASY TEST II
LANCETS .............................................................. 101
DIASTAR EASY TEST
LANCETS .............................................................. 101
DIASTAT ACUDIAL
....................................................................................................... 18
DIASTAT PEDIATRIC
....................................................................................................... 18
DIASTIX ...................................................................... 74
.......................................................................................................
...................................................................................................
...................................................................................................
101
diatrue control level 3
...................................................................................................
101
diatrue plus test
74
diazepam ...................................................................... 15
DIAZEPAM INTENSOL
....................................................................................................... 15
DIBENZYLINE
....................................................................................................... 33
DICLEGIS .................................................................. 29
diclofenac potassium
........................................................................................................... 7
diclofenac sodium
............................................................................... 7, 66, 137
diclofenac sodium er
........................................................................................................... 7
diclofenac-misoprostol
........................................................................................................... 7
dicloxacillin sodium
................................................................................................... 140
dicyclomine hcl
................................................................................................... 145
didanosine ................................................................. 47
DIFFERIN .................................................................. 63
DIFICID ......................................................................... 97
DIFIL-G FORTE
....................................................................................................... 16
diflorasone diacetate
....................................................................................................... 68
DIFLUCAN .............................................................. 29
diflunisal .......................................................................... 9
DIGIBAR 190
....................................................................................................... 81
DIGOX ............................................................................. 52
digoxin ............................................................................ 52
dihydroergotamine mesylate
................................................................................................... 121
DILACOR XR
....................................................................................................... 51
DILANTIN ................................................................ 20
DILANTIN INFATABS
....................................................................................................... 20
DILATRATE-SR
....................................................................................................... 14
DILAUDID ................................................................... 9
dilt-cd ............................................................................... 51
diltiazem hcl ........................................................... 52
diltiazem hcl cd
....................................................................................................... 52
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
161
Index
Index
Index
diltiazem hcl er
doxycycline monohydrate
DUET DHA 430EC
.......................................................................................................
52
diltiazem hcl er beads
.......................................................................................................
52
diltiazem hcl er coated beads
52
dilt-xr ................................................................................ 51
diltzac ............................................................................... 52
DIMETANE DX
....................................................................................................... 60
DIOVAN ....................................................................... 33
DIOVAN HCT
....................................................................................................... 35
DIPENTUM ............................................................. 88
diphenatol .................................................................. 28
diphenoxylate-atropine
....................................................................................................... 28
DIPROLENE .......................................................... 68
DIPROLENE AF
....................................................................................................... 68
dipyridamole .......................................................... 92
discount drug mart test
....................................................................................................... 75
disopyramide phosphate
....................................................................................................... 15
disulfiram ............................................................... 140
DITROPAN XL
................................................................................................... 148
DIURIL ........................................................................... 82
divalproex sodium
....................................................................................................... 20
divalproex sodium er
....................................................................................................... 20
DIVIGEL ...................................................................... 87
DIVISTA ...................................................................... 94
DOLOPHINE
........................................................................................................... 9
donepezil hcl ...................................................... 141
DONNATAL ...................................................... 145
DONNATAL EXTENTABS
................................................................................................... 145
DORAL ........................................................................... 96
DORYX ...................................................................... 144
dorzolamide hcl
................................................................................................... 136
dorzolamide hcl-timolol mal
................................................................................................... 132
DOVONEX ............................................................... 66
doxazosin mesylate
....................................................................................................... 34
doxepin hcl ............................................................... 23
doxycycline hyclate
................................................................................................... 144
.......................................................................................................
144
DOXYTEX ................................................................ 30
DRISDOL ................................................................ 149
DRITHO-CREME HP
....................................................................................................... 66
dronabinol ................................................................. 29
DROPLET LANCETS ULTRA
THIN 30G ............................................................... 101
DROPLET LANCING DEVICE
................................................................................................... 101
drospirenone-ethinyl estradiol
....................................................................................................... 54
DROXIA ....................................................................... 93
drug emporium test
....................................................................................................... 75
drug mart glucose
....................................................................................................... 25
drug mart lancets thin 26g
................................................................................................... 101
drug mart lancets ultra thin
................................................................................................... 101
DRUG MART LANCING
DEVICE ..................................................................... 101
DRUG MART ON-THE-GO
LANCET 30G
................................................................................................... 101
drug mart unifine pentips
................................................................................................... 113
DRUG MART UNILET
LANCETS 28G
................................................................................................... 101
DRUG MART UNILET
LANCETS 30G
................................................................................................... 101
DUAC ................................................................................ 62
duane reade lancet altern site
................................................................................................... 101
duane reade lancet super thin
................................................................................................... 101
duane reade lancet ultra thin
................................................................................................... 101
duane reade test
....................................................................................................... 75
duane reade unifine pentips
................................................................................................... 113
DUAVEE ..................................................................... 87
DUET DHA .......................................................... 126
DUET DHA 400
................................................................................................... 126
DUET DHA 400EC
................................................................................................... 126
DUET DHA 430
................................................................................................... 126
...................................................................................................
...................................................................................................
...................................................................................................
127
DUET DHA COMPLETE
...................................................................................................
127
DUET DHA EC
127
DUETACT ................................................................. 24
DUEXIS ............................................................................. 7
DULERA ...................................................................... 17
duloxetine hcl
....................................................................................................... 22
DUO-CARE CONTROL
SOLUTION .......................................................... 101
DUO-CARE TEST
....................................................................................................... 75
DUONEB ..................................................................... 17
DURAGESIC-100
........................................................................................................... 9
DURAGESIC-12
........................................................................................................... 9
DURAGESIC-25
........................................................................................................... 9
DURAGESIC-50
........................................................................................................... 9
DURAGESIC-75
........................................................................................................... 9
DURAPREP ............................................................ 46
duraxin ............................................................................... 8
DUREZOL ............................................................. 136
DUTOPROL ............................................................ 36
DYAZIDE ................................................................... 81
DYMISTA .............................................................. 131
DYRENIUM ........................................................... 82
DYSPORT .............................................................. 132
E.E.S. 400 .................................................................... 97
E.E.S. GRANULES
....................................................................................................... 97
E.S.P. .................................................................................. 37
earloop mask
................................................................................................... 117
EASIVENT ........................................................... 119
EASIVENT MASK LARGE
................................................................................................... 119
EASIVENT MASK MEDIUM
................................................................................................... 119
EASIVENT MASK SMALL
................................................................................................... 119
easy check control
................................................................................................... 101
easy check glucose test
....................................................................................................... 75
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
162
126
DUET DHA BALANCED
Index
Index
Index
easy comfort insulin syringe
EASY TOUCH LANCETS
32G/TWIST .......................................................... 102
EASY TOUCH LANCETS
33G/TWIST .......................................................... 102
EASY TOUCH LANCING
DEVICE ..................................................................... 102
EASY TOUCH PEN NEEDLES
................................................................................................... 114
EASY TOUCH SAFETY
LANCETS 21G
................................................................................................... 102
EASY TOUCH SAFETY
LANCETS 23G
................................................................................................... 102
EASY TOUCH SAFETY
LANCETS 26G
................................................................................................... 102
EASY TOUCH SAFETY
LANCETS 28G
................................................................................................... 102
EASY TOUCH TEST
....................................................................................................... 75
easy trak blood glucose test
....................................................................................................... 75
easy trak control
................................................................................................... 102
EASY TWIST & CAP LANCETS
................................................................................................... 102
EASYGLUCO
....................................................................................................... 75
EASYGLUCO CONTROL
................................................................................................... 102
EASYMAX 15 LEVEL 1
CONTROL ............................................................. 102
EASYMAX 15 LEVEL 2
CONTROL ............................................................. 102
EASYMAX 15 TEST
....................................................................................................... 75
EASYMAX CONTROL
................................................................................................... 102
EASYMAX TEST
....................................................................................................... 75
easyplus blood glucose test
....................................................................................................... 75
EASYPRO BLOOD GLUCOSE
TEST ................................................................................... 75
EASYPRO PLUS
....................................................................................................... 75
EASYTEST II LANCETS
................................................................................................... 102
EASYTEST LANCETS
................................................................................................... 102
ECLIPSE CONTROL
................................................................................................... 102
ECLIPSE TEST
...................................................................................................
113
easy comfort lancets
...................................................................................................
101
easy comfort pen needles
...................................................................................................
113
easy mini lancing device
...................................................................................................
101
easy plus blood glucose test
.......................................................................................................
75
easy plus control
...................................................................................................
101
easy plus ii control
...................................................................................................
101
easy plus ii glucose test
.......................................................................................................
75
EASY STEP CONTROL
...................................................................................................
101
EASY STEP TEST
.......................................................................................................
75
easy talk blood glucose test
.......................................................................................................
75
easy talk control
101
EASY TOUCH ALCOHOL PREP
MEDIUM ................................................................. 111
EASY TOUCH CONTROL HIGH
& LOW ........................................................................ 101
EASY TOUCH HEALTHPRO
TEST ................................................................................... 75
EASY TOUCH INSULIN
SAFETY SYR
................................................................................................... 113
EASY TOUCH INSULIN
SYRINGE ................................................................ 113
easy touch lancets
................................................................................................... 101
EASY TOUCH LANCETS 21G
................................................................................................... 101
EASY TOUCH LANCETS 23G
................................................................................................... 102
EASY TOUCH LANCETS 26G
................................................................................................... 102
EASY TOUCH LANCETS 28G
................................................................................................... 102
EASY TOUCH LANCETS
28G/TWIST .......................................................... 102
EASY TOUCH LANCETS 30G
................................................................................................... 102
EASY TOUCH LANCETS
30G/TWIST .......................................................... 102
EASY TOUCH LANCETS 32G
................................................................................................... 102
...................................................................................................
.......................................................................................................
75
EC-NAPROSYN
...........................................................................................................
7
econazole nitrate
64
ECOZA ............................................................................ 64
ed baclofen ........................................................... 130
ED CHLORPED
....................................................................................................... 30
ED CYTE F .............................................................. 94
EDARBI ......................................................................... 33
EDARBYCLOR
....................................................................................................... 35
ED-CHLOR-TAN
....................................................................................................... 30
EDECRIN .................................................................... 82
EDEX ................................................................................. 52
ED-FLEX ......................................................................... 8
EDLUAR ...................................................................... 96
ed-spaz ........................................................................ 145
EDURANT ................................................................ 47
EEMT ................................................................................. 86
EEMT HS .................................................................... 86
EFFER-K .................................................................. 122
effervescent pot chloride
................................................................................................... 122
EFFEXOR XR
........................................................................................... 22, 23
EFFIENT ...................................................................... 93
EFLOW SCF AEROSOL HEAD
................................................................................................... 118
EFUDEX ....................................................................... 65
ELAPRASE .............................................................. 85
ELDEPRYL ............................................................. 43
ELELYSO ................................................................... 93
element compact control 2
................................................................................................... 102
element compact control 3
................................................................................................... 102
element compact test
....................................................................................................... 75
ELEMENT CONTROL
................................................................................................... 102
ELEMENT PLUS CONTROL
................................................................................................... 102
ELEMENT PLUS TEST
....................................................................................................... 75
ELEMENT TEST
....................................................................................................... 75
ELESTAT ................................................................ 136
ELESTRIN ................................................................. 87
ELIDEL .......................................................................... 71
ELIGARD ................................................................... 40
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
163
Index
Index
Index
ELIMITE ...................................................................... 72
ELINEST ...................................................................... 54
ELIPHOS ..................................................................... 89
ELIQUIS ....................................................................... 18
ELITE DC AUTO ADAPTER
................................................................................................... 118
ELITE-OB .............................................................. 127
ELITE-OB 400
................................................................................................... 127
elite-thin insulin syringe
................................................................................................... 114
ELIXOPHYLLIN
....................................................................................................... 17
ELMIRON .................................................................. 90
ELOCON ...................................................................... 68
EMADINE ............................................................. 136
EMBRACE BLOOD GLUCOSE
TEST ................................................................................... 75
EMBRACE CONTROL
................................................................................................... 102
EMBRACE EVO BLOOD
GLUCOSE TEST
....................................................................................................... 75
EMBRACE PRO GLUCOSE
TEST ................................................................................... 75
EMCYT .......................................................................... 40
EMEND .......................................................................... 29
EMLA ................................................................................ 71
EMOQUETTE
....................................................................................................... 54
EMSAM ......................................................................... 21
EMTRIVA .................................................................. 47
enalapril maleate
....................................................................................................... 33
enalapril-hydrochlorothiazide
....................................................................................................... 34
ENBREL ........................................................................... 8
ENBREL SURECLICK
........................................................................................................... 8
ENCARE .................................................................. 148
ENDOCET ................................................................. 12
ENDODAN ............................................................... 12
ENDOMETRIN
................................................................................................... 149
ENDUR-ACIN
................................................................................................... 150
ENJUVIA ..................................................................... 87
enoxaparin sodium
....................................................................................................... 18
ENPRESSE-28
....................................................................................................... 57
ENSKYCE ................................................................. 54
entacapone ............................................................... 43
ENTERO VU
ergocalciferol
.......................................................................................................
81
ENTOCORT EC
58
enulose ............................................................................ 88
ENVISION AUTOCODE TEST
....................................................................................................... 75
ENVISION CONTROL
................................................................................................... 102
EPANED ....................................................................... 33
EPIDRIN ................................................................... 120
EPIDUO ......................................................................... 62
EPIFLUR .................................................................. 121
EPIFOAM ................................................................... 69
EPIKLOR ................................................................. 122
epinastine hcl
................................................................................................... 136
epinephrine hcl
....................................................................................................... 17
EPIPEN 2-PAK
................................................................................................... 149
EPIPEN JR ............................................................. 149
EPIPEN JR 2-PAK
................................................................................................... 149
EPITOL ........................................................................... 19
EPIVIR ............................................................................. 47
EPIVIR HBV .......................................................... 47
eplerenone ................................................................. 36
epoprostenol sodium
....................................................................................................... 52
eprosartan mesylate
....................................................................................................... 33
EPZICOM ................................................................... 46
eql color lancets 21g
................................................................................................... 102
eql color lancets micro 33g
................................................................................................... 102
eql niacin ................................................................. 150
eql short pen needle
................................................................................................... 114
eql super thin lancets 30g
................................................................................................... 102
eql thin lancets 26g
................................................................................................... 102
EQL TRUETEST TEST
....................................................................................................... 75
EQL TRUETRACK TEST
....................................................................................................... 75
eql ultra short pen needle
................................................................................................... 114
EQUAGESIC
........................................................................................................... 8
EQUETRO ................................................................. 43
.......................................................................................................
149
ERGOMAR .......................................................... 121
ERIVEDGE .............................................................. 39
ERRIN .............................................................................. 58
ERTACZO ................................................................. 64
ery .......................................................................................... 61
ERYGEL ....................................................................... 61
ERYPED 200
....................................................................................................... 97
ERYPED 400
....................................................................................................... 97
ERY-TAB .................................................................... 97
ERYTHROCIN STEARATE
....................................................................................................... 97
erythromycin .......................................... 61, 133
erythromycin base
....................................................................................................... 97
erythromycin-sulfisoxazole
....................................................................................................... 37
ESCAVITE ............................................................ 125
ESCAVITE LQ
................................................................................................... 125
escitalopram oxalate
....................................................................................................... 21
ESGIC ................................................................................... 8
esomeprazole strontium
................................................................................................... 146
ESSIAN .......................................................................... 86
ESSIAN H.S. .......................................................... 86
est estrogens-methyltest
....................................................................................................... 86
est estrogens-methyltest ds
....................................................................................................... 86
est estrogens-methyltest hs
....................................................................................................... 86
ESTARYLLA
....................................................................................................... 54
estazolam .................................................................... 96
ESTRACE ................................................... 87, 149
ESTRADERM
....................................................................................................... 87
estradiol ........................................................................ 87
estradiol-norethindrone acet
....................................................................................................... 86
ESTRASORB
....................................................................................................... 87
ESTRING ................................................................. 149
ESTROGEL ............................................................. 87
estropipate ................................................................ 87
ESTROSTEP FE
....................................................................................................... 57
eszopiclone ............................................................... 96
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
164
Index
Index
Index
ethambutol hcl
EXTAVIA ............................................................... 142
EXTINA ......................................................................... 64
extra-virt plus dha
................................................................................................... 129
EYLEA ........................................................................ 133
E-Z JECT LANCET
MICRO-THIN 33G
................................................................................................... 101
E-Z JECT LANCET SUPER
THIN 30G ............................................................... 101
E-Z JECT LANCETS
................................................................................................... 101
E-Z JECT LANCETS 21G
................................................................................................... 101
E-Z JECT LANCETS THIN 26G
................................................................................................... 101
EZ SMART BLOOD GLUCOSE
LANCETS .............................................................. 102
EZ SMART BLOOD GLUCOSE
TEST ................................................................................... 76
EZ SMART PLUS GLUCOSE
TEST ................................................................................... 76
E-Z SPACER ...................................................... 119
E-Z SPACER THE BODY
GUARDS PK
................................................................................................... 119
E-Z-CAT DRY
....................................................................................................... 81
E-Z-DISK ..................................................................... 81
E-Z-DOSE .................................................................. 81
E-Z-HD ............................................................................ 81
EZ-LETS LANCETS 21G
................................................................................................... 102
EZ-LETS LANCETS 23G
................................................................................................... 102
EZ-LETS LANCETS 26G
................................................................................................... 102
EZ-LETS LANCETS 28G
................................................................................................... 102
EZ-LETS LANCETS 30G
................................................................................................... 103
E-Z-PAQUE ............................................................. 81
E-Z-PASTE ............................................................... 81
fabb ...................................................................................... 94
FABIOR ......................................................................... 63
FABRAZYME
....................................................................................................... 85
FACTIVE ..................................................................... 87
fa-cyanocobalamin-pyridoxine
....................................................................................................... 94
FALESSA .................................................................... 54
FALMINA .................................................................. 54
famciclovir ................................................................ 48
famotidine .............................................................. 145
FAMVIR ....................................................................... 49
FANAPT ....................................................................... 44
FANAPT TITRATION PACK
....................................................................................................... 44
FARESTON ............................................................. 39
FARXIGA ................................................................... 27
FASLODEX ............................................................. 40
FASTTAKE TEST
....................................................................................................... 76
fa-vitamin b-6-vitamin b-12
....................................................................................................... 94
FAZACLO ..................................................... 44, 45
FC FEMALE CONDOM
....................................................................................................... 98
FC2 FEMALE CONDOM
....................................................................................................... 98
fe 90 plus ..................................................................... 95
FEIBA NF ................................................................... 91
FEIBA VH IMMUNO
....................................................................................................... 91
felbamate ..................................................................... 20
FELBATOL ............................................................. 20
FELDENE ....................................................................... 7
felodipine er ............................................................ 52
FEM PH ...................................................................... 148
FEMARA ..................................................................... 40
FEMCAP ...................................................................... 98
FEMCON FE .......................................................... 54
FEMHRT 1/5 .......................................................... 86
FEMHRT LOW DOSE
....................................................................................................... 86
FEMRING .............................................................. 149
fenofibrate ................................................................. 31
fenofibrate micronized
....................................................................................................... 31
fenofibric acid
....................................................................................................... 31
FENOGLIDE ......................................................... 31
fentanyl ............................................................................... 9
fentanyl citrate
........................................................................................................... 9
FENTORA ..................................................................... 9
FERIVA ......................................................................... 94
FERIVAFA ............................................................... 94
ferocon ............................................................................ 94
ferotrin ............................................................................ 94
ferotrinsic ................................................................... 94
FERRALET 90
....................................................................................................... 95
ferraplus 90 ............................................................. 95
ferrex 150 forte
....................................................................................................... 94
FERREX 150 FORTE PLUS
....................................................................................................... 94
38
ethosuximide .......................................................... 20
etodolac ............................................................................. 7
etodolac er .................................................................... 7
EURAX ........................................................................... 72
EVAMIST ................................................................... 87
EVENCARE + BLOOD
GLUCOSE TEST
....................................................................................................... 76
EVENCARE BLOOD GLUCOSE
TEST ................................................................................... 76
EVENCARE CONTROL
LOW/HIGH .......................................................... 102
EVENCARE G2 LOW/HIGH
CONTROL ............................................................. 102
EVENCARE G2 TEST
....................................................................................................... 76
EVENCARE G3 LOW/HIGH
CONTROL ............................................................. 102
EVENCARE G3 TEST
....................................................................................................... 76
EVICEL .......................................................................... 95
EVISTA .......................................................................... 84
EVOCLIN ................................................................... 61
EVOLUTION AUTOCODE
....................................................................................................... 76
EVOLUTION CONTROL
................................................................................................... 102
EVOXAC ................................................................. 124
EVZIO .............................................................................. 28
EXACTECH R-S-G TEST
....................................................................................................... 76
EXACTECH TEST
....................................................................................................... 76
EXACTUSS ............................................................. 60
EXALGO ......................................................................... 9
exel pen needles 1/2"
................................................................................................... 114
EXEL PEN NEEDLES 1/3"
................................................................................................... 114
exel pen needles 1/4"
................................................................................................... 114
EXELDERM ........................................................... 64
EXELON .................................................................. 141
exemestane ............................................................... 40
EXFORGE ................................................................. 35
EXFORGE HCT
....................................................................................................... 36
EXJADE ........................................................................ 28
EXODERM ............................................................... 64
exotic-hc ................................................................... 138
express med test strip pack
....................................................................................................... 76
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
165
Index
Index
Index
FERREX 28 .............................................................. 95
FERRIPROX .......................................................... 28
FERRLECIT ............................................................ 95
FERROCITE PLUS
....................................................................................................... 94
FERROGELS FORTE
....................................................................................................... 94
FERRO-PLEX HEMATINIC
....................................................................................................... 94
FERROTRIN .......................................................... 94
FETZIMA .................................................................... 23
FETZIMA TITRATION
....................................................................................................... 23
FEXMID .................................................................... 130
FIBRICOR ................................................................. 31
FIFTY50 ALCOHOL PREP
................................................................................................... 111
FIFTY50 CONTROL 2.0
................................................................................................... 103
FIFTY50 GLUCOSE TEST 2.0
....................................................................................................... 76
FIFTY50 LANCING DEVICE
................................................................................................... 103
FIFTY50 PEN NEEDLES
................................................................................................... 114
FIFTY50 SAFETY SEAL
LANCETS .............................................................. 103
FIFTY50 SUPERIOR COMFORT
SYR ................................................................................... 114
filter air pp ........................................................... 118
FINACEA .................................................................... 72
finasteride .................................................................. 90
FINE 30 ....................................................................... 103
FINGERSTIX LANCETS
................................................................................................... 103
FIORICET ...................................................................... 8
FIORICET/CODEINE
....................................................................................................... 11
FIORINAL ..................................................................... 8
FIORINAL/CODEINE #3
....................................................................................................... 11
FIRAZYR .................................................................... 92
FIRMAGON ............................................................ 40
FIRST-PROGESTERONE VGS
100 ...................................................................................... 149
FIRST-PROGESTERONE VGS
200 ...................................................................................... 149
FIRST-PROGESTERONE VGS
25 .......................................................................................... 149
FIRST-PROGESTERONE VGS
400 ...................................................................................... 149
FIRST-PROGESTERONE VGS
50 .......................................................................................... 149
FIRST-VANCOMYCIN 25
fluorometholone
.......................................................................................................
37
FIRST-VANCOMYCIN 50
37
FLAGYL ....................................................................... 37
FLAGYL ER ........................................................... 37
FLAREX ................................................................... 136
FLEBOGAMMA
................................................................................................... 139
FLEBOGAMMA DIF
................................................................................................... 139
flecainide acetate
....................................................................................................... 15
FLECTOR ................................................................... 65
FLOMAX ..................................................................... 90
FLONASE .............................................................. 131
FLO-PRED ................................................................ 58
FLOVENT DISKUS
....................................................................................................... 16
FLOVENT HFA
....................................................................................................... 16
FLUCAINE ........................................................... 136
fluconazole ............................................................... 29
flucytosine .................................................................. 29
fludrocortisone acetate
....................................................................................................... 59
FLUMADINE
....................................................................................................... 49
flunisolide .............................................................. 131
fluocinolone acetonide
....................................................................................... 68, 138
fluocinolone acetonide body
....................................................................................................... 68
fluocinolone acetonide scalp
....................................................................................................... 68
fluocinonide ............................................................ 68
fluocinonide-e
....................................................................................................... 68
FLUORABON
................................................................................................... 121
FLUOR-A-DAY
................................................................................................... 121
fluorescein-benoxinate
................................................................................................... 136
FLUORIDEX DAILY DEFENSE
................................................................................................... 123
FLUORIDEX ENHANCED
WHITENING
................................................................................................... 123
FLUORIDEX SENSITIVITY
RELIEF ....................................................................... 123
FLUOR-I-STRIPS A.T.
................................................................................................... 136
fluoritab .................................................................... 121
.......................................................................................................
136
FLUOR-OP ........................................................... 136
FLUOROPLEX
....................................................................................................... 65
fluorouracil .............................................................. 65
fluoxetine hcl
....................................................................................................... 21
fluoxetine hcl (pmdd)
................................................................................................... 142
fluphenazine hcl
....................................................................................................... 45
FLURA-DROPS
................................................................................... 121, 122
FLURA-SAFE
................................................................................................... 136
flurazepam hcl
....................................................................................................... 96
flurbiprofen .................................................................. 7
flurbiprofen sodium
................................................................................................... 137
FLUROX .................................................................. 136
flutamide ...................................................................... 39
fluticasone propionate
....................................................................................... 68, 131
fluvastatin sodium
....................................................................................................... 32
fluvoxamine maleate
....................................................................................................... 21
fluvoxamine maleate er
....................................................................................................... 21
FML .................................................................................. 136
FML FORTE ...................................................... 136
FML LIQUIFILM
................................................................................................... 136
focalgin-b ............................................................... 130
FOCALIN ........................................................................ 4
FOCALIN XR
........................................................................................................... 4
folbee ................................................................................. 94
folbee plus ............................................................. 124
FOLBEE PLUS CZ
................................................................................................... 125
folcal dha ................................................................ 129
FOLCAPS ................................................................... 94
FOLCAPS OMEGA 3
................................................................................................... 127
FOLGARD OS
................................................................................................... 125
folic acid ...................................................................... 93
FOLIVANE-EC CALCIUM DHA
NF ........................................................................................ 129
FOLIVANE-F
....................................................................................................... 95
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
166
Index
Index
Index
FOLIVANE-OB
FORADIL AEROLIZER
FURADANTIN
...................................................................................................
127
FOLIVANE-PLUS
.......................................................................................................
94
FOLIVANE-PRX DHA NF
129
folplex 2.2 ................................................................... 94
foltrin ................................................................................ 94
fondaparinux sodium
....................................................................................................... 18
FORA CONTROL
................................................................................................... 103
FORA D10 BLOOD GLUCOSE
TEST ................................................................................... 76
FORA D15C BLOOD GLUCOSE
TEST ................................................................................... 76
FORA D15G BLOOD GLUCOSE
TEST ................................................................................... 76
FORA D15Z BLOOD GLUCOSE
TEST ................................................................................... 76
FORA D20 BLOOD GLUCOSE
TEST ................................................................................... 76
FORA G20 BLOOD GLUCOSE
TEST ................................................................................... 76
FORA G30A BLOOD GLUCOSE
TEST ................................................................................... 76
FORA G71A BLOOD GLUCOSE
TEST ................................................................................... 76
FORA G90 BLOOD GLUCOSE
TEST ................................................................................... 76
FORA GD20 TEST
....................................................................................................... 76
FORA LANCETS
................................................................................................... 103
FORA LANCING DEVICE
................................................................................................... 103
FORA V10 BLOOD GLUCOSE
TEST ................................................................................... 76
FORA V12 BLOOD GLUCOSE
TEST ................................................................................... 76
FORA V20 BLOOD GLUCOSE
TEST ................................................................................... 76
FORA V22 BLOOD GLUCOSE
TEST ................................................................................... 76
FORA V30A BLOOD GLUCOSE
TEST ................................................................................... 76
FORACARE GD40 TEST
....................................................................................................... 76
FORACARE GDH CONTROL
................................................................................................... 103
FORACARE PREMIUM V10
TEST ................................................................................... 77
FORACARE TEST N GO TEST
....................................................................................................... 77
...................................................................................................
17
FORANE ...................................................................... 89
FORFIVO XL
....................................................................................................... 21
FORMADON
....................................................................................................... 46
FORMALAZ .......................................................... 46
formaldehyde
....................................................................................................... 46
FORMA-RAY
....................................................................................................... 46
FORTEO ....................................................................... 83
FORTESTA .............................................................. 13
FOSAMAX ............................................................... 83
FOSAMAX PLUS D
....................................................................................................... 83
FOSCAVIR ............................................................... 47
fosinopril sodium
....................................................................................................... 33
fosinopril sodium-hctz
....................................................................................................... 34
FOSRENOL ............................................................. 89
FRAGMIN ................................................................. 18
freds pharmacy autolet lancing
................................................................................................... 103
freds pharmacy unifine pentip+
................................................................................................... 114
freds pharmacy unifine pentips
................................................................................................... 114
freds pharmacy unilet lanc 28g
................................................................................................... 103
freds pharmacy unilet lanc 30g
................................................................................................... 103
FREESTYLE CONTROL
SOLUTION .......................................................... 103
FREESTYLE INSULINX TEST
....................................................................................................... 77
FREESTYLE LANCETS
................................................................................................... 103
FREESTYLE LITE TEST
....................................................................................................... 77
FREESTYLE PRECISION INS
SYR ................................................................................... 114
FREESTYLE TEST
....................................................................................................... 77
FREESTYLE UNISTICK II
LANCETS .............................................................. 103
FROVA ....................................................................... 121
FUL-GLO ................................................................ 137
full kit nebulizer set
................................................................................................... 118
FULYZAQ ................................................................. 28
.......................................................................................................
147
furosemide ................................................................. 82
FUSION PLUS
....................................................................................................... 94
FUZEON ....................................................................... 46
FYCOMPA ................................................................ 18
gabapentin ................................................................ 19
GABITRIL ................................................................. 20
galantamine hydrobromide
................................................................................................... 141
galantamine hydrobromide er
................................................................................................... 141
GALZIN ..................................................................... 123
GAMASTAN S/D
................................................................................................... 139
GAMMAGARD
................................................................................................... 139
GAMMAGARD S/D
................................................................................................... 139
GAMMAGARD S/D LESS IGA
................................................................................................... 139
GAMMAPLEX
................................................................................................... 139
GAMUNEX ......................................................... 139
ganciclovir sodium
....................................................................................................... 48
GANITE ......................................................................... 83
gani-tuss nr .............................................................. 59
GARAMYCIN
................................................................................................... 133
GASTRINEX NF
................................................................................................... 145
GASTROCROM
....................................................................................................... 88
GASTROGRAFIN
....................................................................................................... 81
GASTROMARK
....................................................................................................... 81
gatifloxacin .......................................................... 133
GATTEX ...................................................................... 89
GAVILYTE-C
....................................................................................................... 97
GAVILYTE-G
....................................................................................................... 97
GAVILYTE-N WITH FLAVOR
PACK ................................................................................. 97
ge100 blood glucose test
....................................................................................................... 77
ge100 control
................................................................................................... 103
GEBAUERS PAIN EASE
....................................................................................................... 72
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
167
Index
Index
Index
GEBAUERS SPRAY AND
STRETCH ................................................................... 72
GELCLAIR ........................................................... 124
GELFILM ................................................................ 136
GEL-ONE ................................................................ 131
GELX ............................................................................. 124
gemfibrozil ................................................................ 31
GENERESS FE
....................................................................................................... 54
generlac ........................................................................ 89
GENGRAF ................................................................. 49
GENOTROPIN
....................................................................................................... 83
GENOTROPIN MINIQUICK
....................................................................................................... 83
GENTAK ................................................................. 133
gentamicin sulfate
....................................................................................... 64, 133
gentasol ..................................................................... 133
GENTLE-LET GP LANCETS
................................................................................................... 103
GENTLE-LET LANCETS
................................................................................................... 103
GENTLE-LET PLATFORMS
................................................................................................... 103
GEODON ..................................................................... 43
GESTICARE DHA
................................................................................................... 129
ght test ............................................................................. 77
giant eagle pharm test
....................................................................................................... 77
GIANVI .......................................................................... 54
GIAZO ............................................................................. 88
GILDAGIA ............................................................... 54
GILDESS 1.5/30
....................................................................................................... 54
GILDESS 1/20
....................................................................................................... 54
GILDESS FE 1.5/30
....................................................................................................... 54
GILDESS FE 1/20
....................................................................................................... 54
GILENYA ............................................................... 142
GILOTRIF .................................................................. 41
GILPHEX TR
....................................................................................................... 60
GILTUSS ..................................................................... 60
GILTUSS PED-C
....................................................................................................... 60
GILTUSS TR
....................................................................................................... 60
GLASSIA ................................................................. 143
GLEEVEC .................................................................. 41
glimepiride ............................................................... 27
glipizide ......................................................................... 27
glipizide er ................................................................ 27
GLIPIZIDE XL
....................................................................................................... 27
glipizide-metformin hcl
....................................................................................................... 24
global alcohol prep ease
................................................................................................... 111
global ease inject pen needles
................................................................................................... 114
global inject ease insulin syr
................................................................................................... 114
global inject ease lancets 28g
................................................................................................... 103
global inject ease lancets 30g
................................................................................................... 103
global lancing device
................................................................................................... 103
GLUCAGEN .......................................................... 25
GLUCAGEN HYPOKIT
....................................................................................................... 25
GLUCAGON EMERGENCY
....................................................................................................... 25
GLUCO BURST
....................................................................................................... 25
GLUCO PERFECT 3 TEST
....................................................................................................... 77
GLUCOCARD 01 CONTROL
................................................................................................... 103
GLUCOCARD 01 SENSOR
....................................................................................................... 77
GLUCOCARD 01 TEST
....................................................................................................... 77
GLUCOCARD EXPRESSION
CONTROL ............................................................. 103
GLUCOCARD EXPRESSION
TEST ................................................................................... 77
GLUCOCARD VITAL TEST
....................................................................................................... 77
GLUCOCARD X-SENSOR
....................................................................................................... 77
GLUCOCARD X-SENSOR
CONTROL ............................................................. 103
GLUCOCOM CONTROL
................................................................................................... 103
GLUCOCOM LANCETS 28G
................................................................................................... 103
GLUCOCOM LANCETS 30G
................................................................................................... 103
GLUCOCOM LANCETS 33G
................................................................................................... 103
GLUCOCOM TEST
....................................................................................................... 77
GLUCOLAB CONTROL
...................................................................................................
77
GLUCOLET 2 AUTOMATIC
LANCING .............................................................. 103
GLUCONAVII BLOOD
GLUCOSE TEST
....................................................................................................... 77
GLUCOPHAGE
....................................................................................................... 24
GLUCOPHAGE XR
....................................................................................................... 24
GLUCOPRO INSULIN SYRINGE
................................................................................................... 114
glucose ............................................................................ 25
glucose control
................................................................................................... 103
GLUCOSOURCE LANCET
DEVICE ..................................................................... 103
GLUCOSOURCE LANCETS
................................................................................................... 103
GLUCOSTIX
....................................................................................................... 77
GLUCOTROL
....................................................................................................... 27
GLUCOTROL XL
....................................................................................................... 27
GLUCOVANCE
....................................................................................................... 24
GLUMETZA .......................................................... 24
GLUTOSE 15
....................................................................................................... 25
GLUTOSE 45
....................................................................................................... 25
glyburide ...................................................................... 27
glyburide micronized
........................................................................................... 27, 28
glyburide-metformin
....................................................................................................... 24
GLYCATE ............................................................. 145
glycine ............................................................................. 90
glycine urologic
....................................................................................................... 90
glycopyrrolate
................................................................................................... 145
glycron ............................................................................ 28
GLYNASE ................................................................. 28
GLYSET ........................................................................ 23
GMATE BLOOD GLUCOSE
TEST ................................................................................... 77
GMATE CONTROL LEVEL 2
................................................................................................... 103
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
168
103
GLUCOLAB TEST
Index
Index
Index
gnp alcohol swabs
guanfacine hcl
healthy accents lancing device
...................................................................................................
111
gnp clickfine pen needles
114
gnp glucose .............................................................. 25
gnp lancets ............................................................ 103
gnp lancets 21g
................................................................................................... 103
gnp lancets micro thin 33g
................................................................................................... 103
gnp lancets super thin 30g
................................................................................................... 103
gnp lancets thin
................................................................................................... 103
gnp lancets thin 26g
................................................................................................... 103
gnp micro thin lancets 33g
................................................................................................... 103
gnp niacin .............................................................. 150
gnp niacin tr ....................................................... 150
gnp quick dissolve glucose
....................................................................................................... 25
gnp super thin lancets 30g
................................................................................................... 103
GOLYTELY ............................................................ 97
GORDOFILM
....................................................................................................... 71
GORDONS UREA
....................................................................................................... 69
grafco silver nit applicator
....................................................................................................... 67
GRALISE ................................................................. 142
GRALISE STARTER
................................................................................................... 142
granisetron hcl
....................................................................................................... 28
GRANISOL .............................................................. 28
GRANIX ....................................................................... 93
GRIFULVIN V
....................................................................................................... 29
griseofulvin microsize
....................................................................................................... 29
griseofulvin ultramicrosize
....................................................................................................... 29
GRIS-PEG .................................................................. 29
grx hicort 25 ........................................................... 13
guaiatussin ac
....................................................................................................... 59
guaifenesin ac
....................................................................................................... 59
guaifenesin dac
....................................................................................................... 60
guaifenesin-codeine
....................................................................................................... 59
...................................................................................................
34
guiatuss ac ................................................................ 59
GYNAZOLE-1
................................................................................................... 148
GYNOL II ............................................................... 148
GYNOL II EXTRA STRENGTH
................................................................................................... 148
H&H THINLET LANCETS 26G
................................................................................................... 104
H&H THINLET LANCETS 30G
................................................................................................... 104
HAEMOLANCE
................................................................................................... 104
HAEMOLANCE LOW FLOW
LANCETS .............................................................. 104
HAEMOLANCE PLUS
................................................................................................... 104
HAEMOLANCE PLUS HIGH
FLOW ............................................................................ 104
HAEMOLANCE PLUS LOW
FLOW ............................................................................ 104
HAEMOLANCE PLUS MAX
FLOW ............................................................................ 104
HAEMOLANCE PLUS
PEDIATRIC FLOW
................................................................................................... 104
HALCION .................................................................. 96
halobetasol propionate
....................................................................................................... 68
HALOG .......................................................................... 68
haloperidol ............................................................... 44
haloperidol lactate
....................................................................................................... 44
HALOTIN ................................................................... 64
hc pram .......................................................................... 13
HEALTH ALLIANCE
....................................................................................................... 77
HEALTH CARE LANCING
DEVICE ..................................................................... 104
healthwise alcohol prep
................................................................................................... 111
healthwise lancets 30g
................................................................................................... 104
healthwise lancing pen
................................................................................................... 104
healthwise mini pen needles
................................................................................................... 114
healthwise pen needles
................................................................................................... 114
healthwise short pen needles
................................................................................................... 114
healthwise unifine pentips
................................................................................................... 114
.......................................................................................................
...................................................................................................
104
healthy accents unifine pentip
...................................................................................................
114
healthy accents unilet lancets
...................................................................................................
104
HEALTHY LIVING FILTERS
...................................................................................................
118
HEALTHY LIVING MASKS
...................................................................................................
118
HEALTHY LIVING
REPLACEMENT KIT
118
HEATHER ................................................................. 58
h-e-b incontrol adv lancing
................................................................................................... 104
h-e-b incontrol lancets 28g
................................................................................................... 104
h-e-b incontrol lancets 30g
................................................................................................... 104
h-e-b incontrol pen needles
................................................................................................... 114
HECORIA ................................................................... 50
HELIXATE FS
....................................................................................................... 91
HEMA-COMBISTIX
....................................................................................................... 80
hematinic plus complex
....................................................................................................... 94
hematinic plus vit/minerals
....................................................................................................... 94
hematinic/folic acid
....................................................................................................... 95
HEMATOGEN FA
....................................................................................................... 94
HEMATOGEN FORTE
....................................................................................................... 94
hemenatal ob
................................................................................................... 127
hemenatal ob + dha
................................................................................................... 127
hemetab ......................................................................... 95
HEMOCYTE PLUS
....................................................................................................... 94
HEMOCYTE-F
....................................................................................................... 95
hemocyte-plus
....................................................................................................... 94
HEMOFIL M .......................................................... 91
hemorrhoidal-hc
....................................................................................................... 13
HEMRIL-30 ............................................................. 14
HEPAGAM B
................................................................................................... 139
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
169
Index
Index
Index
HEPSERA ................................................................... 48
HETLIOZ ..................................................................... 96
HEXALEN ................................................................. 39
HIPREX ..................................................................... 147
HIZENTRA .......................................................... 139
HIZENTRA 20%
................................................................................................... 139
hm glucose ................................................................ 25
hm lancets micro thin 33g
................................................................................................... 104
hm lancets ultra thin 30g
................................................................................................... 104
hm niacin ................................................................. 150
HOMATROPAIRE
................................................................................................... 132
homatropine hbr
................................................................................................... 132
HORIZANT ......................................................... 143
HUMALOG KWIKPEN
....................................................................................................... 27
HUMALOG MIX 50/50
....................................................................................................... 27
HUMALOG MIX 50/50
KWIKPEN ................................................................. 27
HUMALOG MIX 50/50 PEN
....................................................................................................... 27
HUMALOG MIX 75/25
....................................................................................................... 27
HUMALOG MIX 75/25
KWIKPEN ................................................................. 27
HUMALOG MIX 75/25 PEN
....................................................................................................... 27
HUMALOG PEN
....................................................................................................... 27
HUMATE-P ............................................................. 91
HUMATROPE
....................................................................................................... 83
HUMATROPEN FOR 12MG
................................................................................................... 114
HUMATROPEN FOR 24MG
................................................................................................... 114
HUMATROPEN FOR 6MG
................................................................................................... 114
HUMIRA .......................................................................... 6
HUMIRA PEN
........................................................................................................... 6
HUMIRA PEN-CROHNS
STARTER ....................................................................... 6
HUMIRA PEN-PSORIASIS
STARTER ....................................................................... 6
HUMULIN 70/30 KWIKPEN
....................................................................................................... 27
HUMULIN 70/30 PEN
....................................................................................................... 27
HUMULIN N KWIKPEN
HYOMAX-SL
.......................................................................................................
27
HUMULIN N PEN
.......................................................................................................
27
27
HYCAMTIN ........................................................... 42
HYCET ............................................................................ 11
hydralazine hcl
....................................................................................................... 37
hydrochlorothiazide
....................................................................................................... 82
hydrocod polst-cpm polst er
....................................................................................................... 61
hydrocodone-acetaminophen
....................................................................................................... 11
hydrocodone-homatropine
....................................................................................................... 59
hydrocodone-ibuprofen
....................................................................................................... 11
hydrocortisone
............................................................................... 13, 58, 68
hydrocortisone ace-pramoxine
........................................................................................... 13, 69
hydrocortisone acetate
....................................................................................................... 14
hydrocortisone acetate-aloe
....................................................................................................... 69
hydrocortisone butyr lipo base
....................................................................................................... 68
hydrocortisone butyrate
....................................................................................................... 68
hydrocortisone valerate
....................................................................................................... 68
hydrocortisone-acetic acid
................................................................................................... 138
hydrocortisone-iodoquinol
....................................................................................................... 64
hydromet ...................................................................... 59
hydromorphone hcl
........................................................................................................... 9
hydroxychloroquine sulfate
....................................................................................................... 38
hydroxyurea ............................................................ 42
hydroxyzine hcl
....................................................................................................... 14
hydroxyzine pamoate
....................................................................................................... 14
hygel ................................................................................... 70
HYLIRA ........................................................................ 70
HYOMAX .............................................................. 145
HYOMAX-FT
................................................................................................... 145
145
HYOPHEN ............................................................ 147
hyoscyamine sulfate
................................................................................................... 145
hyoscyamine sulfate er
................................................................................................... 145
hyosyne ....................................................................... 145
HYPERCARE
....................................................................................................... 72
HYPERHEP B S/D
................................................................................................... 139
HYPERRHO S/D
................................................................................................... 139
HYPERSAL ............................................................. 61
HYPERTET S/D
................................................................................................... 139
HYPOLANCE AST LANCING
................................................................................................... 104
HYSKON ..................................................................... 73
hy-vee glucose
....................................................................................................... 25
hy-vee insulin syringe
................................................................................................... 114
HY-VEE LANCETS
................................................................................................... 104
hy-vee thin lancets
................................................................................................... 104
HYZAAR ..................................................................... 35
ibandronate sodium
....................................................................................................... 83
IBUDONE .................................................................. 11
ibuprofen ......................................................................... 7
ICLUSIG ....................................................................... 41
IFEREX 150 FORTE
....................................................................................................... 94
ILARIS ................................................................................. 6
ILEVRO ..................................................................... 137
ILOTYCIN ............................................................. 133
IMBRUVICA
....................................................................................................... 41
IMDUR ............................................................................ 14
imipramine hcl
....................................................................................................... 23
imipramine pamoate
....................................................................................................... 23
imiquimod .................................................................. 70
IMITREX ................................................................. 121
IMITREX STATDOSE SYSTEM
................................................................................................... 121
IMPLANON ............................................................ 57
IMURAN ...................................................................... 50
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
170
145
HYOMAX-SR
HUMULIN R U-500
(CONCENTRATED)
.......................................................................................................
...................................................................................................
Index
Index
Index
INATAL ADVANCE
INTERMEZZO
JANUMET XR
127
INATAL GT ........................................................ 127
INATAL ULTRA
................................................................................................... 127
INCIVEK ..................................................................... 48
INCRELEX ............................................................... 84
indapamide ............................................................... 82
INDERAL LA
....................................................................................................... 51
INDERAL XL
....................................................................................................... 51
INDOCIN ......................................................................... 7
indomethacin
........................................................................................................... 7
indomethacin er
........................................................................................................... 7
infanate balance
................................................................................................... 129
INFASURF ............................................................ 143
INFINITY BLOOD GLUCOSE
TEST ................................................................................... 77
INFINITY CONTROL
................................................................................................... 104
inhaler companions
................................................................................................... 118
inject-ease .............................................................. 114
INJECT-EASE AUTOMATIC
INJECTOR ............................................................. 114
INLYTA ......................................................................... 41
INNOSPIRE REPLACEMENT
FILTER ....................................................................... 118
INSPIREASE
................................................................................................... 119
INSPIREASE BAGS
................................................................................................... 119
INSPIREASE MOUTHPIECE
................................................................................................... 119
INSPIREASE RESERVOIR
BAGS ............................................................................. 119
INSPRA .......................................................................... 36
INSTA-GLUCOSE
....................................................................................................... 25
insupen pen needles
................................................................................................... 114
INSUPEN SENSITIVE
................................................................................................... 114
INSUPEN ULTRAFIN
................................................................................................... 114
INTEGRA F ............................................................. 95
INTEGRA PLUS
....................................................................................................... 94
INTELENCE .......................................................... 47
...................................................................................................
96
INTROL ......................................................................... 82
INTRON-A ................................................................ 42
INTROVALE
....................................................................................................... 56
INTUNIV ......................................................................... 4
INVEGA ........................................................................ 44
INVIRASE ................................................................. 47
INVOKANA ........................................................... 27
iophen c-nr ............................................................... 59
IOPIDINE ................................................................ 133
ipratropium bromide
....................................................................................... 16, 131
ipratropium-albuterol
....................................................................................................... 17
IPRIVASK ................................................................. 18
irbesartan ................................................................... 33
irbesartan-hydrochlorothiazide
....................................................................................................... 35
IROSPAN 24/6
....................................................................................................... 94
ISENTRESS ............................................................ 46
ISOCHRON ............................................................. 14
isoditrate er ............................................................. 14
isoflurane .................................................................... 89
isometheptene-apap-dichloral
................................................................................................... 120
isoniazid ....................................................................... 38
ISOPTIN SR ............................................................ 52
ISOPTO CARBACHOL
................................................................................................... 133
ISOPTO HOMATROPINE
................................................................................................... 132
ISOPTO HYOSCINE
................................................................................................... 132
ISORDIL TITRADOSE
....................................................................................................... 14
isosorbide dinitrate
....................................................................................................... 14
isosorbide dinitrate er
....................................................................................................... 14
isosorbide mononitrate
....................................................................................................... 14
isosorbide mononitrate er
....................................................................................................... 14
isovate .............................................................................. 68
ISTALOL ................................................................. 132
itraconazole ............................................................ 29
JAKAFI ........................................................................... 42
JALYN ............................................................................. 91
JANTOVEN ............................................................. 17
JANUMET ................................................................. 24
.......................................................................................................
24
JANUVIA .................................................................... 26
JENCYCLA ............................................................. 58
JENTADUETO
....................................................................................................... 24
JETREA ..................................................................... 137
JEVANTIQUE
....................................................................................................... 86
JOLESSA ..................................................................... 56
JOLIVETTE ............................................................. 58
J-TIP KIT W/VIAL ADAPTERS
................................................................................................... 114
JUBLIA ........................................................................... 64
JUNEL 1.5/30
....................................................................................................... 55
JUNEL 1/20 .............................................................. 55
JUNEL FE 1.5/30
....................................................................................................... 55
JUNEL FE 1/20
....................................................................................................... 55
JUXTAPID ................................................................ 32
KADIAN ........................................................................... 9
KALBITOR .............................................................. 92
KALETRA ................................................................. 46
kalexate .......................................................................... 50
KALYDECO ...................................................... 143
KAON-CL-10
................................................................................................... 122
KAPVAY ......................................................................... 4
KARBINAL ER
....................................................................................................... 30
KARIDIUM ......................................................... 122
KARIGEL ............................................................... 123
KARIGEL-N ....................................................... 123
KARIVA ....................................................................... 54
KAYEXALATE
....................................................................................................... 50
KAZANO ..................................................................... 24
KCENTRA ................................................................. 91
k-effervescent
................................................................................................... 122
KEFLEX ........................................................................ 53
KELNOR 1/35
....................................................................................................... 55
KENALOG ................................................................ 68
KEPPRA ........................................................................ 19
KEPPRA XR .......................................................... 19
KERAFOAM ......................................................... 69
KERAFOAM 42
....................................................................................................... 69
KERALAC ................................................................. 70
KERLONE ................................................................. 51
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
171
Index
Index
Index
kerr drug test strip pack
kp miconazole nitrate
lady lite lancets
.......................................................................................................
77
KERR TRIPLE DYE SWABS
46
KETEK ............................................................................ 37
KETOCARE ............................................................ 77
ketoconazole ................................... 29, 64, 65
KETODAN ................................................................ 65
KETO-DIASTIX
....................................................................................................... 80
ketoprofen ...................................................................... 7
ketorolac tromethamine
........................................................................................... 7, 137
KETOSTIX ............................................................... 77
KHEDEZLA ............................................................ 23
KINERET ........................................................................ 6
kinney lancets
................................................................................................... 104
kinney thin lancets
................................................................................................... 104
kinray test ................................................................... 77
KIONEX ........................................................................ 50
KLARON ..................................................................... 61
KLONOPIN ............................................................. 18
KLOR-CON ......................................................... 122
KLOR-CON 10
................................................................................................... 122
KLOR-CON M10
................................................................................................... 122
KLOR-CON M15
................................................................................................... 122
KLOR-CON M20
................................................................................................... 122
KLOR-CON/EF
................................................................................................... 122
kmart valu insulin syringe 29g
................................................................................................... 114
kmart valu insulin syringe 30g
................................................................................................... 114
KOATE-DVI .......................................................... 91
KOGENATE FS
....................................................................................................... 91
KOGENATE FS BIO-SET
....................................................................................................... 92
KOKO PEAK PRO
MOUTHPIECE
................................................................................................... 118
KOLNATAL DHA
................................................................................................... 129
KOMBIGLYZE XR
....................................................................................................... 24
KORLYM .................................................................... 26
kp cetirizine hcl
....................................................................................................... 30
.......................................................................................................
.......................................................................................................
65
kp omeprazole magnesium
146
K-PHOS ..................................................................... 122
K-PHOS NO 2
....................................................................................................... 89
K-PRIME ................................................................. 122
KRISTALOSE
....................................................................................................... 97
kroger blood glucose test
....................................................................................................... 77
kroger glucose
....................................................................................................... 25
kroger lancets
................................................................................................... 104
kroger lancets 21g
................................................................................................... 104
kroger lancets micro thin 33g
................................................................................................... 104
kroger lancets super thin
................................................................................................... 104
kroger lancets thin
................................................................................................... 104
kroger lancets thin 26g
................................................................................................... 104
kroger lancets ultrathin 30g
................................................................................................... 104
kroger lancing device
................................................................................................... 104
kroger pen needles
................................................................................................... 114
kroger premium glucose test
....................................................................................................... 77
kroger test .................................................................. 77
KRYSTEXXA
....................................................................................................... 91
KURIC ............................................................................. 65
KURVELO ................................................................ 55
KUVAN ......................................................................... 85
k-vescent ................................................................... 122
KYNAMRO ............................................................. 31
labetalol hcl ............................................................ 50
LABSTIX ..................................................................... 80
LACRISERT ....................................................... 132
lactated ringers
....................................................................................................... 50
lactic acid ................................................................... 70
LACTOCAL-F
................................................................................................... 127
lactulose ....................................................................... 97
lactulose encephalopathy
....................................................................................................... 89
...................................................................................................
104
LAMICTAL ............................................................. 19
LAMICTAL ODT
....................................................................................................... 19
LAMICTAL STARTER
....................................................................................................... 19
LAMICTAL XR
....................................................................................................... 19
LAMISIL ...................................................................... 29
lamivudine ................................................................. 47
lamivudine-zidovudine
....................................................................................................... 46
lamotrigine ............................................................... 19
lamotrigine er
....................................................................................................... 19
lancet device ...................................................... 104
lancets .......................................................................... 104
lancets 28g ............................................................ 104
lancets 30g ............................................................ 104
lancets micro thin 33g
................................................................................................... 104
lancets super thin 28g
................................................................................................... 104
lancets thin ........................................................... 104
LANCETS ULTRA FINE
................................................................................................... 104
LANCETS ULTRA THIN
................................................................................................... 104
lancets ultra thin 30g
................................................................................................... 104
lancing device
................................................................................................... 104
LANOXIN .................................................................. 52
lansoprazole ....................................................... 146
LANTUS ....................................................................... 27
LANTUS SOLOSTAR
....................................................................................................... 27
LARIN 1/20 .............................................................. 55
LARIN FE 1.5/30
....................................................................................................... 55
LARIN FE 1/20
....................................................................................................... 55
LASIX ............................................................................... 82
LASTACAFT
................................................................................................... 136
latanoprost ........................................................... 137
LATRIX ......................................................................... 70
LATUDA ......................................................... 43, 44
lavare wound wash
....................................................................................................... 72
LAZANDA .................................................................... 9
LAZERFORMALYDE
....................................................................................................... 46
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
172
Index
Index
Index
leader advanced lancing device
................................................................................................... 104
leader glucose
....................................................................................................... 25
leader quick dissolve glucose
....................................................................................................... 26
LEADER UNIFINE PENTIPS
................................................................................................... 114
LEADER UNIFINE PENTIPS
PLUS ............................................................................... 114
LEENA ............................................................................ 57
leflunomide ................................................................... 8
LESCOL ........................................................................ 32
LESCOL XL ........................................................... 32
LESSINA ..................................................................... 55
LETAIRIS ................................................................... 53
letrozole ........................................................................ 40
leucovorin calcium
....................................................................................................... 42
LEUKERAN ........................................................... 39
LEUKINE .................................................................... 93
leuprolide acetate
....................................................................................................... 40
levalbuterol hcl
....................................................................................................... 17
LEVAQUIN ............................................................. 87
LEVATOL ................................................................. 51
LEVEMIR ................................................................... 27
LEVEMIR FLEXPEN
....................................................................................................... 27
levetiracetam
....................................................................................................... 19
levetiracetam er
....................................................................................................... 19
levobunolol hcl
................................................................................................... 132
levocarnitine .......................................................... 84
levocetirizine dihydrochloride
....................................................................................................... 30
levofloxacin ............................................. 87, 133
levomefolate dha
................................................................................................... 129
LEVONEST ............................................................. 57
levonorgest-eth estrad 91-day
....................................................................................................... 56
levonorgestrel-ethinyl estrad
....................................................................................................... 55
LEVORA 0.15/30 (28)
....................................................................................................... 55
LEVOTHROID
................................................................................................... 144
levothyroxine sodium
................................................................................................... 144
LEVOXYL ............................................................. 144
LEVULAN KERASTICK
LITE TOUCH LANCING PEN
................................................................................................... 105
LITE TOUCH PEN NEEDLES
................................................................................................... 115
LITEAIRE .............................................................. 119
LITETOUCH INSULIN
SYRINGE ................................................................ 115
LITETOUCH LANCETS
................................................................................................... 105
LITETOUCH MASK LARGE
................................................................................................... 118
LITETOUCH MASK MEDIUM
................................................................................................... 118
LITETOUCH MASK SMALL
................................................................................................... 118
LITETOUCH PEN NEEDLES
................................................................................................... 115
lithium carbonate
....................................................................................................... 43
lithium carbonate er
....................................................................................................... 43
LITHOBID ................................................................. 43
LITHOSTAT .......................................................... 91
LIVALO ......................................................................... 32
live better adv lancing device
................................................................................................... 105
live better lancet super thin
................................................................................................... 105
live better lancet ultra thin
................................................................................................... 105
live better pen needles
................................................................................................... 115
l-methylfolate pnv dha
................................................................................................... 129
LO LOESTRIN FE
....................................................................................................... 54
LOCOID ........................................................................ 68
LOCOID LIPOCREAM
....................................................................................................... 68
LOESTRIN 1.5/30 (21)
....................................................................................................... 55
LOESTRIN 1/20 (21)
....................................................................................................... 55
LOESTRIN FE 1.5/30
....................................................................................................... 55
LOESTRIN FE 1/20
....................................................................................................... 55
lofene ................................................................................. 28
LOFIBRA .................................................................... 31
LOKARA ..................................................................... 69
LOMOTIL .................................................................. 28
long test ......................................................................... 77
longs glucose
....................................................................................................... 25
66
LEXAPRO ................................................................. 21
LEXIVA ......................................................................... 47
LIALDA ......................................................................... 88
LIBERTY GLUCOSE CONTROL
................................................................................................... 104
LIBERTY GLUCOSE CONTROL
MID ................................................................................... 104
LIBERTY MINI LANCING
DEVICE ..................................................................... 104
LIBERTY NEXT GENERATION
TEST ................................................................................... 77
liberty test .................................................................. 77
LIDAZONE HC
....................................................................................................... 13
lidocaine ....................................................................... 71
lidocaine hcl ........................................... 71, 123
lidocaine viscous
................................................................................................... 123
lidocaine-hydrocortisone ace
....................................................................................................... 13
lidocaine-prilocaine
....................................................................................................... 71
LIDOCORT .............................................................. 13
LIDODERM ............................................................ 71
lidorx ................................................................................. 71
life medical test
....................................................................................................... 77
LIFESCAN UNISTIK 2
................................................................................................... 104
LIFESCAN UNISTIK II
LANCETS .............................................................. 104
lindane ............................................................................ 72
LINZESS ...................................................................... 89
liothyronine sodium
................................................................................................... 144
LIPITOR ........................................................................ 32
LIPOFEN ..................................................................... 31
LIPTRUZET ............................................................ 31
LIQUID E-Z-PAQUE
....................................................................................................... 81
LIQUID POLIBAR
....................................................................................................... 81
LIQUID POLIBAR PLUS
....................................................................................................... 81
lisinopril ....................................................................... 33
lisinopril-hydrochlorothiazide
....................................................................................................... 34
lite touch lancets
................................................................................................... 104
LITE TOUCH LANCING
DEVICE ..................................................................... 104
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
173
Index
Index
Index
longs lancets standard
LUPRON DEPOT-PED
MAXZIDE ................................................................. 81
MAXZIDE-25
....................................................................................................... 81
m-clear wc ................................................................. 59
MD-GASTROVIEW
....................................................................................................... 81
medichoice safety lancet
................................................................................................... 105
medichoice safety lancet extra
................................................................................................... 105
medichoice safety lancet norm
................................................................................................... 105
medicine shoppe lancets
................................................................................................... 105
medicine shoppe lancets thin
................................................................................................... 105
medicine shoppe pen needles
................................................................................................... 115
medi-lance lancets
................................................................................................... 105
MEDISENSE GLUCOSE
KETONE CONTR
................................................................................................... 105
MEDISENSE HI/MID/LOW
CONTROL ............................................................. 105
MEDISENSE HIGH/LOW
CONTROL ............................................................. 105
MEDISENSE MID CONTROL
................................................................................................... 105
MEDISENSE THIN LANCETS
................................................................................................... 105
MEDLANCE EXTRA 21G
................................................................................................... 105
MEDLANCE LITE 25G
................................................................................................... 105
MEDLANCE PLUS EXTRA 21G
................................................................................................... 105
MEDLANCE PLUS LANCETS
................................................................................................... 105
MEDLANCE PLUS LITE 25G
................................................................................................... 105
MEDLANCE PLUS SPECIAL
0.8MM .......................................................................... 105
MEDLANCE PLUS SUPERLITE
30G ..................................................................................... 105
MEDLANCE PLUS UNIVERSAL
21G ..................................................................................... 105
MEDLANCE UNIVERSAL 21G
................................................................................................... 105
MEDROL ..................................................................... 58
MEDROL (PAK)
....................................................................................................... 58
medroxyprogesterone acetate
....................................................................................... 58, 140
...................................................................................................
105
longs lancets thin
...................................................................................................
105
longs lancets ultra thin
105
LONOX .......................................................................... 28
LOPID ............................................................................... 31
LOPRESSOR
....................................................................................................... 51
LOPRESSOR HCT
....................................................................................................... 36
LOPROX ...................................................................... 64
loratadine ................................................................... 30
lorazepam ................................................................... 15
LORAZEPAM INTENSOL
....................................................................................................... 15
LORCET ....................................................................... 11
LORCET HD .......................................................... 11
LORTAB ...................................................................... 11
LORYNA ..................................................................... 55
LORZONE ............................................................. 130
losartan potassium
....................................................................................................... 33
losartan potassium-hctz
....................................................................................................... 35
LOSEASONIQUE
....................................................................................................... 56
LOTEMAX ........................................................... 136
LOTENSIN ............................................................... 33
LOTENSIN HCT
....................................................................................................... 34
LOTREL ........................................................................ 34
LOTRISONE .......................................................... 64
LOTRONEX ........................................................... 89
lovastatin ..................................................................... 32
LOVAZA ..................................................................... 31
LOVENOX ................................................................ 18
LOW-OGESTREL
....................................................................................................... 55
loxapine succinate
....................................................................................................... 45
LOXITANE .............................................................. 45
LOZI-FLUR ......................................................... 122
LTA 360 KIT ..................................................... 123
LUCENTIS ............................................................ 133
LUDENT .................................................................. 122
LUFYLLIN ............................................................... 17
LUMIGAN ............................................................. 137
LUNESTA .................................................................. 96
LUPANETA PACK
....................................................................................................... 84
LUPRON DEPOT
....................................................................................................... 40
...................................................................................................
84
LUTERA ....................................................................... 55
LUVOX CR .............................................................. 21
LUXIQ ............................................................................. 69
LUZU ................................................................................. 65
LYRICA ......................................................................... 19
LYSODREN ............................................................ 39
LYSTEDA .................................................................. 95
LYZA ................................................................................. 58
MACNATAL CN DHA
................................................................................................... 129
MACROBID ....................................................... 147
MACRODANTIN
................................................................................................... 147
MACUGEN .......................................................... 133
mafenide acetate
....................................................................................................... 67
MAGELLAN INSULIN SAFETY
SYR ................................................................................... 115
major comfort lancets
................................................................................................... 105
MAKENA ............................................................... 140
MALARONE
....................................................................................................... 38
malathion .................................................................... 72
margesic ........................................................................... 8
MARINOL ................................................................. 29
marlissa ......................................................................... 55
MARNATAL-F
................................................................................................... 127
MARPLAN ............................................................... 21
marten-tab ..................................................................... 8
martinic ......................................................................... 94
MASK VORTEX
................................................................................................... 119
MATULANE ......................................................... 42
MATZIM LA
....................................................................................................... 52
MAVIK ........................................................................... 33
MAXALT ................................................................ 121
MAXALT-MLT
................................................................................................... 121
MAXARON FORTE
....................................................................................................... 94
MAXIBAR ................................................................. 81
MAXI-COMFORT INSULIN
SYRINGE ................................................................ 115
MAXIDEX ............................................................. 136
MAXIMA BLOOD GLUCOSE
TEST ................................................................................... 77
MAXIMA CONTROL
................................................................................................... 105
MAXITROL ........................................................ 135
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
174
Index
Index
Index
mefenamic acid
METADATE CD
methyltest-est estrogens hs
...........................................................................................................
7
mefloquine hcl
38
MEGACE ES
140
MEGACE ORAL
.......................................................................................................
40
megestrol acetate
.......................................................................................................
40
meijer alcohol swabs
...................................................................................................
111
meijer blood glucose test
.......................................................................................................
77
meijer glucose
.......................................................................................................
25
MEIJER LANCETS
...................................................................................................
105
MEIJER LANCETS THIN
105
MEIJER LANCETS UNIVERSAL
21G ..................................................................................... 105
MEIJER LANCETS UNIVERSAL
30G ..................................................................................... 105
MEIJER LANCETS UNIVERSAL
33G ..................................................................................... 105
meijer pen needles
................................................................................................... 115
meijer premium glucose test
....................................................................................................... 77
MEIJER SUPER THIN
LANCETS .............................................................. 105
meijer test ................................................................... 77
MEIJER TRUETEST TEST
....................................................................................................... 77
MEIJER TRUETRACK TEST
....................................................................................................... 78
MEKINIST ................................................................ 41
meloxicam ...................................................................... 7
MELOXICAM COMFORT PAC
........................................................................................................... 7
MENEST ...................................................................... 87
MENOSTAR .......................................................... 87
meperidine hcl
........................................................................................................... 9
meperitab ........................................................................ 9
MEPHYTON ...................................................... 149
meprobamate
....................................................................................................... 14
mercaptopurine
....................................................................................................... 39
mesalamine .............................................................. 88
MESNEX ..................................................................... 42
MESTINON ............................................................. 38
...................................................................................................
4
METADATE ER
.......................................................................................................
...................................................................................................
...........................................................................................................
4
metaxalone ........................................................... 130
metformin hcl
....................................................................................................... 24
metformin hcl er
....................................................................................................... 24
metformin hcl er (osm)
....................................................................................................... 24
methadone hcl
....................................................................................................... 10
METHADONE HCL INTENSOL
....................................................................................................... 10
METHADOSE
....................................................................................................... 10
METHADOSE SUGAR-FREE
....................................................................................................... 10
methamphetamine hcl
........................................................................................................... 3
methazolamide
....................................................................................................... 81
methenamine hippurate
................................................................................................... 147
methenamine mandelate
................................................................................................... 147
methimazole ........................................................ 144
methitest ....................................................................... 13
methocarbamol
................................................................................................... 130
methotrexate ........................................................... 39
methscopolamine bromide
................................................................................................... 145
methyldopa ............................................................... 34
methylergonovine maleate
................................................................................................... 139
METHYLIN ................................................................. 4
METHYLIN ER
........................................................................................................... 5
methylphenidate hcl
........................................................................................................... 5
methylphenidate hcl er
........................................................................................................... 5
methylphenidate hcl er (cd)
........................................................................................................... 5
methylphenidate hcl er (la)
........................................................................................................... 5
methylprednisolone
....................................................................................................... 58
methylprednisolone (pak)
....................................................................................................... 58
methyltest-est estrogens
....................................................................................................... 86
...........................................................................................................
86
metipranolol ....................................................... 132
metoclopramide hcl
....................................................................................................... 88
metolazone ................................................................ 82
METOPIRONE
....................................................................................................... 72
metoprolol succinate er
....................................................................................................... 51
metoprolol tartrate
....................................................................................................... 51
metoprolol-hydrochlorothiazide
....................................................................................................... 36
METOZOLV ODT
....................................................................................................... 88
METROCREAM
....................................................................................................... 72
METROGEL ........................................................... 72
METROGEL-VAGINAL
................................................................................................... 149
METROLOTION
....................................................................................................... 72
metronidazole
........................................................................... 37, 72, 149
METVIXIA ............................................................... 66
MEVACOR .............................................................. 32
MEXAR WASH
....................................................................................................... 67
mexiletine hcl
....................................................................................................... 15
MIACALCIN
....................................................................................................... 83
micaderm .................................................................... 65
MICATIN .................................................................... 65
miconazole nitrate
....................................................................................................... 65
MICRHOGAM
ULTRA-FILTERED PLUS
................................................................................................... 139
MICRO GUARD
....................................................................................................... 65
MICRO-BUMINTEST
....................................................................................................... 78
MICROCHAMBER
................................................................................................... 119
MICRODOT CONTROL
................................................................................................... 105
MICRODOT CONTROL
HIGH/LOW .......................................................... 105
MICRODOT TEST
....................................................................................................... 78
MICROELITE BATTERY
................................................................................................... 118
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
175
Index
Index
Index
MICROELITE FILTER
REPLACEMENTS
MINOCIN ............................................................... 144
minocycline hcl
................................................................................................... 144
minocycline hcl er
................................................................................................... 144
minoxidil ...................................................................... 37
MIRAPEX .................................................................. 43
MIRAPEX ER
....................................................................................................... 43
MIRCETTE .............................................................. 54
MIRENA ....................................................................... 58
mirtazapine .............................................................. 20
MIRVASO ................................................................. 72
misoprostol .......................................................... 146
MITOSOL ............................................................... 133
MOBIC ................................................................................ 7
modafinil .......................................................................... 5
MODERIBA ............................................................ 48
MODERIBA 1200 DOSE PACK
....................................................................................................... 48
MODERIBA 800 DOSE PACK
....................................................................................................... 48
MODICON (28)
....................................................................................................... 55
moexipril hcl .......................................................... 33
moexipril-hydrochlorothiazide
....................................................................................................... 34
mometasone furoate
....................................................................................................... 69
MONOCLATE-P
....................................................................................................... 92
MONODOX ......................................................... 144
MONOJECT INSULIN SYRINGE
................................................................................................... 115
MONOJECT ULTRA COMFORT
SYRINGE ................................................................ 115
MONOJECTOR END CAPS
................................................................................................... 105
MONOJECTOR OPD END CAPS
................................................................................................... 105
MONOLET LANCETS
................................................................................................... 105
MONOLET OPD LANCETS
................................................................................................... 105
MONOLETTOR SAFETY
LANCETS .............................................................. 106
MONO-LINYAH
....................................................................................................... 55
MONONESSA
....................................................................................................... 55
MONONINE ........................................................... 92
monsels ferric subsulfate
....................................................................................................... 95
montelukast sodium
...................................................................................................
118
MICROGESTIN 1.5/30
.......................................................................................................
55
MICROGESTIN 1/20
.......................................................................................................
55
MICROGESTIN FE 1.5/30
.......................................................................................................
55
MICROGESTIN FE 1/20
55
MICRO-K ................................................................ 122
MICROLET LANCETS
................................................................................................... 105
MICROLIFE DIGITAL PEAK
FLOW ............................................................................ 117
micronized colestipol hcl
....................................................................................................... 31
MICROSPACER
................................................................................................... 119
MICROTAINER SAFETY FLOW
LANCET ................................................................... 105
MICROZIDE .......................................................... 82
midazolam hcl
....................................................................................................... 96
midodrine hcl
................................................................................................... 149
MIGERGOT ........................................................ 120
migragesic ida
................................................................................................... 120
MIGRAL ................................................................... 121
MIGRALAM ...................................................... 120
MIGRANAL ....................................................... 121
MILLIPRED ............................................................ 59
MILLIPRED DP
....................................................................................................... 59
MILLIPRED DP 12-DAY
....................................................................................................... 59
MIMVEY ..................................................................... 86
MINASTRIN 24 FE
....................................................................................................... 55
mini lancing device
................................................................................................... 105
MINI WRIGHT PEAK FLOW
METER ....................................................................... 117
MINIELITE FILTER
REPLACEMENTS
................................................................................................... 118
MINIELITE RECHARGEABLE
BATTERY ............................................................. 118
MINIPRESS ............................................................ 34
MINIRIN ...................................................................... 86
MINITRAN .............................................................. 14
MINIVELLE ........................................................... 87
.......................................................................................................
16
MONUROL .......................................................... 147
MOORE MONO INSULIN
SYRINGE ................................................................ 115
MORGIDOX ...................................................... 144
morphine sulfate
....................................................................................................... 10
morphine sulfate (concentrate)
....................................................................................................... 10
morphine sulfate (pf)
....................................................................................................... 10
morphine sulfate er
....................................................................................................... 10
MOTOFEN ................................................................ 28
MOVIPREP .............................................................. 97
MOXATAG ......................................................... 140
MOXEZA ................................................................ 133
MS CONTIN ........................................................... 10
ms quick dissolve glucose
....................................................................................................... 26
MST 600 ............................................................................ 9
MUCOTROL ..................................................... 124
MULTAQ .................................................................... 15
multi vit/fl ............................................................... 126
multi vita-bets/fluoride
................................................................................................... 126
multi vitamin/fluoride
................................................................................................... 126
MULTIGEN ............................................................. 94
MULTIGEN FOLIC
....................................................................................................... 94
MULTIGEN PLUS
....................................................................................................... 94
multi-lancet device
................................................................................................... 106
multiple vitamins/fluoride
................................................................................................... 126
MULTISTIX ........................................................... 80
MULTISTIX 10 SG
....................................................................................................... 80
MULTISTIX 5
....................................................................................................... 80
MULTISTIX 7
....................................................................................................... 80
MULTISTIX 8
....................................................................................................... 80
MULTISTIX 9
....................................................................................................... 80
MULTISTIX 9 SG
....................................................................................................... 80
multi-vit/fluoride
................................................................................................... 126
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
176
Index
Index
Index
multi-vit/fluoride/iron
mytussin dac ........................................................... 60
MYZILRA .................................................................. 57
na ferric gluc cplx in sucrose
....................................................................................................... 95
NABI-HB ................................................................. 139
nabumetone ................................................................. 7
nadolol ............................................................................ 51
nadolol-bendroflumethiazide
....................................................................................................... 36
NAFRINSE ........................................................... 122
NAFRINSE DAILY
ACIDULATED
................................................................................................... 123
NAFRINSE DAILY/NEUTRAL
................................................................................................... 123
NAFRINSE DROPS
................................................................................................... 122
NAFRINSE WEEKLY
................................................................................................... 123
NAFTIN ......................................................................... 64
NAGLAZYME
....................................................................................................... 85
NALFON .......................................................................... 7
naltrexone hcl
....................................................................................................... 28
NAMENDA ......................................................... 141
NAMENDA TITRATION PAK
................................................................................................... 141
NAMENDA XR
................................................................................................... 141
NAMENDA XR TITRATION
PACK ............................................................................. 141
NAPRELAN ................................................................ 7
NAPROSYN ............................................................... 7
naproxen .......................................................................... 7
naproxen dr ................................................................. 7
naproxen sodium
........................................................................................................... 7
naratriptan hcl
................................................................................................... 121
NARDIL ........................................................................ 21
NASCOBAL ........................................................... 93
NASONEX ............................................................ 131
NATACHEW
................................................................................................... 127
NATACYN ........................................................... 134
natal-v rx ................................................................. 127
NATALVIRT 90 DHA
................................................................................................... 129
NATALVIRT CA
................................................................................................... 129
NATALVIRT FLT
....................................................................................................... 95
NATALVIT .......................................................... 127
NATAZIA ................................................................... 56
nateglinide ................................................................ 27
NATELLE ONE
................................................................................................... 127
NATROBA ................................................................ 72
NATURE-THROID
................................................................................................... 144
NAVARRO BLOOD GLUCOSE
TEST ................................................................................... 78
nebulizer air tube/plugs
................................................................................................... 118
nebulizer mask pediatric
................................................................................................... 118
NEBUPENT ............................................................. 37
NEBUSAL ................................................................. 61
NECON 0.5/35 (28)
....................................................................................................... 55
NECON 1/35 (28)
....................................................................................................... 55
NECON 1/50 (28)
....................................................................................................... 55
NECON 7/7/7
....................................................................................................... 57
NEEVO DHA
................................................................................... 127, 129
nefazodone hcl
....................................................................................................... 22
neo-fradin ....................................................................... 5
NEOFRIN ................................................................ 134
neomycin sulfate
........................................................................................................... 5
neomycin-bacitracin zn-polymyx
................................................................................................... 134
neomycin-polymyxin b gu
....................................................................................................... 90
neomycin-polymyxin-dexameth
................................................................................................... 135
neomycin-polymyxin-gramicidin
................................................................................................... 134
neomycin-polymyxin-hc
................................................................................................... 138
NEO-POLYCIN
................................................................................................... 134
NEO-POLYCIN HC
................................................................................................... 135
NEORAL ...................................................................... 49
NEOSPORIN ..................................................... 134
NEOSPORIN AF
....................................................................................................... 65
NEOSPORIN GU IRRIGANT
....................................................................................................... 90
NEOTUSS PLUS
....................................................................................................... 60
NEOTUSS-D .......................................................... 59
...................................................................................................
125
multivitamin/fluoride
...................................................................................................
126
multi-vitamin/fluoride
...................................................................................................
126
multi-vitamin/fluoride/iron
...................................................................................................
126
multivitamins/fluoride
...................................................................................................
126
multi-vitamins/fluoride
...................................................................................................
126
multi-vits/fluoride
...................................................................................................
126
mult-vitamin/fluoride
126
mupirocin ................................................................... 64
mupirocin calcium
....................................................................................................... 64
MUSE ................................................................................ 52
MVC-FLUORIDE
................................................................................................... 126
MYAMBUTOL
....................................................................................................... 38
myci-gc ........................................................................... 59
mycophenolate mofetil
....................................................................................................... 50
mycophenolic acid
....................................................................................................... 50
mydral .......................................................................... 132
MYDRIACYL
................................................................................................... 133
myferon 150 forte
....................................................................................................... 94
MYGLUCOHEALTH CONTROL
................................................................................................... 106
MYGLUCOHEALTH LANCETS
30G ..................................................................................... 106
MYGLUCOHEALTH TEST
....................................................................................................... 78
MYKIDZ IRON FL
................................................................................................... 126
MYLERAN ............................................................... 39
MYNATAL .......................................................... 127
MYNATAL ADVANCE
................................................................................................... 127
mynephrocaps
................................................................................................... 124
MYORISAN ............................................................ 63
MYOXIN ................................................................. 138
MYRBETRIQ
................................................................................................... 148
MYSOLINE ............................................................. 19
mytussin ac ............................................................... 59
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
177
Index
Index
Index
NEPHPLEX RX
NEXPLANON
NORDIPEN DELIVERY
SYSTEM ................................................................... 115
NORDITROPIN
....................................................................................................... 84
NORDITROPIN FLEXPRO
....................................................................................................... 84
NORDITROPIN NORDIFLEX
PEN ....................................................................................... 84
norethindrone
....................................................................................................... 58
norethindrone acetate
................................................................................................... 140
norgestimate-eth estradiol
....................................................................................................... 55
norgestim-eth estrad triphasic
....................................................................................................... 57
NORINYL 1+35 (28)
....................................................................................................... 55
NORINYL 1+50 (28)
....................................................................................................... 55
NORITATE .............................................................. 72
NOROXIN ................................................................. 87
NORPACE ................................................................. 15
NORPACE CR
....................................................................................................... 15
NORPRAMIN
....................................................................................................... 23
NOR-QD ....................................................................... 58
NORTREL 0.5/35 (28)
....................................................................................................... 55
NORTREL 1/35 (21)
....................................................................................................... 55
NORTREL 1/35 (28)
....................................................................................................... 55
NORTREL 7/7/7
....................................................................................................... 57
nortriptyline hcl
....................................................................................................... 23
nortuss-ex ................................................................... 59
NORVASC ................................................................ 52
NORVIR ........................................................................ 47
nose clip .................................................................... 118
NOVA MAX CONTROL
................................................................................................... 106
NOVA MAX GLUCOSE TEST
....................................................................................................... 78
NOVA MAX PLUS GLU/KET
CONTROL ............................................................. 106
NOVA SAFETY LANCETS 23G
................................................................................................... 106
NOVA SAFETY LANCETS 28G
................................................................................................... 106
NOVA SUREFLEX LANCETS
................................................................................................... 106
...................................................................................................
125
NEPHROCAPS
...................................................................................................
124
NEPHROCAPS QT
...................................................................................................
124
NEPHRON FA
.......................................................................................................
95
NEPHRONEX
...................................................................................................
124
NEPTAZANE
81
NESINA ......................................................................... 26
NESSI SPACER WITH MASK
LARGE ........................................................................ 119
NESSI SPACER WITH MASK
SM/MED ................................................................... 120
NESSI SPACER WITH
MOUTHPIECE
................................................................................................... 120
NESTABS ............................................................... 127
NESTABS ABC
................................................................................................... 128
NESTABS DHA
................................................................................................... 127
NETGROUP LANCETS
................................................................................................... 106
NEULASTA ............................................................ 93
NEUMEGA .............................................................. 93
NEUPOGEN ........................................................... 93
NEUPRO ...................................................................... 43
neurin-sl ....................................................................... 94
NEURONTIN
....................................................................................................... 19
NEUTEK 2TEK CONTROL
................................................................................................... 106
NEUTEK 2TEK TEST
....................................................................................................... 78
NEUTRAGARD ADVANCED
................................................................................................... 123
NEUTRASAL
................................................................................................... 124
NEVANAC ........................................................... 137
nevirapine .................................................................. 47
NEXA PLUS ....................................................... 129
NEXA SELECT
................................................................................................... 129
NEXAVAR ............................................................... 41
NEXGEN CONTROL
................................................................................................... 106
NEXGEN TEST
....................................................................................................... 78
NEXIUM .................................................................. 146
.......................................................................................................
57
niacin ............................................................................ 150
niacin er .................................................................... 150
niacin er (antihyperlipidemic)
....................................................................................................... 32
niacin-50 .................................................................. 150
NIACOR ........................................................................ 32
NIASPAN .................................................................... 32
nicardipine hcl
....................................................................................................... 52
NICAZELDOXY 30
................................................................................................... 143
NICAZELDOXY 60
................................................................................................... 143
NICOMIDE .......................................................... 130
NIFEDIAC CC
....................................................................................................... 52
NIFEDICAL XL
....................................................................................................... 52
nifedipine .................................................................... 52
nifedipine er ............................................................ 52
nifedipine er osmotic
....................................................................................................... 52
NILANDRON
....................................................................................................... 39
nimodipine ................................................................ 52
NIRAVAM ................................................................ 15
nisoldipine er
....................................................................................................... 52
NITRO-BID ............................................................. 14
NITRO-DUR .......................................................... 14
nitrofurantoin
................................................................................................... 147
nitrofurantoin macrocrystal
................................................................................................... 147
nitrofurantoin monohyd macro
................................................................................................... 147
nitroglycerin ........................................................... 14
nitroglycerin er
....................................................................................................... 14
NITROLINGUAL
....................................................................................................... 14
NITROMIST ........................................................... 14
NITROSTAT .......................................................... 14
NITRO-TIME
....................................................................................................... 14
nizatidine ................................................................. 145
NIZORAL ................................................................... 65
NODOLOR ........................................................... 120
NORA-BE ................................................................... 58
NORCO .......................................................................... 11
NORDIPEN 5 INJECTION
DEVICE ..................................................................... 115
.......................................................................................................
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Index
Index
Index
NOVA SUREFLEX LANCING
DEVICE ..................................................................... 106
NOVACORT .......................................................... 69
NOVAFERRUM
....................................................................................................... 95
NOVOFINE ......................................................... 115
NOVOFINE AUTOCOVER
................................................................................................... 115
NOVOLOG ............................................................... 27
NOVOLOG FLEXPEN
....................................................................................................... 27
NOVOLOG MIX 70/30
....................................................................................................... 27
NOVOLOG MIX 70/30
FLEXPEN ................................................................... 27
NOVOSEVEN RT
....................................................................................................... 92
NOVOTWIST
................................................................................................... 115
NOXAFIL ................................................................... 29
np thyroid ............................................................... 144
NPLATE ........................................................................ 94
NUCORT ..................................................................... 69
NUCYNTA ............................................................... 10
NUCYNTA ER
....................................................................................................... 10
NUEDEXTA ....................................................... 143
NUFOL ............................................................................ 94
NULECIT .................................................................... 95
NULEV ....................................................................... 145
NULOJIX ..................................................................... 50
NULYTELY WITH FLAVOR
PACKS ............................................................................ 97
NUOX ............................................................................... 63
nutri-tab ob + dha
................................................................................................... 127
NUTRIVIT ............................................................. 125
NUTROPIN AQ
....................................................................................................... 84
NUTROPIN AQ NUSPIN 10
....................................................................................................... 84
NUTROPIN AQ NUSPIN 20
....................................................................................................... 84
NUTROPIN AQ NUSPIN 5
....................................................................................................... 84
NUTROPIN AQ PEN
....................................................................................................... 84
NUVARING ............................................................ 57
NUVIGIL ......................................................................... 5
NUZOLE ...................................................................... 65
NYAMYC ................................................................... 64
NYMALIZE ............................................................. 52
nystatin ............................................... 29, 64, 123
nystatin-triamcinolone
ON CALL LANCETS
64
NYSTOP ....................................................................... 64
OB COMPLETE
................................................................................................... 127
OB COMPLETE 400
................................................................................................... 127
OB COMPLETE ONE
................................................................................................... 127
OB COMPLETE PETITE
................................................................................................... 127
OB COMPLETE PREMIER
................................................................................................... 127
OB COMPLETE/DHA
................................................................................................... 127
OB-NATAL ONE
................................................................................................... 127
O-CAL PRENATAL
................................................................................................... 127
OCELLA ....................................................................... 55
OCTAGAM .......................................................... 139
octreotide acetate
....................................................................................................... 86
OCUFEN .................................................................. 137
OCUFLOX ............................................................. 134
ofloxacin ....................................... 87, 134, 137
olanzapine ................................................................. 45
olanzapine-fluoxetine hcl
................................................................................................... 141
OLUX ................................................................................ 69
OLUX-E ......................................................................... 69
OLYSIO ......................................................................... 48
OMECLAMOX-PAK
................................................................................................... 147
omega-3-acid ethyl esters
....................................................................................................... 31
omeprazole ........................................................... 146
omeprazole-sodium bicarbonate
................................................................................................... 146
OMNARIS ............................................................. 131
OMNIFLEX DIAPHRAGM
....................................................................................................... 98
OMNIPRED ......................................................... 136
OMNITROPE
....................................................................................................... 84
OMNITROPE PEN 10 INJ
DEVICE ..................................................................... 115
OMNITROPE PEN 5 INJ
DEVICE ..................................................................... 115
OMONTYS ............................................................... 93
ON CALL EXPRESS BLOOD
GLUCOSE ................................................................. 78
ON CALL EXPRESS GLUCOSE
CONTR ....................................................................... 106
.......................................................................................................
106
ON CALL LANCING DEVICE
................................................................................................... 106
ON CALL PLUS BLOOD
GLUCOSE ................................................................. 78
ON CALL PLUS GLUCOSE
CONTROL ............................................................. 106
ON CALL PLUS LANCETS
................................................................................................... 106
ON CALL PLUS LANCING
DEVICE ..................................................................... 106
ON CALL VIVID BLOOD
GLUCOSE ................................................................. 78
ON CALL VIVID GLUCOSE
CONTROL ............................................................. 106
ondansetron ............................................................ 28
ondansetron hcl
....................................................................................................... 28
ONE FLOW TESTER
................................................................................................... 118
ONETOUCH CLUB LANCETS
FINE PT ..................................................................... 106
ONETOUCH COMBO PACK
................................................................................................... 106
ONETOUCH DELICA LANCETS
33G ..................................................................................... 106
ONETOUCH DELICA LANCETS
FINE ................................................................................. 106
ONETOUCH DELICA LANCING
DEV .................................................................................. 106
ONETOUCH FINEPOINT
LANCETS .............................................................. 106
ONETOUCH LANCETS
................................................................................................... 106
ONETOUCH SURESOFT
LANCING DEV
................................................................................................... 106
ONETOUCH TEST
....................................................................................................... 78
ONETOUCH ULTRA BLUE
....................................................................................................... 78
ONETOUCH ULTRA CONTROL
................................................................................................... 106
ONETOUCH ULTRASOFT
LANCETS .............................................................. 106
ONETOUCH VERIO
....................................................................................... 78, 106
ONFI .................................................................................... 19
ONGLYZA ................................................................ 26
ONMEL .......................................................................... 29
OPANA ........................................................................... 10
OPANA ER ............................................................... 10
opium ................................................................................ 28
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
179
Index
Index
Index
OPSUMIT ................................................................... 53
OPTASE ........................................................................ 70
OPTICHAMBER ADVANTAGE
................................................................................................... 120
OPTICHAMBER
ADVANTAGE-LG MASK
................................................................................................... 120
OPTICHAMBER
ADVANTAGE-MED MASK
................................................................................................... 120
OPTICHAMBER
ADVANTAGE-SM MASK
................................................................................................... 120
OPTICHAMBER DIAMOND
................................................................................................... 120
OPTICHAMBER DIAMOND-LG
MASK ........................................................................... 120
OPTICHAMBER DIAMOND-MD
MASK ........................................................................... 120
OPTICHAMBER DIAMOND-SM
MASK ........................................................................... 120
OPTICHAMBER FACE
MASK-LARGE
................................................................................................... 120
OPTICHAMBER FACE
MASK-MEDIUM
................................................................................................... 120
OPTICHAMBER FACE
MASK-SMALL
................................................................................................... 120
OPTIHALER ...................................................... 120
OPTIONS CONCEPTROL
................................................................................................... 148
OPTIONS GYNOL II
CONTRACEPTIVE
................................................................................................... 148
OPTIPRANOLOL
................................................................................................... 132
OPTIUM TEST
....................................................................................................... 78
OPTIUMEZ TEST
....................................................................................................... 78
OPTIVAR ................................................................ 136
OPTUMRX BLOOD GLUCOSE
TEST ................................................................................... 78
OPTUMRX GLUCOSE
CONTROL ............................................................. 106
ORACEA ..................................................................... 72
ORACIT ......................................................................... 90
ORAFATE ............................................................. 124
ORALONE ............................................................ 124
ORAMAGICRX
................................................................................................... 124
ORAP ............................................................................. 143
ORAPRED ................................................................. 59
ORAPRED ODT
....................................................................................................... 59
ORAVIG ................................................................... 123
ORBIVAN CF
........................................................................................................... 8
ORENCIA ....................................................................... 8
ORFADIN ................................................................... 85
orphenadrine citrate er
................................................................................................... 130
orphenadrine-aspirin-caffeine
................................................................................................... 130
ORSINI INSULIN SYRINGE
................................................................................................... 115
ORSYTHIA .............................................................. 55
ORTHO DIAPHRAGM COIL
....................................................................................................... 98
ORTHO DIAPHRAGM FLAT
....................................................................................................... 98
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-EST 0.625
....................................................................................................... 87
ORTHO-EST 1.25
....................................................................................................... 87
ORTHO-NOVUM 1/35 (28)
....................................................................................................... 55
ORTHO-NOVUM 7/7/7 (28)
....................................................................................................... 57
ORTHOVISC
................................................................................................... 131
oscimin ....................................................................... 145
oscimin sr ............................................................... 145
OSENI ............................................................................... 24
OSMOPREP ............................................................ 97
OTEZLA ........................................................................... 8
otic care .................................................................... 138
otic edge ................................................................... 138
oticin .............................................................................. 138
OTICIN HC NR
................................................................................................... 138
OTIRX .......................................................................... 138
oto-end 10 .............................................................. 138
otomar ......................................................................... 138
otomax-hc ............................................................... 138
OTOZIN ..................................................................... 138
OTREXUP ..................................................................... 6
OVACE PLUS
....................................................................................................... 67
OVACE PLUS WASH
....................................................................................................... 67
OVACE WASH
....................................................................................................... 67
OVCON-35 (28)
....................................................................................................... 55
OVIDE ............................................................................. 72
OXANDRIN ............................................................ 12
oxandrolone ............................................................ 12
oxaprozin ........................................................................ 7
oxazepam .................................................................... 15
oxcarbazepine
....................................................................................................... 19
OXECTA ...................................................................... 10
OXISTAT .................................................................... 65
OXSORALEN ULTRA
....................................................................................................... 66
OXTELLAR XR
....................................................................................................... 19
oxybutynin chloride
................................................................................................... 147
oxybutynin chloride er
................................................................................................... 148
oxycodone hcl
....................................................................................................... 10
oxycodone-acetaminophen
....................................................................................................... 12
oxycodone-aspirin
....................................................................................................... 12
oxycodone-ibuprofen
....................................................................................................... 12
OXYCONTIN
....................................................................................................... 10
oxymorphone hcl
....................................................................................................... 10
oxymorphone hcl er
....................................................................................................... 10
OXYTROL ............................................................ 147
OZURDEX ............................................................ 136
PACERONE ............................................................ 15
PAIRE OB .............................................................. 129
PALGIC ......................................................................... 30
PAMELOR ................................................................ 23
pamidronate disodium
....................................................................................................... 83
PAMINE .................................................................... 145
PAMINE FORTE
................................................................................................... 145
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
180
Index
Index
Index
PANCREAZE
PCE ........................................................................................ 97
PEAK AIR PEAK FLOW METER
................................................................................................... 117
PEDIAPRED .......................................................... 59
PEDIATEX TDM
....................................................................................................... 60
pediatric aerosol mask
................................................................................................... 118
pediatric mouthpiece
................................................................................................... 118
PEDIATRIC PANDA MASK
................................................................................................... 120
pedi-dri ........................................................................... 64
peg 3350/electrolytes
....................................................................................................... 97
peg 3350-kcl-na bicarb-nacl
....................................................................................................... 97
peg-3350/electrolytes
....................................................................................................... 97
PEGANONE ........................................................... 20
PEGASYS ................................................................... 48
PEGASYS PROCLICK
....................................................................................................... 48
PEG-INTRON
....................................................................................................... 48
PEG-INTRON REDIPEN
....................................................................................................... 48
PEG-INTRON REDIPEN PAK 4
....................................................................................................... 48
pen needles ........................................................... 115
pen needles 1/2"
................................................................................................... 115
pen needles 3/16"
................................................................................................... 115
pen needles 5/16"
................................................................................................... 115
penicillin v potassium
................................................................................................... 140
PENLAC ....................................................................... 64
PENLET II BLOOD SAMPLER
................................................................................................... 106
PENLET II REPLACEMENT
CAP ................................................................................... 106
PENNSAID ............................................................... 65
PENTASA .................................................................. 88
pentopak ....................................................................... 92
pentoxifylline er
....................................................................................................... 92
PEPCID ....................................................................... 145
PERCOCET ............................................................. 12
PERCODAN ........................................................... 12
PERFECT LANCETS 28G
................................................................................................... 106
PERFECT LANCETS 30G
.......................................................................................................
81
PANDA MASK LARGE
...................................................................................................
120
PANDA MASK MEDIUM
...................................................................................................
120
PANDA MASK SMALL
120
PANDEL ....................................................................... 69
PANRETIN ............................................................... 66
pantoprazole sodium
................................................................................................... 146
PARAFON FORTE DSC
................................................................................................... 130
PARAGARD INTRAUTERINE
COPPER ........................................................................ 57
parcaine .................................................................... 135
PAREMYD ........................................................... 137
PARI ALTERA NEBULIZER
HANDSET ............................................................. 118
PARI BABY CONVERSION KIT
................................................................................................... 118
PARI ERAPID NEBULIZER
HANDSET ............................................................. 118
PARI EXPIRATORY FILTER
SET .................................................................................... 118
PARI MASK SET
................................................................................................... 118
PARI SOFT PLASTIC ADULT
MASK ........................................................................... 118
PARI SOFT PLASTIC PED
MASK ........................................................................... 118
paricalcitol ............................................................... 85
PARLODEL ............................................................. 43
PARNATE ................................................................. 21
paromomycin sulfate
........................................................................................................... 5
paroxetine hcl
....................................................................................................... 21
paroxetine hcl er
....................................................................................................... 22
PASER ............................................................................. 38
PATADAY ............................................................ 136
PATANASE ......................................................... 131
PATANOL ............................................................. 136
PAXIL ............................................................................... 22
PAXIL CR .................................................................. 22
pc lancets super thin 30g
................................................................................................... 106
pc unifine pentips
................................................................................................... 115
pca injector .......................................................... 115
PCCA ACACIA SYRUP BASE
................................................................................................... 140
...................................................................................................
...................................................................................................
106
PERFOROMIST
17
PERIDEX ................................................................. 123
perindopril erbumine
....................................................................................................... 33
PERIO MED ....................................................... 123
PERIOGARD
................................................................................................... 123
permethrin ................................................................. 72
perphenazine
....................................................................................................... 45
PERSANTINE
....................................................................................................... 93
PERSONAL BEST FULL
RANGE ....................................................................... 117
PERSONAL BEST LOW RANGE
................................................................................................... 117
PERTZYE ................................................................... 81
PEXEVA ....................................................................... 22
PFLEX .......................................................................... 118
pharmacist choice alcohol
................................................................................................... 112
PHARMACIST CHOICE
AUTOCODE .......................................................... 78
pharmacist choice lancets
................................................................................................... 106
PHARMACY COUNTER
LANCETS .............................................................. 106
PHENADOZ ........................................................... 30
PHENAZO ................................................................. 91
phenazopyridine hcl
....................................................................................................... 91
phenelzine sulfate
....................................................................................................... 21
phenobarbital
........................................................................................... 95, 96
phenylephrine hcl
................................................................................................... 134
phenylhistine dh
....................................................................................................... 61
PHENYTEK ............................................................ 20
phenytoin ..................................................................... 20
PHENYTOIN INFATABS
....................................................................................................... 20
phenytoin sodium extended
....................................................................................................... 20
PHILITH ....................................................................... 55
phluorivit ................................................................. 126
phosenamine ...................................................... 147
PHOS-FLUR ....................................................... 123
PHOSLO ....................................................................... 89
PHOSLYRA ............................................................ 89
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
181
Index
Index
Index
PHOSPHA 250 NEUTRAL
pnv-omega ............................................................. 127
pnv-select ................................................................ 127
pnv-total ................................................................... 127
POCKET CHAMBER
................................................................................................... 120
POCKET PEAK FLOW METER
................................................................................................... 117
POCKET SPACER
................................................................................................... 120
POCKETCHEM EZ CONTROL
................................................................................................... 106
POCKETCHEM EZ TEST
....................................................................................................... 78
POCKETPEAK PEAK FLOW
METER ....................................................................... 117
podactin ........................................................................ 65
podocon ......................................................................... 71
podofilox ...................................................................... 71
POLIBAR ACB
....................................................................................................... 81
POLYCIN ................................................................ 134
polycin b ................................................................... 134
poly-dex ..................................................................... 135
polyethylene glycol 3350
................................................................................................... 140
poly-iron 150 forte
....................................................................................................... 95
polymyxin b-trimethoprim
................................................................................................... 134
polysaccharide iron forte
....................................................................................................... 95
POLYTRIM ......................................................... 134
POLY-VI-FLOR
................................................................................................... 126
POLY-VI-FLOR/IRON
................................................................................................... 126
polyvitamin/fluoride
................................................................................................... 126
poly-vitamin/fluoride
................................................................................................... 126
POMALYST ........................................................... 40
PONSTEL ....................................................................... 7
PORTIA-28 ............................................................... 55
pot bicarb-pot chloride
................................................................................................... 122
POTABA .................................................................. 150
potassium bicarbonate
................................................................................................... 122
potassium chloride
................................................................................................... 122
potassium chloride crys er
................................................................................................... 122
potassium chloride er
................................................................................... 122, 123
potassium citrate-citric acid
...................................................................................................
122
PHOSPHASAL
...................................................................................................
147
PHOSPHOLINE IODIDE
...................................................................................................
133
PHYSIOLYTE
.......................................................................................................
50
PHYSIOSOL IRRIGATION
50
PICATO ......................................................................... 66
PIKO 1 .......................................................................... 117
pillow mask/adult
................................................................................................... 118
pillow mask/child
................................................................................................... 118
pillow mask/pediatric
................................................................................................... 118
pilocarpine hcl
................................................................................... 124, 133
PILOPINE HS
................................................................................................... 133
PIMTREA ................................................................... 54
pinnacaine otic
................................................................................................... 137
pioglitazone hcl
....................................................................................................... 27
pioglitazone hcl-glimepiride
....................................................................................................... 24
pioglitazone hcl-metformin hcl
....................................................................................................... 24
PIRMELLA 1/35
....................................................................................................... 55
PIRMELLA 7/7/7
....................................................................................................... 57
piroxicam ........................................................................ 7
PLAQUENIL ......................................................... 38
plastic adapter
................................................................................................... 115
PLAVIX ......................................................................... 93
PLETAL ......................................................................... 92
PLEXION .................................................................... 62
PLEXION CLEANSER
....................................................................................................... 62
PLEXION CLEANSING CLOTH
....................................................................................................... 62
PLIAGLIS ................................................................... 71
pnv fe fum/docusate/folic acid
................................................................................................... 127
pnv ob+dha ......................................................... 129
pnv-dha ...................................................................... 129
pnv-dha+docusate
................................................................................................... 129
pnv-first ..................................................................... 129
.......................................................................................................
90
POTIGA ......................................................................... 19
PR NATAL 400
................................................................................................... 128
PRADAXA ................................................................ 18
pramcort ....................................................................... 13
pramipexole dihydrochloride
....................................................................................................... 43
PRAMOSONE
....................................................................................................... 69
PRAMOSONE E
....................................................................................................... 69
pramoxine-chloroxylenol
................................................................................................... 138
pramoxine-hc-chloroxylenol aq
................................................................................................... 138
PRANDIMET
....................................................................................................... 24
PRANDIN ................................................................... 27
PRASCION ............................................................... 62
PRASCION FC
....................................................................................................... 62
PRASCION RA
....................................................................................................... 62
PRAVACHOL
....................................................................................................... 32
pravastatin sodium
....................................................................................................... 32
prazosin hcl ............................................................. 34
PRECISION GLUCOSE
CONTROL ............................................................. 106
PRECISION GLUCOSE
CONTROL SOLN
................................................................................................... 107
PRECISION GLUCOSE
KETONE CONTR
................................................................................................... 107
PRECISION
GLUCOSE/KETONE CONTR
................................................................................................... 107
PRECISION PCX
....................................................................................................... 78
PRECISION PCX PLUS TEST
....................................................................................................... 78
PRECISION POINT OF CARE
TEST ................................................................................... 78
PRECISION QID TEST
....................................................................................................... 78
PRECISION SOF-TACT TEST
....................................................................................................... 78
PRECISION SUREDOSE PLUS
SYR ................................................................................... 115
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
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Index
Index
Index
PRECISION SURE-DOSE
SYRINGE ................................................................ 115
PRECISION THIN LANCETS
................................................................................................... 107
PRECISION THINS GP
LANCETS .............................................................. 107
PRECISION ULTRA LANCET
................................................................................................... 107
PRECISION XTRA BLOOD
GLUCOSE ................................................................. 78
PRECOSE ................................................................... 23
PRED FORTE
................................................................................................... 136
PRED MILD ....................................................... 136
PRED-G ..................................................................... 135
PRED-G S.O.P.
................................................................................................... 135
prednicarbate
....................................................................................................... 69
prednisolone ........................................................... 59
prednisolone acetate
................................................................................................... 136
prednisolone sodium phosphate
....................................................................................................... 59
prednisone ................................................................. 59
prednisone (pak)
....................................................................................................... 59
PREDNISONE INTENSOL
....................................................................................................... 59
PREFERA OB
................................................................................................... 127
PREFERA OB + DHA
................................................................................................... 127
PREFERAOB ONE
................................................................................................... 129
preferred plus glucose
....................................................................................................... 25
preferred plus lancets colored
................................................................................................... 107
preferred plus lancets thin
................................................................................................... 107
preferred plus unifine pentips
................................................................................................... 115
PREFEST ..................................................................... 86
PREFOL-DHA
................................................................................................... 129
PRE-FOLIC .............................................................. 94
PRELONE .................................................................. 59
PREMARIN ............................................. 87, 149
PREMPHASE
....................................................................................................... 86
PREMPRO ................................................................. 86
prena1 pearl ....................................................... 127
prena1 plus/quatrefolic
PRENTIF CAVITY-RIM CERV
CAP ....................................................................................... 98
PRENTIF FITTING SET
....................................................................................................... 98
PREPIDIL ............................................................... 138
PREPOPIK ................................................................ 97
PREQUE 10 ......................................................... 129
PRESTIGE GLUCOSE
CONTROL ............................................................. 107
prestige smart system test
....................................................................................................... 78
PRESTIGE TEST
....................................................................................................... 78
PRESTIGE VALUE PACK
....................................................................................................... 78
PREVACID .......................................................... 146
PREVACID SOLUTAB
................................................................................................... 146
PREVALITE ........................................................... 31
PREVIDENT 5000 BOOSTER
................................................................................................... 123
PREVIDENT 5000 BOOSTER
PLUS ............................................................................... 123
PREVIFEM ............................................................... 56
PREVPAC .............................................................. 147
PREZISTA ................................................................. 47
PRIALT .............................................................................. 9
PRIFTIN ........................................................................ 38
PRILOSEC ............................................................ 146
PRILOSEC OTC
................................................................................................... 146
primidone ................................................................... 19
PRIMLEV ................................................................... 12
PRIMSOL .................................................................... 37
PRINIVIL .................................................................... 33
PRINZIDE .................................................................. 34
PRISTIQ ........................................................................ 23
PRIVIGEN ............................................................. 139
PROAIR HFA
....................................................................................................... 17
probenecid ................................................................ 91
PROCARDIA
....................................................................................................... 52
PROCARDIA XL
....................................................................................................... 52
PROCENTRA
........................................................................................................... 3
PROCHIEVE ..................................................... 149
prochlorperazine
....................................................................................................... 45
prochlorperazine maleate
....................................................................................................... 45
PROCORT ................................................................. 13
PROCRIT .................................................................... 93
...................................................................................................
129
prena1/quatrefolic
129, 130
prenacare ............................................................... 127
prenaissance ...................................................... 129
prenaissance 90 dha
................................................................................................... 129
prenaissance balance
................................................................................................... 129
prenaissance dha
................................................................................................... 129
prenaissance harmony dha
................................................................................................... 127
prenaissance next
................................................................................................... 130
prenaissance next-b
................................................................................................... 130
prenaissance plus
................................................................................................... 129
prenaissance promise
................................................................................................... 129
PRENATA ............................................................. 127
prenatabs fa ........................................................ 127
PRENATABS RX
................................................................................................... 127
prenatal 19 ........................................................... 127
PRENATAL AD
................................................................................................... 127
PRENATAL
MULTIVITAMIN-ULTRA
................................................................................................... 127
prenatal plus iron
................................................................................................... 127
prenatal+dha
................................................................................................... 129
PRENATAL-U
................................................................................................... 127
PRENATE .............................................................. 130
PRENATE AM
................................................................................................... 130
PRENATE DHA
................................................................................................... 129
PRENATE ELITE
................................................................................................... 127
PRENATE ENHANCE
................................................................................................... 129
PRENATE ESSENTIAL
................................................................................................... 127
PRENATE MINI
................................................................................................... 129
PRENATE RESTORE
................................................................................................... 129
PRENEXA ............................................................. 129
...................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
183
Index
Index
Index
PROCTOCARE-HC
PROGLYCEM
PRUDOXIN ............................................................. 66
pseudoeph-bromphen-dm
....................................................................................................... 60
PSS SELECT GP LANCETS
................................................................................................... 107
PSS SELECT PLATFORMS
................................................................................................... 107
PSS SELECT SAFETY
LANCETS .............................................................. 107
PTS PANELS GLUCOSE TEST
....................................................................................................... 79
PULMICORT
....................................................................................................... 16
PULMICORT FLEXHALER
....................................................................................................... 16
PULMOSAL ........................................................... 61
PULMOZYME
................................................................................................... 143
purefe ob plus
................................................................................................... 127
purefe plus ................................................................. 95
purevit dualfe plus
....................................................................................................... 95
PURINETHOL
....................................................................................................... 39
px advanced lancing device
................................................................................................... 107
px extra short pen needles
................................................................................................... 115
px glucose .................................................................. 25
px insulin syringe
................................................................................................... 115
px lancet auto injector
................................................................................................... 107
px lancets ................................................................ 107
px lancets ultra thin
................................................................................................... 107
px niacin ................................................................... 150
px pen needle
................................................................................................... 115
px shortlength pen needles
................................................................................................... 115
PYLERA ................................................................... 147
pyrazinamide
....................................................................................................... 38
pyridostigmine bromide
....................................................................................................... 38
qc advanced lancing device
................................................................................................... 107
qc alcohol swabs
................................................................................................... 112
qc insulin syringe
................................................................................................... 115
.......................................................................................................
14
PROCTOCREAM HC
.......................................................................................................
14
PROCTOFOAM HC
.......................................................................................................
13
PROCTO-PAK
.......................................................................................................
14
PROCTOSOL HC
.......................................................................................................
14
PROCTOZONE-HC
14
PROCYSBI ............................................................... 90
PRODIGY AUTOCODE BLOOD
GLUCOSE ................................................................. 78
PRODIGY BLOOD GLUCOSE
TEST ................................................................................... 78
PRODIGY CONTROL
SOLUTION .......................................................... 107
PRODIGY EJECT BLOOD
GLUCOSE ................................................................. 79
PRODIGY INSULIN PEN
NEEDLES ............................................................... 115
PRODIGY INSULIN SYRINGE
................................................................................................... 115
PRODIGY LANCETS 21G
................................................................................................... 107
PRODIGY LANCETS 26G
................................................................................................... 107
PRODIGY LANCETS 28G
................................................................................................... 107
PRODIGY LANCING DEVICE
................................................................................................... 107
PRODIGY MINI PEN NEEDLES
................................................................................................... 115
PRODIGY NO CODING BLOOD
GLUC ................................................................................. 79
PRODIGY SAFETY LANCETS
26G ..................................................................................... 107
PRODIGY SHORT PEN
NEEDLES ............................................................... 115
PRODIGY TWIST TOP
LANCETS 28G
................................................................................................... 107
PRODIGY VOICE BLOOD
GLUCOSE ................................................................. 79
PRODRIN ............................................................... 120
PROFERRIN-FORTE
....................................................................................................... 95
PROFILNINE SD
....................................................................................................... 92
progesterone ...................................................... 140
progesterone micronized
................................................................................................... 140
.......................................................................................................
26
PROGRAF ................................................................. 50
PROLASTIN ...................................................... 143
PROLASTIN-C
................................................................................................... 143
PROLENSA ......................................................... 137
PROLIA ......................................................................... 83
PROMACTA .......................................................... 94
promethazine hcl
....................................................................................................... 30
promethazine-codeine
....................................................................................................... 61
promethazine-dm
....................................................................................................... 60
PROMETHEGAN
....................................................................................................... 30
PROMETRIUM
................................................................................................... 140
propafenone hcl
....................................................................................................... 15
propafenone hcl er
....................................................................................................... 15
proparacaine hcl
................................................................................................... 135
proparacaine-fluorescein
................................................................................................... 137
propranolol hcl
....................................................................................................... 51
propranolol hcl er
....................................................................................................... 51
propylthiouracil
................................................................................................... 144
PROSCAR .................................................................. 90
PROSTIN E2 ...................................................... 139
PROTECTIRON
....................................................................................................... 95
PROTHELIAL
................................................................................................... 124
PROTONIX .......................................................... 146
PROTOPIC ................................................................ 71
protriptyline hcl
....................................................................................................... 23
PROVENTIL HFA
....................................................................................................... 17
PROVERA ............................................................. 140
PROVIDA OB
................................................................................................... 127
PROVIGIL ..................................................................... 5
PROVOCHOLINE
....................................................................................................... 72
PROZAC ....................................................................... 22
PROZAC WEEKLY
....................................................................................................... 22
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
184
Index
Index
Index
qc lancets super thin 30g
RA E-ZJECT LANCETS 28G
re urea 50 ................................................................... 70
READI-CAT ........................................................... 81
READI-CAT 2
....................................................................................................... 81
reality lancets
................................................................................................... 107
reality swabs ...................................................... 112
reality trigger lancets
................................................................................................... 107
reaphirm ................................................................... 129
REBETOL .................................................................. 48
REBIF ............................................................................ 142
REBIF REBIDOSE
................................................................................................... 142
REBIF REBIDOSE TITRATION
PACK ............................................................................. 142
REBIF TITRATION PACK
................................................................................................... 142
RECLAST ................................................................... 83
RECLIPSEN ............................................................ 56
RECOMBINATE
....................................................................................................... 92
rectacort-hc ............................................................. 14
RECTIV ......................................................................... 14
REFUAH PLUS BLOOD
GLUCOSE TEST
....................................................................................................... 79
REFUAH PLUS GLUCOSE
CONTROL ............................................................. 107
REGENECARE
....................................................................................................... 72
REGLAN ...................................................................... 88
REGRANEX ........................................................... 72
RELAGARD ....................................................... 148
relcof c ............................................................................ 59
RELENZA DISKHALER
....................................................................................................... 49
RELHIST ..................................................................... 60
RELION ALCOHOL SWABS
................................................................................................... 112
RELION BLOOD GLUCOSE
TEST ................................................................................... 79
RELION CONFIRM/MICRO
TEST ................................................................................... 79
RELION GLUCOSE
........................................................................................... 25, 26
RELION GLUCOSE DRINK
....................................................................................................... 26
RELION INSULIN SYRINGE
................................................................................................... 116
RELI-ON INSULIN SYRINGE
................................................................................................... 116
RELION KETONE
....................................................................................................... 79
...................................................................................................
107
qc lancets ultra thin
...................................................................................................
107
qc pen needles
...................................................................................................
115
qc unifine pentips
115
QNASL ........................................................................ 131
QUALAQUIN
....................................................................................................... 38
QUARTETTE
....................................................................................................... 56
QUASENSE ............................................................. 56
QUESTRAN ............................................................ 31
QUESTRAN LIGHT
....................................................................................................... 31
quetiapine fumarate
....................................................................................................... 45
QUFLORA PEDIATRIC
................................................................................................... 126
QUICKTEK CONTROL
SOLUTION .......................................................... 107
QUICKTEK TEST
....................................................................................................... 79
QUILLIVANT XR
........................................................................................................... 5
quinapril hcl ........................................................... 33
quinapril-hydrochlorothiazide
....................................................................................................... 34
quinidine gluconate er
....................................................................................................... 15
quinidine sulfate
....................................................................................................... 15
quinine sulfate
....................................................................................................... 38
QUINTET AC BLOOD
GLUCOSE TEST
....................................................................................................... 79
QUINTET BLOOD GLUCOSE
TEST ................................................................................... 79
QUINTET CONTROL
HIGH/NORMAL
................................................................................................... 107
QUINZYME ................................................................ 5
QUTENZA ................................................................. 71
QUTENZA (2 PATCH)
....................................................................................................... 71
QVAR ................................................................................ 16
ra alcohol swabs
................................................................................................... 112
ra antifungal .......................................................... 65
RA E-ZJECT COLOR LANCETS
33G ..................................................................................... 107
...................................................................................................
107
RA E-ZJECT LANCETS THIN
26G ..................................................................................... 107
RA E-ZJECT LANCETS THIN
28G ..................................................................................... 107
RA E-ZJECT LANCETS ULTRA
THIN ............................................................................... 107
ra glucose ....................................................... 25, 26
ra lancing device
................................................................................................... 107
ra niacin ................................................................... 150
ra no flush niacin
................................................................................................... 150
ra pen needles
................................................................................................... 116
RA TRUETEST TEST
....................................................................................................... 79
rabeprazole sodium
................................................................................................... 146
RADIOGARDASE
....................................................................................................... 28
ramipril .......................................................................... 33
RANEXA ..................................................................... 14
ranitidine hcl
................................................................................................... 146
RAPAFLO .................................................................. 90
RAPAMUNE ......................................................... 50
RAVICTI ...................................................................... 85
RAYOS ........................................................................... 59
RAZADYNE ...................................................... 141
RAZADYNE ER
................................................................................................... 141
RE 10 WASH
....................................................................................................... 67
re 40 .................................................................................... 70
RE BENZOTIC
................................................................................................... 137
re chlordiazepoxide/clidinium
................................................................................................... 145
RE DUALVIT OB
................................................................................................... 127
RE DUALVIT PLUS
....................................................................................................... 95
re multivit with fluoride
................................................................................................... 126
RE OB + DHA
................................................................................................... 129
re pramoxine-hc
................................................................................................... 138
re prenatal multivitamin/iron
................................................................................................... 128
re sa ..................................................................................... 71
re urea 40 ................................................................... 70
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
185
Index
Index
Index
RELION LANCETS
MICRO-THIN 33G
RENEW ADVANCED LANCING
DEVICE ..................................................................... 108
reno caps ................................................................. 124
RENVELA ................................................................. 89
repaglinide ............................................................... 27
repan ...................................................................................... 8
replacement air filter
................................................................................................... 118
replacement filters
................................................................................................... 118
REPREXAIN ......................................................... 11
REQUIP ......................................................................... 43
REQUIP XL ............................................................. 43
RESCON-JR ............................................................ 60
RESCON-MX
....................................................................................................... 60
RESCRIPTOR
....................................................................................................... 47
RESCULA .............................................................. 137
RESECTISOL
....................................................................................................... 90
RESPA-BR ................................................................ 30
RESTASIS ............................................................. 135
RESTORIL ................................................................ 96
RETIN-A ...................................................................... 63
RETIN-A MICRO
....................................................................................................... 63
RETIN-A MICRO PUMP
....................................................................................................... 63
RETROVIR .............................................................. 47
REVATIO ................................................................... 53
REVEAL BLOOD GLUCOSE
TEST ................................................................................... 79
REVIA .............................................................................. 28
REVINA ........................................................................ 70
REVLIMID ............................................................... 49
REXALL BLOOD GLUCOSE
TEST ................................................................................... 79
REXALL LANCETS ULTRA
THIN 30G ............................................................... 108
REYATAZ ................................................................. 47
REZIRA ......................................................................... 61
RHEUMATREX
........................................................................................................... 6
RHINOCORT AQUA
................................................................................................... 131
RHOGAM ULTRA-FILTERED
PLUS ............................................................................... 139
RHOPHYLAC
................................................................................................... 139
RIASTAP ..................................................................... 92
RIAX ................................................................................... 63
RIBASPHERE
....................................................................................................... 48
RIBATAB ................................................................... 48
ribavirin ........................................................................ 48
RIDAURA ...................................................................... 6
RIFADIN ...................................................................... 38
RIFAMATE ............................................................. 38
rifampin ......................................................................... 38
RIFATER ..................................................................... 38
RIGHTEST ALTERNATE SITE
ADAPT ........................................................................ 108
RIGHTEST GC300 CONTROL
................................................................................................... 108
RIGHTEST GD500 LANCING
DEVICE ..................................................................... 108
RIGHTEST GL300 LANCETS
................................................................................................... 108
RIGHTEST GS100 BLOOD
GLUCOSE ................................................................. 79
RIGHTEST GS300 BLOOD
GLUCOSE ................................................................. 79
RIGHTEST GS550 BLOOD
GLUCOSE ................................................................. 79
RILUTEK ................................................................ 131
riluzole ........................................................................ 131
rimantadine hcl
....................................................................................................... 49
ringers irrigation
....................................................................................................... 50
RIOMET ........................................................................ 24
RISPERDAL ........................................................... 44
RISPERDAL M-TAB
....................................................................................................... 44
risperidone ............................................................... 44
RISPERIDONE M-TAB
....................................................................................................... 44
RITALIN .......................................................................... 5
RITALIN LA .............................................................. 5
RITALIN SR ............................................................... 5
RITEFLO ................................................................. 120
rivastigmine tartrate
................................................................................................... 141
rixubis .............................................................................. 92
rizatriptan benzoate
................................................................................................... 121
R-NATAL OB
................................................................................................... 129
robafen ac .................................................................. 59
ROBAXIN .............................................................. 130
ROBAXIN-750
................................................................................................... 130
ROBINUL ............................................................... 145
ROBINUL-FORTE
................................................................................................... 145
ROCALTROL
....................................................................................................... 85
107
RELION LANCETS STANDARD
21G ..................................................................................... 107
RELION LANCETS THIN 26G
................................................................................................... 107
RELION LANCETS
ULTRA-THIN 30G
................................................................................................... 107
RELION LANCING DEVICE
................................................................................................... 107
RELION MINI PEN NEEDLES
................................................................................................... 116
RELION PEN NEEDLES
................................................................................................... 116
RELION PRIME TEST
....................................................................................................... 79
RELION SHORT PEN NEEDLES
................................................................................................... 116
RELION ULTIMA TEST
....................................................................................................... 79
RELION ULTRA THIN
LANCETS 30G
................................................................................................... 108
RELION ULTRA THIN PLUS
LANCETS .............................................................. 108
RELISTOR ................................................................ 89
relnate dha ............................................................ 128
RELPAX ................................................................... 121
REMEDY ANTIFUNGAL
....................................................................................................... 65
REMERON ............................................................... 20
REMERON SOLTAB
....................................................................................................... 20
REMEVEN ................................................................ 70
REMODULIN
....................................................................................................... 52
RENACIDIN .......................................................... 90
renaf ............................................................................... 122
RENAGEL ................................................................. 89
RENAL ........................................................................ 124
RENALPREN
................................................................................................... 124
re-nata 29 ob
................................................................................................... 128
RENATABS ........................................................ 124
RENATABS WITH IRON
................................................................................................... 125
rena-vite rx ........................................................... 124
RENAX ....................................................................... 125
RENEW ADV CARTRIDGE
REFILLS ................................................................... 108
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
186
Index
Index
Index
ROMILAR AC
SALKERA ................................................................. 71
salsalate ............................................................................ 9
SALVAX DUO PLUS
....................................................................................................... 71
SAMI THE SEAL FILTERS
................................................................................................... 118
SAMSCA ..................................................................... 86
SANCTURA ....................................................... 148
SANCUSO ................................................................. 28
SANDIMMUNE
....................................................................................................... 49
SANDOSTATIN
....................................................................................................... 86
SANDOSTATIN LAR DEPOT
....................................................................................................... 86
SANTYL ....................................................................... 70
SAPHRIS ..................................................................... 45
SARAFEM ............................................................ 142
SAVELLA .............................................................. 141
SAVELLA TITRATION PACK
................................................................................................... 141
sb alcohol prep
................................................................................................... 112
sb lancets thin
................................................................................................... 108
sb lancets ultra thin
................................................................................................... 108
scalacort ....................................................................... 69
SCLEROSOL INTRAPLEURAL
................................................................................................... 143
se 10-5 ss ..................................................................... 62
SEASONIQUE
....................................................................................................... 56
SEB-PREV ................................................................ 67
SEB-PREV WASH
....................................................................................................... 67
SECONAL ................................................................. 96
SECTRAL ................................................................... 51
SECURA ANTIFUNGAL
....................................................................................................... 65
SECURA ANTIFUNGAL EXTRA
THICK .............................................................................. 65
select-lite device/lancets
................................................................................................... 108
select-lite lancing device
................................................................................................... 108
SELECT-OB ....................................................... 128
SELECT-OB+DHA
................................................................................................... 129
selegiline hcl .......................................................... 43
selenium sulfide
....................................................................................................... 67
SELFEMRA ........................................................ 142
SELRX ............................................................................. 67
SELZENTRY
59
romycin ...................................................................... 134
ropinirole hcl
....................................................................................................... 43
ropinirole hcl er
....................................................................................................... 43
ROSADAN ................................................................ 72
ROSADERM .......................................................... 62
ROSANIL CLEANSER
....................................................................................................... 62
ROSE GLO ........................................................... 137
ROXICET .................................................................... 12
ROXICODONE
....................................................................................................... 10
ROZEREM ................................................................ 96
RYTHMOL ............................................................... 15
RYTHMOL SR
....................................................................................................... 15
SABRIL .......................................................................... 20
SAFESNAP INSULIN SYRINGE
................................................................................................... 116
SAFE-T-LANCE
................................................................................................... 108
SAFE-T-LANCE PLUS
................................................................................................... 108
safety lancet 21g/pressure act
................................................................................................... 108
safety lancet 28g/pressure act
................................................................................................... 108
SAFETY LANCET 2MM
................................................................................................... 108
SAFETY LANCETS
................................................................................................... 108
SAFETY LANCETS 21G
................................................................................................... 108
safety lancets 28g
................................................................................................... 108
SAFETY LET LANCETS
................................................................................................... 108
SAFETY SEAL LANCETS
................................................................................................... 108
SAFETY-GLIDE SYRINGE
................................................................................................... 116
SAFYRAL .................................................................. 56
SAIZEN .......................................................................... 84
SAIZEN CLICK.EASY
....................................................................................................... 84
SALACYN ................................................................. 71
SALAGEN ............................................................. 124
SALICEPT ............................................................. 124
salicylic acid .......................................................... 71
salicylic acid wart remover
....................................................................................................... 71
.......................................................................................................
.......................................................................................................
46
SEMPREX-D
60
se-natal 19 ............................................................. 128
SENSIPAR ................................................................ 84
SENTRAVIL PM-25
....................................................................................................... 20
sentry test .................................................................... 79
SEPTRA ........................................................................ 37
SEPTRA DS ............................................................ 37
SEREVENT DISKUS
....................................................................................................... 17
SEROPHENE
....................................................................................................... 83
SEROQUEL ............................................................. 45
SEROQUEL XR
....................................................................................................... 45
SEROSTIM ............................................................... 84
sertraline hcl ......................................................... 22
se-tan plus ................................................................. 95
sevoflurane ............................................................... 89
sf ........................................................................................... 123
sf 5000 plus .......................................................... 124
SFROWASA ........................................................... 88
SHOPKO ALCOHOL SWABS
................................................................................................... 112
SHOPKO AUTOLET LANCING
DEVICE ..................................................................... 108
SHOPKO ON-THE-GO
LANCETS 30G
................................................................................................... 108
SHOPKO UNIFINE PENTIPS
................................................................................................... 116
SHOPKO UNILET LANCETS
28G ..................................................................................... 108
SHOPKO UNILET LANCETS
30G ..................................................................................... 108
shoprite test ............................................................. 79
SHUR-SEAL CONTRACEPTIVE
................................................................................................... 148
SIDESTREAM ADULT FACE
MASK ........................................................................... 118
SIDESTREAM PEDIATRIC
FACE MASK
................................................................................................... 118
SIDESTREAM PLS ADULT
FACE MASK
................................................................................................... 118
SIGNIFOR ................................................................. 86
sildenafil citrate
....................................................................................................... 53
SILENOR ..................................................................... 96
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
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Index
Index
Index
silicone mask/adult
SMART DIABETES XPRES
TEST ................................................................................... 79
SMART SENSE COLOR
LANCETS 33G
................................................................................................... 108
SMART SENSE GLUCOSE
....................................................................................................... 25
SMART SENSE PREMIUM
TEST ................................................................................... 79
SMART SENSE STANDARD
LANCETS .............................................................. 108
SMART SENSE SUPER THIN
LANCETS .............................................................. 108
SMART SENSE THIN LANCETS
26G ..................................................................................... 108
SMART SENSE VALUE TEST
....................................................................................................... 79
SMARTEST BLOOD GLUCOSE
TEST ................................................................................... 79
SMARTEST CONTROL
MEDIUM ................................................................. 108
SMARTEST LANCETS 28G
................................................................................................... 108
smz-tmp ds ................................................................. 37
sodiphluor .............................................................. 122
sodium chloride
........................................................................................... 61, 90
sodium fluoride
................................................................................................... 122
sodium hyaluronate
....................................................................................................... 70
sodium phenylbutyrate
....................................................................................................... 85
sodium polystyrene sulfonate
....................................................................................................... 50
sodium sulfacetamide
....................................................................................................... 67
sodium sulfacetamide wash
....................................................................................................... 67
SOJOURN .................................................................. 89
SOLARAZE ............................................................. 66
SOLARTEK GLUCOSE
CONTROL ............................................................. 108
SOLIA ............................................................................... 56
SOLIRIS ........................................................................ 92
SOLODYN ............................................................ 144
SOLTAMOX .......................................................... 39
SOLUS V2 CONTROL
................................................................................................... 108
SOLUS V2 LANCETS 28G
................................................................................................... 108
SOLUS V2 LANCING DEVICE
................................................................................................... 109
SOLUS V2 TEST
...................................................................................................
118
silicone mask/infant
...................................................................................................
118
silicone mask/pediatric
118
SILVADENE ......................................................... 67
silver sulfadiazine
....................................................................................................... 67
SIMBRINZA ...................................................... 133
SIMCOR ........................................................................ 31
SIMPLE DIAGNOSTICS
LANCING DEV
................................................................................................... 108
SIMPONI ......................................................................... 6
SIMPONI ARIA
........................................................................................................... 6
SIMULECT .............................................................. 50
simvastatin ................................................................ 32
SINEMET .................................................................... 43
SINEMET CR
....................................................................................................... 43
SINGLE-LET
................................................................................................... 108
SINGULAIR ........................................................... 16
SIRTURO .................................................................... 38
SITZMARKS
....................................................................................................... 81
SIVEXTRO ............................................................... 38
SKELAXIN .......................................................... 130
SKELID .......................................................................... 83
SKLICE .......................................................................... 72
SKYLA ............................................................................ 58
SLO-NIACIN
................................................................................................... 150
sm alcohol prep
................................................................................................... 112
sm antifungal miconazole
....................................................................................................... 65
sm glucose ..................................................... 25, 26
sm lancets 21g
................................................................................................... 108
sm lancets 33g
................................................................................................... 108
sm niacin cr ......................................................... 150
sm super thin lancets 30g
................................................................................................... 108
sm thin lancets 26g
................................................................................................... 108
SMART DIABETES VANTAGE
LANCETS .............................................................. 108
SMART DIABETES VANTAGE
LANCING .............................................................. 108
...................................................................................................
79
SOLUS V2 TWIST LANCETS
30G ..................................................................................... 109
SOMA ........................................................................... 130
SOMATULINE DEPOT
....................................................................................................... 86
SOMAVERT .......................................................... 83
SONATA ...................................................................... 96
SOOTHE & COOL INZO
ANTIFUNGAL
....................................................................................................... 65
SORIATANE
....................................................................................................... 66
SORILUX .................................................................... 66
SORINE ......................................................................... 51
sotalol hcl ................................................................... 51
sotalol hcl (af)
....................................................................................................... 51
SOTRET ........................................................................ 63
SOVALDI ................................................................... 48
SPECTRACEF
....................................................................................................... 53
SPIRIVA HANDIHALER
....................................................................................................... 16
spironolactone
....................................................................................................... 82
spironolactone-hctz
....................................................................................................... 82
SPORANOX ........................................................... 29
SPORANOX PULSEPAK
....................................................................................................... 29
SPRINTEC 28
....................................................................................................... 56
SPRIX .................................................................................... 7
SPRYCEL ................................................................... 41
SPS ......................................................................................... 50
SRONYX ..................................................................... 56
SSD ........................................................................................ 67
SSD AF ........................................................................... 67
SSKI ................................................................................. 122
sss 10-5 .......................................................................... 62
STALEVO 100
....................................................................................................... 43
STALEVO 125
....................................................................................................... 43
STALEVO 150
....................................................................................................... 43
STALEVO 200
....................................................................................................... 43
STALEVO 50
....................................................................................................... 43
STALEVO 75
....................................................................................................... 43
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
188
Index
Index
Index
stannous fluoride
SULFAZINE EC
SURELITE LANCETS
124
STARLIX ..................................................................... 27
stavudine ...................................................................... 47
STAVZOR ................................................................. 20
STERILANCE PA
................................................................................................... 109
STERILANCE TL
................................................................................................... 109
STERILE TALC POWDER
................................................................................................... 143
sterile water for irrigation
....................................................................................................... 50
STIMATE .................................................................... 86
STIVARGA .............................................................. 41
STRATTERA
........................................................................................................... 4
STRIANT ..................................................................... 13
STRIBILD .................................................................. 46
STROMECTOL
....................................................................................................... 14
STROVITE FORTE
................................................................................................... 125
SUBOXONE ........................................................... 12
SUBSYS ........................................................................ 10
SUCLEAR .................................................................. 97
SUCRAID ................................................................... 81
sucralfate ................................................................ 146
SULAR ............................................................................ 52
sulfacetamide sodium
........................................................................... 61, 67, 134
sulfacetamide sodium (acne)
....................................................................................................... 61
sulfacetamide sodium-sulfur
....................................................................................................... 62
sulfacetamide sod-sulfur wash
....................................................................................................... 62
sulfacetamide-prednisolone
................................................................................................... 135
sulfacetamide-sulfur wash
....................................................................................................... 62
SULFACLEANSE 8/4
....................................................................................................... 62
sulfamethoxazole-tmp ds
....................................................................................................... 37
sulfamethoxazole-trimethoprim
....................................................................................................... 37
SULFAMYLON
....................................................................................................... 67
sulfasalazine .......................................................... 88
SULFATRIM PEDIATRIC
....................................................................................................... 37
SULFAZINE ........................................................... 88
...................................................................................................
88
SULFOAM ................................................................ 63
sulindac ............................................................................. 7
sumatriptan succinate
................................................................................................... 121
SUPARTZ ............................................................... 131
super thin lancets
................................................................................................... 109
SUPERVITE EC
................................................................................................... 125
SUPHERA .................................................................. 62
SUPPRELIN LA
....................................................................................................... 84
SUPRANE .................................................................. 89
SUPRAX ....................................................................... 53
supreme ii high/low control
................................................................................................... 109
SUPREME TEST
....................................................................................................... 79
SUPREP BOWEL PREP
....................................................................................................... 97
sure comfort alcohol prep
................................................................................................... 112
sure comfort insulin syringe
................................................................................................... 116
sure comfort lancets 28g
................................................................................................... 109
sure comfort lancets 30g
................................................................................................... 109
sure comfort lancing pen
................................................................................................... 109
sure comfort pen needles
................................................................................................... 116
SURE EDGE GLUCOSE
CONTROL ............................................................. 109
SURE EDGE TEST
....................................................................................................... 79
SURECHEK BLOOD GLUCOSE
TEST ................................................................................... 80
SURECHEK CONTROL
SOLUTION .......................................................... 109
SURE-FINE PEN NEEDLES
................................................................................................... 116
SURE-JECT INSULIN SYRINGE
................................................................................................... 116
SURE-LANCE FLAT LANCETS
................................................................................................... 109
SURE-LANCE LANCETS 26G
................................................................................................... 109
SURE-LANCE THIN LANCETS
28G ..................................................................................... 109
SURE-LANCE ULTRA THIN
LANCETS .............................................................. 109
.......................................................................................................
109
SURE-PEN ............................................................ 109
SURE-PREP ALCOHOL PREP
................................................................................................... 112
SURESTEP GLUCOSE
CONTROL ............................................................. 109
SURESTEP PRO HIGH
GLUCOSE ............................................................. 109
SURESTEP PRO LOW
GLUCOSE ............................................................. 109
SURESTEP PRO NORMAL
GLUCOSE ............................................................. 109
SURESTEP PRO TEST
....................................................................................................... 80
SURESTEP TEST
....................................................................................................... 80
SURE-TEST EASYPLUS
CONTROL ............................................................. 109
SURE-TEST EASYPLUS MINI
TEST ................................................................................... 79
SURE-TOUCH LANCETS
UNIVERSAL
................................................................................................... 109
SURMONTIL
....................................................................................................... 23
SUSTIVA ..................................................................... 47
SUTENT ........................................................................ 41
SYEDA ............................................................................ 56
SYLATRON ............................................................ 42
SYMAX DUOTAB
................................................................................................... 145
SYMAX FASTABS
................................................................................................... 145
SYMAX-SL ......................................................... 145
SYMAX-SR ......................................................... 145
SYMBICORT
....................................................................................................... 17
SYMBYAX .......................................................... 141
SYMLINPEN 120
....................................................................................................... 24
SYMLINPEN 60
....................................................................................................... 24
SYNAGEX ............................................................ 125
SYNAGIS ................................................................ 139
SYNALAR ................................................................. 69
SYNALGOS-DC
....................................................................................................... 11
SYNAREL ................................................................. 84
SYNATEK ............................................................. 125
SYNERA ...................................................................... 71
SYNTHROID
................................................................................................... 144
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
189
Index
Index
Index
SYNVISC ONE
TEKTURNA ........................................................... 36
TEKTURNA HCT
....................................................................................................... 36
TELCARE BLOOD GLUCOSE
TEST ................................................................................... 80
TELCARE GLUCOSE
CONTROL ............................................................. 109
temazepam ................................................................ 96
TEMODAR ............................................................... 39
TEMOVATE .......................................................... 69
TEMOVATE E
....................................................................................................... 69
temozolomide
....................................................................................................... 39
TENCON .......................................................................... 8
TENEX ............................................................................ 34
TENORETIC 100
....................................................................................................... 36
TENORETIC 50
....................................................................................................... 36
TENORMIN ............................................................ 51
TERAZOL 3 ........................................................ 148
TERAZOL 7 ........................................................ 148
terazosin hcl ........................................................... 34
terbinafine hcl
....................................................................................................... 29
terbutaline sulfate
....................................................................................................... 17
terconazole ........................................................... 148
TERRELL ................................................................... 89
TERSI ................................................................................ 67
TERUMO INSULIN SYRINGE
................................................................................................... 116
TERUMO SURGUARD INSULIN
SYR ................................................................................... 116
TESSALON PERLES
....................................................................................................... 59
TESTIM ......................................................................... 13
testosterone .............................................................. 13
testosterone cypionate
....................................................................................................... 13
TESTRED ................................................................... 13
TETCAINE ........................................................... 135
tetracaine hcl
................................................................................................... 135
tetracycline hcl
................................................................................................... 144
TETRAVISC ...................................................... 135
TETRAVISC FORTE
................................................................................................... 135
TEVETEN .................................................................. 33
TEVETEN HCT
....................................................................................................... 35
TEV-TROPIN
131
SYPRINE ..................................................................... 49
T.R.U.E. TEST
....................................................................................................... 72
TABLOID ................................................................... 39
TACLONEX ........................................................... 69
tacrolimus .................................................................. 50
TAFINLAR ............................................................... 40
TAGITOL V ............................................................ 81
tai doc control
................................................................................................... 109
TAMIFLU ................................................................... 49
tamoxifen citrate
....................................................................................................... 39
tamsulosin hcl
....................................................................................................... 90
TANDEM DHA
................................................................................................... 128
TANDEM F .............................................................. 95
TANDEM OB
................................................................................................... 128
TANZEUM ............................................................... 26
TAPAZOLE ......................................................... 144
TARCEVA ................................................................. 41
TARGRETIN
........................................................................................... 42, 66
TARKA ........................................................................... 34
TARON EC CALCIUM
................................................................................................... 129
taron forte .................................................................. 95
TARON-BC ......................................................... 128
TARON-C DHA
................................................................................................... 128
TARON-CRYSTALS
....................................................................................................... 90
TARON-PREX
................................................................................................... 129
TASIGNA ................................................................... 41
TASMAR ..................................................................... 42
TAZORAC ................................................................. 66
TAZTIA XT ............................................................. 52
tbc ........................................................................................... 70
TECFIDERA ...................................................... 142
TECHLITE AST LANCETS
................................................................................................... 109
TECHLITE LANCETS
................................................................................................... 109
TECHLITE LANCETS 30G
................................................................................................... 109
TEGRETOL ............................................................. 19
TEGRETOL-XR
....................................................................................................... 19
TEKAMLO ............................................................... 36
...................................................................................................
84
TEXACORT ............................................................ 69
tgq 30pse/150gfn/15dm
....................................................................................................... 60
tgq 30pse/3brm/15dm
....................................................................................................... 60
tgt advanced lancing device
................................................................................................... 109
tgt alcohol swabs
................................................................................................... 112
tgt blood glucose test
....................................................................................................... 80
tgt glucose ................................................................. 25
tgt lancet alternate site
................................................................................................... 109
tgt lancet micro thin 33g
................................................................................................... 109
tgt lancet super thin 30g
................................................................................................... 109
tgt lancet thin 23g
................................................................................................... 109
tgt lancet thin 26g
................................................................................................... 109
tgt lancet ultra thin 28g
................................................................................................... 109
tgt lancet ultra thin 30g
................................................................................................... 109
tgt lancing device
................................................................................................... 109
THALOMID ............................................................ 49
THEO-24 ...................................................................... 17
THEOCHRON
....................................................................................................... 17
theophylline ............................................................. 17
theophylline er
....................................................................................................... 17
THERABENZAPRINE-90-5
................................................................................................... 131
THERMAZENE
....................................................................................................... 67
THINLETS GP LANCETS
................................................................................................... 109
THINLETS LANCET
................................................................................................... 109
THINPRO INSULIN SYRINGE
................................................................................................... 116
THIOLA ......................................................................... 91
thioridazine hcl
....................................................................................................... 45
thiothixene ................................................................. 46
THRESHOLD IMT
................................................................................................... 118
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
190
Index
Index
Index
THYMOGLOBULIN
tobramycin-dexamethasone
TRANSDERM-SCOP
49
THYROGEN .......................................................... 72
THYROLAR-1
................................................................................................... 144
THYROLAR-1/2
................................................................................................... 144
THYROLAR-1/4
................................................................................................... 144
THYROLAR-2
................................................................................................... 144
THYROLAR-3
................................................................................................... 144
tiagabine hcl .......................................................... 20
TIAZAC ......................................................................... 52
ticlopidine hcl
....................................................................................................... 93
TIGAN ............................................................................. 29
TIKOSYN ................................................................... 15
TILIA FE ...................................................................... 57
timolol maleate
................................................................................................... 132
TIMOPTIC ............................................................. 132
TIMOPTIC OCUDOSE
................................................................................................... 132
TIMOPTIC-XE
................................................................................................... 132
TINDAMAX ........................................................... 37
tinidazole ..................................................................... 37
TIROSINT .............................................................. 144
TISSEEL VH .......................................................... 95
TISSEEL VHSD
....................................................................................................... 95
TIS-U-SOL ................................................................ 50
TIVICAY ..................................................................... 46
tizanidine hcl
................................................................................................... 130
tl gard rx ...................................................................... 94
TL G-FOL OS
................................................................................................... 125
tl icon ................................................................................ 95
tl urea ............................................................................... 70
tl-assure one ....................................................... 129
tl-care dha ............................................................. 128
tl-fluorivite ............................................................ 126
tl-select ....................................................................... 129
tl-select dha ......................................................... 129
TOBI ........................................................................................ 5
TOBI PODHALER
........................................................................................................... 5
TOBRADEX ....................................................... 135
TOBRADEX ST
................................................................................................... 135
tobramycin .................................................... 5, 134
.......................................................................................................
135
tobrasol ...................................................................... 134
TOBREX .................................................................. 134
TODAY SPONGE
....................................................................................................... 98
todays health lancing device
................................................................................................... 109
todays health mini pen needles
................................................................................................... 116
todays health pen needles
................................................................................................... 116
todays health short pen needle
................................................................................................... 116
todays health thin lancets 28g
................................................................................................... 109
todays health thin lancets 30g
................................................................................................... 109
TOFRANIL ............................................................... 23
TOFRANIL-PM
....................................................................................................... 23
tolazamide ................................................................. 28
tolmetin sodium
........................................................................................................... 7
tolterodine tartrate er
................................................................................................... 148
TOPAMAX ............................................................... 19
TOPAMAX SPRINKLE
....................................................................................................... 19
topcare clickfine pen needles
................................................................................................... 116
TOPICORT ............................................................... 69
TOPICORT SPRAY
....................................................................................................... 69
TOPIRAGEN
....................................................................................................... 19
topiramate ................................................................. 19
topisulf ............................................................................ 62
TOPROL XL ........................................................... 51
torsemide ..................................................................... 82
TRACLEER ............................................................. 53
TRADJENTA
....................................................................................................... 26
tramadol hcl ........................................................... 10
tramadol hcl er
....................................................................................................... 10
tramadol hcl er (biphasic)
....................................................................................................... 10
tramadol-acetaminophen
....................................................................................................... 12
TRANDATE ........................................................... 51
trandolapril ............................................................. 33
tranexamic acid
....................................................................................................... 95
...................................................................................................
.......................................................................................................
29
TRANXENE-T
.......................................................................................................
15
tranylcypromine sulfate
.......................................................................................................
21
TRAVATAN Z
137
travoprost ............................................................... 137
trazodone hcl
....................................................................................................... 22
TRECATOR ............................................................ 38
TRELSTAR DEPOT
....................................................................................................... 40
TRELSTAR DEPOT MIXJECT
....................................................................................................... 40
TRELSTAR LA
....................................................................................................... 40
TRELSTAR LA MIXJECT
....................................................................................................... 40
TRELSTAR MIXJECT
....................................................................................................... 40
tretinoin ............................................................. 42, 63
tretinoin microsphere
....................................................................................................... 63
tretinoin microsphere pump
....................................................................................................... 63
TRETIN-X ................................................................. 63
TRETTEN ................................................................... 92
TREXALL .................................................................. 39
TREXIMET .......................................................... 120
TRI RX ........................................................................ 128
triadvance .............................................................. 128
triamcinolone acetonide
....................................................................... 69, 124, 131
triamterene-hctz
....................................................................................................... 82
TRIANEX ................................................................... 69
triazolam ...................................................................... 96
TRIBENZOR ......................................................... 36
TRICARE PRENATAL
COMPLEAT ....................................................... 128
TRICARE PRENATAL DHA
ONE .................................................................................. 128
TRI-CHLOR ............................................................ 67
TRICODE AR
....................................................................................................... 61
TRICON ......................................................................... 95
TRICOR ......................................................................... 31
TRIDERM .................................................................. 69
TRI-ESTARYLLA
....................................................................................................... 57
trifluoperazine hcl
....................................................................................................... 46
...................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
191
Index
Index
Index
trifluridine ............................................................. 134
trigels-f forte .......................................................... 95
TRIGLIDE ................................................................. 31
trihexyphenidyl hcl
....................................................................................................... 42
TRI-LEGEST FE
....................................................................................................... 57
TRILEPTAL ............................................................ 19
TRI-LINYAH
....................................................................................................... 57
TRILIPIX ..................................................................... 31
TRILYTE ..................................................................... 97
trimethobenzamide hcl
....................................................................................................... 29
trimethoprim .......................................................... 37
trinatal gt ................................................................ 128
trinatal ultra ....................................................... 128
TRINATE ................................................................ 128
TRINESSA (28)
....................................................................................................... 57
TRI-NORINYL (28)
....................................................................................................... 57
triphrocaps ........................................................... 124
triple antibiotic
................................................................................................... 134
triple-vitamin/fluoride
................................................................................................... 126
TRI-PREVIFEM
....................................................................................................... 57
TRI-SPRINTEC
....................................................................................................... 57
tri-tabs dha ........................................................... 128
TRIVEEN-DUO DHA
................................................................................................... 128
TRIVEEN-ONE
................................................................................................... 128
TRIVEEN-PRX RNF
................................................................................................... 129
TRIVEEN-TEN
................................................................................................... 129
TRIVEEN-U ........................................................ 128
TRI-VI-FLOR
................................................................................................... 126
tri-vi-floro .............................................................. 126
tri-vit/fluoride
................................................................................................... 126
tri-vit/fluoride/iron
................................................................................................... 126
tri-vitamin/fluoride
................................................................................................... 126
TRIVORA (28)
....................................................................................................... 57
TROKENDI XR
....................................................................................................... 19
tropicamide .......................................................... 133
trospium chloride
................................................................................................... 148
trospium chloride er
................................................................................................... 148
true care test strip pack
....................................................................................................... 80
TRUE METRIX BLOOD
GLUCOSE TEST
....................................................................................................... 80
TRUECONTROL GLUCOSE
CONT LEV 0
................................................................................................... 109
TRUECONTROL GLUCOSE
CONT LEV 1
................................................................................................... 109
TRUEDRAW LANCING
DEVICE ..................................................................... 109
TRUEPLUS INSULIN SYRINGE
................................................................................................... 116
TRUEPLUS LANCETS 26G
................................................................................................... 109
TRUEPLUS LANCETS 28G
................................................................................................... 109
TRUEPLUS LANCETS 30G
................................................................................................... 110
TRUEPLUS LANCETS 33G
................................................................................................... 110
TRUEPLUS SAFETY LANCETS
28G ..................................................................................... 110
TRUETEST CONTROL LEVEL 1
................................................................................................... 110
TRUETEST CONTROL LEVEL 2
................................................................................................... 110
TRUETEST CONTROL LEVEL 3
................................................................................................... 110
TRUETEST TEST
....................................................................................................... 80
TRUETRACK GLUCOSE
CONTROL ............................................................. 110
TRUETRACK TEST
....................................................................................................... 80
TRUSOPT ............................................................... 136
TRUVADA ............................................................... 46
TRUZONE PEAK FLOW
METER ....................................................................... 117
tubing/wing tip
................................................................................................... 118
TUDORZA PRESSAIR
....................................................................................................... 16
TUSNEL ........................................................................ 60
tusnel ped-c ............................................................. 60
TUSSICAPS ............................................................ 61
TUSSIGON ............................................................... 59
TUSSIONEX PENNKINETIC ER
....................................................................................................... 61
TUSSO-DMR
....................................................................................................... 60
TWINJECT ........................................................... 149
TYKERB ...................................................................... 41
TYLENOL WITH CODEINE #3
....................................................................................................... 11
TYLENOL WITH CODEINE #4
....................................................................................................... 11
TYSABRI ................................................................ 142
TYVASO ...................................................................... 52
TYVASO REFILL
....................................................................................................... 52
TYVASO STARTER
....................................................................................................... 52
TYZEKA ...................................................................... 48
TYZINE ..................................................................... 131
UCERIS .......................................................................... 59
U-CORT ......................................................................... 69
UDAMIN SP ....................................................... 125
U-KERA E ................................................................. 70
ULESFIA ..................................................................... 72
ULORIC ......................................................................... 91
ULTANE ...................................................................... 89
ULTICARE INSULIN SAFETY
SYR ................................................................................... 116
ULTICARE INSULIN SYRINGE
................................................................................................... 116
ULTICARE MICRO PEN
NEEDLES ............................................................... 116
ULTICARE MINI PEN
NEEDLES ............................................................... 116
ULTICARE PEN NEEDLES
................................................................................................... 116
ULTICARE SHORT PEN
NEEDLES ............................................................... 116
ULTICARE THIN LANCETS
28G ..................................................................................... 110
ULTICARE THIN LANCETS
30G ..................................................................................... 110
ULTI-LANCE AUTO-ADJUST
DEVICE ..................................................................... 110
ULTI-LANCE AUTOMATIC
................................................................................................... 110
ULTI-LANCE MINI
ADJUSTABLE
................................................................................................... 110
ultilet alcohol swab
................................................................................................... 112
ultilet alcohol swabs
................................................................................................... 112
ULTILET BASIC LANCETS 30G
................................................................................................... 110
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
192
Index
Index
Index
ULTILET CLASSIC LANCETS
................................................................................................... 110
ultilet glucose
....................................................................................................... 26
ULTILET INSULIN SYRINGE
................................................................................................... 116
ULTILET INSULIN SYRINGE
SHORT ........................................................................ 116
ULTILET LANCETS
................................................................................................... 110
ULTILET OPERATING DEVICE
................................................................................................... 110
ULTILET SAFETY LANCETS
23G ..................................................................................... 110
ULTILET ULTI-LANCE ADJ
DEVICE ..................................................................... 110
ULTIMA TEST
....................................................................................................... 80
ultimatecare advantage
................................................................................................... 128
ultimatecare combo
................................................................................................... 128
ultra comfort insulin syringe
................................................................................................... 117
ULTRA NATALCARE
................................................................................................... 128
ultra tabs ................................................................. 128
ultra thin lancets 28g
................................................................................................... 110
ultra thin lancets 30g
................................................................................................... 110
ULTRACET ............................................................. 12
ULTRALANCE
................................................................................................... 110
ULTRAM ..................................................................... 10
ULTRAM ER
....................................................................................................... 10
ultra-natal .............................................................. 128
ULTRA-THIN II AUTO LANCET
................................................................................................... 110
ULTRA-THIN II INS SYR
SHORT ........................................................................ 117
ULTRA-THIN II INSULIN
SYRINGE ................................................................ 117
ULTRA-THIN II LANCETS
................................................................................................... 110
ULTRA-THIN II MINI PEN
NEEDLE ................................................................... 117
ULTRA-THIN II PEN NEEDLE
SHORT ........................................................................ 117
ULTRA-THIN II PEN NEEDLES
................................................................................................... 117
ULTRATRAK PRO CONTROL
................................................................................................... 110
ULTRATRAK PRO TEST
UNISTIK 3 NORMAL
80
ULTRATRAK ULTIMATE
CONTROL ............................................................. 110
ULTRATRAK ULTIMATE TEST
....................................................................................................... 80
ULTRAVATE
....................................................................................................... 69
ULTRESA .................................................................. 81
UMECTA ..................................................................... 70
UMECTA PD
....................................................................................................... 70
UNIFINE PENTIPS
................................................................................................... 117
unifine pentips plus
................................................................................................... 117
UNILET COMFORTOUCH
LANCET ................................................................... 110
UNILET EXCELITE
................................................................................................... 110
UNILET EXCELITE II
................................................................................................... 110
UNILET G.P. LANCET
................................................................................................... 110
UNILET G.P. SUPERLITE
LANCET ................................................................... 110
UNILET GP 28 ULTRA THIN
................................................................................................... 110
UNILET LANCET
................................................................................................... 110
UNILET SUPERLITE LANCET
................................................................................................... 110
UNIRETIC ................................................................. 34
UNISTIK 1 ............................................................ 110
UNISTIK 2 ............................................................ 110
UNISTIK 2 COMFORT
................................................................................................... 110
UNISTIK 2 EXTRA
................................................................................................... 110
UNISTIK 2 NEONATAL
................................................................................................... 110
UNISTIK 2 NORMAL
................................................................................................... 110
UNISTIK 2 SUPER
................................................................................................... 110
UNISTIK 3 ............................................................ 110
UNISTIK 3 COMFORT
................................................................................................... 110
UNISTIK 3 EXTRA
................................................................................................... 110
UNISTIK 3 GENTLE
................................................................................................... 110
UNISTIK 3 NEONATAL
................................................................................................... 110
.......................................................................................................
...................................................................................................
110
UNISTIK CZT COMFORT
...................................................................................................
110
UNISTIK CZT NORMAL
...................................................................................................
110
UNISTRIP CONTROL
...................................................................................................
111
UNISTRIP1 GENERIC
80
UNITHROID ...................................................... 144
UNITHROID DIRECT
................................................................................................... 144
UNIVASC ................................................................... 33
UNIVERSAL 1 LANCETS THIN
26G ..................................................................................... 111
UNIVERSAL 1 LANCETS
ULTRA THIN
................................................................................................... 111
up & up glucose
....................................................................................................... 25
ur n-c ............................................................................. 147
URAMAXIN .......................................................... 70
urea ...................................................................................... 70
urea hydrating
....................................................................................................... 70
urea in zn undecyl-lactic acid
....................................................................................................... 70
urea nail ....................................................................... 70
urea nail film
....................................................................................................... 70
urea40 .............................................................................. 70
urea-c40 ....................................................................... 70
URELLE .................................................................... 147
UREX ............................................................................. 147
URIBEL ..................................................................... 147
URIMAR-T ........................................................... 147
urin ds .......................................................................... 147
URISTIX ....................................................................... 80
URISTIX 4 ................................................................. 80
UROCIT-K 10
....................................................................................................... 90
UROCIT-K 5 .......................................................... 90
UROQID #2 ......................................................... 147
UROXATRAL
....................................................................................................... 90
URSO 250 ................................................................... 87
URSO FORTE
....................................................................................................... 87
ursodiol .......................................................................... 87
URYL ............................................................................. 147
USTELL ..................................................................... 147
UTA .................................................................................. 147
uticap ............................................................................ 147
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
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Index
Index
Index
UTIRA-C .................................................................. 147
UTOPIC ......................................................................... 70
UTRONA-C ......................................................... 147
VAGIFEM .............................................................. 149
valacyclovir hcl
....................................................................................................... 48
VALCHLOR ........................................................... 65
VALCYTE ................................................................. 48
VALIUM ...................................................................... 15
valproic acid .......................................................... 20
valsartan-hydrochlorothiazide
....................................................................................................... 35
VALTREX ................................................................. 48
value plus glucose
........................................................................................... 25, 26
value plus lancet standard 21g
................................................................................................... 111
value plus lancets super thin
................................................................................................... 111
value plus lancets thin 26g
................................................................................................... 111
value plus lancing device
................................................................................................... 111
valumark lancet super thin 30g
................................................................................................... 111
valumark lancet ultra thin 28g
................................................................................................... 111
valumark pen needles
................................................................................................... 117
valved holding chamber
................................................................................................... 120
VANCOCIN HCL
....................................................................................................... 37
vancomycin hcl
....................................................................................................... 37
VANDAZOLE
................................................................................................... 149
VANISHPOINT INSULIN
SYRINGE ................................................................ 117
VANOXIDE-HC
....................................................................................................... 62
VANTAS ...................................................................... 40
VARIBAR HONEY
....................................................................................................... 81
VARIBAR NECTAR
....................................................................................................... 81
VARIBAR PUDDING
....................................................................................................... 81
VARIBAR THIN HONEY
....................................................................................................... 81
VARIBAR THIN LIQUID
....................................................................................................... 81
VARIZIG ................................................................. 139
VASCEPA .................................................................. 31
VASERETIC .......................................................... 34
VASOLEX ................................................................. 70
VASOTEC ................................................................. 33
VCF VAGINAL
CONTRACEPTIVE
................................................................................................... 148
VECAMYL ............................................................... 36
VECTICAL ............................................................... 66
VELETRI ..................................................................... 53
VELIVET ..................................................................... 57
VELPHORO ............................................................ 89
VEMAVITE-PRX 2
................................................................................................... 129
vena-bal dha ...................................................... 128
venatal complete dha
................................................................................................... 128
venatal-fa ................................................................ 128
venlafaxine hcl
....................................................................................................... 23
venlafaxine hcl er
....................................................................................................... 23
VENOFER ................................................................. 95
VENTAVIS .............................................................. 53
VENTOLIN HFA
....................................................................................................... 17
VERAMYST ...................................................... 131
verapamil hcl
....................................................................................................... 52
verapamil hcl er
....................................................................................................... 52
VERDESO ................................................................. 69
VEREGEN ................................................................. 63
VERELAN ................................................................. 52
VERELAN PM
....................................................................................................... 52
VERIPRED 20
....................................................................................................... 59
VERSACLOZ
....................................................................................................... 45
VERSICLEAR
....................................................................................................... 64
VESICARE ........................................................... 148
VESTURA ................................................................. 56
VEXOL ....................................................................... 136
VFEND ............................................................................ 30
VIBRAMYCIN
................................................................................................... 144
VICODIN ..................................................................... 11
VICODIN ES
....................................................................................................... 11
VICODIN HP
....................................................................................................... 11
VICOPROFEN
....................................................................................................... 11
VICTORY AGM-4000 TEST
80
VICTORY CONTROL LEVEL
1/2 ........................................................................................ 111
VICTOZA ................................................................... 26
VICTRELIS ............................................................. 48
VIDA MIA AUTOLET
LANCING DEV
................................................................................................... 111
VIDA MIA UNIFINE PENTIPS
................................................................................................... 117
VIDA MIA UNILET LANCETS
28G ..................................................................................... 111
VIDA MIA UNILET LANCETS
30G ..................................................................................... 111
VIDEX ............................................................................. 47
VIDEX EC ................................................................. 47
VIGAMOX ............................................................ 134
VIIBRYD ..................................................................... 22
VIMIZIM ..................................................................... 85
VIMOVO ......................................................................... 7
VIMPAT ............................................................ 19, 20
VINACAL .............................................................. 128
VINACAL B ....................................................... 128
VINATE AZ EXTRA
................................................................................................... 128
VINATE CALCIUM
................................................................................................... 128
VINATE DHA RF
................................................................................................... 128
VINATE GT ........................................................ 128
VINATE IC ........................................................... 128
VINATE II ............................................................. 128
VINATE M ........................................................... 128
vinate ultra ........................................................... 128
VIOKACE .................................................................. 81
viorele .............................................................................. 54
VIRACEPT ............................................................... 47
VIRAMUNE ........................................................... 47
VIRAMUNE XR
....................................................................................................... 47
VIRAZOLE .............................................................. 49
VIREAD ........................................................................ 47
VIROPTIC ............................................................. 134
virt-bal dha .......................................................... 128
virt-bal dha plus
................................................................................................... 128
virt-caps .................................................................... 124
virti-sulf ......................................................................... 62
virt-pn ........................................................................... 128
virt-pn dha ............................................................. 129
virt-pn plus ........................................................... 128
virt-select ................................................................ 129
virtussin a/c ............................................................. 59
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
194
Index
Index
Index
virt-vite ........................................................................... 94
virt-vite plus ........................................................ 124
VISTARIL .................................................................. 15
VISTIDE ....................................................................... 48
VISUDYNE ......................................................... 135
VITAFOL ................................................................ 125
VITAFOL ULTRA
................................................................................................... 129
VITAFOL-NANO
................................................................................................... 128
VITAFOL-OB
................................................................................................... 128
VITAFOL-OB+DHA
................................................................................................... 129
VITAFOL-ONE
................................................................................................... 129
VITAFOL-PLUS
................................................................................................... 129
VITAFOL-PN
................................................................................................... 128
VITAL-D RX
................................................................................................... 124
VITALET PRO LANCETS
................................................................................................... 111
VITALET PRO PLUS LANCETS
................................................................................................... 111
VITAMEDMD ONE
RX/QUATREFOLIC
................................................................................................... 129
VITAMEDMD PLUS
RX/QUATREFOLIC
................................................................................................... 129
VITAMEDMD REDICHEW RX
................................................................................................... 130
vitamin d (ergocalciferol)
................................................................................................... 149
vitamins acd-fluoride
................................................................................................... 126
VITAPEARL ...................................................... 128
VITA-PREN ........................................................ 128
VITAZOL .................................................................... 72
VITUZ .............................................................................. 61
VIVA DHA ........................................................... 128
VIVACTIL ................................................................. 23
VIVELLE-DOT
....................................................................................................... 87
VIVITROL ................................................................. 28
v-natal dha ............................................................ 128
VOCAL POINT BLOOD
GLUCOSE TEST
....................................................................................................... 80
VOCAL POINT CONTROL
................................................................................................... 111
VOGELXO ................................................................ 13
VOGELXO PUMP
warfarin sodium
13
vol-care rx ............................................................. 124
vol-nate ...................................................................... 128
vol-tab rx ................................................................. 128
VOLTAREN ........................................................... 65
VOLTAREN-XR
........................................................................................................... 7
VOLUMEN .............................................................. 81
voriconazole ........................................................... 30
VORTEX VALVED HOLDING
CHAMBER ........................................................... 120
VOSOL HC ........................................................... 138
VOSPIRE ER
....................................................................................................... 17
VOTRIENT .............................................................. 41
vp-ch plus ............................................................... 129
vp-ch-pnv ................................................................ 129
vp-ggr-b6 prenatal
................................................................................................... 130
vp-heme ob ........................................................... 128
vp-heme ob + dha
................................................................................................... 128
vp-heme one ........................................................ 129
vp-pnv-dha ............................................................ 128
VPRIV .............................................................................. 93
V-R MONO INSULIN SYRINGE
................................................................................................... 117
VUSION ........................................................................ 64
VYFEMLA ................................................................ 56
VYTONE ..................................................................... 64
VYTORIN .................................................................. 31
VYVANSE .................................................................... 3
W&F LANCETS 26G
................................................................................................... 111
W&F LANCETS COLORED 21G
................................................................................................... 111
walgreens adv travel lancets
................................................................................................... 111
walgreens glucose
........................................................................................... 25, 26
WALGREENS LANCETS
................................................................................................... 111
walgreens lancets micro thin
................................................................................................... 111
walgreens lancets super thin
................................................................................................... 111
WALGREENS LANCING
DEVICE ..................................................................... 111
WALGREENS THIN LANCETS
................................................................................................... 111
WALGREENS ULTRA THIN
LANCETS .............................................................. 111
WAL-ITIN ................................................................. 30
.......................................................................................................
.......................................................................................................
18
WATCHHALER
...................................................................................................
120
WAVESENSE PRESTO
80
WEBCOL ALCOHOL PREP
LARGE ........................................................................ 112
WEBCOL ALCOHOL PREP
MEDIUM ................................................................. 112
wegmans unifine pentips plus
................................................................................................... 117
WELCHOL ............................................................... 31
WELLBUTRIN
....................................................................................................... 21
WELLBUTRIN SR
....................................................................................................... 21
WELLBUTRIN XL
....................................................................................................... 21
WERA ............................................................................... 56
WESTCORT ........................................................... 69
WESTHROID
................................................................................................... 144
WESTHROID-P
................................................................................................... 144
WIDE-SEAL DIAPHRAGM 60
....................................................................................................... 98
WIDE-SEAL DIAPHRAGM 65
....................................................................................................... 98
WIDE-SEAL DIAPHRAGM 70
....................................................................................................... 98
WIDE-SEAL DIAPHRAGM 75
....................................................................................................... 98
WIDE-SEAL DIAPHRAGM 80
....................................................................................................... 98
WIDE-SEAL DIAPHRAGM 85
....................................................................................................... 98
WIDE-SEAL DIAPHRAGM 90
....................................................................................................... 98
WIDE-SEAL DIAPHRAGM 95
....................................................................................................... 98
WILATE ........................................................................ 92
WINDMILL TRAINER
................................................................................................... 118
winn dixie medic test
....................................................................................................... 80
WINRHO SDF
................................................................................................... 139
WP THYROID
................................................................................................... 144
WYMZYA FE
....................................................................................................... 56
XALATAN ............................................................ 137
XALKORI .................................................................. 41
.......................................................................................................
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
195
Index
Index
Index
XANAX ......................................................................... 15
XANAX XR ............................................................ 15
XARELTO ................................................................. 18
XARTEMIS XR
....................................................................................................... 12
XELJANZ ....................................................................... 6
XELODA ..................................................................... 39
XENAZINE .......................................................... 141
XEOMIN .................................................................. 132
XERAC AC .............................................................. 72
XERESE ........................................................................ 67
XGEVA .......................................................................... 83
XIAFLEX .................................................................... 49
XIFAXAN .................................................................. 37
XODOL .......................................................................... 11
XOLAIR ........................................................................ 15
XOLEGEL ................................................................. 65
XOPENEX ................................................................. 17
XOPENEX CONCENTRATE
....................................................................................................... 17
XOPENEX HFA
....................................................................................................... 17
XPRES CONTROL
................................................................................................... 111
XTANDI ........................................................................ 39
X-VIATE ...................................................................... 70
XYLOCAINE
....................................................................................................... 71
XYNTHA ..................................................................... 92
XYNTHA SOLOFUSE
....................................................................................................... 92
XYREM ..................................................................... 141
XYZAL ........................................................................... 30
YASMIN 28 ............................................................. 56
YAZ ...................................................................................... 56
YODOXIN ..................................................................... 5
zaclir cleansing
....................................................................................................... 63
ZADITOR ............................................................... 136
zafirlukast .................................................................. 16
zaleplon ......................................................................... 96
ZAMICET ................................................................... 11
ZANAFLEX ........................................................ 130
ZARAH ........................................................................... 56
ZARONTIN ............................................................. 20
ZAROXOLYN
....................................................................................................... 82
ZATEAN-CH
................................................................................................... 129
ZATEAN-PN ..................................................... 128
ZATEAN-PN DHA
................................................................................................... 130
ZATEAN-PN PLUS
................................................................................................... 128
ZAVESCA ................................................................. 93
ZAZOLE ................................................................... 149
Z-COF I ........................................................................... 60
ZEBETA ........................................................................ 51
ZEBUTAL ...................................................................... 8
ZEGERID ................................................................ 146
ZELAPAR .................................................................. 43
ZELBORAF ............................................................. 40
ZEMAIRA .............................................................. 143
ZEMPLAR ................................................................. 85
ZENATANE ............................................................ 63
ZENCHENT ............................................................ 56
ZENCHENT FE
....................................................................................................... 56
ZENCIA ......................................................................... 62
ZENPEP ......................................................................... 81
ZENZEDI ................................................................. 3, 4
ZEOSA ............................................................................. 56
ZERIT ................................................................................ 47
ZESTORETIC
....................................................................................................... 34
ZESTRIL ...................................................................... 33
ZETIA ............................................................................... 32
ZETONNA ............................................................. 131
ZIAC .................................................................................... 36
ZIAGEN ......................................................................... 47
zidovudine .................................................................. 47
zingiber ...................................................................... 130
ZIOPTAN ................................................................ 137
ziprasidone hcl
....................................................................................................... 44
ZIPSOR ............................................................................... 8
ZIRGAN .................................................................... 134
ZITHRANOL
....................................................................................................... 66
ZITHRANOL-RR
....................................................................................................... 66
ZITHROMAX
....................................................................................................... 97
ZITHROMAX TRI-PAK
....................................................................................................... 97
ZITHROMAX Z-PAK
....................................................................................................... 97
ZMAX ............................................................................... 97
ZOCOR ........................................................................... 32
ZOFRAN ...................................................................... 28
ZOFRAN ODT
....................................................................................................... 28
ZOHYDRO ER
....................................................................................................... 11
ZOLADEX ................................................................. 40
zoledronic acid
....................................................................................................... 83
ZOLINZA .................................................................... 40
zolmitriptan ......................................................... 121
ZOLOFT ........................................................................ 22
zolpidem tartrate
....................................................................................................... 96
zolpidem tartrate er
....................................................................................................... 96
ZOLPIMIST ............................................................. 96
ZOLVIT ......................................................................... 11
ZOMETA ..................................................................... 83
ZOMIG ........................................................................ 121
ZOMIG ZMT
................................................................................................... 121
ZONALON ................................................................ 66
ZONATUSS ............................................................. 59
ZONEGRAN .......................................................... 20
zonisamide ................................................................ 20
ZORBTIVE ............................................................... 84
ZORTRESS .............................................................. 50
ZORVOLEX ............................................................... 8
zotane hc .................................................................. 138
ZOVIA 1/35E (28)
....................................................................................................... 56
ZOVIRAX ...................................................... 48, 67
ZUBSOLV ................................................................. 12
ZUPLENZ ................................................................... 28
ZYCLARA ................................................................. 71
ZYCLARA PUMP
....................................................................................................... 71
ZYFLO ............................................................................. 16
ZYFLO CR ................................................................ 16
ZYLET ......................................................................... 135
ZYLOPRIM ............................................................. 91
ZYMAXID ............................................................. 134
ZYPREXA ................................................................. 45
ZYPREXA ZYDIS
....................................................................................................... 45
ZYTIGA ......................................................................... 39
ZYVOX .......................................................................... 38
2015 Aetna Pharmacy Plan Drug List - Three Tier Open Commercial Fully Insured
196