Aetna 2015 Formulary updates for self insured and custom fully insured commercial plans

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1 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter abacavir PB SPB Moved to Specialty abacavir/lamivudine/ PB SPB Moved to Specialty zidovudine ABILIFY (PA, ST) 3 3 olanzapine, quetiapine, risperidone, ziprasidone, Latuda ABILIFY DISCMELT (#) Added PA, ABILIFY SOLUTION (ST) 3 3 olanzapine, quetiapine, risperidone, ziprasidone, Latuda ABSORICA (ST, QL) 3 3 minocycline, doxycycline, ACTIVELLA (QL) 3 3 estradiol/norethindrone acetate, PREMARIN, PREMPHASE, PREMPRO ACTONEL (#) 2 3 alendronate weekly ADRENACLICK ( PA, ST) 3 3 AUVI-Q, EpiPen, EpiPen Jr. Added PA, ADVAIR DISKUS (QL) 3 2, Removed PA ADVAIR HFA (QL) 3 2, Removed PA AEROSPAN (QL, ST) 3 3 ASMANEX, QVAR,, FLOVENT/HFA AGGRENOX (#) ALOXI (#) ALVESCO (QL, ST) 3 3 ASMANEX, QVAR,, FLOVENT/HFA amethia 1 1 $0^, amethia LO 1 1 $0^, amethyst 1 1 $0^, AMITIZA (QL) 2 2 lactulose amnesteem (QL, ST) 1 1 minocycline, doxycycline, AMPYRA PB SNPB Moved to Specialty ANDRODERM (PA, #) 3 3 ANDROGEL, TESTIM Added PA, Anticipate Generic to Become ANDROGEL (PA, #) 2 2 Added PA, Anticipate Generic to Become

2 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter ANGELIQ (QL) 3 3 PREMARIN, PREMPHASE, PREMPRO APTIVUS CAP, SOLN PB SNPB Moved to Specialty ARCAPTA (QL) 3 3 FORADIL, SEREVENT ASACOL HD (#) 2 2 ASTEPRO NASAL 2 3 ipratropium nasal ATRALIN (#) ATRIPLA NPB SNPB Moved to Specialty AUVI-Q 3 2 Removed PA, Removed ST AVINZA (PA)(#) 3 3 controlled-release morphine sulfate tablets, OPANA ER Added PA, Anticipate Generic to Become AVODART (#) AXERT ( #) 3 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan AXIRON (PA) 3 3 ANDROGEL, TESTIM Added PA AZULFIDINE (ST) 3 3 ASACOL HD, DELIZICOL, LIALDA, PENTASA AZULFIDINE EN TABS (ST) 3 3 ASACOL HD, DELIZICOL, LIALDA, PENTASA BARACLUDE (#) BECONASE AQ (ST) 3 3 budesonide, flunisolide, fluticasone, triamcinolone, NASONEX, VERAMYST BROVANA (QL, ST) 3 3 FORADIL, SEREVENT, budesonide INHALATION SUS 1 1 (Respules) (QL) bupropion (QL) 1 1, $0^ (for smoking cessation only) camrese (QL) 1 1 $0^, camrese LO (QL) 1 1 $0^,

3 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter CAVERJECT (#) CELEBREX (#) 3 3 CELEXA (QL) 3 3 Removed ST -Added to QL CENESTIN (QL) 2 3 PREMARIN, PREMPHASE, PREMPRO Cervical Caps (FEMCAP, PRENTIF) (QL) 3 3 CHANTIX 0.5 and 1 mg (QL) 3 3, $0^ CIMZIA SPB SNPB CIPRO HC OTIC (#) claravis (QL, ST) 1 1 minocycline, doxycycline, CLIMARA PRO (#) estradiol patch, VIVELLE-DOT COLAZAL (ST) 3 3 ASACOL HD, DELIZICOL, LIALDA, PENTASA Combination Contraceptives - Oral (QL) Combination Contraceptives - Transdermal (ORTHO-EVRA) (QL) Combination Contraceptives - Vaginal (NUVARING) (QL) COMBIPATCH (#) 3 3 estradiol patch, VIVELLE-DOT COMBIVIR NPB SNPB Moved to Specialty COMPLERA NPB SNPB Moved to Specialty Contraceptive Sponge (QL) 3 3 COPAXONE 20mg/mL (#) CRIXIVAN NPB SNPB Moved to Specialty CYMBALTA 3 3 venlafaxine/er, cyclobenzaprine, gabapentin, tramadol Removed ST daysee (QL) 1 1 $0^,

4 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter DAYTRANA (PA, ST, #) 2 3 amphetamine/dextroamphe tamine/ SR, methylphenidate/er, STRATTERA, VYVANSE DEPOCYT (#) Added PA,, Anticipate Generic to Become Diaphragms (ORHTO-FLEX 3 3 WIDESEAL,ONIFLEX) (QL) didanosine ec cap PB SPB Moved to Specialty DIFFERIN 3% gel 2 3 RENTIN-A MICRO gel Removed PA DIPENTUM (ST) 3 3 ASACOL HD, DELIZICOL, LIALDA, PENTASA DIVIGEL 2 3 estradiol patch, VIVELLE-DOT DULERA (QL) 2 2 DURAGESIC 3 3 fentanyl patch Removed ST EDURANT NPB SNPB Moved to Specialty ELESTRIN (QL) 3 3 estradiol patch EMEND capsules (#) Emergency Contraceptives OTC OTC (ELLA, PLAN B) (QL) EMTRIVA CAP, SOLN NPB SNPB Moved to Specialty ENABLEX (ST) 2 2 trospium/er, tolteridine/er ENJUVIA (QL) 2 3 PREMARIN, PREMPHASE, PREMPRO EPIPEN AUTO-INJECTOR (#) EPIVIR TABS, SOLN PB SPB Moved to Specialty EPZICOM NPB SNPB Moved to Specialty ESTRASORB (QL, #) 3 3, Anticipate Generic to Become ESTROGEL (QL) 3 3 estradiol patch, VIVELLE-DOT eszopiclone (PA, ST) 1 1 estazolam, zolpidem Added PA, EVAMIST (QL) 2 3 estradiol patch, VIVELLE-DOT EXFORGE (#)

5 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter EXFORGE HCT (#) FACTIVE (#) FAZACLO ODT (#) Female Condoms (REALITY, FC FEMALE) (QL) 3 3 FEMHRT (QL) 3 3 PREMARIN, PREMPHASE, PREMPRO FEMRING (QL, #) 2 3 PREMARIN VAGINAL CREAM, Anticipate Generic to Become FENOGLIDE (#) FLONASE (ST) 3 3 budesonide, flunisolide, fluticasone, triamcinolone, NASONEX, VERAMYST FLOVENT DISKUS (QL) 2 2 FLOVENT HFA (QL) 2 2 FOCALIN XR (#) amphetamine/dextroamphe tamine/ SR, methylphenidate/er, STRATTERA, VYVANSE FORADIL (QL) 2 2, Removed PA FORTESTA (PA) 3 3 ANDROGEL, TESTIM Added PA FROVA (#) 3 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan FUZEON (#) NPB SNPB Moved to Specialty, Anticipate Generic to Become GELNIQUE 10% (ST) 3 3 trospium/er, tolteridine/er ENABLEX, MYRBTRIQ, VESICARE GELNIQUE 3% (ST) 2 3 trospium/er, tolteridine/er ENABLEX, MYRBTRIQ, VESICARE GENERESS FE (#) giavi (QL) 1 1, $0^

6 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter GIAZO (ST) 3 3 ASACOL HD, DELIZICOL, LIALDA, PENTASA GRALISE (ST) 3 3 gabapentin, Removed PA HORIZANT (ST) 3 3 cabergoline, gabapentin, pramipexole IMITREX INJ 3 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan IMITREX SPR 3 3 naratriptan, rizatriptan, sumatriptan nasal spray, zolmitriptan IMITREX TAB 3 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan, Removed PA Removed ST Removed ST Removed ST INTEGRILIN (#) INTELENCE NPB SNPB Moved to Specialty Intrauterine Device -IUD 3 3 (PARAGARD) (QL) introvale 1 1 $0^, INTUNIV (#) 3 3 amphetamine/dextroamphe tamine/ SR, methylphenidate/er, STRATTERA, VYVANSE INVIRASE CAP, TAB NPB SNPB Moved to Specialty INVOKAMET (QL) 2 2 INVOKANA (QL) 2 2 ISENTRESS TAB, CHEW TAB, NPB SNPB Moved to Specialty SUSP JALYN (#) JANUMET (QL) 2 2 JANUMET XR (QL) 2 2 JANUVIA (QL) 2 2 JENTADUETO (QL) 2 2 jolessa (QL) 1 1 $0^, KALETRA SOLN, TAB PB SPB Moved to Specialty KHEDEZLA (PA) 3 3 venlafaxine/er, citalopram, escitalopram Added PA KOMBIGLYZE XR (QL) 2 2

7 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter lamivudine PB SPB Moved to Specialty lamivudine/zidovudine PB SPB Moved to Specialty latanoprost (QL) 1 1 LATISSE (#) LESCOL (ST) 3 3 fluvastatin, CRESTOR levonor/ethi tab (QL) 1 1, $0^ LEXIVA PB SPB Moved to Specialty LINZESS (QL) 3 2, Removed PA LIPOFEN (#) LIVALO (ST) 3 3 atorvastatin, simvastatin, fluvastatin, CRESTOR loryna (QL) 1 1, $0^ LOVAZA (QL, ST) 2 3 fenofibrate, VASCEPA, LUMIGAN (QL, #) 2 2, Anticipate Generic to Become LUNESTA (ST) 3 3 estazolam, zolpidem LYRICA CAP (ST) 3 3 amitriptyline, cyclobenzaprine, gabapentin, tramadol LYRICA SOL (ST) 2 3 amitriptyline, cyclobenzaprine, gabapentin, tramadol mimvey (QL) 1 1 MIRENA (#) (QL), added QL MS CONTIN (QL) 3 3 morphine sulfate ER myorisan (QL, ST) 1 1 minocycline, doxycycline, NAMENDA (#) NAMENDA Oral Solution (#) nevirapine/ er PB SPB Moved to Specialty NEXIUM (#) Nicotine Inhaler (NICOTROL) 3 3, $0^ (QL) Nicotine Nasal Solution (NICOTORL NS) (QL) 3 3, $0^

8 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter Nicotine polacrilex Gum NICORETTE (QL) Nicotine polacrilex Lozenge (NICORETTE, COMMITT) (QL) 3 3, $0^ 3 3, $0^ norethindrone (QL) 1 1 NORVIR CAP, SOLN, TAB PB SPB Moved to Specialty omega-3-acid (QL) 1 1 ONGLYZA (QL) 2 2 ORTHO TRI-CYCLEN LO (#) OXYTROL (#) trospium/er, tolteridine/er, ENABLEX, MYRBTRIQ, VESICARE PATANOL (#) PERFOROMIST (QL, ST) 2 3 FORADIL, SEREVENT, PREFEST (QL) 3 3 PREMARIN, PREMPHASE, PREMPRO PREZISTA SUSP, TAB PB SPB Moved to Specialty PROAIR HFA (QL) 2 2 Progestin contraceptives -Oral (QL) Progestin Contraceptives - Medical Medical Implants (IMPLANON, NEXPLANON) Progestin Contraceptives - Injectable - (DEPO-PROVERA) Medical Medical Progestin Contraceptives - IUD (MIRENA, SKYLA) (QL) PROTOPIC (#) 3 3 Proventil HFA (QL, ST) 2 3 VENTOLIN, PROAIR, PULMICORT FLEXHALER 3 3 ASMANEX, QVAR, (QL, ST) PULMICORT RESPULES (QL) 3 3 budesonide respules quasense (QL) 1 1, $0^ RAPAMUNE Tablets 1mg & 2mg (#)

9 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter RELENZA (#) RENAGEL (#) RESCRIPTOR DISPER TAB, ORAL NPB SNPB Moved to Specialty RESCULA (QL, ST) 3 3 latanoprost, TRAVATAN Z, RETROVIR CAP, SYRUP, TAB NPB SNPB Moved to Specialty REYATAZ PB SPB Moved to Specialty SAPHRIS (ST) 3 3 olanzapine, quetiapine, risperidone, ziprasidone, LATUDA SELZENTRY NPB SNPB Moved to Specialty SEREVENT (QL) 2 2, Removed PA SIMCOR 2 3 simvastatin, niacin er SIMPONI SPB SNPB Spermicides (QL) OTC OTC SPIRIVA (QL) 2 2 stavudine PB SPB Moved to Specialty STRIANT (PA) 3 3 ANDROGEL, TESTIM Added PA STRIBILD NPB SNPB Moved to Specialty SUSTIVA CAP, TAB NPB SNPB Moved to Specialty SYMBICORT (QL) 2 2 TARGRETIN Caps (#) TARKA (#) TASIGNA (ST) SPB SNPB Gleevec TESTIM (PA) 2 2 Added PA testosterone Gel (generic) (PA) 1 1 Added PA TEVETEN HCT (#) TIVICAY NPB SNPB Moved to Specialty TRACLEER (#) TRADJENTA (QL) 2 2 Transdermal Nicotine Patch 3 3, $0^ (NICODERM) (QL) travoprost (QL) 1 1

10 Key: #- ; $0^-Health Care Reform Zero-Dollar; OTC-Over-the-Counter TRELSTAR (#) TRIZIVIR NPB SNPB Moved to Specialty TRUVADA PB SPB Moved to Specialty TUDORZA (QL, ST) 3 3 SPIRIVA, VELTIN(#) VENTOLIN HFA (QL) 3 2, Removed PA, Removed ST VESICARE (ST) 2 2 trospium/er, tolteridine/er VIDEX EC CAPS, VIDEX SOLN PB SPB Moved to Specialty VIRACEPT NPB SNPB Moved to Specialty VIRAMUNE TABS, SUSP NPB SNPB Moved to Specialty VIRAMUNE XR NPB SNPB Moved to Specialty VIREAD TAB, POWDER PB SPB Moved to Specialty VOGELXO (PA) 3 3 ANDROGEL, TESTIM Added PA WELCHOL (#) XALATAN (QL) 3 3 XENAZINE (#) XOPENEX HFA (QL) 3 3 VENTOLIN, PROAIR, Removed PA xulane (QL) 1 1 Remove PA, ZAVESCA (#) zenatane (QL, ST) 1 1 minocycline, doxycycline, ZERIT CAPS, SOLN NPB SNPB Moved to Specialty ZIAGEN TABS, SOLN NPB SNPB Moved to Specialty zidovudine PB SPB Moved to Specialty ZIOPTAN (QL) 3 3 ZYBAN (QL) 3 3 ZYVOX Tabs (#)

11 Please note that if your prescription drug benefits plan changes, the information in this letter 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 Aetna Pharmacy Plan 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 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. Split Fill Drugs listed are managed by 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 the Aetna Pharmacy Plan 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 The drugs on the Aetna Pharmacy Plan 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 Aetna Pharmacy Plan 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 Aetna Inc.

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