2016 exclusions drug list

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1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2016 exclusions drug list D (5/16)

2 These drugs are not covered under your plan. There are preferred alternatives for these conditions that are covered by your plan. Key UPPERCASE lowercase italics Brand-name medicine Generic medicine

3 Allergy ALLEGRA/ALLEGRA-D RX (fexofenadine) ALLEGRA/ALLEGRA-D OTC Analgesics CAMBIA (diclofenac) CATAFLAM,* IMITREX,* AMERGE,* MAXALT* Antibiotics COMFORT PAC (cyclobenzaprine) COMFORT PAC (ibuprofen) COMFORT PAC (meloxicam) COMFORT PAC (naproxen) COMFORT PAC (tizanidine) CONZIP (tramadol er) DUEXIS (ibuprofen/famotidine) FLECTOR PATCH (diclofenac epolamine) IC-400, IC-800 OXECTA (oxycodone) RYBIX ODT (tramadol) tramadol er 150 mg VIMOVO (naproxen/esomeprazole) ZIPSOR (diclofenac) ACTICLATE (doxycycline) ADOXA* (doxycycline) AVIDOXY KIT (doxycycline) DORYX (doxycycline) MONODOX* 75 mg (doxycycline) MORGIDOX KIT (doxycycline + cleanser) OCUDOX KIT (doxycycline + lid scrub) ORACEA (doxycycline) DYNACIN TABLETS* (minocycline) MINOCIN KIT (minocycline) MINOCIN TABLETS* (minocycline) SOLODYN* (minocycline) FLEXERIL* MOTRIN* MOBIC* NAPROSYN* ZANAFLEX* ULTRAM* MOTRIN* + PEPCID* ORAL CATAFLAM* or VOLTAREN* MOTRIN* PERCOCET* ULTRAM* ULTRAM* NEXIUM* + NAPROSYN* ORAL CATAFLAM* or VOLTAREN* MONODOX* 50 mg, 100 mg; VIBRAMYCIN* 50 mg, 100 mg DYNACIN* or MINOCIN* CAPSULES Antihyperlipidemic FENOGLIDE* (fenofibrate) Other generic fenofibrates Antivirals SITAVIG (acyclovir) ZOVIRAX* CAPS, TABS, CREAM, OINTMENT *Generic available. 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.

4 Cardiovascular Central nervous system (CNS) antidepressants/ other CNS antianxiety agents CARDIZEM CD* (diltiazem)** CADUET* (amlodipine/atorvastatin) VASOTEC* (enalapril maleate)** APLENZIN (bupropion HBr) FORFIVO XL (bupropion HCl extended release) WELLBUTRIN XL (bupropion)* PEXEVA (paroxetine) ATIVAN* (lorazepam)** DILTIAZEM ER* NORVASC* + LIPITOR* enalapril maleate* bupropion IR*/XL* PAXIL* lorazepam* CNS antiseizure STAVZOR (valproic acid) DEPAKENE* CNS sedativehypnotics CNS attention deficit hyperactivity disorder EDLUAR (sublingual zolpidem) INTERMEZZO (sublingual zolpidem) ZOLPIMIST ORAL SPRAY (zolpidem) SILENOR (doxepin) ZENZEDI 2.5 mg, 7.5 mg, 15 mg, 20 mg, 30 mg (dextroamphetamine sulfate) AMBIEN* SINEQUAN* DEXEDRINE* Dermatological ABSORICA (isotretinoin) AMNESTEEM, CLARAVIS, MYORISAN, SOTRET ACANYA GEL PUMP (benzoyl peroxide/clindamycin) ATRALIN* (tretinoin)** BENZACLIN (benzoyl peroxide/clindamycin) CARAC* (fluorouracil)** CICLODAN KIT (ciclopirox + toe freshener) CLINDACIN PAC (clindamycin + cleanser) CLINDAREACH (clindamycin) CLOBETA KIT (clobetasol + coal tar) CNL8 KIT (ciclopirox + remover, emery board) DESONIL COMBO PACK (desonide + emollient) ECOZA (econazole) HALONATE OINTMENT/FOAM (halobetasol/ ammonium lactate) KETODAN KIT (ketoconazole/cleanser) MOMEXIN COMBO PACK (mometasone/ammonium lactate) NAPRO, NAPRODERM (naproxen) Topical benzoyl peroxide + clindamycin Topical tretinoin* Topical benzoyl peroxide + clindamycin fluorouracil* PENLAC* CLEOCIN-T* TEMOVATE,* ULTRAVATE,* DIPROLENE* PENLAC* DESOWEN* SPECTAZOLE CREAM* ULTRAVATE* (LAC-HYDRIN* is available as OTC.) NIZORAL* ELOCON* (LAC-HYDRIN* is available as OTC.) ORAL CATAFLAM* or VOLTAREN* **Generic available. **Only the brand is considered excluded.

5 Dermatological ONMEL (itraconazole) SPORANOX* PEDIADERM HC KIT (hydrocortisone) PEDIPIROX-4 (ciclopirox) HYTONE* PENLAC* ROSADAN KIT (metronidazole) METROGEL 0.75%* SELRX SHAMPOO (selenium sulfide) SORILUX (calcipotriene) SUMADAN,* SUMAXIN CP (sodium sulfacetamide/ sulfur kit) SYNALAR TS KIT (fluocinolone/skin cleanser) TERBINEX KIT (terbinafine) TOPICORT SPRAY (desoximetasone) TRETIN-X KIT (tretinoin) ULTRAVATE PAC (halobetasol/lactic acid) ULTRAVATE X (halobetasol/lactic acid) VANOS* (fluocinonide)** ZYCLARA (imiquimod) ZYPRAM CREAM (hydrocortisone + pramoxine) selenium sulfide Topical corticosteroids PLEXION* SYNALAR* LAMISIL TABLETS* TOPICORT* CREAM, GEL, OINTMENT RETIN-A* ULTRAVATE* CREAM, OINTMENT fluocinonide* ALDARA* ANALPRAM HC* Endocrine ALL NON LIFESCAN BRAND TEST STRIPS LIFESCAN BRAND TEST STRIPS Gastrointestinal (GI) other ANDRODERM (testosterone) AXIRON (testosterone) FORTESTA (testosterone) STRIANT (testosterone) BINOSTO (alendronate) FORTAMET* (metformin extended release) GLUMETZA* (metformin extended release) GENOTROPIN HUMATROPE NORDITROPIN NUTROPIN/NUTROPIN AQ SAIZEN SEROSTIM TEV-TROPIN VALTROPIN ZOMACTON METOZOLV (metoclopramide) ZUPLENZ (ondansetron film) ANDROGEL 1.62% FOSAMAX* GLUCOPHAGE IR*/XR* OMNITROPE REGLAN* ZOFRAN* **Generic available. **Only the brand is considered excluded.

6 Migraine products ALSUMA (sumatriptan inj) IMITREX* MIGRANAL* (dihydroergotamine)** SUMAVEL (sumatriptan needleless TREXIMET (sumatriptan/naproxen) dihydroergotamine nasal spray* IMITREX* IMITREX* + NAPROSYN* Muscle relaxants AMRIX 15 mg, 30 mg (cyclobenzaprine) FLEXERIL* 10 mg Prescription GI ulcer medicine Respiratory nasal/ cough and cold LORZONE (chlorzoxazone) SOMA 250 mg (carisoprodol) ZANAFLEX CAPSULES (tizanidine) DEXILANT*** esomeprazole strontium OMECLAMOX-PAK (amoxicillin/clarithromycin/ omeprazole) PREVACID* RX (lansoprazole) PRILOSEC POWDER PACKET (omeprazole) ZANTAC EFFERDOSE (ranitidine) ZEGERID* RX (omeprazole/sodium bicarbonate) DYMISTA (azelastine/fluticasone) NASACORT AQ RX (triamcinolone) ZONATUSS (benzonatate) PARAFON FORTE DSC* SOMA* 350 mg ZANAFLEX* TABLETS PROTONIX*, NEXIUM*, PRILOSEC OTC, PREVACID OTC NEXIUM* PREVPAC* PREVACID OTC PRILOSEC OTC ZANTAC* TABLETS ZEGERID OTC ASTELIN* + FLONASE* NASACORT OTC TESSALON PERLES* Urinary OXYTROL RX (oxybutynin) OXYTROL OTC **Generic available. **Only the brand is considered excluded. ***Does not apply to Small Group plans. Please remember that this is not a complete list of medications covered under your plan. Because there are thousands of medications included in your pharmacy benefit, we only list the most common ones. Certain drugs such as those for smoking cessation or vitamins may not be covered by your particular pharmacy plan. Diabetic supplies may be covered under your medical plan. If you have any questions about your pharmacy benefits, please visit and log in to your secure member website. If you don t have access to our website, call the toll-free number on your member ID card. To check coverage and copay information for a specific medicine, visit and log in to your secure member website. For more details, please call the toll-free number on your member ID card. This is not an inclusive list. Products that are not represented on this list may be subject to plan-specific copayment or coinsurance. Void where prohibited by law. Specific prescription benefits plan design may not cover certain categories or may be subject to additional charges or restrictions, regardless of their appearance in this document. Aetna may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. Information is believed to be accurate as of the production date; however, it is subject to change. For questions, please call the toll-free number on your member ID card Aetna Inc D (5/16)

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