Pharmacy

Formulary drug list

The formulary is a list of drugs chosen by Aetna Better Health of Kentucky and a team of doctors and pharmacists. Drugs on this list are generally covered under the plan as long as they are medically necessary. Members must fill their prescriptions at an Aetna Better Health of Kentucky network pharmacy and follow other plan rules.

Please review the formulary for any restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health of Kentucky patient.

You can download the formulary. You can also view a list of this month's formulary updates.

You now have the ability to search for drugs using our new Formulary Search Tool. Searches can be performed by drug name or by drug class. The tool will provide formulary status, generic alternatives and if there are any clinical edits (Prior Authorization, Quantity Limits, Age Limits etc).

Common Preferred Drug List (PDL)

Drug Recall - Immediate Action Needed

Aetna Better Health of Kentucky also covers certain over-the-counter drugs if they are on our list. Some of these may have rules about how they can be covered. If the rules for that drug are met, we will cover the drug. Over-the-counter drugs must have a prescription for them to be covered at no cost to our members.

Guidelines (effective 10.01.2019) for pharmacy prior authorization for:

Aetna Better Health of Kentucky also covers certain over-the-counter drugs if they are on our list. Some of these may have rules about how they can be covered. If the rules for that drug are met, we will cover the drug. Over-the-counter drugs must have a prescription for them to be covered at no cost to our members.

Kentucky Medicaid Buprenorphine Universal PA Form

Kentucky Medicaid Universal PA Form

Aetna Universal Pharmacy Prior Authorization 

 

To search press "CTRL + F" and type in the name you are looking for

Afinitor-Afinitor Disperz

Ampyra 

Anticoagulants-Injectable

Antidepressants Non-Preferred

Aranesp -Mircera

Armodafinil - Modafinil

Atypical Antipsychotics

Botulinum Toxins

Brand Name Drugs

Buprenorphine Universal 

Calcitonin Gene-Related Pepticde Receptor (Aimovig, Ajovy, Emgality)

Capecitabine

CNS Stimulants

Colony Stimulating Factors  (ex: Zarxio, Nivestym, Fulphila, Udenyca, Neupogen, Neulasta, Granix, Leukine)

Compounded Drug Products

Cytokine and CAM Antagonists  (ex: Enbrel, Humira, Kevzara)

Daliresp

Daraprim   Updated 10.01.2019

DPP-4 Inhibitors

Eligard-Trelstar-Vantas 

Epogen - Procrit - Retacrit

Eucrisa

Forteo 

GLP-1 Agonists

Growth Hormones 

Hemophilia  NEW 10.01.2019

Hepatitis C 

Hereditary Angioedema

HP Acthar

Hyaluronic Acid Derivatives 

Hyperlipidemia Medications (Omega-3 Carboxylic Acid)

IL-5 Antagonists

Imatinib

Immune Globulins

Increlex

IPF Agents

Inhaled Antibiotics for CF

Inlyta 

Insulin Pens 

Interferons   NEW 10.01.2019

Jakafi

Jardiance

 

Kalydeco

Leuprolide Acetate 

Lucemyra

Lupron Depot-Lupaneta

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591

PCN: ADV

Group: RX8831

November 2019

No changes

 

October 2019

No changes

 

September 2019

Additions:

  • Ambrisentan Tabs 5mg, 10mg (Prior Authorization Required, Quantity Level Limit)
  • Bosentan Tabs 62.5mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Febuxostat Tabs 40mg, 80mg (Step Therapy Required)
  • Ramelteon Tab 8mg (Step Therapy Required, Quantity Level Limit)
  • Ribavirin Caps 200mg (Step Therapy Required)
  • Ribavirin Tabs 200mg (Step Therapy Required)

Removals:

  • Letairis Tabs 5mg, 10mg (Brand)
  • Rozerem Tab 8mg (Brand)
  • Tracleer Tabs 62.5mg, 125mg (Brand)
  • Uloric Tabs 40mg, 80mg (Brand)

 

August 2019

Additions:

  • Butenafine Cream 1% (OTC)
  • Emtricitabine-Rilpivirine-Tenofovir AF Tab 200-25-25mg (Quantity Level Limit)
  • Lidocaine Patch 4% (Quantity Level Limit
  • Thyroid Tabs 180mg, 240mg, 300mg (Quantity Level Limit)

Removals:

  • Atabex EC Tab
  • Atabex Prenatal Chewable Tab
  • Be Well Rounded Pak
  • Benziq Wash Liquid 5.25%
  • Bio-Statin Powder
  • Biotuss Liquid
  • BP Wash Liquid 2.5%
  • Brainstrong Prenatal Mis
  • Brompheniramine Chewable Tab 12mg
  • Butalbital-Acetaminophen-Caffeine Caps 50-300-40mg, 50-325-40mg
  • Cadeau DHA Cap
  • Calcium Carbonate Powder
  • Calcium Citrate Tab 200mg, 250mg
  • Calna Tab
  • Capzasin-P Cream 0.035%
  • Centrum Special Prenatal Pak
  • Children’s ASA Free Elixir 80mg/2.5ml
  • Chlorhexidine Gluconate Solution 20%
  • Ciclopirox Gel 0.77%
  • Clotrimazole w/ Betamethasone Lotion 1-0.05%
  • Colestipol Granules 5gm
  • CVS Antacid Supreme Suspension
  • CVS Prenatal Chewable Gummy
  • D3 Dots Tab 2000 Units
  • Entecavir Oral Solution 0.05mg/ml
  • Epinastine Ophthalmic Solution 0.05%
  • EQ Aspirin EC Tab 500mg
  • Ergocal Cap 2500 Units
  • Erythromycin Ethysuccinate Suspension 200mg/5ml, 400mg/5ml
  • Esterified Estrogens Tab 0.3mg, 0.625mg, 1.25mg, 2.5mg
  • Estradiol / Estradiol-Norgestimate Tab 1mg(15) / 1-0.09mg(15)
  • Etodolac ER Tabs 400mg, 500mg, 600mg
  • Eye Drops Solution 0.25%
  • Fluorabon Drops
  • Fluoride Sensitive Paste 1.1-5%
  • Fluoridex Concentrate Daily
  • Fluoroplex Cream 1%
  • Fluphenazine Elixir 2.5mg/5ml
  • Fluphenazine Injection 2.5mg/ml
  • Flura-Drops 4 drops = 1mg
  • Gas-X Infant Drops
  • Gentamicin Sulfate Powder
  • Gleostine Caps
  • Glucose Chewable Tab 5gm
  • Homatropine Ophthalmic Solution 5%
  • Hypersal Neb 3.5%
  • KPN Prenatal Tab
  • Lanacort 10 Cream 1%
  • Laxative Chewable Tab 15mg
  • Lindane Shampoo 1%
  • Little Tummy Laxative Drops
  • Mag Oxide Tab 250mg
  • Magnesium Tab 250mg, 400mg
  • Metamucil Powder Original
  • Moexipril Tabs 7.5mg, 15mg
  • MV-One Caps
  • Mynatal Cap
  • Mynate 90 Plus Tab
  • Nasal Mist Aerosol 0.9%
  • Nature-Throid Tab 2gr
  • Nebusal Neb 6%
  • Neotuss Liquid
  • Nexium 24hr Cap OTC 20mg
  • Niacin Tab 50mg, 250mg
  • Nutricion Porvida Tab
  • Obestetrix-DHA Pak
  • Obstetrix EC Tab
  • Olopatadine Ophthalmic Solution 0.2%
  • Omega-3 Fish Cap 300mg
  • One A Day Mis Prenatal Tab
  • One A Day Prenatal Tab
  • Oyster Shell/D Tab 500mg, 600mg
  • Perry Prenatal Cap
  • Pinworm Medicine Suspension
  • Pinworm Medicine Tabs
  • Prenatal Formula Cap
  • Prenatal Multi + DHA Cap
  • Prenatal Nutrients Tab
  • Prenatal Omega-3 Cap
  • Prenatal Tab
  • Prenatal Tab Complete
  • Prenatal+DHA Mis
  • Quinidine Gluconate CR Tab 324mg
  • RA Aspirin Tab 500mg
  • RA Calcium Hi-Cal Tab
  • RA Calcium High Potassium Tab
  • RA Col-Rite Cap 50mg
  • RA Iron Tab 27mg
  • RA Magnesium Cap 500mg
  • RA Therapeutic Shampoo
  • Replesta Wafer 50000 Units
  • Silver Nitrate Applicators
  • Sleep Aid Tab 50mg
  • Sodium Fluoride Tab 0.5mg, 1mg
  • Sorbitol Solution 70%
  • TGT APAP Infant Drops
  • TGT Lubricant Eye Drops
  • Theranatal Complete Mis
  • Theranatal One Cap
  • Theranatal Ovavite Pak
  • Theratears Ophthalmic Solution
  • Thyroid Tab 130mg
  • Titralac Chewable Tab 420mg
  • Vancomycin Suspension + Syrspend
  • Vazobid-PD Suspension
  • Via-Pren Tab
  • Vitamin D2 Tab 400 Units
  • Vitamin D3 Cap 400 Units
  • Vitamin D3 Chewable Tab 1000 Units, 5000 Units
  • Vitamin for Hair Tab
  • Wal-Mucil Powder
  • X-Seb T Perl Shampoo 10%

Other Updates:

  • Abacavir Sulfate Solution 20mg/ml (Quantity Level Limit)
  • Abacavir Sulfate Tab 300mg (Quantity Level Limit)
  • Abacavir Sulfate-Lamivudine Tab 600-300mg (Quantity Level Limit)
  • Abacavir-Dolutegravir-Lamivudine Tab 600-50-300mg (Quantity Level Limit)
  • Abacavir-Lamivudine-Zidovudine Tab 300-150-300mg (Quantity Level Limit)
  • Atazanavir Sulfate Caps 150mg, 200mg, 300mg (Quantity Level Limit)
  • Atazanavir Sulfate Oral Powder Packet 50mg (Quantity Level Limit)
  • Atazanavir Sulfate-Cobicistat Tab 300-150mg (Prior Authorization Required, Quantity Level Limit)
  • Azelastine Ophthalmic Solution 0.05% (Quantity Level Limit)
  • Calcipotriene Cream 0.005% (Prior Authorization Required, Quantity Level Limit)
  • Calcipotriene Ointment 0.005% (Prior Authorization Required, Quantity Level Limit)
  • Calcipotriene Solution 0.005% (Prior Authorization Required, Quantity Level Limit)
  • Ciclopirox Cream 0.77% (Step Therapy Required)
  • Ciclopirox Shampoo 1% (Step Therapy Required)
  • Ciclopirox Suspension 0.77% (Step Therapy Required)
  • Clozapine Tabs 25mg, 50mg, 100mg, 200mg (Age Limit)
  • Cobicistat Tab 150mg (Quantity Level Limit)
  • Darunavir Ethanolate Suspension 100mg/ml (Prior Authorization Required, Quantity Level Limit)
  • Darunavir Ethanolate Tabs 75mg, 150mg, 600mg, 800mg (Prior Authorization Required, Quantity Level Limit)
  • Delavirdine Mesylate Tab 100mg (Prior Authorization Required)
  • Delavirdine Mesylate Tab 200mg (Prior Authorization Required, Quantity Level Limit)
  • Didanosine DR Caps 125mg, 200mg, 250mg, 400mg (Quantity Level Limit)
  • Didanosine Solution 2gm, 4gm (Quantity Level Limit)
  • Dolutegravir Sodium-RilpivirineTab 50-25mg (Prior Authorization Required)
  • Efavirenz Caps 50mg, 200mg (Quantity Level Limit)
  • Efavirenz Tab 600mg (Quantity Level Limit)
  • Efavirenz-Emtricitabine-Tenofovir DF Tab 600-200-300mg (Quantity Level Limit)
  • Elvitegravir-Cobicstat-Emtricitabine-Tenofovir DF Tab 150-150-200-300mg (Prior Authorization Required)
  • Emtricitabine Cap 200mg (Quantity Level Limit)
  • Emtricitabine Solution 10mg/ml (Quantity Level Limit)
  • Emtricitabine-Rilpivirine-Tenofovir DF Tab 200-25-300mg (Quantity Level Limit)
  • Enfuviritide Injection 90mg (Prior Authorization Required, Quantity Level Limit)
  • Estradiol Vaginal Tab 10mcg (Quantity Level Limit)
  • Etravirine Tabs 25mg, 100mg, 200mg (Prior Authorization Required, Quantity Level Limit)
  • Fluocinolone Cream 0.025% (Quantity Level Limit)
  • Fluocinolone Ointment 0.025% (Quantity Level Limit)
  • Fosamprenavir Calcium Suspension 50mg/ml (Prior Authorization Required, Quantity Level Limit)
  • Fosamprenavir Calcium Tab 700mg (Prior Authorization Required, Quantity Level Limit)
  • Indinavir Sulfate Caps 200mg, 400mg (Prior Authorization Required, Quantity Level Limit)
  • Lamivudine Oral Solution 10mg/ml (Quantity Level Limit)
  • Lamivudine Tabs 150mg, 300mg (Quantity Level Limit)
  • Lamivudine-Zidovudine Tab 150-300mg (Quantity Level Limit)
  • Lidocaine Cream 4% (Quantity Level Limit)
  • Lidocaine Gel 2% (Quantity Level Limit)
  • Lidocaine-Prilocaine Cream 2.5-2.5% (Quantity Level Limit)
  • Liothyronine Tabs 5mcg, 50mcg (Quantity Level Limit)
  • Lopinavir-Ritonavir Solution 400-100mg/5ml (Prior Authorization Required, Quantity Level Limit)
  • Lopinavir-Ritonavir Tabs 100-25mg, 200-50mg (Prior Authorization Required, Quantity Level Limit)
  • Maraviroc Tabs 25mg, 75mg, 150mg, 300mg (Prior Authorization Required)
  • Nelfinavir Mesylate Tabs 250mg, 625mg (Prior Authorization Required, Quantity Level Limit)
  • Nevirapine ER Tabs 100mg, 400mg (Quantity Level Limit)
  • Nevirapine Suspension 50mg/5ml (Quantity Level Limit)
  • Nevirapine Tab 200mg (Quantity Level Limit)
  • Norethindrone Tab 5mg (Step Therapy Required)
  • Olanzapine ODT Tabs (Age Limit)
  • Olanzapine Orally Disintegrating Tabs 5mg, 10mg, 15mg, 20mg (Age Limit)
  • Olanzapine Tabs (Age Limit)
  • Olanzapine Tabs 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg (Age Limit)
  • Quetiapine Tabs (Age Limit)
  • Raltegravir Potassium Packet for Suspension 100mg (Quantity Level Limit)
  • Raltegravir Potassium Tab 400mg (Quantity Level Limit)
  • Rilpivirine Tab 25mg (Quantity Level Limit)
  • Risperidone ODT Tabs (Age Limit)
  • Risperidone Oral Solution 1mg/ml (Age Limit)
  • Risperidone Tabs (Age Limit)
  • Ritonavir Cap 100mg (Quantity Level Limit)
  • Ritonavir Oral Solution 80mg/ml (Quantity Level Limit)
  • Ritonavir Tab 100mg (Quantity Level Limit)
  • Saquinavir Mesylate Cap 200mg (Prior Authorization Required)
  • Saquinavir Mesylate Tab 500mg (Prior Authorization Required, Quantity Level Limit)
  • Sertraline Concentrate Oral Solution 20mg/ml (Age Limit)
  • Stavudine Caps 15mg, 20mg, 30mg, 40mg (Quantity Level Limit)
  • Stavudine Oral Solution 1mg/ml (Quantity Level Limit)
  • Tenofovir Disoproxil Fumarate Powder 40mg/gm (Prior Authorization Required, Quantity Level Limit)
  • Thyroid Tabs 15mg, 30mg, 60mg, 90mg, 120mg (Quantity Level Limit)
  • Tipranavir Cap 250mg (Prior Authorization Required, Quantity Level Limit)
  • Tipranavir Oral Solution 100mg/ml (Prior Authorization Required, Quantity Level Limit)
  • Zidovudine Cap 100mg (Quantity Level Limit)
  • Zidovudine Syrup 10mg/ml (Quantity Level Limit)
  • Zidovudine Tab 300mg (Quantity Level Limit)
  • Ziprasidone Caps 20mg, 40mg, 60mg, 80mg (Age Limit)

 

July 2019

Additions:

  • Cefixime Cap 400mg (Quantity Level Limit)
  • Erlotinib Tab 150mg (Prior Authorization Required)
  • Kevzara Injection 150mg, 200mg (Prior Authorization Required, Quantity Level Limit)
  • Mesalamine DR Cap 400mg (Quantity Level Limit)
  • Vivitrol Injection 380mg (Prior Authorization Required)

Removals:

  • Suprax Cap 400mg (brand)
  • Tarceva Tab 150mg (brand)

Other Updates:

  • Vivitrol Injection 380mg (Prior Authorization Removed for Substance Use Disorder) 

 

June 2019

Additions:

  • Docosanol Cream 10%
  • Melatonin Tabs 1mg, 3mg, 5mg

Removals:

  • Abreva Cream 10% (brand)

 

May 2019

Additions:

  • Erythromycin Ethylsuccinate Suspension 400mg/5ml
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)
  • Sirolimus Solution 1mg/ml

Removals:

  • Eryped Suspension (brand) 400mg/5ml
  • Rapamune Solution (brand) 1mg/ml

 

April 2019

No Changes

 

March 2019

Additions:

  • Admelog Vial 300 units/3mL
  • Albuterol HFA Inhaler 90mcg –Generic Ventolin HFA (Quantity Level Limit)
  • Mesalamine Suppository 1000mg
  • Toremifene Tab 60mg

Removals:

  • Canasa Suppository 1000mg
  • Fareston Tab 60mg

Other Updates:

  • Butalbital Containing Products (Quantity Level Limit)

 

February 2019

Additions:

  • Arnuity Ellipta Inhaler
  • Eligard Kit 7.5mg, 22.5mg, 30mg, 45mg (Prior Authorization Required)
  • Flebogamma IV Solution 5gm/50ml, 10gm/100ml, 20gm/200ml (Prior Authorization Required)
  • Immune Globulin IV Solution 1gm/10ml, 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml, 30gm/300ml, 40gm/400ml (Prior Authorization Required)
  • Leuprolide Acetate Kit 1mg/0.2ml (Prior Authorization Required)
  • Ozempic Injection (Step Therapy, Quantity Level Limit)
  • Prenatal Vitamin with Docusate-Ferrous Fumarate-Folic Acid Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Iron Carbonyl-Folic Acid Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Minerals-Iron Bisglyc-Iron Prot Succ-Folic Acid-Calcium-Omega 3 Pack 29-1-200-250mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 20-20-1.25mg (Quantity Level Limit)
  • Pseudoephedrine Liquid 15mg/5ml
  • Segluromet Tabs (Step Therapy, Quantity Level Limit)
  • Steglatro Tabs (Step Therapy, Quantity Level Limit)
  • Victoza Injection (Step Therapy, Quantity Level Limit)
  • Zoladex Implant 3.6mg (Prior Authorization Required)

Removals:

  • Alprazolam Orally Disintegrating Tabs
  • Cleocin Vaginal Ovule 100mg
  • Clorazepate Tabs
  • Condylox Gel 0.5%
  • Cortifoam Aerosol Rectal
  • Dihydroergotamine Products
  • Dulera Inhaler
  • Elidel Cream 1%
  • Ergotamine Products
  • Ergotamine/Caffeine Products
  • Flovent Diskus Inhalers
  • Humalog Vials/Pens
  • Invokamet Tabs
  • Invokana Tabs
  • Levonorgestrel/Ethinyl Estradiol Tab 0.1-0.02mg (84) & 0.01mg (7)
  • Levonorgestrel/Ethinyl Estradiol Tab 0.15-0.03mg (84) & 0.01mg (7)
  • Lidocaine/Hydrocortisone Kit 20x7gm
  • Lidocaine/Hydrocortisone Kit 3-1%
  • Meprobamate Tabs
  • Miconazole-3 Vaginal Suppository 200mg
  • Neonatal Plus Tab
  • Nitro-Bid Packets 2%
  • Novolog Vials/Pens
  • Penicillamine Cap 250mg
  • Plan B Tabs (Brand Only)
  • Prenatal Vitamin and Minerals without Vit A with Iron Polysaccharide Complex-Folic Acid-Calcium-Omega 3 Pack 32-1-200mg
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid-DSS-Fish Oil Cap 27-1-500mg
  • Prenatal Vitamin with Ferrous Fumarate-L Methylfolate-Folic Acid Tab 27-0.6-0.4mg
  • Prenatal Vitamin with Ferrous-Fumarate-Folic Acid Tab 65-1mg
  • Prenatal Vitamin with Iron Carbonyl-Iron Aspart Glyc-Folic Acid-Omega 3 Cap 27-1mg
  • Prenatal Vitamin with Iron Polysaccharide Complex-Folic Acid Chewable Tab 29-1mg
  • Prenatal Vitamin with Minerals-Iron Polysaccharide Complex-Folic Acid-DHA Pack 29-1 & 250mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-DSS-Folic Acid-DHA Cap 27-1.25-300mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-L Methylfolate-Folic Acid-DHA Cap 27-0.6-0.4-300mg
  • Prenatal Vitamin without Vit A with Iron Bisglycinate-Folic Acid-Omega 3 Pack 32-1mg
  • Prenatal Vitamin without Vit A with Iron Carbonyl-Ferrous Gluconate-Folic Acid-Vitamin B6 Pack 20-1mg
  • Prenatal Vitamin without Vit A with Iron Carbonyl-Ferrous Gluconate-DSS-Folic Acid-DHA Pack 27-1mg & 250mg
  • Pulmicort Flexhalers
  • Qvar Inhalers
  • Relenza Diskhaler
  • Synjardy Tabs
  • Terconazole Vaginal Suppository 80mg
  • Thalomid Caps
  • Triazolam Caps
  • Tricare Tab
  • Trimethobenzamide Caps 300mg
  • Trulicity Injection

Other Updates:

  • Abilify Maintena Injections (Quantity Level Limit)
  • Acyclovir Suspension 200mg/5ml (Age Limit)
  • Alprazolam SR Tabs (Age Limit)
  • Alprazolam Tabs (Quantity Level Limit)
  • Aristada Injections (Quantity Level Limit)
  • Breo Ellipta Inhalers (Age Limit)
  • Buprenorphine Tabs (Quantity Level Limit, Age Limit, Prior Authorization Required)
  • Buprenorphine-Naloxone Tabs (Quantity Level Limit, Age Limit, Removed Prior Authorization Required, Age)
  • Calcipotriene Ointment 0.005% (Quantity Level Limit)
  • Calcipotriene Solution 0.005% (Quantity Level Limit)
  • Carafate Suspension 1gm/10ml (Age Limit)
  • Chlordiazepoxide Caps (Quantity Level Limit)
  • Citalopram Solution 10mg/5ml (Age Limit)
  • Clozapine Tabs (Quantity Level Limit)
  • Codeine Containing Products (Age Limit)
  • Dicyclomine Solution 10mg/ml (Age Limit)
  • Escitalopram Solution 5mg/5ml (Age Limit)
  • Famotidine Suspension 40mg/5ml (Age Limit)
  • Flovent HFA Inhaler (Age Limit)
  • Fluphenazine Decanoate Vial 25mg/ml (Quantity Level Limit)
  • Fluphenazine Elixir 2.5mg/5ml (Quantity Level Limit)
  • Fluphenazine Tabs (Quantity Level Limit)
  • Fluphenazine vial 2.5mg/ml (Quantity Level Limit)
  • Haloperidol Concentrate 2mg/ml (Quantity Level Limit)
  • Haloperidol Decanoate Injections (Quantity Level Limit)
  • Haloperidol Lactate Injection (Quantity Level Limit)
  • Haloperidol Tabs (Quantity Level Limit)
  • Hydrocodone Containing Products (Age Limit)
  • Hydroxyzine HCL Tabs (Quantity Level Limit)
  • Invega Sustena Injections (Quantity Level Limit)
  • Invega Trinza Injections (Quantity Level Limit)
  • Jardiance Tabs (Remove Step Therapy, Add Prior Authorization Required)
  • Lansoprazole Suspension 3mg/ml (Age Limit)
  • Lithium Carbonate Caps (Quantity Level Limit)
  • Lithium Carbonate ER Tab 300mg, 450mg (Quantity Level Limit)
  • Lithium Carbonate Tab 300mg (Quantity Level Limit)
  • Lithium Solution 8meq/5ml (Quantity Level Limit)
  • Lorazepam Tabs (Quantity Level Limit)
  • Loxapine Caps (Quantity Level Limit)
  • Nitrofurantoin Suspension 25mg/5ml (Age Limit)
  • Notriptyline Solution 10mg/5ml (Age Limit)
  • Olanzapine Orally Disintegrating Tabs (Quantity Level Limit)
  • Olanzapine Tabs (Quantity Level Limit)
  • Omeprazole Suspension 2mg/ml (Age Limit)
  • Oseltamivir Cap 30mg (Quantity Level Limit, Age Limit)
  • Oseltamivir Caps 45mg, 75mg (Quantity Level Limit)
  • Oseltamivir Suspension 6mg/ml (Quantity Level Limit, Age Limit)
  • Oxazepam Caps (Quantity Level Limit)
  • Perphenazine Tabs (Quantity Level Limit)
  • Prednisone Solution 5mg/5ml (Age Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-0.8mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 28-0.8mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 28-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 60-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid-Omega 3 Cap 53.5-38-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Minerals-Ferrous Fumarate-Folic Acid-DHA Pack 28-0.8-200mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Cap 106.5-1mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 130-92.4-1mg(Quantity Level Limit)
  • Prochlorperazine Suppository 25mg (Quantity Level Limit)
  • Prochlorperazine Tabs (Quantity Level Limit)
  • Quetiapine Tabs (Quantity Level Limit)
  • Risperdal Consta Injections (Quantity Level Limit)
  • Risperidone Oral Solution 1mg/ml (Quantity Level Limit)
  • Risperidone Orally Disintegrating Tabs (Quantity Level Limit)
  • Risperidone Tabs (Quantity Level Limit)
  • Thioridazine Tabs (Quantity Level Limit)
  • Thiothixene Caps (Quantity Level Limit)
  • Tramadol Tabs (Age Limit)
  • Trifluoperazine Tabs (Quantity Level Limit)
  • Ziprasidone Caps (Quantity Level Limit)
  • Zoladex Implant 10.8mg (Prior Authorization Required)

 

January 2019

No Changes

 

December 2018

Additions:

  • Itraconazole Solution 10mg/ml
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)

Removals:

  • Sporanox Solution 10mg/ml
  • Tamiflu Capsules (brand)

Other Updates:

  • Enoxaparin Inj – All strengths (Quantity Level Limit)

 

November 2018

Additions:

  • Albendazole Tab 200mg (Step Therapy Required)
  • Fluticasone-Salmeterol Aer Powder Inhaler 55-14mcg/act, 113-14mcg/act, 232-14mcg/act

Removals:

  • Albenza Tab 200mg

 

October 2018

Additions:

  • Admelog Vial
  • Loratadine Chewable Tab 5mg (Quantity Level Limit)
  • Prasugrel Tabs (Quantity Level Limit)
  • Tadalafil Tab 20mg (Step Therapy, Quantity Level Limit)
  • Tazarotene Cream 0.1% (Quantity Level Limit)
  • Tymlos Pen (Prior Authorization Required, Quantity Level Limit)
  • Valganciclovir Tab 450mg (Quantity Level Limit)

Removals:

  • Adcirca Tab 20mg

Other Updates:

  • Ondansetron Tabs 4mg, 8mg (Quantity Level Limit)
  • Tizanidine Tabs 2mg, 4mg (Quantity Level Limit)

 

September 2018

Additions:

  • Humira Pen Kit CD/UC/HS Starter Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen PS/UV Starter Kit 80mg/0.8ml and 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Symtuza Tab (Quantity Level Limit)

 

August 2018

Additions:

  • Cimduo Tabs (Quantity Level Limit)
  • Omega 3 Ethyl Esters Cap (Step Therapy, Quantity Level Limit)
  • Retacrit Injection (Prior Authorization Required)
  • Sevelamer Carbonate Tab 800mg (Step Therapy, Quantity Level Limit)
  • Telmisartan Tabs 20mg, 40mg, 80mg (Quantity Level Limit)
  • Tolterodine ER Caps 2mg, 4mg (Step Therapy, Quantity Level Limit)
  • Vemlidy Tab 25mg (Quantity Level Limit)
  • Verzenio Tabs (Prior Authorization Required)

Removals:

  • Amlodipine-Valsartan-Hydrochlorothiazide Tabs
  • Betaxolol Tabs
  • Calcitriol Solution
  • Captopril-Hydrochlorothiazide Tabs
  • Chlorpropramide Tabs
  • Climara Pro Patch
  • Desipramine Tabs
  • Diltiazem CD Cap 360mg
  • Femring
  • Fenofibrate Tab 48mg, 145mg
  • Fenofibric Cap DR
  • Fenoprofen Tab 600mg
  • Lidocaine Cream 3%
  • Marplan Tab 10mg
  • Meclofenamate Sodium Caps
  • Methyltestosterone Cap 10mg
  • Nadolol Tabs
  • Nisoldipine ER Tabs
  • Ondansetron Solution
  • Pindolol Tabs
  • Pioglitazone-Glimepiride Tabs
  • Pioglitazone-Metformin Tabs
  • Potassium/Sodium Citrates & Citric Acid Solution
  • Premarin Tablets
  • Premarin Vaginal Cream
  • Premphase Tablets
  • Prempro Tablets
  • Protriptyline Tabs
  • Tolazamide Tabs
  • Tolbutamide Tab 500mg
  • Tranylcypromine Tab 10mg
  • Verapamil XR 24 hour Cap 100mg, 200mg, 300mg

Other Updates:

  • Amlodipine Tabs 2.5mg, 5mg (Quantity Level Limit)
  • Baraclude Solution (Quality Level Limit)
  • Benazepril Tabs 5mg, 10mg, 20mg (Quantity Level Limit)
  • Benzonatate Caps 100mg, 200mg (Age Limit, Quantity Level Limit)
  • Diazepam Rectal Gel 2.5mg, 10mg, 20mg (Quantity Level Limit)
  • Diclofenac 1% Gel (Quantity Level Limit, Term Step Therapy)
  • Diltiazem CD Cap 180mg (Quantity Level Limit)
  • Diltiazem ER Beads Cap 180mg (Quantity Level Limit)
  • Diltiazem ER Cap 180mg (Quantity Level Limit)
  • Elmiron Cap (Prior Authorization Required)
  • Enalapril Tabs 2.5mg, 5mg, 10mg (Quantity Level Limit)
  • Estradiol Vaginal Cream 0.01% (Prior Authorization Required)
  • Estring Vaginal Ring 2mg (Quantity Level Limit)
  • Flunisolide Nasal Solution 25mcg/act (Quantity Level Limit)
  • Fosinopril Tabs 10mg, 20mg (Quantity Level Limit)
  • Griseofulvin Suspension (Step Therapy)
  • Griseofulvin Tabs (Step Therapy)
  • Hydrocodone-Homatropine Syrup (Age Limit, Quantity Level Limit)
  • Hydrocodone-Homatropine Tablets (Age Limit, Quantity Level Limit)
  • Lidocaine 5% Ointment (Prior Authorization Required)
  • Lisinopril Tabs 2.5mg, 5mg, 10mg, 20mg, 30mg (Quantity Level Limit)
  • Losartan Potassium Tab 25mg (Quantity Level Limit)
  • Mometasone Furoate Nasal Suspension 50mcg/act (Quantity Level Limit)
  • Oxybutynin ER Tab 15mg (Quantity Level Limit)
  • Oxybutynin IR Tab 5mg (Quantity Level Limit)
  • Oxybutynin Syrup (Quantity Level Limit)
  • Propranolol ER Cap 80mg (Quantity Level Limit)
  • Quinapril Tabs 5mg, 10mg, 20mg (Quantity Level Limit)
  • Ramipril Caps 1.25mg, 2.5mg, 5mg (Quantity Level Limit)
  • Tolterodine Tabs 1mg, 2mg (Step Therapy)
  • Trospium ER Cap 60mg (Step Therapy)
  • Trospium Tab 2mg (Step Therapy)

 

July 2018

Additions:

  • Baclofen Tab 5mg (Quantity Level Limit)
  • Diphenhydramine Liquid 6.25mg/ml
  • Norvir Powder Packets 100mg
  • Pediatric Multiple Vitamins with Iron Drops 11mg/ml
  • Phytonadione Tab 5mg
  • Zenpep Cap 15,000 Units
  • Zenpep Cap 3000 Units

Removals:

  • Mephyton Tab 5mg

 

June 2018

Additions:

  • Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8ml and 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen-Injector Kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 10mg/0.1ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 20mg/0.2ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Praziquantel Tab 600mg (Prior Authorization Required)
  • Symfi Tab (Quantity Level Limit)
  • Tasigna Cap 50mg (Prior Authorization Required, Quantity Level Limit)
  • Zenpep Cap 10,000 Units

Removals:

  • Biltricide Tab 600mg

 

May 2018

Additions:

  • Colchicine 0.6mg caps (Quantity Level Limit)
  • Firvanq Sln 25mg/mL, 50mg/mL
  • Gleostine 10mg, 40mg, 100mg
  • Hepatitis A vaccine
  • Imbruvica 70mg caps, 420mg, 560mg tabs (Prior Authorization Required, Quantity Level Limit)
  • Jardiance tab (Quantity Level Limit, Step Therapy Required)
  • Ritonavir 100mg tab
  • Symfi Lo tab (Quantity Level Limit)
  • Synjardy tab (Quantity Level Limit, Step Therapy Required)
  • Synjardy XR 5/1000mg, 10/1000mg, 12.5/1000, 25/1000mg (Quantity Level Limit, Step Therapy Required)

Removals:

  • Norvir

Other Updates:

  • All Opioids (Change Quality Level Limit)
  • Naproxen Susp 125mg/5mL (Change Step Therapy)
  • Omeprazole 20mg tab (Change Reject Message)
  • Rosuvastatin tabs (Remove Prior Authorization, Remove Step Therapy)
  • Short Acting Opioids (except Fentanyl) (Added Quantity Level Limit)
  • Vancomycin caps (Change Reject Message)

 

April 2018

Additions:

  • Biktarvy 50-200-25mg, with QLL
  • Flovent HFA 110mcg, 220mcg, 44mcg (Quantity Level Limit)
  • Zenpep 5000U & 25,000U

 

March 2018

Additions:

  • Aristada (Prior Authorization Requirement)
  • Efavirenz 600mg

 

February 2018

Additions:

  • Efavirenz 50mg, 200mg
  • Janumet 50-500mg, 50-1000mg (Quantity Level Limit, Step Therapy Required)
  • Janumet XR 50-500mg, 50-1000mg, 100-1000mg (Prior Authorization Required, Quantity Level Limit)
  • Januvia 25mg, 50mg, 100mg (Quantity Level Limit, Step Therapy Required)
  • Juluca 50-25mg (Quantity Level Limit)
  • Qvar Redihaler 40mcg, 80mcg (Quantity Level Limit)
  • Tenofovir 300mg (Quantity Level Limit)

Removals:

  • Albuterol ER Tablets (GF)
  • Albuterol Tablets (GF)
  • Amcinonide Cream 0.1% (GF)
  • Amcinonide Lotion 0.1% (GF)
  • Betopic-S susp 0.25% (GF)
  • Brimonidine 0.15% ophth soln (GF)
  • Cefixime Suspension
  • Cephalexin tablets
  • Ciloxan Ophth Ointment 0.3%
  • Ciprofloxacin ER tablets
  • Clobetasol Aerosolized Foam 0.05%
  • Clobetasol Lotion 0.05%
  • Clobetasol Shampoo 0.05%
  • Desonide Cream 0.05%
  • Desonide Lotion 0.05%
  • Desonide Ointment 0.05%
  • Desoximetasone Cream 0.05%
  • Desoximetasone Cream 0.25%
  • Desoximetasone Gel 0.05%
  • Desoximetasone Ointment 0.05%
  • Desoximetasone Ointment 0.25%
  • Diflorasone Cream 0.05%
  • Diflorasone Ointment 0.05%
  • Fluocinonide Cream 0.1%
  • FML Forte 0.25% (GF)
  • Fondaparinux (GF)
  • Fragmin (GF)
  • Gatifloxacin Ophth Solution 0.5%
  • HC Butyrate Cream 0.1%
  • HC Butyrate Ointment 0.1%
  • HC Butyrate Solution 0.1%
  • HC Valerate Cream 0.2%
  • HC Valerate Ointment 0.2%
  • Jentadueto
  • Jentadueto XR
  • Modafinil
  • Morphine ER Capsule (GF)
  • Moxifloxacin Ophth Solution 0.5%
  • Neomycin/polymixin/HC Ophth Susp
  • Ofloxacin tablets
  • Oxycodone 5mg CAPSULE (GF)
  • Oxycodone concentrated solution (20mg/mL) (GF)
  • Oxymorphone IR tablets (GF)
  • Pred Mild 0.12% (GF)
  • Prednicarbate Cream 0.1%
  • Suprax chew tablets
  • Sustiva (added generic Efavirenz)
  • Terbutaline Tablets (GF)
  • Tobradex Ophth Ointment 0.3-0.1%
  • Tobramycin/dexamethasone Ophth Suspension 0.3-0.1%
  • Tobrex Ophth Ointment 0.3%
  • Tradjenta
  • Vancomycin Capsules
  • Viread

Other Updates:

  • All Opioids (Changed Quantity Level Limit)
  • Betamethasone Dipropionate Augmented Gel 0.05% (Added Quantity Level Limit)
  • Betamethasone Dipropionate Augmented Lotion 0.05% (Added Quantity Level Limit)
  • Betamethasone Dipropionate Augmented Ointment 0.05% (Added Quantity Level Limit)
  • Betamethasone Dipropionate Ointment 0.05% (Added Quantity Level Limit)
  • Betaxolol 0.5% ophth soln (Added Quantity Level Limit)
  • Brinzolamide ophth soln (Added Quantity Level Limit)
  • Carteolol 1% ophth soln (Added Quantity Level Limit)
  • Ciprofloxacin Suspension 250mg/5mL (Added Quantity Level Limit)
  • Clobetasol Cream 0.05% (Added Step Therapy)
  • Clobetasol Cream Emulsion 0.05% (Added Quantity Level Limit)
  • Clobetasol Gel 0.05% (Added Step Therapy)
  • Clobetasol Ointment 0.05% (Added Step Therapy)
  • Clobetasol Solution 0.05% (Added Quantity Level Limit)
  • Combigan ophth soln (Added Step Therapy)
  • Duloxetine Capsules (Added Quantity Level Limit)
  • Fluocinonide Gel 0.05% (Added Quantity Level Limit)
  • Fluocinonide Ointment 0.05% (Added Quantity Level Limit)
  • Halobetasol Cream 0.05% (Added Quantity Level Limit)
  • Halobetasol Ointment 0.05% (Added Quantity Level Limit)
  • Levobunolol 0.5% ophth soln (Added Quantity Level Limit)
  • Metipranolol 0.3% ophth soln (Added Quantity Level Limit)
  • Naproxen Suspension 125mg/5mL (Added Step Therapy)
  • Short-acting opioids (Added Quantity Level Limit)
  • Timolol ophth gel (Added Step Therapy)

 

January 2018

Additions:

  • Abilify Maintena Prefilled Syringe 300mg, 400mg (Prior Authorization Required)
  • Abilify Maintena reconstituted 300mg, 400mg (Prior Authorization Required)
  • Armodafinil 50mg, 150mg, 200mg, 250mg
  • Avonex IM inj kit 30mcg; auto inj kit 30mcg/0.5mL; prefilled syringe kit 30mcg/0.5mL (Prior Authorization Required, Quantity Level Limit)
  • BD Pen Needles 29g x 5mm; 29g x 8mm; 29g x 12.7mm; 29g x 13mm; 30g x 5mm; 31g x 5mm; 31g x 8mm; 32g x 4mm; 32g x 6mm (Step Therapy Requirement)
  • Carbamide Peroxide 6.5% Otic Sln
  • Carboxymethylcellulose Sodium Opth Sln 0.25%
  • Eliquis 2.5mg, 5mg (Prior Authorization Required, Quantity Level Limit)
  • Invega Sustenna 39mg/0.25mL; 78mg/0.5mL; 117mg/0.75mL; 156mg/mL; 234mg/1.5mL (Prior Authorization Required)
  • Invega Trinza 273mg/0.875mL; 410mg/1.315mL; 546mg/1.75mL; 819mg/2.625mL (Prior Authorization Required)
  • Opsumit 10mg (Prior Authorization Required, Quantity Level Limit)
  • Oseltamivir Susp 6mg/mL
  • Risperdal Consta 12.5mg, 25mg, 37.5mg, 50mg (Prior Authorization Required)
  • Tracleer 32mg tab (Quantity Level Limit)
  • Zenprep 20,000U cap

Removal:

  • Tamiflu Susp 6mg/ml

 

December 2017

Additions:

  • Abacavir Sln 20mg/mL
  • Enbrel Subq Sln Cartridge 50mg/mL (Prior Authorization Required)
  • Glatiramer Inj 40mg/mL (Prior Authorization Required, Quantity Level Limit)

Removals:

  • Copaxone
  • Ziagen

 

November 2017

Additions:

  • Fosamprenavir 700mg
  • Mavyret (Prior Authorization Required)

Removal:

  • Zepatier

 

October 2017

Additions:

  • Canagliflozine-Metformin ER (Quantity Level Limit, Step Therapy Required)
  • Doxylamine Succinate 25mg
  • Duloxetine 40mg (Quantity Level Limit)
  • Guanfacine ER 1mg, 2mg, 3mg, & 4mg (Quantity Level Limit)
  • Octreotide inj 50mcg/mL, 100mcg/mL, 200mcg/mL, 500mcg/mL, 1000mcg/mL (Prior Authorization Required)
  • Pyridoxine 25mg
  • Vancomycin Oral Sln 25mg/mL & 50mg/mL

Removal:

  • Somatuline ER inj 90mg/0.3mL, 60mg/0.2mL, 120mg/0.5mL

Other Updates:

  • Gabapentin (Added Quantity Level Limit)

 

September 2017

Additions:

  • Butalbital containing products (Quantity Level Limit)
  • Mesalamine 1.2gm (Quantity Level Limit)
  • Moxifloxacin 0.5%

 

August 2017

Additions:

  • Basaglar
  • Biltricide (Prior Authorization Required)
  • Corlanor (Quantity Level Limit, Step Therapy Required)
  • Epoprostenol Sodium for inj (Prior Authorization Required)
  • Kitabis (Prior Authorization Required)
  • Letairis tabs (Prior Authorization Required, Quantity Level Limit)
  • Lidocaine 4% Cream
  • Pulmozyme (Prior Authorization Required, Quantity Level Limit)
  • Ribasphere 200mg tabs & caps
  • Spinosad Susp 0.9% (Step Therapy Required)
  • Tracleer tabs (Prior Authorization Required, Quantity Level Limit)

Removals:

  • Alcohol pads/swabs (certain NDCs ONLY)
  • Azelastine HCl Nasal Spray 0.15%
  • Benzyl Alcohol Lotion 5%
  • Cetirizine Chew tabs 5 & 10mg
  • Chlorpromazine HCl 10mg, 25mg, 50mg, 100mg, 200mg tabs
  • Doxycycline Hyclate DR tabs
  • Doxycycline Monohydrate 75mg caps
  • Econazole Nitrate Cream 1%
  • Ery tabs (all strengths)
  • Erythrocin 250mg tabs
  • Erythromycin Base tabs
  • Erythromycin DR cap
  • Erythromycin ES 400mg
  • Fluoxetine 10mg tabs
  • Fluphenazine HCl 1mg, 2.5mg, 5mg, 10mg tabs
  • Lantus SoloStar Pen
  • Lantus Vials
  • Levemir Flextouch
  • Levemir Vials
  • Metronidazole 1% gel
  • Niacin ER tabs
  • Nitroglycerin Sln Pump Spray
  • Potassium Chloride 10% & 20% Sln
  • Potassium Chloride 20mEq & 25mEq Powder packs
  • Ribavirin 200mg caps
  • Ribavirin 200mg, 400mg, 600mg tabs
  • Ribavirin Pack
  • Tetracycline caps (all strengths)

Other Updates:

  • Acyclovir Ointment 5% (Added Quantity Level Limit)
  • Adcirca (Added Quantity Level Limit, Added Step Therapy)
  • Albenza (Added Step Therapy)
  • Malathion Lotion 0.5% (Added Step Therapy)
  • Multaq (Added Quantity Level Limit, Added Step Therapy)
  • Permethrin Lotion 1% (Added Quantity Level Limit)

 

July 2017

Additions:

  • NP Thyroid 120mg
  • NP Thyroid 15mg

 

June 2017

Other Updates:

  • Adapalene Cream (Added Step Therapy)
  • Adapalene Gel 0.1% (Added Step Therapy)
  • Albuterol Neb 0.63mg/3mL (Added Step Therapy)
  • Albuterol Neb 1.25mg/3mL (Added Step Therapy)
  • Chantix Pak and tabs (Removed Prior Authorization)
  • Nicotrol Inhaler (Removed Prior Authorization)
  • Nicotrol NS (Removed Prior Authorization)
  • Tretinoin Cream 0.025% (Added Step Therapy)
  • Tretinoin Cream 0.05% (Added Step Therapy)
  • Tretinoin Cream 0.1% (Added Step Therapy)
  • Tretinoin Gel 0.01% (Added Step Therapy)
  • Tretinoin Gel 0.025% (Added Step Therapy)

 

May 2017

Additions:

  • Hydroxyprogesterone
  • Methylphenidate LA 60mg
  • OTC Differin Gel

Other Updates:

  • Buspirone 15mg (Changed Quantity Level Limit)
  • Ribavirin (Changed Step Therapy)
  • Gabapentin Solution (Changed Quantity Level Limit)

Aetna Better Health Specialty Drug Program is managed through CVS Health Specialty Pharmacy. The Specialty pharmacies fill prescriptions and ship drugs for complex medical conditions, including hepatitis C, multiple sclerosis, hemophilia, rheumatoid arthritis and most cancer drugs. Medications provided through CVS specialty pharmacy include injectable, oral and inhaled drugs.

The Specialty Drug Program provides care management services to your members, including:

  • 24 hours a day, seven days a week access to a pharmacist
  • Disease-specific education and counseling by the CareTeamTM. The CareTeamTM are clinical professionals who review dosing and medication schedules, identify injection issues, provide education of potential side effects and provide information to help your patient to manage their medical condition.
  • Care coordination
  • Delivery of Specialty drugs to your patient’s home and/or your office in temperature-controlled packaging with the required supplies, i.e. needles, syringes, and alcohol wipes or patients can be directed to drop off and pick up most of their prescriptions at any CVS Pharmacy location (including those inside Target stores*)

Contact CVS Specialty Pharmacy at 1-800-237-2767 from 7:30 a.m. (EST) to 9:00 p.m. (EST) time, Monday – Friday. CVS Specialty Pharmacy will assist you in filling your patient’s specialty drug. Prior Authorization (PA) still applies to specific specialty drugs. You can check our health plan website to confirm PA requirements on the medications listed below.

Specialty medications can be delivered to the provider’s office, member’s home, or other location as requested.

Additional Pharmacies in the specialty network:

BioPlus: Phone: 1-800-628-6965; Fax: 1-833-670-2942

BioRx (Diplomat): Phone: 1-513-792-7080; Fax: 1-513-792-3838

BriovaRx of Indiana: Phone:1-855-427-4682; Fax: 1-877-342-4596

BriovaRx of Tennessee: Phone: 1-615-791-8679; Fax: 1-888-791-7666

Duncan Prescription Center: Phone: 1-270-247-3725; Fax: 1-270-247-6033

Duncan Specialty Pharmacy: Phone: 1-270-247-3725; Fax: 1-270-247-6033

Elwyn Specialty Pharmacy: Phone: 1-855-359-9676; Fax: 1-610-545-6033

Nufactor Inc: Phone: 1-844-871-4773; Fax: 1-844-871-4776

SenderraRx Phone: 1-888-777-5547; Fax: 1-888-777-5645

SimplicityRx: Phone: 1- 513-878-1285; Fax: 1-844-513-6337

Walmart Pharmacies (Specialty Only): Phone: 1-877-453-4566; Fax: 1-866-537-0877

WellPartner Pharmacy: Phone: 1-800-473-3516; Fax: 1-877-597-3070

University of Kentucky Specialty Pharmacy: Phone: 1-844-730-5913; Fax: 1-859-218-5413

 

The step therapy program requires that you prescribe certain first-line drugs, either generic drugs or formulary brand drugs, before you can prescribe specific, second-line drugs. The formulary identifies drugs with these guidelines as “STEP.” See the link below.

Step Therapy Guidelines 

In addition, certain drugs on the formulary have quantity limits. The formulary flags these drugs with the letters “QLL” The QLLs are established based on FDA-approved dosing levels and nationally- established, recognized guidelines pertaining to the treatment and management of the condition being treated.

To request an override for the step therapy and/or quantity limit, please fax the correct pharmacy Prior Authorization request form to 1-855-799-2550. You can include any medical records that will support your request.