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October 2023
Drugs not covered — and their covered
alternatives for the Aetna Standard Formulary
2023 Formulary Exclusions Drug List
The drugs on this list have been removed from your
plan’s formulary. If you continue using a drug listed
under “formulary drug removals”, you may have to
pay the full cost. Ask your doctor to choose one of
the generic or brand formulary options from the list.
Key
UPPERCASE
Brand-name medicine
Upper and lowercase
italics
Branded generic medicine
lowercase italics
Generic medicine
Category
Drug Class
Formulary Drug
Removals
Formulary Options
Acromegaly
SANDOSTATIN LAR
1
SIGNIFOR LAR
1
SOMAVERT
1
SOMATULINE DEPOT
Allergies
Antihistamines
dexchlorpheniramine
Diphen Elixir
RyClora
CARBINOXAMINE TABLET 6 MG
levocetirizine
Allergies
Nasal Steroids / Combinations
BECONASE AQ
DYMISTA
OMNARIS
QNASL
ZETONNA
azelastine-fluticasone, flunisolide, fluticasone, mometasone
Anti-infectives, Antibacterials
Erythromycins / Macrolides
E.E.S. GRANULES
ERYPED
erythromycins
Anti-infectives, Antibacterials
Tetracyclines
doxycycline hyclate delayed-rel tablet
doxycycline hyclate tablet 50 mg
doxycycline hyclate tablet 75 mg
doxycycline hyclate tablet 150 mg
doxycycline monohydrate capsule 75 mg
doxycycline monohydrate capsule 150 mg
minocycline ext-rel
CoreMino
Mondoxyne NL capsule 75 mg
Targadox
DORYX
DORYX MPC
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
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 Assurance
Pennsylvania Inc., Aetna Health Insurance company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and
Wyoming by Aetna Health of Utah Inc. and 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. Pharmacy benefits are administered by an affiliated pharmacy benefit manager, CVS Caremark. Aetna is part of the CVS Health family of companies.
997050-01-07 (10/23)
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Category
Drug Class
Formulary Drug
Removals
Formulary Options
Anti-infectives, Antibacterials
Miscellaneous
nitrofurantoin (NDC* 16571074024 only)
MACRODANTIN
nitrofurantoin (except NDC* 16571074024)
Anti-infectives, Antifungals
flucytosine capsule 500 mg
fluconazole
posaconazole delayed-rel tablet
NOXAFIL
fluconazole, itraconazole
CRESEMBA
itraconazole
tavaborole
terbinafine tablet
Anti-infectives,
Antiretroviral
Agents
Combination Agents
COMPLERA
1
STRIBILD
1
efavirenz-emtricitabine-tenofovir disoproxil fumarate,
efavirenz-lamivudine-tenofovir disoproxil fumarate, BIKTARVY, DOVATO,
GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ
TRUVADA
1
abacavir-lamivudine, emtricitabine-tenofovir disoproxil fumarate,
lamivudine-zidovudine, CIMDUO, DESCOVY
Anti-infectives,
Antiretroviral Agents
Fusion Inhibitors
SELZENTRY
1
maraviroc
Anti-infectives,
Antiretroviral Agents
Protease Inhibitors
APTIVUS
1
Talk to your doctor
LEXIVA
1
VIRACEPT
1
atazanavir, lopinavir-ritonavir, EVOTAZ, PREZCOBIX, PREZISTA
Anti-infectives, Antivirals
Cytomegalovirus
†
VALCYTE
valganciclovir
Anti-infectives, Antivirals
Hepatitis B
†
BARACLUDE TABLET
1
EPIVIR HBV
1
VEMLIDY
1
entecavir, lamivudine, tenofovir disoproxil fumarate
Anti-infectives, Antivirals
Hepatitis C
†
MAVYRET
1
EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI
2
VIEKIRA PAK
1
ZEPATIER
1
EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)
Anti-infectives, Antivirals
Herpes
†
acyclovir cream
VALTREX
acyclovir capsule, acyclovir tablet, valacyclovir
Anti-infectives
Miscellaneous
DARAPRIM
pyrimethamine
Antiobesity
CONTRAVE
XENICAL
orlistat, QSYMIA, SAXENDA, WEGOVY
Antiseizure Agents
topiramate ext-rel capsule (generics for
QUDEXY XR only)
LAMICTAL
LAMICTAL ODT
carbamazepine, carbamazepine ext-rel, clobazam, clonazepam, divalproex sodium,
divalproex sodium ext-rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel,
levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin,
phenytoin sodium extended, primidone, rufinamide, tiagabine, topiramate,
valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI XR,
XCOPRI
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Category
Drug Class
Formulary Drug
Removals
Formulary Options
BANZEL
FINTEPLA
1
ONFI
clobazam, clonazepam, lamotrigine, rufinamide, topiramate, TROKENDI XR
SABRIL
1
vigabatrin
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
carbamazepine, carbamazepine ext-rel, clonazepam, divalproex sodium,
divalproex sodium ext-rel, ethosuximide, gabapentin, lacosamide, lamotrigine,
lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine,
phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine,
topiramate, valproic acid, zonisamide, APTIOM, FYCOMPA, OXTELLAR XR,
TROKENDI XR, XCOPRI
DILANTIN
KEPPRA
KEPPRA XR
LAMICTAL XR
TEGRETOL
TEGRETOL XR
TRILEPTAL
VIMPAT
ZONEGRAN
carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-
rel, gabapentin, lacosamide, lamotrigine, lamotrigine ext-rel, levetiracetam,
levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin,
phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid,
zonisamide, APTIOM, FYCOMPA, OXTELLAR XR, TROKENDI XR, XCOPRI
DIACOMIT
1
Talk to your doctor
Anxiety
†
Benzodiazepines
ATIVAN
XANAX
XANAX XR
alprazolam, clonazepam, diazepam, lorazepam, oxazepam
Asthma
†
Beta Agonists, Short-Acting
albuterol sulfate CFC-free aerosol
(NDC* 66993001968 only)
PROAIR HFA
PROAIR RESPICLICK
PROVENTIL HFA
VENTOLIN HFA
XOPENEX HFA
albuterol sulfate CFC-free aerosol (except NDC* 66993001968),
levalbuterol tartrate CFC-free aerosol
Asthma
†
Leukotriene Modulators
zileuton ext-rel
SINGULAIR
montelukast, zafirlukast
Asthma
†
Steroid Inhalants
ALVESCO
ARNUITY ELLIPTA
ASMANEX
ASMANEX HFA
FLOVENT DISKUS
FLOVENT HFA
QVAR REDIHALER
3
PULMICORT FLEXHALER
Asthma
†
or Chronic Obstructive
Pulmonary Disease (COPD)
†
Steroid / Beta Agonist
Combinations
DULERA
ADVAIR DISKUS, ADVAIR HFA**, BREO ELLIPTA**, SYMBICORT
Asthma
†
Severe Asthma
NUCALA LYOPHILIZED POWDER
1
DUPIXENT, FASENRA, NUCALA (except lyophilized powder), TEZSPIRE, XOLAIR
Attention Deficit Hyperactivity
Disorder
†
ADDERALL
EVEKEO
amphetamine-dextroamphetamine mixed salts, methylphenidate
ADDERALL XR
ADZENYS XR-ODT
APTENSIO XR
CONCERTA
DAYTRANA
DYANAVEL XR
FOCALIN XR
JORNAY PM
amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel,
methylphenidate ext-rel, AZSTARYS
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Category
Drug Class
Formulary Drug
Removals
Formulary Options
MYDAYIS
QUILLICHEW ER
QUILLIVANT XR
INTUNIV
amphetamine-dextroamphetamine mixed salts ext-rel, atomoxetine,
dexmethylphenidate ext-rel, guanfacine ext-rel, methylphenidate ext-rel,
AZSTARYS, QELBREE
Autoimmune Agents
Physician-Administered Agents
ACTEMRA INTRAVENOUS
1
ORENCIA INTRAVENOUS
1
REMICADE, SIMPONI ARIA
AVSOLA
1
CIMZIA LYOPHILIZED POWDER
1
INFLECTRA
1
RENFLEXIS
1
ILUMYA, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS,
STELARA INTRAVENOUS
ENTYVIO (For Crohn’s Disease Only)
1
REMICADE, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS
Autoimmune Agents
Self-Administered Agents
Ankylosing Spondylitis
†
SIMPONI
1
TALTZ
1
XELJANZ
1
XELJANZ XR
1
COSENTYX, ENBREL, HUMIRA, RINVOQ
Autoimmune Agents
Self-Administered Agents
Crohn's Disease
†
None
HUMIRA, RINVOQ, SKYRIZI SUBCUTANEOUS, STELARA SUBCUTANEOUS
Autoimmune Agents
Self-Administered Agents
Non-Radiographic Axial
Spondyloarthritis
†
TALTZ
1
CIMZIA PREFILLED SYRINGE, COSENTYX, RINVOQ
Autoimmune Agents
Self-Administered Agents
Psoriasis
†
COSENTYX
1
ENBREL
1
HUMIRA, OTEZLA, SKYRIZI SUBCUTANEOUS, STELARA SUBCUTANEOUS,
TALTZ, TREMFYA
Autoimmune Agents
Self-Administered Agents
Psoriatic Arthritis
†
ORENCIA CLICKJECT
1
ORENCIA SUBCUTANEOUS
1
SIMPONI
1
TALTZ
1
XELJANZ
1
XELJANZ XR
1
COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, SKYRIZI SUBCUTANEOUS,
STELARA SUBCUTANEOUS, TREMFYA
Autoimmune Agents
Self-Administered Agents
Rheumatoid Arthritis
†
ACTEMRA ACTPEN
1
ACTEMRA SUBCUTANEOUS
1
KINERET
1
SIMPONI
1
ENBREL, HUMIRA, KEVZARA, ORENCIA CLICKJECT,
ORENCIA SUBCUTANEOUS, RINVOQ, XELJANZ, XELJANZ XR
Autoimmune Agents
Self-Administered Agents
Ulcerative Colitis
†
SIMPONI
1
HUMIRA, RINVOQ, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR,
ZEPOSIA
Autoimmune Agents
Self-Administered Agents
All Other Conditions
†
ACTEMRA ACTPEN
1
ACTEMRA SUBCUTANEOUS
1
KINERET
1
ORENCIA CLICKJECT
1
ORENCIA SUBCUTANEOUS
1
ENBREL, HUMIRA
Botulinum Toxins
BOTOX
1
Talk to your doctor
Cancer
Antimetabolites
ALIMTA
pemetrexed
Cancer
Biosimilars
RIABNI
1
TRUXIMA
1
RUXIENCE
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Category
Drug Class
Formulary Drug
Removals
Formulary Options
Cancer
Chronic Myelogenous
Leukemia
†
Kinase Inhibitors
GLEEVEC
1
ICLUSIG
1
TASIGNA
1
imatinib mesylate, BOSULIF, SPRYCEL
Cancer
Follicular Lymphoma
†
PI3K Inhibitors
ALIQOPA
1
Talk to your doctor
Cancer
Melanoma
†
BRAF/MEK Inhibitors
MEKINIST
1
COTELLIC, MEKTOVI
TAFINLAR
1
BRAFTOVI, ZELBORAF
Cancer
Monoclonal Antibodies
AVASTIN
1
ZIRABEV
HERCEPTIN
1
HERCEPTIN HYLECTA
1
KANJINTI, TRAZIMERA
RITUXAN
1
RUXIENCE
Cancer
mTOR Inhibitors
AFINITOR
1
AFINITOR DISPERZ
1
everolimus
Cancer
Multiple Myeloma
†
Proteasome Inhibitors
BORTEZOMIB
1
KYPROLIS
1
bortezomib, NINLARO
Cancer
Non-Small Cell Lung Cancer
†
ALK Inhibitors
XALKORI
1
ALECENSA, ALUNBRIG, ZYKADIA
Cancer
PARP Inhibitor
RUBRACA
1
LYNPARZA, ZEJULA
Cancer
Prostate
†
Antiandrogens
NILANDRON
ZYTIGA
1
abiraterone, bicalutamide, ERLEADA, XTANDI, YONSA
Cancer
Prostate
†
Luteinizing Hormone-Releasing
Hormone (LHRH) Agonists
FIRMAGON
1
LUPRON DEPOT
1
TRELSTAR MIXJECT
1
ZOLADEX
1
ELIGARD
Cancer
Renal Cell Carcinoma
Kinase Inhibitors
SUTENT
1
VOTRIENT
1
sunitinib, CABOMETYX, INLYTA, LENVIMA, NEXAVAR
Cancer
Miscellaneous
TARGRETIN
1
bexarotene
Cardiovascular
Antiarrhythmics
BETAPACE
BETAPACE AF
sotalol
MULTAQ
NEXTERONE
amiodarone
NORPACE
disopyramide
Cardiovascular
Antilipemics
Cholesterol Absorption Inhibitors
ZETIA
ezetimibe
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Category
Drug Class
Formulary Drug
Removals
Formulary Options
Cardiovascular
Antilipemics
Fibrates
fenofibrate capsule 30 mg
fenofibrate capsule 50 mg
fenofibrate capsule 90 mg
fenofibrate capsule 130 mg
fenofibrate tablet 40 mg
fenofibrate tablet 120 mg
FENOGLIDE TABLET 120 MG
TRICOR
fenofibrate (except fenofibrate capsule 30 mg, 50 mg, 90 mg, 130 mg;
fenofibrate tablet 40 mg, 120 mg), fenofibric acid delayed-rel
Cardiovascular
Antilipemics
HMG-CoA Reductase Inhibitors
(HMGs or Statins) / Combinations
4
ALTOPREV
CRESTOR
LESCOL XL
LIPITOR
LIVALO
atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin,
simvastatin
Cardiovascular
Antilipemics
MTP Inhibitors
JUXTAPID
1
REPATHA
Cardiovascular
Antilipemics
Niacins
niacin tablet 500 mg
Niacor
niacin ext-rel
Cardiovascular
Antilipemics
Omega-3 Fatty Acids
icosapent ethyl
LOVAZA
omega-3 acid ethyl esters, VASCEPA
Cardiovascular
Antilipemics
PCSK9 Inhibitors
PRALUENT
1
REPATHA
Cardiovascular
Digitalis Glycosides
LANOXIN TABLET
(125 MCG and 250 MCG only)
digoxin
Cardiovascular
Diuretics
DYRENIUM
amiloride, triamterene
Cardiovascular
Nitrates
isosorbide dinitrate 40 mg
isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate
Cardiovascular
Pulmonary Arterial
Hypertension
Endothelin Receptor
Antagonists
LETAIRIS
1
TRACLEER
1
ambrisentan, bosentan, OPSUMIT
Cardiovascular
Pulmonary Arterial
Hypertension
Phosphodiesterase Inhibitors
ADCIRCA
1
REVATIO
1
sildenafil, tadalafil
Cardiovascular
Pulmonary Arterial
Hypertension
Prostaglandin Vasodilators
REMODULIN
1
treprostinil
TYVASO DPI
1
Talk to your doctor
Cardiovascular
Miscellaneous
NORTHERA
1
midodrine
Carnitine Deficiency
CARNITOR
CARNITOR SF
levocarnitine
Category
Drug Class
Formulary Drug
Removals
Formulary Options
Chronic Obstructive Pulmonary
Disease (COPD)
†
Anticholinergics
INCRUSE ELLIPTA
TUDORZA
SPIRIVA
Chronic Obstructive Pulmonary
Disease (COPD)
†
Anticholinergic / Beta Agonist
Combinations
Long Acting
BEVESPI AEROSPHERE
ANORO ELLIPTA, STIOLTO RESPIMAT
Contraceptives
Oral
BALCOLTRA
BEYAZ
MINASTRIN 24 FE
SEASONIQUE
TAYTULLA
YASMIN
YAZ
ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate,
ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate,
ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,
LO LOESTRIN FE, NATAZIA
Contraceptives
Progestin Intrauterine Devices
LILETTA
1
KYLEENA, MIRENA, SKYLA
Contraceptives
Vaginal
ethinyl estradiol-etonogestrel
EluRyng
ANNOVERA, NUVARING
Cushing’s Syndrome
KORLYM
1
Talk to your doctor
Cystic Fibrosis
†
Inhaled Antibiotics
BETHKIS
1
CAYSTON
1
KITABIS PAK
1
TOBI
1
TOBI PODHALER
1
tobramycin inhalation solution
Dental
Cavity/Caries Prevention
PREVIDENT
Talk to your doctor
Depression
†
Antidepressants, Selective
Serotonin Reuptake Inhibitors
(SSRIs)
fluoxetine tablet 60 mg
paroxetine HCl ext-rel
(NDC* 60505367503 only)
LEXAPRO
PAXIL
PAXIL CR
PEXEVA
PROZAC
VIIBRYD
ZOLOFT
citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg,
fluoxetine tablet [generics for SARAFEM]), paroxetine HCl,
paroxetine HCl ext-rel (except NDC* 60505367503), sertraline, TRINTELLIX
Depression
†
Antidepressants, Serotonin
Norepinephrine Reuptake
Inhibitors (SNRIs)
venlafaxine ext-rel tablet (except 225 mg)
CYMBALTA
EFFEXOR XR
PRISTIQ
desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
Depression
†
Antidepressants,
Miscellaneous Agents
bupropion ext-rel tablet 450 mg
bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg)
Depression and/or Schizophrenia
†
Antipsychotics, Atypicals
ABILIFY
FANAPT
LATUDA
SEROQUEL XR
aripiprazole, clozapine, lurasidone, olanzapine, quetiapine, quetiapine ext-rel,
risperidone, ziprasidone, VRAYLAR
Dermatology
Acne
†
adapalene pad
clindamycin gel (NDC* 68682046275 only)
Vanoxide-HC
ACANYA
ACZONE
adapalene (except adapalene pad), benzoyl peroxide,
clindamycin gel (except NDC* 68682046275), clindamycin solution,
clindamycin-benzoyl peroxide, dapsone, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, AKLIEF, ARAZLO, EPIDUO, ONEXTON,
TWYNEO, WINLEVI
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Category
Drug Class
Formulary Drug
Removals
Formulary Options
AZELEX
DIFFERIN LOTION
FABIOR
TAZORAC
VELTIN
ZIANA
Dermatology
Actinic Keratosis
†
fluorouracil cream 0.5%
CARAC
fluorouracil cream 5%, fluorouracil solution, imiquimod, ZYCLARA
Dermatology
Anti-infective / Anti-inflammatory
NEO-SYNALAR
desonide (except desonide gel) or hydrocortisone WITH gentamicin
Dermatology
Antibiotics
mupirocin cream
gentamicin, mupirocin ointment
Dermatology
Antipsoriatics
calcipotriene cream
calcipotriene foam
calcitriol ointment
CALCIPOTRIENE FOAM
SORILUX
TAZORAC
VECTICAL
calcipotriene ointment, calcipotriene solution, VTAMA, ZORYVE
calcipotriene-betamethasone
DUOBRII
calcipotriene ointment or calcipotriene solution WITH
desoximetasone (except desoximetasone ointment 0.05%),
fluocinonide (except fluocinonide cream 0.1%) or BRYHALI; ENSTILAR, VTAMA,
ZORYVE
Dermatology
Atopic Dermatitis
†
doxepin cream
desonide (except desonide gel), hydrocortisone, pimecrolimus, tacrolimus,
EUCRISA
ELIDEL
pimecrolimus, tacrolimus, EUCRISA
Dermatology
Rosacea
†
doxycycline monohydrate delayed-rel capsule
ORACEA
ivermectin cream
FINACEA GEL
MIRVASO
NORITATE
azelaic acid gel, brimonidine gel, metronidazole, FINACEA FOAM, RHOFADE,
SOOLANTRA
Dermatology
Scars
CICATRACE
POLYTOZA
RECEDO
SCARSILK PAD
SILIVEX
SILTREX
Talk to your doctor
Dermatology
Seborrheic Dermatitis
†
ketoconazole foam 2%
Ketodan
ketoconazole shampoo 2%, selenium sulfide lotion 2.5%
Dermatology
Skin Inflammation and Hives
†
Low Potency Corticosteroids
desonide gel
DesRx
flurandrenolide cream
flurandrenolide lotion
CORDRAN CREAM
CORDRAN LOTION
desonide (except desonide gel), hydrocortisone
Dermatology
Skin Inflammation and Hives
†
Medium Potency Corticosteroids
clocortolone cream
desoximetasone ointment 0.05%
flurandrenolide ointment
hydrocortisone butyrate lipophilic cream 0.1%
hydrocortisone butyrate lotion
triamcinolone aerosol 0.2%
triamcinolone ointment 0.05%
Trianex
CORDRAN OINTMENT
hydrocortisone butyrate cream, hydrocortisone butyrate ointment,
hydrocortisone butyrate solution, mometasone, triamcinolone cream,
triamcinolone lotion, triamcinolone ointment (except triamcinolone ointment 0.05%)
-
-
-
-
Category
Drug Class
Formulary Drug
Removals
Formulary Options
Dermatology
Skin Inflammation and Hives
†
High Potency Corticosteroids
betamethasone dipropionate ointment 0.05%
diflorasone cream
diflorasone ointment
halcinonide cream
APEXICON E
HALOG
desoximetasone (except desoximetasone ointment 0.05%),
fluocinonide (except fluocinonide cream 0.1%), BRYHALI
Dermatology
Skin Inflammation and Hives
†
Very High Potency Corticosteroids
clobetasol emollient foam
clobetasol spray
fluocinonide cream 0.1%
Tovet
CLOBEX SPRAY
CORDRAN TAPE
OLUX-E
ULTRAVATE
clobetasol cream, clobetasol foam (except clobetasol emollient foam), clobetasol
gel,
clobetasol lotion, clobetasol ointment, halobetasol cream, halobetasol ointment
Dermatology
Warts
VEREGEN
imiquimod
Dermatology
Wound Care Products
ALEVICYN GEL
ALEVICYN SG
ALEVICYN SOLUTION
desonide (except desonide gel), hydrocortisone
Dermatology
Miscellaneous Skin Conditions
ATOPADERM
BENSAL HP
EPICERAM
KAMDOY
SYNERDERM
desonide (except desonide gel), hydrocortisone
luliconazole
oxiconazole
(NDCs* 00168035830, 51672135902 only)
ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, NAFTIN
Diabetes
†
Biguanides
metformin ext-rel (generics for FORTAMET
and GLUMETZA only)
FORTAMET
GLUMETZA
RIOMET
metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA)
Diabetes
†
Dipeptidyl Peptidase-4
(DPP-4) Inhibitors
NESINA
ONGLYZA
TRADJENTA
JANUVIA
Diabetes
†
Dipeptidyl Peptidase
-
4
(D
PP-4) Inhibitor Combinations
JENTADUETO
JENTADUETO XR
KAZANO
KOMBIGLYZE XR
JANUMET, JANUMET XR
OSENI
JANUMET, JANUMET XR; JANUVIA WITH pioglitazone
Diabetes
†
Injectable Incretin Mimetics
BYDUREON BCISE
BYETTA
MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, VICTOZA
Diabetes
†
Insulins
APIDRA
HUMALOG
FIASP, NOVOLOG
HUMALOG MIX 50/50
NOVOLOG MIX 70/30
HUMALOG MIX 75/25
NOVOLOG MIX 70/30
HUMULIN 70/30
5
NOVOLIN 70/30
5
HUMULIN N
5
NOVOLIN N
5
HUMULIN R
5
NOVOLIN R
5
NOTE: Humulin R U-500 concentrate will not
be subject to removal and will continue to be
covered.
-
-
-
-
-
-
- -
Category
Drug Class
Formulary Drug
Removals
Formulary Options
Diabetes
†
Long Acting Insulins
6
LANTUS
BASAGLAR, LEVEMIR
Diabetes
†
Insulin Sensitizers
ACTOS
pioglitazone
Diabetes
†
Sodium-Glucose
Co-transporter 2 (SGLT2) Inhibitors
INVOKANA
FARXIGA, JARDIANCE
Diabetes
†
Sodium-Glucose
Co-transporter 2 (SGLT2) Inhibitor /
Biguanide Combinations
INVOKAMET
INVOKAMET XR
SYNJARDY, SYNJARDY XR, XIGDUO XR
Diabetes
†
Sodium-Glucose
Co-transporter 2 (SGLT2) Inhibitor /
Dipeptidyl Peptidase-4 (DPP-4)
Inhibitor Combinations
QTERN
GLYXAMBI
Diabetes
†
Supplies, Needles
7
NOVO NORDISK NEEDLES
OWEN MUMFORD NEEDLES
PERRIGO NEEDLES
ULTIMED NEEDLES
All other insulin needles that are not
BD ULTRAFINE brand
BD ULTRAFINE NEEDLES
Diabetes
†
Supplies, Syringes
7
ALLISON MEDICAL INSULIN SYRINGES
TRIVIDIA INSULIN SYRINGES
ULTIMED INSULIN SYRINGES
All other insulin syringes that are not
BD ULTRAFINE brand
BD ULTRAFINE INSULIN SYRINGES
Diabetes
†
Supplies, Test Strips and Kits
8, 9
BREEZE 2 STRIPS AND KITS
CONTOUR NEXT STRIPS AND KITS
CONTOUR STRIPS AND KITS
FREESTYLE STRIPS AND KITS
All other test strips that are not
ACCU-CHEK or ONETOUCH brand
ACCU-CHEK AVIVA PLUS STRIPS AND KITS
8
,
ACCU-CHEK GUIDE STRIPS AND KITS
8
,
ACCU-CHEK SMARTVIEW STRIPS AND KITS
8
,
ONETOUCH ULTRA STRIPS AND KITS
8
,
ONETOUCH VERIO STRIPS AND KITS
8
ENLITE CONTINUOUS
GLUCOSE MONITORING SYSTEM
EVERSENSE CONTINUOUS
GLUCOSE MONITORING SYSTEM
FREESTYLE LIBRE CONTINUOUS
GLUCOSE MONITORING SYSTEM
GUARDIAN CONNECT CONTINUOUS
GLUCOSE MONITORING SYSTEM
GUARDIAN REAL-TIME CONTINUOUS
GLUCOSE MONITORING SYSTEM
All other continuous glucose
monitoring systems that are
not DEXCOM brand
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
Dietary Supplements
FOSTEUM
FOSTEUM PLUS
alendronate, ibandronate, risedronate
Activite
10
Dexifol
10
Genicin Vita-S
10
HylaVite
10
MultiPro
10
TronVite
10
Vitasure
10
FERIVA 21/7
10
FLORIVA
10
generic multivitamins
-
-
Category
Drug Class
Formulary Drug
Removals
Formulary Options
FLORIVA PLUS
10
NICADAN
10
NICAPRIN
10
NICAZEL
10
NICAZEL FORTE
10
NICOMIDE
10
POLY-VI-FLOR
10
POLY-VI-FLOR WITH IRON
10
RHEUMATE
10
TALIVA
10
TRI-VI-FLOR
10
XYZBAC
10
All other brand multivitamins
10
Folvite-D
10
ORTHO D
10
ORTHO DF
10
folic acid, generic multivitamins
VASCULERA
Talk to your doctor
Endocrine and Metabolic
Corticosteroids
prednisolone solution 10 mg/5 mL
prednisolone solution 20 mg/5 mL
Millipred
BETAMETHASONE ACETATE
-
BETAMETHASONE SODIUM
PHOSPHATE
RAYOS
dexamethasone, hydrocortisone, methylprednisolone,
prednisolone solution (except prednisolone solution 10 mg/5 mL, 20 mg/5 mL),
prednisone
Endocrine and Metabolic
Hereditary Tyrosinemia Type 1
Agents
NITYR
1
ORFADIN
Endocrine and Metabolic
Potassium-Removing Agents
LOKELMA
VELTASSA
Endocrine and Metabolic
Progestins
PROMETRIUM
medroxyprogesterone; progesterone, micronized
Endocrine and Metabolic
Severe Hypoglycemia
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
glucagon, human recombinant; BAQSIMI; GVOKE; ZEGALOGUE
Endocrine and Metabolic
Vasopressin Receptor Antagonists
JYNARQUE
1
Talk to your doctor
Endocrine and Metabolic
Miscellaneous
CARBAGLU
1
carglumic acid
CYSTADANE
1
betaine
Endometriosis
†
ZOLADEX
1
MYFEMBREE, ORILISSA
Erectile Dysfunction
†
Phosphodiesterase Inhibitors
CIALIS
STENDRA
VIAGRA
sildenafil, tadalafil
Fertility Regulators
Follicle-Stimulating Hormones
FOLLISTIM AQ
1
GONAL-F
CHORIONIC GONADOTROPIN
1
NOVAREL
1
PREGNYL
1
OVIDREL
Gastrointestinal
Anticholinergics
chlordiazepoxide-clidinium
(NDCs* 11534019701, 42494040901,
51293069601, 51293069610,
67877073101,
70700018501 only)
hyoscyamine sulfate ext-rel
GLYCOPYRROLATE TABLET 1.5 MG
LIBRAX
dicyclomine
-
Category
Drug Class
Formulary Drug
Removals
Formulary Options
Gastrointestinal
Antidiarrheals
ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG
MYTESI
diphenoxylate-atropine, loperamide
Gastrointestinal
Antiemetics
TRANSDERM SCOP
meclizine, scopolamine transdermal
Gastrointestinal
Irritable Bowel Syndrome
†
AMITIZA
lubiprostone, LINZESS, SYMPROIC
Gastrointestinal
Laxatives
LACTULOSE PAK
lactulose solution
peg 3350-electrolytes
(generics for MOVIPREP only)
GOLYTELY
MOVIPREP
OSMOPREP
SUPREP
peg 3350-electrolytes (except generics for MOVIPREP), CLENPIQ
Gastrointestinal
Opioid-Induced Constipation
MOVANTIK
lubiprostone, SYMPROIC
Gastrointestinal
Probiotics
ZELAC
Talk to your doctor
Gastrointestinal
Proton Pump Inhibitors (PPIs)
dexlansoprazole delayed-rel
lansoprazole delayed-rel
orally disintegrating tablet
omeprazole-sodium bicarbonate
pantoprazole delayed-rel suspension
ACIPHEX
ACIPHEX SPRINKLE
DEXILANT
NEXIUM
PREVACID
PRILOSEC
PROTONIX
ZEGERID
esomeprazole delayed-rel, lansoprazole delayed-rel capsule,
omeprazole delayed-rel, pantoprazole delayed-rel tablet
Gastrointestinal
Ulcer Treatment
sucralfate suspension
CARAFATE
sucralfate tablet
Gaucher Disease
ELELYSO
1
CERDELGA, CEREZYME
Genitourinary
Interstitial Cystitis
ELMIRON
RIMSO-50
Talk to your doctor
Genitourinary
Miscellaneous
LITHOSTAT
Talk to your doctor
THIOLA
1
THIOLA EC
1
tiopronin
Gout
†
colchicine capsule
COLCRYS
colchicine tablet, MITIGARE
ULORIC
allopurinol
Growth Hormones
HUMATROPE
1
NUTROPIN AQ
1
OMNITROPE
1
SAIZEN
1
GENOTROPIN, NORDITROPIN
Hematologic
Anticoagulants
Injectable
HEPARIN SODIUM IN 5% DEXTROSE
enoxaparin, fondaparinux
-
Category
Drug Class
Formulary Drug
Removals
Formulary Options
Hematologic
Anticoagulants
Oral
PRADAXA warfarin, ELIQUIS, XARELTO
Hematologic
Chelating Agents
CUPRIMINE
1
penicillamine
DESFERAL
1
EXJADE
1
FERRIPROX
1
JADENU
1
deferasirox, deferiprone, deferoxamine
SYPRINE
1
trientine
Hematologic
Erythropoiesis-Stimulating Agents
EPOGEN
1
ARANESP, PROCRIT, RETACRIT
Hematologic
Hemophilia B
BENEFIX
1
IXINITY
1
RIXUBIS
1
ALPROLIX, REBINYN
Hematologic
Miscellaneous Bleeding Disorders
Agents
FEIBA
1
NOVOSEVEN RT, SEVENFACT
Hematologic
Neutropenia Colony
Stimulating Factors
FULPHILA
1
NEULASTA
1
NEULASTA ONPRO
1
UDENYCA
1
ZIEXTENZO
GRANIX
1
LEUKINE
1
NEUPOGEN
1
ZARXIO
1
NIVESTYM
Hematologic
Platelet Aggregation Inhibitors
PLAVIX
clopidogrel, prasugrel, BRILINTA
ZONTIVITY
Talk to your doctor
NPLATE
1
DOPTELET, PROMACTA, TAVALISSE
High Blood Pressure
†
ACE Inhibitors
EPANED
enalapril, fosinopril, lisinopril, quinapril, ramipril
High Blood Pressure
†
ACE Inhibitor / Diuretic
Combinations
ZESTORETIC
fosinopril-hydrochlorothiazide, lisinopril-hydrochlorothiazide,
quinapril-hydrochlorothiazide
High Blood Pressure
†
Angiotensin II Receptor
Antagonists
ATACAND
BENICAR
COZAAR
DIOVAN
EDARBI
MICARDIS
candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan
High Blood Pressure
†
Angiotensin II Receptor
Antagonist / Diuretic Combinations
ATACAND HCT
BENICAR HCT
DIOVAN HCT
EDARBYCLOR
HYZAAR
MICARDIS HCT
candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide,
losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide,
telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide
High Blood Pressure
†
Angiotensin II Receptor
Antagonist / Calcium Channel
Blocker Combinations
AZOR
EXFORGE
amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan
-
Category
Drug Class
Formulary Drug
Removals
Formulary Options
High Blood Pressure
†
Angiotensin II Receptor
Antagonist / Calcium Channel
Blocker / Diuretic Combinations
EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-
hydrochlorothiazide
High Blood Pressure
†
Beta-blockers
BYSTOLIC
COREG CR
INDERAL LA
INDERAL XL
INNOPRAN XL
TOPROL-XL
atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel,
metoprolol tartrate, nadolol, nebivolol, pindolol, propranolol, propranolol ext-rel
High Blood Pressure
†
Calcium Channel Blockers
NORVASC
amlodipine
diltiazem ext-rel
(generics for CARDIZEM LA only)
Matzim LA
CARDIZEM
CARDIZEM CD
CARDIZEM LA
diltiazem ext-rel (except generics for CARDIZEM LA)
Huntington's Disease
XENAZINE
1
tetrabenazine, AUSTEDO, AUSTEDO XR
Immunology
Disease Modifying Antirheumatic
Agents
OTREXUP
1
RASUVO
Immunology
Hereditary Angioedema
BERINERT
1
FIRAZYR
1
icatibant, RUCONEST
CINRYZE
1
ORLADEYO, TAKHZYRO
Immunology
Miscellaneous
ARCALYST
1
ILARIS
Inflammatory Bowel Disease (IBD)
Ulcerative Colitis
†
budesonide ext-rel tablet
ASACOL HD
COLAZAL
DELZICOL
LIALDA
PENTASA
balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine,
sulfasalazine delayed-rel
Interferons
†
PEGASYS
1
Talk to your doctor
Kidney Disease
†
Phosphate Binders
lanthanum carbonate
FOSRENOL
RENVELA
calcium acetate, sevelamer carbonate, AURYXIA, VELPHORO
Menopausal Symptom Agents
Oral
paroxetine mesylate capsule 7.5 mg
paroxetine HCl
MENEST
OSPHENA
PREMARIN
estradiol
Menopausal Symptom Agents
Transdermal
CLIMARA (except CLIMARA PRO)
MINIVELLE
VIVELLE-DOT
estradiol, DIVIGEL, EVAMIST
Menopausal Symptom Agents
Vaginal
estradiol vaginal tablet
Yuvafem
ESTRING
FEMRING
INTRAROSA
PREMARIN CREAM
estradiol vaginal cream, IMVEXXY, VAGIFEM
Multiple Sclerosis
AUBAGIO
1
EXTAVIA
1
GILENYA
1
dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AVONEX,
BETASERON, COPAXONE, KESIMPTA, MAYZENT, OCREVUS, REBIF,
TYSABRI, VUMERITY, ZEPOSIA
-
- -
-
-
Category
Drug Class
Formulary Drug
Removals
Formulary Options
LEMTRADA
1
TECFIDERA
1
Musculoskeletal
carisoprodol 250 mg
chlorzoxazone 250 mg
chlorzoxazone 375 mg
chlorzoxazone 500 mg
(NDC* 73007001303 only)
chlorzoxazone 750 mg
cyclobenzaprine ext-rel capsule
cyclobenzaprine tablet 7.5 mg
metaxalone 400 mg
methocarbamol 500 mg
(NDC* 69036091010 only)
methocarbamol 750 mg
(NDCs* 69036093090, 70868090190 only)
orphenadrine-aspirin-caffeine
Fexmid
Lorzone
Orphengesic Forte
AMRIX
NORGESIC FORTE
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
Narcolepsy
Wakefulness Promoters
NUVIGIL
PROVIGIL
armodafinil, modafinil, SUNOSI, WAKIX, XYWAV
Nephropathic Cystinosis
PROCYSBI
1
CYSTAGON
Ophthalmic
Allergies
ALREX
BEPREVE
LASTACAFT
ZERVIATE
azelastine, bepotastine, cromolyn sodium, olopatadine
Ophthalmic
Anti-infectives
AZASITE
CILOXAN
ciprofloxacin, erythromycin, gentamicin, levofloxacin, moxifloxacin, ofloxacin,
sulfacetamide, tobramycin, BESIVANCE
Ophthalmic
Anti-infective / Anti-inflammatory
TOBRADEX ST
ZYLET
neomycin-polymyxin B-bacitracin-hydrocortisone,
neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone,
TOBRADEX OINTMENT
Ophthalmic
Anti-inflammatory, Nonsteroidal
ACUVAIL
BROMSITE
NEVANAC
bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA
Ophthalmic
Anti-inflammatory, Steroidal
FLAREX
FML FORTE
FML LIQUIFILM
INVELTYS
LOTEMAX
LOTEMAX SM
MAXIDEX
PRED FORTE
PRED MILD
dexamethasone, difluprednate, loteprednol, prednisolone acetate 1%
Ophthalmic
Antivirals
ZIRGAN
trifluridine
Ophthalmic
Artificial Tears
LACRISERT
RESTASIS, XIIDRA
Ophthalmic
Glaucoma
LUMIGAN
RHOPRESSA
ROCKLATAN
TRAVATAN Z
VYZULTA
bimatoprost, latanoprost, travoprost, ZIOPTAN
BETIMOL
TIMOPTIC OCUDOSE
timolol maleate solution, BETOPTIC S
- -
Category
Drug Class
Formulary Drug
Removals
Formulary Options
COMBIGAN brimonidine-timolol
Ophthalmic
Miscellaneous
AVENOVA
Talk to your doctor
Opioid Dependency
SUBOXONE
buprenorphine-naloxone sublingual, ZUBSOLV
Osteoarthritis
†
Viscosupplements
GEL-ONE
1
HYALGAN
1
MONOVISC
1
ORTHOVISC
1
SYNVISC
1
SYNVISC-ONE
1
VISCO-3
1
DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
Osteoporosis
†
Calcium Regulators
MIACALCIN INJECTION
alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA,
TYMLOS
Otic
Anti-infective / Anti-inflammatory
ciprofloxacin-fluocinolone
CIPRO HC
CIPRODEX
ciprofloxacin-dexamethasone, ofloxacin otic
Overactive Bladder / Incontinence
†
Urinary Antispasmodics
DETROL LA
MYRBETRIQ
OXYTROL
TOVIAZ
darifenacin ext-rel, fesoterodine ext-rel, oxybutynin ext-rel, solifenacin, tolterodine,
tolterodine ext-rel, trospium, trospium ext-rel, GEMTESA
Pain
Headache
†
butalbital-acetaminophen capsule
butalbital-acetaminophen tablet 25-325 mg
butalbital-acetaminophen tablet 50-300 mg
butalbital-acetaminophen-caffeine capsule
diclofenac potassium powder
Bupap
BUTALBITAL-ACETAMINOPHEN
(NDC* 69499034230 only)
CAMBIA
FIORICET CAPSULE
diclofenac sodium, ibuprofen,
naproxen (except naproxen CR or naproxen suspension)
dihydroergotamine spray
ergotamine-caffeine
Migergot
CAFERGOT
MAXALT
MAXALT-MLT
eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT,
ONZETRA XSAIL, UBRELVY, ZEMBRACE SYMTOUCH
sumatriptan-naproxen
TREXIMET
diclofenac sodium, ibuprofen or naproxen (except naproxen CR or
naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan,
zolmitriptan, NURTEC ODT, ONZETRA XSAIL, UBRELVY or
ZEMBRACE SYMTOUCH
Pain
Neuropathic Pain
†
LYRICA
duloxetine, pregabalin, pregabalin ext-rel
Pain
Opioid Analgesics
BUTRANS
buprenorphine transdermal, BELBUCA
SUBSYS
fentanyl transmucosal lozenge
levorphanol
oxymorphone ext-rel
HYSINGLA ER
NUCYNTA ER
OXYCONTIN
fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel, methadone,
morphine ext-rel, XTAMPZA ER
NUCYNTA
hydromorphone, morphine, oxycodone
PERCOCET
hydrocodone-acetaminophen, oxycodone-acetaminophen
tramadol (NDC* 52817019610 only)
tramadol ext-rel capsule
tramadol (except NDC* 52817019610), tramadol ext-rel tablet
Category
Drug Class
Formulary Drug
Removals
Formulary Options
Pain and Inflammation
†
Nonsteroidal Anti-inflammatory
Drugs (NSAIDs) / Combinations
ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam tablet or
naproxen (except naproxen CR or naproxen suspension) WITH
esomeprazole delayed-rel, lansoprazole delayed-rel capsule,
omeprazole delayed-rel, or pantoprazole delayed-rel tablet
CELEBREX celecoxib, diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (exce
pt
naproxen CR or naproxen suspension)
diclofenac sodium solution 2%
Capsi
nac
Diclofex DC
Diclosaicin
Iclofenac CP
Inflammacin
Kapzin DC
NuDiclo SoluPak
NuDiclo TabPak
Pennsaicin
Sure Result DSS Premium Pack
Ziclocin Pak
Ziclopro
PENNSAID
diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution 1.5%,
ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen
suspension)
diclofenac potassium capsule 25 mg
diclofenac
potassium tablet 25 mg
fenoprofen
indomethacin capsule 20 mg
ketoprofen capsule 25 mg
ketoprofen ext-rel capsule
mefenamic acid (NDC* 69336012830 only)
meloxicam capsule
naproxen CR
naproxen suspension
Lofena
FENOPROFEN CAPSULE
INDOCIN
NAPRELAN
SPRIX
ZORVOLEX
diclofenac sodium, ibuprofen, meloxicam tablet,
naproxen (except naproxen CR or naproxen suspension)
naproxen-esomeprazole
diclofenac sodium, ibuprofen, meloxicam tablet or naproxen (except naproxen CR
or naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel
capsule, omeprazole delayed-rel, or pantoprazole delayed-rel tablet
Parkinson's Disease
APOKYN
1
INBRIJA, KYNMOBI
NOURIANZ entacapone, pr
amipexole, pramipexole ext-rel, rasagiline, ropinirole,
ropinirole ext-rel, selegiline, NEUPRO
Phenylketonuria
KUVAN
1
sapropterin
Postherpetic Neuralgia
HORIZANT gabapentin, pregabalin, pregabalin ext-rel, GRALISE
Premenstrual Dysphoric Disorder
(PMDD)
fluoxetine tablet (generics for SARAFEM
only)
fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for
SARAFEM]), paroxetine HCl ext-rel (except NDC* 60505367503), sertraline
Prenatal Vitamins
11
AZESCO
CITRANATAL
PRENATAL PLUS
VITAFOL-ONE
ZALVIT
All other brand prenatal vitamins
generic prenatal vitamins
Prostate Condition
Benign Prostatic Hyperplasia
†
JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin,
silodosin, tamsulosin or terazosin
RAPAFLO
UROXATRAL
alf
uzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
Category
Drug Class
Formulary Drug
Removals
Formulary Options
Pseudobulbar Affect
NUEDEXTA Talk to your doctor
Respiratory
Alpha-1 Antitrypsin Deficiency
ARALAST NP
1
GLASSIA
1
PROLASTIN-C, ZEMAIRA
Respiratory
Anaphylaxis Treatment Agents
ADRENALIN
SYMJEPI
epinephrine, AUVI-Q, EPIPEN, EPIPEN JR
Respiratory
Cough
benzonatate
(NDCs* 69336012615, 69499032915 only)
benzonatate (except NDCs* 69336012615, 69499032915)
Respiratory
Idiopathic Pulmonary Fibrosis
ESBRIET
1
pirfenidone, OFEV
Respiratory
Phosphodiesterase-4 Inhibitors
DALIRESP roflumilast
Respiratory
Xanthines
THEO-24 formoterol inhalation solution, ipratropium inhalation solution, SEREVENT,
SPIRIVA,
STRIVERDI RESPIMAT, YUPELRI
Sleep Disorder
Hypnotics, Non-benzodiazepines
quazepam
zolpidem sublingual
EDLUAR
LUNESTA
ROZEREM
SILENOR
ZOLPIMIST
doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, BELSOMRA,
DAYVIGO
Testosterone Replacement
†
Androgens
testosterone gel 1% (authorized generics for
TESTIM and VOGELXO only)
ANDROGEL
FORTESTA
TESTIM
VOGELXO
testosterone gel (except authorized generics for TESTIM and VOGELXO),
testosterone solution, NATESTO
Thyroid Supplements
CYTOMEL levothyroxine, liothyronine, SYNTHROID
TIROSINT levoth
yroxine, SYNTHROID
Urea Cycle Disorders
BUPHENYL
1
RAVICTI
1
sodium phenylbutyrate
Category
Drug Class
Other Considerations
All Drugs
On a quarterly basis, new and existing products - including limited source generics, products with significant cost inflation, and
specialty and non-specialty products - may be re-evaluated to determine appropriate formulary placement. These evaluations will
assess whether clinically appropriate and cost-effective options remain available on the formulary and may result in removal,
addition or deletion of a product.
Atopic Dermatitis
†
As new atopic dermatitis products launch, all existing products in the class will be re-evaluated to determine appropriate formulary
placement. These evaluations will assess whether clinically appropriate and cost-effective options are available on the formulary and
may result in removal, addition or deletion of a product on the first day of any calendar month.
Autoimmune and Hepatitis C
†
For some clients, an Indication-Based Formulary will be utilized for products in these classes and may result in additional removals
for certain conditions only.
Drugs for Infusion Into Spaces
Other Than the Blood
A drug that must be infused into a space other than the blood will generally not be covered under the prescription drug benefit.
New-to-Market Agents
1
New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately.
Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be
presented to the CVS Caremark
®
National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review
and approval.
The listed formulary options ar
e subject to change.
List of Formulary Drug Removals
ABILIFY
ACANYA
ACIPHEX
ACIPHEX SPRINKLE
ACTEMRA ACTPEN
1
ACTEMRA INTRAVENOUS
1
ACTEMRA SUBCUTANEOUS
1
Activite
10
ACTOS
ACUVAIL
acyclovir cream
ACZONE
adapalene pad
ADCIRCA
1
ADDERALL
ADDERALL XR
ADRENALIN
ADZENYS XR-ODT
AFINITOR
1
AFINITOR DISPERZ
1
albuterol sulfate CFC-free aerosol
(NDC* 66993001968 only)
ALEVICYN GEL
ALEVICYN SG
ALEVICYN SOLUTION
ALIMTA
ALIQOPA
1
ALLISON MEDICAL INSULIN SYRING
ALREX
ALTOPREV
ALVESCO
AMITIZA
AMRIX
ANDROGEL
APEXICON E
APIDRA
APOKYN
1
APTENSIO XR
APTIVUS
1
ARALAST NP
1
ARCALYST
1
ARNUITY ELLIPTA
ARTHROTEC
ASACOL HD
ASMANEX
ES
7
ASMANEX HFA
ATACAND
ATACAND HCT
ATIVAN
ATO
PADERM
AUBAGIO
1
AVASTIN
1
AVENOVA
AVSOLA
1
AZASITE
AZELEX
AZESCO
11
AZOR
BALCOLTRA
BANZEL
BARACLUDE TABLET
1
BECONASE AQ
BENEFIX
1
BENICAR
BENICAR HCT
BENSAL HP
benzonatate (NDCs* 69336012615, 69499032915 only)
BEPREVE
BERINERT
1
BETAMETHASONE ACETATE-
BETAMETHASONE SODIUM PHOSPHATE
betamethasone dipropionate ointment 0.05%
BETAPACE
BETAPACE AF
BETHKIS
1
BETIMOL
BEVESPI AEROSPHERE
BEYAZ
BORTEZOMIB
1
BOTOX
1
BREEZE 2 STRIPS AND KITS
9
BROMSITE
budesonide ext-rel tablet
Bupap
BUPHENYL
1
bupropion ext-rel tablet 450 mg
butalbital-acetaminophen capsule
butalbital-acetaminophen tablet 25-325 mg
butalbital-acetaminophen tablet 50-300 mg
BUTALBITAL-ACETAMINOPHEN
(NDC* 69499034230 only)
butalbital-acetaminophen-caffeine capsule
BUTRANS
BYDUREON BCISE
BYETTA
BYSTOLIC
CAFERGOT
calcipotriene cream
calcipotriene foam
CALCIPOTRIENE FOAM
calcipotriene-betamethasone
calcitriol ointment
CAMBIA
Capsinac
CARAC
CARAFATE
CARBAGLU
1
CARBINOXAMINE TABLET 6 MG
CARDIZEM
CARDIZEM CD
CARDIZEM LA
carisoprodol 250 mg
CARNITOR
CARNITOR SF
CAYSTON
1
CELEBREX
chlordiazepoxide-clidinium (NDCs* 11534019701,
42494040901, 51293069601, 51293069610,
67877073101, 70700018501 only)
chlorzoxazone 250 mg
chlorzoxazone 375 mg
chlorzoxazone 500 mg (NDC* 73007001303 only)
chlorzoxazone 750 mg
CHORIONIC GONADOTROPIN
1
CIALIS
CICATRACE
CILOXAN
CIMZIA LYOPHILIZED POWDER
1
CINRYZE
1
CIPRO HC
CIPRODEX
ciprofloxacin-fluocinolone
CITRANATAL
11
CLIMARA (except CLIMARA PRO)
clindamycin gel (NDC* 68682046275 only)
clobetasol emollient foam
clobetasol spray
CLOBEX SPRAY
clocortolone cream
COLAZAL
colchicine capsule
COLCRYS
COMBIGAN
COMPLERA
1
CONCERTA
CONTOUR NEXT STRIPS AND KITS
9
CONTOUR STRIPS AND KITS
9
CONTRAVE
CORDRAN CREAM
CORDRAN LOTION
CORDRAN OINTMENT
CORDRAN TAPE
COREG CR
CoreMino
COZAAR
CRESEMBA
CRESTOR
CUPRIMINE
1
cyclobenzaprine ext-rel capsule
cyclobenzaprine tablet 7.5 mg
CYMBALTA
CYSTADANE
1
CYTOMEL
DALIRESP
DARAPRIM
DAYTRANA
DELZICOL
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
DESFERAL
1
desonide gel
desoximetasone ointment 0.05%
DesRx
DETROL LA
dexchlorpheniramine
Dexifol
10
DEXILANT
dexlansoprazole delayed-rel
DIACOMIT
1
diclofenac potassium capsule 25 mg
diclofenac potassium powder
diclofenac potassium tablet 25 mg
diclofenac sodium solution 2%
Diclofex DC
Diclosaicin
DIFFERIN LOTION
diflorasone cream
diflorasone ointment
dihydroergotamine spray
DILANTIN
diltiazem ext-rel (generics for CARDIZEM LA only)
DIOVAN
DIOVAN HCT
Diphen Elixir
DORYX
DORYX MPC
doxepin cream
doxycycline hyclate delayed-rel tablet
doxycycline hyclate tablet 50 mg
doxycycline hyclate tablet 75 mg
doxycycline hyclate tablet 150 mg
doxycycline monohydrate capsule 75 mg
doxycycline monohydrate capsule 150 mg
doxycycline monohydrate delayed-rel capsule
DULERA
DUOBRII
DYANAVEL XR
DYMISTA
DYRENIUM
EDARBI
EDARBYCLOR
EDLUAR
E.E.S. GRANULES
EFFEXOR XR
ELELYSO
1
ELIDEL
ELMIRON
EluRyng
ENLITE CONTINUOUS
GLUCOSE MONITORING
SYSTEM
ENTERAGAM
ENTYVIO (For Crohn's Disease Only)
1
EPANED
EPICERAM
EPIVIR HBV
1
EPOGEN
1
ergotamine-caffeine
ERYPED
ESBRIET
1
estradiol vaginal tablet
ESTRING
ethinyl estradiol-etonogestrel
EVEKEO
EVERSENSE CONTINUOUS
GLUCOSE MONITORING SYSTEM
EXFORGE
EXFORGE HCT
EXJADE
1
EXTAVIA
1
FABIOR
FANAPT
FEIBA
1
FEMRING
fenofibrate capsule 30 mg
fenofibrate capsule 50 mg
fenofibrate capsule 90 mg
fenofibrate capsule 130 mg
fenofibrate tablet 40 mg
fenofibrate tablet 120 mg
FENOGLIDE TABLET 120 MG
fenoprofen
FENOPROFEN CAPSULE
FERIVA 21/7
10
FERRIPROX
1
Fexmid
FINACEA GEL
FINTEPLA
1
FIORICET CAPSULE
FIRAZYR
1
FIRMAGON
1
FLAREX
FLORIVA
10
FLORIVA PLUS
10
FLOVENT DISKUS
FLOVENT HFA
flucytosine capsule 500 mg
fluocinonide cream 0.1%
fluorouracil cream 0.5%
fluoxetine tablet (generics for SARAFEM only)
fluoxetine tablet 60 mg
flurandrenolide cream
flurandrenolide lotion
flurandrenolide ointment
FML FORTE
FML LIQUIFILM
FOCALIN XR
FOLLISTIM AQ
1
Folvite-D
10
FORTAMET
FORTESTA
FOSRENOL
FOSTEUM
FOSTEUM PLUS
FREESTYLE LIBRE CONTINUOUS
GLUCOSE MONITORING SYSTEM
FREESTYLE STRIPS AND KITS
9
FULPHILA
1
GEL-ONE
1
Genicin Vita-S
10
GILENYA
1
GLASSIA
1
GLEEVEC
1
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
GLUMETZA
GLYCOPYRROLATE TABLET 1.5 MG
GOLYTELY
GRANIX
1
GUARDIAN CONNECT CONTINUOUS
GLUCOSE MONITORING SYSTEM
GUARDIAN REAL-TIME CONTINUOUS
GLUCOSE MONITORING SYSTEM
halcinonide cream
HALOG
HEPARIN SODIUM IN 5% DEXTROSE
HERCEPTIN
1
HERCEPTIN HYLECTA
1
HORIZANT
HUMALOG
HUMALOG MIX 50/50
HUMALOG MIX 75/25
HUMATROPE
1
HUMULIN 70/30
5
HUMULIN N
5
HUMULIN R
5
HYALGAN
1
hydrocortisone butyrate lipophilic cream 0.1%
hydrocortisone butyrate lotion
HylaVite
10
hyoscyamine sulfate ext-rel
HYSINGLA ER
HYZAAR
Iclofenac CP
ICLUSIG
1
icosapent ethyl
INCRUSE ELLIPTA
INDERAL LA
INDERAL XL
INDOCIN
indomethacin capsule 20 mg
Inflammacin
INFLECTRA
1
INNOPRAN XL
INTRAROSA
INTUNIV
INVELTYS
INVOKAMET
INVOKAMET XR
INVOKANA
isosorbide dinitrate 40 mg
ivermectin cream
IXINITY
1
JADENU
1
JALYN
JENTADUETO
JENTADUETO XR
JORNAY PM
JUXTAPID
1
JYNARQUE
1
KAMDOY
Kapzin DC
KAZANO
KEPPRA
KEPPRA XR
ketoconazole foam 2%
Ketodan
ketoprofen capsule 25 mg
ketoprofen ext-rel capsule
KINERET
1
KITABIS PAK
1
KOMBIGLYZE XR
KORLYM
1
KUVAN
1
KYPROLIS
1
LACRISERT
LACTULOSE PAK
LAMICTAL
LAMICTAL ODT
LAMICTAL XR
LANOXIN TABLET (125 MCG and 250 MCG only)
lansoprazole delayed-rel orally disintegrating tablet
lanthanum carbonate
LANTUS
LASTACAFT
LATUDA
LEMTRADA
1
LESCOL XL
LETAIRIS
1
LEUKINE
1
levorphanol
LEXAPRO
LEXIVA
1
LIALDA
LIBRAX
LILETTA
1
LIPITOR
LITHOSTAT
LIVALO
Lofena
LOKELMA
Lorzone
LO
TEMAX
LOTEMAX SM
LOVAZA
luliconazole
LUMIGAN
LUNESTA
LUPRON DEPOT
1
LYRICA
MACRODANTIN
Matzim LA
MAVYRET
1
MAXALT
MAXALT-MLT
MAXIDEX
mefenamic acid (NDC* 69336012830 only)
MEKINIST
1
meloxicam capsule
MENEST
metaxalone 400 mg
metformin ext-rel
(generics for FORTAMET and GLUMETZA only)
methocarbamol 500 mg (NDC* 69036091010 only)
methocarbamol 750 mg
(NDCs* 69036093090, 70868090190 only)
MIACALCIN INJECTION
MICARDIS
MICARDIS HCT
Migergot
Millipred
MINASTRIN 24 FE
MINIVELLE
minocycline ext-rel
MIRVASO
Mondoxyne NL capsule 75 mg
MONOVISC
1
MOVANTIK
MOVIPREP
MULTAQ
MultiPro
10
mupirocin cream
MYDAYIS
MYRBETRIQ
MYTESI
NAPRELAN
naproxen CR
naproxen suspension
naproxen-esomeprazole
NEO-SYNALAR
NESINA
NEULASTA
1
NEULASTA ONPRO
1
NEUPOGEN
1
NEVANAC
NEXIUM
NEXTERONE
niacin tablet 500 mg
Niacor
NICADAN
10
NICAPRIN
10
NICAZEL
10
NICAZEL FORTE
10
NICOMIDE
10
NILANDRON
nitrofurantoin (NDC* 16571074024 only)
NITYR
1
NORGESIC FORTE
NORITATE
NORPACE
NORTHERA
1
NORVASC
NOURIANZ
NOVAREL
1
NOVO NORDISK NEEDLES
7
NOXAFIL
NPLATE
1
NUCALA LYOPHILIZED POWDER
1
NUCYNTA
NUCYNTA ER
NuDiclo SoluPak
NuDiclo TabPak
NUEDEXTA
NUTROPIN AQ
1
NUVIGIL
OLUX-E
omeprazole-sodium bicarbonate
OMNARIS
OMNITROPE
1
ONFI
ONGLYZA
ORENCIA INTRAVENOUS
1
orphenadrine-aspirin-caffeine
Orphengesic Forte
ORTHO D
10
ORTHO DF
10
ORTHOVISC
1
OSENI
OSMOPREP
OSPHENA
OTREXUP
1
OWEN MUMFORD NEEDLES
7
oxiconazole (NDCs* 00168035830, 51672135902 only)
OXYCONTIN
oxymorphone ext-rel
OXYTROL
pantoprazole delayed-rel suspension
paroxetine HCl ext-rel (NDC* 60505367503 only)
paroxetine mesylate capsule 7.5 mg
PAXIL
PAXIL CR
peg 3350-electrolytes (generics for MOVIPREP only)
PEGASYS
1
Pennsaicin
PENNSAID
PENTASA
PERCOCET
PERRIGO NEEDLES
7
PEXEVA
PLAVIX
POLYTOZA
POLY-VI-FLOR
10
POLY-VI-FLOR WITH IRON
10
posaconazole delayed-rel tablet
PRADAXA
PRALUENT
1
PRED FORTE
PRED MILD
prednisolone solution 10 mg/5 mL
prednisolone solution 20 mg/5 mL
PREGNYL
1
PREMARIN
PREMARIN CREAM
PRENATAL PLUS
11
PREVACID
PREVIDENT
PRILOSEC
PRISTIQ
PROAIR HFA
PROAIR RESPICLICK
PROCYSBI
1
PROMETRIUM
PROTONIX
PROVENTIL HFA
PROVIGIL
PROZAC
QNASL
QTERN
quazepam
QUILLICHEW ER
QUILLIVANT XR
QVAR REDIHALER
3
RAPAFLO
RAVICTI
1
RAYOS
RECEDO
REMODULIN
1
RENFLEXIS
1
RENVELA
REVATIO
1
RHEUMATE
10
RHOPRESSA
RIABNI
1
RIMSO-50
RIOMET
RITUXAN
1
RIXUBIS
1
ROCKLATAN
ROZEREM
RUBRACA
1
RyClora
SABRIL
1
SAIZEN
1
SANDOSTATIN LAR
1
SCARSILK PAD
SEASONIQUE
SELZENTRY
1
SEROQUEL XR
SIGNIFOR LAR
1
SILENOR
SILIVEX
SILTREX
SIMPONI
1
SINGULAIR
SOMAVERT
1
SORILUX
SPRIX
STENDRA
STRIBILD
1
SUBOXONE
SUBSYS
sucralfate suspension
sumatriptan-naproxen
SUPREP
Sure Result DSS Premium Pack
SUTENT
1
SYMJEPI
SYNERDERM
SYNVISC
1
SYNVISC-ONE
1
SYPRINE
1
TAFINLAR
1
TALIVA
10
Targadox
TARGRETIN
1
TASIGNA
1
tavaborole
TAYTULLA
TAZORAC
TECFIDERA
1
TEGRETOL
TEGRETOL XR
TESTIM
testosterone gel 1%
(authorized generics for TESTIM and VOGELXO only)
THEO-24
THIOLA
1
THIOLA EC
1
TIMOPTIC OCUDOSE
TIROSINT
TOBI
1
TOBI PODHALER
1
TOBRADEX ST
topiramate ext-rel capsule (generics for QUDEXY XR only)
TOPROL-XL
Tovet
TOVIAZ
TRACLEER
1
TRADJENTA
tramadol (NDC* 52817019610 only)
tramadol ext-rel capsule
TRANSDERM SCOP
TRAVATAN Z
TRELSTAR MIXJECT
1
TREXIMET
triamcinolone aerosol 0.2%
triamcinolone ointment 0.05%
Trianex
TRICOR
TRILEPTAL
TRI-VI-FLOR
10
TRIVIDIA INSULIN SYRINGES
7
TronVite
10
TRUVADA
1
TRUXIMA
1
TUDORZA
TYVASO DPI
1
UDENYCA
1
ULORIC
ULTIMED INSULIN SYRINGES
7
ULTIMED NEEDLES
7
ULTRAVATE
UROXATRAL
VALCYTE
VALTREX
Vanoxide-HC
VASCULERA
VECTICAL
VELTIN
VEMLIDY
1
venlafaxine ext-rel tablet (except 225 mg)
VENTOLIN HFA
VEREGEN
VIAGRA
VIEKIRA PAK
1
VIIBRYD
VIMPAT
VIRACEPT
1
VISCO-3
1
VITAFOL-ONE
11
Vitasure
10
VIVELLE-DOT
VOGELXO
VOTRIENT
1
VYZULTA
XALKORI
1
XANAX
XANAX XR
XENAZINE
1
XENICAL
XOPENEX HFA
XYZBAC
10
YASMIN
YAZ
Yuvafem
ZALVIT
11
ZARXIO
1
ZEGERID
ZELAC
ZEPATIER
1
ZERVIATE
ZESTORETIC
ZETIA
ZETONNA
ZIANA
Ziclocin Pak
Ziclopro
zileuton ext-rel
ZIRGAN
ZOLADEX
1
ZOLOFT
zolpidem sublingual
ZOLPIMIST
ZONEGRAN
ZONTIVITY
ZORVOLEX
ZYLET
ZYTIGA
1
This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available
covered options. For a summary of your coverage or benefits plan log in to your secure member site at www.aetna.com
. Or call the toll-free number on your member ID card.
. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this
information and any health-related questions you haveThis list is subject to change.
Subject to applicable laws and regulations.
†
This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.
* Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and
package size.
** Listing does not include certain NDCs*.
1
An exception process may exist for specific clinical or regulatory circumstances that may require coverage of a non-covered medication. If your doctor believes you have a specific
clinical need for a non-covered product, they should fax an exception request to: 1-888-487-9257.
2
For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).
3
QVAR REDIHALER covered for members 5 years of age and under.
4
If approved for coverage and prescribed for primary prevention of cardiovascular disease, may be covered without cost sharing through an exceptions process.
5
Rebranded or private label formulations are not covered (i.e., RELION).
6
Long Acting Insulins - First Generation.
7
BD ULTRAFINE syringes and needles are the only preferred options.
8
An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or
ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746.
9
ACCU-CHEK or ONETOUCH brand test strips are the only preferred options.
10
Generic multivitamins (except Activite, Dexifol, Folvite-D, Genicin Vita-S, HylaVite, Multipro, TronVite, Vitasure) are the only preferred options.
11
Generic prenatal vitamins are the only preferred options.
Please note that if your prescription drug benefits plan changes, the information here may no longer apply. Medications on the A
etna Drug Guide, precertification, step-therapy and
quantity limits lists are subject to change. Not all health services are covered. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking
cessation. 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. The drugs on the Pharmacy Drug Guide (formulary), Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and step
therapy drug coverage review programs are not available in all service areas. 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
Pharmacy Drug Guide (formulary), 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,
certain fully insured commercial California members (except Federal Employee Health Benefit Plan members) who obtained approval from an Aetna plan for coverage of drugs that are
later added to the Preauthorization or Step Therapy Lists or removed from the Pharmacy Drug Guide will continue to have those drugs covered, for as long as the treating in-network
provider continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. Aetna reserves
the right to periodically request clinical information from your provider to assess your medical condition and the appropriateness of your ongoing treatment. Failure to provide clinical
information could result in subsequent denial of coverage for this medication. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO)
members (except Federal Employee Health Benefit Plan members) who are receiving coverage for drugs that are added to the Precertification or Step-Therapy Lists will continue to have
those drugs covered for as long as the prescriber 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. In certain states, including Arkansas, Colorado, Connecticut, Delaware, Georgia, Illinois, Louisiana, Maryland, Minnesota, North Dakota,
Pennsylvania and Texas, step therapy programs do not apply to fully insured members utilizing prescription drugs for the treatment of stage-four advanced, metastatic cancer. 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. CVS Caremark Mail Service Pharmacy is part of the CVS Health family of companies.
997050-01-07 (10/23)
