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2020 Aetna Pharmacy Drug Guide Aetna Standard Plan

Aetna.com Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna HealthAssurance 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. 2021 Pharmacy Drug Guide - Aetna Standard Plan

Table of Contents

INFORMATIONAL SECTION...... 6 *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 16 *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS...... 19 *ALTERNATIVE MEDICINES* - VITAMINS AND MINERALS...... 19 *AMEBICIDES* - DRUGS FOR INFECTIONS...... 19 *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS...... 19 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER...... 19 *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER...... 25 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER...... 27 *ANDROGENS-ANABOLIC* - HORMONES...... 32 *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS...... 33 *ANTACIDS* - DRUGS FOR THE STOMACH...... 34 *ANTHELMINTICS* - DRUGS FOR INFECTIONS...... 34 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART...... 34 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 35 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART...... 36 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS...... 36 *ANTICOAGULANTS* - DRUGS FOR THE BLOOD...... 41 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 42 *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 47 *ANTIDIABETICS* - HORMONES...... 50 *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH...... 57 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING...57 *ANTIEMETICS* - DRUGS FOR THE STOMACH...... 58 *ANTIFUNGALS* - DRUGS FOR INFECTIONS...... 59 *ANTIHISTAMINES* - DRUGS FOR THE LUNGS...... 60 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART...... 61 *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART...... 63 *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS...... 66 *ANTIMALARIALS* - DRUGS FOR INFECTIONS...... 68 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 69 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS...... 69 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER...... 70 *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 79 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 81 *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS...... 84 *ANTIVIRALS* - DRUGS FOR INFECTIONS...... 84 *BETA BLOCKERS* - DRUGS FOR THE HEART...... 89 *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART...... 91 *CARDIOTONICS* - DRUGS FOR THE HEART...... 92 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART...... 92 *CEPHALOSPORINS* - DRUGS FOR INFECTIONS...... 94 *CHEMICALS*...... 95 *CONTRACEPTIVES* - DRUGS FOR WOMEN...... 96 *CORTICOSTEROIDS* - HORMONES...... 106 TOC-3 *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS...... 108 *DERMATOLOGICALS* - DRUGS FOR THE SKIN...... 110 *DIAGNOSTIC PRODUCTS*...... 133 ...... *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* - DRUGS FOR NUTRITION . 143 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH...... 145 *DIURETICS* - DRUGS FOR THE HEART...... 145 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES...... 146 *ESTROGENS* - HORMONES...... 151 *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS...... 153 *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH...... 153 *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER...... 156 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM 157 *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER...... 158 *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD...... 159 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION...... 163 *HEMOSTATICS* - DRUGS FOR THE BLOOD...... 168 *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 168 *LAXATIVES* - DRUGS FOR THE STOMACH...... 169 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER...... 172 *MACROLIDES* - DRUGS FOR INFECTIONS...... 172 *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT...... 173 *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM...... 218 *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION...... 220 *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS...... 222 *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT...... 224 *MULTIVITAMINS* - DRUGS FOR NUTRITION...... 226 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES...... 235 *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE...... 238 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 238 *NUTRIENTS* - DRUGS FOR NUTRITION...... 239 *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE...... 240 *OTIC AGENTS* - DRUGS FOR THE EAR...... 246 *OXYTOCICS* - HORMONES...... 247 *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS...... 247 *PENICILLINS* - DRUGS FOR INFECTIONS...... 249 *PHARMACEUTICAL ADJUVANTS*...... 250 *PROGESTINS* - HORMONES...... 252 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM...... 252 *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS...... 258 *SULFONAMIDES* - DRUGS FOR INFECTIONS...... 259 *TETRACYCLINES* - DRUGS FOR INFECTIONS...... 259 *THYROID AGENTS* - HORMONES...... 261 *ULCER...... DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH . 262 *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM...... 264 *VACCINES* - BIOLOGICAL AGENTS...... 265 *VAGINALTOC-4 AND RELATED PRODUCTS* - DRUGS FOR WOMEN...... 265 *VASOPRESSORS* - DRUGS FOR THE HEART...... 266 *VITAMINS* - DRUGS FOR NUTRITION...... 267

TOC-5 How to use this guide

Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.

Your plan includes You’re covered for all types of medicine — some more expensive, and some less. • Brand and generic drugs that are hand-picked for their quality and effectiveness • Generic: the lowest cost • A specialty pharmacy that fills specialty prescriptions • Preferred brand: a slightly higher cost (ones that are injected, infused or taken by mouth) — • Non-preferred brand: a higher cost and provides services that include personal • Preferred Specialty: lower cost for specialty drugs support, helpful resources and training, and free secure home delivery • Non-preferred Specialty: higher cost for non-preferred specialty drugs • A home delivery pharmacy that delivers maintenance drugs to your home or wherever Your pharmacy plan may not have all the coverage levels you choose (for drugs that are taken regularly to listed above so check your plan documents to see how treat conditions like diabetes or asthma) much you will pay.

What you can expect to pay For your exact coverage and cost, and to learn more about your plan With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or Visit the website that’s on your member ID card. a percentage of the drug’s/medicine’s price. Then log in to your account, where you can:

Each drug is grouped as a generic, a brand or a • Find out the coverage* and estimate of cost for specialty drug. The preferred drugs within these specific drugs groups will generally save you money compared • View your deductibles and plan limits to a non-preferred drug. Typically, generic drugs • Order medications are less expensive than brands. • Check your pharmacy order status Specialty prescription drugs typically include higher-cost • Get a member ID card drugs that require special handling, special storage or • View your claims, Explanation of Benefits and more. monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.

* Check your plan documents for coverage information. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking cessation.

1 Have more questions about your CVS Caremark Mail Service Pharmacy™ pharmacy benefits? You can have maintenance drugs sent right to your home We’re here to help. There are several ways you can or anywhere else you choose by CVS Caremark Mail learn more about your benefits: Service Pharmacy. These are drugs that are taken regularly for chronic conditions like diabetes or asthma. • Check your Plan Design and Benefits Summary in Depending on your plan, you can get up to a 90-day your enrollment kit. supply of medicine for less cost. It’s fast and convenient, • Call the toll-free number on your member ID card. and standard shipping is always free. • Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on Get started right away your member ID card to search for the “Pharmacy FAQ.” You can submit your order using one of these options:

Specialty Pharmacy Network 1. Online — Visit your secure member website and An in-network specialty pharmacy can fill your sign in to your account. There you can add or prescriptions for specialty drugs. These are the types remove your prescriptions. of drugs that may be injected, infused or taken by mouth. 2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. They often need special storage and handling. And they If you need the help of a telephone device for the need to be delivered quickly. A nurse or pharmacist may hard of hearing, call 1-877-833-2779. monitor you during your treatment, if needed. With this type of pharmacy, you can get 3. Mail — Get a new prescription from your doctor. Then this medicine sent right to your home. mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form. How to get started with a specialty pharmacy

Ordering your prescriptions through our specialty Your doctor can submit your order using one of pharmacy is easy. And we typically offer a 30-day these options: medicine supply. 1. Online — They can submit your prescriptions using • To transfer your prescription, just call us toll-free the e-prescribe services on our provider website. at 1-866-353-1892. 2. Fax — They can fax your prescription to • For a new prescription, your doctor can send it to 1-877-270-3317. Make sure they include your member us in one of four ways: ID number, date of birth and mailing address on the 1. Electronically: Through e-prescribe fax cover sheet. Only a doctor may fax a prescription. 2. Fax: 1-866-329-2779

3. Phone: 1-866-782-2779, option 2

If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that’s on your member ID card, to search for the “Patient Profile Form.”

2 Frequently asked questions

How can I save on prescriptions? What is step therapy?

Here are some tips to pay less out of pocket for your Some drugs require step therapy. This means that prescription drugs: you must try one or more prerequisite drug(s) before a step therapy drug is covered. • Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary). The prerequisite drugs have U.S. Food and Drug • Ask your doctor to consider prescribing generic Administration (FDA) approval and may cost less. They drugs instead of brand-name drugs. treat the same condition as the step therapy drug. • Our home delivery pharmacy may save you money. If you don’t try the appropriate prerequisite drug first, you For more information, visit the website on your may need to pay full cost for the step-therapy drug. member ID card and log in to your account. What are quantity limits? What are generic drugs? Quantity limits help your doctor and pharmacist make Generic drugs are proven to be just as safe and effective sure that you use your drug correctly and safely. We use as brand-name drugs. They contain the same active medical guidelines and FDA-approved recommendations ingredients in the same amounts as the brand-name from drug makers to set these coverage limits. The drugs and work the same way. So they have the same quantity limit program includes: risks and benefits as brand-name drugs. However, they • Dose efficiency edits — Limits prescription coverage typically cost less. to one dose per day for drugs that have approval for When appropriate, your doctor may decide to prescribe once-daily dosing a generic drug or allow the pharmacist to substitute a • Maximum daily dose — If a prescription is lower than generic drug. the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy What is precertification? • Quantity limits over time — Limits prescription Precertification is one way that we can help you and your coverage to a specific number of units over a specific doctor find safe, appropriate drugs and keep costs down. amount of time Precertification means that you or your doctor need to get approval from the plan before certain drugs will be What if I need a drug that requires an exception covered. Generally, precertification applies to drugs that: to the precertification, step therapy or quantity • Are often taken in the wrong way limits requirements? Or what if I need a drug that’s not covered under my plan? • Should only be used for certain conditions • Often cost more than other drugs that are proven In certain cases, you or your prescriber can request a to be just as effective medical exception to the precertification, step therapy or quantity limits requirements or for a drug that’s not Keep in mind that your doctor must contact us to request covered on your plan. You can ask for your request to be approval of coverage for these drugs. expedited. Expedited coverage decisions are made within 24 hours.

We’ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design.

3 How can your provider request a medical Can the formulary change during the year? exception? The formulary can change throughout the year. • Submit their request through our secure provider Some reasons why it can change include: website on NaviNet®. • New drugs are approved. • Call the Aetna Pharmacy Precertification Unit: • Existing drugs are removed from the market. Non-Specialty 1-800-294-5979 or Specialty 1-866-814-5506. • Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs • Fax the completed request form to: are not generally covered in a formulary. Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155. • Brand-name drugs lose patent protection and generic versions become available. When this happens, the • Mail the completed request form to: generic drug will be covered in place of the brand- Aetna Pharmacy Management name drug. The brand-name drug is likely to become 1300 East Campbell Road non-formulary or covered at a higher cost. See the Richardson, TX 75081 “What are generic drugs?” section above for more information. Pharmacy and Therapeutics (P&T) committee

The services of an independent National Pharmacy and Therapeutics Committee (“P&T Committee”) are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee’s voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Voting members of the P&T Committee are not employees of CVS Caremark and must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

4 Commercial 1557 Nondiscrimination Notice

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and their affiliates (Aetna).

5

Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.

Please note that if your prescription drug benefits plan changes, the information here may no longer apply. Medications on the Aetna Drug Guide, precertification, step-therapy and quantity limits lists are subject to change. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Pharmacy Drug Guide (formulary) may be subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug. Louisiana members: depending on your specific plan and the prescription medication in question, you may in some instances be subject to an excess consumer cost burden for prescription drugs as defined by your state. 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. Aetna or its affiliate(s) may receive rebates from drug manufacturers. Rebates may reduce the amount a member pays the pharmacy for covered prescriptions. Information is 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 medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications 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. 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.

Aetna.com

©2020 Aetna Inc. Drug Notes Drug Tier CE = Copay Exception: Available CE = Copay Exception: Available to some members at no cost with a to some members at no cost with a prescription from your provider prescription from your provider when obtained at an in-network when obtained at an in-network pharmacy. Certain limitations may pharmacy. Certain limitations apply. may apply. IBC = Indication Based Coverage G = Generics LGC = Lowest Generic Copay NF = Non-formulary, not covered Applies unless exception request granted N8 = Drug Specific Coverage NPB = Non-Preferred Brands SPC = Select Plan Coverage: lowercase italics = Generic drugs NPSP = Non-Preferred Specialty Only available for select plans. UPPERCASE = Brand name PB = Preferred Brands Refer to member plan documents drugs PSP = Preferred Specialty for coverage. Prescription Drug Name Drug Tier Drug Notes *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM ADDERALL XR ORAL CAPSULE EXTENDED N8 (Listing does not include RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 NPB certain NDCs) MG, 5 MG (amphetamine-dextroamphetamine) ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 MG, 45 MG, 55 MG, 70 NF MG, 85 MG (methylphenidate hcl) ADZENYS ER ORAL SUSPENSION EXTENDED NF RELEASE 1.25 MG/ML (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 12.5 MG, 15.7 MG, 18.8 MG, 3.1 NF MG, 6.3 MG, 9.4 MG (amphetamine) amphetamine sulfate oral tablet 10 mg, 5 mg G amphetamine-dextroamphet er oral capsule extended release 24 N8 (Listing does not include G hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg certain NDCs) amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, G 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, NF 60 MG (methylphenidate hcl) armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg G atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 G mg, 60 mg, 80 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 16 Prescription Drug Name Drug Tier Drug Notes caffeine citrate oral solution 20 mg/ml, 60 mg/3ml G clonidine hcl er oral tablet extended release 12 hour 0.1 mg G CONCERTA ORAL TABLET EXTENDED RELEASE 18 N8 (Listing does not include NPB MG, 27 MG, 36 MG, 54 MG (methylphenidate hcl) certain NDCs) CONTRAVE ORAL TABLET EXTENDED RELEASE 12 NF SPC HOUR 8-90 MG (naltrexone-bupropion hcl) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG NF (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 NF MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate) dexmethylphenidate hcl er oral capsule extended release 24 hour G 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg G dextroamphetamine sulfate er oral capsule extended release 24 G hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral solution 5 mg/5ml G dextroamphetamine sulfate oral tablet 10 mg, 5 mg G DYANAVEL XR ORAL SUSPENSION EXTENDED NPB RELEASE 2.5 MG/ML (amphetamine) EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15 NF MG, 20 MG, 5 MG (amphetamine sulfate) EVEKEO ORAL TABLET 10 MG, 5 MG (amphetamine NF sulfate) guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 G mg, 3 mg, 4 mg INTUNIV ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1 MG, 2 MG, 3 MG, 4 MG (guanfacine hcl) JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG NF (methylphenidate hcl) LOMAIRA ORAL TABLET 8 MG (phentermine hcl) NF methylphenidate hcl (Metadate Er Oral Tablet Extended G Release 20 Mg) methamphetamine hcl oral tablet 5 mg G methylphenidate hcl er (cd) oral capsule extended release 10 G mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 17 Prescription Drug Name Drug Tier Drug Notes methylphenidate hcl er (la) oral capsule extended release 24 G hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 20 G mg methylphenidate hcl er oral tablet extended release 18 mg, 27 N8 (Listing does not include G mg, 36 mg, 54 mg certain NDCs) methylphenidate hcl er oral tablet extended release 24 hour 18 G mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 72 mg NPB methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml G methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg G methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg G modafinil oral tablet 100 mg, 200 mg G MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine- PB dextroamphetamine) NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 NF MG (armodafinil) QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG NF (phentermine-topiramate) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG NPB (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION NPB RECONSTITUTED ER 25 MG/5ML (methylphenidate hcl) RELEXXII ORAL TABLET EXTENDED RELEASE 72 NF MG (methylphenidate hcl) SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) NF VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 PB MG, 50 MG, 60 MG, 70 MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, PB 30 MG, 40 MG, 50 MG, 60 MG (lisdexamfetamine dimesylate) dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Mg) G ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 G MG, 7.5 MG (dextroamphetamine sulfate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 18 Prescription Drug Name Drug Tier Drug Notes *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 PB BAU (timothy grass pollen allergen) ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 NPB SQ-HDM (dust mite mixed allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 PB IR (grass mix pollens allergen ext) RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 PB AMB A 1-U (short ragweed pollen ext) sorrel/dock mix subcutaneous solution 1:20 NF *ALTERNATIVE MEDICINES* - VITAMINS AND MINERALS EC-RX DHEA EXTERNAL CREAM 10 %, 4 % (prasterone NF (dhea)) NEOKE RA LIPOIC ORAL POWDER 800 MG/GM (alpha- NF lipoic acid) *AMEBICIDES* - DRUGS FOR INFECTIONS SOLOSEC ORAL PACKET 2 GM (secnidazole) NF *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML NPB (amikacin sulfate liposome) BETHKIS INHALATION NEBULIZATION SOLUTION PSP 300 MG/4ML (tobramycin) KITABIS PAK INHALATION NEBULIZATION NPSP SOLUTION 300 MG/5ML (tobramycin) neomycin sulfate oral tablet 500 mg G paromomycin sulfate oral capsule 250 mg G TOBI INHALATION NEBULIZATION SOLUTION 300 NF MG/5ML (tobramycin) TOBI PODHALER INHALATION CAPSULE 28 MG NF (tobramycin) tobramycin inhalation nebulization solution 300 mg/5ml G *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION NF AUTO-INJECTOR 162 MG/0.9ML (tocilizumab) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 19 Prescription Drug Name Drug Tier Drug Notes ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, NF 400 MG/20ML, 80 MG/4ML (tocilizumab) ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 162 MG/0.9ML (tocilizumab) ARCALYST SUBCUTANEOUS SOLUTION NPSP RECONSTITUTED 220 MG (rilonacept) ARTHROTEC ORAL TABLET DELAYED RELEASE 50- NF 0.2 MG, 75-0.2 MG (diclofenac-misoprostol) CALDOLOR INTRAVENOUS SOLUTION 800 NPB MG/200ML (ibuprofen) CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, NPB 50 MG (celecoxib) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg G DAYPRO ORAL TABLET 600 MG (oxaprozin) NPB dermacinrx analgesic combopak combination kit 75 mg NF dfs dr/ms/menth/cap pak combination kit 75 mg NF diclofenac potassium oral tablet 50 mg G diclofenac sodium er oral tablet extended release 24 hour 100 G mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 G mg diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75- G 0.2 mg DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen- NPB famotidine) ENBREL MINI SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSP CARTRIDGE 50 MG/ML (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML PSP (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for all PSP SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSP RECONSTITUTED 25 MG (etanercept) conditions except Psoriasis) ENBREL SURECLICK SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSP AUTO-INJECTOR 50 MG/ML (etanercept) conditions except Psoriasis) equapax/ibuprofen/minrex oral therapy pack 800 mg NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 20 Prescription Drug Name Drug Tier Drug Notes etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, G 600 mg etodolac oral capsule 200 mg, 300 mg G etodolac oral tablet 400 mg, 500 mg G fenoprofen calcium oral capsule 200 mg, 400 mg NF fenoprofen calcium oral tablet 600 mg NF FENORTHO ORAL CAPSULE 200 MG (fenoprofen NF calcium) flurbiprofen oral tablet 100 mg, 50 mg G HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 PSP MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PSP 40 MG/0.4ML, 40 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML PSP (adalimumab) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PSP (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 PSP MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML (adalimumab) ibuprofen (Ibu Oral Tablet 400 Mg, 600 Mg, 800 Mg) G ibuprofen oral suspension 100 mg/5ml G ibuprofen oral tablet 400 mg, 600 mg, 800 mg G ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML NPSP (canakinumab) INDOCIN ORAL SUSPENSION 25 MG/5ML NF (indomethacin) INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) NF indomethacin er oral capsule extended release 75 mg G indomethacin oral capsule 20 mg NF indomethacin oral capsule 25 mg, 50 mg G diclofenac sodium-capsaicin (Inflammacin Combination NF Therapy Pack 75 & 0.025 Mg-%)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 21 Prescription Drug Name Drug Tier Drug Notes INFLATHERM COMBINATION THERAPY PACK 75 & NF 3-3 MG & % (diclofenac-menthol-camphor) ketoprofen er oral capsule extended release 24 hour 200 mg NF ketoprofen oral capsule 25 mg NF ketorolac tromethamine oral tablet 10 mg G KEVZARA SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) KEVZARA SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) KINERET SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 100 MG/0.67ML (anakinra) leflunomide oral tablet 10 mg, 20 mg G LODINE ORAL TABLET 400 MG (etodolac) NF meclofenamate sodium oral capsule 100 mg, 50 mg G mefenamic acid oral capsule 250 mg NF meloxicam oral tablet 15 mg, 7.5 mg G MOBIC ORAL TABLET 15 MG, 7.5 MG (meloxicam) NPB nabumetone oral tablet 500 mg, 750 mg G NALFON ORAL CAPSULE 400 MG (fenoprofen calcium) NPB NAPRELAN ORAL TABLET EXTENDED RELEASE 24 NF HOUR 375 MG, 500 MG, 750 MG (naproxen sodium) naproxen dr oral tablet delayed release 375 mg, 500 mg G naproxen oral suspension 125 mg/5ml NF naproxen oral tablet 250 mg, 375 mg, 500 mg G naproxen sodium er oral tablet extended release 24 hour 375 mg, NF 500 mg naproxen sodium oral tablet 275 mg, 550 mg G naproxen-esomeprazole oral tablet delayed release 375-20 mg, NF 500-20 mg diclofenac sodium-capsaicin (Nudiclo Tabpak Combination NF Therapy Pack 75 & 0.025 Mg-%) NUDROXIPAK COMBINATION THERAPY PACK 200 NF MG (celecoxib-capsaic-men-methsal) NUDROXIPAK DSDR-50 COMBINATION KIT 50 MG NF (diclofenac sodium-liniment)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 22 Prescription Drug Name Drug Tier Drug Notes NUDROXIPAK DSDR-75 COMBINATION KIT 75 MG NF (diclofenac sodium-liniment) NUDROXIPAK E-400 COMBINATION KIT 400 MG NF (etodolac-liniment) NUDROXIPAK I-800 COMBINATION KIT 800 MG NF (ibuprofen-liniment) NUDROXIPAK M-15 COMBINATION KIT 15 MG NF (meloxicam-liniment) NUDROXIPAK N-500 COMBINATION KIT 500 MG NF (nabumetone-liniment) OLUMIANT ORAL TABLET 1 MG, 2 MG (baricitinib) NF IBC (Preferred agent for ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION Rheumatoid Arthritis. Not PSP AUTO-INJECTOR 125 MG/ML (abatacept) covered for other conditions) ORENCIA INTRAVENOUS SOLUTION NF RECONSTITUTED 250 MG (abatacept) IBC (Preferred agent for ORENCIA SUBCUTANEOUS SOLUTION PREFILLED Rheumatoid Arthritis. Not SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML PSP covered for other (abatacept) conditions) IBC (Preferred agent for OTEZLA ORAL TABLET 30 MG (apremilast) PSP Psoriasis and Psoriatic Arthritis) IBC (Preferred agent for OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 PSP Psoriasis and Psoriatic MG (apremilast) Arthritis) OTREXUP SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, NF 17.5 MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML (methotrexate (anti-rheumatic)) oxaprozin oral tablet 600 mg G piroxicam oral capsule 10 mg, 20 mg G PREVIDOLRX ANALGESIC COMBINATION THERAPY PACK 75-20-0.025 MG-MG-% (diclofenac- NF omeprazole-capsicum) QMIIZ ODT ORAL TABLET DISPERSIBLE 15 MG, 7.5 NF MG (meloxicam)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 23 Prescription Drug Name Drug Tier Drug Notes RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 PSP MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) READYSHARP ANESTH + KETOROLAC INJECTION KIT 15 & 0.5 & 1 MG/ML-%-% (ketorolac & bupivacaine & NF lido) READYSHARP KETOROLAC INJECTION KIT 15 NF MG/ML (ketorolac tromethamine) RIDAURA ORAL CAPSULE 3 MG (auranofin) NPB RINVOQ ORAL TABLET EXTENDED RELEASE 24 IBC (Preferred agent for PSP HOUR 15 MG (upadacitinib) Rheumatoid Arthritis) SIMPONI ARIA INTRAVENOUS SOLUTION 50 PSP MG/4ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION AUTO- NF INJECTOR 100 MG/ML, 50 MG/0.5ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab) SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac NF tromethamine) sulindac oral tablet 150 mg, 200 mg G TIVORBEX ORAL CAPSULE 20 MG (indomethacin) NF tolmetin sodium oral capsule 400 mg G tolmetin sodium oral tablet 600 mg G TORONOVA II SUIK COMBINATION KIT 30 MG/ML NF (ketorolac trometh & anesthetic) TORONOVA SUIK COMBINATION KIT 30 MG/ML NF (ketorolac trometh & anesthetic) VIMOVO ORAL TABLET DELAYED RELEASE 375-20 NPB MG, 500-20 MG (naproxen-esomeprazole) VIVLODEX ORAL CAPSULE 10 MG, 5 MG (meloxicam) NF IBC (Preferred agent for XELJANZ ORAL TABLET 10 MG (tofacitinib citrate) PSP Ulcerative Colitis (after failure of Humira))

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 24 Prescription Drug Name Drug Tier Drug Notes IBC (Preferred agent for Rheumatoid Arthritis and Ulcerative Colitis (after XELJANZ ORAL TABLET 5 MG (tofacitinib citrate) PSP failure of Humira). Not covered for Psoriatic Arthritis.) IBC (Preferred agent for XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 Rheumatoid Arthritis. Not PSP HOUR 11 MG (tofacitinib citrate) covered for Psoriatic Arthritis.) IBC (Preferred agent for XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 PSP Ulcerative Colitis (after HOUR 22 MG (tofacitinib citrate) failure of Humira)) ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) NPB ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) NF *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER ALLZITAL ORAL TABLET 25-325 MG (butalbital- NF acetaminophen) aspirin adult low dose oral tablet delayed release 81 mg CE aspirin ec low strength oral tablet delayed release 81 mg CE aspirin low dose oral tablet chewable 81 mg CE aspirin low dose oral tablet delayed release 81 mg CE aspirin oral tablet chewable 81 mg CE aspirin oral tablet delayed release 81 mg CE ASPIR-LOW ORAL TABLET DELAYED RELEASE 81 CE MG (aspirin) BAYER ASPIRIN EC LOW DOSE ORAL TABLET CE DELAYED RELEASE 81 MG (aspirin) BAYER LOW DOSE ORAL TABLET CHEWABLE 81 MG CE (aspirin) BAYER LOW DOSE ORAL TABLET DELAYED CE RELEASE 81 MG (aspirin) butalbital-acetaminophen (Bupap Oral Tablet 50-300 Mg) NF butalbital-acetaminophen oral tablet 50-300 mg NF butalbital-acetaminophen oral tablet 50-325 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 25 Prescription Drug Name Drug Tier Drug Notes butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 NF mg butalbital-apap-caffeine oral tablet 50-325-40 mg G butalbital-aspirin-caffeine oral capsule 50-325-40 mg G childrens aspirin low strength oral tablet chewable 81 mg CE childrens aspirin oral tablet chewable 81 mg CE cvs aspirin low dose oral tablet delayed release 81 mg CE cvs aspirin low strength oral tablet delayed release 81 mg CE diflunisal oral tablet 500 mg G ECOTRIN LOW STRENGTH ORAL TABLET DELAYED CE RELEASE 81 MG (aspirin) eq childrens aspirin oral tablet chewable 81 mg CE eql aspirin low dose oral tablet chewable 81 mg CE butalbital-apap-caffeine (Esgic Oral Capsule 50-325-40 Mg) NF ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- NPB caffeine) FIORICET ORAL CAPSULE 50-300-40 MG (butalbital- NF apap-caffeine) FIORINAL ORAL CAPSULE 50-325-40 MG (butalbital- NPB aspirin-caffeine) gnp adult aspirin low strength oral tablet chewable 81 mg CE gnp aspirin oral tablet delayed release 81 mg CE h-e-b aspirin oral tablet delayed release 81 mg CE hm aspirin oral tablet chewable 81 mg CE kls aspirin low dose oral tablet delayed release 81 mg CE kp aspirin oral tablet delayed release 81 mg CE MINIPRIN LOW DOSE ORAL TABLET DELAYED CE RELEASE 81 MG (aspirin) px aspirin oral tablet chewable 81 mg CE px enteric aspirin oral tablet delayed release 81 mg CE qc childrens aspirin oral tablet chewable 81 mg CE ra aspirin adult low dose oral tablet chewable 81 mg CE ra aspirin childrens oral tablet chewable 81 mg CE ra aspirin ec adult low st oral tablet delayed release 81 mg CE ra childrens aspirin oral tablet chewable 81 mg CE 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 26 Prescription Drug Name Drug Tier Drug Notes salsalate oral tablet 500 mg, 750 mg G sb childrens aspirin oral tablet chewable 81 mg CE sm aspirin adult low strength oral tablet chewable 81 mg CE sm aspirin adult low strength oral tablet delayed release 81 mg CE sm childrens aspirin oral tablet chewable 81 mg CE ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE 81 CE MG (aspirin) TENCON ORAL TABLET 50-325 MG (butalbital- G acetaminophen) butalbital-apap-caffeine (Vanatol Lq Oral Solution 50-325-40 NF Mg/15Ml) butalbital-apap-caffeine (Zebutal Oral Capsule 50-325-40 Mg) NF *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER acetaminophen-codeine #3 oral tablet 300-30 mg G acetaminophen-codeine oral solution 120-12 mg/5ml G acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg G ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG NPB (fentanyl citrate) APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, NF 8.16-325 MG (benzhydrocodone-acetaminophen) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg G ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG, 30 MG, 60 MG (morphine NF sulfate) butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- G 325-40-30 Mg) BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG PB (buprenorphine hcl) BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 NPB MG (buprenorphine hcl-naloxone hcl) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg G buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 G mg, 4-1 mg, 8-2 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 27 Prescription Drug Name Drug Tier Drug Notes buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2- G 0.5 mg, 8-2 mg buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, G 20 mcg/hr, 5 mcg/hr, 7.5 mcg/hr butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- G 40-30 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg G butorphanol tartrate nasal solution 10 mg/ml G BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 NF MCG/HR (buprenorphine) codeine sulfate oral tablet 60 mg NPB CONZIP ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 100 MG, 200 MG, 300 MG (tramadol hcl) DILAUDID INJECTION SOLUTION 1 MG/ML, 2 NF MG/ML (hydromorphone hcl) DILAUDID ORAL LIQUID 1 MG/ML (hydromorphone hcl) NPB DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG NPB (hydromorphone hcl) DOLOPHINE ORAL TABLET 10 MG, 5 MG (methadone NPB hcl) DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 NPB MCG (sufentanil citrate) DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR NPB 100 MCG/HR (fentanyl) DURAGESIC-12 TRANSDERMAL PATCH 72 HOUR 12 NPB MCG/HR (fentanyl) DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR 25 NPB MCG/HR (fentanyl) DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR 50 NPB MCG/HR (fentanyl) DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR 75 NPB MCG/HR (fentanyl) oxycodone-acetaminophen (Endocet Oral Tablet 10-325 Mg, G 2.5-325 Mg, 5-325 Mg, 7.5-325 Mg) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, G 200 mcg, 400 mcg, 600 mcg, 800 mcg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 28 Prescription Drug Name Drug Tier Drug Notes fentanyl citrate buccal tablet 200 mcg, 400 mcg, 600 mcg, 800 G mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 G mcg/hr FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 NPB MCG, 600 MCG, 800 MCG (fentanyl citrate) FIORINAL/CODEINE #3 ORAL CAPSULE 50-325-40-30 NPB MG (butalbital-asa-caff-codeine) hydrocodone bitartrate er oral capsule extended release 12 hour G 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg hydrocodone-acetaminophen oral solution 5-217 mg/10ml G hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, G 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 G mg hydromorphone hcl er oral tablet extended release 24 hour 12 G mg, 16 mg, 32 mg, 8 mg hydromorphone hcl injection solution 1 mg/ml NPB hydromorphone hcl oral liquid 1 mg/ml G hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg G hydromorphone hcl rectal suppository 3 mg NPB HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE- DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, NF 60 MG, 80 MG (hydrocodone bitartrate) KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, NPB 50 MG, 60 MG, 80 MG (morphine sulfate) LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 NF MCG/ACT, 400 MCG/ACT (fentanyl citrate) levorphanol tartrate oral tablet 2 mg, 3 mg NF LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- NPB acetaminophen) meperidine hcl oral solution 50 mg/5ml G meperidine hcl oral tablet 50 mg G methadone hcl (Methadone Hcl Intensol Oral Concentrate 10 G Mg/Ml)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 29 Prescription Drug Name Drug Tier Drug Notes methadone hcl oral concentrate 10 mg/ml G methadone hcl oral solution 10 mg/5ml, 5 mg/5ml G methadone hcl oral tablet 10 mg, 5 mg G methadone hcl oral tablet soluble 40 mg G methadone hcl solution 10 mg/ml injection 10 mg/ml G methadone hcl solution 10 mg/ml injection 10 mg/ml NPB methadone hcl-nacl intravenous solution prefilled syringe 1-0.9 NPB mg/ml-% METHADOSE ORAL CONCENTRATE 10 MG/ML NPB (methadone hcl) methadone hcl (Methadose Oral Tablet Soluble 40 Mg) G METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 NPB MG/ML (methadone hcl) morphine sulfate (concentrate) oral solution 20 mg/ml, 5 G mg/0.25ml morphine sulfate er beads oral capsule extended release 24 hour G 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 10 mg, G 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 100 mg, 15 mg, G 200 mg, 30 mg, 60 mg morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml G morphine sulfate oral tablet 15 mg, 30 mg G morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg G MS CONTIN ORAL TABLET EXTENDED RELEASE 100 NPB MG, 15 MG, 200 MG, 30 MG, 60 MG (morphine sulfate) nalocet oral tablet 2.5-300 mg NF NORCO ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 NPB MG (hydrocodone-acetaminophen) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG PB (tapentadol hcl) NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG PB (tapentadol hcl) OPANA ORAL TABLET 10 MG (oxymorphone hcl) NPB OXAYDO ORAL TABLET 5 MG, 7.5 MG (oxycodone hcl) NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 30 Prescription Drug Name Drug Tier Drug Notes oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, G 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg oxycodone hcl oral capsule 5 mg G oxycodone hcl oral concentrate 100 mg/5ml G oxycodone hcl oral solution 5 mg/5ml G oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg G oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5- G 325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 4.8355-325 mg G OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 NF MG, 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 10 mg, NF 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg oxymorphone hcl oral tablet 10 mg, 5 mg G pentazocine-naloxone hcl oral tablet 50-0.5 mg G PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5- NF 325 MG, 7.5-325 MG (oxycodone-acetaminophen) PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 NF MG (oxycodone-acetaminophen) PROBUPHINE IMPLANT KIT SUBCUTANEOUS NF IMPLANT 74.2 MG (buprenorphine hcl) ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG NPB (oxycodone hcl) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML NPB (buprenorphine) SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4- NF 1 MG, 8-2 MG (buprenorphine hcl-naloxone hcl) SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 PB MCG, 800 MCG (fentanyl) tramadol hcl er (biphasic) oral tablet extended release 24 hour G 100 mg, 200 mg, 300 mg tramadol hcl er oral capsule extended release 24 hour 100 mg, G 150 mg, 200 mg, 300 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 31 Prescription Drug Name Drug Tier Drug Notes tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 G mg, 300 mg tramadol hcl oral tablet 100 mg NF tramadol hcl oral tablet 50 mg G tramadol-acetaminophen oral tablet 37.5-325 mg G TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- G dihydrocodeine) ULTRACET ORAL TABLET 37.5-325 MG (tramadol- NPB acetaminophen) ULTRAM ORAL TABLET 50 MG (tramadol hcl) NPB XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG PB (oxycodone) ZOHYDRO ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG NF (hydrocodone bitartrate) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7- 0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 PB MG, 8.6-2.1 MG (buprenorphine hcl-naloxone hcl) *ANDROGENS-ANABOLIC* - HORMONES ANADROL-50 ORAL TABLET 50 MG (oxymetholone) NPB ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 PB MG/24HR, 4 MG/24HR (testosterone) ANDROGEL GEL 50 MG/5GM (1%) TRANSDERMAL 50 NF MG/5GM (1%) (testosterone) ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%), NF 50 MG/5GM (1%) (testosterone) danazol oral capsule 100 mg, 200 mg, 50 mg G DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML (testosterone NPB cypionate) ec-rx testosterone transdermal cream 0.2 %, 0.4 %, 10 %, 20 % NF FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%) NF (testosterone) methitest oral tablet 10 mg NPB methyltestosterone oral capsule 10 mg G NATESTO NASAL GEL 5.5 MG/ACT (testosterone) NF 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 32 Prescription Drug Name Drug Tier Drug Notes oxandrolone oral tablet 10 mg, 2.5 mg G TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML NF (testosterone cypionate) TESTOPEL IMPLANT PELLET 75 MG (testosterone) NPB testosterone compounding kit transdermal cream 20 % NF testosterone cypionate intramuscular solution 100 mg/ml, 200 G mg/ml testosterone enanthate intramuscular solution 200 mg/ml G testosterone gel 12.5 mg/act (1%) transdermal 12.5 mg/act G (1%) testosterone gel 12.5 mg/act (1%) transdermal 12.5 mg/act NF (1%) testosterone gel 50 mg/5gm (1%) transdermal 50 mg/5gm (1%) G testosterone gel 50 mg/5gm (1%) transdermal 50 mg/5gm (1%) NF testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm G (1.62%) testosterone transdermal solution 30 mg/act G VOGELXO GEL 50 MG/5GM (1%) TRANSDERMAL 50 NF MG/5GM (1%) (testosterone) VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT NF (1%) (testosterone) VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) XYOSTED SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML NF (testosterone enanthate) *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone PB acetate) hydrocortisone (perianal) external cream 1 %, 2.5 % G hydrocortisone ace-pramoxine external cream 1-1 % G hydrocortisone rectal enema 100 mg/60ml G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 33 Prescription Drug Name Drug Tier Drug Notes PROCORT EXTERNAL CREAM 1.85-1.15 % NPB (hydrocortisone ace-pramoxine) PROCTOFOAM HC EXTERNAL FOAM 1-1 % PB (hydrocortisone ace-pramoxine) hydrocortisone (Procto-Med Hc External Cream 2.5 %) G hydrocortisone (Procto-Pak External Cream 1 %) G hydrocortisone (Proctozone-Hc External Cream 2.5 %) G RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) NPB UCERIS RECTAL FOAM 2 MG/ACT (budesonide) NPB *ANTACIDS* - DRUGS FOR THE STOMACH sodium bicarbonate oral powder NPB *ANTHELMINTICS* - DRUGS FOR INFECTIONS albendazole oral tablet 200 mg G benznidazole oral tablet 100 mg, 12.5 mg NPB EMVERM ORAL TABLET CHEWABLE 100 MG PB (mebendazole) ivermectin oral tablet 3 mg G praziquantel oral tablet 600 mg G *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART DILATRATE-SR ORAL CAPSULE EXTENDED NPB RELEASE 40 MG (isosorbide dinitrate) GONITRO SUBLINGUAL PACKET 400 MCG NF (nitroglycerin) ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG NPB (isosorbide dinitrate) isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg G isosorbide dinitrate oral tablet 40 mg NF isosorbide mononitrate er oral tablet extended release 24 hour G 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg G nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 G Mg/Hr, 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) NITRO-BID TRANSDERMAL OINTMENT 2 % NPB (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 PB MG/HR, 0.8 MG/HR (nitroglycerin) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 34 Prescription Drug Name Drug Tier Drug Notes nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg G nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, G 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray G NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 NPB MG/SPRAY (nitroglycerin) NITROMIST TRANSLINGUAL AEROSOL SOLUTION NPB 400 MCG/SPRAY (nitroglycerin) ranolazine er oral tablet extended release 12 hour 1000 mg, 500 G mg *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, G 2 mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 NPB MG/ML (alprazolam) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg G alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg G alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, G 2 mg, 3 mg buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg G chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg G clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg G diazepam oral concentrate 5 mg/ml G diazepam oral solution 5 mg/5ml G diazepam oral tablet 10 mg, 2 mg, 5 mg G hydroxyzine hcl oral syrup 10 mg/5ml G hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg G hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg G lorazepam oral concentrate 2 mg/ml G lorazepam oral tablet 0.5 mg, 1 mg, 2 mg G meprobamate oral tablet 200 mg, 400 mg G oxazepam oral capsule 10 mg, 15 mg, 30 mg G XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG NF (alprazolam)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 35 Prescription Drug Name Drug Tier Drug Notes XANAX XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 0.5 MG, 1 MG, 2 MG, 3 MG (alprazolam) *ANTIARRHYTHMICS* - DRUGS FOR THE HEART amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg G disopyramide phosphate oral capsule 100 mg, 150 mg G dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg G flecainide acetate oral tablet 100 mg, 150 mg, 50 mg G mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg G MULTAQ ORAL TABLET 400 MG (dronedarone hcl) PB NORPACE CR ORAL CAPSULE EXTENDED RELEASE PB 12 HOUR 100 MG, 150 MG (disopyramide phosphate) amiodarone hcl (Pacerone Oral Tablet 100 Mg, 200 Mg, 400 G Mg) propafenone hcl er oral capsule extended release 12 hour 225 G mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg G quinidine gluconate er oral tablet extended release 324 mg G quinidine sulfate oral tablet 200 mg, 300 mg G TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 NPSP MCG (dofetilide) *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT PB (fluticasone-salmeterol) AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT NF (fluticasone-salmeterol) albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 G mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 36 Prescription Drug Name Drug Tier Drug Notes albuterol sulfate hfa inhalation aerosol solution 108 (90 base) G mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 G mg/0.5ml albuterol sulfate oral syrup 2 mg/5ml G albuterol sulfate oral tablet 2 mg, 4 mg G ALVESCO INHALATION AEROSOL SOLUTION 160 NF MCG/ACT, 80 MCG/ACT (ciclesonide) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- PB vilanterol) ARCAPTA NEOHALER INHALATION CAPSULE 75 NPB MCG (indacaterol maleate) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 PB MCG/ACT, 50 MCG/ACT (fluticasone furoate) ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NF MCG/INH (mometasone furoate) ASMANEX (14 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NF MCG/INH (mometasone furoate) ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 NF MCG/INH, 220 MCG/INH (mometasone furoate) ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NF MCG/INH (mometasone furoate) ASMANEX (7 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 NF MCG/INH (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT (mometasone NF furoate) ATROVENT HFA INHALATION AEROSOL SOLUTION NPB 17 MCG/ACT (ipratropium bromide hfa) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 NF MCG/ACT (glycopyrrolate-formoterol) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 37 Prescription Drug Name Drug Tier Drug Notes BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 PB MCG/INH (fluticasone furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160- NPB 9-4.8 MCG/ACT (budeson-glycopyrrol-formoterol) BROVANA INHALATION NEBULIZATION SOLUTION NPB 15 MCG/2ML (arformoterol tartrate) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 G mg/2ml CINQAIR INTRAVENOUS SOLUTION 100 MG/10ML NF (reslizumab) COMBIVENT RESPIMAT INHALATION AEROSOL NPB SOLUTION 20-100 MCG/ACT (ipratropium-albuterol) cromolyn sodium inhalation nebulization solution 20 mg/2ml G DALIRESP ORAL TABLET 250 MCG, 500 MCG PB (roflumilast) DIFIL-G FORTE ORAL LIQUID 100-100 MG/5ML G (dyphylline-guaifenesin) DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT (mometasone furo- NF formoterol fum) ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML NPB (theophylline) FASENRA PEN SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 30 MG/ML (benralizumab) FASENRA SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 30 MG/ML (benralizumab) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 PB MCG/BLIST, 50 MCG/BLIST (fluticasone propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT (fluticasone PB propionate hfa) fluticasone-salmeterol inhalation aerosol powder breath NF activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH (umeclidinium NF bromide)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 38 Prescription Drug Name Drug Tier Drug Notes ipratropium bromide inhalation solution 0.02 % G ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml G levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, G 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml levalbuterol tartrate inhalation aerosol 45 mcg/act G LONHALA MAGNAIR REFILL KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) montelukast sodium oral packet 4 mg G montelukast sodium oral tablet 10 mg G montelukast sodium oral tablet chewable 4 mg, 5 mg G NUCALA SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 100 MG/ML (mepolizumab) NUCALA SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 100 MG/ML (mepolizumab) NUCALA SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 100 MG (mepolizumab) PERFOROMIST INHALATION NEBULIZATION PB SOLUTION 20 MCG/2ML (formoterol fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 108 MCG/ACT NF (albuterol sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION 108 NF (90 BASE) MCG/ACT (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) NF MCG/ACT (albuterol sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION NF 108 (90 BASE) MCG/ACT (albuterol sulfate) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 PB MCG/ACT (budesonide) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone PB diprop hfa)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 39 Prescription Drug Name Drug Tier Drug Notes SEEBRI NEOHALER INHALATION CAPSULE 15.6 NF MCG (glycopyrrolate) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE PB (salmeterol xinafoate) SINGULAIR ORAL PACKET 4 MG (montelukast sodium) NF SINGULAIR ORAL TABLET 10 MG (montelukast sodium) NF SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG NF (montelukast sodium) SPIRIVA HANDIHALER INHALATION CAPSULE 18 PB MCG (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT (tiotropium PB bromide monohydrate) STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT (tiotropium bromide- PB olodaterol) STRIVERDI RESPIMAT INHALATION AEROSOL PB SOLUTION 2.5 MCG/ACT (olodaterol hcl) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT (budesonide-formoterol PB fumarate) terbutaline sulfate oral tablet 2.5 mg, 5 mg G THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 G mg theophylline er oral tablet extended release 24 hour 400 mg, 600 G mg theophylline oral solution 80 mg/15ml G TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, PB 200-62.5-25 MCG/INH (fluticasone-umeclidin-vilant) TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT NF (aclidinium bromide) UTIBRON NEOHALER INHALATION CAPSULE 27.5- NF 15.6 MCG (indacaterol-glycopyrrolate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 40 Prescription Drug Name Drug Tier Drug Notes VENTOLIN HFA INHALATION AEROSOL SOLUTION NF 108 (90 BASE) MCG/ACT (albuterol sulfate) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 150 MG/ML, 75 MG/0.5ML (omalizumab) XOLAIR SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 150 MG (omalizumab) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT NF (levalbuterol tartrate) YUPELRI INHALATION SOLUTION 175 MCG/3ML PB (revefenacin) zafirlukast oral tablet 10 mg, 20 mg G zileuton er oral tablet extended release 12 hour 600 mg G ZYFLO ORAL TABLET 600 MG (zileuton) NPB *ANTICOAGULANTS* - DRUGS FOR THE BLOOD acd formula a in vitro solution 0.73-2.45-2.2 gm/100ml NPB ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 NPB GM/100ML (anticoagulant cit dext soln a) anticoagulant cit dext soln a in vitro solution 0.8-2.45-2.2 NPB gm/100ml anticoagulant sodium citrate in vitro solution 4 gm/100ml NPB bivalirudin rtu intravenous solution 250 mg/50ml NPB ELIQUIS DVT/PE STARTER PACK ORAL TABLET PB THERAPY PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) PB enoxaparin sodium injection solution 300 mg/3ml G enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, G 80 mg/0.8ml fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 G mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 PB UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML (dalteparin sodium) heparin sodium (porcine) injection solution 1000 unit/ml, 10000 G unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 41 Prescription Drug Name Drug Tier Drug Notes hepmed combination kit 100&0.9&2.5-2.5 ut/ml&% NF warfarin sodium (Jantoven Oral Tablet 1 Mg, 10 Mg, 2 Mg, 2.5 G LGC Mg, 3 Mg, 4 Mg, 5 Mg, 6 Mg, 7.5 Mg) LOVENOX INJECTION SOLUTION 300 MG/3ML NPB (enoxaparin sodium) LOVENOX SUBCUTANEOUS SOLUTION 100 MG/ML, 120 MG/0.8ML, 150 MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, NPB 60 MG/0.6ML, 80 MG/0.8ML (enoxaparin sodium) PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG NF (dabigatran etexilate mesylate) REGIOCIT IN VITRO SOLUTION 0.529 % (anticoagulant NPB na cit (crrt)) SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG NF (edoxaban tosylate) TRICITRASOL IN VITRO CONCENTRATE 46.7 % NPB (anticoagulant sodium citrate) warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 G LGC mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 PB MG (rivaroxaban) XARELTO STARTER PACK ORAL TABLET THERAPY PB PACK 15 & 20 MG (rivaroxaban) *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 NPB MG (eslicarbazepine acetate) BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) NPB BANZEL ORAL TABLET 200 MG, 400 MG (rufinamide) NPB BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML NPB (brivaracetam) BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) NPB BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 NPB MG, 75 MG (brivaracetam) carbamazepine er oral capsule extended release 12 hour 100 mg, G 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 mg, G 200 mg, 400 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 42 Prescription Drug Name Drug Tier Drug Notes carbamazepine oral suspension 100 mg/5ml G carbamazepine oral tablet 200 mg G carbamazepine oral tablet chewable 100 mg G CELONTIN ORAL CAPSULE 300 MG (methsuximide) NPB clobazam oral suspension 2.5 mg/ml G clobazam oral tablet 10 mg, 20 mg G clonazepam oral tablet 0.5 mg, 1 mg, 2 mg G clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 G mg, 2 mg DIACOMIT ORAL CAPSULE 250 MG, 500 MG NPB (stiripentol) DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) NPB DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG NPB (diazepam) DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) NPB diazepam rectal gel 10 mg, 2.5 mg, 20 mg G DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium NPB extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) NPB divalproex sodium er oral tablet extended release 24 hour 250 G mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg G divalproex sodium oral tablet delayed release 125 mg, 250 mg, G 500 mg EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) NPSP carbamazepine (Epitol Oral Tablet 200 Mg) G ethosuximide oral capsule 250 mg G ethosuximide oral solution 250 mg/5ml G FANATREX FUSEPAQ ORAL SUSPENSION 25 MG/ML NF (gabapentin) felbamate oral suspension 600 mg/5ml G felbamate oral tablet 400 mg, 600 mg G FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine NPSP hcl) FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) PB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 43 Prescription Drug Name Drug Tier Drug Notes FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, PB 6 MG, 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg G gabapentin oral solution 250 mg/5ml, 300 mg/6ml G gabapentin oral tablet 600 mg, 800 mg G LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, NPB 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 NPB MG, 200 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, NPB 25 MG (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG NPB (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 NPB MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 NPB & 50 & 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 NPB MG (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 G mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg G lamotrigine oral tablet chewable 25 mg, 5 mg G lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 G mg lamotrigine starter kit-blue oral kit 35 x 25 mg G lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg G lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg G levetiracetam er oral tablet extended release 24 hour 500 mg, G 750 mg levetiracetam oral solution 100 mg/ml G levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg G LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 NPB MG, 25 MG, 300 MG, 50 MG, 75 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 44 Prescription Drug Name Drug Tier Drug Notes NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam PB (anticonvulsant)) NEURONTIN ORAL SOLUTION 250 MG/5ML NPB (gabapentin) ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) NF ONFI ORAL TABLET 10 MG, 20 MG (clobazam) NF oxcarbazepine oral suspension 300 mg/5ml G oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg G OXTELLAR XR ORAL TABLET EXTENDED RELEASE PB 24 HOUR 150 MG, 300 MG, 600 MG (oxcarbazepine) phenytoin oral suspension 125 mg/5ml G phenytoin oral tablet chewable 50 mg G phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 G mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 G mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml G primidone oral tablet 250 mg, 50 mg G levetiracetam (Roweepra Oral Tablet 500 Mg) G SABRIL ORAL PACKET 500 MG (vigabatrin) NF SABRIL ORAL TABLET 500 MG (vigabatrin) NF SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG NF (levetiracetam) lamotrigine (Subvenite Oral Tablet 100 Mg, 150 Mg, 200 Mg, G 25 Mg) lamotrigine (Subvenite Starter Kit-Blue Oral Kit 35 X 25 Mg) G lamotrigine (Subvenite Starter Kit-Green Oral Kit 84 X 25 Mg G & 14X100 Mg) lamotrigine (Subvenite Starter Kit-Orange Oral Kit 42 X 25 G Mg & 7 X 100 Mg) SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG NF (clobazam) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg G topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, G 200 mg, 25 mg, 50 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 45 Prescription Drug Name Drug Tier Drug Notes topiramate oral capsule sprinkle 15 mg, 25 mg G topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg G TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG PB (topiramate) valproic acid oral capsule 250 mg G valproic acid oral solution 250 mg/5ml G VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML PB (diazepam) VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PB PACK 7.5 MG/0.1ML (diazepam) VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PB PACK 10 MG/0.1ML (diazepam) VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML PB (diazepam) vigabatrin oral packet 500 mg G vigabatrin oral tablet 500 mg G vigabatrin (Vigadrone Oral Packet 500 Mg) G VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) PB VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 PB MG (lacosamide) XCOPRI (250 MG DAILY DOSE) ORAL TABLET PB THERAPY PACK 50 & 200 MG (cenobamate) XCOPRI (350 MG DAILY DOSE) ORAL TABLET PB THERAPY PACK 150 & 200 MG (cenobamate) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 PB MG (cenobamate) XCOPRI ORAL TABLET THERAPY PACK 14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 MG & PB 14 X100 MG (cenobamate) ZARONTIN ORAL SOLUTION 250 MG/5ML NPB (ethosuximide) ZONEGRAN ORAL CAPSULE 100 MG, 25 MG NF (zonisamide) zonisamide oral capsule 100 mg, 25 mg, 50 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 46 Prescription Drug Name Drug Tier Drug Notes *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 G mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg G APLENZIN ORAL TABLET EXTENDED RELEASE 24 NF HOUR 174 MG, 348 MG, 522 MG (bupropion hbr) bupropion hcl er (sr) oral tablet extended release 12 hour 100 G mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 G mg, 300 mg bupropion hcl er (xl) oral tablet extended release 24 hour 450 NF mg bupropion hcl oral tablet 100 mg, 75 mg G citalopram hydrobromide oral solution 10 mg/5ml G citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg G LGC clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg G CYMBALTA ORAL CAPSULE DELAYED RELEASE NF PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl) desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 G mg, 75 mg desvenlafaxine er tablet extended release 24 hour 100 mg oral G 100 mg desvenlafaxine er tablet extended release 24 hour 100 mg oral NPB 100 mg desvenlafaxine er tablet extended release 24 hour 50 mg oral 50 G mg desvenlafaxine er tablet extended release 24 hour 50 mg oral 50 NPB mg desvenlafaxine succinate er oral tablet extended release 24 hour G 100 mg, 25 mg, 50 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, G 75 mg doxepin hcl oral concentrate 10 mg/ml G duloxetine hcl oral capsule delayed release particles 20 mg, 30 G mg, 40 mg, 60 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 47 Prescription Drug Name Drug Tier Drug Notes EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 150 MG, 37.5 MG, 75 MG (venlafaxine hcl) EMSAM TRANSDERMAL PATCH 24 HOUR 12 NPB MG/24HR, 6 MG/24HR, 9 MG/24HR (selegiline) escitalopram oxalate oral solution 5 mg/5ml G escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg G FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran NPB hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR NPB THERAPY PACK 20 & 40 MG (levomilnacipran hcl) fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg G LGC fluoxetine hcl oral capsule delayed release 90 mg G fluoxetine hcl oral solution 20 mg/5ml G fluoxetine hcl oral tablet 10 mg, 20 mg G fluoxetine hcl oral tablet 60 mg NF fluvoxamine maleate er oral capsule extended release 24 hour G 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg G imipramine hcl oral tablet 10 mg, 25 mg, 50 mg G imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 G mg LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG NF (escitalopram oxalate) maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg G MARPLAN ORAL TABLET 10 MG (isocarboxazid) NPB mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg G mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg G nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 G mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg G nortriptyline hcl oral solution 10 mg/5ml G paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, G 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg G LGC

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 48 Prescription Drug Name Drug Tier Drug Notes PAXIL CR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 12.5 MG, 25 MG, 37.5 MG (paroxetine hcl) PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) NF PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine hcl) PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine mesylate) phenelzine sulfate oral tablet 15 mg G PRISTIQ ORAL TABLET EXTENDED RELEASE 24 NF HOUR 100 MG, 25 MG, 50 MG (desvenlafaxine succinate) protriptyline hcl oral tablet 10 mg, 5 mg G PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG NF (fluoxetine hcl) REMERON ORAL TABLET 15 MG (mirtazapine) NPB sertraline hcl oral concentrate 20 mg/ml G sertraline hcl oral tablet 100 mg, 25 mg, 50 mg G LGC SPRAVATO (56 MG DOSE) NASAL SOLUTION NPB THERAPY PACK 28 MG/DEVICE (esketamine hcl) SPRAVATO (84 MG DOSE) NASAL SOLUTION NPB THERAPY PACK 28 MG/DEVICE (esketamine hcl) tranylcypromine sulfate oral tablet 10 mg G trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg G trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg G TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG PB (vortioxetine hbr) venlafaxine hcl er oral capsule extended release 24 hour 150 mg, G 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 mg, NF 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 225 mg G venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 G mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG NF (vilazodone hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG NF (vilazodone hcl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 49 Prescription Drug Name Drug Tier Drug Notes ZULRESSO INTRAVENOUS SOLUTION 100 MG/20ML NF (brexanolone) *ANTIDIABETICS* - HORMONES acarbose oral tablet 100 mg, 25 mg, 50 mg G ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG NF (pioglitazone hcl) ADLYXIN STARTER PACK SUBCUTANEOUS PEN- NF INJECTOR KIT 10 & 20 MCG/0.2ML (lixisenatide) ADLYXIN SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 20 MCG/0.2ML (lixisenatide) ADMELOG SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin lispro) AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 NF UNIT & 90X12 UNIT (insulin regular human) alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg NF alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg NF alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5- NF 45 mg, 25-15 mg, 25-30 mg, 25-45 mg APIDRA INJECTION SOLUTION 100 UNIT/ML (insulin NF glulisine) APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin glulisine) AVANDIA ORAL TABLET 2 MG, 4 MG (rosiglitazone NPB maleate) BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE PB (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE PB (glucagon) BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin glargine) BYDUREON BCISE SUBCUTANEOUS AUTO- NF INJECTOR 2 MG/0.85ML (exenatide) BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG NF (exenatide) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 10 MCG/0.04ML (exenatide)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 50 Prescription Drug Name Drug Tier Drug Notes BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 5 MCG/0.02ML (exenatide) CYCLOSET ORAL TABLET 0.8 MG (bromocriptine NPB mesylate) FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin PB propanediol) FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin aspart PB (w/niacinamide)) FIASP PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin aspart (w/niacinamide)) FORTAMET ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 500 MG (metformin hcl) glimepiride oral tablet 1 mg, 2 mg, 4 mg G LGC glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 G LGC mg glipizide oral tablet 10 mg, 5 mg G LGC glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 G LGC mg glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5- G LGC 500 mg GLUCAGEN HYPOKIT INJECTION SOLUTION PB RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency injection kit 1 mg PB GLUMETZA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 500 MG (metformin hcl) glyburide micronized oral tablet 1.5 mg G glyburide micronized oral tablet 3 mg, 6 mg G LGC glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg G LGC glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 G LGC mg GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG PB (empagliflozin-linagliptin)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 51 Prescription Drug Name Drug Tier Drug Notes GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 PB MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 PB MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 200 UNIT/ML (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML NF (insulin lispro prot & lispro) HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION NF (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML NF (insulin lispro prot & lispro) HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION NF (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin lispro) HUMALOG SUBCUTANEOUS SOLUTION NF CARTRIDGE 100 UNIT/ML (insulin lispro) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NF (insulin nph isophane & regular) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70- NF 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph NF human (isophane)) HUMULIN N SUBCUTANEOUS SUSPENSION 100 NF UNIT/ML (insulin nph human (isophane)) HUMULIN R INJECTION SOLUTION 100 UNIT/ML NF (insulin regular human) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML (insulin PB regular human) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 52 Prescription Drug Name Drug Tier Drug Notes HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML (insulin regular PB human) INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, NF 50-1000 MG, 50-500 MG (canagliflozin-metformin hcl) INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 NF MG, 50-500 MG (canagliflozin-metformin hcl) INVOKANA ORAL TABLET 100 MG, 300 MG NF (canagliflozin) JANUMET ORAL TABLET 50-1000 MG, 50-500 MG PB (sitagliptin-metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG PB (sitagliptin-metformin hcl) JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG PB (sitagliptin phosphate) JARDIANCE ORAL TABLET 10 MG, 25 MG PB (empagliflozin) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, NF 2.5-850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG (linagliptin- NF metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG NF (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG NF (saxagliptin-metformin) LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin glargine) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NF (insulin glargine) LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin detemir) LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin detemir)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 53 Prescription Drug Name Drug Tier Drug Notes metformin hcl er (mod) oral tablet extended release 24 hour NF 1000 mg, 500 mg metformin hcl er (osm) oral tablet extended release 24 hour NF 1000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 mg G LGC metformin hcl er oral tablet extended release 24 hour 750 mg G metformin hcl oral solution 500 mg/5ml G metformin hcl oral tablet 1000 mg, 500 mg, 850 mg G LGC miglitol oral tablet 100 mg, 25 mg, 50 mg G MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 NF UT/100ML-% (insulin regular(human) in nacl) nateglinide oral tablet 120 mg, 60 mg G LGC NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG NF (alogliptin benzoate) NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NF (insulin nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML PB (insulin nph isophane & regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML (insulin nph isophane & NF regular) NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) PB 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN N FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph NF human (isophane)) NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph PB human (isophane)) NOVOLIN N RELION SUBCUTANEOUS SUSPENSION NF 100 UNIT/ML (insulin nph human (isophane)) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 PB UNIT/ML (insulin nph human (isophane)) NOVOLIN R FLEXPEN INJECTION SOLUTION PEN- PB INJECTOR 100 UNIT/ML (insulin regular human)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 54 Prescription Drug Name Drug Tier Drug Notes NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin regular NF human) NOVOLIN R INJECTION SOLUTION 100 UNIT/ML PB (insulin regular human) NOVOLIN R RELION INJECTION SOLUTION 100 NF UNIT/ML (insulin regular human) NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML PB (insulin aspart prot & aspart) NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION PB (70-30) 100 UNIT/ML (insulin aspart prot & aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE 100 UNIT/ML (insulin aspart) NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin aspart) ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) NF OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG (alogliptin- NF pioglitazone) OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS PB SOLUTION PEN-INJECTOR 2 MG/1.5ML (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 2 MG/1.5ML (semaglutide) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg G LGC pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg G pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg G LGC PROGLYCEM ORAL SUSPENSION 50 MG/ML NPB (diazoxide) QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin- NF saxagliptin) repaglinide oral tablet 0.5 mg, 1 mg, 2 mg G LGC RIOMET ORAL SOLUTION 500 MG/5ML (metformin hcl) NF RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG PB (semaglutide)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 55 Prescription Drug Name Drug Tier Drug Notes SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 NF MG, 7.5-1000 MG, 7.5-500 MG (ertugliflozin-metformin hcl) SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-33 UNT-MCG/ML (insulin glargine- PB lixisenatide) STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin NF l-pyroglutamicac) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG NF (ertugliflozin-sitagliptin) SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 2700 MCG/2.7ML (pramlintide acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 1500 MCG/1.5ML (pramlintide acetate) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, PB 5-1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 PB MG (empagliflozin-metformin hcl) tolbutamide oral tablet 500 mg G TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML (insulin PB glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 300 UNIT/ML (insulin glargine) TRADJENTA ORAL TABLET 5 MG (linagliptin) NF TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin PB degludec) TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin degludec) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, PB 5-2.5-1000 MG (empagliflozin-linaglip-metform) TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, PB 4.5 MG/0.5ML (dulaglutide) VICTOZA SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 18 MG/3ML (liraglutide)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 56 Prescription Drug Name Drug Tier Drug Notes XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, PB 5-500 MG (dapagliflozin-metformin hcl) XULTOPHY SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML (insulin degludec- PB liraglutide) *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml G diphenoxylate-atropine oral tablet 2.5-0.025 mg G loperamide hcl oral capsule 2 mg G MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin- NF atropine) MYTESI ORAL TABLET DELAYED RELEASE 125 MG NF (crofelemer) opium oral tincture 10 mg/ml (1%) G probichew oral tablet chewable NF prodigen oral capsule NF provad oral capsule NF RESTORA RX ORAL CAPSULE 60-1.25 MG (lactobacillus NPB casei-folic acid) VSL#3 DS ORAL PACKET (probiotic product) NPB zelac oral capsule NF *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING BRIDION INTRAVENOUS SOLUTION 200 MG/2ML, 500 NF MG/5ML (sugammadex sodium) CHEMET ORAL CAPSULE 100 MG (succimer) NPB deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg G deferoxamine mesylate injection solution reconstituted 2 gm, G 500 mg DESFERAL INJECTION SOLUTION RECONSTITUTED NPSP 500 MG (deferoxamine mesylate) EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, NPSP 500 MG (deferasirox) FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 57 Prescription Drug Name Drug Tier Drug Notes FERRIPROX ORAL TABLET 1000 MG, 500 MG NPSP (deferiprone) FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG NPSP (deferiprone) JADENU ORAL TABLET 180 MG, 360 MG, 90 MG NPSP (deferasirox) JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, NPSP 90 MG (deferasirox) naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml G naloxone hcl injection solution auto-injector 2 mg/0.4ml NF naloxone hcl injection solution cartridge 0.4 mg/ml G naloxone hcl injection solution prefilled syringe 2 mg/2ml G naltrexone hcl oral tablet 50 mg G NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) PB PROVAYBLUE INTRAVENOUS SOLUTION 50 NF MG/10ML (methylene blue (antidote)) RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue NPB insoluble) VIVITROL INTRAMUSCULAR SUSPENSION NPSP RECONSTITUTED 380 MG (naltrexone) *ANTIEMETICS* - DRUGS FOR THE STOMACH AKYNZEO INTRAVENOUS SOLUTION 235-0.25 NPB MG/20ML (fosnetupitant-palonosetron) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 235-0.25 MG (fosnetupitant- NPB palonosetron) AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- NPB palonosetron) ANZEMET ORAL TABLET 100 MG, 50 MG (dolasetron NPB mesylate) aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg G BONJESTA ORAL TABLET EXTENDED RELEASE 20- NF 20 MG (doxylamine-pyridoxine) CINVANTI INTRAVENOUS EMULSION 130 MG/18ML NF (aprepitant) DICLEGIS ORAL TABLET DELAYED RELEASE 10-10 NPB MG (doxylamine-pyridoxine) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 58 Prescription Drug Name Drug Tier Drug Notes doxylamine-pyridoxine oral tablet delayed release 10-10 mg G dronabinol oral capsule 10 mg, 2.5 mg, 5 mg G EMEND INTRAVENOUS SOLUTION NPB RECONSTITUTED 150 MG (fosaprepitant dimeglumine) EMEND ORAL CAPSULE 40 MG, 80 MG (aprepitant) NPB EMEND ORAL SUSPENSION RECONSTITUTED 125 NPB MG/5ML (aprepitant) EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG NPB (aprepitant) granisetron hcl oral tablet 1 mg G MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG NPB (dronabinol) meclizine hcl oral tablet 12.5 mg, 25 mg G ondansetron hcl oral solution 4 mg/5ml G ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg G ondansetron oral tablet dispersible 4 mg, 8 mg G SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR PB (granisetron) scopolamine transdermal patch 72 hour 1 mg/3days G SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 NF MG/0.4ML (granisetron) SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) NF TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH NF 72 HOUR 1 MG/3DAYS (scopolamine base) TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH NF 72 HOUR 1 MG/3DAYS (scopolamine base) trimethobenzamide hcl oral capsule 300 mg G VARUBI (180 MG DOSE) ORAL TABLET THERAPY NPB PACK 2 X 90 MG (rolapitant hcl) ZUPLENZ ORAL FILM 4 MG, 8 MG (ondansetron) NF *ANTIFUNGALS* - DRUGS FOR INFECTIONS bio-statin oral capsule 1000000 unit, 500000 unit NPB bio-statin oral powder G CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium NPB sulfate) fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 59 Prescription Drug Name Drug Tier Drug Notes fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg G flucytosine oral capsule 250 mg G flucytosine oral capsule 500 mg NF griseofulvin microsize oral suspension 125 mg/5ml G griseofulvin microsize oral tablet 500 mg G griseofulvin ultramicrosize oral tablet 125 mg, 250 mg G itraconazole oral capsule 100 mg G itraconazole oral solution 10 mg/ml G ketoconazole oral tablet 200 mg G NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) NPB NOXAFIL ORAL TABLET DELAYED RELEASE 100 NPB MG (posaconazole) nystatin oral tablet 500000 unit G posaconazole oral tablet delayed release 100 mg NF terbinafine hcl oral tablet 250 mg G tolsura oral capsule 65 mg NF voriconazole oral suspension reconstituted 40 mg/ml G voriconazole oral tablet 200 mg, 50 mg G *ANTIHISTAMINES* - DRUGS FOR THE LUNGS carbinoxamine maleate oral solution 4 mg/5ml G carbinoxamine maleate oral tablet 4 mg G carbinoxamine maleate oral tablet 6 mg NF cetirizine hcl oral solution 1 mg/ml G clemastine fumarate oral tablet 2.68 mg G cyproheptadine hcl oral syrup 2 mg/5ml G cyproheptadine hcl oral tablet 4 mg G desloratadine oral tablet 5 mg G desloratadine oral tablet dispersible 2.5 mg, 5 mg G dexchlorpheniramine maleate oral solution 2 mg/5ml NF diphen oral elixir 12.5 mg/5ml NF diphenhydramine hcl oral elixir 12.5 mg/5ml G KARBINAL ER ORAL SUSPENSION EXTENDED NPB RELEASE 4 MG/5ML (carbinoxamine maleate) levocetirizine dihydrochloride oral solution 2.5 mg/5ml G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 60 Prescription Drug Name Drug Tier Drug Notes levocetirizine dihydrochloride oral tablet 5 mg G promethazine hcl oral syrup 6.25 mg/5ml G promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg G promethazine hcl rectal suppository 12.5 mg, 25 mg G promethazine hcl (Promethegan Rectal Suppository 12.5 Mg, G 25 Mg) PROMETHEGAN RECTAL SUPPOSITORY 50 MG G (promethazine hcl) RYCLORA ORAL SOLUTION 2 MG/5ML NF (dexchlorpheniramine maleate) RYVENT ORAL TABLET 6 MG (carbinoxamine maleate) G *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART ALTOPREV ORAL TABLET EXTENDED RELEASE 24 NF HOUR 20 MG, 40 MG, 60 MG (lovastatin) ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate NPB micronized) atorvastatin calcium oral tablet 10 mg, 20 mg CE LGC atorvastatin calcium oral tablet 40 mg, 80 mg G LGC cholestyramine light oral packet 4 gm G cholestyramine light oral powder 4 gm/dose G cholestyramine oral packet 4 gm G cholestyramine oral powder 4 gm/dose G colesevelam hcl oral packet 3.75 gm G colesevelam hcl oral tablet 625 mg G colestipol hcl oral granules 5 gm G colestipol hcl oral packet 5 gm G colestipol hcl oral tablet 1 gm G CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG NF (rosuvastatin calcium) equapax/atorvastatin/coq10 oral therapy pack 20 & 100 mg NF EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 NF MG, 20 MG, 40 MG, 5 MG (rosuvastatin calcium) ezetimibe oral tablet 10 mg G ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, G 10-80 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 61 Prescription Drug Name Drug Tier Drug Notes fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 G mg, 67 mg fenofibrate oral capsule 150 mg, 50 mg G fenofibrate oral tablet 120 mg NF fenofibrate oral tablet 145 mg, 160 mg, 40 mg, 48 mg, 54 mg G fenofibric acid oral capsule delayed release 135 mg, 45 mg G fenofibric acid oral tablet 105 mg G FENOGLIDE ORAL TABLET 120 MG (fenofibrate) NF FIBRICOR ORAL TABLET 105 MG, 35 MG (fenofibric NPB acid) flolipid oral suspension 20 mg/5ml, 40 mg/5ml NF fluvastatin sodium er oral tablet extended release 24 hour 80 mg G fluvastatin sodium oral capsule 20 mg, 40 mg G gemfibrozil oral tablet 600 mg G LGC JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 NPSP MG (lomitapide mesylate) LESCOL XL ORAL TABLET EXTENDED RELEASE 24 NF HOUR 80 MG (fluvastatin sodium) LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG NF (atorvastatin calcium) LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin NF calcium) lovastatin oral tablet 10 mg, 20 mg, 40 mg G LGC NEXLETOL ORAL TABLET 180 MG (bempedoic acid) PB NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- PB ezetimibe) niacin (antihyperlipidemic) oral tablet 500 mg NF niacin er (antihyperlipidemic) oral tablet extended release 1000 G mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG (niacin NF (antihyperlipidemic)) omega-3 rx complete oral therapy pack 1 gm NF OMEGA-3/D-3 WELLNESS PACK ORAL KIT 1 & 1000 NF GM & UNIT (omega-3-acid ethyl esters & d3) omega-3-acid ethyl esters oral capsule 1 gm G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 62 Prescription Drug Name Drug Tier Drug Notes PRALUENT SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 150 MG/ML (alirocumab) PRALUENT SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 75 MG/ML (alirocumab) pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg G LGC cholestyramine light (Prevalite Oral Packet 4 Gm) G cholestyramine light (Prevalite Oral Powder 4 Gm/Dose) G REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS NF SOLUTION CARTRIDGE 420 MG/3.5ML (evolocumab) REPATHA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 140 MG/ML (evolocumab) REPATHA SURECLICK SUBCUTANEOUS SOLUTION NF AUTO-INJECTOR 140 MG/ML (evolocumab) rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg CE LGC simvastatin oral tablet 80 mg G LGC sure result o3d3 system oral kit 1 & 1000 gm & unit NF TRICOR ORAL TABLET 145 MG, 48 MG (fenofibrate) NF VASCEPA ORAL CAPSULE 0.5 GM, 1 GM (icosapent PB ethyl) ZETIA ORAL TABLET 10 MG (ezetimibe) NF ZYPITAMAG ORAL TABLET 2 MG, 4 MG (pitavastatin NF magnesium) *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART aliskiren fumarate oral tablet 150 mg, 300 mg G amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, G LGC 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, G LGC 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, G LGC 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 G LGC mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 NF MG, 32-25 MG (candesartan cilexetil-hctz)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 63 Prescription Drug Name Drug Tier Drug Notes ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG NF (candesartan cilexetil) atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg G benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg, 5-6.25 mg BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, NF 40-25 MG (olmesartan medoxomil-hctz) BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG NF (olmesartan medoxomil) bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 G LGC mg, 5-6.25 mg candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg G LGC candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, G LGC 32-25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg G LGC captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, G 50-15 mg, 50-25 mg clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg G LGC clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, G 0.3 mg/24hr DEMSER ORAL CAPSULE 250 MG (metyrosine) NPB DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- NF hydrochlorothiazide) DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 NF MG (valsartan) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg G DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- NF hydrochlorothiazide) EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan NF medoxomil) EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG NF (azilsartan-chlorthalidone) enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg G LGC enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg G LGC 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 64 Prescription Drug Name Drug Tier Drug Notes EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) NPB eplerenone oral tablet 25 mg, 50 mg G EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160- 25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG NF (amlodipine-valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 NF MG, 5-320 MG (amlodipine besylate-valsartan) fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg G LGC fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg G LGC guanfacine hcl oral tablet 1 mg, 2 mg G hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg G hydralazine hcl oral tablet 25 mg G LGC irbesartan oral tablet 150 mg, 300 mg, 75 mg G LGC irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- G LGC 12.5 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg G LGC lisinopril oral tablet 30 mg, 40 mg G lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg losartan potassium oral tablet 100 mg, 25 mg, 50 mg G LGC losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50- G LGC 12.5 mg methyldopa oral tablet 250 mg, 500 mg G methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 G mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 G mg, 50-25 mg minoxidil oral tablet 10 mg, 2.5 mg G moexipril hcl oral tablet 15 mg, 7.5 mg G NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 50-0.9 MG/100ML-% (nitroprusside sodium- NF nacl) olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg G LGC olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, G LGC 40-25 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 65 Prescription Drug Name Drug Tier Drug Notes olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- G LGC 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg G LGC phenoxybenzamine hcl oral capsule 10 mg G prazosin hcl oral capsule 1 mg, 2 mg, 5 mg G PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 NF MG (perindopril arg-amlodipine) propranolol-hctz oral tablet 40-25 mg, 80-25 mg G QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) NPB quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg G LGC TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 PB MG, 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG (aliskiren NPB fumarate) telmisartan oral tablet 20 mg, 40 mg, 80 mg G LGC telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 G LGC mg, 80-5 mg telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg G LGC terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg G LGC trandolapril oral tablet 1 mg, 2 mg, 4 mg G LGC trandolapril-verapamil hcl er oral tablet extended release 1-240 G mg, 2-180 mg, 2-240 mg, 4-240 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg G LGC valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 G LGC mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) NPB *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS AEMCOLO ORAL TABLET DELAYED RELEASE 194 NPB MG (rifamycin sodium) ALINIA ORAL SUSPENSION RECONSTITUTED 100 NPB MG/5ML (nitazoxanide) ALINIA ORAL TABLET 500 MG (nitazoxanide) NPB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 66 Prescription Drug Name Drug Tier Drug Notes atovaquone oral suspension 750 mg/5ml G CAYSTON INHALATION SOLUTION NPSP RECONSTITUTED 75 MG (aztreonam lysine) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg G clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml G dapsone oral tablet 100 mg, 25 mg G FIRST-METRONIDAZOLE ORAL SUSPENSION NF RECONSTITUTED 50 MG/ML (metronidazole benzoate) FIRVANQ ORAL SOLUTION RECONSTITUTED 25 NF MG/ML, 50 MG/ML (vancomycin hcl) HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz G acd-ph sal) IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) NPB LAMPIT ORAL TABLET 120 MG, 30 MG (nifurtimox) NPB linezolid oral suspension reconstituted 100 mg/5ml G linezolid oral tablet 600 mg G MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 NF MG (nitrofurantoin macrocrystal) me/naphos/mb/hyo1 oral tablet 81.6 mg G methenamine hippurate oral tablet 1 gm G methenamine mandelate oral tablet 0.5 gm, 1 gm G METRONIDAZOLE BENZO+SYRSPEND ORAL SUSPENSION RECONSTITUTED 50 MG/ML NF (metronidazole benzoate) metronidazole oral capsule 375 mg G metronidazole oral tablet 250 mg, 500 mg G MONUROL ORAL PACKET 3 GM (fosfomycin NPB tromethamine) NEBUPENT INHALATION SOLUTION NPB RECONSTITUTED 300 MG (pentamidine isethionate) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg G nitrofurantoin monohyd macro oral capsule 100 mg G nitrofurantoin oral suspension 25 mg/5ml G meth-hyo-m bl-na phos-ph sal (Phosphasal Oral Tablet 81.6 G Mg)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 67 Prescription Drug Name Drug Tier Drug Notes PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim NPB hcl) RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM (imipenem-cilastatin- NPB relebactam) SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) NPB sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml G sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 G mg sulfamethoxazole-trimethoprim (Sulfatrim Pediatric Oral G Suspension 200-40 Mg/5Ml) tinidazole oral tablet 250 mg, 500 mg G trimethoprim oral tablet 100 mg G meth-hyo-m bl-na phos-ph sal (Uribel Oral Capsule 118 Mg) G URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na G phos-ph sal) uro-458 oral tablet 81 mg G uro-mp oral capsule 118 mg G meth-hyo-m bl-na phos-ph sal (Ustell Oral Capsule 120 Mg) G uticap oral capsule 120 mg G meth-hyo-m bl-na phos-ph sal (Utira-C Oral Tablet 81.6 Mg) G meth-hyo-m bl-na phos-ph sal (Utrona-C Oral Tablet 81.6 Mg) G vancomycin hcl intravenous solution 1250 mg/250ml, 1750 NPB mg/350ml, 500 mg/100ml, 750 mg/150ml vancomycin hcl oral capsule 125 mg, 250 mg G VANCOMYCIN+SYRSPEND SF ORAL SUSPENSION 50 NF MG/ML (vancomycin hcl) meth-hyo-m bl-na phos-ph sal (Vilamit Mb Oral Capsule 118 G Mg) meth-hyo-m bl-na phos-ph sal (Vilevev Mb Oral Tablet 81 Mg) G XENLETA ORAL TABLET 600 MG (lefamulin acetate) NPB XIFAXAN ORAL TABLET 200 MG (rifaximin) NPB XIFAXAN ORAL TABLET 550 MG (rifaximin) PB *ANTIMALARIALS* - DRUGS FOR INFECTIONS ARAKODA ORAL TABLET 100 MG (tafenoquine NF succinate) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 68 Prescription Drug Name Drug Tier Drug Notes atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg G chloroquine phosphate oral tablet 250 mg, 500 mg G COARTEM ORAL TABLET 20-120 MG (artemether- NPB lumefantrine) DARAPRIM ORAL TABLET 25 MG (pyrimethamine) NF hydroxychloroquine sulfate oral tablet 200 mg G KRINTAFEL ORAL TABLET 150 MG (tafenoquine NF succinate) mefloquine hcl oral tablet 250 mg G PLAQUENIL ORAL TABLET 200 MG (hydroxychloroquine PB sulfate) primaquine phosphate oral tablet 26.3 mg G pyrimethamine oral tablet 25 mg G quinine sulfate oral capsule 324 mg G *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES FIRDAPSE ORAL TABLET 10 MG (amifampridine NPB phosphate) guanidine hcl oral tablet 125 mg NPB MESTINON ORAL SOLUTION 60 MG/5ML NPB (pyridostigmine bromide) MESTINON ORAL TABLET 60 MG (pyridostigmine NPB bromide) pyridostigmine bromide er oral tablet extended release 180 mg G pyridostigmine bromide oral solution 60 mg/5ml G pyridostigmine bromide oral tablet 60 mg G RUZURGI ORAL TABLET 10 MG (amifampridine) NPB *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS cycloserine oral capsule 250 mg G ethambutol hcl oral tablet 100 mg, 400 mg G isoniazid oral syrup 50 mg/5ml G isoniazid oral tablet 100 mg, 300 mg G PASER ORAL PACKET 4 GM (aminosalicylic acid) NPB pretomanid oral tablet 200 mg NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 69 Prescription Drug Name Drug Tier Drug Notes PRIFTIN ORAL TABLET 150 MG (rifapentine) NPB pyrazinamide oral tablet 500 mg G rifabutin oral capsule 150 mg G rifampin oral capsule 150 mg, 300 mg G RIFAMPIN+SYRSPEND SF ORAL SUSPENSION 25 NF MG/ML (rifampin) SIRTURO ORAL TABLET 20 MG (bedaquiline fumarate) NPB TRECATOR ORAL TABLET 250 MG (ethionamide) NPB *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER abiraterone acetate oral tablet 250 mg G ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 NPSP UNIT/0.5ML (interferon gamma-1b) AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 PSP MG, 5 MG (everolimus) AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 PSP MG (everolimus) ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) PSP ALIQOPA INTRAVENOUS SOLUTION NF RECONSTITUTED 60 MG (copanlisib hcl) ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG PSP (brigatinib) ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 PSP MG (brigatinib) anastrozole oral tablet 1 mg G ASPARLAS INTRAVENOUS SOLUTION 3750 NPSP UNIT/5ML (calaspargase pegol-mknl) BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG NPSP (erdafitinib) BELEODAQ INTRAVENOUS SOLUTION NPSP RECONSTITUTED 500 MG (belinostat) BELRAPZO INTRAVENOUS SOLUTION 100 MG/4ML NF (bendamustine hcl) BESPONSA INTRAVENOUS SOLUTION NPSP RECONSTITUTED 0.9 MG (inotuzumab ozogamicin) bexarotene oral capsule 75 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 70 Prescription Drug Name Drug Tier Drug Notes bicalutamide oral tablet 50 mg G BLENREP INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (belantamab mafodotin-blmf) bortezomib intravenous solution reconstituted 3.5 mg NF BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG PSP (bosutinib) BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) NPSP CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PSP (cabozantinib s-malate) capecitabine oral tablet 150 mg, 500 mg G CAPRELSA ORAL TABLET 300 MG (vandetanib) NPB COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 NPSP MG (cabozantinib s-malate) COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 NPSP MG & 80 MG (cabozantinib s-malate) COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG NPSP (cabozantinib s-malate) COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) PSP COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) NPSP cyclophosphamide intravenous solution 1 gm/5ml, 500 mg/2.5ml NPSP cyclophosphamide oral capsule 25 mg, 50 mg G CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, NPB 500 MG/50ML (ramucirumab) DARZALEX FASPRO SUBCUTANEOUS SOLUTION NF 1800-30000 MG-UT/15ML (daratumumab-hyaluronidase-fihj) DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib NF maleate) ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide PSP acetate (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide PSP acetate (4 month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide PSP acetate (6 month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide PSP acetate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 71 Prescription Drug Name Drug Tier Drug Notes EMCYT ORAL CAPSULE 140 MG (estramustine phosphate PB sodium) ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) PSP ERLEADA ORAL TABLET 60 MG (apalutamide) PSP erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg G ERWINAZE INJECTION SOLUTION RECONSTITUTED NPSP 10000 UNIT (asparaginase erwinia chrysanth) etoposide oral capsule 50 mg G EVOMELA INTRAVENOUS SOLUTION NF RECONSTITUTED 50 MG (melphalan hcl) exemestane oral tablet 25 mg G FARYDAK ORAL CAPSULE 10 MG, 20 MG (panobinostat NF lactate) FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG/VIAL (degarelix NPSP acetate) FIRMAGON SUBCUTANEOUS SOLUTION NPSP RECONSTITUTED 80 MG (degarelix acetate) flutamide oral capsule 125 mg G GLEEVEC ORAL TABLET 100 MG, 400 MG (imatinib NF mesylate) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG NPB (lomustine) GLIADEL WAFER IMPLANT WAFER 7.7 MG NPB (carmustine in polifeprosan) HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION NF 600-10000 MG-UNT/5ML (trastuzumab-hyaluronidase-oysk) HERZUMA INTRAVENOUS SOLUTION NF RECONSTITUTED 150 MG, 420 MG (trastuzumab-pkrb) HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan NPSP hcl) hydroxyurea oral capsule 500 mg G IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PSP (palbociclib) IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PSP (palbociclib)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 72 Prescription Drug Name Drug Tier Drug Notes IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib NPSP mesylate) imatinib mesylate oral tablet 100 mg, 400 mg G IMLYGIC INTRALESIONAL SUSPENSION 1000000 NPSP UNIT/ML, 100000000 UNIT/ML (talimogene laherparepvec) INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML-%, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 NF MG/160ML-%, 1700-0.9 MG/170ML-%, 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-% (gemcitabine hcl-nacl) INLYTA ORAL TABLET 1 MG, 5 MG (axitinib) NPSP INQOVI ORAL TABLET 35-100 MG (decitabine- NF cedazuridine) INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) NF INTRON A INJECTION SOLUTION 10000000 UNIT/ML, NPSP 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon NPSP alfa-2b) IRESSA ORAL TABLET 250 MG (gefitinib) PSP JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 NPSP MG (ruxolitinib phosphate) JELMYTO SOLUTION RECONSTITUTED 80 (2 X 40) NPSP MG (mitomycin) KANJINTI INTRAVENOUS SOLUTION NF RECONSTITUTED 150 MG, 420 MG (trastuzumab-anns) KHAPZORY INTRAVENOUS SOLUTION NF RECONSTITUTED 175 MG, 300 MG (levoleucovorin) KISQALI (200 MG DOSE) ORAL TABLET THERAPY PSP PACK 200 MG (ribociclib succinate) KISQALI (400 MG DOSE) ORAL TABLET THERAPY PSP PACK 200 MG (ribociclib succinate) KISQALI (600 MG DOSE) ORAL TABLET THERAPY PSP PACK 200 MG (ribociclib succinate) KISQALI FEMARA (400 MG DOSE) ORAL TABLET PSP THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 73 Prescription Drug Name Drug Tier Drug Notes KISQALI FEMARA (600 MG DOSE) ORAL TABLET PSP THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KISQALI FEMARA(200 MG DOSE) ORAL TABLET PSP THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KOSELUGO ORAL CAPSULE 10 MG, 25 MG (selumetinib NPSP sulfate) KYPROLIS INTRAVENOUS SOLUTION NF RECONSTITUTED 10 MG, 30 MG, 60 MG (carfilzomib) LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 10 MG (lenvatinib mesylate) LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 3 X 4 MG (lenvatinib mesylate) LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 10 & 4 MG (lenvatinib mesylate) LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 10 MG & 2 X 4 MG (lenvatinib mesylate) LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 2 X 10 MG (lenvatinib mesylate) LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 2 X 10 MG & 4 MG (lenvatinib mesylate) LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 4 MG (lenvatinib mesylate) LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 2 X 4 MG (lenvatinib mesylate) letrozole oral tablet 2.5 mg G leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg G LEUKERAN ORAL TABLET 2 MG (chlorambucil) PB leuprolide acetate injection kit 1 mg/0.2ml G LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG NPSP (trifluridine-tipiracil) LORBRENA ORAL TABLET 100 MG, 25 MG (lorlatinib) NPSP LUMOXITI INTRAVENOUS SOLUTION NPSP RECONSTITUTED 1 MG (moxetumomab pasudotox-tdfk) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT NPSP 3.75 MG (leuprolide acetate) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT NF 7.5 MG (leuprolide acetate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 74 Prescription Drug Name Drug Tier Drug Notes LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT NPSP 11.25 MG (leuprolide acetate (3 month)) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT NF 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT NF 30 MG (leuprolide acetate (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT NF 45 MG (leuprolide acetate (6 month)) LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) PSP LYSODREN ORAL TABLET 500 MG (mitotane) PB MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) PB megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml G megestrol acetate oral tablet 20 mg, 40 mg G MEKINIST ORAL TABLET 0.5 MG, 2 MG (trametinib NPSP dimethyl sulfoxide) melphalan oral tablet 2 mg G mercaptopurine oral tablet 50 mg G MESNEX ORAL TABLET 400 MG (mesna) NPB methotrexate sodium (pf) injection solution 1 gm/40ml, 250 G mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml G methotrexate sodium injection solution reconstituted 1 gm G methotrexate sodium oral tablet 2.5 mg G MVASI INTRAVENOUS SOLUTION 100 MG/4ML, 400 NF MG/16ML (bevacizumab-awwb) MYLERAN ORAL TABLET 2 MG (busulfan) PB MYLOTARG INTRAVENOUS SOLUTION NPSP RECONSTITUTED 4.5 MG (gemtuzumab ozogamicin) NERLYNX ORAL TABLET 40 MG (neratinib maleate) NPSP NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) NPSP NILANDRON ORAL TABLET 150 MG (nilutamide) NF nilutamide oral tablet 150 mg G NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PSP (ixazomib citrate) NUBEQA ORAL TABLET 300 MG (darolutamide) PSP

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 75 Prescription Drug Name Drug Tier Drug Notes ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) PSP OGIVRI INTRAVENOUS SOLUTION NF RECONSTITUTED 150 MG, 420 MG (trastuzumab-dkst) ONCASPAR INJECTION SOLUTION 750 UNIT/ML NPSP (pegaspargase) ONUREG ORAL TABLET 200 MG, 300 MG (azacitidine) NF paclitaxel intravenous concentrate 100 mg/16.67ml G PARAPLATIN INTRAVENOUS SOLUTION 1000 NPSP MG/100ML (carboplatin) PERJETA INTRAVENOUS SOLUTION 420 MG/14ML PSP (pertuzumab) PHESGO SUBCUTANEOUS SOLUTION 60-60-2000 MG- MG-U/ML, 80-40-2000 MG-MG-U/ML (pertuz-trastuz- PSP hyaluron-zzxf) PIQRAY (200 MG DAILY DOSE) ORAL TABLET NF THERAPY PACK 200 MG (alpelisib) PIQRAY (250 MG DAILY DOSE) ORAL TABLET NF THERAPY PACK 200 & 50 MG (alpelisib) PIQRAY (300 MG DAILY DOSE) ORAL TABLET NF THERAPY PACK 2 X 150 MG (alpelisib) POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 140 MG, 30 MG (polatuzumab vedotin- NF piiq) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG NPSP (pomalidomide) PORTRAZZA INTRAVENOUS SOLUTION 800 NPB MG/50ML (necitumumab) PROLEUKIN INTRAVENOUS SOLUTION NPSP RECONSTITUTED 22000000 UNIT (aldesleukin) PURIXAN ORAL SUSPENSION 2000 MG/100ML NPSP (mercaptopurine) RETEVMO ORAL CAPSULE 40 MG, 80 MG (selpercatinib) NF romidepsin intravenous solution 27.5 mg/5.5ml NPSP ROZLYTREK ORAL CAPSULE 100 MG, 200 MG NPSP (entrectinib) RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PSP (rucaparib camsylate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 76 Prescription Drug Name Drug Tier Drug Notes RYDAPT ORAL CAPSULE 25 MG (midostaurin) PSP SARCLISA INTRAVENOUS SOLUTION 100 MG/5ML, NF 500 MG/25ML (isatuximab-irfc) SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen NPB citrate) SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 PSP MG, 70 MG, 80 MG (dasatinib) STIVARGA ORAL TABLET 40 MG (regorafenib) NPSP SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 PSP MG (sunitinib malate) SYNRIBO SUBCUTANEOUS SOLUTION NPB RECONSTITUTED 3.5 MG (omacetaxine mepesuccinate) TABLOID ORAL TABLET 40 MG (thioguanine) PB TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib NPSP mesylate) TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib NPSP mesylate) TALZENNA ORAL CAPSULE 0.25 MG, 1 MG (talazoparib NF tosylate) tamoxifen citrate oral tablet 10 mg, 20 mg CE TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG NPSP (erlotinib hcl) TARGRETIN ORAL CAPSULE 75 MG (bexarotene) NPSP TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG NF (nilotinib hcl) TECARTUS INTRAVENOUS SUSPENSION NPSP (brexucabtagene autoleucel) TEMODAR INTRAVENOUS SOLUTION NPSP RECONSTITUTED 100 MG (temozolomide) TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, NPSP 20 MG, 250 MG, 5 MG (temozolomide) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 G mg, 5 mg TICE BCG INTRAVESICAL SUSPENSION NPB RECONSTITUTED 50 MG (bcg live) toremifene citrate oral tablet 60 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 77 Prescription Drug Name Drug Tier Drug Notes TOTECT INTRAVENOUS SOLUTION NF RECONSTITUTED 500 MG (dexrazoxane hcl) TREANDA INTRAVENOUS SOLUTION NPSP RECONSTITUTED 100 MG, 25 MG (bendamustine hcl) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, NPSP 3.75 MG (triptorelin pamoate) tretinoin oral capsule 10 mg G TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG PB (methotrexate sodium) TRODELVY INTRAVENOUS SOLUTION NPSP RECONSTITUTED 180 MG (sacituzumab govitecan-hziy) TRUXIMA INTRAVENOUS SOLUTION 100 MG/10ML, NF 500 MG/50ML (rituximab-abbs) TUKYSA ORAL TABLET 150 MG, 50 MG (tucatinib) NPSP TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) NF TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) PSP VANTAS SUBCUTANEOUS KIT 50 MG (histrelin acetate) NPSP VELCADE INJECTION SOLUTION RECONSTITUTED PSP 3.5 MG (bortezomib) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 NPSP MG (abemaciclib) VITRAKVI ORAL CAPSULE 100 MG, 25 MG (larotrectinib NPSP sulfate) VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG NF (dacomitinib) VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) PSP VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG (daunorubicin-cytarabine NPSP lipo) XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) NPSP XELODA ORAL TABLET 150 MG, 500 MG (capecitabine) NPSP XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML NF (radium ra 223 dichloride) XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) PSP XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 78 Prescription Drug Name Drug Tier Drug Notes XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) XTANDI ORAL CAPSULE 40 MG (enzalutamide) PSP YONSA ORAL TABLET 125 MG (abiraterone acetate) PSP ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) PSP ZELBORAF ORAL TABLET 240 MG (vemurafenib) NPSP ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 NPSP MG (goserelin acetate) ZOLINZA ORAL CAPSULE 100 MG (vorinostat) PSP ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) NF ZYKADIA ORAL TABLET 150 MG (ceritinib) NPSP ZYTIGA ORAL TABLET 250 MG, 500 MG (abiraterone NF acetate) *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM amantadine hcl oral capsule 100 mg G amantadine hcl oral syrup 50 mg/5ml G amantadine hcl oral tablet 100 mg G APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE NF 30 MG/3ML (apomorphine hcl) benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg G bromocriptine mesylate oral capsule 5 mg G bromocriptine mesylate oral tablet 2.5 mg G carbidopa oral tablet 25 mg G carbidopa-levodopa er oral tablet extended release 25-100 mg, G 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 G mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 G mg, 25-250 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 79 Prescription Drug Name Drug Tier Drug Notes carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150- G 200 mg, 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML NPSP (carbidopa-levodopa) entacapone oral tablet 200 mg G GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 137 MG, 68.5 MG (amantadine hcl) INBRIJA INHALATION CAPSULE 42 MG (levodopa) PSP NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 PB MG/24HR, 8 MG/24HR (rotigotine) NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) NF OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY NF PACK 129 & 193 MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE NF 24 HOUR 129 MG, 193 MG, 258 MG (amantadine hcl) pramipexole dihydrochloride er oral tablet extended release 24 G hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 G mg, 0.75 mg, 1 mg, 1.5 mg rasagiline mesylate oral tablet 0.5 mg, 1 mg G ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 G mg, 4 mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 G mg, 5 mg RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG NPB (carbidopa-levodopa) selegiline hcl oral capsule 5 mg G selegiline hcl oral tablet 5 mg G tolcapone oral tablet 100 mg G trihexyphenidyl hcl oral solution 0.4 mg/ml G trihexyphenidyl hcl oral tablet 2 mg, 5 mg G XADAGO ORAL TABLET 100 MG, 50 MG (safinamide NF mesylate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 80 Prescription Drug Name Drug Tier Drug Notes ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG NPB (selegiline hcl) *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM ABILIFY MAINTENA INTRAMUSCULAR PREFILLED PB SYRINGE 300 MG, 400 MG (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG PB (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, NF 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, NF 30 MG, 5 MG (aripiprazole) ADASUVE INHALATION AEROSOL POWDER NPB BREATH ACTIVATED 10 MG (loxapine) aripiprazole oral solution 1 mg/ml G aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg G aripiprazole oral tablet dispersible 10 mg, 15 mg G ARISTADA INITIO INTRAMUSCULAR PREFILLED NPB SYRINGE 675 MG/2.4ML (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 NPB MG/3.2ML (aripiprazole lauroxil) chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml NPB chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, G 50 mg clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg G clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 G mg, 25 mg CLOZARIL ORAL TABLET 200 MG, 50 MG (clozapine) NPB prochlorperazine (Compro Rectal Suppository 25 Mg) G EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG (carbamazepine NPB (antipsychotic)) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 NF MG, 6 MG, 8 MG (iloperidone)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 81 Prescription Drug Name Drug Tier Drug Notes FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & NF 6 MG (iloperidone) fluphenazine decanoate injection solution 25 mg/ml G fluphenazine hcl injection solution 2.5 mg/ml G fluphenazine hcl oral concentrate 5 mg/ml G fluphenazine hcl oral elixir 2.5 mg/5ml G fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg G GEODON INTRAMUSCULAR SOLUTION NPB RECONSTITUTED 20 MG (ziprasidone mesylate) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 NPB MG (ziprasidone hcl) haloperidol decanoate intramuscular solution 100 mg/ml, 50 G mg/ml haloperidol lactate injection solution 5 mg/ml G haloperidol lactate oral concentrate 2 mg/ml G haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg G INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, NPB 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML (paliperidone palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 NF MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML (paliperidone palmitate) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 PB MG, 80 MG (lurasidone hcl) lithium carbonate er oral tablet extended release 300 mg, 450 G mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg G lithium carbonate oral tablet 300 mg G lithium oral solution 8 meq/5ml NPB loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg G molindone hcl oral tablet 10 mg, 25 mg, 5 mg G NUPLAZID ORAL CAPSULE 34 MG (pimavanserin NPSP tartrate) NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) NPSP

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 82 Prescription Drug Name Drug Tier Drug Notes olanzapine intramuscular solution reconstituted 10 mg G olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 G mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg G paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 G mg, 6 mg, 9 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg G PERSERIS SUBCUTANEOUS PREFILLED SYRINGE PB 120 MG, 90 MG (risperidone) prochlorperazine edisylate injection solution 10 mg/2ml, 50 G mg/10ml prochlorperazine maleate oral tablet 10 mg, 5 mg G prochlorperazine rectal suppository 25 mg G quetiapine fumarate er oral tablet extended release 24 hour 150 G mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, G 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 NPB MG, 3 MG, 4 MG (brexpiprazole) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, NPB 37.5 MG, 50 MG (risperidone microspheres) risperidone oral solution 1 mg/ml G risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg G risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 G mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 NPB MG, 2.5 MG, 5 MG (asenapine maleate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG NF (quetiapine fumarate) thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg G thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg G trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg G VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 83 Prescription Drug Name Drug Tier Drug Notes VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 PB MG (cariprazine hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 PB MG (cariprazine hcl) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg G ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 NPB MG (olanzapine pamoate) *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS benzalkonium chloride external solution , 50 % NPB chlorhexidine gluconate solution 20 % NPB formaldehyde external solution 10 % G formaldehyde external solution 37 % NPB glutaraldehyde external solution 25 % NPB hydrogen peroxide solution 30 % G iodine tincture external tincture 2 % NPB *ANTIVIRALS* - DRUGS FOR INFECTIONS abacavir sulfate oral solution 20 mg/ml G abacavir sulfate oral tablet 300 mg G abacavir sulfate-lamivudine oral tablet 600-300 mg G abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg G acyclovir oral capsule 200 mg G acyclovir oral suspension 200 mg/5ml G acyclovir oral tablet 400 mg, 800 mg G adefovir dipivoxil oral tablet 10 mg G APTIVUS ORAL CAPSULE 250 MG (tipranavir) NPSP APTIVUS ORAL SOLUTION 100 MG/ML (tipranavir) NPSP atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg G ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz- PSP emtricitab-tenofovir) BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) PSP BARACLUDE ORAL TABLET 0.5 MG, 1 MG (entecavir) NF BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- PSP emtricitab-tenofov) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 84 Prescription Drug Name Drug Tier Drug Notes CIMDUO ORAL TABLET 300-300 MG (lamivudine- PSP tenofovir) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- NF rilpivir-tenofovir) CRIXIVAN ORAL CAPSULE 200 MG, 400 MG (indinavir NPSP sulfate) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- NF lamivudin-tenofov df) DESCOVY ORAL TABLET 200-25 MG (emtricitabine- PSP tenofovir af) didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg G DOVATO ORAL TABLET 50-300 MG (dolutegravir- PSP lamivudine) EDURANT ORAL TABLET 25 MG (rilpivirine hcl) PSP efavirenz oral capsule 200 mg, 50 mg G efavirenz oral tablet 600 mg G EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) PSP EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) PSP entecavir oral tablet 0.5 mg, 1 mg G EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir- PSP velpatasvir) EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir- IBC (Preferred for all PSP velpatasvir) genotypes) EPIVIR HBV ORAL SOLUTION 5 MG/ML (lamivudine) NF EPIVIR HBV ORAL TABLET 100 MG (lamivudine) NF EVOTAZ ORAL TABLET 300-150 MG (atazanavir- PSP cobicistat) famciclovir oral tablet 125 mg, 250 mg, 500 mg G favipiravir oral tablet 200 mg NPB fosamprenavir calcium oral tablet 700 mg G FUZEON SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 90 MG (enfuvirtide) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg- PSP cobic-emtricit-tenofaf) HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG PSP (ledipasvir-sofosbuvir)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 85 Prescription Drug Name Drug Tier Drug Notes HARVONI ORAL TABLET 45-200 MG, 90-400 MG IBC (Preferred for PSP (ledipasvir-sofosbuvir) genotypes 1,4,5,6) HEPSERA ORAL TABLET 10 MG (adefovir dipivoxil) NF INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG PSP (etravirine) INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) NPSP ISENTRESS HD ORAL TABLET 600 MG (raltegravir PSP potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir PSP potassium) ISENTRESS ORAL TABLET 400 MG (raltegravir PSP potassium) ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 PSP MG (raltegravir potassium) JULUCA ORAL TABLET 50-25 MG (dolutegravir- NPSP rilpivirine) KALETRA ORAL TABLET 100-25 MG, 200-50 MG PSP (lopinavir-ritonavir) lamivudine oral solution 10 mg/ml G lamivudine oral tablet 100 mg, 150 mg, 300 mg G lamivudine-zidovudine oral tablet 150-300 mg G ledipasvir-sofosbuvir oral tablet 90-400 mg NF LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir NPSP calcium) lopinavir-ritonavir oral solution 400-100 mg/5ml G MAVYRET ORAL TABLET 100-40 MG (glecaprevir- NF pibrentasvir) nevirapine er oral tablet extended release 24 hour 100 mg, 400 G mg nevirapine oral suspension 50 mg/5ml G nevirapine oral tablet 200 mg G NORVIR ORAL PACKET 100 MG (ritonavir) PSP NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) PSP ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab- PSP rilpivir-tenofov af) oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 86 Prescription Drug Name Drug Tier Drug Notes oseltamivir phosphate oral suspension reconstituted 6 mg/ml G PEGASYS SUBCUTANEOUS SOLUTION 180 NF MCG/0.5ML, 180 MCG/ML (peginterferon alfa-2a) PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML NPSP (peginterferon alfa-2b) PIFELTRO ORAL TABLET 100 MG (doravirine) NF PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) NPB PREZCOBIX ORAL TABLET 800-150 MG (darunavir- PSP cobicistat) PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir PSP ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 PSP MG (darunavir ethanolate) RAPIVAB INTRAVENOUS SOLUTION 200 MG/20ML NPB (peramivir) RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER PB (zanamivir) remdesivir intravenous solution reconstituted 150 mg NPB REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG NPSP (atazanavir sulfate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) NPSP ribavirin inhalation solution reconstituted 6 gm G ribavirin oral capsule 200 mg G ribavirin oral tablet 200 mg G rimantadine hcl oral tablet 100 mg G ritonavir oral tablet 100 mg G SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) NPSP SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, NPSP 75 MG (maraviroc) SITAVIG BUCCAL TABLET 50 MG (acyclovir) NPB sofosbuvir-velpatasvir oral tablet 400-100 mg NF SOVALDI ORAL PACKET 150 MG, 200 MG (sofosbuvir) NPSP SOVALDI ORAL TABLET 200 MG, 400 MG (sofosbuvir) NPSP stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 87 Prescription Drug Name Drug Tier Drug Notes STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- NF cobic-emtricit-tenofdf) SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- PSP lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- PSP lamivudine-tenofovir) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun- PSP cobic-emtricit-tenofaf) TEMIXYS ORAL TABLET 300-300 MG (lamivudine- PSP tenofovir) tenofovir disoproxil fumarate oral tablet 300 mg G TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG PSP (dolutegravir sodium) TIVICAY PD ORAL TABLET SOLUBLE 5 MG PSP (dolutegravir sodium) TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- PSP dolutegravir-lamivud) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, PSP 167-250 MG, 200-300 MG (emtricitabine-tenofovir df) TYBOST ORAL TABLET 150 MG (cobicistat) NPSP valacyclovir hcl oral tablet 1 gm, 500 mg G VALCYTE ORAL SOLUTION RECONSTITUTED 50 NF MG/ML (valganciclovir hcl) VALCYTE ORAL TABLET 450 MG (valganciclovir hcl) NF valganciclovir hcl oral solution reconstituted 50 mg/ml G valganciclovir hcl oral tablet 450 mg G VALTREX ORAL TABLET 1 GM, 500 MG (valacyclovir NF hcl) VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide NF fumarate) VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5- NF 75-50 &250 MG (ombitas-paritapre-ritona-dasab) VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir NPSP mesylate) VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil NPSP fumarate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 88 Prescription Drug Name Drug Tier Drug Notes VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 NPSP MG (tenofovir disoproxil fumarate) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- IBC (Preferred for all PSP velpatasv-voxilaprev) genotypes) XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY NF PACK 2 X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY NF PACK 2 X 40 MG (baloxavir marboxil) ZEPATIER ORAL TABLET 50-100 MG (elbasvir- NF grazoprevir) zidovudine oral capsule 100 mg G zidovudine oral syrup 50 mg/5ml G zidovudine oral tablet 300 mg G *BETA BLOCKERS* - DRUGS FOR THE HEART acebutolol hcl oral capsule 200 mg, 400 mg G atenolol oral tablet 100 mg, 25 mg, 50 mg G LGC ATENOLOL+SYRSPEND SF ORAL SUSPENSION 1 NF MG/ML (atenolol) BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl) betaxolol hcl oral tablet 10 mg, 20 mg G bisoprolol fumarate oral tablet 10 mg, 5 mg G BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG PB (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg G LGC carvedilol phosphate er oral capsule extended release 24 hour 10 G mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 10 MG, 20 MG, 40 MG (carvedilol phosphate) FIRST - METOPROLOL ORAL SOLUTION 10 MG/ML NF (metoprolol tartrate) FIRST-ATENOLOL ORAL SOLUTION 10 MG/ML, 2 NF MG/ML (atenolol)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 89 Prescription Drug Name Drug Tier Drug Notes HEMANGEOL ORAL SOLUTION 4.28 MG/ML NPB (propranolol hcl) INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol NF hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG (propranolol hcl sr NF beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG NF (metoprolol succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg G metoprolol succinate er oral tablet extended release 24 hour 100 G mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg G LGC metoprolol tartrate oral tablet 37.5 mg, 75 mg G nadolol oral tablet 20 mg, 40 mg, 80 mg G pindolol oral tablet 10 mg, 5 mg G propranolol hcl er oral capsule extended release 24 hour 120 mg, G 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml G propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg G LGC propranolol hcl oral tablet 60 mg G sotalol hcl (Sorine Oral Tablet 120 Mg, 80 Mg) G LGC sotalol hcl (Sorine Oral Tablet 160 Mg, 240 Mg) G sotalol hcl (af) oral tablet 120 mg G LGC sotalol hcl (af) oral tablet 160 mg, 80 mg G sotalol hcl oral tablet 120 mg, 80 mg G LGC sotalol hcl oral tablet 160 mg, 240 mg G SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) NPB timolol maleate oral tablet 10 mg, 20 mg, 5 mg G TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG (metoprolol NF succinate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 90 Prescription Drug Name Drug Tier Drug Notes *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART AMLODIPINE BES+SYRSPEND SF ORAL NF SUSPENSION 1 MG/ML (amlodipine besylate) amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg G LGC CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, NF 360 MG (diltiazem hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 NF MG (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG NF (diltiazem hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended G Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 NF MG (amlodipine besylate-celecoxib) diltiazem hcl er beads oral capsule extended release 24 hour 120 G mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 G hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 NF hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, G 60 mg, 90 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg G LGC dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, G 240 mg felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, G 5 mg isradipine oral capsule 2.5 mg, 5 mg G KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine NF benzoate) diltiazem hcl coated beads (Matzim La Oral Tablet Extended NF Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) nicardipine hcl oral capsule 20 mg, 30 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 91 Prescription Drug Name Drug Tier Drug Notes nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, G 90 mg nifedipine er osmotic release oral tablet extended release 24 hour G 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg G nimodipine oral capsule 30 mg G nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, G 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG NF (amlodipine besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) NPB diltiazem hcl er beads (Taztia Xt Oral Capsule Extended G Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) verapamil hcl er oral capsule extended release 24 hour 100 mg, G 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg G LGC verapamil hcl er oral tablet extended release 180 mg, 240 mg G verapamil hcl oral tablet 120 mg, 40 mg, 80 mg G LGC *CARDIOTONICS* - DRUGS FOR THE HEART digoxin (Digitek Oral Tablet 125 Mcg, 250 Mcg) G digoxin (Digox Oral Tablet 125 Mcg, 250 Mcg) G digoxin oral solution 0.05 mg/ml G digoxin oral tablet 125 mcg, 250 mcg G LANOXIN ORAL TABLET 125 MCG, 250 MCG (digoxin) NF LANOXIN ORAL TABLET 62.5 MCG (digoxin) PB *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART ABLYSINOL INTRA-ARTERIAL SOLUTION (dehydrated NF alcohol) ADCIRCA ORAL TABLET 20 MG (tadalafil (pah)) NF ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, PSP 2.5 MG (riociguat) tadalafil (pah) (Alyq Oral Tablet 20 Mg) G ambrisentan oral tablet 10 mg, 5 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 92 Prescription Drug Name Drug Tier Drug Notes amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 G LGC mg, 5-40 mg, 5-80 mg BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- PB hydralazine) bi-mix intracavernosal solution reconstituted 150-5 mg NF SPC bosentan oral tablet 125 mg, 62.5 mg G cardioplegic perfusion solution G CIALIS ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG NF SPC (tadalafil) CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine NPB hcl) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine PB hcl) ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 PB MG (sacubitril-valsartan) epoprostenol sodium intravenous solution reconstituted 0.5 mg, G 1.5 mg FLOLAN INTRAVENOUS SOLUTION NPSP RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium) LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) NF OPSUMIT ORAL TABLET 10 MG (macitentan) PSP ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil PSP diolamine) quad-mix intracavernosal solution reconstituted 150-10-0.1-1 NF mg REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 NPSP MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML NF (sildenafil citrate) REVATIO ORAL SUSPENSION RECONSTITUTED 10 NF MG/ML (sildenafil citrate) REVATIO ORAL TABLET 20 MG (sildenafil citrate) NF sildenafil citrate oral suspension reconstituted 10 mg/ml G sildenafil citrate oral tablet 20 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 93 Prescription Drug Name Drug Tier Drug Notes STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG NF SPC (avanafil) super bi-mix intracavernosal solution reconstituted 150-10 mg NF SPC super quad-mix intracavernosal solution reconstituted 150-20- NF SPC 0.2-2 mg super tri-mix intracavernosal solution reconstituted 150-10-100 NF SPC mg-mg-mcg tadalafil (pah) oral tablet 20 mg G TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) NF TRACLEER ORAL TABLET SOLUBLE 32 MG (bosentan) NF treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 G mg/20ml, 50 mg/20ml tri-mix intracavernosal solution reconstituted 150-5-50 mg-mg- NF mcg TYVASO INHALATION SOLUTION 0.6 MG/ML NPSP (treprostinil) TYVASO REFILL INHALATION SOLUTION 0.6 NPSP MG/ML (treprostinil) TYVASO STARTER INHALATION SOLUTION 0.6 NPSP MG/ML (treprostinil) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 PSP MCG (selexipag) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 PSP MCG (selexipag) VELETRI INTRAVENOUS SOLUTION NPSP RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium) VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 NPSP MCG/ML (iloprost) VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG NF SPC (sildenafil citrate) VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) NPSP VYNDAQEL ORAL CAPSULE 20 MG (tafamidis NF meglumine (cardiac)) *CEPHALOSPORINS* - DRUGS FOR INFECTIONS cefaclor er oral tablet extended release 12 hour 500 mg NPB cefaclor oral capsule 250 mg, 500 mg G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 94 Prescription Drug Name Drug Tier Drug Notes cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, G 375 mg/5ml cefadroxil oral capsule 500 mg G cefadroxil oral suspension reconstituted 250 mg/5ml, 500 G mg/5ml cefadroxil oral tablet 1 gm G cefdinir oral capsule 300 mg G cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml G cefixime oral capsule 400 mg G cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml G cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, G 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg G cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml G cefprozil oral tablet 250 mg, 500 mg G cefuroxime axetil oral tablet 250 mg, 500 mg G cephalexin oral capsule 250 mg, 500 mg, 750 mg G cephalexin oral suspension reconstituted 125 mg/5ml, 250 G mg/5ml cephalexin oral tablet 250 mg, 500 mg G FETROJA INTRAVENOUS SOLUTION NPB RECONSTITUTED 1 GM (cefiderocol sulfate tosylate) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 PB MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG PB (cefixime) *CHEMICALS* almond oil (sweet) oil NPB base g almond oil (sweet) oil NPB benzyl benzoate liquid NPB calcium folinate powder NPB castor oil oil NPB coconut oil oil NPB cottonseed oil oil NPB glycine soya protein solution NPB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 95 Prescription Drug Name Drug Tier Drug Notes hydroxyprogesterone caproate powder NPB leucovorin calcium powder NPB linseed oil oil NPB macadamia nut oil oil NPB olive oil oil NPB peanut oil oil NPB pyrimethamine powder NPB safflower oil oil NPB sesame oil oil NPB soybean oil oil NPB *CONTRACEPTIVES* - DRUGS FOR WOMEN levonorgestrel-ethinyl estrad (Afirmelle Oral Tablet 0.1-20 Mg- CE Mcg) AFTERA ORAL TABLET 1.5 MG (levonorgestrel) CE levonorgestrel-ethinyl estrad (Altavera Oral Tablet 0.15-30 Mg- CE Mcg) alyacen 1/35 oral tablet 1-35 mg-mcg CE alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg CE levonorgest-eth estrad 91-day (Amethia Lo Oral Tablet 0.1- CE 0.02 & 0.01 Mg) levonorgest-eth estrad 91-day (Amethia Oral Tablet 0.15-0.03 CE &0.01 Mg) levonorgestrel-ethinyl estrad (Amethyst Oral Tablet 90-20 CE Mcg) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR PB (segesterone-ethinyl estradiol) desogestrel-ethinyl estradiol (Apri Oral Tablet 0.15-30 Mg- CE Mcg) norethin-eth estrad triphasic (Aranelle Oral Tablet 0.5/1/0.5-35 CE Mg-Mcg) levonorgest-eth estrad 91-day (Ashlyna Oral Tablet 0.15-0.03 CE &0.01 Mg) levonorgestrel-ethinyl estrad (Aubra Eq Oral Tablet 0.1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Aubra Oral Tablet 0.1-20 Mg- CE Mcg) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 96 Prescription Drug Name Drug Tier Drug Notes norethindrone acet-ethinyl est (Aurovela 1.5/30 Oral Tablet 1.5- CE 30 Mg-Mcg) norethindrone acet-ethinyl est (Aurovela 1/20 Oral Tablet 1-20 CE Mg-Mcg) norethin ace-eth estrad-fe (Aurovela 24 Fe Oral Tablet 1-20 CE Mg-Mcg(24)) norethin ace-eth estrad-fe (Aurovela Fe 1.5/30 Oral Tablet 1.5- CE 30 Mg-Mcg) norethin ace-eth estrad-fe (Aurovela Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Aviane Oral Tablet 0.1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Ayuna Oral Tablet 0.15-30 Mg- CE Mcg) desogestrel-ethinyl estradiol (Azurette Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) NPB (levonorgest-eth estrad-fe bisg) norethindrone-eth estradiol (Balziva Oral Tablet 0.4-35 Mg- CE Mcg) desogestrel-ethinyl estradiol (Bekyree Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth NF estrad-levomefol) norethin ace-eth estrad-fe (Blisovi 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Blisovi Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Blisovi Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) briellyn oral tablet 0.4-35 mg-mcg CE norethindrone (Camila Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Camrese Lo Oral Tablet 0.1- CE 0.02 & 0.01 Mg) levonorgest-eth estrad 91-day (Camrese Oral Tablet 0.15-0.03 CE &0.01 Mg)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 97 Prescription Drug Name Drug Tier Drug Notes desogestrel-ethinyl estradiol (Caziant Oral Tablet CE 0.1/0.125/0.15 -0.025 Mg) levonorgestrel-ethinyl estrad (Chateal Eq Oral Tablet 0.15-30 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Chateal Oral Tablet 0.15-30 Mg- CE Mcg) norgestrel-ethinyl estradiol (Cryselle-28 Oral Tablet 0.3-30 Mg- CE Mcg) norethindrone-eth estradiol (Cyclafem 1/35 Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Cyclafem 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Eq Oral Tablet 0.15-30 CE Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone-eth estradiol (Dasetta 1/35 Oral Tablet 1-35 Mg- CE Mcg) norethin-eth estrad triphasic (Dasetta 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) levonorgest-eth estrad 91-day (Daysee Oral Tablet 0.15-0.03 CE &0.01 Mg) norethindrone (Deblitane Oral Tablet 0.35 Mg) CE levonorgestrel-ethinyl estrad (Delyla Oral Tablet 0.1-20 Mg- CE Mcg) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML PB (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg CE (21/5) drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- CE 0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg CE ECONTRA EZ ORAL TABLET 1.5 MG (levonorgestrel) CE ECONTRA ONE-STEP ORAL TABLET 1.5 MG CE (levonorgestrel)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 98 Prescription Drug Name Drug Tier Drug Notes norgestrel-ethinyl estradiol (Elinest Oral Tablet 0.3-30 Mg- CE Mcg) ELLA ORAL TABLET 30 MG (ulipristal acetate) NPB etonogestrel-ethinyl estradiol (Eluryng Vaginal Ring 0.12-0.015 CE Mg/24Hr) desogestrel-ethinyl estradiol (Emoquette Oral Tablet 0.15-30 CE Mg-Mcg) levonorg-eth estrad triphasic (Enpresse-28 Oral Tablet 50- CE 30/75-40/ 125-30 Mcg) desogestrel-ethinyl estradiol (Enskyce Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone (Errin Oral Tablet 0.35 Mg) CE norgestimate-eth estradiol (Estarylla Oral Tablet 0.25-35 Mg- CE Mcg) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg- CE mcg etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24hr CE levonorgestrel-ethinyl estrad (Falmina Oral Tablet 0.1-20 Mg- CE Mcg) levonorgest-eth estrad 91-day (Fayosim Oral Tablet 42-21-21-7 CE Days) norgestimate-eth estradiol (Femynor Oral Tablet 0.25-35 Mg- CE Mcg) drospirenone-ethinyl estradiol (Gianvi Oral Tablet 3-0.02 Mg) CE norethindrone acet-ethinyl est (Hailey 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Hailey 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethindrone (Heather Oral Tablet 0.35 Mg) CE norethindrone (Incassia Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Introvale Oral Tablet 0.15-0.03 CE Mg) desogestrel-ethinyl estradiol (Isibloom Oral Tablet 0.15-30 Mg- CE Mcg) drospirenone-ethinyl estradiol (Jasmiel Oral Tablet 3-0.02 Mg) CE norethindrone (Jencycla Oral Tablet 0.35 Mg) CE

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 99 Prescription Drug Name Drug Tier Drug Notes levonorgest-eth estrad 91-day (Jolessa Oral Tablet 0.15-0.03 CE Mg) desogestrel-ethinyl estradiol (Juleber Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone acet-ethinyl est (Junel 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethindrone acet-ethinyl est (Junel 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Junel Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Junel Fe 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Junel Fe 24 Oral Tablet 1-20 Mg- CE Mcg(24)) norethin-eth estradiol-fe (Kaitlib Fe Oral Tablet Chewable 0.8- CE 25 Mg-Mcg) desogestrel-ethinyl estradiol (Kalliga Oral Tablet 0.15-30 Mg- CE Mcg) desogestrel-ethinyl estradiol (Kariva Oral Tablet 0.15-0.02/0.01 CE Mg (21/5)) ethynodiol diac-eth estradiol (Kelnor 1/35 Oral Tablet 1-35 CE Mg-Mcg) ethynodiol diac-eth estradiol (Kelnor 1/50 Oral Tablet 1-50 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Kurvelo Oral Tablet 0.15-30 Mg- CE Mcg) KYLEENA INTRAUTERINE INTRAUTERINE DEVICE CE 19.5 MG (levonorgestrel) norethindrone acet-ethinyl est (Larin 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethindrone acet-ethinyl est (Larin 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Larin 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Larin Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Larin Fe 1/20 Oral Tablet 1-20 Mg- CE Mcg) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 100 Prescription Drug Name Drug Tier Drug Notes levonorgestrel-ethinyl estrad (Larissia Oral Tablet 0.1-20 Mg- CE Mcg) norethin-eth estradiol-fe (Layolis Fe Oral Tablet Chewable 0.8- CE 25 Mg-Mcg) norethin-eth estrad triphasic (Leena Oral Tablet 0.5/1/0.5-35 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Lessina Oral Tablet 0.1-20 Mg- CE Mcg) levonorg-eth estrad triphasic (Levonest Oral Tablet 50-30/75- CE 40/ 125-30 Mcg) levonorgest-eth est & eth est oral tablet 42-21-21-7 days CE levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, CE 0.15-0.03 &0.01 mg, 0.15-0.03 mg levonorgestrel oral tablet 1.5 mg CE levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 CE mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 CE mcg levonorgestrel-ethinyl estrad (Levora 0.15/30 (28) Oral Tablet CE 0.15-30 Mg-Mcg) LILETTA (52 MG) INTRAUTERINE INTRAUTERINE NF DEVICE 19.5 MCG/DAY (levonorgestrel) levonorgestrel-ethinyl estrad (Lillow Oral Tablet 0.15-30 Mg- CE Mcg) LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 CE MCG (norethin-eth estrad-fe biphas) drospirenone-ethinyl estradiol (Loryna Oral Tablet 3-0.02 Mg) CE norgestrel-ethinyl estradiol (Low-Ogestrel Oral Tablet 0.3-30 CE Mg-Mcg) drospirenone-ethinyl estradiol (Lo-Zumandimine Oral Tablet CE 3-0.02 Mg) levonorgestrel-ethinyl estrad (Lutera Oral Tablet 0.1-20 Mg- CE Mcg) norethindrone (Lyza Oral Tablet 0.35 Mg) CE marlissa oral tablet 0.15-30 mg-mcg CE medroxyprogesterone acetate intramuscular suspension 150 CE mg/ml

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 101 Prescription Drug Name Drug Tier Drug Notes medroxyprogesterone acetate intramuscular suspension prefilled CE syringe 150 mg/ml norethin ace-eth estrad-fe (Melodetta 24 Fe Oral Tablet CE Chewable 1-20 Mg-Mcg(24)) norethin ace-eth estrad-fe (Mibelas 24 Fe Oral Tablet CE Chewable 1-20 Mg-Mcg(24)) norethindrone acet-ethinyl est (Microgestin 1.5/30 Oral Tablet CE 1.5-30 Mg-Mcg) norethindrone acet-ethinyl est (Microgestin 1/20 Oral Tablet 1- CE 20 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1.5/30 Oral Tablet CE 1.5-30 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1/20 Oral Tablet 1- CE 20 Mg-Mcg) norgestimate-eth estradiol (Mili Oral Tablet 0.25-35 Mg-Mcg) CE MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 NF MG-MCG(24) (norethin ace-eth estrad-fe) MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) NPB (desogestrel-ethinyl estradiol) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE CE DEVICE 20 MCG/24HR (levonorgestrel) norgestimate-eth estradiol (Mono-Linyah Oral Tablet 0.25-35 CE Mg-Mcg) MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) CE MY WAY ORAL TABLET 1.5 MG (levonorgestrel) CE NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol NF valerate-dienogest) norethindrone-eth estradiol (Necon 0.5/35 (28) Oral Tablet 0.5- CE 35 Mg-Mcg) NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) CE drospirenone-ethinyl estradiol (Nikki Oral Tablet 3-0.02 Mg) CE norethindrone (Nora-Be Oral Tablet 0.35 Mg) CE norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg CE norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- CE mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg CE

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 102 Prescription Drug Name Drug Tier Drug Notes norethindrone oral tablet 0.35 mg CE norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, CE 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg CE norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25 CE mcg, 0.18/0.215/0.25 mg-35 mcg norethindrone (Norlyda Oral Tablet 0.35 Mg) CE norethindrone (Norlyroc Oral Tablet 0.35 Mg) CE norethindrone-eth estradiol (Nortrel 0.5/35 (28) Oral Tablet CE 0.5-35 Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (21) Oral Tablet 1-35 CE Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (28) Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Nortrel 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) NUVARING VAGINAL RING 0.12-0.015 MG/24HR NF (etonogestrel-ethinyl estradiol) drospirenone-ethinyl estradiol (Ocella Oral Tablet 3-0.03 Mg) CE OPCICON ONE-STEP ORAL TABLET 1.5 MG CE (levonorgestrel) OPTION 2 ORAL TABLET 1.5 MG (levonorgestrel) CE levonorgestrel-ethinyl estrad (Orsythia Oral Tablet 0.1-20 Mg- CE Mcg) ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.215/0.25 NF MG-25 MCG (norgestim-eth estrad triphasic) PARAGARD INTRAUTERINE COPPER CE INTRAUTERINE INTRAUTERINE DEVICE (copper) norethindrone-eth estradiol (Philith Oral Tablet 0.4-35 Mg- CE Mcg) desogestrel-ethinyl estradiol (Pimtrea Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) norethindrone-eth estradiol (Pirmella 1/35 Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Pirmella 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 103 Prescription Drug Name Drug Tier Drug Notes levonorgestrel-ethinyl estrad (Portia-28 Oral Tablet 0.15-30 CE Mg-Mcg) PREVENTEZA ORAL TABLET 1.5 MG (levonorgestrel) CE norgestimate-eth estradiol (Previfem Oral Tablet 0.25-35 Mg- CE Mcg) REACT ORAL TABLET 1.5 MG (levonorgestrel) CE desogestrel-ethinyl estradiol (Reclipsen Oral Tablet 0.15-30 CE Mg-Mcg) levonorgest-eth estrad 91-day (Rivelsa Oral Tablet 42-21-21-7 CE Days) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth NPB estrad-levomefol) levonorgest-eth estrad 91-day (Setlakin Oral Tablet 0.15-0.03 CE Mg) norethindrone (Sharobel Oral Tablet 0.35 Mg) CE desogestrel-ethinyl estradiol (Simliya Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) levonorgest-eth estrad 91-day (Simpesse Oral Tablet 0.15-0.03 CE &0.01 Mg) SKYLA INTRAUTERINE INTRAUTERINE DEVICE CE 13.5 MG (levonorgestrel) SLYND ORAL TABLET 4 MG (drospirenone) NF norgestimate-eth estradiol (Sprintec 28 Oral Tablet 0.25-35 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Sronyx Oral Tablet 0.1-20 Mg- CE Mcg) drospirenone-ethinyl estradiol (Syeda Oral Tablet 3-0.03 Mg) CE TAKE ACTION ORAL TABLET 1.5 MG (levonorgestrel) CE norethin ace-eth estrad-fe (Tarina 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Tarina Fe 1/20 Eq Oral Tablet 1-20 CE Mg-Mcg) norethin ace-eth estrad-fe (Tarina Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) NF (norethin ace-eth estrad-fe)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 104 Prescription Drug Name Drug Tier Drug Notes norethindron-ethinyl estrad-fe (Tilia Fe Oral Tablet 1-20/1- CE 30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri Femynor Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Estarylla Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norethindron-ethinyl estrad-fe (Tri-Legest Fe Oral Tablet 1- CE 20/1-30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri-Linyah Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Estarylla Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Marzia Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Mili Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Sprintec Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Mili Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Previfem Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Sprintec Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) levonorg-eth estrad triphasic (Trivora (28) Oral Tablet 50- CE 30/75-40/ 125-30 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Lo Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norethindrone (Tulana Oral Tablet 0.35 Mg) CE drospiren-eth estrad-levomefol (Tydemy Oral Tablet 3-0.03- CE 0.451 Mg) desogestrel-ethinyl estradiol (Velivet Oral Tablet 0.1/0.125/0.15 CE -0.025 Mg) levonorgestrel-ethinyl estrad (Vienva Oral Tablet 0.1-20 Mg- CE Mcg)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 105 Prescription Drug Name Drug Tier Drug Notes viorele oral tablet 0.15-0.02/0.01 mg (21/5) CE norethindrone-eth estradiol (Vyfemla Oral Tablet 0.4-35 Mg- CE Mcg) norgestimate-eth estradiol (Vylibra Oral Tablet 0.25-35 Mg- CE Mcg) norethindrone-eth estradiol (Wera Oral Tablet 0.5-35 Mg-Mcg) CE norethin-eth estradiol-fe (Wymzya Fe Oral Tablet Chewable CE 0.4-35 Mg-Mcg) XULANE TRANSDERMAL PATCH WEEKLY 150-35 CE MCG/24HR (norelgestromin-eth estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl NF estradiol) drospirenone-ethinyl estradiol (Zarah Oral Tablet 3-0.03 Mg) CE ethynodiol diac-eth estradiol (Zovia 1/35E (28) Oral Tablet 1- CE 35 Mg-Mcg) drospirenone-ethinyl estradiol (Zumandimine Oral Tablet 3- CE 0.03 Mg) *CORTICOSTEROIDS* - HORMONES beta 1 kit injection kit 30 mg/5ml NF betamethasone combo injection suspension 6 (3-3) mg/ml, 7 (4- NF 3) mg/ml budesonide er oral tablet extended release 24 hour 9 mg G budesonide oral capsule delayed release particles 3 mg G CELESTONE SOLUSPAN INJECTION SUSPENSION 6 NF (3-3) MG/ML (betamethasone sod phos & acet) CONTRAST ALLERGY PREMED PACK ORAL KIT 3 X NF 50 MG & 1 X 50 MG (prednisone-diphenhydramine hcl) cortisone acetate oral tablet 25 mg G dexamethasone (Decadron Oral Tablet 0.5 Mg, 0.75 Mg, 4 G Mg, 6 Mg) dexamethasone (la) injection suspension 8 mg/ml NF DEXAMETHASONE INTENSOL ORAL NPB CONCENTRATE 1 MG/ML (dexamethasone) dexamethasone oral elixir 0.5 mg/5ml G dexamethasone oral solution 0.5 mg/5ml G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 106 Prescription Drug Name Drug Tier Drug Notes dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, G 4 mg, 6 mg dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg G (35), 1.5 mg (51) DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 NF MG/5ML (dexamethasone sodium phosphate) DMT SUIK COMBINATION KIT 10 MG/ML (dexameth NF sod phos & anesthetic) DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5 NF MG (dexamethasone) EMFLAZA ORAL SUSPENSION 22.75 MG/ML NF (deflazacort) EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG NF (deflazacort) fludrocortisone acetate oral tablet 0.1 mg G dexamethasone (Hidex 6-Day Oral Tablet Therapy Pack 1.5 G Mg (21)) hydrocortisone oral tablet 10 mg, 20 mg, 5 mg G lidocidex i injection solution 5-10 mg/1.5ml NF MEDROL ORAL TABLET 2 MG (methylprednisolone) NPB MEDROLOAN II SUIK COMBINATION KIT 40 MG/ML NF (methylprednisolone & anesth) MEDROLOAN SUIK COMBINATION KIT 40 MG/ML NF (methylprednisolone & anesth) methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg G methylprednisolone oral tablet therapy pack 4 mg G MILLIPRED DP 12-DAY ORAL TABLET THERAPY NF PACK 5 MG (48) (prednisolone) MILLIPRED ORAL TABLET 5 MG (prednisolone) NF pod-care 100c injection kit 30 mg/5ml NF prednisolone oral solution 15 mg/5ml G prednisolone sodium phosphate oral solution 10 mg/5ml, 15 G mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 G mg, 30 mg

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 107 Prescription Drug Name Drug Tier Drug Notes PREDNISONE INTENSOL ORAL CONCENTRATE 5 NPB MG/ML (prednisone) prednisone oral solution 5 mg/5ml G prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg G prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 G mg (21), 5 mg (48) PRO-C-DURE 6 INJECTION KIT 3 X 40 MG/ML NF (triamcinolone acetonide) RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2 NF MG, 5 MG (prednisone) READYSHARP ANESTH + DEXAMETH INJECTION KIT 10 & 0.5 & 1 MG/ML-%-% (dexameth sod phos-bupiv- NF lido) READYSHARP ANESTH + METHYLPRED INJECTION KIT 80 & 0.5 & 1 MG/ML-%-% (methylprednisol & bupiv & NF lido) READYSHARP BETAMETHASONE INJECTION KIT 30 NF MG/5ML (betamethasone sod phos & acet) READYSHARP DEXAMETHASONE INJECTION KIT 10 NF MG/ML (dexamethasone sodium phosphate) ROPIDEX INJECTION KIT 10-0.5 MG/ML-% (dexamet sod NF phos pf & ropiv pf) TAPERDEX 12-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (49) (dexamethasone) dexamethasone (Taperdex 6-Day Oral Tablet Therapy Pack NF 1.5 Mg) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (27) (dexamethasone) ZILRETTA INTRA-ARTICULAR SUSPENSION NF RECONSTITUTED ER 32 MG (triamcinolone acetonide) *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS acetylcysteine inhalation solution 10 %, 20 % G benzonatate capsule 150 mg oral 150 mg G benzonatate capsule 150 mg oral 150 mg NF benzonatate oral capsule 100 mg, 200 mg G pseudoeph-bromphen-dm (Bromfed Dm Oral Syrup 30-2-10 G Mg/5Ml)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 108 Prescription Drug Name Drug Tier Drug Notes CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR 2.5-120 MG (desloratadine- NPB pseudoephedrine) g tussin ac oral solution 100-10 mg/5ml G GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- NPB guaifenesin) GILTUSS TR ORAL TABLET 10-28-388 MG NPB (phenylephrine-dm-gg) guaiatussin ac oral syrup 100-10 mg/5ml G guaifenesin-codeine oral solution 100-10 mg/5ml G hydrocod polst-cpm polst er oral suspension extended release 10- G 8 mg/5ml hydrocodone-homatropine oral syrup 5-1.5 mg/5ml G hydrocodone-homatropine oral tablet 5-1.5 mg G hydromet oral syrup 5-1.5 mg/5ml G HYPERSAL INHALATION NEBULIZATION NPB SOLUTION 3.5 % (sodium chloride) NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML NPB (phenylephrine-chlorphen-dm) promethazine-codeine oral solution 6.25-10 mg/5ml G promethazine-codeine oral syrup 6.25-10 mg/5ml G promethazine-dm oral syrup 6.25-15 mg/5ml G promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml G promethazine-phenylephrine oral syrup 6.25-5 mg/5ml G pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml G SEMPREX-D ORAL CAPSULE 8-60 MG (acrivastine- NPB pseudoephedrine) sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 G %, 7 % TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 NPB HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE NF 12 HOUR 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED NPB RELEASE 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) virtussin a/c oral solution 100-10 mg/5ml G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 109 Prescription Drug Name Drug Tier Drug Notes virtussin dac oral solution 30-10-100 mg/5ml G *DERMATOLOGICALS* - DRUGS FOR THE SKIN lidocaine hcl (7T Lido External Gel 2 %) G ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 NPB MG, 35 MG, 40 MG (isotretinoin) ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- NF benzoyl perox) ACCUCAINE COMBINATION KIT 1 % (lido-pentaf- NF tetrafl-ultrasound) aceso ag external pad 4"x4" NF acitretin oral capsule 10 mg, 17.5 mg, 25 mg G ACTICOAT 7 EXTERNAL PAD 2"X2" , 4"X5" (silver) NPB ACTICOAT ABSORBENT EXTERNAL PAD 4"X5" (silver) NPB ACTICOAT ANTIMICROBIAL EXTERNAL PAD 2"X2" , NPB 4"X4" (silver) ACTICOAT FLEX 3 4"X4" EXTERNAL PAD (wound NPB dressings) ACUICYN EXTERNAL SOLUTION (eyelid cleansers) NF acyclovir external cream 5 % NF acyclovir external ointment 5 % G ACZONE EXTERNAL GEL 7.5 % (dapsone) NPB adapalene external cream 0.1 % G adapalene external gel 0.1 %, 0.3 % G adapalene external pad 0.1 % NF adapalene-benzoyl peroxide external gel 0.1-2.5 % G ADVANCED ALLERGY COLLECTION EXTERNAL NF KIT 2.5 % (hydrocortisone) aftertest topical pain relief external stick 10 % NF ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) NPB ala-cort external cream 1 %, 2.5 % G alclometasone dipropionate external cream 0.05 % G alclometasone dipropionate external ointment 0.05 % G ALCORTIN A EXTERNAL GEL 1-2-1 % (iodoquinol-hc- NF aloe polysacch) alevamax external cream NPB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 110 Prescription Drug Name Drug Tier Drug Notes ALEVICYN ANTIPRURITIC EXTERNAL GEL NF (dermatological products, misc.) ALEVICYN ANTIPRURITIC SG EXTERNAL GEL NF (dermatological products, misc.) ALEVICYN DERMAL SPRAY EXTERNAL SOLUTION NF (wound cleansers) ALLEVYN AG ADHESIVE EXTERNAL PAD NPB 12.5X12.5CM , 17.5X17.5CM , 7.5X7.5CM (silver) ALLEVYN AG NON-ADHESIVE EXTERNAL PAD NPB 2"X2" , 4"X4" , 6"X6" , 8"X8" (silver) ALLEVYN AG SACRUM 6-3/4" EXTERNAL (silver) NPB ALLEVYN AG SACRUM 9"X9" EXTERNAL (silver) NPB ALLEVYN GENTLE EXTERNAL PAD (wound dressings) NPB ALTABAX EXTERNAL OINTMENT 1 % (retapamulin) NPB ALTRENO EXTERNAL LOTION 0.05 % (tretinoin) NF amcinonide external cream 0.1 % G amcinonide external lotion 0.1 % G amcinonide external ointment 0.1 % NPB AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) NF ammonium lactate external cream 12 % G ammonium lactate external lotion 12 % G isotretinoin (Amnesteem Oral Capsule 10 Mg, 20 Mg, 40 Mg) G ANACAINE EXTERNAL OINTMENT 10 % (benzocaine) NPB APEXICON E EXTERNAL CREAM 0.05 % (diflorasone NF diacet emoll base) APRIZIO PAK EXTERNAL KIT 2.5-2.5 % (lidocaine- NF prilocaine-dressing) AQUACEL AG BURN EXTERNAL PAD 4"X5" (silver- NF carboxymethylcellulose) ARAZLO EXTERNAL LOTION 0.045 % (tazarotene) NPB arnica flower tincture NPB ASTERO EXTERNAL GEL 4 % (lidocaine hcl) NF atopaderm external cream NF ATOPICLAIR EXTERNAL CREAM (dermatological NPB products, misc.)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 111 Prescription Drug Name Drug Tier Drug Notes ATRAPRO CP EXTERNAL KIT (wound dressings) NF ATRAPRO DERMAL SPRAY EXTERNAL LIQUID NF (wound cleansers) ATRAPRO HYDROGEL EXTERNAL GEL (wound NF dressings) AVENOVA EXTERNAL SOLUTION 0.01 % (eyelid NF cleansers) tretinoin (Avita External Cream 0.025 %) G tretinoin (Avita External Gel 0.025 %) G azelaic acid external gel 15 % G AZELEX EXTERNAL CREAM 20 % (azelaic acid) NF balsam peru-castor oil external ointment NF beau rx external gel NF bensal hp external ointment 3-6 % NF BENZACLIN EXTERNAL GEL 1-5 % (clindamycin phos- NF benzoyl perox) BENZACLIN WITH PUMP EXTERNAL GEL 1-5 % NF (clindamycin phos-benzoyl perox) BENZEPRO EXTERNAL 5.8 % (benzoyl peroxide) NF BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 % (benzoyl NF peroxide) benzoyl peroxide (Benzepro External Foam 5.3 %) G BENZEPRO EXTERNAL LIQUID 6.8 % (benzoyl peroxide) NF benzoyl peroxide (Benzepro Short Contact External Foam 9.8 G %) benzoin external tincture NPB benzoyl perox-hydrocortisone external lotion 5-0.5 % G benzoyl peroxide external foam 9.8 % G benzoyl peroxide-erythromycin external gel 5-3 % G BESER EXTERNAL KIT 0.05 % (fluticasone-emollient) NF fluticasone propionate (Beser External Lotion 0.05 %) G betamethasone dipropionate aug external cream 0.05 % G betamethasone dipropionate aug external gel 0.05 % G betamethasone dipropionate aug external lotion 0.05 % G betamethasone dipropionate aug external ointment 0.05 % G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 112 Prescription Drug Name Drug Tier Drug Notes betamethasone dipropionate external cream 0.05 % G betamethasone dipropionate external lotion 0.05 % G betamethasone dipropionate external ointment 0.05 % G betamethasone valerate external cream 0.1 % G betamethasone valerate external foam 0.12 % G betamethasone valerate external lotion 0.1 % G betamethasone valerate external ointment 0.1 % G boric acid external granules NPB bp wash external liquid 2.5 %, 7 % G bpco external ointment NF BRYHALI EXTERNAL LOTION 0.01 % (halobetasol PB propionate) CADIRAMD EXTERNAL KIT 2.5-2.5 % (lido-prilocaine- NF blood collect) calcipotriene external cream 0.005 % NF calcipotriene external ointment 0.005 % G calcipotriene external solution 0.005 % G calcipotriene-betameth diprop external ointment 0.005-0.064 % NF calcipotriene-betameth diprop external suspension 0.005-0.064 NF % calcipotriene (Calcitrene External Ointment 0.005 %) G calcitriol external ointment 3 mcg/gm NF CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone PB acetonide) CARAC EXTERNAL CREAM 0.5 % (fluorouracil) NF scar treatment products (Celacyn External Gel) G CENTANY EXTERNAL OINTMENT 2 % (mupirocin) NPB CERACADE EXTERNAL EMULSION (dermatological NF products, misc.) CERAMAX EXTERNAL CREAM (dermatological products, NF misc.) CERAMAX EXTERNAL LOTION (dermatological NF products, misc.) CETACAINE EXTERNAL LIQUID 2-2-14 % (butamben- NF tetracaine-benzocaine)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 113 Prescription Drug Name Drug Tier Drug Notes ciclopirox (Ciclodan External Solution 8 %) G ciclopirox external gel 0.77 % G ciclopirox external shampoo 1 % G ciclopirox external solution 8 % G ciclopirox olamine external cream 0.77 % G ciclopirox olamine external suspension 0.77 % G isotretinoin (Claravis Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) clindamycin phosphate (Clindacin Etz External Swab 1 %) G clindamycin phosphate (Clindacin-P External Swab 1 %) G clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, G 1.2-5 % clindamycin phosphate external foam 1 % G clindamycin phosphate external gel 1 % NF clindamycin phosphate external lotion 1 % G clindamycin phosphate external solution 1 % G clindamycin phosphate external swab 1 % G clindamycin-tretinoin external gel 1.2-0.025 % G clobetasol prop emollient base external cream 0.05 % G clobetasol propionate e external cream 0.05 % G clobetasol propionate emulsion external foam 0.05 % G clobetasol propionate external cream 0.05 % G clobetasol propionate external foam 0.05 % G clobetasol propionate external gel 0.05 % G clobetasol propionate external liquid 0.05 % NF clobetasol propionate external lotion 0.05 % G clobetasol propionate external ointment 0.05 % G clobetasol propionate external shampoo 0.05 % G clobetasol propionate external solution 0.05 % G CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol NF propionate) clobetasol propionate (Clodan External Shampoo 0.05 %) G CLODERM EXTERNAL CREAM 0.1 % (clocortolone NPB pivalate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 114 Prescription Drug Name Drug Tier Drug Notes clotrimazole external cream 1 % G clotrimazole external solution 1 % G clotrimazole-betamethasone external cream 1-0.05 % G clotrimazole-betamethasone external lotion 1-0.05 % G coal tar external solution 20 % G COLLATYL EXTERNAL GEL (silver) NF CONDYLOX EXTERNAL GEL 0.5 % (podofilox) PB COPASIL EXTERNAL GEL (scar treatment products) NPB CORDRAN EXTERNAL CREAM 0.025 % (flurandrenolide) NPB CORDRAN EXTERNAL OINTMENT 0.05 % NF (flurandrenolide) CORDRAN EXTERNAL TAPE 4 MCG/SQCM NPB (flurandrenolide) CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5 NPB (neomycin-polymyxin-hc) CORTISPORIN EXTERNAL OINTMENT 1 % (bacit-poly- NPB neo hc) IBC (Preferred agent for COSENTYX (300 MG DOSE) SUBCUTANEOUS Ankylosing Spondylitis and SOLUTION PREFILLED SYRINGE 150 MG/ML PSP Psoriatic Arthritis. Not (secukinumab) covered for Psoriasis) IBC (Preferred agent for COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS Ankylosing Spondylitis and PSP SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis) IBC (Preferred agent for COSENTYX SENSOREADY PEN SUBCUTANEOUS Ankylosing Spondylitis and PSP SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis) IBC (Preferred agent for COSENTYX SUBCUTANEOUS SOLUTION PREFILLED Ankylosing Spondylitis and PSP SYRINGE 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis) CROTAN EXTERNAL LOTION 10 % (crotamiton) G CURITY HYPERTONIC NACL STRIP EXTERNAL NPB (wound dressings)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 115 Prescription Drug Name Drug Tier Drug Notes CURITY NACL DRESSING 6"X6-3/4" EXTERNAL PAD NPB (wound dressings) CUTIVATE EXTERNAL LOTION 0.05 % (fluticasone NPB propionate) dapsone external gel 5 % G DENAVIR EXTERNAL CREAM 1 % (penciclovir) NPB DERMACINRX CLORHEXACIN EXTERNAL KIT 4 & 2 NF & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) DERMACINRX DUOPATCH PHARMAPAK EXTERNAL THERAPY PACK 5 & 3-10 % (methyl NF salicylate-lido-menthol) DERMACINRX LEXITRAL PHARMAPAK COMBINATION THERAPY PACK 1.5 & 0.025 % NF (diclofenac sodium-capsaicin) DERMACINRX NEUROTRAL PHARMAPAK EXTERNAL THERAPY PACK 5 & 0.025 % (lidocaine- NF capsaicin) DERMACINRX PHN EXTERNAL THERAPY PACK 5 & NF 5 % (lidocaine-dimethicone) dermacinrx surgical combopak combination kit NF DERMACINRX SURGICAL PHARMAPAK EXTERNAL NF KIT 4 & 2 & 5 % (CREAM) (chlorhex-mupir-dimeth-silicone) DERMACINRX THERAZOLE PAK EXTERNAL THERAPY PACK 1-0.05 & 20 % (clotrimazole-betameth & zn NF ox) DERMACINRX ZRM EXTERNAL THERAPY PACK 5 % NF (lidocaine-emollient) DERMULCERA EXTERNAL OINTMENT (balsam peru- NF castor oil) DESONATE EXTERNAL GEL 0.05 % (desonide) NPB desonide external cream 0.05 % G desonide external lotion 0.05 % G desonide external ointment 0.05 % G desoximetasone external cream 0.05 %, 0.25 % G desoximetasone external gel 0.05 % G desoximetasone external liquid 0.25 % G desoximetasone external ointment 0.05 %, 0.25 % G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 116 Prescription Drug Name Drug Tier Drug Notes DEXERYL EXTERNAL CREAM (dermatological products, NPB misc.) dfs/ms/menth/cap pak combination kit 1.5 % NF DIAB EXTERNAL GEL (wound dressings) NPB DIAB F.D.G. FREEZE-DRIED EXTERNAL GEL (wound NPB dressings) diclofenac epolamine external patch 1.3 % G diclofenac sodium external gel 3 % G diclofenac sodium external solution 1.5 % G diclofenac sodium gel 1 % external (rx) 1 % G diclofenac sodium gel 1 % external (rx) 1 % NF DICLOFONO EXTERNAL GEL 1.6 % (diclofenac sodium) NF diclopr external kit 1 & 10-30 % NF diclosaicin combination therapy pack 1.5 & 0.025 % NF diclovix combination kit 1.5 & 2-2.5-4 % NF diclozor external therapy pack 1 % NF DIFFERIN EXTERNAL LOTION 0.1 % (adapalene) NF diflorasone diacetate external cream 0.05 % NF diflorasone diacetate external ointment 0.05 % NF dimentho external therapy pack 1.5 & 10 % NF DIPROLENE AF EXTERNAL CREAM 0.05 % NPB (betamethasone dipropionate aug) doxepin hcl external cream 5 % NF doxycycline oral capsule delayed release 40 mg G DRYSOL EXTERNAL SOLUTION 20 % (aluminum NPB chloride) DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol NPB prop-tazarotene) DUPIXENT SUBCUTANEOUS SOLUTION PEN- PSP INJECTOR 300 MG/2ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 200 MG/1.14ML, 300 MG/2ML (dupilumab) econazole nitrate external cream 1 % G ECOZA EXTERNAL FOAM 1 % (econazole nitrate) NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 117 Prescription Drug Name Drug Tier Drug Notes ELETONE EXTERNAL CREAM (dermatological products, NPB misc.) ELIDEL EXTERNAL CREAM 1 % (pimecrolimus) NPB ELLZIA PAK EXTERNAL THERAPY PACK 0.1 & 5 % NF (triamcinolone acet-dimethicone) EMULSION SB EXTERNAL EMULSION (dermatological NPB products, misc.) enovarx-diclofenac sodium external cream 2.5 % NF ENSTILAR EXTERNAL FOAM 0.005-0.064 % NPB (calcipotriene-betameth diprop) ENTTY SPRAY EXTERNAL EMULSION (dermatological NPB products, misc.) EPICERAM EXTERNAL EMULSION (dermatological NF products, misc.) EPICYN EXTERNAL SOLUTION (hypochlorous acid) NF EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- PB benzoyl peroxide) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) NPB ERTACZO EXTERNAL CREAM 2 % (sertaconazole nitrate) NPB ery external pad 2 % G erythromycin external gel 2 % G erythromycin external solution 2 % G ESKATA EXTERNAL SOLUTION 40 % (hydrogen NF peroxide) essentra wipes 9x9" external 70 % NPB EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) PB EXELDERM EXTERNAL CREAM 1 % (sulconazole NPB nitrate) EXELDERM EXTERNAL SOLUTION 1 % (sulconazole NPB nitrate) EXODERM EXTERNAL LOTION 25-1 % (sod thiosulfate- NPB salicylic acd) EXTINA EXTERNAL FOAM 2 % (ketoconazole) NPB FABIOR EXTERNAL FOAM 0.1 % (tazarotene) NF FINACEA EXTERNAL FOAM 15 % (azelaic acid) PB FINACEA EXTERNAL GEL 15 % (azelaic acid) NF 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 118 Prescription Drug Name Drug Tier Drug Notes flexin external patch 0.0375-5 % NF fluocinolone acetonide body external oil 0.01 % G fluocinolone acetonide external cream 0.01 %, 0.025 % G fluocinolone acetonide external ointment 0.025 % G fluocinolone acetonide external solution 0.01 % G fluocinolone acetonide scalp external oil 0.01 % G fluocinonide emulsified base external cream 0.05 % G fluocinonide external cream 0.05 % G fluocinonide external cream 0.1 % NF fluocinonide external gel 0.05 % G fluocinonide external ointment 0.05 % G fluocinonide external solution 0.05 % G FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) NPB fluorouracil external cream 0.5 % NF fluorouracil external cream 5 % G fluorouracil external solution 2 %, 5 % G fluovix external therapy pack 0.1 % NF flurandrenolide external cream 0.05 % G flurandrenolide external lotion 0.05 % NF flurandrenolide external ointment 0.05 % NF fluticasone propionate external cream 0.05 % G fluticasone propionate external lotion 0.05 % G fluticasone propionate external ointment 0.005 % G FROTEK EXTERNAL CREAM 10 % (ketoprofen) NF fungimez external solution NF GEBAUERS PAIN EASE EXTERNAL AEROSOL NPB (pentafluoroprop-tetrafluoroeth) GEBAUERS SPRAY AND STRETCH EXTERNAL NPB AEROSOL (pentafluoroprop-tetrafluoroeth) gen7t external lotion 3.5 % NF gen7t external patch 3.5 % NF gen7t plus external lotion 3.5-7 % NF gen7t plus external patch 3.5-7 % NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 119 Prescription Drug Name Drug Tier Drug Notes GENADUR EXTERNAL LIQUID (dermatological products, NPB misc.) gentamicin sulfate external cream 0.1 % G gentamicin sulfate external ointment 0.1 % G glycolic acid solution 70 % NPB lidocaine hcl (Glydo External Prefilled Syringe 2 %) G GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % NPB (salicylic acid-lactic acid) halcinonide external cream 0.1 % G halobetasol propionate external cream 0.05 % G halobetasol propionate external foam 0.05 % NF halobetasol propionate external ointment 0.05 % G HALOG EXTERNAL CREAM 0.1 % (halcinonide) NPB HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) NPB HALOG EXTERNAL SOLUTION 0.1 % (halcinonide) NPB HPR PLUS EXTERNAL CREAM (dermatological products, NPB misc.) HPR PLUS EXTERNAL FOAM (dermatological products, NPB misc.) HPR PLUS HYDROGEL EXTERNAL KIT (dermatological NPB products, misc.) hyalucil-4 transdermal cream 2-4 % NF HYCLODEX EXTERNAL SOLUTION 0.012 % NF (hypochlorous acid) hydrocortisone butyr lipo base external cream 0.1 % NF hydrocortisone butyrate external cream 0.1 % NF hydrocortisone butyrate external lotion 0.1 % G hydrocortisone butyrate external ointment 0.1 % G hydrocortisone butyrate external solution 0.1 % G hydrocortisone external cream 1 %, 2.5 % G hydrocortisone external lotion 2.5 % G hydrocortisone external ointment 1 %, 2.5 % G hydrocortisone valerate external cream 0.2 % G hydrocortisone valerate external ointment 0.2 % G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 120 Prescription Drug Name Drug Tier Drug Notes HYDROFERA BLUE 6"X6" EXTERNAL PAD (wound NPB dressings) HYDROFERA BLUE FOAM DRESSING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE FOAM/TUNNELING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE MRF DRESSING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE READY FOAM EXTERNAL PAD NPB (wound dressings) hygel external gel 2.5 % NF HYLATOPIC PLUS EXTERNAL CREAM (dermatological NPB products, misc.) HYLATOPIC PLUS EXTERNAL LOTION (dermatological NPB products, misc.) HYPOCYN EXTERNAL SOLUTION (eyelid cleansers) NPB ILUMYA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 100 MG/ML (tildrakizumab-asmn) imiquimod external cream 5 % G imiquimod pump external cream 3.75 % G IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol NF propionate) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg G JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) NPB KAMDOY EXTERNAL EMULSION (dermatological NF products, misc.) KELARX EXTERNAL GEL (scar treatment products) NF KENDALL ALGINATE 12" ROPE EXTERNAL (wound NPB dressings) KENDALL ALGINATE DRESS 2"X2" EXTERNAL PAD NPB (wound dressings) KENDALL ALGINATE DRESS 4"X4" EXTERNAL PAD NPB (hydroactive dressings) KENDALL ALGINATE DRESS 4"X8" EXTERNAL PAD NPB (wound dressings) KENDALL AMORPHOUS WOUND EXTERNAL GEL NPB (wound dressings) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 121 Prescription Drug Name Drug Tier Drug Notes KENDALL HYDROGEL GAUZE 2"X2" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL GAUZE 4"X4" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL GAUZE 4"X8" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL WOUND DRESS EXTERNAL NPB (hydroactive dressings) KERAGEL EXTERNAL GEL (wound dressings) NPB KERAGELT EXTERNAL GEL (wound dressings) NPB KERAMATRIX REPLICINE 10CMX10CM EXTERNAL NPB SHEET (wound dressings) KERAMATRIX REPLICINE 5CMX5CM EXTERNAL NPB SHEET (wound dressings) KERYDIN EXTERNAL SOLUTION 5 % (tavaborole) NPB ketoconazole external cream 2 % G ketoconazole external foam 2 % NF ketoconazole external shampoo 2 % G ketoconazole (Ketodan External Foam 2 %) NF KETOPHENE RAPIDPAQ EXTERNAL CREAM 20 % NF (ketoprofen) KIVIK EXTERNAL EMULSION (dermatological products, NF misc.) L.E.T. EXTERNAL GEL 4-0.05-0.5 % (lido-epinephrine- NF tetracaine) lactic acid e external cream 10-3500 %-unt/30gm G lactic acid external lotion 10 % G LDO PLUS EXTERNAL GEL 4 % (lidocaine hcl) NF levatio external patch 0.03-5 % NF LEVICYN DERMAL SPRAY EXTERNAL SOLUTION NF (wound cleansers) LEVICYN EXTERNAL GEL (dermatological products, NF misc.) LEXETTE EXTERNAL FOAM 0.05 % (halobetasol NF propionate) lidocaine external ointment 5 % G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 122 Prescription Drug Name Drug Tier Drug Notes lidocaine external patch 5 % G lidocaine hcl external solution 4 % G lidocaine hcl urethral/mucosal external gel 2 % G lidocaine hcl urethral/mucosal external prefilled syringe 2 % G lidocaine-prilocaine external cream 2.5-2.5 % G lidocaine-tetracaine external cream 23-7 % NF lidocaine-tetracaine external cream 7-7 % NF LIDODERM EXTERNAL PATCH 5 % (lidocaine) PB lidopac external kit 5 % NF LIDOPURE PATCH EXTERNAL KIT 5 % (lidocaine- NF adhesive sheets) LIDOTHOL EXTERNAL GEL 4.5-5 % (lidocaine-menthol) NF LIDOTHOL EXTERNAL PATCH 4.5-5 % (lidocaine- NF menthol) LIDOTRAL EXTERNAL CREAM 3.88 % (lidocaine hcl) NF LIDOTREX EXTERNAL GEL 2 % (lidocaine-collagen-aloe NF vera) lindane external shampoo 1 % G LMR PLUS EXTERNAL KIT 5 & 0.5-0.5 % (lidocaine- NF camphor-menthol) LOPROX EXTERNAL CREAM 0.77 % (ciclopirox olamine) NF LOPROX EXTERNAL KIT 0.77 % (SUSP) (ciclopirox NF olamine-cleanser) LOPROX EXTERNAL SUSPENSION 0.77 % (ciclopirox NF olamine) LOYON EXTERNAL SOLUTION (dermatological products, NPB misc.) luliconazole external cream 1 % G LUXAMEND EXTERNAL CREAM (wound dressings) NPB mafenide acetate external packet 5 % G malathion external lotion 0.5 % G MENTAX EXTERNAL CREAM 1 % (butenafine hcl) NPB methoxsalen rapid oral capsule 10 mg G metronidazole external cream 0.75 % G metronidazole external gel 0.75 %, 1 % G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 123 Prescription Drug Name Drug Tier Drug Notes metronidazole external lotion 0.75 % G miconazole-zinc oxide-petrolat external ointment 0.25-15-81.35 G % MICROCYN EXTERNAL LIQUID 0.023 % (wound NPB cleansers) MIMYX EXTERNAL CREAM (dermatological products, NPB misc.) MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) NF mometasone furoate external cream 0.1 % G mometasone furoate external ointment 0.1 % G mometasone furoate external solution 0.1 % G mupirocin calcium external cream 2 % NF mupirocin external ointment 2 % G isotretinoin (Myorisan Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) naftifine hcl external cream 1 %, 2 % G NAFTIN EXTERNAL GEL 1 %, 2 % (naftifine hcl) PB NEOCERA EXTERNAL CREAM (dermatological products, NPB misc.) NEOSALUS CP EXTERNAL CREAM (dermatological NPB products, misc.) NEOSALUS EXTERNAL CREAM (dermatological NPB products, misc.) NEOSALUS EXTERNAL FOAM (dermatological products, NPB misc.) NEOSALUS EXTERNAL LOTION (dermatological NPB products, misc.) NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % NPB (neomycin-fluocinolone) clindamycin-benzoyl per (refr) (Neuac External Gel 1.2-5 %) G NEURAPTINE EXTERNAL CREAM 10 % (gabapentin) NF NIVATOPIC PLUS EXTERNAL CREAM (dermatological NPB products, misc.) flurandrenolide (Nolix External Cream 0.05 %) G flurandrenolide (Nolix External Lotion 0.05 %) G NORITATE EXTERNAL CREAM 1 % (metronidazole) NF 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 124 Prescription Drug Name Drug Tier Drug Notes NOVACORT EXTERNAL GEL 1-2 % (pramoxine-hc) NF NUCARACLINPAK EXTERNAL KIT 1 % (clindamycin NF phos- moisturizer) NUCARARXPAK EXTERNAL KIT 1-2.5 % (clindamycin- NF benzoyl per-moist) NUDERMRXPAK 120 EXTERNAL THERAPY PACK NF 0.005-5 % (calcipotriene-dimethicone) NUDERMRXPAK 60 EXTERNAL THERAPY PACK NF 0.005-5 % (calcipotriene-dimethicone) diclofenac sodium-capsaicin (Nudiclo Solupak Combination NF Therapy Pack 1.5 & 0.025 %) NUSURGEPAK SURGICAL PREP/CARE EXTERNAL NF KIT 4 & 2 & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) NUTRASEB EXTERNAL CREAM (antiseborrheic products, NPB misc.) NUVAIL EXTERNAL SOLUTION (dermatological NPB products, misc.) nystatin (Nyamyc External Powder 100000 Unit/Gm) G nystatin external cream 100000 unit/gm G nystatin external ointment 100000 unit/gm G nystatin external powder 100000 unit/gm G nystatin-triamcinolone external cream 100000-0.1 unit/gm-% G nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% G nystatin (Nystop External Powder 100000 Unit/Gm) G OLUX-E EXTERNAL FOAM 0.05 % (clobetasol propionate NF emulsion) ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- PB benzoyl perox) ORACEA ORAL CAPSULE DELAYED RELEASE 40 MG PB (doxycycline) ORMECA COMBINATION KIT 3 & 46-0.4-1.1 %-MG NF (diclofenac-b6-fa-b12) OVACE PLUS EXTERNAL FOAM 9.8 % (sulfacetamide NF sodium) oxiconazole nitrate external cream 1 % NF OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 125 Prescription Drug Name Drug Tier Drug Notes paingo kft external kit 2.5-2.5-10-30 % NF PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone NPB probutate) PANRETIN EXTERNAL GEL 0.1 % (alitretinoin) NPB PENLEN EXTERNAL EMULSION (dermatological NF products, misc.) PENNSAID EXTERNAL SOLUTION 2 % (diclofenac NF sodium) permethrin external cream 5 % G PHLAG SPRAY EXTERNAL EMULSION (dermatological NPB products, misc.) PICATO EXTERNAL GEL 0.015 %, 0.05 % (ingenol PB mebutate) PICO WOUND THERAPY SYSTEM EXTERNAL KIT NPB (wound dressings) pimecrolimus external cream 1 % G PLIAGLIS EXTERNAL CREAM 7-7 % (lidocaine- NF tetracaine) podofilox external solution 0.5 % G PR BENZOYL PEROXIDE EXTERNAL LIQUID 6.9 % NF (benzoyl peroxide) benzoyl peroxide (Pr Benzoyl Peroxide Wash External Liquid 7 G %) PR CREAM EXTERNAL KIT (dermatological products, NPB misc.) PRAMOX EXTERNAL GEL 1 % (pramoxine hcl) G PRE & POST SX POUCH EXTERNAL THERAPY PACK NF 4 & 2 & 5 % (chlorhex-mupirocin-dimethicone) prednicarbate external cream 0.1 % G prednicarbate external ointment 0.1 % G premium scar external patch 2-4-30 % NF prepiv supply combination kit 2.5-2.5 & 0.9 % NF PRESERA EXTERNAL FOAM (dermatological products, NPB misc.) PRIZOTRAL EXTERNAL KIT 2.5-2.5 & 3.88 % (lidocaine- NF prilocaine)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 126 Prescription Drug Name Drug Tier Drug Notes PROMISEB EXTERNAL CREAM (antiseborrheic products, NPB misc.) PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % NPB (tacrolimus) PROTYL AG EXTERNAL GEL 1 % (silver) NF PRUCLAIR EXTERNAL CREAM (dermatological products, NPB misc.) PRUMYX EXTERNAL CREAM (dermatological products, NPB misc.) psorcon external cream 0.05 % NF pyrogallic acid external ointment 25-2 % NPB QBREXZA EXTERNAL PAD 2.4 % (glycopyrronium NPB tosylate) QUINIXIL EXTERNAL THERAPY PACK 0.1 & 5 % NF (mometasone furo-dimethicone) QUINJA EXTERNAL GEL 1.25-1 % (iodoquinol-aloe NF polysaccharide) QUTENZA (2 PATCH) EXTERNAL KIT 8 % (capsaicin- NPB cleansing gel) QUTENZA EXTERNAL KIT 8 % (capsaicin-cleansing gel) NPB RADIAGEL EXTERNAL GEL (wound dressings) NPB RECEDO EXTERNAL GEL (scar treatment products) NF RECURA EXTERNAL CREAM (misc antifungal combo NF products) REGENECARE EXTERNAL GEL 2 % (lidocaine-collagen- NPB aloe vera) REGRANEX EXTERNAL GEL 0.01 % (becaplermin) NPB remigen external cream NPB resorcinol-sulfur external lotion 2-5 % G RESTORE SILVER DRESSING EXTERNAL PAD 2"X2" , NPB 4"X4.75" (calcium alginate-silver) RESTORE SILVER DRESSING EXTERNAL PAD 4"X4" , NPB 4"X5" , 6"X8" (silver) RETIN-A MICRO EXTERNAL GEL 0.04 %, 0.1 % NPB (tretinoin microsphere)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 127 Prescription Drug Name Drug Tier Drug Notes RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.06 NPB %, 0.08 %, 0.1 % (tretinoin microsphere) REXASIL PATCH & VITAMIN E LIQ EXTERNAL KIT NF (silicone-vitamin e) RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) NPB RIAX EXTERNAL FOAM 5.5 %, 9.5 % (benzoyl peroxide) NPB metronidazole (Rosadan External Cream 0.75 %) G metronidazole (Rosadan External Gel 0.75 %) G RTD WOUND CARE DRESSING EXTERNAL PAD NPB (wound dressings) salimez external cream 6 % G salimez forte external cream 10 % NPB SANTYL EXTERNAL OINTMENT 250 UNIT/GM NPB (collagenase) scarcin external gel NPB scarcin external liquid NF scarsilk external gel NF SCARZEN SKIN REPAIR EXTERNAL KIT 0.1 & 5 % NF (LOTION) (triamcinolone-dimeth-silicone) SCENESSE SUBCUTANEOUS IMPLANT 16 MG NPSP (afamelanotide acetate) SEBUDERM EXTERNAL GEL (dermatological products, NPB misc.) selenium sulfide external lotion 2.5 % G SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone NPB dipropionate) silipac external kit NF SILIQ SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 210 MG/1.5ML (brodalumab) silver sulfadiazine external cream 1 % G SKLICE EXTERNAL LOTION 0.5 % (ivermectin) NPB SKYRIZI (150 MG DOSE) SUBCUTANEOUS IBC (Preferred agent for PREFILLED SYRINGE KIT 75 MG/0.83ML (risankizumab- PSP Psoriasis) rzaa) sodium hyaluronate external gel 0.2 % G sodium sulfacetamide wash external liquid 10 % NPB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 128 Prescription Drug Name Drug Tier Drug Notes SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) PB SOOTHEE EXTERNAL PATCH 0.5-0.0375-5-2 % (lido- NF capsaicin-men-methyl sal) SORIATANE ORAL CAPSULE 10 MG, 25 MG (acitretin) NPB SORILUX EXTERNAL FOAM 0.005 % (calcipotriene) NF spinosad external suspension 0.9 % G silver sulfadiazine (Ssd External Cream 1 %) G IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML PSP Ulcerative Colitis after (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA SUBCUTANEOUS SOLUTION PREFILLED PSP Ulcerative Colitis after SYRINGE 45 MG/0.5ML, 90 MG/ML (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) sulconazole nitrate external solution 1 % NPB sulfacetamide sodium (acne) external lotion 10 % G sulfacetamide sodium-sulfur external pad 10-4 % G sulfamez wash external emulsion 10-1 % G SULFAMYLON EXTERNAL CREAM 85 MG/GM NPB (mafenide acetate) sulfurated lime external solution NPB suvicort external emulsion NF SX1 MEDICATED POST-OPERATIVE EXTERNAL KIT NF 2 % (lidocaine hcl & post-op system) SYNALAR EXTERNAL SOLUTION 0.01 % (fluocinolone NPB acetonide) SYNERA EXTERNAL PATCH 70-70 MG (lidocaine- NPB tetracaine) SYNERDERM EXTERNAL EMULSION (dermatological NF products, misc.)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 129 Prescription Drug Name Drug Tier Drug Notes TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % NPB (calcipotriene-betameth diprop) tacrolimus external ointment 0.03 %, 0.1 % G IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION AUTO- Psoriasis. Not covered for PSP INJECTOR 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION PREFILLED Psoriasis. Not covered for PSP SYRINGE 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) TARGRETIN EXTERNAL GEL 1 % (bexarotene) NPSP tazarotene external cream 0.1 % G TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % (tazarotene) NF TAZORAC EXTERNAL GEL 0.05 % (tazarotene) NF TAZORAC EXTERNAL GEL 0.1 % (tazarotene) PB TEGADERM AG MESH EXTERNAL PAD 2"X2" , 4"X5" , NPB 4"X8" , 8"X8" (silver) TEMOVATE EXTERNAL CREAM 0.05 % (clobetasol PB propionate) TETRIX EXTERNAL CREAM (dermatological products, NPB misc.) TEXACORT EXTERNAL SOLUTION 2.5 % PB (hydrocortisone) THERAHONEY EXTERNAL GEL (wound dressings) NPB THERAHONEY EXTERNAL SHEET (wound dressings) NPB TOLAK EXTERNAL CREAM 4 % (fluorouracil) PB TOPICORT EXTERNAL CREAM 0.25 % (desoximetasone) NPB TOPICORT EXTERNAL GEL 0.05 % (desoximetasone) NPB TOPICORT EXTERNAL OINTMENT 0.25 % NPB (desoximetasone) TREMFYA SUBCUTANEOUS SOLUTION PEN- IBC (Preferred agent for PSP INJECTOR 100 MG/ML (guselkumab) Psoriasis) TREMFYA SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for PSP SYRINGE 100 MG/ML (guselkumab) Psoriasis) tretinoin external cream 0.025 %, 0.05 %, 0.1 % G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 130 Prescription Drug Name Drug Tier Drug Notes tretinoin external gel 0.01 %, 0.025 %, 0.05 % G tretinoin microsphere external gel 0.04 %, 0.1 % G tretinoin microsphere pump external gel 0.04 % G triamcinolone acetonide external aerosol solution 0.147 mg/gm NF triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % G triamcinolone acetonide external lotion 0.025 %, 0.1 % G triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 G % TRIAMSIL COMBIPAK EXTERNAL THERAPY PACK NF 0.1 & 5 % (triamcinolone acet-silicone) triamsil multipak external therapy pack 0.1 & 5 % NF triamcinolone acetonide (Trianex External Ointment 0.05 %) NPB triamcinolone acetonide (Triderm External Cream 0.1 %, 0.5 G %) triple complex formula 3 kit external cream 20-2-10 % NF turpentine external spirit NPB ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol NPB propionate) urea (Uredeb External Cream 39 %) G URESOL EXTERNAL CREAM 42.5 % (urea) NF benzoyl perox-hydrocortisone (Vanoxide-Hc External Lotion 5- NF 0.5 %) VAROPHEN EXTERNAL KIT 1.5-10-15 % (diclofenac& NF menthol-methyl sal) VECTICAL EXTERNAL OINTMENT 3 MCG/GM NF (calcitriol) VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin- NF tretinoin) VENELEX EXTERNAL OINTMENT (balsam peru-castor NPB oil) VENIPUNCTURE PX1 PHLEBOTOMY EXTERNAL KIT NF 2 % (lidocaine hcl-blood collection) VERDESO EXTERNAL FOAM 0.05 % (desonide) NPB VEREGEN EXTERNAL OINTMENT 15 % (sinecatechins) NF vexasyn external gel NF VOLTAREN EXTERNAL GEL 1 % (diclofenac sodium) NPB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 131 Prescription Drug Name Drug Tier Drug Notes vp gkl kit external cream 20-2-10 % NF VUSION EXTERNAL OINTMENT 0.25-15-81.35 % NPB (miconazole-zinc oxide-petrolat) wpr plus wound healing system external therapy pack 4 & 10-30 NF % XALIX EXTERNAL SOLUTION 28 % (salicylic acid) NF XEPI EXTERNAL CREAM 1 % (ozenoxacin) NPB XERAC AC EXTERNAL SOLUTION 6.25 % (aluminum NPB chloride in alcohol) XERALUX EXTERNAL CREAM (dermatological products, NPB misc.) XERESE EXTERNAL CREAM 5-1 % (acyclovir- NPB hydrocortisone) XEROFORM OIL EMULSION 2"X2" EXTERNAL PAD NPB (bismuth tribromoph-petrolatum) XEROFORM OIL EMULSION GAUZE EXTERNAL NPB PAD (bismuth tribromoph-petrolatum) XEROFORM OIL EMULSION STRIP EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM OIL ROLL 4"X9' EXTERNAL 3 % (bismuth NPB tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM PETROLAT PATCH 2"X2" EXTERNAL NPB PAD (bismuth tribromoph-petrolatum) XEROFORM PETROLAT PATCH 4"X4" EXTERNAL NPB PAD (bismuth tribromoph-petrolatum) XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL NPB (bismuth tribromoph-petrolatum) XOLEGEL EXTERNAL GEL 2 % (ketoconazole) NF XRYLIX EXTERNAL THERAPY PACK 1.5 % (diclofenac NF sod-adhesive sheet) zaclir cleansing external lotion 8 % NPB zanabin hydrogel external gel NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 132 Prescription Drug Name Drug Tier Drug Notes isotretinoin (Zenatane Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) ZIANA EXTERNAL GEL 1.2-0.025 % (clindamycin- NF tretinoin) ZILACAINE PATCH EXTERNAL THERAPY PACK 5 % NF (lidocaine-silicone) ZTLIDO EXTERNAL PATCH 1.8 % (lidocaine) NF ZYCLARA EXTERNAL CREAM 3.75 % (imiquimod) PB ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) PB *DIAGNOSTIC PRODUCTS* 12-PANEL POC TOXICOLOGY SYSTEM IN VITRO KIT NPB (drug assay (urine)) ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose NF blood) ACCU-CHEK COMPACT PLUS IN VITRO STRIP (glucose NF blood) ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) NF ACCU-CHEK SMARTVIEW IN VITRO STRIP (glucose NF blood) ACCUTREND GLUCOSE IN VITRO STRIP (glucose NF blood) ADVANCE INTUITION TEST IN VITRO STRIP (glucose NF blood) ADVANCE MICRO-DRAW TEST IN VITRO STRIP NF (glucose blood) ADVOCATE REDI-CODE IN VITRO STRIP (glucose NF blood) ADVOCATE REDI-CODE+ TEST IN VITRO STRIP NF (glucose blood) ADVOCATE TEST IN VITRO STRIP (glucose blood) NF AGAMATRIX AMP TEST IN VITRO STRIP (glucose NF blood) AGAMATRIX JAZZ TEST IN VITRO STRIP (glucose NF blood) AGAMATRIX KEYNOTE TEST IN VITRO STRIP NF (glucose blood)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 133 Prescription Drug Name Drug Tier Drug Notes AGAMATRIX PRESTO TEST IN VITRO STRIP (glucose NF blood) ASSURE 3 TEST IN VITRO STRIP (glucose blood) NF ASSURE 4 TEST IN VITRO STRIP (glucose blood) NF ASSURE II CHECK IN VITRO STRIP (glucose blood) NF ASSURE II IN VITRO STRIP (glucose blood) NF ASSURE PLATINUM IN VITRO STRIP (glucose blood) NF ASSURE PRISM MULTI TEST IN VITRO STRIP (glucose NF blood) ASSURE PRO TEST IN VITRO STRIP (glucose blood) NF barium sulfate powder NPB BIOSCANNER GLUCOSE TEST IN VITRO STRIP NF (glucose blood) blood glucose test in vitro strip NF CAREONE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) CARESENS N GLUCOSE TEST IN VITRO STRIP (glucose NF blood) CARETOUCH TEST IN VITRO STRIP (glucose blood) NF cervical specimen collection swab NPB CHEMSTRIP K IN VITRO STRIP (acetone (urine) test) NPB CHEMSTRIP UGK IN VITRO STRIP (urine glucose-ketones NPB test) CLEVER CHEK AUTO-CODE TEST IN VITRO STRIP NF (glucose blood) CLEVER CHEK AUTO-CODE VOICE IN VITRO STRIP NF (glucose blood) CLEVER CHEK TEST IN VITRO STRIP (glucose blood) NF CLEVER CHOICE AUTO-CODE TEST IN VITRO STRIP NF (glucose blood) CLEVER CHOICE MICRO TEST IN VITRO STRIP NF (glucose blood) CLEVER CHOICE NO CODING IN VITRO STRIP NF (glucose blood) CLEVER CHOICE TALK SYSTEM IN VITRO STRIP NF (glucose blood)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 134 Prescription Drug Name Drug Tier Drug Notes CONTOUR NEXT TEST IN VITRO STRIP (glucose blood) NF CONTOUR TEST IN VITRO STRIP (glucose blood) NF COOL BLOOD GLUCOSE TEST STRIPS IN VITRO NF STRIP (glucose blood) CVS ADVANCED GLUCOSE TEST IN VITRO STRIP NF (glucose blood) cvs glucose meter test strips in vitro strip NF CVS KETONE CARE IN VITRO STRIP (urine glucose- NPB ketones test) CYSTOGRAFIN URETHRAL SOLUTION 30 % NPB (diatrizoate meglumine) CYSTOGRAFIN-DILUTE URETHRAL SOLUTION 18 % NPB (diatrizoate meglumine) CYSVIEW INTRAVESICAL SOLUTION NPB RECONSTITUTED 100 MG (hexaminolevulinate hcl) D-CARE BLOOD GLUCOSE IN VITRO STRIP (glucose NF blood) DIASTIX IN VITRO STRIP (glucose urine test-glucose ox) NPB DIATHRIVE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) DIATHRIVE GLUCOSE TEST IN VITRO STRIP (glucose NF blood) DIATHRIVE+ GLUCOSE TEST IN VITRO STRIP (glucose NF blood) diatrue plus test in vitro strip NF DUO-CARE TEST IN VITRO STRIP (glucose blood) NF d-xylose powder NPB easy plus ii glucose test in vitro strip NF EASY STEP TEST IN VITRO STRIP (glucose blood) NF easy talk blood glucose test in vitro strip NF EASY TOUCH TEST IN VITRO STRIP (glucose blood) NF easy trak blood glucose test in vitro strip NF easy trak ii glucose test in vitro strip NF EASYGLUCO IN VITRO STRIP (glucose blood) NF EASYGLUCO PLUS IN VITRO STRIP (glucose blood) NF EASYMAX 15 TEST IN VITRO STRIP (glucose blood) NF 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 135 Prescription Drug Name Drug Tier Drug Notes EASYMAX TEST IN VITRO STRIP (glucose blood) NF EASYPRO BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EASYPRO PLUS IN VITRO STRIP (glucose blood) NF element compact test in vitro strip NF ELEMENT TEST IN VITRO STRIP (glucose blood) NF EMBRACE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EMBRACE EVO BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) EMBRACE PRO GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EMBRACE TALK GLUCOSE TEST IN VITRO STRIP NF (glucose blood) eq blood glucose test in vitro strip NF EVENCARE + BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) EVENCARE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EVENCARE G2 TEST IN VITRO STRIP (glucose blood) NF EVENCARE G3 TEST IN VITRO STRIP (glucose blood) NF EVENCARE MINI GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EVENCARE PROVIEW GLUCOSE TEST IN VITRO NF STRIP (glucose blood) EVOLUTION AUTOCODE IN VITRO STRIP (glucose NF blood) EXACTECH R-S-G TEST IN VITRO STRIP (glucose blood) NF EXACTECH TEST IN VITRO STRIP (glucose blood) NF EZ SMART BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EZ SMART PLUS GLUCOSE TEST IN VITRO STRIP NF (glucose blood) E-Z-HD ORAL SUSPENSION RECONSTITUTED 98 % NPB (barium sulfate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 136 Prescription Drug Name Drug Tier Drug Notes E-Z-PAQUE ORAL SUSPENSION RECONSTITUTED 96 NPB % (barium sulfate) FIFTY50 GLUCOSE TEST 2.0 IN VITRO STRIP (glucose NF blood) FORA 6 CONNECT IN VITRO STRIP (glucose blood) NF FORA BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D15G BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D40/G31 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) FORA G20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA G30/PREM V10 GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GD20 TEST IN VITRO STRIP (glucose blood) NF FORA GD50 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GTEL BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GTEL BLOOD KETONE TEST IN VITRO STRIP NPB (ketone blood test) FORA TN'G/TN'G VOICE IN VITRO STRIP (glucose NF blood) FORA V10 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V12 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V30A BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORACARE GD40 TEST IN VITRO STRIP (glucose blood) NF FORACARE PREMIUM V10 TEST IN VITRO STRIP NF (glucose blood)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 137 Prescription Drug Name Drug Tier Drug Notes FORACARE TEST N GO TEST IN VITRO STRIP (glucose NF blood) FORTISCARE TEST IN VITRO STRIP (glucose blood) NF FREESTYLE INSULINX TEST IN VITRO STRIP (glucose NF blood) FREESTYLE LITE TEST IN VITRO STRIP (glucose blood) NF FREESTYLE PRECISION NEO TEST IN VITRO STRIP NF (glucose blood) FREESTYLE TEST IN VITRO STRIP (glucose blood) NF ge100 blood glucose test in vitro strip NF GENULTIMATE TEST IN VITRO STRIP (glucose blood) NPB ght test in vitro strip NF GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 NPB GM (aminolevulinic acid hcl) GLUCO PERFECT 3 TEST IN VITRO STRIP (glucose NF blood) GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP NF (glucose blood) GLUCOCARD EXPRESSION TEST IN VITRO STRIP NF (glucose blood) GLUCOCARD SHINE TEST IN VITRO STRIP (glucose NF blood) GLUCOCARD VITAL TEST IN VITRO STRIP (glucose NF blood) GLUCOCARD X-SENSOR IN VITRO STRIP (glucose NF blood) GLUCOCOM TEST IN VITRO STRIP (glucose blood) NF GLUCONAVII BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) glucose meter test in vitro strip NF gnp easy touch glucose test in vitro strip NF goodsense blood glucose in vitro strip NF HARMONY BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) HW EMBRACE PRO GLUCOSE TEST IN VITRO STRIP NF (glucose blood)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 138 Prescription Drug Name Drug Tier Drug Notes HW EMBRACE TALK GLUCOSE TEST IN VITRO NF STRIP (glucose blood) IGLUCOSE TEST STRIPS IN VITRO STRIP (glucose NF blood) IN TOUCH BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) INFINITY BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) INFINITY VOICE IN VITRO STRIP (glucose blood) NF KETO-DIASTIX IN VITRO STRIP (urine glucose-ketones NPB test) ketone test in vitro strip NPB KETOSTIX IN VITRO STRIP (acetone (urine) test) NPB kroger blood glucose test in vitro strip NF kroger premium glucose test in vitro strip NF kroger test in vitro strip NF LEU TECHNELITE COMBINATION KIT (technet tc 99m NF pertechnetate) LIBERTY NEXT GENERATION TEST IN VITRO STRIP NF (glucose blood) liberty test in vitro strip NF LIQUID E-Z-PAQUE ORAL SUSPENSION 60 % (barium NPB sulfate) MACRILEN ORAL PACKET 60 MG (macimorelin acetate) NF diatrizoate meglumine & sodium (Md-Gastroview Oral G Solution 66-10 %) meijer blood glucose test in vitro strip NF meijer essential glucose test in vitro strip NF meijer premium glucose test in vitro strip NF MEIJER TRUETEST TEST IN VITRO STRIP (glucose NF blood) MEIJER TRUETRACK TEST IN VITRO STRIP (glucose NF blood) METOPIRONE ORAL CAPSULE 250 MG (metyrapone) NPB MICRODOT TEST IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 139 Prescription Drug Name Drug Tier Drug Notes MM EASY TOUCH GLUCOSE IN VITRO STRIP (glucose NF blood) MYGLUCOHEALTH TEST IN VITRO STRIP (glucose NF blood) NEUTEK 2TEK TEST IN VITRO STRIP (glucose blood) NF NOVA MAX GLUCOSE TEST IN VITRO STRIP (glucose NF blood) NOVA MAX PLUS KETONE TEST IN VITRO STRIP NPB (ketone blood test) OMNIPAQUE ORAL SOLUTION 12 MG/ML, 9 MG/ML NPB (iohexol) one drop test in vitro strip NF ONETOUCH ULTRA IN VITRO STRIP (glucose blood) PB ONETOUCH VERIO IN VITRO STRIP (glucose blood) PB OPTIUM TEST IN VITRO STRIP (glucose blood) NF OPTIUMEZ TEST IN VITRO STRIP (glucose blood) NF ph strips in vitro diagnostic test NPB PHARMACIST CHOICE AUTOCODE IN VITRO STRIP NF (glucose blood) pharmacist choice no coding in vitro strip NF POCKETCHEM EZ TEST IN VITRO STRIP (glucose blood) NF PRECISION PCX IN VITRO STRIP (glucose blood) NF PRECISION PCX PLUS TEST IN VITRO STRIP (glucose NF blood) PRECISION POINT OF CARE TEST IN VITRO STRIP NF (glucose blood) PRECISION QID TEST IN VITRO STRIP (glucose blood) NF PRECISION SOF-TACT TEST IN VITRO STRIP (glucose NF blood) PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) PRECISION XTRA KETONE IN VITRO STRIP (ketone NPB blood test) premium blood glucose test in vitro strip NF pro voice v8/v9 glucose in vitro strip NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 140 Prescription Drug Name Drug Tier Drug Notes PRODIGY NO CODING BLOOD GLUC IN VITRO NF STRIP (glucose blood) PROVOCHOLINE INHALATION SOLUTION NPB RECONSTITUTED 100 MG (methacholine chloride) PTS PANELS GLUCOSE TEST IN VITRO STRIP (glucose NF blood) PTS PANELS KETONE TEST IN VITRO STRIP (ketone NPB blood test) QUICKTEK TEST IN VITRO STRIP (glucose blood) NF QUINTET AC BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) QUINTET BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RA TRUETEST TEST IN VITRO STRIP (glucose blood) NF READI-CAT 2 ORAL SUSPENSION 2 % (barium sulfate) NPB REFUAH PLUS BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) RELION BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RELION CONFIRM/MICRO TEST IN VITRO STRIP NF (glucose blood) RELION KETONE IN VITRO STRIP (acetone (urine) test) NPB RELION KETONE TEST IN VITRO STRIP (acetone NPB (urine) test) RELION PRIME TEST IN VITRO STRIP (glucose blood) NF RELION ULTIMA TEST IN VITRO STRIP (glucose blood) NF REXALL BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RIGHTEST GS100 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) RIGHTEST GS300 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) RIGHTEST GS550 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) SMART SENSE PREMIUM TEST IN VITRO STRIP NF (glucose blood)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 141 Prescription Drug Name Drug Tier Drug Notes SMART SENSE VALUE TEST IN VITRO STRIP (glucose NF blood) SMARTEST BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) SOLUS V2 TEST IN VITRO STRIP (glucose blood) NF SUPREME TEST IN VITRO STRIP (glucose blood) NF SURE EDGE TEST IN VITRO STRIP (glucose blood) NF SURECHEK BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) SURE-TEST EASYPLUS MINI TEST IN VITRO STRIP NF (glucose blood) TAGITOL V ORAL SUSPENSION 40 % (barium sulfate) NPB TECHNELITE COMBINATION KIT (technet tc 99m NF pertechnetate) TELCARE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) tgt blood glucose test in vitro strip NF THYROGEN INTRAMUSCULAR SOLUTION NPSP RECONSTITUTED 1.1 MG (thyrotropin alfa) TOXICOLOGY MED COLLECTION SYS IN VITRO KIT NPB (drug assay (urine)) true focus blood glucose strip in vitro strip NF TRUE METRIX BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) TRUETEST TEST IN VITRO STRIP (glucose blood) NF TRUETRACK TEST IN VITRO STRIP (glucose blood) NF ULTIMA TEST IN VITRO STRIP (glucose blood) NF ULTRATRAK PRO TEST IN VITRO STRIP (glucose blood) NF ULTRATRAK ULTIMATE TEST IN VITRO STRIP NF (glucose blood) UNISTRIP1 GENERIC IN VITRO STRIP (glucose blood) NF VARIBAR HONEY ORAL SUSPENSION 40 % (barium NPB sulfate) VARIBAR NECTAR ORAL SUSPENSION 40 % (barium NPB sulfate) VARIBAR PUDDING ORAL PASTE 40 % (barium sulfate) NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 142 Prescription Drug Name Drug Tier Drug Notes VARIBAR THIN HONEY ORAL SUSPENSION 40 % NPB (barium sulfate) VARIBAR THIN LIQUID ORAL SUSPENSION NPB RECONSTITUTED 40 % (barium sulfate) verasens blood glucose test in vitro strip NF VIVAGUARD INO TEST STRIPS IN VITRO STRIP NF (glucose blood) VOCAL POINT BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) xenon xe 133 inhalation gas 10 mci, 20 mci NPB *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* - DRUGS FOR NUTRITION AMINOPMRMS ORAL CAPSULE (nutritional supplements) NPB APP SLIM RMS ORAL CAPSULE (nutritional supp - diet NPB aids) nutritional supplements (Asilnasalrms Oral Capsule) G ASTAMED MYO ORAL CAPSULE (astaxanthin- NF tocotrienol-zn-d3) CAMINO PRO COMPLETE/GLYTACTIN ORAL BAR NPB (nutritional supplements) ELFOLATE PLUS ORAL TABLET 3-35-2 MG (l- NF methylfolate-b6-b12) ENTERAGAM ORAL PACKET 5 GM (sbi/protein isolate) NF FOSTEUM ORAL CAPSULE 27-20-200 MG-MG-UNIT NF (genistein-zn chelate-vit d) FOSTEUM PLUS ORAL CAPSULE (dietary management NF product) GALAXTRA ORAL POWDER (galactose) NF GLYTACTIN BUILD 10PE ORAL PACKET (nutritional NPB supplements) GLYTACTIN BURST ORAL PACKET (nutritional NPB supplements) GLYTACTIN COMPLETE 10PE ORAL BAR (nutritional NPB supplements) GLYTACTIN SWIRL 15PE ORAL PACKET (nutritional NPB supplements) HCU EASY ORAL TABLET (nutritional supplements) NF 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 143 Prescription Drug Name Drug Tier Drug Notes KETOVIE ORAL LIQUID (nutritional supplements) NPB KETOVIE PEPTIDE ORAL LIQUID (nutritional NPB supplements) LDL CARE ORAL POWDER (dietary management product) NF MSUD EASY ORAL TABLET (nutritional supplements) NF neoke bhb oral powder NF NICAPRIN ORAL TABLET (dietary management product) NF nicazyme oral tablet NF NOURISH ORAL LIQUID (nutritional supplements) NPB omnivex oral tablet NF PKU EASY ORAL TABLET (nutritional supplements) NF pro-critic oral packet NPB PROMACTIN AA PLUS 20PE ORAL SUSPENSION NF (nutritional supplements) RHEUMATE ORAL CAPSULE (dietary management NF product) ribozel oral capsule NF sodium saccharin granules NPB sodium saccharin powder NPB thrivacin 30 oral liquid NPB thrivacin detox oral liquid NPB TOBAKIENT ORAL CAPSULE (dietary management NF product) TYLACTIN COMPLETE 15 PE ORAL BAR (nutritional NPB supplements) TYR EASY ORAL TABLET (nutritional supplements) NF VASCULERA ORAL TABLET (dietary management NF product) vb6 p5p oral powder NF XAQUIL XR ORAL TABLET EXTENDED RELEASE 30 NF MG (levomefolate glucosamine) xyzbac oral tablet NF zyvit oral tablet NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 144 Prescription Drug Name Drug Tier Drug Notes *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 PB UNIT, 36000 UNIT, 6000 UNIT (pancrelipase (lip-prot- amyl)) enzadyne oral capsule NF PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 NPB UNIT, 4200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 24000-86250 UNIT, 4000 UNIT, NPB 8000 UNIT (pancrelipase (lip-prot-amyl)) SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) NPB VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT PB (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000- PB 126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot- amyl)) *DIURETICS* - DRUGS FOR THE HEART acetazolamide er oral capsule extended release 12 hour 500 mg G acetazolamide oral tablet 125 mg, 250 mg G ALDACTAZIDE ORAL TABLET 50-50 MG NPB (spironolactone-hctz) amiloride hcl oral tablet 5 mg G amiloride-hydrochlorothiazide oral tablet 5-50 mg G LGC bumetanide oral tablet 0.5 mg, 1 mg, 2 mg G CAROSPIR ORAL SUSPENSION 25 MG/5ML NF (spironolactone) chlorthalidone oral tablet 25 mg, 50 mg G DIURIL ORAL SUSPENSION 250 MG/5ML NPB (chlorothiazide) DYRENIUM ORAL CAPSULE 100 MG, 50 MG NF (triamterene) ethacrynic acid oral tablet 25 mg G furosemide oral solution 10 mg/ml, 8 mg/ml G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 145 Prescription Drug Name Drug Tier Drug Notes furosemide oral tablet 20 mg, 40 mg, 80 mg G LGC hydrochlorothiazide oral capsule 12.5 mg G LGC hydrochlorothiazide oral tablet 12.5 mg G hydrochlorothiazide oral tablet 25 mg, 50 mg G LGC indapamide oral tablet 1.25 mg, 2.5 mg G methazolamide oral tablet 25 mg, 50 mg G metolazone oral tablet 10 mg, 2.5 mg, 5 mg G spironolactone oral tablet 100 mg, 50 mg G spironolactone oral tablet 25 mg G LGC spironolactone-hctz oral tablet 25-25 mg G torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg G triamterene oral capsule 100 mg, 50 mg G triamterene-hctz oral capsule 37.5-25 mg G LGC triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg G LGC *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) NPSP ALDURAZYME INTRAVENOUS SOLUTION 2.9 NPSP MG/5ML (laronidase) alendronate sodium oral solution 70 mg/75ml G alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg G BINOSTO ORAL TABLET EFFERVESCENT 70 MG NPB (alendronate sodium) BUPHENYL ORAL POWDER 3 GM/TSP (sodium NF phenylbutyrate) BUPHENYL ORAL TABLET 500 MG (sodium NF phenylbutyrate) cabergoline oral tablet 0.5 mg G calcitonin (salmon) nasal solution 200 unit/act G calcitriol oral capsule 0.25 mcg, 0.5 mcg G calcitriol oral solution 1 mcg/ml G CARNITOR ORAL SOLUTION 1 GM/10ML (levocarnitine) NF CARNITOR ORAL TABLET 330 MG (levocarnitine) NF CARNITOR SF ORAL SOLUTION 1 GM/10ML NF (levocarnitine) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 146 Prescription Drug Name Drug Tier Drug Notes CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix PSP SPC acetate) cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg G clomiphene citrate oral tablet 50 mg G SPC DDAVP RHINAL TUBE NASAL SOLUTION 0.01 % PB (desmopressin ace refrigerated) desmopressin ace spray refrig nasal solution 0.01 % G desmopressin acetate oral tablet 0.1 mg, 0.2 mg G desmopressin acetate spray nasal solution 0.01 % G doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg G EGRIFTA SV SUBCUTANEOUS SOLUTION NPSP RECONSTITUTED 2 MG (tesamorelin acetate) ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML NPSP (idursulfase) EVENITY SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 105 MG/1.17ML (romosozumab-aqqg) FABRAZYME INTRAVENOUS SOLUTION NPSP RECONSTITUTED 35 MG, 5 MG (agalsidase beta) FENSOLVI (6 MONTH) SUBCUTANEOUS KIT 45 MG NPSP (PED) (leuprolide acetate (6 month)) FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300 UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML NF (follitropin beta) FORTEO SUBCUTANEOUS SOLUTION PEN- PSP INJECTOR 600 MCG/2.4ML (teriparatide (recombinant)) FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, NPB 70-5600 MG-UNIT (alendronate-cholecalciferol) GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, NF 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG (somatropin) GENOTROPIN SUBCUTANEOUS SOLUTION NF RECONSTITUTED 12 MG, 5 MG (somatropin) GONAL-F INJECTION SOLUTION RECONSTITUTED PSP SPC 1050 UNIT, 450 UNIT (follitropin alfa)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 147 Prescription Drug Name Drug Tier Drug Notes GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 PSP SPC UNIT/1.5ML (follitropin alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION PSP SPC RECONSTITUTED 75 UNIT (follitropin alfa) HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG NF (somatropin) ibandronate sodium oral tablet 150 mg G INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML NPSP (mecasermin) JYNARQUE ORAL TABLET THERAPY PACK 15 MG, NPSP 30 & 15 MG (tolvaptan) KANUMA INTRAVENOUS SOLUTION 20 MG/10ML NPSP (sebelipase alfa) KUVAN ORAL PACKET 100 MG, 500 MG (sapropterin NPSP dihydrochloride) KUVAN ORAL TABLET SOLUBLE 100 MG (sapropterin NPSP dihydrochloride) levocarnitine oral solution 1 gm/10ml G levocarnitine oral tablet 330 mg G LUMIZYME INTRAVENOUS SOLUTION NPSP RECONSTITUTED 50 MG (alglucosidase alfa) LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, NPSP 3.75 & 5 MG (leuprolide & norethindrone) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR NPSP KIT 11.25 MG, 15 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED), 30 MG (PED) (leuprolide acetate (3 NPSP month)) MENOPUR SUBCUTANEOUS SOLUTION NPSP SPC RECONSTITUTED 75 UNIT (menotropins) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NF (calcitonin (salmon)) MIACALCIN NASAL SOLUTION 200 UNIT/ACT NF (calcitonin (salmon)) NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML NPSP (galsulfase) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 148 Prescription Drug Name Drug Tier Drug Notes NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, NPSP SPC 25 MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) NOCDURNA SUBLINGUAL TABLET SUBLINGUAL NPB 27.7 MCG, 55.3 MCG (desmopressin acetate) NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15 PSP MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML (somatropin) NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS NF SOLUTION PEN-INJECTOR 10 MG/2ML (somatropin) NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS NF SOLUTION PEN-INJECTOR 20 MG/2ML (somatropin) NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS NF SOLUTION PEN-INJECTOR 5 MG/2ML (somatropin) octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, G 200 mcg/ml, 50 mcg/ml, 500 mcg/ml OMNITROPE SUBCUTANEOUS SOLUTION NF CARTRIDGE 10 MG/1.5ML, 5 MG/1.5ML (somatropin) OMNITROPE SUBCUTANEOUS SOLUTION NF RECONSTITUTED 5.8 MG (somatropin) ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG PSP (nitisinone) ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) PSP ORILISSA ORAL TABLET 150 MG, 200 MG (elagolix PB sodium) OSPHENA ORAL TABLET 60 MG (ospemifene) NF OVIDREL SUBCUTANEOUS INJECTABLE 250 PSP SPC MCG/0.5ML (choriogonadotropin alfa) PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML NF (pegvaliase-pqpz) paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg G PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5 NF MG/0.5ML, 5 MG/ML (etelcalcetide hcl) PROLIA SUBCUTANEOUS SOLUTION PREFILLED PSP SPC SYRINGE 60 MG/ML (denosumab) raloxifene hcl oral tablet 60 mg CE

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 149 Prescription Drug Name Drug Tier Drug Notes RAVICTI ORAL LIQUID 1.1 GM/ML (glycerol NF phenylbutyrate) RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 NPB MCG (calcifediol) RECLAST INTRAVENOUS SOLUTION 5 MG/100ML NPSP (zoledronic acid) risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg G risedronate sodium oral tablet delayed release 35 mg G SAIZEN INJECTION SOLUTION RECONSTITUTED 5 NF MG, 8.8 MG (somatropin (non-refrigerated)) SAIZENPREP INJECTION SOLUTION NF RECONSTITUTED 8.8 MG (somatropin (non-refrigerated)) SAMSCA ORAL TABLET 15 MG, 30 MG (tolvaptan) NPSP SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, NPSP 50 MCG/ML, 500 MCG/ML (octreotide acetate) SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT NF 10 MG, 20 MG, 30 MG (octreotide acetate) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG NPSP (cinacalcet hcl) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG (somatropin (non- NPSP refrigerated)) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 20 MG, 30 MG, 40 MG, 60 NPSP MG (pasireotide pamoate) SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, NPSP 0.6 MG/ML, 0.9 MG/ML (pasireotide diaspartate) sodium phenylbutyrate oral powder 3 gm/tsp G sodium phenylbutyrate oral tablet 500 mg G SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide PSP acetate) SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG NF (pegvisomant) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin NPSP acetate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 150 Prescription Drug Name Drug Tier Drug Notes SUPPRELIN LA SUBCUTANEOUS KIT 50 MG (histrelin NPSP acetate (cpp)) SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin NPB acetate) TEPEZZA INTRAVENOUS SOLUTION NPSP RECONSTITUTED 500 MG (teprotumumab-trbw) teriparatide (recombinant) subcutaneous solution pen-injector NF 620 mcg/2.48ml TRIPTODUR INTRAMUSCULAR SUSPENSION NF RECONSTITUTED ER 22.5 MG (triptorelin pamoate) TYMLOS SUBCUTANEOUS SOLUTION PEN- PSP INJECTOR 3120 MCG/1.56ML (abaloparatide) VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML NPSP (elosulfase alfa) XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML NPSP SPC (denosumab) zoledronic acid intravenous concentrate 4 mg/5ml G zoledronic acid intravenous solution 5 mg/100ml G ZOMACTON (FOR ZOMA-JET 10) SUBCUTANEOUS NF SOLUTION RECONSTITUTED 10 MG (somatropin) ZOMACTON SUBCUTANEOUS SOLUTION NF RECONSTITUTED 10 MG, 5 MG (somatropin) ZORBTIVE SUBCUTANEOUS SOLUTION NPSP RECONSTITUTED 8.8 MG (somatropin (non-refrigerated)) *ESTROGENS* - HORMONES ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 NPB MG/24HR (estradiol) estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg, G 1-0.5 Mg) ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG NPB (drospirenone-estradiol) bi-est 50:50 transdermal cream NF bi-est 80:20 progesterone transdermal cream NF bi-est progest-testosterone transdermal cream NF BIEST/PROGESTERONE TRANSDERMAL CREAM NF (estradiol-estriol-progesterone)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 151 Prescription Drug Name Drug Tier Drug Notes BIJUVA ORAL CAPSULE 1-100 MG (estradiol- NPB progesterone) CLIMARA PRO TRANSDERMAL PATCH WEEKLY PB 0.045-0.015 MG/DAY (estradiol-levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY PB (estradiol-norethindrone acet) DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML NPB (estradiol valerate) DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML NPB (estradiol cypionate) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 PB MG/1.25GM (estradiol) estradiol (Dotti Transdermal Patch Twice Weekly 0.025 Mg/24Hr, 0.0375 Mg/24Hr, 0.05 Mg/24Hr, 0.075 Mg/24Hr, G 0.1 Mg/24Hr) DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- PB bazedoxifene) ec-rx estradiol transdermal cream 0.4 %, 0.6 % NF ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM NPB (0.06%) (estradiol) estradiol oral tablet 0.5 mg, 1 mg, 2 mg G estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 G mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 G mg/24hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml G estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg G estriol-progesterone micro transdermal cream 4-20 mg/gm NF ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM NPB (0.06%) (estradiol) EVAMIST TRANSDERMAL SOLUTION 1.53 PB MG/SPRAY (estradiol) norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg- G Mcg, 1-5 Mg-Mcg)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 152 Prescription Drug Name Drug Tier Drug Notes norethindrone-eth estradiol (Jinteli Oral Tablet 1-5 Mg-Mcg) G MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG NF (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 NPB MCG/24HR (estradiol) estradiol-norethindrone acet (Mimvey Oral Tablet 1-0.5 Mg) G MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 NF MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol) norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg- G mcg ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 PB & 300 MG (elagolix-estradiol-norethind) PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- NPB norgestimate) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, NF 0.9 MG, 1.25 MG (estrogens conjugated) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- PB medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, PB 0.625-2.5 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 NF MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol) *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS BAXDELA ORAL TABLET 450 MG (delafloxacin NPB meglumine) CIPRO ORAL SUSPENSION RECONSTITUTED 250 NPB MG/5ML (5%) (ciprofloxacin) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg G levofloxacin oral solution 25 mg/ml G levofloxacin oral tablet 250 mg, 500 mg, 750 mg G moxifloxacin hcl oral tablet 400 mg G ofloxacin oral tablet 300 mg, 400 mg G *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH alosetron hcl oral tablet 0.5 mg, 1 mg G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 153 Prescription Drug Name Drug Tier Drug Notes AMITIZA ORAL CAPSULE 24 MCG, 8 MCG NF (lubiprostone) APRISO ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 0.375 GM (mesalamine) ASACOL HD ORAL TABLET DELAYED RELEASE 800 NF MG (mesalamine) AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric NPB citrate) AZULFIDINE EN-TABS ORAL TABLET DELAYED NPB RELEASE 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) NPB balsalazide disodium oral capsule 750 mg G calcium acetate (phos binder) oral capsule 667 mg G calcium acetate (phos binder) oral tablet 667 mg G CHENODAL ORAL TABLET 250 MG (chenodiol) NPB CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) NPSP CIMZIA PREFILLED SUBCUTANEOUS KIT 2 X 200 NF MG/ML (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 NF MG/ML (certolizumab pegol) CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab NF pegol) COLAZAL ORAL CAPSULE 750 MG (balsalazide disodium) NF cromolyn sodium oral concentrate 100 mg/5ml G DELZICOL ORAL CAPSULE DELAYED RELEASE 400 NF MG (mesalamine) DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) NPB ENTEREG ORAL CAPSULE 12 MG (alvimopan) NPB ENTYVIO INTRAVENOUS SOLUTION NF RECONSTITUTED 300 MG (vedolizumab) enulose oral solution 10 gm/15ml G FOSRENOL ORAL PACKET 1000 MG, 750 MG NF (lanthanum carbonate) FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 NF MG, 750 MG (lanthanum carbonate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 154 Prescription Drug Name Drug Tier Drug Notes GATTEX SUBCUTANEOUS KIT 5 MG (teduglutide NPSP (rdna)) generlac oral solution 10 gm/15ml G INFLECTRA INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (infliximab-dyyb) lactulose encephalopathy oral solution 10 gm/15ml G lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 NF mg LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM NF (mesalamine) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG PB (linaclotide) LOTRONEX ORAL TABLET 0.5 MG, 1 MG (alosetron hcl) NPB mesalamine er oral capsule extended release 24 hour 0.375 gm G mesalamine oral capsule delayed release 400 mg G mesalamine oral tablet delayed release 1.2 gm, 800 mg G mesalamine rectal enema 4 gm G mesalamine rectal suppository 1000 mg G mesalamine-cleanser rectal kit 4 gm G metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml G metoclopramide hcl oral tablet 10 mg, 5 mg G metoclopramide hcl oral tablet dispersible 10 mg NPB metoclopramide hcl oral tablet dispersible 5 mg G MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride NF succinate) MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol PB oxalate) OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) NPSP PENTASA ORAL CAPSULE EXTENDED RELEASE 250 PB MG, 500 MG (mesalamine) PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium PB acetate (phos binder)) RELISTOR ORAL TABLET 150 MG (methylnaltrexone NPB bromide) RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, NPB 8 MG/0.4ML (methylnaltrexone bromide) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 155 Prescription Drug Name Drug Tier Drug Notes REMICADE INTRAVENOUS SOLUTION PSP RECONSTITUTED 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (infliximab-abda) sevelamer carbonate oral packet 0.8 gm, 2.4 gm G sevelamer carbonate oral tablet 800 mg G sevelamer hcl oral tablet 400 mg, 800 mg G SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) NPB IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA INTRAVENOUS SOLUTION 130 MG/26ML PSP Ulcerative Colitis after (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) sulfasalazine oral tablet 500 mg G sulfasalazine oral tablet delayed release 500 mg G SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) PB TRULANCE ORAL TABLET 3 MG (plecanatide) NPB ursodiol oral capsule 300 mg G ursodiol oral tablet 250 mg, 500 mg G URSODIOL+SYRSPEND SF ORAL SUSPENSION 30 NF MG/ML (ursodiol) VELPHORO ORAL TABLET CHEWABLE 500 MG PB (sucroferric oxyhydroxide) VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) PB ZELNORM ORAL TABLET 6 MG (tegaserod maleate) NF *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER anesthesia s/i-40a intravenous kit 200 mg/20ml NF anesthesia s/i-40h intravenous kit 200 mg/20ml NF anesthesia s/i-40s intravenous kit 200 mg/20ml NF desflurane inhalation solution G isoflurane inhalation solution G sevoflurane inhalation solution G isoflurane (Terrell Inhalation Solution) G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 156 Prescription Drug Name Drug Tier Drug Notes *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM acetic acid irrigation solution 0.25 % G alfuzosin hcl er oral tablet extended release 24 hour 10 mg G aminoacetic acid irrigation solution 1.5 % G sodium chloride (gu irrigant) (Argyle Sterile Saline Irrigation G Solution 0.9 %) CARDURA XL ORAL TABLET EXTENDED RELEASE NPB 24 HOUR 4 MG, 8 MG (doxazosin mesylate) sodium chloride (gu irrigant) (Curity Sterile Saline Irrigation G Solution 0.9 %) CYSTAGON ORAL CAPSULE 150 MG, 50 MG PSP (cysteamine bitartrate) cytra k crystals oral packet 3300-1002 mg G dutasteride oral capsule 0.5 mg G dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg G ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate NPB sodium) finasteride oral tablet 5 mg G glycine irrigation solution 1.5 % G JALYN ORAL CAPSULE 0.5-0.4 MG (dutasteride- NF tamsulosin hcl) K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac NPB phosphates) LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic NPB acid) neomycin-polymyxin b gu irrigation solution 40-200000 G ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate- NPB citric acid) phenazopyridine hcl (Phenazo Oral Tablet 200 Mg) G pot & sod cit-cit ac oral solution 550-500-334 mg/5ml G potassium citrate er oral tablet extended release 10 meq (1080 G mg), 15 meq (1620 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 1100-334 mg/5ml G PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 NF MG, 75 MG (cysteamine bitartrate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 157 Prescription Drug Name Drug Tier Drug Notes PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine NF bitartrate) RAPAFLO ORAL CAPSULE 4 MG, 8 MG (silodosin) NF RENACIDIN IRRIGATION SOLUTION (citric ac- NPB gluconolact-mg carb) RESECTISOL IRRIGATION SOLUTION 5 % (mannitol NPB (gu irrigant)) RIMSO-50 INTRAVESICAL SOLUTION 50 % (dimethyl NF sulfoxide) silodosin oral capsule 4 mg, 8 mg G sod citrate-citric acid oral solution 500-334 mg/5ml G sodium chloride irrigation solution 0.9 % G sorbitol irrigation solution 3 %, 3.3 % NPB sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml NPB tamsulosin hcl oral capsule 0.4 mg G potassium citrate-citric acid (Taron-Crystals Oral Packet 3300- G 1002 Mg) THIOLA EC ORAL TABLET DELAYED RELEASE 100 NPB MG, 300 MG (tiopronin) tricitrates oral solution 550-500-334 mg/5ml G UROXATRAL ORAL TABLET EXTENDED RELEASE NF 24 HOUR 10 MG (alfuzosin hcl) *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER allopurinol oral tablet 100 mg, 300 mg G colchicine oral capsule 0.6 mg G colchicine oral tablet 0.6 mg G colchicine-probenecid oral tablet 0.5-500 mg G COLCRYS ORAL TABLET 0.6 MG (colchicine) NF febuxostat oral tablet 40 mg, 80 mg G KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML NPSP (pegloticase) probenecid oral tablet 500 mg G ULORIC ORAL TABLET 40 MG, 80 MG (febuxostat) NPB ZYLOPRIM ORAL TABLET 100 MG, 300 MG (allopurinol) NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 158 Prescription Drug Name Drug Tier Drug Notes *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NPSP 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) adynovate intravenous solution reconstituted 1000 unit, 1500 PSP unit, 2000 unit, 250 unit, 3000 unit, 500 unit, 750 unit AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT NPSP (antihemophil fact single chain) AGGRASTAT INTRAVENOUS CONCENTRATE 3.75 NF MG/15ML (tirofiban hcl) ALBUMINEX INTRAVENOUS SOLUTION 25 %, 5 % NF (albumin human-kjda) ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 NPSP UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT NPSP (coagulation factor ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, NF 3000 UNIT, 4000 UNIT, 500 UNIT (coagulation factor ix (rfixfc)) anagrelide hcl oral capsule 0.5 mg, 1 mg G aspirin-dipyridamole er oral capsule extended release 12 hour G 25-200 mg BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix NPSP (recomb)) BERINERT INTRAVENOUS KIT 500 UNIT (c1 esterase NF inhibitor (human)) BRILINTA ORAL TABLET 60 MG, 90 MG (ticagrelor) PB CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) NF cilostazol oral tablet 100 mg, 50 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 159 Prescription Drug Name Drug Tier Drug Notes CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT (c1 esterase inhibitor NPSP (human)) clopidogrel bisulfate oral tablet 300 mg, 75 mg G COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT (coagulation NPSP factor x (human)) DEFITELIO INTRAVENOUS SOLUTION 200 MG/2.5ML NF (defibrotide sodium) dipyridamole oral tablet 25 mg, 50 mg, 75 mg G ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NF 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT (antihem fact (bdd-rfviiifc)) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant NPSP cmplx) FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML NPSP (icatibant acetate) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT (c1 esterase NPSP inhibitor (human)) HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML NPSP (emicizumab-kxwh) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 NPSP UNIT (antihemophilic factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500- NPSP 1200 UNIT (antihemophilic factor-vwf) icatibant acetate subcutaneous solution 30 mg/3ml G IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, NPSP 3500 UNIT, 500 UNIT (coagulation factor ix (rix-fp)) IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NPSP 250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix (recomb)) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 160 Prescription Drug Name Drug Tier Drug Notes JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT (ahf (bdd- PSP rfviii peg-aucl)) KENGREAL INTRAVENOUS SOLUTION NF RECONSTITUTED 50 MG (cangrelor tetrasodium) KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT NPSP (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT NPSP (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihemophilic PSP factor (recomb)) KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, PSP 3000 UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) MONONINE INTRAVENOUS SOLUTION NPSP RECONSTITUTED 1000 UNIT (coagulation factor ix) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSP 250 UNIT, 3000 UNIT, 500 UNIT (antihemophil fact bd truncated) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation NPSP factor viia recomb) NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT PSP (antihem fact (bdd-rfviii,sim)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, PSP 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihem fact (bdd-rfviii,sim)) obizur intravenous solution reconstituted 500 unit NF pentoxifylline er oral tablet extended release 400 mg G PLAVIX ORAL TABLET 75 MG (clopidogrel bisulfate) NF prasugrel hcl oral tablet 10 mg, 5 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 161 Prescription Drug Name Drug Tier Drug Notes PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT NPSP (factor ix complex) REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT PSP (coagulation factor ix glycopeg) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, NPSP 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT (antihemophilic factor (recomb)) RETAVASE HALF-KIT INTRAVENOUS KIT 1 X 10 NF UNIT (reteplase) RETAVASE INTRAVENOUS KIT 2 X 10 UNIT (reteplase) NF rixubis intravenous solution reconstituted 1000 unit, 2000 unit, NPSP 250 unit, 3000 unit, 500 unit RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT (c1 esterase inhibitor PSP (recomb)) SEVENFACT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 5 MG (coagulation factor viia- NF jncw) SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML NPSP (eculizumab) TAKHZYRO SUBCUTANEOUS SOLUTION 300 PSP MG/2ML (lanadelumab-flyo) TAVALISSE ORAL TABLET 100 MG, 150 MG NF (fostamatinib disodium) ULTOMIRIS INTRAVENOUS SOLUTION 1100 NF MG/11ML, 300 MG/30ML, 300 MG/3ML (ravulizumab-cwvz) VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT (von willebrand NF factor (recomb)) WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 NPSP UNIT (antihemophilic factor-vwf) XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, NPSP 250 UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem fact NPSP (bdd-rfviii,mor)) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 162 Prescription Drug Name Drug Tier Drug Notes YOSPRALA ORAL TABLET DELAYED RELEASE 325- NF 40 MG, 81-40 MG (aspirin-omeprazole) ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) NF *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION cyanocobalamin-methylcobalamin (Abaneu-Sl Sublingual G Tablet Sublingual 600-600 Mcg) active fe oral tablet 75-1.25 mg NPB ADAKVEO INTRAVENOUS SOLUTION 100 MG/10ML NPSP (crizanlizumab-tmca) folic acid-vit b6-vit b12 (Airavite Oral Tablet 2.5-25-1 Mg) G ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, PSP 40 MCG/ML, 60 MCG/ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 PSP MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML (darbepoetin alfa) b-6 folic acid oral capsule 8.333-100-1 mg NPB bp vit 3 oral capsule 1 mg NPB CENFOL ORAL TABLET 2.3-24.5-2 MG (folic acid-vit b6- NPB vit b12) CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) PSP CEREZYME INTRAVENOUS SOLUTION PSP RECONSTITUTED 400 UNIT (imiglucerase) CIFEREX ORAL CAPSULE 1-3775 MG-UNIT (folic acid- NPB cholecalciferol) cifrazol oral capsule 1-3775 mg-unit NPB iron-folic acid-c-b6-b12-zinc (Corvita 150 Oral Tablet 150-1.25 G Mg) CORVITE 150 ORAL TABLET (iron combinations) NPB corvite fe oral tablet NPB cvs folic acid oral tablet 800 mcg CE cyanocobalamin injection solution 1000 mcg/ml G DOPTELET ORAL TABLET 20 MG (avatrombopag PSP maleate) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 163 Prescription Drug Name Drug Tier Drug Notes DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG NPB (hydroxyurea) durachol oral capsule 1-3775 mg-unit NPB ELELYSO INTRAVENOUS SOLUTION NF RECONSTITUTED 200 UNIT (taliglucerase alfa) EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 NF UNIT/ML (epoetin alfa) FA-8 ORAL CAPSULE 0.8 MG (folic acid) CE FA-8 ORAL TABLET 800 MCG (folic acid) CE fabb oral tablet 2.2-25-1 mg G fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg G FERIVA 21/7 ORAL TABLET 75-1 MG (feasp-b12-fa-c-dss- NF succac-zn) ferocon oral capsule G ferotrinsic oral capsule G ferraplus 90 oral tablet 90-1 mg NPB fe fum-fa-b cmp-c-zn-mg-mn-cu (Ferrocite Plus Oral Tablet G 106-1 Mg) FERRO-PLEX HEMATINIC ORAL TABLET 115-1 MG NPB (fe fum-dss-c-e-b12-if-fa) FERROTRIN ORAL CAPSULE (iron-b12-vit c-fa-ifc) NPB folbee oral tablet 2.5-25-1 mg G folic acid injection solution 5 mg/ml G folic acid oral capsule 0.8 mg CE folic acid oral tablet 1 mg CE FOLI-D ORAL TABLET 1-2000 MG-UNIT (folic acid- NF cholecalciferol) folite oral tablet NF FOLIVANE-F ORAL CAPSULE 125-1 MG (fe fum-fepoly- NPB fa-vit c-vit b3) FOLIVANE-PLUS ORAL CAPSULE (fefum-fepoly-fa-b NPB cmp-c-biot) folplex 2.2 oral tablet 2.2-25-0.5 mg G foltrin oral capsule G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 164 Prescription Drug Name Drug Tier Drug Notes folic acid-cholecalciferol (Folvite-D Oral Tablet 1-3775 Mg- NF Unit) FULPHILA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 6 MG/0.6ML (pegfilgrastim-jmdb) FUSION PLUS ORAL CAPSULE (iron-fa-b cmp-c-biot- NPB probiotic) GENICIN VITA-D ORAL TABLET 1-3775 MG-UNIT NF (folic acid-cholecalciferol) GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, NF 480 MCG/1.6ML (tbo-filgrastim) GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (tbo- NF filgrastim) hematinic plus vit/minerals oral tablet 106-1 mg G hematinic/folic acid oral tablet 324-1 mg G HEMOCYTE PLUS ORAL CAPSULE 106-1 MG (fe fum-fa- NPB b cmp-c-zn-mg-mn-cu) ferrous fumarate-folic acid (Hemocyte-F Oral Tablet 324-1 G Mg) hemocyte-plus oral tablet 106-1 mg G hydroxocobalamin acetate intramuscular solution 1000 mcg/ml G ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG (iron- NF vit c-vit b12-folic acid) iron polysacch cmplx-b12-fa (Iferex 150 Forte Oral Capsule G 150-25-1 Mg-Mcg-Mg) INTEGRA F ORAL CAPSULE 125-1 MG (fe fum-fepoly-fa- NPB vit c-vit b3) INTEGRA PLUS ORAL CAPSULE (fefum-fepoly-fa-b cmp- NPB c-biot) fefum-fepo-fa-b cmp-c-zn-mn-cu (K-Tan Plus Oral Capsule G 162-115.2-1 Mg) LEUKINE INJECTION SOLUTION RECONSTITUTED NPSP 250 MCG (sargramostim) miglustat oral capsule 100 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 165 Prescription Drug Name Drug Tier Drug Notes MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 NF MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML (methoxy peg-epoetin beta) MULPLETA ORAL TABLET 3 MG (lusutrombopag) PSP MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe NPB asp gly-succ-c-thre-b12-fa) MULTIGEN ORAL TABLET 70 MG (fe-succ-c-thre-b12-des NPB stomach) MULTIGEN PLUS ORAL TABLET 50-101-1 MG (feasp- NPB fefum -suc-c-thre-b12-fa) NASCOBAL NASAL SOLUTION 500 MCG/0.1ML NPB (cyanocobalamin) NEULASTA ONPRO SUBCUTANEOUS PREFILLED NF SYRINGE KIT 6 MG/0.6ML (pegfilgrastim) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 6 MG/0.6ML (pegfilgrastim) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 NF MCG/1.6ML (filgrastim) NEUPOGEN INJECTION SOLUTION PREFILLED NF SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim) NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 PSP MCG/1.6ML (filgrastim-aafi) NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim- PSP aafi) NPLATE SUBCUTANEOUS SOLUTION NF RECONSTITUTED 125 MCG (romiplostim) NPLATE SUBCUTANEOUS SOLUTION NPSP RECONSTITUTED 250 MCG, 500 MCG (romiplostim) NUFERA ORAL TABLET (iron combinations) NPB folic acid-vit b6-vit b12 (Nufol Oral Tablet 2.5-25-1 Mg) G ortho df oral capsule 1-3775 mg-unit NF poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg G polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 166 Prescription Drug Name Drug Tier Drug Notes PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 NF UNIT/ML, 40000 UNIT/ML (epoetin alfa) PROMACTA ORAL PACKET 12.5 MG, 25 MG NPSP (eltrombopag olamine) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 NPSP MG (eltrombopag olamine) REBLOZYL SUBCUTANEOUS SOLUTION NF RECONSTITUTED 25 MG, 75 MG (luspatercept-aamt) RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 PSP UNIT/ML (epoetin alfa-epbx) revesta oral capsule 1-5750 mg-unit NF SIKLOS ORAL TABLET 100 MG, 1000 MG (hydroxyurea) NPB sm folic acid oral tablet 400 mcg CE TALIVA ORAL CAPSULE 1 MG (fa-b6-b12-omega 3- NF phytosterols) taron forte oral capsule NPB tl-hem 150 oral tablet 150-1 mg G fe fumarate-b12-vit c-fa-ifc (Tricon Oral Capsule) G TRIFERIC HEMODIALYSIS PACKET 272 MG (ferric NF pyrophosphate citrate) TRIFERIC HEMODIALYSIS SOLUTION 27.2 MG/5ML NF (ferric pyrophosphate citrate) trigels-f forte oral capsule 460-60-0.01-1 mg G UDENYCA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 6 MG/0.6ML (pegfilgrastim-cbqv) virt-fefa plus oral capsule NF folic acid-vit b6-vit b12 (Virt-Gard Oral Tablet 2.2-25-1 Mg) G VITAMEZ ORAL CAPSULE 1 MG (fa-b6-b12-omega 3- NPB phytosterols) VPRIV INTRAVENOUS SOLUTION RECONSTITUTED NPSP 400 UNIT (velaglucerase alfa) yl folic acid oral tablet 400 mcg CE ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim- NF sndz) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 167 Prescription Drug Name Drug Tier Drug Notes ZAVESCA ORAL CAPSULE 100 MG (miglustat) NPB ZIEXTENZO SUBCUTANEOUS SOLUTION PSP PREFILLED SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez) *HEMOSTATICS* - DRUGS FOR THE BLOOD AMICAR ORAL SOLUTION 0.25 GM/ML (aminocaproic NF acid) aminocaproic acid oral tablet 1000 mg, 500 mg G ARTISS EXTERNAL SOLUTION (fibrin sealant component) NPB GEL-FLOW EXTERNAL KIT (gelatin absorb-thrombin) NF GELFOAM-JMI POWDER EXTERNAL KIT (gelatin NF absorb-thrombin) GELFOAM-JMI SPONGE EXTERNAL KIT (gelatin NF absorb-thrombin) RECOTHROM EXTERNAL SOLUTION NPB RECONSTITUTED 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION NPB RECONSTITUTED 20000 UNIT (thrombin (recombinant)) THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 NPB UNIT (thrombin) THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 NPB UNIT (thrombin) THROMBIN-JMI EXTERNAL SOLUTION NPB RECONSTITUTED 20000 UNIT, 5000 UNIT (thrombin) THROMBOGEN EXTERNAL KIT 10000 UNIT (thrombin) NPB THROMBOGEN EXTERNAL SOLUTION NPB RECONSTITUTED 1000 UNIT, 10000 UNIT (thrombin) TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML (fibrin NPB sealant component) TISSEEL EXTERNAL SOLUTION (fibrin sealant NPB component) tranexamic acid oral tablet 650 mg G *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 PB MG (suvorexant) doxepin hcl oral tablet 3 mg, 6 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 168 Prescription Drug Name Drug Tier Drug Notes EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 NPB MG, 5 MG (zolpidem tartrate) estazolam oral tablet 1 mg, 2 mg G eszopiclone oral tablet 1 mg, 2 mg, 3 mg G flurazepam hcl oral capsule 15 mg, 30 mg G INTERMEZZO SUBLINGUAL TABLET SUBLINGUAL NF 1.75 MG (zolpidem tartrate) LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG NF (eszopiclone) midazolam hcl oral syrup 2 mg/ml G MIDAZOLAM+SYRSPEND SF ORAL SUSPENSION 1 NF MG/ML (midazolam) mko melt dose pack mouth/throat troche 3-25-2 mg NF phenobarbital oral elixir 20 mg/5ml G phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 G mg, 60 mg, 64.8 mg, 97.2 mg PRECEDEX INTRAVENOUS SOLUTION 1000 NPB MCG/250ML (dexmedetomidine hcl in nacl) quazepam oral tablet 15 mg NF ramelteon oral tablet 8 mg G ROZEREM ORAL TABLET 8 MG (ramelteon) NF SECONAL ORAL CAPSULE 100 MG (secobarbital sodium) NPB SILENOR ORAL TABLET 3 MG, 6 MG (doxepin hcl) NPB temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg G triazolam oral tablet 0.125 mg, 0.25 mg G zaleplon oral capsule 10 mg, 5 mg G zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 G mg zolpidem tartrate oral tablet 10 mg, 5 mg G zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg G ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem NF tartrate) *LAXATIVES* - DRUGS FOR THE STOMACH ALOPHEN ORAL TABLET DELAYED RELEASE 5 MG CE (bisacodyl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 169 Prescription Drug Name Drug Tier Drug Notes bisacodyl ec oral tablet delayed release 5 mg CE bisacodyl rectal suppository 10 mg CE cascara sagrada oral fluid extract 1 gm/ml NPB CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM - CE GM/160ML (sod picosulfate-mag ox-cit acd) constulose oral solution 10 gm/15ml G correct oral tablet delayed release 5 mg CE CORRECTOL ORAL TABLET DELAYED RELEASE 5 CE MG (bisacodyl) cvs c-lax laxative oral tablet delayed release 5 mg CE ducodyl oral tablet delayed release 5 mg CE eq womens laxative oral tablet delayed release 5 mg CE eql gentle laxative oral tablet delayed release 5 mg CE eql laxative oral tablet delayed release 5 mg CE FEENAMINT ORAL TABLET DELAYED RELEASE 5 CE MG (bisacodyl) GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 CE GM (peg 3350-kcl-nabcb-nacl-nasulf) peg 3350-kcl-nabcb-nacl-nasulf (Gavilyte-G Oral Solution CE Reconstituted 236 Gm) bisacodyl-peg-kcl-nabicar-nacl (Gavilyte-H Oral Kit 5-210 Mg- CE Gm) peg 3350-kcl-na bicarb-nacl (Gavilyte-N With Flavor Pack CE Oral Solution Reconstituted 420 Gm) gentle laxative oral tablet delayed release 5 mg CE GIALAX ORAL KIT (polyethylene glycol 3350) NF GNP BISA-LAX ORAL TABLET DELAYED RELEASE 5 CE MG (bisacodyl) gnp gentle laxative oral tablet delayed release 5 mg CE gnp gentle laxative rectal suppository 10 mg CE gnp laxative rectal suppository 10 mg CE gnp womens gentle laxative oral tablet delayed release 5 mg CE GOLYTELY ORAL SOLUTION RECONSTITUTED 236 NF GM (peg 3350-kcl-nabcb-nacl-nasulf) hm laxative oral tablet delayed release 5 mg CE

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 170 Prescription Drug Name Drug Tier Drug Notes hm laxative rectal suppository 10 mg CE kp bisacodyl oral tablet delayed release 5 mg CE KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) NPB lactulose oral packet 10 gm NF lactulose oral solution 10 gm/15ml, 20 gm/30ml G laxative oral tablet delayed release 5 mg CE laxative rectal suppository 10 mg CE mineral oil heavy oral oil G MOVIPREP ORAL SOLUTION RECONSTITUTED 100 NF GM (peg-kcl-nacl-nasulf-na asc-c) OSMOPREP ORAL TABLET 1.102-0.398 GM (sod phos NF mono-sod phos dibasic) PCP 100 COMBINATION KIT (mgcit-bisacod-pet-peg- NF metoclop) peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm CE peg-3350/electrolytes oral solution reconstituted 236 gm CE bisacodyl-peg-kcl-nabicar-nacl (Peg-Prep Oral Kit 5-210 Mg- CE Gm) PLENVU ORAL SOLUTION RECONSTITUTED 140 GM NF (peg-kcl-nacl-nasulf-na asc-c) qc gentle laxative oral tablet delayed release 5 mg CE qc gentle laxative rectal suppository 10 mg CE ra fast relief laxative rectal suppository 10 mg CE ra laxative oral tablet delayed release 5 mg CE ra stimulant laxative rectal suppository 10 mg CE sb bisacodyl laxative ec oral tablet delayed release 5 mg CE sb laxative rectal suppository 10 mg CE sm gentle laxative oral tablet delayed release 5 mg CE sm laxative rectal suppository 10 mg CE SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13- CE 1.6 GM/177ML (na sulfate-k sulfate-mg sulf) THE MAGIC BULLET RECTAL SUPPOSITORY 10 MG CE (bisacodyl) peg 3350-kcl-na bicarb-nacl (Trilyte Oral Solution CE Reconstituted 420 Gm)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 171 Prescription Drug Name Drug Tier Drug Notes veracolate oral tablet delayed release 5 mg CE womans laxative oral tablet delayed release 5 mg CE *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER bupivacaine hcl injection solution 0.125 % NPB lidocaine in dextrose solution 5-7.5 % NPB lidomark 2/5 injection kit 2 % NPB READYSHARP-A INJECTION KIT 1 & 0.5 % (lidocaine NF hcl-bupivacaine hcl) reck solution prefilled syringe 123-0.25-0.04- 15 mg/50ml NF *MACROLIDES* - DRUGS FOR INFECTIONS azithromycin oral packet 1 gm G azithromycin oral suspension reconstituted 100 mg/5ml, 200 G mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg G clarithromycin er oral tablet extended release 24 hour 500 mg G clarithromycin oral suspension reconstituted 125 mg/5ml, 250 G mg/5ml clarithromycin oral tablet 250 mg, 500 mg G DIFICID ORAL TABLET 200 MG (fidaxomicin) PB E.E.S. 400 ORAL TABLET 400 MG (erythromycin G ethylsuccinate) E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML (erythromycin NF ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED NF 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 400 ORAL SUSPENSION RECONSTITUTED NF 400 MG/5ML (erythromycin ethylsuccinate) erythromycin base (Ery-Tab Oral Tablet Delayed Release 250 G Mg, 333 Mg, 500 Mg) ERYTHROCIN STEARATE ORAL TABLET 250 MG G (erythromycin stearate) erythromycin base oral capsule delayed release particles 250 mg G erythromycin base oral tablet 250 mg, 500 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 172 Prescription Drug Name Drug Tier Drug Notes erythromycin ethylsuccinate oral suspension reconstituted 200 G mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg G erythromycin oral tablet delayed release 250 mg, 333 mg, 500 G mg ZITHROMAX ORAL TABLET 250 MG (azithromycin) NPB *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT 1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , NF 31g x 8 mm , 32g x 4 mm , 32g x 6 mm , 33g x 4 mm 1st tier unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm , 33g x 4 mm 1st tier unilet comfortouch PB ABOUTTIME PEN NEEDLE 30G X 8 MM , 31G X 5 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) ACCU-CHEK AVIVA CONNECT KIT W/DEVICE (blood NF glucose monitoring suppl) ACCU-CHEK AVIVA DEVICE (blood glucose monitoring NF suppl) ACCU-CHEK AVIVA PLUS KIT W/DEVICE (blood NF glucose monitoring suppl) ACCU-CHEK COMPACT PLUS CARE KIT (blood glucose NF monitoring suppl) ACCU-CHEK FASTCLIX LANCET KIT (lancets misc.) NPB ACCU-CHEK FASTCLIX LANCETS (lancets) PB ACCU-CHEK FLEXLINK PLUS 10MM (insulin infusion NPB pump supplies) ACCU-CHEK FLEXLINK PLUS 6MM (insulin infusion NPB pump supplies) ACCU-CHEK FLEXLINK PLUS 8MM (insulin infusion NPB pump supplies) ACCU-CHEK GUIDE KIT W/DEVICE (blood glucose NF monitoring suppl) ACCU-CHEK GUIDE ME KIT W/DEVICE (blood glucose NF monitoring suppl) ACCU-CHEK LINKASSIST (insulin pump accessories) NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 173 Prescription Drug Name Drug Tier Drug Notes ACCU-CHEK MULTICLIX LANCET DEV KIT (lancets NPB misc.) ACCU-CHEK MULTICLIX LANCETS (lancets) PB ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE NF (blood glucose monitoring suppl) ACCU-CHEK PLASTIC CARTRIDGE (insulin infusion NPB pump supplies) ACCU-CHEK RAPID-D INFUSION SET (insulin infusion NPB pump supplies) ACCU-CHEK RAPID-D LINK (insulin infusion pump NPB supplies) ACCU-CHEK SAFE-T PRO LANCETS (lancets) PB ACCU-CHEK SOFTCLIX LANCET DEV KIT (lancets NPB misc.) ACCU-CHEK SOFTCLIX LANCETS (lancets) PB ACCU-CHEK SPIRIT BATTERY KIT (insulin pump NPB accessories) ACCU-CHEK TENDER II SET 24" (insulin infusion pump NPB supplies) ACCU-CHEK TENDER II SET 31" (insulin infusion pump NPB supplies) ACCU-CHEK TENDER II SET 43" (insulin infusion pump NPB supplies) ACCU-CHEK ULTRAFLEX INF SET (insulin infusion NPB pump supplies) ACCU-CHEK ULTRAFLEX-1 INF SET (insulin infusion NPB pump supplies) acti-lance 28g PB acti-lance lite lancets 28g PB acti-lance special lancets 17g PB acti-lance universal 23g PB adjustable lancing device NPB ADVANCE INTUITION METER DEVICE (blood glucose NF monitoring suppl) ADVANCE INTUITION MONITOR KIT (blood glucose NF monitoring suppl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 174 Prescription Drug Name Drug Tier Drug Notes ADVANCE MICRO-DRAW METER DEVICE (blood NF glucose monitoring suppl) ADVOCATE ARM BPM DEVICE (blood pressure NF monitoring) ADVOCATE BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) ADVOCATE BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) ADVOCATE DUO DEVICE (blood glucose-bp monitor) NPB ADVOCATE DUO KIT (blood glucose-bp monitor) NPB ADVOCATE INSULIN PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 33G X 4 MM (insulin pen NF needle) ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ADVOCATE LANCETS 30G (lancets) PB ADVOCATE LANCING DEVICE (lancet devices) NPB ADVOCATE RAPID-SAFE LANCING (lancet devices) NPB ADVOCATE REDI-CODE DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE KIT W/DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE+ DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE+ TALKING KIT W/DEVICE NF (blood glucose monitoring suppl) ADVOCATE SAFETY LANCETS (lancets) PB ADVOCATE SAFETY LANCETS 26G (lancets) PB AGAMATRIX AMP DEVICE (blood glucose monitoring NF suppl) AGAMATRIX CONTROL LEVEL 2 IN VITRO NPB SOLUTION (blood glucose calibration) AGAMATRIX CONTROL LEVEL 4 IN VITRO NPB SOLUTION (blood glucose calibration)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 175 Prescription Drug Name Drug Tier Drug Notes AGAMATRIX JAZZ WIRELESS 2 KIT W/DEVICE (blood NF glucose monitoring suppl) AGAMATRIX PRESTO KIT W/DEVICE (blood glucose NF monitoring suppl) AGAMATRIX PRESTO PRO METER DEVICE (blood NF glucose monitoring suppl) AGAMATRIX ULTRA-THIN LANCETS (lancets) PB aimsco twist lancets 32g PB AIMSCO TWIST LANCETS 33G (lancets) PB ALCOH-GLOVE CONTOURED WIPE PAD (alcohol NPB swabs) alcohol pads pad 70 % NPB alcohol prep pad NPB alcohol prep pad 70 % NPB alcohol swabs pad NPB ALCOHOL SWABSTICK PAD 70 % (alcohol swabs) NPB alcohol wipes pad 70 % NPB alcoh-wipe sheet NPB alternate site lancing device NPB AMD FOAM DRESSING PAD 3-1/2"X3" , 4"X4" , 6"X6" NPB (gauze pads & dressings) APLICARE ALCOHOL SWABSTICK PAD 70 % (alcohol NPB swabs) AQUALANCE LANCETS 30G (lancets) PB ASSURE 3 METER KIT (blood glucose monitoring suppl) NF ASSURE 4 METER DEVICE (blood glucose monitoring NF suppl) assure comfort lancets 28g PB ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) ASSURE ID SAFETY PEN NEEDLES 30G X 5 MM , 30G NF X 8 MM , 31G X 5 MM (insulin pen needle) ASSURE LANCETS (lancets) PB ASSURE PLATINUM METER DEVICE (blood glucose NF monitoring suppl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 176 Prescription Drug Name Drug Tier Drug Notes ASSURE PRO BLOOD GLUCOSE METER DEVICE NF (blood glucose monitoring suppl) aurora lancet super thin 30g PB aurora lancet thin 23g PB aurora pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF aurora unifine pentips 31g x 5 mm , 32g x 4 mm NF AUTO-LANCET (lancet devices) NPB AUTO-LANCET MINI (lancet devices) NPB AUTOLET II CLINISAFE KIT (lancets misc.) NPB AUTOLET LANCING DEVICE (lancet devices) NPB AUTOLET LITE CLINISAFE KIT (lancets misc.) NPB AUTOLET LITE STARTER PACK KIT (lancets misc.) NPB AUTOLET MINI (lancet devices) NPB AUTOLET PLATFORMS (lancets misc.) PB AUTOLET PLUS (lancet devices) NPB AUTOSOFT 30 INFUSION SET (insulin infusion pump NPB supplies) AUTOSOFT 90 INFUSION SET (insulin infusion pump NPB supplies) AUTOSOFT XC INFUSION SET (insulin infusion pump NPB supplies) BD AUTOSHIELD 29G X 5MM , 29G X 8MM (insulin pen PB needle) BD AUTOSHIELD DUO 30G X 5 MM (insulin pen needle) PB BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 29G PB X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (insulin syringe-needle PB u-100) BD INSULIN SYRINGE U/F 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 1 ML (insulin PB syringe-needle u-100) BD INSULIN SYRINGE U-100 1 ML (insulin syringes PB (disposable))

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 177 Prescription Drug Name Drug Tier Drug Notes BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML PB (insulin syringe/needle u-500) BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 PB ML (insulin syringe-needle u-100) BD LANCET ULTRAFINE 30G (lancets) PB BD LANCET ULTRAFINE 33G (lancets) PB BD LATITUDE DIABETES KIT (blood glucose monitoring NF suppl) BD LATITUDE DIABETES SYSTEM KIT (blood glucose NF monitoring suppl) BD LOGIC BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) BD MICROTAINER LANCETS (lancets) PB BD PEN NEEDLE MICRO U/F 32G X 6 MM (insulin pen PB needle) BD PEN NEEDLE MINI U/F 31G X 5 MM (insulin pen PB needle) BD PEN NEEDLE NANO 2ND GEN 32G X 4 MM (insulin PB pen needle) BD PEN NEEDLE NANO U/F 32G X 4 MM (insulin pen PB needle) BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM (insulin PB pen needle) BD PEN NEEDLE SHORT U/F 31G X 8 MM (insulin pen PB needle) BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 PB ML, 31G X 15/64" 0.3 ML (insulin syringe-needle u-100) BD SWABS SINGLE USE BUTTERFLY PAD (alcohol NPB swabs) BD VEO INSULIN SYR U/F 1/2UNIT 31G X 15/64" 0.3 ML PB (insulin syringe-needle u-100) BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML PB (insulin syringe-needle u-100) BIOFREQUENCY INSOLES (foot care products) NPB BIOGUARD GAUZE SPONGES PAD 2"X2" , 4"X4" (gauze NPB pads & dressings)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 178 Prescription Drug Name Drug Tier Drug Notes BIOGUARD ISLAND DRESSINGS PAD 4"X10" , 4"X14" , NPB 4"X5" (gauze pads & dressings) BIOGUARD NON-ADHERENT DRESSING PAD 3"X4" , NPB 3"X8" (gauze pads & dressings) BIOTEL CARE BLOOD GLUCOSE SYST KIT W/DEVICE NF (blood glucose monitoring suppl) blood glucose monitor system kit w/device NF blood glucose system pak kit NF bullseye mini safety lancets PB BULLSEYE SAFETY LANCETS (lancets) PB CARDIOCOM LANCING DEVICE (lancet devices) NPB CAREFINE PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , NF 32G X 6 MM (insulin pen needle) careone advanced lancing dev NPB CAREONE BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) careone insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" NF 1 ml careone lancet thin 23g PB careone lancet ultra thin 28g PB careone unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , NF 31g x 8 mm , 32g x 4 mm careone unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm CARESENS LANCETS (lancets) PB CARESENS N GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) CARESENS N VOICE SYSTEM DEVICE (blood glucose NF monitoring suppl) CARETOUCH ALCOHOL PREP PAD 70 % (alcohol swabs) NPB CARETOUCH CONTROL SOL LEVEL 2 IN VITRO NPB LIQUID (blood glucose calibration) CARETOUCH INSULIN SYRINGE 28G X 5/16" 1 ML, NF 29G X 5/16" 1 ML (insulin syringe-needle u-100)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 179 Prescription Drug Name Drug Tier Drug Notes CARETOUCH LANCING/EJECTOR (lancet devices) NPB CARETOUCH MONITOR SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) CARETOUCH PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM (insulin NF pen needle) CARETOUCH SAFETY LANCETS (lancets) PB CARETOUCH SAFETY LANCETS 26G (lancets) PB CARETOUCH TWIST LANCETS 28G (lancets) PB CARETOUCH TWIST LANCETS 30G (lancets) PB CARETOUCH TWIST LANCETS 33G (lancets) PB CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) CE CEQUR SIMPLICITY 2U DEVICE (injection device for NPB insulin) CHOICE DM DIABETES RISK TEST KIT (blood glucose NF monitoring suppl) cicatrace pad sheet NF CLEANLET LANCETS 28G (lancets) PB CLEVER CHEK AUTO-CODE DEVICE (blood glucose-bp NPB monitor) CLEVER CHEK AUTO-CODE SYSTEM DEVICE (blood NF glucose monitoring suppl) CLEVER CHEK AUTO-CODE VOICE DEVICE (blood NF glucose monitoring suppl) CLEVER CHEK LANCETS (lancets) PB CLEVER CHEK SYSTEM KIT W/DEVICE (blood glucose NF monitoring suppl) CLEVER CHOICE AUTO-CODE SYSTEM DEVICE NF (blood glucose monitoring suppl) CLEVER CHOICE COMFORT EZ 29G X 12MM , 33G X 4 NF MM (insulin pen needle) CLEVER CHOICE LANCETS 21G (lancets) PB CLEVER CHOICE LANCETS 23G (lancets) PB CLEVER CHOICE LANCETS 28G (lancets) PB CLEVER CHOICE MICRO SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 180 Prescription Drug Name Drug Tier Drug Notes CLEVER CHOICE MINI SYSTEM DEVICE (blood glucose NF monitoring suppl) CLEVER CHOICE TALK SYSTEM DEVICE (blood glucose NF monitoring suppl) CLICKFINE PEN NEEDLES 31G X 5 MM (insulin pen NF needle) clickfine pen needles 31g x 6 mm , 31g x 8 mm , 32g x 4 mm NF COAGUCHEK LANCETS (lancets) PB COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" NF 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) comfort assured lancets 28g PB comfort assured lancets 33g PB COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, NF 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) COMFORT EZ MICRO PEN NEEDLES 32G X 4 MM NF (insulin pen needle) COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 NF MM , 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM , 33G X 8 MM (insulin pen needle) COMFORT EZ SHORT PEN NEEDLES 31G X 8 MM NF (insulin pen needle) comfort lancets PB COMFORT SHORT INF SET 23"/13MM (insulin infusion NPB pump supplies) COMFORT SHORT INF SET 31"/13MM (insulin infusion NPB pump supplies) COMFORT SHORT INF SET 43"/13MM (insulin infusion NPB pump supplies) CONTOUR MONITOR DEVICE (blood glucose monitoring NF suppl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 181 Prescription Drug Name Drug Tier Drug Notes CONTOUR NEXT EZ KIT W/DEVICE (blood glucose NF monitoring suppl) CONTOUR NEXT LINK KIT W/DEVICE (blood glucose NF monitoring suppl) CONTOUR NEXT MONITOR KIT W/DEVICE (blood NF glucose monitoring suppl) CONTOUR NEXT ONE KIT (blood glucose monitoring NF suppl) COOL MONITOR DEVICE (blood glucose monitoring suppl) NF COOL MONITOR KIT KIT W/DEVICE (blood glucose NF monitoring suppl) CURITY ALCOHOL PREPS PAD 70 % (alcohol swabs) NPB CURITY ALCOHOL SWABS PAD (alcohol swabs) NPB CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4" NPB (gauze pads & dressings) CURITY AMD ANTIMICROBIAL STRIP (gauze pads & NPB dressings) CURITY IODOFORM PACKING STRIP (gauze pads & NPB dressings) CURITY WOUND CLOSURE 1/2"X4" (adhesive bandages) NPB CURITY WOUND CLOSURE 1/4"X1.5" (adhesive NPB bandages) CURITY WOUND CLOSURE 1/4"X3" (adhesive bandages) NPB CURITY WOUND CLOSURE 1/4"X4" (adhesive bandages) NPB CURITY WOUND CLOSURE 1/8"X3" (adhesive bandages) NPB CVS BLOOD GLUCOSE METER KIT W/DEVICE (blood NF glucose monitoring suppl) cvs lancets 21g PB cvs lancets micro thin 33g PB cvs lancets original PB cvs lancets thin 26g PB cvs lancets ultra thin 30g PB cvs lancets ultra-thin 30g PB cvs lancing device NPB cvs prep pad 70 % NPB cvs ultra thin lancets PB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 182 Prescription Drug Name Drug Tier Drug Notes D-CARE GLUCOMETER KIT W/DEVICE (blood glucose NF monitoring suppl) DELTEC COZMO CLEO SET 42" 6MM (insulin infusion NPB pump supplies) DELTEC COZMO CLEO SET 42" 9MM (insulin infusion NPB pump supplies) DEXCOM G4 PLAT PED RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G4 PLATINUM RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous PB blood gluc transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) PB DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood PB gluc sensor) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G5 MOBILE TRANSMITTER (continuous blood PB gluc transmit) DEXCOM G5 RECEIVER KIT DEVICE (continuous blood PB gluc receiver) DEXCOM G6 RECEIVER DEVICE (continuous blood gluc PB receiver) DEXCOM G6 SENSOR (continuous blood gluc sensor) PB DEXCOM G6 TRANSMITTER (continuous blood gluc PB transmit) DIATHRIVE BLOOD GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) DIATHRIVE LANCET ULTRA THIN 30 (lancets) PB DIATHRIVE LANCETS (lancets) PB DIATHRIVE LANCING DEVICE (lancet devices) NPB DIATHRIVE PEN NEEDLE 31G X 5 MM , 31G X 6 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 183 Prescription Drug Name Drug Tier Drug Notes DIATHRIVE+ GLUCOSE MONITOR DEVICE (blood NF glucose monitoring suppl) diatrue plus blood glucose device NF DROPLET INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 15/64" 0.3 ML, 30G X 15/64" 0.5 ML, 30G X 15/64" 1 ML, 30G X 5/16" 0.3 ML, 30G NF X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- needle u-100) DROPLET LANCETS ULTRA THIN 30G (lancets) PB DROPLET LANCING DEVICE (lancet devices) NPB DROPLET MICRON 34G X 3.5 MM (insulin pen needle) NF DROPLET PEN NEEDLES 29G X 10MM , 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , NF 32G X 5 MM , 32G X 6 MM , 32G X 8 MM (insulin pen needle) dropsafe safety pen needles 31g x 6 mm , 31g x 8 mm NF drug mart lancets thin 26g PB DRUG MART ON-THE-GO LANCET 30G (lancets) PB drug mart unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm drug mart unifine pentips plus 32g x 4 mm NF easy comfort alcohol pads pad NPB easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.5 ml, 31g x NF 5/16" 1 ml, 32g x 5/16" 0.5 ml, 32g x 5/16" 1 ml easy comfort lancets PB easy comfort lancets twist top PB easy comfort pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm NF , 32g x 4 mm , 33g x 4 mm , 33g x 5 mm , 33g x 6 mm easy glide pen needles 33g x 4 mm NF easy mini eject lancing device NPB easy mini lancing device NPB easy plus ii glucose system device NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 184 Prescription Drug Name Drug Tier Drug Notes EASY STEP GLUCOSE MONITOR DEVICE (blood glucose NF monitoring suppl) easy talk blood glucose system device NF EASY TOUCH ALCOHOL PREP MEDIUM PAD 70 % NPB (alcohol swabs) EASY TOUCH FLIPLOCK INSULIN SY 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) EASY TOUCH GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 NF ML (insulin syringe-needle u-100) EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X NF 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u- 100) EASY TOUCH LANCETS 21G (lancets) PB EASY TOUCH LANCETS 23G (lancets) PB EASY TOUCH LANCETS 28G (lancets) PB EASY TOUCH LANCETS 30G (lancets) PB EASY TOUCH LANCETS 32G (lancets) PB EASY TOUCH LANCING DEVICE (lancet devices) NPB EASY TOUCH PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 NF MM , 32G X 5 MM , 32G X 6 MM (insulin pen needle) EASY TOUCH SAFETY PEN NEEDLES 29G X 5MM , NF 29G X 8MM , 30G X 8 MM (insulin pen needle) EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) easy trak blood glucose system device NF easy trak ii blood glucose sys device NF EASYGLUCO KIT (blood glucose monitoring suppl) NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 185 Prescription Drug Name Drug Tier Drug Notes EASYMAX 15 LEVEL 2-3 CONTROL IN VITRO LIQUID NPB (blood glucose calibration) EASYMAX CONTROL NORMAL/HIGH IN VITRO NPB LIQUID (blood glucose calibration) EASYMAX NG BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) EASYMAX NG BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) EASYMAX V BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) EASYMAX V BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) EASYPRO BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) EASYPRO PLUS KIT W/DEVICE (blood glucose monitoring NF suppl) ELEMENT AUTOCODE SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) element compact glucose system device NF element compact v glucose sys device NF ELEMENT PLUS DEVICE (blood glucose monitoring suppl) NF EMBRACE BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) EMBRACE EVO GLUCOSE MONITORING KIT NF W/DEVICE (blood glucose monitoring suppl) EMBRACE LANCETS ULTRA THIN 30G (lancets) PB EMBRACE PRO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) EMBRACE TALK BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) EMBRACE TALK MONITORING SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) NF ENLITE SERTER (insulin infusion pump supplies) NPB eql alcohol swabs pad 70 % NPB eql color lancets 21g PB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 186 Prescription Drug Name Drug Tier Drug Notes eql color lancets micro 33g PB eql insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 NF ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml eql super thin lancets 30g PB eql thin lancets 26g PB EROS-CTD DEVICE (clitoral vacuum device) NPB EVENCARE G2 MONITOR DEVICE (blood glucose NF monitoring suppl) EVENCARE G3 MONITOR DEVICE (blood glucose NF monitoring suppl) EVENCARE GLUCOSE MONITORING KIT (blood NF glucose monitoring suppl) EVENCARE MINI MONITOR DEVICE (blood glucose NF monitoring suppl) EVERSENSE SENSOR/HOLDER (continuous blood gluc NF sensor) EVERSENSE SMART TRANSMITTER (continuous blood NF gluc transmit) EVOLUTION AUTOCODE DEVICE (blood glucose NF monitoring suppl) EXCILON AMD DRAIN SPONGES PAD 4"X4" (gauze NPB pads & dressings) EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 NF ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) EXEL COMFORT POINT PEN NEEDLE 29G X 12MM , 31G X 4 MM , 31G X 6 MM , 31G X 8 MM (insulin pen NF needle) E-Z JECT LANCET MICRO-THIN 33G (lancets) PB E-Z JECT LANCET SUPER THIN 30G (lancets) PB E-Z JECT LANCETS (lancets) PB E-Z JECT LANCETS 21G (lancets) PB E-Z JECT LANCETS THIN 26G (lancets) PB EZ SMART BLOOD GLUCOSE LANCETS (lancets) PB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 187 Prescription Drug Name Drug Tier Drug Notes EZ SMART MONITORING SYSTEM DEVICE (blood NF glucose monitoring suppl) EZ SMART PLUS MONITORING SYS DEVICE (blood NF glucose monitoring suppl) EZ-LETS LANCETS 21G (lancets) PB EZ-LETS LANCETS 26G (lancets) PB EZ-LETS LANCETS 28G (lancets) PB EZ-LETS LANCETS 30G (lancets) PB FC FEMALE CONDOM (condoms - female) CE FC2 FEMALE CONDOM (condoms - female) CE FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM CE (cervical caps) FIFTY50 GLUCOSE METER 2.0 KIT W/DEVICE (blood NF glucose monitoring suppl) FIFTY50 PEN NEEDLES 31G X 5 MM , 31G X 8 MM , NF 32G X 4 MM , 32G X 6 MM (insulin pen needle) FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- NF needle u-100) FIFTY50 UNILET LANCETS 33G (lancets) PB FINGERSTIX LANCETS (lancets) PB FORA D10 2-IN-1 MONITOR DEVICE (blood glucose-bp NPB monitor) FORA D15G 2-IN-1 MONITOR DEVICE (blood glucose-bp NPB monitor) FORA D20 2-IN-1 MONITOR DEVICE (blood glucose-bp NPB monitor) FORA D40 GLUCOSE/PRESSURE DEVICE (blood NF glucose-bp monitor) FORA D40G GLUCOSE/PRESSURE DEVICE (blood NF glucose-bp monitor) FORA G20 BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FORA G30A BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GD20 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 188 Prescription Drug Name Drug Tier Drug Notes FORA GD50 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GTEL BLOOD GLUCOSE SYSTEM DEVICE NF (blood glucose monitoring suppl) FORA LANCETS (lancets) PB FORA LANCING DEVICE (lancet devices) NPB FORA PREMIUM V10 BLE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA TEST N' GO MONITOR DEVICE (blood glucose NF monitoring suppl) FORA TN'G VOICE KIT W/DEVICE (blood glucose NF monitoring suppl) FORA V10 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V10/V12/D10/D20 TEST KIT (blood glucose NF monitoring suppl) FORA V12 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V20 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V30A BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V30A BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) FORACARE GD40 MONITOR DEVICE (blood glucose NF monitoring suppl) FORACARE PREMIUM V10 DEVICE (blood glucose NF monitoring suppl) FORACARE TEST N GO MONITOR DEVICE (blood NF glucose monitoring suppl) FORTISCARE GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORTISCARE GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FORTISCARE T1 GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) freds pharmacy autolet lancing NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 189 Prescription Drug Name Drug Tier Drug Notes freds pharmacy unifine pentip+ 31g x 5 mm , 31g x 8 mm NF freds pharmacy unifine pentips 32g x 4 mm NF FREESTYLE FLASH SYSTEM KIT (blood glucose NF monitoring suppl) FREESTYLE FREEDOM KIT (blood glucose monitoring NF suppl) FREESTYLE FREEDOM LITE KIT W/DEVICE (blood NF glucose monitoring suppl) FREESTYLE INSULINX SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) FREESTYLE LIBRE 14 DAY READER DEVICE NF (continuous blood gluc receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood NF gluc sensor) FREESTYLE LIBRE 2 READER SYSTM DEVICE NF (continuous blood gluc receiver) FREESTYLE LIBRE 2 SENSOR SYSTM (continuous blood NF gluc sensor) FREESTYLE LIBRE READER DEVICE (continuous blood NF gluc receiver) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood NF gluc sensor) FREESTYLE LITE DEVICE (blood glucose monitoring suppl) NF FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) FREESTYLE PRECISION NEO SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FREESTYLE SIDEKICK II KIT (blood glucose monitoring NF suppl) FREESTYLE SYSTEM KIT (blood glucose monitoring suppl) NF FREESTYLE UNISTICK II LANCETS (lancets) PB GAMMACORE DEVICE (nerve stimulator) NF GAMMACORE SAPPHIRE 31-DAY DEVICE (nerve NF stimulator) GAMMACORE SAPPHIRE REFILL KIT (nerve stimulator) NF ge100 blood glucose system device NF 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 190 Prescription Drug Name Drug Tier Drug Notes ge100 blood glucose system kit w/device NF GENTEEL BUTTERFLY TOUCH LANCET (lancets) PB GENTEEL CONTACT TIPS (BLUE) (lancets misc.) PB GENTEEL CONTACT TIPS (CLEAR) (lancets misc.) PB GENTEEL CONTACT TIPS (GREEN) (lancets misc.) PB GENTEEL CONTACT TIPS (ORANGE) (lancets misc.) PB GENTEEL CONTACT TIPS (RAINBOW) (lancets misc.) PB GENTEEL CONTACT TIPS (VIOLET) (lancets misc.) PB GENTEEL CONTACT TIPS (YELLOW) (lancets misc.) PB GENTEEL LANCING DEVICE (BLACK) (lancet devices) NPB GENTEEL LANCING DEVICE (BLUE) (lancet devices) NPB GENTEEL LANCING DEVICE (PINK) (lancet devices) NPB GENTEEL LANCING DEVICE (WHITE) (lancet devices) NPB GENTEEL LANCING DEVICE(PURPLE) (lancet devices) NPB GENTEEL LANCING KIT (BLUE) KIT (lancets misc.) NPB GENTEEL NOZZLES (lancets misc.) PB GENTLE-LET GP LANCETS (lancets) PB GENTLE-LET LANCETS (lancets) PB GENTLE-LET PLATFORMS (lancets misc.) PB ght blood glucose monitor kit w/device NF global alcohol prep ease pad 70 % NPB global ease inject pen needles 29g x 12mm , 31g x 5 mm , 31g x NF 8 mm , 32g x 4 mm global easy glide insulin syr 31g x 15/64" 0.3 ml, 31g x 15/64" NF 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml global easy glide pen needles 32g x 4 mm NF global inject ease insulin syr 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml global inject ease lancets 28g PB global inject ease lancets 30g PB global insulin syringes 30g x 1/2" 0.3 ml, 30g x 5/16" 0.3 ml NF global lancing device NPB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 191 Prescription Drug Name Drug Tier Drug Notes GLUCO PERFECT 3 METER DEVICE (blood glucose NF monitoring suppl) GLUCOCARD 01 BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) GLUCOCARD 01 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOCARD 01-MINI GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOCARD EXPRESSION MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) GLUCOCARD SHINE CONNEX KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD SHINE EXPRESS KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD SHINE XL DEVICE (blood glucose NF monitoring suppl) GLUCOCARD VITAL MONITOR KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD X-METER KIT W/DEVICE (blood glucose NF monitoring suppl) GLUCOCOM BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) GLUCOCOM LANCETS 28G (lancets) PB GLUCOCOM LANCETS 30G (lancets) PB GLUCOCOM LANCETS 33G (lancets) PB GLUCOCOM MONITOR KIT W/DEVICE (blood glucose NF monitoring suppl) GLUCONAVII BLOOD GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) GLUCOPRO SYR RES 3ML 22GX3/8" (insulin infusion NPB pump supplies) gnp alcohol swabs pad 70 % NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 192 Prescription Drug Name Drug Tier Drug Notes gnp clickfine pen needles 31g x 6 mm , 31g x 8 mm NF GNP EASY TOUCH GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) gnp insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml gnp lancets PB gnp lancets 21g PB gnp lancets micro thin 33g PB gnp lancets thin PB gnp lancets thin 26g PB gnp micro thin lancets 33g PB gnp super thin lancets 30g PB gnp ulticare pen needles 31g x 8 mm , 32g x 4 mm , 32g x 6 mm NF gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml GOJJI LANCING DEVICE/CLEAR CAP (lancet devices) NPB GOJJI STERILE LANCETS (lancets) PB goodsense blood glucose kit w/device NF goodsense clickfine pen needle 31g x 5 mm NF goodsense lancets 26g univ PB goodsense lancets 30g univ PB goodsense lancets 33g NPB goodsense lancets 33g univ PB goodsense lancing device NPB GOODSENSE PEN NEEDLE PENFINE 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM (insulin pen NF needle) GUARDIAN CONNECT TRANSMITTER (continuous NF blood gluc transmit) GUARDIAN LINK 3 TRANSMITTER (continuous blood NF gluc transmit)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 193 Prescription Drug Name Drug Tier Drug Notes GUARDIAN REAL-TIME CHARGER (continuous glucose NPB monitor sup) GUARDIAN REAL-TIME REPLACE PED DEVICE NPB (continuous blood gluc receiver) GUARDIAN REAL-TIME TEST PLUG (continuous glucose NPB monitor sup) GUARDIAN SENSOR (3) (continuous blood gluc sensor) NF HEALTH CARE LANCING DEVICE (lancet devices) NPB healthwise insulin syr/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g NF x 5/16" 1 ml healthwise micron pen needles 32g x 4 mm NF healthwise mini pen needles 31g x 6 mm NF healthwise pen needles 29g x 12mm NF healthwise short pen needles 31g x 5 mm , 31g x 8 mm NF healthwise unifine pentips 32g x 4 mm NF healthy accents lancing device NPB healthy accents unifine pentip 29g x 12mm , 31g x 5 mm , 31g x NF 6 mm , 31g x 8 mm , 32g x 4 mm healthy accents unilet lancets PB h-e-b incontrol adv lancing NPB h-e-b incontrol alcohol pad NPB h-e-b incontrol lancets 28g PB h-e-b incontrol lancets 30g PB h-e-b incontrol lancets 33g PB h-e-b incontrol pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm H-E-B INCONTROL UNIFINE PENTIP 32G X 4 MM NF (insulin pen needle) HM EMBRACE TALK SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) hm sterile alcohol prep pad NPB HM ULTICARE INSULIN SYRINGE 30G X 1/2" 1 ML, NF 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) HM ULTICARE SHORT PEN NEEDLES 31G X 8 MM NF (insulin pen needle) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 194 Prescription Drug Name Drug Tier Drug Notes HW EMBRACE PRO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) HW EMBRACE TALK BLOOD GLUCOSE DEVICE NF (blood glucose monitoring suppl) HY-VEE LANCETS (lancets) PB hy-vee thin lancets PB IBG STAR BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) IGLUCOSE MONITORING SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) IN TOUCH DEVICE (blood glucose monitoring suppl) NF IN TOUCH LANCING DEVICE (lancet devices) NPB IN TOUCH STERILE LANCETS 30G (lancets) PB INFINITY BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) INFINITY VOICE KIT W/DEVICE (blood glucose NF monitoring suppl) infusion catheter soft 23" NPB infusion catheter soft 31" NPB infusion catheter soft 43" NPB INPEN 100-BLUE-LILLY DEVICE (injection device for NPB insulin) INPEN 100-BLUE-NOVO DEVICE (injection device for NPB insulin) INPEN 100-GRAY-LILLY DEVICE (injection device for NPB insulin) INPEN 100-GREY-NOVO DEVICE (injection device for NPB insulin) INPEN 100-PINK-LILLY DEVICE (injection device for NPB insulin) INPEN 100-PINK-NOVO DEVICE (injection device for NPB insulin) insulin cartridge 3ml NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 195 Prescription Drug Name Drug Tier Drug Notes insulin syringe 27g x 1/2" 0.5 ml, 27g x 1/2" 1 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, NF 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 0.5 ml, 28g x NF 1/2" 1 ml insulin syringe-needle u-100 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x NF 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insupen pen needles 29g x 12mm , 31g x 5 mm , 31g x 8 mm , NF 32g x 4 mm , 33g x 4 mm INSUPEN SENSITIVE 32G X 6 MM , 32G X 8 MM (insulin NF pen needle) INSUPEN ULTRAFIN 30G X 8 MM , 31G X 6 MM , 31G NF X 8 MM (insulin pen needle) KERLIX AMD ANTIMICROBIAL (gauze pads & dressings) NPB KERLIX AMD SUPER SPONGES PAD 6"X6-3/4" (gauze NPB pads & dressings) kinney lancets PB kinney thin lancets PB kinray insulin syringe 29g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g NF x 5/16" 0.5 ml, 31g x 5/16" 1 ml kmart valu insulin syringe 29g u-100 0.5 ml, u-100 1 ml NF kmart valu insulin syringe 30g u-100 0.3 ml, u-100 0.5 ml, u-100 NF 1 ml KROGER AUTOLET LANCING DEVICE (lancet devices) NPB kroger blood glucose kit , w/device NF kroger insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 NF ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml kroger lancets PB kroger lancets super thin PB kroger lancets thin PB kroger pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g NF x 8 mm , 32g x 4 mm , 33g x 4 mm

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 196 Prescription Drug Name Drug Tier Drug Notes kroger premium blood glucose kit w/device NF lancet device NPB lancet device with ejector NPB lancet transporter case PB lancets PB lancets 30g PB lancets micro thin 33g PB lancets thin PB LANCETS ULTRA FINE (lancets) PB lancets ultra thin 30g PB lancing device NPB LANZO (lancet devices) NPB ldr blood glucose truetest kit w/device NF leader insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 NF ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml LEADER UNIFINE PENTIPS 31G X 5 MM , 32G X 4 MM NF (insulin pen needle) LEADER UNIFINE PENTIPS PLUS 31G X 5 MM , 31G X NF 8 MM , 32G X 4 MM (insulin pen needle) liberty blood glucose meter device NF LIBERTY NXT GENERATION MONITOR DEVICE NF (blood glucose monitoring suppl) LIFESCAN UNISTIK 2 (lancets) PB LIFESCAN UNISTIK II LANCETS (lancets) PB lite touch lancets PB LITE TOUCH LANCING PEN (lancet devices) NPB LITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, NF 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) LITETOUCH LANCETS (lancets) PB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 197 Prescription Drug Name Drug Tier Drug Notes LITETOUCH PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM (insulin NF pen needle) live better adv lancing device NPB live better lancet ultra thin PB longs insulin syringe 31g x 5/16" 0.5 ml NF longs lancets standard PB longs lancets thin PB longs lancets ultra thin PB MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, NF 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) MARATHON MEDICAL PENTIPS 29G X 12MM , 31G X NF 5 MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) MAXICOMFORT II PEN NEEDLE 31G X 6 MM (insulin NF pen needle) MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 NF ML, 28G X 1/2" 1 ML (insulin syringe-needle u-100) MAXI-COMFORT SAFETY PEN NEEDLE 29G X 5MM , NF 29G X 8MM (insulin pen needle) MAXICOMFORT SYR 27G X 1/2" 27G X 1/2" 0.5 ML, 27G NF X 1/2" 1 ML (insulin syringe-needle u-100) medic insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml NF medichoice safety lancet extra PB medicine shoppe pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 NF mm MEDISENSE THIN LANCETS (lancets) PB MEDLANCE PLUS EXTRA 21G (lancets) PB MEDLANCE PLUS LANCETS (lancets) PB MEDLANCE PLUS LITE 25G (lancets) PB MEDLANCE PLUS SPECIAL 0.8MM (lancets) PB MEDLANCE PLUS SUPERLITE 30G (lancets) PB MEDLANCE PLUS UNIVERSAL 21G (lancets) PB meijer blood glucose kit w/device NF meijer essential blood glucose kit w/device NF 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 198 Prescription Drug Name Drug Tier Drug Notes MEIJER LANCETS THIN (lancets) PB MEIJER LANCETS UNIVERSAL 21G (lancets) PB MEIJER LANCETS UNIVERSAL 30G (lancets) PB MEIJER LANCETS UNIVERSAL 33G (lancets) PB meijer pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF meijer premium blood glucose kit w/device NF MEIJER SUPER THIN LANCETS (lancets) PB MEIJER TRUE2GO BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUERESULT GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUETRACK GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) MI PASTE DENTAL PASTE (dentifrices) NPB MI PASTE PLUS DENTAL PASTE (dentifrices) NPB MICRODOT BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) MICROLET LANCETS (lancets) PB MICROLET NEXT LANCING DEVICE (lancet devices) NPB mini lancing device NPB MINILINK REAL-TIME TRANSMITTER (insulin pump NF accessories) MINIMED 630G GUARDIAN PRESS (insulin pump NPB accessories) MINIMED GUARDIAN LINK 3 (insulin pump accessories) NF MINIMED GUARDIAN SENSOR 3 (continuous blood gluc NF sensor) MINIMED PUMP RESERVOIR 3ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 1.8ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 3ML (insulin infusion pump NPB supplies) MIO INFUSION SET 18" 6MM (insulin infusion pump NPB supplies)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 199 Prescription Drug Name Drug Tier Drug Notes MIO INFUSION SET 23" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 9MM (insulin infusion pump NPB supplies) MM EASY TOUCH GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl) mm insulin syringe/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g NF x 5/16" 1 ml MM PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 NF MM , 32G X 4 MM (insulin pen needle) MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" NF 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) MONOJECT INSULIN SYRINGE U-100 1 ML (insulin NF syringes (disposable)) MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" NF 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u-100) MONOLET LANCETS (lancets) PB MONOLET OPD LANCETS (lancets) PB MONOLETTOR SAFETY LANCETS (lancets) PB mpd safety lancet 21g PB mpd safety lancet 23g PB mpd safety lancet 28g PB mpd safety lancet 30g PB ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x NF 5/16" 1 ml MULTI-LANCET DEVICE 2 KIT (lancets misc.) NPB MYGLUCOHEALTH BLOOD GLUCOSE KIT NF W/DEVICE (blood glucose monitoring suppl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 200 Prescription Drug Name Drug Tier Drug Notes MYGLUCOHEALTH LANCETS 30G (lancets) PB NEUTEK 2TEK GLUCOSE/PRESSURE DEVICE (blood NPB glucose-bp monitor) NORDIPEN 5 INJECTION DEVICE (injection device) NF NORDIPEN DELIVERY SYSTEM (injection device) NF NOVA MAX BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) NOVA MAX BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) NOVA SAFETY LANCETS 23G (lancets) PB NOVA SAFETY LANCETS 28G (lancets) PB NOVA SUREFLEX LANCETS (lancets) PB NOVA SUREFLEX LANCING DEVICE (lancet devices) NPB NOVOFINE 32G X 6 MM (insulin pen needle) NF NOVOFINE AUTOCOVER 30G X 8 MM (insulin pen NF needle) NOVOFINE PLUS 32G X 4 MM (insulin pen needle) NF NOVOPEN ECHO DEVICE (injection device for insulin) NPB NOVOTWIST 32G X 5 MM (insulin pen needle) NF OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM CE (diaphragms) OMNIPOD DASH 5 PACK PODS (insulin disposable pump) PB OMNIPOD STARTER KIT (insulin disposable pump) PB OMNITROPE PEN 10 INJ DEVICE (injection device) NF OMNITROPE PEN 5 INJ DEVICE (injection device) NF one drop blood glucose monitor kit w/device NF ONETOUCH CLUB LANCETS FINE PT (lancets) PB ONETOUCH DELICA LANCETS 30G (lancets) PB ONETOUCH DELICA LANCETS 33G (lancets) PB ONETOUCH DELICA LANCING DEV (lancet devices) NPB ONETOUCH DELICA PLUS LANCET30G (lancets) PB ONETOUCH DELICA PLUS LANCET33G (lancets) PB ONETOUCH DELICA PLUS LANCING (lancet devices) NPB ONETOUCH SURESOFT LANCING DEV (lancets misc.) NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 201 Prescription Drug Name Drug Tier Drug Notes ONETOUCH ULTRA 2 KIT W/DEVICE (blood glucose PB monitoring suppl) ONETOUCH ULTRA MINI KIT W/DEVICE (blood glucose PB monitoring suppl) ONETOUCH ULTRALINK KIT W/DEVICE (blood glucose PB monitoring suppl) ONETOUCH ULTRASOFT LANCETS (lancets) PB ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE PB (blood glucose monitoring suppl) ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE (blood PB glucose monitoring suppl) ONETOUCH VERIO KIT W/DEVICE (blood glucose PB monitoring suppl) ONETOUCH VERIO REFLECT KIT W/DEVICE (blood PB glucose monitoring suppl) ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE PB (blood glucose monitoring suppl) OPTIUM BLOOD GLUCOSE MONITOR KIT W/DEVICE NF (blood glucose monitoring suppl) OPTIUM GLUCOSE MONITOR SYSTEM DEVICE (blood NF glucose monitoring suppl) PARADIGM PUMP RESERVOIR 1.8ML (insulin infusion NPB pump supplies) PARADIGM PUMP RESERVOIR 3ML (insulin infusion NPB pump supplies) PARADIGM QUICK-SET 18" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 23" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 23" 9MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 32" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 32" 9MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 43" 6MM (insulin infusion pump NPB supplies)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 202 Prescription Drug Name Drug Tier Drug Notes PARADIGM QUICK-SET 43" 9MM (insulin infusion pump NPB supplies) PARADIGM REAL-TIME TRANSMITTER (insulin pump NPB accessories) PARADIGM SILHOUETTE 18" 13MM (insulin infusion NPB pump supplies) PARADIGM SILHOUETTE 32" 17MM (insulin infusion NPB pump supplies) PARADIGM SILHOUETTE COMBO 23" (insulin infusion NPB pump supplies) PARADIGM SILHOUETTE FULL 23" (insulin infusion NPB pump supplies) PARADIGM SURE-T 23" 6MM (insulin infusion pump NPB supplies) PARADIGM SURE-T 23" 8MM (insulin infusion pump NPB supplies) pc lancets super thin 30g PB pc unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g NF x 8 mm pen needles 1/2" 29g x 12mm NF pen needles 29g x 12mm , 30g x 5 mm , 30g x 8 mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g NF x 6 mm pen needles 3/16" 31g x 5 mm NF pen needles 5/16" 30g x 8 mm , 31g x 8 mm NF PENLET II BLOOD SAMPLER KIT (lancets misc.) NPB PENLET II REPLACEMENT CAP (lancets misc.) PB PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G NF X 8 MM , 32G X 4 MM (insulin pen needle) PERFECT LANCETS 28G (lancets) PB PERFECT LANCETS 30G (lancets) PB PHARMACIST CHOICE AUTOCODE SYS KIT NF W/DEVICE (blood glucose monitoring suppl) PHARMACIST CHOICE LANCETS (lancets) PB PHARMACIST CHOICE MINI SYSTEM DEVICE (blood NF glucose monitoring suppl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 203 Prescription Drug Name Drug Tier Drug Notes PHARMACY COUNTER LANCETS (lancets) PB pip lancets 28g PB pip lancets 30g PB POCKETCHEM EZ SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) polytoza patch sheet NF PRECISION LINK KIT (blood glucose monitoring suppl) NF PRECISION QID MONITOR DEVICE (blood glucose NF monitoring suppl) PRECISION SOF-TACT MONITOR DEVICE (blood NF glucose monitoring suppl) PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X 3/8" 0.5 ML, NF 30G X 5/16" 0.3 ML (insulin syringe-needle u-100) PRECISION XTRA DEVICE (blood glucose monitoring NF suppl) PRECISION XTRA KIT , W/DEVICE (blood glucose NF monitoring suppl) PRECISION XTRA MONITOR DEVICE (blood glucose NF monitoring suppl) preferred plus insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml preferred plus lancets colored PB preferred plus lancets thin PB preferred plus unifine pentips 29g x 12mm , 31g x 5 mm , 31g x NF 6 mm , 31g x 8 mm , 32g x 4 mm pressure activat safety lancet PB PREVENT SAFETY PEN NEEDLES 31G X 6 MM , 31G X NF 8 MM (insulin pen needle) pro comfort alcohol pad 70 % NPB PRO COMFORT INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 204 Prescription Drug Name Drug Tier Drug Notes pro comfort lancets 30g PB pro comfort lancets 31g PB pro comfort pen needles 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , NF 32g x 6 mm pro voice v8 glucose system device NF pro voice v9 glucose system device NF PRODIGY AUTOCODE BLOOD GLUCOSE DEVICE NF (blood glucose monitoring suppl) PRODIGY AUTOCODE BLOOD GLUCOSE KIT NF W/DEVICE (blood glucose monitoring suppl) PRODIGY INSULIN SYRINGE 28G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u- NF 100) PRODIGY LANCETS 28G (lancets) PB PRODIGY LANCING DEVICE (lancet devices) NPB PRODIGY POCKET BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) PRODIGY SAFETY LANCETS 26G (lancets) PB PRODIGY VOICE BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) PSS SELECT GP LANCETS (lancets) PB PSS SELECT PLATFORMS (lancets misc.) PB PSS SELECT SAFETY LANCETS (lancets) PB push button safety lancets PB push button safety lancets 28g PB px extra short pen needles 31g x 6 mm NF px insulin syringe 30g x 1/2" 0.5 ml NF px lancet auto injector NPB px lancets ultra thin PB px mini pen needles 31g x 5 mm NF px pen needle 29g x 12mm , 31g x 8 mm NF px shortlength pen needles 31g x 8 mm NF qc advanced lancing device NPB qc alcohol swabs pad 70 % NPB qc lancets super thin 30g PB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 205 Prescription Drug Name Drug Tier Drug Notes qc lancets ultra thin PB qc pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF qc unifine pentips 32g x 4 mm NF qc unilet lancets 28g PB qc unilet lancets micro thin PB QUICKTEK KIT (blood glucose monitoring suppl) NF QUICKTEK/METER KIT (blood glucose monitoring suppl) NF QUINTET AC BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) QUINTET BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) ra alcohol swabs pad 70 % NPB ra blood glucose monitor device NF RA E-ZJECT COLOR LANCETS 33G (lancets) PB RA E-ZJECT LANCETS 28G (lancets) PB RA E-ZJECT LANCETS THIN 26G (lancets) PB RA E-ZJECT LANCETS THIN 28G (lancets) PB RA E-ZJECT LANCETS ULTRA THIN (lancets) PB ra insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" NF 0.5 ml, 30g x 5/16" 1 ml ra pen needles 31g x 5 mm , 31g x 8 mm NF RA TRUE2GO BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) RA TRUERESULT BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RAPPORT RLS KIT (impotence aid device) NPB RAPPORT VTD KIT (impotence aid device) NPB READYLANCE SAFETY LANCETS (lancets) PB reality insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x NF 1/2" 0.5 ml, 29g x 1/2" 1 ml reality lancets PB reality swabs pad NPB reality trigger lancets PB REFUAH PLUS MONITORING SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 206 Prescription Drug Name Drug Tier Drug Notes RELION ALL-IN-ONE DEVICE (blood gluc meter disp- NF strips) RELION CONFIRM GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) RELI-ON INSULIN SYRINGE 29G 0.3 ML, 29G 0.5 ML, 29G X 1/2" 1 ML, 30G 0.3 ML, 30G 0.5 ML, 30G 1 ML NF (insulin syringe-needle u-100) RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G NF X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) RELION INSULIN SYRINGE 31G X 15/64" 0.5 ML (insulin PB syringe-needle u-100) RELION LANCET DEVICES 30G (lancet devices) NPB RELION LANCETS MICRO-THIN 33G (lancets) PB RELION LANCETS STANDARD 21G (lancets) PB RELION LANCETS THIN 26G (lancets) PB RELION LANCETS ULTRA-THIN 30G (lancets) PB RELION LANCING DEVICE (lancet devices) NPB RELION LANCING DEVICE KIT (lancets misc.) NPB RELION MICRO KIT W/DEVICE (blood glucose monitoring NF suppl) RELION MINI PEN NEEDLES 31G X 6 MM (insulin pen NF needle) RELION PEN NEEDLES 29G X 12MM , 31G X 6 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) RELION PREMIER BLU MONITOR DEVICE (blood NF glucose monitoring suppl) RELION PREMIER COMPACT SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) RELION PREMIER VOICE MONITOR DEVICE (blood NF glucose monitoring suppl) RELION PRIME MONITOR DEVICE (blood glucose NF monitoring suppl) RELION SHORT PEN NEEDLES 31G X 8 MM (insulin pen NF needle)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 207 Prescription Drug Name Drug Tier Drug Notes RELION ULTIMA GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) RELION ULTRA THIN LANCETS 30G (lancets) PB RELION ULTRA THIN PLUS LANCETS (lancets) PB REMESENSE DENTAL 3 % (dental desensitizing product) NPB REXALL BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST ALTERNATE SITE ADAPT (lancets misc.) PB RIGHTEST GD500 LANCING DEVICE (lancet devices) NPB RIGHTEST GL300 LANCETS (lancets) PB RIGHTEST GM100 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GM300 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GM550 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) SAFESNAP INSULIN SYRINGE 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X NF 5/16" 0.5 ML (insulin syringe-needle u-100) SAFE-T-LANCE (lancets) PB SAFE-T-LANCE PLUS (lancets) PB safety insulin syringes 27g x 1/2" 1 ml, 29g x 1/2" 0.5 ml, 29g x NF 1/2" 1 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml safety lancet 23g/pressure act PB safety lancet 30g/pressure act PB SAFETY LET LANCETS (lancets) PB SAFETY SEAL LANCETS (lancets) PB saps care alcohol prep pad 70 % NPB saps health care alcohol prep pad 70 % NPB saps health twist top lancets NPB saps twist top lancets PB sapscare twist top lancets PB sb alcohol prep pad 70 % NPB sb insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" NF 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 1 ml

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 208 Prescription Drug Name Drug Tier Drug Notes sb lancets thin PB sb lancets ultra thin PB select-lite lancing device NPB SHOPKO ALCOHOL SWABS PAD 70 % (alcohol swabs) NPB SHOPKO AUTOLET LANCING DEVICE (lancet devices) NPB SHOPKO UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM NF , 31G X 8 MM , 32G X 4 MM (insulin pen needle) SHOPKO UNIFINE PENTIPS PLUS 29G X 12MM , 31G X NF 5 MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) side button safety lancet PB SILHOUETTE 13MM (insulin infusion pump supplies) NPB SILHOUETTE 17MM (insulin infusion pump supplies) NPB SILHOUETTE INFUSION SET 23" (insulin infusion pump NPB supplies) SILHOUETTE INFUSION SET 43" (insulin infusion pump NPB supplies) silivex sheet NF SILTREX SHEET (occlusive silicone sheets) NF SIMPLE DIAGNOSTICS LANCING DEV (lancet devices) NPB SINGLE-LET (lancets) PB sm alcohol prep pad 70 % NPB sm lancets 33g PB SM TRUEDRAW LANCING DEVICE (lancet devices) NPB SMART DIABETES VANTAGE LANCING (lancet devices) NPB SMART SENSE COLOR LANCETS 33G (lancets) PB SMART SENSE PREMIUM SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) SMART SENSE STANDARD LANCETS (lancets) PB SMART SENSE SUPER THIN LANCETS (lancets) PB SMART SENSE THIN LANCETS 26G (lancets) PB SMART SENSE VALUE GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) SMARTEST EJECT DEVICE (blood glucose monitoring NF suppl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 209 Prescription Drug Name Drug Tier Drug Notes SMARTEST EJECT STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST LANCETS 28G (lancets) PB SMARTEST PERSONA STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST PRONTO STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST PROTEGE DEVICE (blood glucose monitoring NF suppl) SMARTEST PROTEGE STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SOLUS V2 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) SOLUS V2 BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) SOLUS V2 LANCETS 28G (lancets) PB SOLUS V2 LANCING DEVICE (lancet devices) NPB SOLUS V2 TWIST LANCETS 30G (lancets) PB STERILANCE PA (lancets misc.) PB STERILANCE TL (lancets) PB super thin lancets PB sure comfort alcohol prep pad 70 % NPB sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml sure comfort lancets 18g PB sure comfort lancets 21g PB sure comfort lancets 23g PB sure comfort lancets 30g PB sure comfort lancing pen NPB sure comfort pen needles 29g x 12.7mm , 30g x 8 mm , 31g x 5 NF mm , 31g x 8 mm , 32g x 6 mm

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 210 Prescription Drug Name Drug Tier Drug Notes SURE EDGE GLUCOSE MONITOR DEVICE (blood NF glucose monitoring suppl) SURECHEK BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) SURECHEK BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) SURE-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 NF MM , 31G X 8 MM (insulin pen needle) SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) SURE-LANCE FLAT LANCETS (lancets) PB SURE-LANCE LANCETS 26G (lancets) PB SURELITE LANCETS (lancets) PB SURE-PEN (lancet devices) NPB SURE-T INFUSION SET 18" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 23" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 32" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 6MM (insulin infusion pump NPB supplies) SURE-T INFUSION SET 8MM (insulin infusion pump NPB supplies) SURE-TEST EASYPLUS MINI METER DEVICE (blood NF glucose monitoring suppl) SURE-TOUCH LANCETS UNIVERSAL (lancets) PB T:FLEX T:LOCK CARTRIDGE 4.8ML (insulin infusion NPB pump supplies) T:SLIM T:LOCK INSULIN CART 3ML (insulin infusion NPB pump supplies) techlite insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g NF x 15/64" 0.3 ml, 31g x 15/64" 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 211 Prescription Drug Name Drug Tier Drug Notes TECHLITE PEN NEEDLES 29G X 10MM , 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , NF 32G X 6 MM , 32G X 8 MM (insulin pen needle) TELCARE BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) TELFA AMD ISLAND DRESSING PAD 4"X5" , 4"X8" NPB (gauze pads & dressings) TELFA AMD NON-ADHERENT PAD 3"X8" (gauze pads & NPB dressings) tgt blood glucose monitoring kit w/device NF tgt lancet micro thin 33g PB tgt lancet thin 26g PB tgt lancet ultra thin 30g PB tgt lancing device NPB THINLETS GP LANCETS (lancets) PB todays health mini pen needles 31g x 6 mm NF todays health pen needles 29g x 12mm NF todays health short pen needle 31g x 8 mm NF topcare clickfine pen needles 31g x 6 mm , 31g x 8 mm NF topcare lancets micro-thin 33g PB topcare ultra comfort ins syr 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g NF x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml travel lancets PB TRAVEL LANCETS ADVANCED 28G (lancets) PB true comfort insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml NF true comfort pen needles 31g x 5 mm , 31g x 6 mm , 32g x 4 mm NF true comfort twist top lancets PB TRUE FOCUS BLOOD GLUCOSE METER DEVICE NF (blood glucose monitoring suppl) TRUE METRIX AIR GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) TRUE METRIX AIR GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 212 Prescription Drug Name Drug Tier Drug Notes TRUE METRIX GO GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl) TRUE METRIX METER DEVICE (blood glucose monitoring NF suppl) TRUE METRIX METER KIT W/DEVICE (blood glucose NF monitoring suppl) TRUEDRAW LANCING DEVICE (lancet devices) NPB TRUEPLUS 5-BEVEL PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM NF (insulin pen needle) TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) TRUEPLUS LANCETS 26G (lancets) PB TRUEPLUS LANCETS 28G (lancets) PB TRUEPLUS LANCETS 30G (lancets) PB TRUEPLUS LANCETS 33G (lancets) PB TRUEPLUS PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM (insulin pen NF needle) TRUEPLUS SAFETY LANCETS 28G (lancets) PB TRUERESULT BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) TRUETRACK BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) TRUETRACK BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) TRUETRACK SMART SYSTEM KIT (blood glucose NF monitoring suppl) TRUSTEEL INFUSION SET (insulin infusion pump supplies) NPB ULTICARE ALCOHOL SWABS PAD (alcohol swabs) NPB ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 213 Prescription Drug Name Drug Tier Drug Notes ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 0.5 ML, 31G X 1/4" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTICARE MICRO PEN NEEDLES 31G X 6 MM , 31G X NF 8 MM , 32G X 4 MM (insulin pen needle) ULTICARE MINI PEN NEEDLES 31G X 6 MM , 32G X 6 NF MM (insulin pen needle) ULTICARE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM NF (insulin pen needle) ULTICARE SHORT PEN NEEDLES 31G X 8 MM (insulin NF pen needle) ultiguard safepack pen needle 31g x 5 mm , 31g x 6 mm , 31g x NF 8 mm , 32g x 4 mm , 32g x 6 mm ULTI-LANCE AUTOMATIC (lancet devices) NPB ultilet alcohol swabs pad NPB ULTILET CLASSIC LANCETS (lancets) PB ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G NF X 5/16" 0.3 ML, 31G X 5/16" 1 ML (insulin syringe-needle u- 100) ULTILET INSULIN SYRINGE SHORT 30G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" NF 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTILET LANCETS (lancets) PB ULTILET PEN NEEDLE 29G X 12.7MM , 31G X 5 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) ULTILET SAFETY LANCETS (lancets) PB ULTILET SAFETY LANCETS 23G (lancets) PB ULTIMA KIT (blood glucose monitoring suppl) NF ultra comfort insulin syringe 30g x 5/16" 0.3 ml NF ultra thin lancets 31g PB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 214 Prescription Drug Name Drug Tier Drug Notes ULTRA THIN PEN NEEDLES 32G X 4 MM (insulin pen NF needle) ULTRA TRAK PRO BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) ultracare insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" NF 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ultra-care lancets 30g PB ultracare pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , NF 32g x 4 mm , 32g x 5 mm , 32g x 6 mm , 33g x 4 mm ultra-comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ULTRALANCE (lancets misc.) PB ULTRA-THIN II AUTO LANCET (lancets) PB ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 NF ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- needle u-100) ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) ULTRA-THIN II LANCETS (lancets) PB ULTRA-THIN II MINI PEN NEEDLE 31G X 5 MM NF (insulin pen needle) ULTRA-THIN II PEN NEEDLE SHORT 31G X 8 MM NF (insulin pen needle) ULTRA-THIN II PEN NEEDLES 29G X 12.7MM (insulin NF pen needle) ULTRATRAK ACTIVE DEVICE (blood glucose monitoring NF suppl) ULTRATRAK PRO DEVICE (blood glucose monitoring NF suppl) ULTRATRAK ULTIMATE MONITOR DEVICE (blood NF glucose monitoring suppl) UNIFINE PENTIPS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 NF MM , 33G X 4 MM (insulin pen needle)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 215 Prescription Drug Name Drug Tier Drug Notes UNIFINE PENTIPS PLUS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , NF 33G X 4 MM (insulin pen needle) UNIFINE SAFECONTROL PEN NEEDLE 30G X 5 MM , NF 30G X 8 MM (insulin pen needle) UNILET COMFORTOUCH LANCET (lancets) PB UNILET EXCELITE (lancets) PB UNILET EXCELITE II (lancets) PB UNILET G.P. LANCET (lancets) PB UNILET G.P. SUPERLITE LANCET (lancets) PB UNILET GP 28 ULTRA THIN (lancets) PB UNILET LANCET (lancets) PB UNILET MICRO-THIN 33G (lancets) PB UNILET SUPERLITE LANCET (lancets) PB UNILET SUPER-THIN 30G (lancets) PB UNILET ULTRA-THIN 28G (lancets) PB UNISTIK 1 (lancets misc.) PB UNISTIK 2 (lancets misc.) PB UNISTIK 2 COMFORT (lancets misc.) PB UNISTIK 2 EXTRA (lancets misc.) PB UNISTIK 2 NEONATAL (lancets misc.) PB UNISTIK 2 NORMAL (lancets misc.) PB UNISTIK 2 SUPER (lancets misc.) PB UNISTIK 3 (lancets misc.) PB UNISTIK 3 COMFORT (lancets misc.) PB UNISTIK 3 EXTRA (lancets misc.) PB UNISTIK 3 GENTLE (lancets) PB UNISTIK 3 NEONATAL (lancets misc.) PB UNISTIK 3 NORMAL (lancets misc.) PB UNISTIK CZT COMFORT (lancets misc.) PB UNISTIK CZT NORMAL (lancets misc.) PB UNISTIK PRO SAFETY LANCET (lancets) PB UNISTIK SAFETY LANCETS 28G (lancets) PB UNISTIK SAFETY LANCETS 30G (lancets) PB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 216 Prescription Drug Name Drug Tier Drug Notes UNISTIK TOUCH SAFETY LANC 21G (lancets) PB UNISTIK TOUCH SAFETY LANC 23G (lancets) PB UNISTIK TOUCH SAFETY LANC 28G (lancets) PB UNISTIK TOUCH SAFETY LANC 30G (lancets) PB UNIVERSAL 1 LANCETS THIN 26G (lancets) PB UNIVERSAL 1 LANCETS THIN 33G (lancets) PB UNIVERSAL 1 LANCETS ULTRA THIN (lancets) PB value health insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml NF value plus lancet standard 21g PB value plus lancets super thin PB valumark lancet ultra thin 28g PB valumark pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 30G X 1/2" 0.5 ML, 30G X 3/16" 0.5 ML, NF 30G X 3/16" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) VARISOFT INFUSION SET (insulin infusion pump supplies) NPB verasens blood glucose meter device NF verasens blood glucose system kit w/device NF V-GO 20 KIT (insulin disposable pump) PB V-GO 30 KIT (insulin disposable pump) PB V-GO 40 KIT (insulin disposable pump) PB VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 NF MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) VIVAGUARD INO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) VIVAGUARD LANCETS (lancets) PB VIVAGUARD LANCING DEVICE (lancet devices) NPB VOCAL POINT BLOOD GLUCOSE SYS DEVICE (blood NF glucose monitoring suppl) vp insulin syringe 29g x 1/2" 0.3 ml NF walgreens adv travel lancets PB WALGREENS LANCETS (lancets) PB walgreens lancets micro thin PB walgreens lancets super thin PB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 217 Prescription Drug Name Drug Tier Drug Notes WALGREENS THIN LANCETS (lancets) PB WALGREENS ULTRA THIN LANCETS (lancets) PB WAVESENSE AMP KIT W/DEVICE (blood glucose NF monitoring suppl) WEBCOL ALCOHOL PREP LARGE PAD 70 % (alcohol NPB swabs) WEBCOL ALCOHOL PREP MEDIUM PAD 70 % (alcohol NPB swabs) wegmans unifine pentips plus 31g x 5 mm , 31g x 6 mm , 31g x 8 NF mm , 32g x 4 mm WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM AIMOVIG SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe) AJOVY SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 225 MG/1.5ML (fremanezumab-vfrm) AJOVY SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 225 MG/1.5ML (fremanezumab-vfrm) almotriptan malate oral tablet 12.5 mg, 6.25 mg G CAFERGOT ORAL TABLET 1-100 MG (ergotamine- NF caffeine)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 218 Prescription Drug Name Drug Tier Drug Notes CAMBIA ORAL PACKET 50 MG (diclofenac NF potassium(migraine)) dihydroergotamine mesylate injection solution 1 mg/ml G dihydroergotamine mesylate nasal solution 4 mg/ml NF eletriptan hydrobromide oral tablet 20 mg, 40 mg G EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML PB (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 120 MG/ML (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 120 MG/ML (galcanezumab-gnlm) ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 NPB MG (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg NF frovatriptan succinate oral tablet 2.5 mg G MIGERGOT RECTAL SUPPOSITORY 2-100 MG NF (ergotamine-caffeine) MIGRAINE PACK COMBINATION THERAPY PACK 50 NF MG (sumatriptan-homeopathic prod) MIGRANAL NASAL SOLUTION 4 MG/ML NPB (dihydroergotamine mesylate) MIGRANOW COMBINATION THERAPY PACK 50 & 4- NF 10 MG & % (sumatriptan & camphor-menthol) naratriptan hcl oral tablet 1 mg, 2.5 mg G NURTEC ORAL TABLET DISPERSIBLE 75 MG PB (rimegepant sulfate) ONZETRA XSAIL NASAL EXHALER POWDER 11 PB MG/NOSEPC (sumatriptan succinate) REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan PB succinate) rizatriptan benzoate oral tablet 10 mg, 5 mg G rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg G sumatriptan nasal solution 20 mg/act, 5 mg/act G sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 219 Prescription Drug Name Drug Tier Drug Notes sumatriptan succinate refill subcutaneous solution cartridge 4 G mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml G sumatriptan succinate subcutaneous solution auto-injector 4 G mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 G mg/0.5ml sumatriptan-naproxen sodium oral tablet 85-500 mg NF TOSYMRA NASAL SOLUTION 10 MG/ACT (sumatriptan) NF TREXIMET ORAL TABLET 85-500 MG (sumatriptan- NF naproxen sodium) UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) PB ZEMBRACE SYMTOUCH SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 MG/0.5ML (sumatriptan PB succinate) zolmitriptan oral tablet 2.5 mg, 5 mg G zolmitriptan oral tablet dispersible 2.5 mg, 5 mg G ZOMIG NASAL SOLUTION 2.5 MG, 5 MG (zolmitriptan) PB *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6- NPB b12-boron-mg) EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 NPB MEQ (potassium bicarb-citric acid) potassium bicarbonate (Effer-K Oral Tablet Effervescent 25 G Meq) FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium CE fluoride-vitamin d) FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML CE (sodium fluoride) fluoritab oral solution 0.275 (0.125 f) mg/drop CE fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, CE 2.2 (1 f) mg FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) CE MG/DROP (sodium fluoride) GALZIN ORAL CAPSULE 25 MG, 50 MG (zinc acetate NPB (oral)) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 220 Prescription Drug Name Drug Tier Drug Notes iodine strong oral solution 5 % G potassium chloride (Klor-Con 10 Oral Tablet Extended G Release 10 Meq) potassium chloride crys er (Klor-Con M10 Oral Tablet G Extended Release 10 Meq) KLOR-CON M15 ORAL TABLET EXTENDED G RELEASE 15 MEQ (potassium chloride crys er) potassium chloride crys er (Klor-Con M20 Oral Tablet G Extended Release 20 Meq) potassium chloride (Klor-Con Oral Packet 20 Meq) G potassium chloride (Klor-Con Oral Tablet Extended Release 8 G Meq) potassium chloride (Klor-Con Sprinkle Oral Capsule Extended G Release 10 Meq, 8 Meq) potassium bicarbonate (Klor-Con/Ef Oral Tablet Effervescent G 25 Meq) K-PHOS ORAL TABLET 500 MG (potassium phosphate NPB monobasic) potassium bicarbonate (K-Prime Oral Tablet Effervescent 25 G Meq) K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ PB (potassium chloride) sodium fluoride (Nafrinse Drops Oral Solution 0.275 (0.125 F) CE Mg/Drop) sodium fluoride (Nafrinse Oral Tablet Chewable 2.2 (1 F) Mg) CE k phos mono-sod phos di & mono (Phospha 250 Neutral Oral G Tablet 155-852-130 Mg) phosphorous oral tablet 155-852-130 mg G k phos mono-sod phos di & mono (Phospho-Trin 250 Neutral G Oral Tablet 155-852-130 Mg) potassium chloride crys er oral tablet extended release 10 meq, G 20 meq potassium chloride er oral capsule extended release 10 meq, 8 G meq potassium chloride er oral tablet extended release 10 meq, 20 G meq, 8 meq potassium chloride oral packet 20 meq G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 221 Prescription Drug Name Drug Tier Drug Notes potassium chloride oral solution 20 meq/15ml (10%), 40 G meq/15ml (20%) sodium fluoride oral solution 1.1 (0.5 f) mg/ml CE sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg CE sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 CE f) mg, 2.2 (1 f) mg THE LIQUILIFT TRACE INTRAVENOUS KIT 10-1000- NF 500-60 MCG/ML (trace minerals cr-cu-mn-se-zn) virt-phos 250 neutral oral tablet 155-852-130 mg G zinc sulfate intravenous solution 3 mg/ml NPB *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS AMPHADASE INJECTION SOLUTION 150 UNIT/ML NF (hyaluronidase bovine) water for irrigation, sterile (Argyle Sterile Water Irrigation G Solution) ASTAGRAF XL ORAL CAPSULE EXTENDED NF RELEASE 24 HOUR 0.5 MG, 1 MG, 5 MG (tacrolimus) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) PB azathioprine oral tablet 50 mg G BENLYSTA INTRAVENOUS SOLUTION NPSP RECONSTITUTED 120 MG, 400 MG (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION AUTO- NPSP INJECTOR 200 MG/ML (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED NPSP SYRINGE 200 MG/ML (belimumab) CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED 500 MG (mycophenolate NF mofetil hcl) CELLCEPT ORAL CAPSULE 250 MG (mycophenolate NF mofetil) CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 NF MG/ML (mycophenolate mofetil) CELLCEPT ORAL TABLET 500 MG (mycophenolate NF mofetil) cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg G cyclosporine modified oral solution 100 mg/ml G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 222 Prescription Drug Name Drug Tier Drug Notes cyclosporine oral capsule 100 mg, 25 mg G DEPEN TITRATABS ORAL TABLET 250 MG NPB (penicillamine) ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 120 MG/ML (satralizumab-mwge) ENVARSUS XR ORAL TABLET EXTENDED RELEASE NF 24 HOUR 0.75 MG, 1 MG, 4 MG (tacrolimus) cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg) G cyclosporine modified (Gengraf Oral Solution 100 Mg/Ml) G sodium polystyrene sulfonate (Kionex Oral Suspension 15 G Gm/60Ml) lactated ringers irrigation solution G LOKELMA ORAL PACKET 10 GM, 5 GM (sodium PB zirconium cyclosilicate) mycophenolate mofetil oral capsule 250 mg G mycophenolate mofetil oral suspension reconstituted 200 mg/ml G mycophenolate mofetil oral tablet 500 mg G mycophenolate sodium oral tablet delayed release 180 mg, 360 G mg MYFORTIC ORAL TABLET DELAYED RELEASE 180 NF MG, 360 MG (mycophenolate sodium) penicillamine oral capsule 250 mg G irrigation solns physiological (Physiolyte Irrigation Solution) G irrigation solns physiological (Physiosol Irrigation Irrigation G Solution) PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG NF (tacrolimus) PROGRAF ORAL PACKET 0.2 MG, 1 MG (tacrolimus) NF RAPAMUNE ORAL SOLUTION 1 MG/ML (sirolimus) NF RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG NF (sirolimus) RESET FOR IOS OR ANDROID APP (digital therapy) NF RESET-O FOR IOS OR ANDROID APP (digital therapy) NF REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 PSP MG, 25 MG, 5 MG (lenalidomide) ringers irrigation irrigation solution G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 223 Prescription Drug Name Drug Tier Drug Notes SANDIMMUNE ORAL SOLUTION 100 MG/ML NPSP (cyclosporine) sirolimus oral solution 1 mg/ml G sirolimus oral tablet 0.5 mg, 1 mg, 2 mg G sodium polystyrene sulfonate oral powder G sodium polystyrene sulfonate oral suspension 15 gm/60ml G sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 G gm/200ml sodium polystyrene sulfonate (Sps Oral Suspension 15 G Gm/60Ml) sterile water for irrigation irrigation solution G SYLVANT INTRAVENOUS SOLUTION NPB RECONSTITUTED 100 MG, 400 MG (siltuximab) tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg G THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, PSP 50 MG (thalidomide) ringers irrigation (Tis-U-Sol Irrigation Solution) G trientine hcl oral capsule 250 mg G VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM PB (patiromer sorbitex calcium) WELLMIND VERTIGO ORAL TABLET (homeopathic NPB products) ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, 1 NF MG (everolimus) *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT AQUORAL MOUTH/THROAT SOLUTION (artificial NPB saliva) BOCASAL MOUTH/THROAT PACKET (artificial saliva) NPB CAPHOSOL MOUTH/THROAT SOLUTION (artificial NPB saliva) sodium fluoride (Cavarest Dental Gel 1.1 %) CE cevimeline hcl oral capsule 30 mg G chlorhexidine gluconate mouth/throat solution 0.12 % G sodium fluoride (Clinpro 5000 Dental Paste 1.1 %) CE clotrimazole mouth/throat troche 10 mg G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 224 Prescription Drug Name Drug Tier Drug Notes sodium fluoride (Denta 5000 Plus Dental Cream 1.1 %) CE sodium fluoride (Dentagel Dental Gel 1.1 %) CE EASYGEL DENTAL GEL 0.4 % (stannous fluoride) CE stannous fluoride (Fluoridex Daily Renewal Mouth/Throat CE Concentrate 0.63 %) sodium fluoride (Fluoridex Enhanced Whitening Dental Paste CE 1.1 %) sod fluoride-potassium nitrate (Fluoridex Sensitivity Relief CE Dental Paste 1.1-5 %) GELCLAIR MOUTH/THROAT GEL (povidone-nahyaluron- NPB glycyrrhet) lidocaine hcl mouth/throat solution 4 % G lidocaine viscous hcl mouth/throat solution 2 % G MUCOSITISRX MOUTH/THROAT PACKET (artificial NF saliva) NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML (sodium CE fluoride-phosphoric acd) NAFRINSE DAILY/NEUTRAL MOUTH/THROAT CE SOLUTION RECONSTITUTED 0.05 % (sodium fluoride) NAFRINSE WEEKLY MOUTH/THROAT SOLUTION CE RECONSTITUTED 0.2 % (sodium fluoride) NEUTRASAL MOUTH/THROAT PACKET (artificial NPB saliva) NUMOISYN MOUTH/THROAT LIQUID (artificial saliva) NPB nystatin mouth/throat suspension 100000 unit/ml G ORAFATE MOUTH/THROAT PASTE 10 % (sucralfate- NPB malate) triamcinolone acetonide (Oralone Mouth/Throat Paste 0.1 %) G ORAVIG BUCCAL TABLET 50 MG (miconazole) NPB chlorhexidine gluconate (Paroex Mouth/Throat Solution 0.12 G %) chlorhexidine gluconate (Periogard Mouth/Throat Solution G 0.12 %) pilocarpine hcl oral tablet 5 mg, 7.5 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 225 Prescription Drug Name Drug Tier Drug Notes PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 NF % (sodium fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % NF (sodium fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE NF 1.1-5 % (sod fluoride-potassium nitrate) PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE NF 1.1 % (sodium fluoride) PREVIDENT 5000 PLUS DENTAL CREAM 1.1 % (sodium NF fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % NF (sod fluoride-potassium nitrate) PREVIDENT DENTAL GEL 1.1 % (sodium fluoride) NF PREVIDENT MOUTH/THROAT SOLUTION 0.2 % NF (sodium fluoride) PROTHELIAL MOUTH/THROAT PASTE 10 % NPB (sucralfate-malate) SALAGEN ORAL TABLET 5 MG, 7.5 MG (pilocarpine hcl) PB SALIVAMAX MOUTH/THROAT PACKET (artificial NPB saliva) sf 5000 plus dental cream 1.1 % CE sf dental gel 1.1 % CE triamcinolone acetonide mouth/throat paste 0.1 % G XEROSTOMIA RELIEF SPRAY MOUTH/THROAT NPB SOLUTION (artificial saliva) *MULTIVITAMINS* - DRUGS FOR NUTRITION activite oral tablet 1 mg NF adc/f (0.5mg/ml) oral solution 0.5 mg/ml G ADRENAL C FORMULA ORAL TABLET (bioflavonoid NPB products) ALIVE PRENATAL ORAL TABLET CHEWABLE 0.4-25 NF MG (prenatal mv & min w/fa-dha) ATABEX EC ORAL TABLET DELAYED RELEASE 29-1 NPB MG (prenatal vit-dss-fe cbn-fa) ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe NPB bisg-fa)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 226 Prescription Drug Name Drug Tier Drug Notes azesco oral tablet 13-1 mg NF biocel oral tablet G b-plex oral tablet G b-plex plus oral tablet G cadeau dha oral capsule 29-0.4-0.8-375 mg NF CITRANATAL 90 DHA ORAL 90-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha) CITRANATAL ASSURE ORAL 35-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha) CITRANATAL B-CALM ORAL 20-1 MG & 2 X 25 MG PB (prenat w/o a fecbnfeglu-fa &b6) CITRANATAL BLOOM DHA ORAL 90-1 & 300 MG PB (prenat w/o a-fecbgl-dss-fa-dha) CITRANATAL BLOOM ORAL TABLET 90-1 MG PB (prenatal-dss-fecb-fegl-fa) CITRANATAL DHA ORAL 27-1 & 250 MG (prenat w/o a- PB fecbgl-dss-fa-dha) CITRANATAL HARMONY ORAL CAPSULE 27-1-260 PB MG (prenat-fefmcb-dss-fa-dha w/o a) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG PB (prenat-fecb-fefum-fa-dha w/o a) CITRANATAL RX ORAL TABLET 27-1 MG (prenat w/o a- PB fecb-fegl-dss-fa) c-nate dha oral capsule 28-1-200 mg NPB cod liver oil oral oil NPB complete natal dha oral 29-1-200 & 250 mg NPB completenate oral tablet chewable 29-1 mg NPB CO-NATAL FA ORAL TABLET (prenatal vit-fe fumarate- NPB fa) CONCEPT DHA ORAL CAPSULE 53.5-38-1 MG (prenat- NPB fefum-fepo-fa-omega 3) CONCEPT OB ORAL CAPSULE 130-92.4-1 MG (prenat w/o NPB a vit-fefum-fepo-fa) CORVITA ORAL TABLET 1.25 MG (multiple vitamins- G minerals-fa) cvs prenatal gummy oral tablet chewable 0.4 mg, 0.4-25 mg NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 227 Prescription Drug Name Drug Tier Drug Notes b complex-c-folic acid (Dexifol Oral Tablet 5 Mg) NF DUET DHA 400 ORAL 25-1 & 400 MG (prenat-fepoly-fered- NPB fa-omega 3) DUET DHA BALANCED ORAL 25-1 & 267 MG (prenat- NPB fepoly-fered-fa-omega 3) ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron G carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- NF omega) FLORIVA ORAL TABLET CHEWABLE 0.25 MG, 0.5 NPB MG, 1 MG (ped multiple vit-minerals-fl) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML NPB (pediatric multivitamins-fl) FOLBEE PLUS CZ ORAL TABLET 5 MG (b-complex-c- G biotin-minerals-fa) folbee plus oral tablet G FOLGARD OS ORAL TABLET 500-1.1 MG (multiple vit- NPB min-calcium-fa) folic-k oral capsule 1 mg NF FOLIVANE-OB ORAL CAPSULE 130-92.4-1 MG (prenat NPB w/o a vit-fefum-fepo-fa) GENICIN VITA-Q ORAL TABLET 1 MG (multiple vitamins NF with fa) b complex-c-folic acid (Genicin Vita-S Oral Tablet 1 Mg) NF hylavite oral tablet NF INATAL GT ORAL TABLET (prenatal vit-dss-fe cbn-fa) G INFUVITE ADULT INTRAVENOUS INJECTABLE NPB (multiple vitamin) INFUVITE PEDIATRIC INTRAVENOUS SOLUTION NPB (pediatric multiple vitamins) kosher prenatal plus iron oral tablet 30-1 mg NF lorid oral tablet 1 mg NF multiple vitamins-minerals (Lysiplex Plus Oral Tablet) G M.V.I. ADULT INTRAVENOUS INJECTABLE (multiple NPB vitamin)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 228 Prescription Drug Name Drug Tier Drug Notes M.V.I. PEDIATRIC INTRAVENOUS SOLUTION NPB RECONSTITUTED (pediatric multiple vitamins) MARNATAL-F ORAL CAPSULE 60-1 MG (prenat w/o a-fe NPB poly cmplx-fa) m-natal plus oral tablet 27-1 mg NF multipro oral capsule NF multi-vit/iron/fluoride oral solution 0.25-10 mg/ml G multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml G multi-vitamin/fluoride oral solution 0.5 mg/ml G multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg G multivitamin/fluoride oral tablet chewable 0.25-0.3 mg, 0.5-0.3 NF mg, 1-0.3 mg multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml G MYNATAL ORAL CAPSULE (prenatal multivit-min-fe-fa) NPB mynatal plus oral tablet NPB mynatal-z oral tablet NPB NATACHEW ORAL TABLET CHEWABLE 28-1 MG NPB (prenatal vit-fe fum-fe bisg-fa) NATALVIT ORAL TABLET (prenatal vit-fe fumarate-fa) NPB NEEVO DHA ORAL CAPSULE 27-1.13 MG (prenat w/oa- NPB fefum-methf-omegas) NEONATAL PLUS ORAL TABLET 27-1 MG (prenatal vit- NPB fe fumarate-fa) b complex-c-folic acid (Nephronex Oral Tablet) G NESTABS DHA ORAL 32-1 MG (prenat-w/oa-fe bisgly-fa- NPB omega) NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- NF methylfol-dha w/o a) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o NPB vit a) NICADAN ORAL TABLET (multiple vitamins-minerals) NF NICAZEL FORTE ORAL TABLET (multiple vitamins- NF minerals) NICAZEL ORAL TABLET (multiple vitamins-minerals) NF NICOMIDE ORAL TABLET 750-27-2-0.5 MG (niacinamide- NF zn-cu-methfo-se-cr) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 229 Prescription Drug Name Drug Tier Drug Notes NIVA-PLUS ORAL TABLET 27-1 MG (prenatal vit-fe NF fumarate-fa) NUTRICAP ORAL TABLET (multiple vitamins-minerals) NPB multiple vitamins-minerals (Nutrifac Zx Oral Tablet) G NUTRIVIT ORAL LIQUID (b complex-lysine-min-fe-fa) NPB OB COMPLETE ONE ORAL CAPSULE 50-1-476 MG NPB (prenat-fecbn-feaspgl-fa-fish) OB COMPLETE ORAL TABLET 50-1.25 MG (prenatal vit- NPB iron carbonyl-fa) OB COMPLETE PETITE ORAL CAPSULE 35-5-1-200 MG NPB (prenat-fecbn-feaspgl-fa-omega) OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG NPB (prenatal-fe cbn-fe asp gly-fa) OB COMPLETE/DHA ORAL CAPSULE 30-10-1-200 MG NPB (prenat-fecbn-feaspgl-fa-omega) OBSTETRIX DHA ORAL 29-1 & 387 MG (prenatal-fecbn- NPB fa-dss-omega 3) OBSTETRIX EC ORAL TABLET 29-1 MG (prenatal vit-dss- NPB fe cbn-fa) OBSTETRIX ONE ORAL CAPSULE 38-1-225 MG (prenat- NF fe-methyl-dss-dha w/o a) O-CAL PRENATAL ORAL TABLET (prenatal vit-fe NPB fumarate-fa) ONE A DAY PRENATAL ORAL TABLET CHEWABLE NF 0.4-25 MG (prenatal mv & min w/fa-dha) ONE-A-DAY WOMENS PRENATAL 1 ORAL CAPSULE NF 28-0.8-235 MG (prenat-fe carbonyl-fa-omega 3) onevite oral tablet 1 mg NPB pnv tabs 29-1 oral tablet 29-1 mg NPB pnv-dha oral capsule 27-0.6-0.4-300 mg G pnv-dha+docusate oral capsule 27-1.25-300 mg NPB pnv-omega oral capsule 28-0.6-0.4-340 mg NPB pnv-select oral tablet 27-0.6-0.4 mg G POLY-VI-FLOR FS ORAL STRIP 0.25 MG, 0.5 MG NF (pediatric multivitamins-fl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 230 Prescription Drug Name Drug Tier Drug Notes POLY-VI-FLOR FS ORAL STRIP 1 MG (pediatric NPB multivitamins-fl) POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML NPB (pediatric multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, NPB 0.5 MG, 1 MG (pediatric multivitamins-fl) POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 NPB MG/ML (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5- NPB 10 MG (ped multivitamins-fl-iron) pregenna oral tablet 20-1 mg NF PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12- NPB fa-ginger) prena 1 true oral 30-1.4 & 300 mg NPB prena1 oral tablet chewable 1.4 mg NPB prena1 pearl oral capsule extended release 30-1.4-200 mg NPB prenaissance oral capsule 29-1.25-325 mg NPB prenaissance plus oral capsule 28-1-250 mg NPB PRENATABS RX ORAL TABLET 29-1 MG (prenatal vit- G iron carbonyl-fa) prenatal + complete multi oral therapy pack 0.267 & 373 mg, NF 18-0.8 & 290 mg prenatal 19 oral tablet G prenatal 19 oral tablet 29-1 mg NPB prenatal 19 oral tablet chewable G prenatal 19 oral tablet chewable 29-1 mg NPB prenatal gummies/dha & fa oral tablet chewable 0.4-32.5 mg NF prenatal multi +dha oral capsule 27-0.8-200 mg NF prenatal oral tablet 27-1 mg NPB prenatal plus iron oral tablet 29-1 mg NPB prenatal vitamin plus low iron oral tablet 27-1 mg NPB PRENATAL-U ORAL CAPSULE 106.5-1 MG (prenatal w/o NPB a vit-fe fum-fa) PRENATE AM ORAL TABLET 1 MG (prenatal ca-b6-b12- NPB fa-ginger)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 231 Prescription Drug Name Drug Tier Drug Notes PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG NPB (prenat-feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG NPB (prenatal-feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 NPB MG (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 NPB MG (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG NPB (prenat-fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG NPB (prenat mv-min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG NPB (prenat-feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 NPB MG (prenat w/o a-fe-methfol-fa-dha) preplus oral tablet 27-1 mg NPB pretab oral tablet 29-1 mg NPB PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe- NF meth-fa-omeg w/o a) PROVIDA OB ORAL CAPSULE 20-20-1.25 MG (prenat w/o NPB a vit-fefum-fepo-fa) QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG NF (multi vit-min-fluoride-fe-fa) QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5 NF MG/ML (ped multivitamins-fl-iron) QUFLORA GUMMIES ORAL TABLET CHEWABLE NF 0.125 MG (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, NPB 0.5 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE NPB 0.25 MG, 0.5 MG, 1 MG (pediatric multivitamins-fl) relnate dha oral capsule 28-1-200 mg NPB RENATABS ORAL TABLET 1 MG (b complex-c-biotin-e-fa) NPB RENATABS WITH IRON ORAL 1 & 100 MG (b complex-c- NPB biotin-e-fa-fe cbn) reno caps oral capsule 1 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 232 Prescription Drug Name Drug Tier Drug Notes REQ 49+ ORAL TABLET (multiple vitamins-minerals) NPB SELECT-OB ORAL TABLET CHEWABLE 29-0.6-0.4 MG NPB (prenat vit-fepoly-methylfol-fa) SELECT-OB ORAL TABLET CHEWABLE 29-1 MG NPB (prenatal vit-fe psac cmplx-fa) SELECT-OB+DHA ORAL 29-1 & 250 MG (prenatal vit- NPB fepoly-fa-dha) se-natal 19 oral tablet 29-1 mg NPB se-natal 19 oral tablet chewable 29-1 mg NPB SIDEROL ORAL TABLET (multiple vitamins-minerals) NPB STROVITE FORTE ORAL SYRUP (multiple vitamins- NPB minerals-fa) SUPERVITE ORAL LIQUID (b complex-lysine-zn-fa) NPB support oral liquid NPB SUPPORT-500 ORAL CAPSULE (specialty vitamins NPB products) SYNAGEX ORAL CAPSULE 1.25 MG (multiple vitamins- NPB minerals-fa) TARON-C DHA ORAL CAPSULE 53.5-38-1 MG (prenat- NPB fefum-fepo-fa-omega 3) TARON-PREX ORAL CAPSULE 30-1.2-265 MG (prenat- NPB fefum-dss-fa-dha w/o a) THERANATAL ONE ORAL CAPSULE 27-1-300 MG NF (prenatal-fefum-fa-dha w/o a) thrivite 19 oral tablet 1 mg NPB thrivite rx oral tablet 29-1 mg NPB TRICARE ORAL TABLET (prenatal vit-fe fumarate-fa) NPB TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1- NPB 500 MG (prenatal-fefum-fa-dss-fish oil) trinatal rx 1 oral tablet 60-1 mg NPB TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) G trinaz oral tablet 12-1 mg NF triphrocaps oral capsule 1 mg G tristart dha oral capsule 31-0.6-0.4-200 mg NF TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat NF w/o a-fecbn-meth-fa-dha) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 233 Prescription Drug Name Drug Tier Drug Notes tri-tabs dha oral 32-1 mg NPB TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 NPB MG/ML (ped vit a-c-d-methylfolate-fl) tri-vi-floro oral suspension 0.25 mg/ml, 0.5 mg/ml NPB tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml G tronvite oral tablet 1 mg NF UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- NPB minerals-fa) urosex oral tablet G v-c forte oral capsule G multiple vitamins-minerals (Vic-Forte Oral Capsule) G VINATE DHA RF ORAL CAPSULE 27-1.13 MG (prenat NPB w/oa-fefum-methf-omegas) VINATE II ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- NPB fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe NPB fumarate-fa) virt-c dha oral capsule 53.5-38-1 mg NPB virt-caps oral capsule 1 mg G virt-nate dha oral capsule 28-1-200 mg NPB virt-pn dha oral capsule 27-0.6-0.4-300 mg NPB virt-pn plus oral capsule 28-0.6-0.4-340 mg NPB multiple vitamins-minerals (Vita S Forte Oral Tablet) G multiple vitamins-minerals (Vitacel Oral Tablet) G VITAFOL GUMMIES ORAL TABLET CHEWABLE 3.33- NF 0.333-34.8 MG (prenatal vit-fe phos-fa-omega) VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3- NF folic acid) VITAFOL ULTRA ORAL CAPSULE 29-0.6-0.4-200 MG NPB (prenat-fe poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal- NPB fe fum-methf-fa w/o a) VITAFOL-OB ORAL TABLET (prenatal vit-fe fumarate-fa) NPB VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv- NPB min-fe fum-fa-dha)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 234 Prescription Drug Name Drug Tier Drug Notes VITAFOL-ONE ORAL CAPSULE 29-1-200 MG (prenatal NPB vit-fepoly-fa-dha) pediatric multivit-minerals-c (Vitamax Pediatric Oral Solution) G VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG (prenat w/o a-fe-methfol-fa- NPB dha) VITAMEDMD REDICHEW RX ORAL TABLET NPB CHEWABLE 1.4 MG (prenat-b2-b6-b12-d3-fa) vita-min oral capsule G vitamins acd-fluoride oral solution 0.25 mg/ml G VITAPEARL ORAL CAPSULE EXTENDED RELEASE NPB 30-1.4-200 MG (prenat-fefum-fered-fa-dha w/oa) vitasure oral tablet 1 mg NF VITATRUE ORAL 30-1.4 & 300 MG (prenat-fechel-fa-dha NPB w/o vit a) VIVA DHA ORAL CAPSULE 28-1-200 MG (prenatal vit-fe NPB fum-fa-omega) vol-plus oral tablet 27-1 mg NPB vol-tab rx oral tablet 29-1 mg NPB vp-heme ob + dha oral 28-6-1 & 203 mg NPB vp-pnv-dha oral capsule 28-1-215.8 mg NPB vp-vite rx oral tablet 1 mg G xvite oral tablet 1 mg NF zalvit oral tablet 13-1 mg NF ZATEAN-PN DHA ORAL CAPSULE 27-0.6-0.4-300 MG NPB (prenat w/o a-fe-methfol-fa-dha) ZATEAN-PN PLUS ORAL CAPSULE 28-0.6-0.4-340 MG NPB (prenat w/o a-fe-methf-fa-omega) *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES AMRIX ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 15 MG, 30 MG (cyclobenzaprine hcl) baclofen oral tablet 10 mg, 20 mg, 5 mg G carisoprodol oral tablet 250 mg, 350 mg G carisoprodol-aspirin-codeine oral tablet 200-325-16 mg G chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg NF 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 235 Prescription Drug Name Drug Tier Drug Notes cyclo/gaba 10/300 oral therapy pack 10-300 mg NF cyclobenzaprine hcl er oral capsule extended release 24 hour 15 NF mg, 30 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg G cyclobenzaprine hcl oral tablet 7.5 mg NF CYCLOPHENE RAPIDPAQ TRANSDERMAL CREAM 5 NF % (cyclobenzaprine hcl) dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg G DUROLANE INTRA-ARTICULAR PREFILLED PSP SYRINGE 60 MG/3ML (sodium hyaluronate (viscosup)) EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate PSP (viscosup)) FEXMID ORAL TABLET 7.5 MG (cyclobenzaprine hcl) NF FIRST-BACLOFEN ORAL SUSPENSION 1 MG/ML, 5 NF MG/ML (baclofen) GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE PSP 30 MG/3ML (cross-linked hyaluronate) GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16.8 MG/2ML (sodium hyaluronate PSP (viscosup)) GENVISC 850 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML (sodium hyaluronate NF (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION 20 NF MG/2ML (sodium hyaluronate (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate NF (viscosup)) HYMOVIS INTRA-ARTICULAR SOLUTION NF PREFILLED SYRINGE 24 MG/3ML (hyaluronan) chlorzoxazone (Lorzone Oral Tablet 375 Mg, 750 Mg) NF MACI INTRA-ARTICULAR SHEET (autolog cult chond NF coll membr) METAXALL CP COMBINATION KIT 800 & 0.025 MG & NF % (metaxalone-capsaicin) metaxalone oral tablet 400 mg NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 236 Prescription Drug Name Drug Tier Drug Notes metaxalone oral tablet 800 mg G methocarbamol oral tablet 500 mg, 750 mg NF MONOVISC INTRA-ARTICULAR SOLUTION NF PREFILLED SYRINGE 88 MG/4ML (hyaluronan) norgesic forte oral tablet 50-770-60 mg NF orphenadrine citrate er oral tablet extended release 12 hour 100 G mg orphenadrine-asa-caffeine oral tablet 50-770-60 mg NF orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet NF 50-770-60 Mg) ORTHOVISC INTRA-ARTICULAR SOLUTION NF PREFILLED SYRINGE 30 MG/2ML (hyaluronan) sodium hyaluronate intra-articular solution prefilled syringe 20 NF mg/2ml SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML (sodium hyaluronate PSP (viscosup)) SYNVISC INTRA-ARTICULAR SOLUTION NF PREFILLED SYRINGE 16 MG/2ML (hylan) SYNVISC ONE INTRA-ARTICULAR SOLUTION NF PREFILLED SYRINGE 48 MG/6ML (hylan) TABRADOL FUSEPAQ ORAL SUSPENSION 1 MG/ML NF (cyclobenzaprine hcl-msm) TABRADOL RAPIDPAQ ORAL SUSPENSION 1 MG/ML NF (cyclobenzaprine hcl-msm) tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg G tizanidine hcl oral tablet 2 mg, 4 mg G TRILURON INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate NF (viscosup)) TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED NF SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED NF SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) ZANAFLEX ORAL CAPSULE 2 MG, 4 MG (tizanidine hcl) NPB ZANAFLEX ORAL TABLET 4 MG (tizanidine hcl) NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 237 Prescription Drug Name Drug Tier Drug Notes *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl NPB (nasal)) ALZAIR ALLERGY NASAL SPRAY NASAL POWDER NF (hypromellose) azelastine hcl nasal solution 0.15 %, 137 mcg/spray G BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY NF (beclomethasone diprop monohyd) DERMACINRX AZENASE PAK NASAL THERAPY NF PACK 137 & 50 MCG/ACT (azelastine-fluticasone) DERMACINRX TICANASE PAK NASAL THERAPY NF PACK 50-2.7 MCG/ACT-% (fluticasone-sodium chloride) DYMISTA NASAL SUSPENSION 137-50 MCG/ACT PB (azelastine-fluticasone) flunisolide nasal solution 25 mcg/act (0.025%) G fluticasone propionate nasal suspension 50 mcg/act G goprelto nasal solution 40 mg/ml NF ipratropium bromide nasal solution 0.03 %, 0.06 % G mometasone furoate nasal suspension 50 mcg/act G olopatadine hcl nasal solution 0.6 % G OMNARIS NASAL SUSPENSION 50 MCG/ACT NF (ciclesonide) QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 NF MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT NF (beclomethasone diprop (nasal)) SINUVA NASAL IMPLANT 1350 MCG (mometasone NF furoate) XHANCE NASAL EXHALER SUSPENSION 93 NPB MCG/ACT (fluticasone propionate) ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT NF (ciclesonide) *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES BOTOX INJECTION SOLUTION RECONSTITUTED 100 NPSP UNIT, 200 UNIT (onabotulinumtoxina) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 238 Prescription Drug Name Drug Tier Drug Notes DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT NPSP (abobotulinumtoxina) EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 NPSP MG/ML (risdiplam) riluzole oral tablet 50 mg G TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) NF XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT NPSP (incobotulinumtoxina) *NUTRIENTS* - DRUGS FOR NUTRITION amino acids (Aminoamrms Oral Capsule) G AMINOPROTECT INTRAVENOUS SOLUTION 5 % NF (amino acid infusion) amino acids (Aminoreliefrms Oral Capsule) G CARDIOVID PLUS ORAL CAPSULE (dha-epa-vit b6-b12- NPB folic acid) clinimix e/dextrose (8/10) intravenous solution 8 % NPB clinimix e/dextrose (8/14) intravenous solution 8 % NPB clinimix/dextrose (6/5) intravenous solution 6 % NPB clinimix/dextrose (8/10) intravenous solution 8 % NPB clinimix/dextrose (8/14) intravenous solution 8 % NPB CLINOLIPID INTRAVENOUS EMULSION 20 % (fat NF emulsion plant based) ELCYS INTRAVENOUS SOLUTION 50 MG/ML (cysteine NF hcl) INTRALIPID INTRAVENOUS EMULSION 20 % (fat NF emulsion plant based) lecithin oral granules NPB lipo-c intramuscular solution NF n-acetyl-l-cysteine oral capsule 600 mg G NEOKE ALCAR ORAL POWDER (acetylcarnitine) NF NEOKE MCT70 ORAL POWDER 70 GM/100GM (medium NF chain triglycerides) NUTRILIPID INTRAVENOUS EMULSION 20 % (fat NF emulsion plant based)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 239 Prescription Drug Name Drug Tier Drug Notes OMEGAVEN INTRAVENOUS EMULSION 10 NF GM/100ML, 5 GM/50ML (fish oil triglyceride based) tri-amino injection solution 100-100-100 mg/ml NF tryptophan oral capsule 500 mg NPB *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE ak-poly-bac ophthalmic ointment 500-10000 unit/gm G AKTEN OPHTHALMIC GEL 3.5 % (lidocaine hcl) NPB ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil NPB sodium) ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide NPB tromethamine) ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % PB (brimonidine tartrate) ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol NF etabonate) tetracaine hcl (Altacaine Ophthalmic Solution 0.5 %) G altafluor benox ophthalmic solution 0.25-0.4 % G phenylephrine hcl (Altafrin Ophthalmic Solution 10 %, 2.5 %) G apraclonidine hcl ophthalmic solution 0.5 % G atropine sulfate ophthalmic ointment 1 % NPB atropine sulfate ophthalmic solution 1 % NPB AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) NPB azelastine hcl ophthalmic solution 0.05 % G AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) PB bacitracin ophthalmic ointment 500 unit/gm G bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm G bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % G BEPREVE OPHTHALMIC SOLUTION 1.5 % (bepotastine NF besilate) BESIVANCE OPHTHALMIC SUSPENSION 0.6 % PB (besifloxacin hcl) BETADINE OPHTHALMIC PREP OPHTHALMIC NPB SOLUTION 5 % (povidone-iodine) betaxolol hcl ophthalmic solution 0.5 % G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 240 Prescription Drug Name Drug Tier Drug Notes BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % PB (timolol hemihydrate) BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % PB (betaxolol hcl) bimatoprost ophthalmic solution 0.03 % NF BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % NPB (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 NPB % (sulfacetamide-prednisolone) brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % G bromfenac sodium (once-daily) ophthalmic solution 0.09 % G BROMSITE OPHTHALMIC SOLUTION 0.075 % NPB (bromfenac sodium) carteolol hcl ophthalmic solution 1 % G CEQUA OPHTHALMIC SOLUTION 0.09 % (cyclosporine) NF CILOXAN OPHTHALMIC OINTMENT 0.3 % PB (ciprofloxacin hcl) ciprofloxacin hcl ophthalmic solution 0.3 % G COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % PB (brimonidine tartrate-timolol) cromolyn sodium ophthalmic solution 4 % G CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % NPB (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % G CYCLOSPORINE IN KLARITY OPHTHALMIC NF EMULSION 0.1 % (cyclosporine) dexamethasone sodium phosphate ophthalmic solution 0.1 % G DEXTENZA OPHTHALMIC INSERT 0.4 MG NF (dexamethasone) DEXYCU INTRAOCULAR SUSPENSION 9 % NF (dexamethasone) diclofenac sodium ophthalmic solution 0.1 % G dorzolamide hcl solution 2 % ophthalmic 2 % NPB dorzolamide hcl solution 2 % ophthalmic 2 % G dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml G dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 241 Prescription Drug Name Drug Tier Drug Notes double pm ophthalmic solution reconstituted 1-0.5 % NF DUREZOL OPHTHALMIC EMULSION 0.05 % PB (difluprednate) epinastine hcl ophthalmic solution 0.05 % G erythromycin ophthalmic ointment 5 mg/gm G EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML PSP (aflibercept) EYLEA INTRAVITREAL SOLUTION PREFILLED PSP SYRINGE 2 MG/0.05ML (aflibercept) FLAREX OPHTHALMIC SUSPENSION 0.1 % NPB (fluorometholone acetate) fluorescein-benoxinate ophthalmic solution 0.25-0.4 % G fluorescein sodium (Fluor-I-Strips A.T. Ophthalmic Strip 1 G Mg) fluorometholone ophthalmic suspension 0.1 % G FLURA-SAFE OPHTHALMIC SOLUTION 0.35-0.4 % NPB (fluorexon-benoxinate) flurbiprofen sodium ophthalmic solution 0.03 % G FML FORTE OPHTHALMIC SUSPENSION 0.25 % PB (fluorometholone) FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 % NF (fluorometholone) FML OPHTHALMIC OINTMENT 0.1 % (fluorometholone) PB gatifloxacin ophthalmic solution 0.5 % G GELFILM OPHTHALMIC FILM (gelatin adsorbable) NPB GENTAK OPHTHALMIC OINTMENT 0.3 % (gentamicin G sulfate) gentamicin sulfate ophthalmic solution 0.3 % G ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) PB INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol NPB etabonate) IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine NPB hcl) ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % NPB (atropine sulfate) ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 242 Prescription Drug Name Drug Tier Drug Notes KLARITY-A OPHTHALMIC SOLUTION 1 % NF (azithromycin) KLARITY-L OPHTHALMIC EMULSION 0.2 %, 0.5 % NF (loteprednol etabonate) LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear NF insert) LASTACAFT OPHTHALMIC SOLUTION 0.25 % PB (alcaftadine) latanoprost ophthalmic solution 0.005 % G levobunolol hcl ophthalmic solution 0.5 % G levofloxacin ophthalmic solution 0.5 % G lissamine green ophthalmic strip 1.5 mg G LOTEMAX OPHTHALMIC GEL 0.5 % (loteprednol NF etabonate) LOTEMAX OPHTHALMIC OINTMENT 0.5 % (loteprednol NF etabonate) LOTEMAX OPHTHALMIC SUSPENSION 0.5 % NF (loteprednol etabonate) LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol NF etabonate) loteprednol etabonate ophthalmic suspension 0.5 % G LUCENTIS INTRAVITREAL SOLUTION 0.3 PSP MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) LUCENTIS INTRAVITREAL SOLUTION PREFILLED PSP SYRINGE 0.3 MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) LUMIGAN OPHTHALMIC SOLUTION 0.01 % PB (bimatoprost) MAXIDEX OPHTHALMIC SUSPENSION 0.1 % PB (dexamethasone) MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 NPB (neomycin-polymyxin-dexameth) MITOSOL OPHTHALMIC KIT 0.2 MG (mitomycin) NPB MOXEZA OPHTHALMIC SOLUTION 0.5 % (moxifloxacin NPB hcl) moxifloxacin hcl ophthalmic solution 0.5 % G NATACYN OPHTHALMIC SUSPENSION 5 % NPB (natamycin) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 243 Prescription Drug Name Drug Tier Drug Notes neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400- G 10000 , 5-400-10000 neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000- G 0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- G 10000-0.1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- G 10000-.025 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 G bacitracin-polymyx-neo-hc (Neo-Polycin Hc Ophthalmic G Ointment 1 %) neomycin-bacitracin zn-polymyx (Neo-Polycin Ophthalmic G Ointment 3.5-400-10000) NEVANAC OPHTHALMIC SUSPENSION 0.1 % PB (nepafenac) ofloxacin ophthalmic solution 0.3 % G olopatadine hcl ophthalmic solution 0.1 %, 0.2 % G OZURDEX INTRAVITREAL IMPLANT 0.7 MG NPSP (dexamethasone) PAREMYD OPHTHALMIC SOLUTION 1-0.25 % NPB (hydroxyamphetamine-tropicamide) PAZEO OPHTHALMIC SOLUTION 0.7 % (olopatadine hcl) PB phenylephrine hcl ophthalmic solution 10 %, 2.5 % G PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION NPB RECONSTITUTED 0.125 % (echothiophate iodide) PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146-20 % (riboflavin 5-phosphate- NF dextran) PHOTREXA-PHOTREXA VISCOUS KIT OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146 &0.146-20 % NF (riboflav5 & riboflav5-dextran) pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % G bacitracin-polymyxin b (Polycin Ophthalmic Ointment 500- G 10000 Unit/Gm) polymyxin b-trimethoprim ophthalmic solution 10000-0.1 G unit/ml-% povidone-iodine ophthalmic solution 5 % NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 244 Prescription Drug Name Drug Tier Drug Notes PRED FORTE OPHTHALMIC SUSPENSION 1 % NF (prednisolone acetate) PRED MILD OPHTHALMIC SUSPENSION 0.12 % PB (prednisolone acetate) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % NPB (gentamicin-prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % NPB (gentamicin-prednisolone acet) prednisolone acetate ophthalmic suspension 1 % G prednisolone acetate p-f ophthalmic suspension 1 % NF prednisolone sodium phosphate ophthalmic solution 1 % NPB prednisolone-gatifloxacin ophthalmic suspension 1-0.5 % NF PROLENSA OPHTHALMIC SOLUTION 0.07 % NF (bromfenac sodium) proparacaine hcl ophthalmic solution 0.5 % G proparacaine-fluorescein ophthalmic solution 0.5-0.25 % G RESTASIS MULTIDOSE OPHTHALMIC EMULSION PB 0.05 % (cyclosporine) RESTASIS OPHTHALMIC EMULSION 0.05 % PB (cyclosporine) RHOPRESSA OPHTHALMIC SOLUTION 0.02 % PB (netarsudil dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % NF (netarsudil-latanoprost) ROSE GLO OPHTHALMIC STRIP 1.5 MG (rose bengal) NPB SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % PB (brinzolamide-brimonidine) sulfacetamide sodium ophthalmic ointment 10 % G sulfacetamide sodium ophthalmic solution 10 % G sulfacetamide-prednisolone ophthalmic solution 10-0.23 % G tetracaine hcl ophthalmic solution 0.5 % G timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % G timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % G (daily) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 NF %, 0.5 % (timolol maleate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 245 Prescription Drug Name Drug Tier Drug Notes TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % PB (tobramycin-dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % PB (tobramycin-dexamethasone) tobramycin ophthalmic solution 0.3 % G tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % G TOBREX OPHTHALMIC OINTMENT 0.3 % (tobramycin) NPB TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % NPB (travoprost) travoprost (bak free) ophthalmic solution 0.004 % G trifluridine ophthalmic solution 1 % G triple pmb ophthalmic solution reconstituted 1-0.5-0.09 % NF triple pmk ophthalmic solution reconstituted 1-0.5-0.5 % NF tropicamide ophthalmic solution 0.5 %, 1 % G VYZULTA OPHTHALMIC SOLUTION 0.024 % NPB (latanoprostene bunod) XELPROS OPHTHALMIC EMULSION 0.005 % NF (latanoprost) XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) PB YUTIQ INTRAVITREAL IMPLANT 0.18 MG (fluocinolone NF acetonide) ZERVIATE OPHTHALMIC SOLUTION 0.24 % (cetirizine NPB hcl) ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % PB (tafluprost) ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) NF ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % NF (loteprednol-tobramycin) *OTIC AGENTS* - DRUGS FOR THE EAR acetic acid otic solution 2 % G CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- NF hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- NF dexamethasone) ciprofloxacin hcl otic solution 0.2 % G ciprofloxacin-dexamethasone otic suspension 0.3-0.1 % G 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 246 Prescription Drug Name Drug Tier Drug Notes ciprofloxacin-fluocinolone pf otic solution 0.3-0.025 % NF CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 NPB MG/ML (neomycin-colist-hc-thonzonium) fluocinolone acetonide (Flac Otic Oil 0.01 %) G fluocinolone acetonide otic oil 0.01 % G hydrocortisone-acetic acid otic solution 1-2 % G neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 G neomycin-polymyxin-hc otic suspension 3.5-10000-1 G ofloxacin otic solution 0.3 % G OTIPRIO INTRATYMPANIC SUSPENSION 6 % NF (ciprofloxacin) OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- NF fluocinolone) *OXYTOCICS* - HORMONES CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) NPB methylergonovine maleate (Methergine Oral Tablet 0.2 Mg) G methylergonovine maleate oral tablet 0.2 mg G PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) NPB PROSTIN E2 VAGINAL SUPPOSITORY 20 MG NPB (dinoprostone) *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS ASCENIV INTRAVENOUS SOLUTION 5 GM/50ML NF (immune globulin (human)-slra) BIVIGAM INTRAVENOUS SOLUTION 5 GM/50ML NPSP (immune globulin (human)) CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM (immune globulin NPSP (human)) CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 NF GM/48ML (immune globulin (human)-hipp) CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML (immune NF globulin (human))

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 247 Prescription Drug Name Drug Tier Drug Notes FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, NPSP 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NPSP 5 GM/50ML (immune globulin (human)) GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM (immune NPSP globulin (human)) GAMMAKED INJECTION SOLUTION 10 GM/100ML, 20 NPSP GM/200ML, 5 GM/50ML (immune globulin (human)) GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, NPSP 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML NPSP (immune globulin (human)) HEPAGAM B INJECTION SOLUTION (hepatitis b immune NPSP globulin) HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin NPSP (human)) HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML (immune NPSP globulin (human)) HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML NF (immune globulin-hyaluronidase) OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 NPSP GM/200ML, 25 GM/500ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML NPB (immune globulin (human)) PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NF 5 GM/50ML (immune globulin (human)-ifas)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 248 Prescription Drug Name Drug Tier Drug Notes PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML (immune NPSP globulin (human)) RHOPHYLAC INJECTION SOLUTION PREFILLED NPSP SYRINGE 1500 UNIT/2ML (rho d immune globulin) SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, NPSP 50 MG/0.5ML (palivizumab) WINRHO SDF INJECTION SOLUTION 15000 NPSP UNIT/13ML, 2500 UNIT/2.2ML (rho d immune globulin) XEMBIFY SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin NF (human)-klhw) ZINPLAVA INTRAVENOUS SOLUTION 1000 MG/40ML NF (bezlotoxumab) *PENICILLINS* - DRUGS FOR INFECTIONS amoxicillin oral capsule 250 mg, 500 mg G amoxicillin oral suspension reconstituted 125 mg/5ml, 200 G mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg G amoxicillin oral tablet chewable 125 mg, 250 mg G amoxicillin-pot clavulanate er oral tablet extended release 12 G hour 1000-62.5 mg amoxicillin-pot clavulanate oral suspension reconstituted 200- 28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 G mg/5ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, G 875-125 mg amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, G 400-57 mg ampicillin oral capsule 500 mg G AUGMENTIN ORAL SUSPENSION RECONSTITUTED NPB 125-31.25 MG/5ML (amoxicillin-pot clavulanate) dicloxacillin sodium oral capsule 250 mg, 500 mg G penicillin v potassium oral solution reconstituted 125 mg/5ml, G 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 249 Prescription Drug Name Drug Tier Drug Notes PFIZERPEN INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT NF (penicillin g potassium) *PHARMACEUTICAL ADJUVANTS* base x flakes NPB benzyl alcohol liquid NPB capsule 0 clear dr capsule NPB capsule coni-snap #0 clear capsule NPB capsule coni-snap #0 purple capsule NPB capsule coni-snap #00 white capsule NPB capsule coni-snap #000 clear capsule NPB capsule coni-snap #1 red/blue capsule NPB capsule coni-snap #1 veggie capsule NPB capsule coni-snap #2 white capsule NPB capsule coni-snap #3 clear capsule NPB capsule coni-snap #3 yellow capsule NPB capsule coni-snap #4 white capsule NPB capsule ezeefit #0 clear capsule NPB capsule ezeefit #00 clear capsule NPB cherry oral syrup NPB cocoa butter NPB corn (syrup) oral syrup NPB DRCAPS SIZE 0 CAPSULE (gelatin capsules (empty)) NPB DRCAPS SIZE 00 CAPSULE (gelatin capsules (empty)) NPB DRCAPS SIZE 1 CAPSULE (gelatin capsules (empty)) NPB empty capsule size 0 white/opa capsule NPB empty capsule size 00 clear capsule NPB empty capsule size 1 clear capsule NPB empty capsule size 1 veg clear capsule NPB empty capsule size 2 clear capsule NPB empty capsule size 3 clear capsule NPB empty capsule size 4 clear capsule NPB empty capsule size 5 clear capsule NPB empty capsule size 7 clear capsule NPB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 250 Prescription Drug Name Drug Tier Drug Notes FLAVOR BLEND ORAL SUSPENSION (oral vehicles) NPB flavor plus oral liquid NPB flavor sweet oral syrup NPB flavor sweet-sf oral syrup NPB mouth wash-gp oral liquid NPB mouthwash-af oral liquid NPB mouthwash-om oral liquid NPB ORA-BLEND ORAL SUSPENSION (oral vehicles) NPB ORA-BLEND SF ORAL SUSPENSION (oral vehicles) NPB ORA-PLUS ORAL LIQUID (oral vehicles) NPB ORA-SWEET ORAL SYRUP (oral vehicles) NPB ORA-SWEET SF ORAL SYRUP (oral vehicles) NPB PCCA SWEET-SF ORAL SYRUP (oral vehicles) NPB PCCA SYRUP VEHICLE ORAL SYRUP (oral vehicles) NPB PCCA-PLUS ORAL SUSPENSION (oral vehicles) NPB polypeg NPB purified water oral liquid NPB simple syrup oral syrup NPB sorbitol solution , 70 % NPB spg supposi-base pellet NPB suppository blend pellet NPB SUSPENDRX W/BITTERBLOC SWEET ORAL NPB SUSPENSION (oral vehicles) SUSPENDRX W/BITTERBLOC UNSWEET ORAL NPB SUSPENSION (oral vehicles) suspension vehicle oral suspension NPB SYRPALTA (RED) ORAL SYRUP (oral vehicles) NPB syrpalta oral syrup 85 % NPB SYRSPEND SF ORAL LIQUID (oral vehicles) NPB SYRSPEND SF PH4 ORAL SUSPENSION NPB RECONSTITUTED (oral vehicles) syrup vehicle oral syrup NPB syrup vehicle sf oral syrup NPB vegetable capsule #0 green capsule NPB 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 251 Prescription Drug Name Drug Tier Drug Notes vegetable capsule #0 white capsule NPB vegetable capsule #00 white capsule NPB vegetable capsule #1 white capsule NPB vegetable capsule #2 white capsule NPB vegetable capsule #3 white capsule NPB vegetable capsule #4 white capsule NPB VERSAFREE ORAL SYRUP (oral vehicles) NPB VERSAPLUS ORAL SYRUP (oral vehicles) NPB WITEPSOL PELLET (hydrogenated vegetable oil) NPB WITEPSOL WAX (hydrogenated vegetable oil) NPB *PROGESTINS* - HORMONES ec-rx progesterone transdermal cream 10 %, 20 % NF hydroxyprogesterone caproate intramuscular oil 250 mg/ml G MAKENA INTRAMUSCULAR OIL 250 MG/ML NPSP (hydroxyprogesterone caproate) MAKENA SUBCUTANEOUS SOLUTION AUTO- NPSP INJECTOR 275 MG/1.1ML (hydroxyprogesterone caproate) medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg G megestrol acetate oral suspension 625 mg/5ml G norethindrone acetate oral tablet 5 mg G progesterone compounding kit transdermal cream 20 % NF progesterone intramuscular oil 50 mg/ml G progesterone micronized oral capsule 100 mg, 200 mg G PROVERA ORAL TABLET 10 MG (medroxyprogesterone NPB acetate) *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM acamprosate calcium oral tablet delayed release 333 mg G ADDYI ORAL TABLET 100 MG (flibanserin) NF AMPYRA ORAL TABLET EXTENDED RELEASE 12 NPSP HOUR 10 MG (dalfampridine) AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) PSP AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG PSP (deutetrabenazine) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 252 Prescription Drug Name Drug Tier Drug Notes AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR NF KIT 30 MCG/0.5ML (interferon beta-1a) AVONEX PREFILLED INTRAMUSCULAR PREFILLED NF SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a) BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95 NF MG (monomethyl fumarate) BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon PSP beta-1b) bupropion hcl er (smoking det) oral tablet extended release 12 CE hour 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET CE 1 MG (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline CE tartrate) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 CE MG X 11 & 1 MG X 42 (varenicline tartrate) chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg G CONVENIENCE PAK COMBINATION THERAPY NF PACK 600 & 5 MG & % (gabapentin & lidocaine) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML PSP (glatiramer acetate) cvs nicotine mouth/throat gum 2 mg, 4 mg CE cvs nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE cvs nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE cvs nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr dalfampridine er oral tablet extended release 12 hour 10 mg G disulfiram oral tablet 250 mg, 500 mg G donepezil hcl oral tablet 10 mg, 23 mg, 5 mg G donepezil hcl oral tablet dispersible 10 mg, 5 mg G eq nicotine mouth/throat gum 4 mg CE eq nicotine mouth/throat lozenge 4 mg CE eq nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE eq nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE eq nicotine step 3 transdermal patch 24 hour 7 mg/24hr CE

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 253 Prescription Drug Name Drug Tier Drug Notes eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr CE eql nicotine polacrilex mouth/throat gum 2 mg CE eql nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE ergoloid mesylates oral tablet 1 mg G EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta- NF 1b) fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg NF galantamine hydrobromide er oral capsule extended release 24 G hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml G galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg G GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) PSP glatiramer acetate subcutaneous solution prefilled syringe 20 G mg/ml, 40 mg/ml glatiramer acetate (Glatopa Subcutaneous Solution Prefilled G Syringe 20 Mg/Ml, 40 Mg/Ml) gnp nicotine mini mouth/throat lozenge 2 mg CE gnp nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE gnp nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE gnp nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr CE goodsense nicotine mouth/throat gum 4 mg CE goodsense nicotine mouth/throat lozenge 4 mg CE GRALISE ORAL TABLET 300 MG, 600 MG (gabapentin PB (once-daily)) hm nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE hm nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE hm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr HORIZANT ORAL TABLET EXTENDED RELEASE 300 NF MG, 600 MG (gabapentin enacarbil) INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine PSP tosylate) INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 PSP MG (valbenazine tosylate) KESIMPTA SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 20 MG/0.4ML (ofatumumab) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 254 Prescription Drug Name Drug Tier Drug Notes KLS QUIT2 MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) KLS QUIT2 MOUTH/THROAT LOZENGE 2 MG (nicotine CE polacrilex) KLS QUIT4 MOUTH/THROAT GUM 4 MG (nicotine CE polacrilex) KLS QUIT4 MOUTH/THROAT LOZENGE 4 MG (nicotine CE polacrilex) LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2ML NF (alemtuzumab) LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) NF LYRICA CR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 165 MG, 330 MG, 82.5 MG (pregabalin) MAVENCLAD (10 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (4 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (5 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (6 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (7 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (8 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (9 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAYZENT ORAL TABLET 0.25 MG, 2 MG (siponimod PSP fumarate) MAYZENT STARTER PACK ORAL TABLET THERAPY PSP PACK 0.25 MG (siponimod fumarate) memantine hcl er oral capsule extended release 24 hour 14 mg, G 21 mg, 28 mg, 7 mg memantine hcl oral solution 10 mg/5ml, 2 mg/ml G memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 255 Prescription Drug Name Drug Tier Drug Notes NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG NPB (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PB PACK 7 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG PB (memantine hcl-donepezil hcl) NICORELIEF MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) nicotine mini mouth/throat lozenge 2 mg CE nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE nicotine step 1 transdermal patch 24 hour 21 mg/24hr CE nicotine step 2 transdermal patch 24 hour 14 mg/24hr CE nicotine step 3 transdermal patch 24 hour 7 mg/24hr CE nicotine transdermal patch 24 hour 21 mg/24hr CE NICOTROL INHALATION INHALER 10 MG (nicotine) CE NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) CE NUEDEXTA ORAL CAPSULE 20-10 MG PB (dextromethorphan-quinidine) OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML PSP (ocrelizumab) olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 G mg, 6-25 mg, 6-50 mg paroxetine mesylate oral capsule 7.5 mg G perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 G mg, 4-25 mg, 4-50 mg pimozide oral tablet 1 mg, 2 mg G PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML NF (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML NF (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 125 MCG/0.5ML (peginterferon beta-1a) 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 256 Prescription Drug Name Drug Tier Drug Notes PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) ra mini nicotine mouth/throat lozenge 2 mg, 4 mg CE ra nicotine mouth/throat gum 2 mg, 4 mg CE ra nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE ra nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML PSP (interferon beta-1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 PSP & 6X22 MCG (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta- PSP 1a) REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG PSP (interferon beta-1a) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg G rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 G mg/24hr, 9.5 mg/24hr SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 NPB MG (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG NPB (milnacipran hcl) sm nicotine mouth/throat gum 4 mg CE sm nicotine mouth/throat lozenge 2 mg CE sm nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE sm nicotine polacrilex mouth/throat lozenge 4 mg CE sm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr sr nicotine mouth/throat gum 2 mg CE TECFIDERA ORAL 120 & 240 MG (dimethyl fumarate) NF TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 NF MG, 240 MG (dimethyl fumarate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 257 Prescription Drug Name Drug Tier Drug Notes TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 284 MG/1.5ML (inotersen sodium) tetrabenazine oral tablet 12.5 mg, 25 mg G THRIVE MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) TYSABRI INTRAVENOUS CONCENTRATE 300 PSP MG/15ML (natalizumab) VUMERITY ORAL CAPSULE DELAYED RELEASE 231 PSP MG (diroximel fumarate) VYLEESI SUBCUTANEOUS SOLUTION AUTO- NF INJECTOR 1.75 MG/0.3ML (bremelanotide acetate) XENAZINE ORAL TABLET 12.5 MG, 25 MG NF (tetrabenazine) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod PSP hcl) ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) PSP ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PSP PACK 0.23MG & 0.46MG & 0.92MG (ozanimod hcl) *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG (alpha1-proteinase NF inhibitor) CUROSURF INTRATRACHEAL SUSPENSION 120 NPB MG/1.5ML, 240 MG/3ML (poractant alfa) ESBRIET ORAL CAPSULE 267 MG (pirfenidone) PSP ESBRIET ORAL TABLET 267 MG, 801 MG (pirfenidone) PSP GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML NF (alpha1-proteinase inhibitor) INFASURF INTRATRACHEAL SUSPENSION 35-0.9 NPB MG/ML-% (calfactant in nacl) KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG NPB (ivacaftor) KALYDECO ORAL TABLET 150 MG (ivacaftor) NPB OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib PSP esylate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 258 Prescription Drug Name Drug Tier Drug Notes ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG NPB (lumacaftor-ivacaftor) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG NPB (lumacaftor-ivacaftor) PROLASTIN-C INTRAVENOUS SOLUTION 1000 PB MG/20ML (alpha1-proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION PSP RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor) PULMOZYME INHALATION SOLUTION 1 MG/ML NPSP (dornase alfa) SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 NPB MG/ML-% (beractant in nacl) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & NPB 150 MG, 50-75 & 75 MG (tezacaftor-ivacaftor) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 NPB & 150 MG (elexacaftor-tezacaftor-ivacaft) ZEMAIRA INTRAVENOUS SOLUTION NF RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor) *SULFONAMIDES* - DRUGS FOR INFECTIONS sulfadiazine oral tablet 500 mg NPB *TETRACYCLINES* - DRUGS FOR INFECTIONS ACTICLATE ORAL TABLET 150 MG, 75 MG (doxycycline NF hyclate) avidoxy oral tablet 100 mg G BENZODOX COMBINATION THERAPY PACK 30 X 100 MG & 4.4%, 60 X 100 MG & 4.4% (doxycycline-benzoyl NF peroxide) minocycline hcl (Coremino Oral Tablet Extended Release 24 NF Hour 135 Mg, 45 Mg, 90 Mg) demeclocycline hcl oral tablet 150 mg, 300 mg G DORYX MPC ORAL TABLET DELAYED RELEASE 120 NF MG (doxycycline hyclate) DORYX ORAL TABLET DELAYED RELEASE 200 MG, NF 50 MG, 80 MG (doxycycline hyclate) doxycycline hyclate oral capsule 100 mg, 50 mg G doxycycline hyclate oral tablet 100 mg, 20 mg G doxycycline hyclate oral tablet 150 mg, 50 mg, 75 mg NF 2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 259 Prescription Drug Name Drug Tier Drug Notes doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, G 50 mg, 75 mg doxycycline hyclate oral tablet delayed release 200 mg NF doxycycline monohydrate oral capsule 100 mg, 50 mg G doxycycline monohydrate oral capsule 150 mg, 75 mg NF doxycycline monohydrate oral suspension reconstituted 25 G mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 G mg MINOCIN ORAL CAPSULE 100 MG (minocycline hcl) NF minocycline hcl er oral capsule extended release 24 hour 135 mg, NF 45 mg, 90 mg minocycline hcl er oral tablet extended release 24 hour 105 mg, NF 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg G minocycline hcl oral tablet 100 mg, 50 mg, 75 mg G MINOLIRA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 105 MG, 135 MG (minocycline hcl) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 100 G Mg) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 75 NF Mg) doxycycline hyclate (Morgidox Oral Capsule 100 Mg) G NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) NPB SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG NF (sarecycline hcl) TARGADOX ORAL TABLET 50 MG (doxycycline hyclate) NF tetracycline hcl oral capsule 250 mg, 500 mg G TYGACIL INTRAVENOUS SOLUTION NF RECONSTITUTED 50 MG (tigecycline) VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline PB calcium) XERAVA INTRAVENOUS SOLUTION NPB RECONSTITUTED 100 MG (eravacycline dihydrochloride) XIMINO ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 135 MG, 45 MG, 90 MG (minocycline hcl)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 260 Prescription Drug Name Drug Tier Drug Notes *THYROID AGENTS* - HORMONES ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, NPB 300 MG (thyroid) CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG NPB (liothyronine sodium) levothyroxine sodium (Euthyrox Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 G Mcg, 50 Mcg, 75 Mcg, 88 Mcg) levothyroxine sodium (Levo-T Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 300 G Mcg, 50 Mcg, 75 Mcg, 88 Mcg) levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, G 75 mcg, 88 mcg levothyroxine sodium (Levoxyl Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 50 G Mcg, 75 Mcg, 88 Mcg) liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg G methimazole oral tablet 10 mg, 5 mg G NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 NPB MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg G propylthiouracil oral tablet 50 mg G TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, NF 25 MCG, 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium) TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 NF MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) levothyroxine sodium (Unithroid Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 G Mcg, 300 Mcg, 50 Mcg, 75 Mcg, 88 Mcg) WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, NPB 65 MG, 97.5 MG (thyroid)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 261 Prescription Drug Name Drug Tier Drug Notes WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG NPB (thyroid) *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG NF (rabeprazole sodium) ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 NF MG, 5 MG (rabeprazole sodium) amoxicill-clarithro-lansopraz oral G belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2- NPB 60 mg CARAFATE ORAL SUSPENSION 1 GM/10ML (sucralfate) NF CARAFATE ORAL TABLET 1 GM (sucralfate) NF chlordiazepoxide-clidinium oral capsule 5-2.5 mg NF cimetidine hcl oral solution 300 mg/5ml G cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg G CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) NPB DEXILANT ORAL CAPSULE DELAYED RELEASE 30 PB MG, 60 MG (dexlansoprazole) dicyclomine hcl oral capsule 10 mg G dicyclomine hcl oral solution 10 mg/5ml G dicyclomine hcl oral tablet 20 mg G ed-spaz oral tablet dispersible 0.125 mg G eq famotidine max st oral tablet 20 mg G ESOMEP-EZS ORAL KIT 20 MG (esomeprazole magnesium) NF esomeprazole magnesium oral capsule delayed release 20 mg, 40 G mg famotidine oral suspension reconstituted 40 mg/5ml G famotidine oral tablet 20 mg, 40 mg G GLYCATE ORAL TABLET 1.5 MG (glycopyrrolate) NF glycopyrrolate oral tablet 1 mg, 2 mg G GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 NF MG/2ML (glycopyrrolate)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 262 Prescription Drug Name Drug Tier Drug Notes hyoscyamine sulfate er oral tablet extended release 12 hour G 0.375 mg hyoscyamine sulfate oral elixir 0.125 mg/5ml G hyoscyamine sulfate oral solution 0.125 mg/ml G hyoscyamine sulfate oral tablet 0.125 mg G hyoscyamine sulfate oral tablet dispersible 0.125 mg G hyoscyamine sulfate sublingual tablet sublingual 0.125 mg G lansoprazole oral capsule delayed release 15 mg, 30 mg G lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg G methscopolamine bromide oral tablet 2.5 mg, 5 mg G misoprostol oral tablet 100 mcg, 200 mcg G NEXIUM ORAL CAPSULE DELAYED RELEASE 20 NF MG, 40 MG (esomeprazole magnesium) NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40 NF MG, 5 MG (esomeprazole magnesium) nizatidine oral capsule 150 mg, 300 mg G nizatidine oral solution 15 mg/ml G hyoscyamine sulfate (Nulev Oral Tablet Dispersible 0.125 Mg) G OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- NPB clarithro-omeprazole) omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg G omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40- NF 1100 mg omeprazole-sodium bicarbonate oral packet 20-1680 mg, 40- NF 1680 mg oscimin oral tablet 0.125 mg G oscimin sr oral tablet extended release 12 hour 0.375 mg G oscimin sublingual tablet sublingual 0.125 mg G pantoprazole sodium oral tablet delayed release 20 mg, 40 mg G PREVACID ORAL CAPSULE DELAYED RELEASE 15 NF MG, 30 MG (lansoprazole) PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole NPB magnesium) propantheline bromide oral tablet 15 mg G PROTONIX ORAL PACKET 40 MG (pantoprazole sodium) NF

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 263 Prescription Drug Name Drug Tier Drug Notes PROTONIX ORAL TABLET DELAYED RELEASE 20 NF MG, 40 MG (pantoprazole sodium) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- PB metronid-tetracyc) rabeprazole sodium oral capsule sprinkle 10 mg NPB rabeprazole sodium oral tablet delayed release 20 mg G sucralfate oral suspension 1 gm/10ml NF sucralfate oral tablet 1 gm G SYMAX DUOTAB ORAL TABLET EXTENDED NPB RELEASE 0.375 MG (hyoscyamine sulfate) hyoscyamine sulfate (Symax-Sr Oral Tablet Extended Release G 12 Hour 0.375 Mg) TALICIA ORAL CAPSULE DELAYED RELEASE 250- NPB 12.5-10 MG (amoxicill-rifabutin-omeprazole) ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG NF (omeprazole-sodium bicarbonate) ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG NF (omeprazole-sodium bicarbonate) *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg G darifenacin hydrobromide er oral tablet extended release 24 G hour 15 mg, 7.5 mg DETROL LA ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 2 MG, 4 MG (tolterodine tartrate) ENABLEX ORAL TABLET EXTENDED RELEASE 24 NF HOUR 15 MG, 7.5 MG (darifenacin hydrobromide) flavoxate hcl oral tablet 100 mg G GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin NPB chloride) MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 25 MG, 50 MG (mirabegron) oxybutynin chloride er oral tablet extended release 24 hour 10 G mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml G oxybutynin chloride oral tablet 5 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 264 Prescription Drug Name Drug Tier Drug Notes OXYTROL TRANSDERMAL PATCH TWICE WEEKLY NF 3.9 MG/24HR (oxybutynin) solifenacin succinate oral tablet 10 mg, 5 mg G tolterodine tartrate er oral capsule extended release 24 hour 2 G mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg G TOVIAZ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 4 MG, 8 MG (fesoterodine fumarate) trospium chloride er oral capsule extended release 24 hour 60 G mg trospium chloride oral tablet 20 mg G *VACCINES* - BIOLOGICAL AGENTS MENQUADFI INTRAMUSCULAR INJECTABLE NPB (meningococcal a c y&w-135 conj) ROTARIX ORAL SUSPENSION RECONSTITUTED NPB (rotavirus vaccine live oral) ROTATEQ ORAL SOLUTION (rotavirus vac live NPB pentavalent) VAXCHORA ORAL SUSPENSION RECONSTITUTED NPB (cholera vac live attenuated) VIVOTIF ORAL CAPSULE DELAYED RELEASE NPB (typhoid vaccine) *VAGINAL AND RELATED PRODUCTS* - DRUGS FOR WOMEN CLEOCIN VAGINAL SUPPOSITORY 100 MG NPB (clindamycin phosphate) clindamycin phosphate vaginal cream 2 % G CLINDESSE VAGINAL CREAM 2 % (clindamycin NPB phosphate (1 dose)) CRINONE VAGINAL GEL 4 %, 8 % (progesterone) PB ENCARE VAGINAL SUPPOSITORY 100 MG (nonoxynol- CE 9) ENDOMETRIN VAGINAL INSERT 100 MG PB (progesterone) estradiol vaginal cream 0.1 mg/gm G estradiol vaginal tablet 10 mcg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 265 Prescription Drug Name Drug Tier Drug Notes ESTRING VAGINAL RING 2 MG (estradiol) NF FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 NF MG/24HR (estradiol acetate) GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole NPB nitrate (1 dose)) IMVEXXY MAINTENANCE PACK VAGINAL INSERT PB 10 MCG, 4 MCG (estradiol) IMVEXXY STARTER PACK VAGINAL INSERT 10 PB MCG, 4 MCG (estradiol) INTRAROSA VAGINAL INSERT 6.5 MG (prasterone) NF metronidazole vaginal gel 0.75 % G miconazole 3 vaginal suppository 200 mg G NUVESSA VAGINAL GEL 1.3 % (metronidazole) NF OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL CE 3 % (nonoxynol-9) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, NF conjugated) SHUR-SEAL CONTRACEPTIVE VAGINAL GEL 2 % CE (nonoxynol-9) terconazole vaginal cream 0.4 %, 0.8 % G terconazole vaginal suppository 80 mg G TRIMO-SAN VAGINAL GEL 0.025-0.01 % (oxyquinoline- NF sod lauryl sulf) metronidazole (Vandazole Vaginal Gel 0.75 %) G VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 CE % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM CE 12.5 % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL GEL 4 % CE (nonoxynol-9) estradiol (Yuvafem Vaginal Tablet 10 Mcg) G *VASOPRESSORS* - DRUGS FOR THE HEART ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 NPB MG/30ML (epinephrine) ADYPHREN AMP II INJECTION KIT 1 MG/ML NF (epinephrine)

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 266 Prescription Drug Name Drug Tier Drug Notes ADYPHREN AMP INJECTION KIT 1 MG/ML NF (epinephrine) ADYPHREN II INJECTION KIT 1 MG/ML (epinephrine) NF ADYPHREN INJECTION KIT 1 MG/ML (epinephrine) NF AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML NF (ephedrine sulfate (pressors)) AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 NF MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine) epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 G mg/0.3ml, 0.3 mg/0.3ml epinephrine injection solution prefilled syringe 1 mg/10ml NF epinephrine intravenous solution prefilled syringe 0.1 mg/10ml NPB epinephrine professional injection kit 1 mg/ml NF EPINEPHRINESNAP-EMS INJECTION KIT 1 MG/ML NF (epinephrine) EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML NF (epinephrine) EPISNAP INJECTION KIT 1 MG/ML (epinephrine) NF GIAPREZA INTRAVENOUS SOLUTION 2.5 MG/ML NF (angiotensin ii acetate) midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg G NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG NF (droxidopa) phenylephrine hcl (pressors) intravenous solution 0.8 mg/10ml NPB phenylephrine hcl intravenous solution 1 mg/10ml NPB SYMJEPI INJECTION SOLUTION PREFILLED PB SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML (epinephrine) *VITAMINS* - DRUGS FOR NUTRITION aminobenzoate potassium oral packet 2 gm G ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML NF (ascorbic acid) ergocal oral capsule 62.5 mcg (2500 ut) NF ergocalciferol oral capsule 1.25 mg (50000 ut) G phytonadione injection solution 1 mg/0.5ml, 10 mg/ml G phytonadione oral tablet 5 mg G

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 267 Prescription Drug Name Drug Tier Drug Notes POTABA ORAL CAPSULE 500 MG (potassium NPB aminobenzoate) pyridoxine hcl injection solution 100 mg/ml G thiamine hcl injection solution 100 mg/ml G vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) G vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml G wheat germ oil oral oil NPB

2021 Pharmacy Drug Guide - Aetna Standard Plan

The formulary is updated the first week of each month

01/01/2021 268 Index 12-PANEL POC ACCU-CHEK NANO ACTICOAT TOXICOLOGY SYSTEM....133 SMARTVIEW...... 174 ANTIMICROBIAL...... 110 1st tier unifine pentips...... 173 ACCU-CHEK PLASTIC ACTICOAT FLEX 3 4"X4"..110 1st tier unifine pentips plus...... 173 CARTRIDGE...... 174 acti-lance 28g...... 174 1st tier unilet comfortouch...... 173 ACCU-CHEK RAPID-D acti-lance lite lancets 28g...... 174 7T Lido...... 110 INFUSION SET...... 174 acti-lance special lancets 17g.. 174 abacavir sulfate...... 84 ACCU-CHEK RAPID-D acti-lance universal 23g...... 174 abacavir sulfate-lamivudine...... 84 LINK...... 174 ACTIMMUNE...... 70 abacavir-lamivudine-zidovudine 84 ACCU-CHEK SAFE-T PRO ACTIQ...... 27 Abaneu-Sl...... 163 LANCETS...... 174 active fe...... 163 ABILIFY...... 81 ACCU-CHEK activite...... 226 ABILIFY MAINTENA...... 81 SMARTVIEW...... 133 ACTOS...... 50 ABILIFY MYCITE...... 81 ACCU-CHEK SOFTCLIX ACUICYN...... 110 abiraterone acetate...... 70 LANCET DEV...... 174 acyclovir...... 84, 110 ABLYSINOL...... 92 ACCU-CHEK SOFTCLIX ACZONE...... 110 ABOUTTIME PEN LANCETS...... 174 ADAKVEO...... 163 NEEDLE...... 173 ACCU-CHEK SPIRIT adapalene...... 110 ABSORICA...... 110 BATTERY KIT...... 174 adapalene-benzoyl peroxide.... 110 acamprosate calcium...... 252 ACCU-CHEK TENDER II ADASUVE...... 81 ACANYA...... 110 SET 24"...... 174 adc/f (0.5mg/ml)...... 226 acarbose...... 50 ACCU-CHEK TENDER II ADCIRCA...... 92 ACCUCAINE...... 110 SET 31"...... 174 ADDERALL XR...... 16 ACCU-CHEK AVIVA...... 173 ACCU-CHEK TENDER II ADDYI...... 252 ACCU-CHEK AVIVA SET 43"...... 174 adefovir dipivoxil...... 84 CONNECT...... 173 ACCU-CHEK ADEMPAS...... 92 ACCU-CHEK AVIVA PLUS ULTRAFLEX INF SET...... 174 ADHANSIA XR...... 16 ...... 133, 173 ACCU-CHEK adjustable lancing device...... 174 ACCU-CHEK COMPACT ULTRAFLEX-1 INF SET....174 ADLYXIN...... 50 PLUS...... 133 ACCUTREND GLUCOSE..133 ADLYXIN STARTER ACCU-CHEK COMPACT acd formula a...... 41 PACK...... 50 PLUS CARE...... 173 ACD-A NOCLOT-50...... 41 ADMELOG...... 50 ACCU-CHEK FASTCLIX acebutolol hcl...... 89 ADRENAL C FORMULA.. 226 LANCET...... 173 aceso ag...... 110 ADRENALIN...... 238, 266 ACCU-CHEK FASTCLIX acetaminophen-codeine...... 27 ADVAIR HFA...... 36 LANCETS...... 173 acetaminophen-codeine #3...... 27 ADVANCE INTUITION ACCU-CHEK FLEXLINK acetazolamide...... 145 METER...... 174 PLUS 10MM...... 173 acetazolamide er...... 145 ADVANCE INTUITION ACCU-CHEK FLEXLINK acetic acid...... 157, 246 MONITOR...... 174 PLUS 6MM...... 173 acetylcysteine...... 108 ADVANCE INTUITION ACCU-CHEK FLEXLINK ACIPHEX...... 262 TEST...... 133 PLUS 8MM...... 173 ACIPHEX SPRINKLE...... 262 ADVANCE MICRO-DRAW ACCU-CHEK GUIDE. 133, 173 acitretin...... 110 METER...... 175 ACCU-CHEK GUIDE ME..173 ACTEMRA...... 20 ADVANCE MICRO-DRAW ACCU-CHEK LINKASSIST ACTEMRA ACTPEN...... 19 TEST...... 133 ...... 173 ACTHAR...... 146 ADVANCED ALLERGY ACCU-CHEK MULTICLIX ACTICLATE...... 259 COLLECTION...... 110 LANCET DEV...... 174 ACTICOAT 7...... 110 ADVATE...... 159 ACCU-CHEK MULTICLIX ACTICOAT ABSORBENT..110 ADVOCATE ARM BPM..... 175 LANCETS...... 174 269 ADVOCATE BLOOD AGAMATRIX JAZZ ALEVICYN GLUCOSE MONITOR...... 175 WIRELESS 2...... 176 ANTIPRURITIC...... 111 ADVOCATE BLOOD AGAMATRIX KEYNOTE ALEVICYN GLUCOSE SYSTEM...... 175 TEST...... 133 ANTIPRURITIC SG...... 111 ADVOCATE DUO...... 175 AGAMATRIX PRESTO...... 176 ALEVICYN DERMAL ADVOCATE INSULIN PEN AGAMATRIX PRESTO SPRAY...... 111 NEEDLES...... 175 PRO METER...... 176 alfuzosin hcl er...... 157 ADVOCATE INSULIN AGAMATRIX PRESTO ALINIA...... 66 SYRINGE...... 175 TEST...... 134 ALIQOPA...... 70 ADVOCATE LANCETS AGAMATRIX ULTRA- aliskiren fumarate...... 63 30G...... 175 THIN LANCETS...... 176 ALIVE PRENATAL...... 226 ADVOCATE LANCING AGGRASTAT...... 159 ALLEVYN AG ADHESIVE 111 DEVICE...... 175 AIMOVIG...... 218 ALLEVYN AG NON- ADVOCATE RAPID-SAFE aimsco twist lancets 32g...... 176 ADHESIVE...... 111 LANCING...... 175 AIMSCO TWIST LANCETS ALLEVYN AG SACRUM 6- ADVOCATE REDI-CODE 33G...... 176 3/4"...... 111 ...... 133, 175 Airavite...... 163 ALLEVYN AG SACRUM ADVOCATE REDI-CODE+175 AIRDUO RESPICLICK 9"X9"...... 111 ADVOCATE REDI-CODE+ 113/14...... 36 ALLEVYN GENTLE...... 111 TALKING...... 175 AIRDUO RESPICLICK allopurinol...... 158 ADVOCATE REDI-CODE+ 232/14...... 36 ALLZITAL...... 25 TEST...... 133 AIRDUO RESPICLICK almond oil (sweet)...... 95 ADVOCATE SAFETY 55/14...... 36 almotriptan malate...... 218 LANCETS...... 175 AJOVY...... 218 ALOCRIL...... 240 ADVOCATE SAFETY AKOVAZ...... 267 alogliptin benzoate...... 50 LANCETS 26G...... 175 ak-poly-bac...... 240 alogliptin-metformin hcl...... 50 ADVOCATE TEST...... 133 AKTEN...... 240 alogliptin-pioglitazone...... 50 adynovate...... 159 AKYNZEO...... 58 ALOMIDE...... 240 ADYPHREN...... 267 ALA SCALP...... 110 ALOPHEN...... 169 ADYPHREN AMP...... 267 ala-cort...... 110 ALORA...... 151 ADYPHREN AMP II...... 266 albendazole...... 34 alosetron hcl...... 153 ADYPHREN II...... 267 ALBUMINEX...... 159 ALPHAGAN P...... 240 ADZENYS ER...... 16 albuterol sulfate...... 37 ALPHANATE/VWF ADZENYS XR-ODT...... 16 albuterol sulfate er...... 36 COMPLEX/HUMAN...... 159 AEMCOLO...... 66 albuterol sulfate hfa...... 37 ALPHANINE SD...... 159 AFINITOR...... 70 alclometasone dipropionate.....110 alprazolam...... 35 AFINITOR DISPERZ...... 70 ALCOH-GLOVE alprazolam er...... 35 Afirmelle...... 96 CONTOURED WIPE...... 176 ALPRAZOLAM INTENSOL 35 AFREZZA...... 50 alcohol pads...... 176 alprazolam xr...... 35 AFSTYLA...... 159 alcohol prep...... 176 ALPROLIX...... 159 AFTERA...... 96 alcohol swabs...... 176 ALREX...... 240 aftertest topical pain relief...... 110 ALCOHOL SWABSTICK....176 ALTABAX...... 111 AGAMATRIX AMP...... 175 alcohol wipes...... 176 Altacaine...... 240 AGAMATRIX AMP TEST..133 alcoh-wipe...... 176 altafluor benox...... 240 AGAMATRIX CONTROL ALCORTIN A...... 110 Altafrin...... 240 LEVEL 2...... 175 ALDACTAZIDE...... 145 Altavera...... 96 AGAMATRIX CONTROL ALDURAZYME...... 146 alternate site lancing device.... 176 LEVEL 4...... 175 ALECENSA...... 70 ALTOPREV...... 61 AGAMATRIX JAZZ TEST.133 alendronate sodium...... 146 ALTRENO...... 111 alevamax...... 110 ALUNBRIG...... 70 270 ALVESCO...... 37 AMRIX...... 235 aripiprazole...... 81 alyacen 1/35...... 96 ANACAINE...... 111 ARISTADA...... 81 alyacen 7/7/7...... 96 ANADROL-50...... 32 ARISTADA INITIO...... 81 Alyq...... 92 anagrelide hcl...... 159 armodafinil...... 16 ALZAIR ALLERGY anastrozole...... 70 ARMOUR THYROID...... 261 NASAL SPRAY...... 238 ANDRODERM...... 32 arnica flower...... 111 Amabelz...... 151 ANDROGEL...... 32 ARNUITY ELLIPTA...... 37 amantadine hcl...... 79 anesthesia s/i-40a...... 156 ARTHROTEC...... 20 ambrisentan...... 92 anesthesia s/i-40h...... 156 ARTISS...... 168 amcinonide...... 111 anesthesia s/i-40s...... 156 ARYMO ER...... 27 AMD FOAM DRESSING... 176 ANGELIQ...... 151 ASACOL HD...... 154 AMELUZ...... 111 ANNOVERA...... 96 ASCENIV...... 247 Amethia...... 96 ANORO ELLIPTA...... 37 Ascomp-Codeine...... 27 Amethia Lo...... 96 ANTARA...... 61 ASCOR...... 267 Amethyst...... 96 anticoagulant cit dext soln a..... 41 Ashlyna...... 96 AMICAR...... 168 anticoagulant sodium citrate.....41 Asilnasalrms...... 143 amiloride hcl...... 145 ANZEMET...... 58 ASMANEX (120 METERED amiloride-hydrochlorothiazide 145 APADAZ...... 27 DOSES)...... 37 aminoacetic acid...... 157 apap-caff-dihydrocodeine...... 27 ASMANEX (14 METERED Aminoamrms...... 239 APEXICON E...... 111 DOSES)...... 37 aminobenzoate potassium...... 267 APIDRA...... 50 ASMANEX (30 METERED aminocaproic acid...... 168 APIDRA SOLOSTAR...... 50 DOSES)...... 37 AMINOPMRMS...... 143 APLENZIN...... 47 ASMANEX (60 METERED AMINOPROTECT...... 239 APLICARE ALCOHOL DOSES)...... 37 Aminoreliefrms...... 239 SWABSTICK...... 176 ASMANEX (7 METERED amiodarone hcl...... 36 APOKYN...... 79 DOSES)...... 37 AMITIZA...... 154 APP SLIM RMS...... 143 ASMANEX HFA...... 37 amitriptyline hcl...... 47 apraclonidine hcl...... 240 ASPARLAS...... 70 AMLODIPINE aprepitant...... 58 aspirin...... 25 BES+SYRSPEND SF...... 91 Apri...... 96 aspirin adult low dose...... 25 amlodipine besy-benazepril hcl..63 APRISO...... 154 aspirin ec low strength...... 25 amlodipine besylate...... 91 APRIZIO PAK...... 111 aspirin low dose...... 25 amlodipine besylate-valsartan...63 APTENSIO XR...... 16 aspirin-dipyridamole er...... 159 amlodipine-atorvastatin...... 93 APTIOM...... 42 ASPIR-LOW...... 25 amlodipine-olmesartan...... 63 APTIVUS...... 84 ASSURE 3 METER...... 176 amlodipine-valsartan-hctz...... 63 AQUACEL AG BURN...... 111 ASSURE 3 TEST...... 134 ammonium lactate...... 111 AQUALANCE LANCETS ASSURE 4 METER...... 176 Amnesteem...... 111 30G...... 176 ASSURE 4 TEST...... 134 amoxapine...... 47 AQUORAL...... 224 assure comfort lancets 28g...... 176 amoxicill-clarithro-lansopraz..262 ARAKODA...... 68 ASSURE ID INSULIN amoxicillin...... 249 ARALAST NP...... 258 SAFETY SYR...... 176 amoxicillin-pot clavulanate.....249 Aranelle...... 96 ASSURE ID SAFETY PEN amoxicillin-pot clavulanate er. 249 ARANESP (ALBUMIN NEEDLES...... 176 AMPHADASE...... 222 FREE)...... 163 ASSURE II...... 134 amphetamine sulfate...... 16 ARAZLO...... 111 ASSURE II CHECK...... 134 amphetamine-dextroamphet er. 16 ARCALYST...... 20 ASSURE LANCETS...... 176 amphetamine- ARCAPTA NEOHALER...... 37 ASSURE PLATINUM...... 134 dextroamphetamine...... 16 Argyle Sterile Saline...... 157 ASSURE PLATINUM ampicillin...... 249 Argyle Sterile Water...... 222 METER...... 176 AMPYRA...... 252 ARIKAYCE...... 19 271 ASSURE PRISM MULTI AUTOLET LITE barium sulfate...... 134 TEST...... 134 CLINISAFE...... 177 BASAGLAR KWIKPEN...... 50 ASSURE PRO BLOOD AUTOLET LITE STARTER base g almond oil (sweet)...... 95 GLUCOSE METER...... 177 PACK...... 177 base x...... 250 ASSURE PRO TEST...... 134 AUTOLET MINI...... 177 BAXDELA...... 153 ASTAGRAF XL...... 222 AUTOLET PLATFORMS... 177 BAYER ASPIRIN EC LOW ASTAMED MYO...... 143 AUTOLET PLUS...... 177 DOSE...... 25 ASTERO...... 111 AUTOSOFT 30 INFUSION BAYER LOW DOSE...... 25 ATABEX EC...... 226 SET...... 177 BD AUTOSHIELD...... 177 ATABEX OB...... 226 AUTOSOFT 90 INFUSION BD AUTOSHIELD DUO.... 177 ATACAND...... 64 SET...... 177 BD INSULIN SYRINGE.....177 ATACAND HCT...... 63 AUTOSOFT XC INFUSION BD INSULIN SYRINGE atazanavir sulfate...... 84 SET...... 177 MICROFINE...... 177 atenolol...... 89 AUVI-Q...... 267 BD INSULIN SYRINGE ATENOLOL+SYRSPEND AVANDIA...... 50 U/F...... 177 SF...... 89 AVENOVA...... 112 BD INSULIN SYRINGE U- atenolol-chlorthalidone...... 64 Aviane...... 97 500...... 178 atomoxetine hcl...... 16 avidoxy...... 259 BD INSULIN SYRINGE atopaderm...... 111 Avita...... 112 ULTRAFINE...... 178 ATOPICLAIR...... 111 AVONEX PEN...... 253 BD LANCET ULTRAFINE atorvastatin calcium...... 61 AVONEX PREFILLED...... 253 30G...... 178 atovaquone...... 67 Ayuna...... 97 BD LANCET ULTRAFINE atovaquone-proguanil hcl...... 69 AZASAN...... 222 33G...... 178 ATRAPRO CP...... 112 AZASITE...... 240 BD LATITUDE DIABETES178 ATRAPRO DERMAL azathioprine...... 222 BD LATITUDE DIABETES SPRAY...... 112 azelaic acid...... 112 SYSTEM...... 178 ATRAPRO HYDROGEL....112 azelastine hcl...... 238, 240 BD LOGIC BLOOD ATRIPLA...... 84 AZELEX...... 112 GLUCOSE MONITOR...... 178 atropine sulfate...... 240 azesco...... 227 BD MICROTAINER ATROVENT HFA...... 37 azithromycin...... 172 LANCETS...... 178 AUBAGIO...... 252 AZOPT...... 240 BD PEN NEEDLE MICRO Aubra...... 96 AZULFIDINE...... 154 U/F...... 178 Aubra Eq...... 96 AZULFIDINE EN-TABS.... 154 BD PEN NEEDLE MINI AUGMENTIN...... 249 Azurette...... 97 U/F...... 178 aurora lancet super thin 30g....177 b-6 folic acid...... 163 BD PEN NEEDLE NANO aurora lancet thin 23g...... 177 bacitracin...... 240 2ND GEN...... 178 aurora pen needles...... 177 bacitracin-polymyxin b...... 240 BD PEN NEEDLE NANO aurora unifine pentips...... 177 bacitra-neomycin-polymyxin- U/F...... 178 Aurovela 1.5/30...... 97 hc...... 240 BD PEN NEEDLE Aurovela 1/20...... 97 baclofen...... 235 ORIGINAL U/F...... 178 Aurovela 24 Fe...... 97 BAFIERTAM...... 253 BD PEN NEEDLE SHORT Aurovela Fe 1.5/30...... 97 BALCOLTRA...... 97 U/F...... 178 Aurovela Fe 1/20...... 97 balsalazide disodium...... 154 BD SAFETYGLIDE AURYXIA...... 154 balsam peru-castor oil...... 112 INSULIN SYRINGE...... 178 AUSTEDO...... 252 BALVERSA...... 70 BD SWABS SINGLE USE AUTO-LANCET...... 177 Balziva...... 97 BUTTERFLY...... 178 AUTO-LANCET MINI...... 177 BANZEL...... 42 BD VEO INSULIN SYR U/F AUTOLET II CLINISAFE.. 177 BAQSIMI ONE PACK...... 50 1/2UNIT...... 178 AUTOLET LANCING BAQSIMI TWO PACK...... 50 BD VEO INSULIN DEVICE...... 177 BARACLUDE...... 84 SYRINGE U/F...... 178 272 beau rx...... 112 bethanechol chloride...... 264 bortezomib...... 71 BECONASE AQ...... 238 BETHKIS...... 19 bosentan...... 93 Bekyree...... 97 BETIMOL...... 241 BOSULIF...... 71 BELBUCA...... 27 BETOPTIC-S...... 241 BOTOX...... 238 BELEODAQ...... 70 BEVESPI AEROSPHERE..... 37 bp vit 3...... 163 belladonna alkaloids-opium.....262 bexarotene...... 70 bp wash...... 113 BELRAPZO...... 70 BEYAZ...... 97 bpco...... 113 BELSOMRA...... 168 bicalutamide...... 71 b-plex...... 227 benazepril hcl...... 64 BIDIL...... 93 b-plex plus...... 227 benazepril-hydrochlorothiazide.64 bi-est 50:50...... 151 BREO ELLIPTA...... 38 BENEFIX...... 159 bi-est 80:20 progesterone...... 151 BREZTRI AEROSPHERE.... 38 BENICAR...... 64 bi-est progest-testosterone...... 151 BRIDION...... 57 BENICAR HCT...... 64 BIEST/PROGESTERONE...151 briellyn...... 97 BENLYSTA...... 222 BIJUVA...... 152 BRILINTA...... 159 bensal hp...... 112 BIKTARVY...... 84 brimonidine tartrate...... 241 BENZACLIN...... 112 bimatoprost...... 241 BRIVIACT...... 42 BENZACLIN WITH PUMP 112 bi-mix...... 93 Bromfed Dm...... 108 benzalkonium chloride...... 84 BINOSTO...... 146 bromfenac sodium (once-daily) BENZEPRO...... 112 biocel...... 227 ...... 241 Benzepro...... 112 BIOFREQUENCY bromocriptine mesylate...... 79 Benzepro Short Contact...... 112 INSOLES...... 178 BROMSITE...... 241 benznidazole...... 34 BIOGUARD GAUZE BROVANA...... 38 BENZODOX...... 259 SPONGES...... 178 BRUKINSA...... 71 benzoin...... 112 BIOGUARD ISLAND BRYHALI...... 113 benzonatate...... 108 DRESSINGS...... 179 budesonide...... 38, 106 benzoyl perox-hydrocortisone. 112 BIOGUARD NON- budesonide er...... 106 benzoyl peroxide...... 112 ADHERENT DRESSING... 179 bullseye mini safety lancets.....179 benzoyl peroxide-erythromycin BIOSCANNER GLUCOSE BULLSEYE SAFETY ...... 112 TEST...... 134 LANCETS...... 179 benztropine mesylate...... 79 bio-statin...... 59 bumetanide...... 145 benzyl alcohol...... 250 BIOTEL CARE BLOOD BUNAVAIL...... 27 benzyl benzoate...... 95 GLUCOSE SYST...... 179 Bupap...... 25 BEPREVE...... 240 bisacodyl...... 170 BUPHENYL...... 146 BERINERT...... 159 bisacodyl ec...... 170 bupivacaine hcl...... 172 BESER...... 112 bisoprolol fumarate...... 89 buprenorphine...... 28 Beser...... 112 bisoprolol-hydrochlorothiazide..64 buprenorphine hcl...... 27 BESIVANCE...... 240 bivalirudin rtu...... 41 buprenorphine hcl-naloxone hcl BESPONSA...... 70 BIVIGAM...... 247 ...... 27, 28 beta 1 kit...... 106 BLENREP...... 71 bupropion hcl...... 47 BETADINE OPHTHALMIC BLEPHAMIDE...... 241 bupropion hcl er (smoking det) PREP...... 240 BLEPHAMIDE S.O.P...... 241 ...... 253 betamethasone combo...... 106 Blisovi 24 Fe...... 97 bupropion hcl er (sr)...... 47 betamethasone dipropionate....113 Blisovi Fe 1.5/30...... 97 bupropion hcl er (xl)...... 47 betamethasone dipropionate Blisovi Fe 1/20...... 97 buspirone hcl...... 35 aug...... 112 blood glucose monitor system..179 butalbital-acetaminophen...... 25 betamethasone valerate...... 113 blood glucose system pak...... 179 butalbital-apap-caff-cod...... 28 BETAPACE...... 89 blood glucose test...... 134 butalbital-apap-caffeine...... 26 BETAPACE AF...... 89 BOCASAL...... 224 butalbital-asa-caff-codeine...... 28 BETASERON...... 253 BONJESTA...... 58 butalbital-aspirin-caffeine...... 26 betaxolol hcl...... 89, 240 boric acid...... 113 butorphanol tartrate...... 28 273 BUTRANS...... 28 CARAFATE...... 262 CARETOUCH SAFETY BYDUREON...... 50 carbamazepine...... 43 LANCETS 26G...... 180 BYDUREON BCISE...... 50 carbamazepine er...... 42 CARETOUCH TEST...... 134 BYETTA 10 MCG PEN...... 50 carbidopa...... 79 CARETOUCH TWIST BYETTA 5 MCG PEN...... 51 carbidopa-levodopa...... 79 LANCETS 28G...... 180 BYSTOLIC...... 89 carbidopa-levodopa er...... 79 CARETOUCH TWIST cabergoline...... 146 carbidopa-levodopa-entacapone 80 LANCETS 30G...... 180 CABLIVI...... 159 carbinoxamine maleate...... 60 CARETOUCH TWIST CABOMETYX...... 71 CARDIOCOM LANCING LANCETS 33G...... 180 cadeau dha...... 227 DEVICE...... 179 CARIMUNE NF...... 247 CADIRAMD...... 113 cardioplegic...... 93 carisoprodol...... 235 CAFERGOT...... 218 CARDIOVID PLUS...... 239 carisoprodol-aspirin-codeine... 235 caffeine citrate...... 17 CARDIZEM...... 91 CARNITOR...... 146 CALCIFOL...... 220 CARDIZEM CD...... 91 CARNITOR SF...... 146 calcipotriene...... 113 CARDIZEM LA...... 91 CAROSPIR...... 145 calcipotriene-betameth diprop.113 CARDURA XL...... 157 carteolol hcl...... 241 calcitonin (salmon)...... 146 CAREFINE PEN NEEDLES Cartia Xt...... 91 Calcitrene...... 113 ...... 179 carvedilol...... 89 calcitriol...... 113, 146 careone advanced lancing dev..179 carvedilol phosphate er...... 89 calcium acetate (phos binder).154 CAREONE BLOOD cascara sagrada...... 170 calcium folinate...... 95 GLUCOSE SYSTEM...... 179 castor oil...... 95 CALDOLOR...... 20 CAREONE BLOOD Cavarest...... 224 CAMBIA...... 219 GLUCOSE TEST...... 134 CAYA...... 180 Camila...... 97 careone insulin syringe...... 179 CAYSTON...... 67 CAMINO PRO careone lancet thin 23g...... 179 Caziant...... 98 COMPLETE/GLYTACTIN.143 careone lancet ultra thin 28g...179 cefaclor...... 94, 95 Camrese...... 97 careone unifine pentips...... 179 cefaclor er...... 94 Camrese Lo...... 97 careone unifine pentips plus.....179 cefadroxil...... 95 candesartan cilexetil...... 64 CARESENS LANCETS...... 179 cefdinir...... 95 candesartan cilexetil-hctz...... 64 CARESENS N GLUCOSE cefixime...... 95 capecitabine...... 71 SYSTEM...... 179 cefpodoxime proxetil...... 95 CAPEX...... 113 CARESENS N GLUCOSE cefprozil...... 95 CAPHOSOL...... 224 TEST...... 134 cefuroxime axetil...... 95 CAPRELSA...... 71 CARESENS N VOICE Celacyn...... 113 capsule 0 clear dr...... 250 SYSTEM...... 179 CELEBREX...... 20 capsule coni-snap #0 clear...... 250 CARETOUCH ALCOHOL celecoxib...... 20 capsule coni-snap #0 purple.... 250 PREP...... 179 CELESTONE SOLUSPAN.. 106 capsule coni-snap #00 white....250 CARETOUCH CONTROL CELLCEPT...... 222 capsule coni-snap #000 clear.. 250 SOL LEVEL 2...... 179 CELLCEPT capsule coni-snap #1 red/blue. 250 CARETOUCH INSULIN INTRAVENOUS...... 222 capsule coni-snap #1 veggie.... 250 SYRINGE...... 179 CELONTIN...... 43 capsule coni-snap #2 white..... 250 CARETOUCH CENFOL...... 163 capsule coni-snap #3 clear...... 250 LANCING/EJECTOR...... 180 CENTANY...... 113 capsule coni-snap #3 yellow....250 CARETOUCH MONITOR cephalexin...... 95 capsule coni-snap #4 white..... 250 SYSTEM...... 180 CEQUA...... 241 capsule ezeefit #0 clear...... 250 CARETOUCH PEN CEQUR SIMPLICITY 2U... 180 capsule ezeefit #00 clear...... 250 NEEDLES...... 180 CERACADE...... 113 captopril...... 64 CARETOUCH SAFETY CERAMAX...... 113 captopril-hydrochlorothiazide...64 LANCETS...... 180 CERDELGA...... 163 CARAC...... 113 CEREZYME...... 163 274 cervical specimen collection.... 134 CINRYZE...... 160 CLEVER CHOICE CERVIDIL...... 247 CINVANTI...... 58 LANCETS 28G...... 180 CETACAINE...... 113 CIPRO...... 153 CLEVER CHOICE MICRO cetirizine hcl...... 60 CIPRO HC...... 246 SYSTEM...... 180 CETROTIDE...... 147 CIPRODEX...... 246 CLEVER CHOICE MICRO cevimeline hcl...... 224 ciprofloxacin hcl...... 153, 241, 246 TEST...... 134 CHANTIX...... 253 ciprofloxacin-dexamethasone..246 CLEVER CHOICE MINI CHANTIX CONTINUING ciprofloxacin-fluocinolone pf.. 247 SYSTEM...... 181 MONTH PAK...... 253 citalopram hydrobromide...... 47 CLEVER CHOICE NO CHANTIX STARTING CITRANATAL 90 DHA...... 227 CODING...... 134 MONTH PAK...... 253 CITRANATAL ASSURE.... 227 CLEVER CHOICE TALK Chateal...... 98 CITRANATAL B-CALM.... 227 SYSTEM...... 134, 181 Chateal Eq...... 98 CITRANATAL BLOOM..... 227 CLICKFINE PEN CHEMET...... 57 CITRANATAL BLOOM NEEDLES...... 181 CHEMSTRIP K...... 134 DHA...... 227 clickfine pen needles...... 181 CHEMSTRIP UGK...... 134 CITRANATAL DHA...... 227 CLIMARA PRO...... 152 CHENODAL...... 154 CITRANATAL HARMONY Clindacin Etz...... 114 cherry...... 250 ...... 227 Clindacin-P...... 114 childrens aspirin...... 26 CITRANATAL MEDLEY...227 clindamycin hcl...... 67 childrens aspirin low strength....26 CITRANATAL RX...... 227 clindamycin palmitate hcl...... 67 chlordiazepoxide hcl...... 35 Claravis...... 114 clindamycin phos-benzoyl chlordiazepoxide-amitriptyline253 CLARINEX-D 12 HOUR.... 109 perox...... 114 chlordiazepoxide-clidinium..... 262 clarithromycin...... 172 clindamycin phosphate.... 114, 265 chlorhexidine gluconate.....84, 224 clarithromycin er...... 172 clindamycin-tretinoin...... 114 chloroquine phosphate...... 69 CLEANLET LANCETS 28G CLINDESSE...... 265 chlorpromazine hcl...... 81 ...... 180 clinimix e/dextrose (8/10)...... 239 chlorthalidone...... 145 clemastine fumarate...... 60 clinimix e/dextrose (8/14)...... 239 chlorzoxazone...... 235 CLENPIQ...... 170 clinimix/dextrose (6/5)...... 239 CHOICE DM DIABETES CLEOCIN...... 265 clinimix/dextrose (8/10)...... 239 RISK TEST...... 180 CLEVER CHEK AUTO- clinimix/dextrose (8/14)...... 239 CHOLBAM...... 154 CODE...... 180 CLINOLIPID...... 239 cholestyramine...... 61 CLEVER CHEK AUTO- Clinpro 5000...... 224 cholestyramine light...... 61 CODE SYSTEM...... 180 clobazam...... 43 CIALIS...... 93 CLEVER CHEK AUTO- clobetasol prop emollient base.114 cicatrace pad...... 180 CODE TEST...... 134 clobetasol propionate...... 114 Ciclodan...... 114 CLEVER CHEK AUTO- clobetasol propionate e...... 114 ciclopirox...... 114 CODE VOICE...... 134, 180 clobetasol propionate emulsion114 ciclopirox olamine...... 114 CLEVER CHEK LANCETS 180 CLOBEX SPRAY...... 114 CIFEREX...... 163 CLEVER CHEK SYSTEM.. 180 Clodan...... 114 cifrazol...... 163 CLEVER CHEK TEST...... 134 CLODERM...... 114 cilostazol...... 159 CLEVER CHOICE AUTO- clomiphene citrate...... 147 CILOXAN...... 241 CODE SYSTEM...... 180 clomipramine hcl...... 47 CIMDUO...... 85 CLEVER CHOICE AUTO- clonazepam...... 43 cimetidine...... 262 CODE TEST...... 134 clonidine...... 64 cimetidine hcl...... 262 CLEVER CHOICE clonidine hcl...... 64 CIMZIA...... 154 COMFORT EZ...... 180 clonidine hcl er...... 17 CIMZIA PREFILLED...... 154 CLEVER CHOICE clopidogrel bisulfate...... 160 CIMZIA STARTER KIT..... 154 LANCETS 21G...... 180 clorazepate dipotassium...... 35 cinacalcet hcl...... 147 CLEVER CHOICE clotrimazole...... 115, 224 CINQAIR...... 38 LANCETS 23G...... 180 clotrimazole-betamethasone....115 275 clozapine...... 81 CO-NATAL FA...... 227 COTEMPLA XR-ODT...... 17 CLOZARIL...... 81 CONCEPT DHA...... 227 cottonseed oil...... 95 c-nate dha...... 227 CONCEPT OB...... 227 CREON...... 145 COAGADEX...... 160 CONCERTA...... 17 CRESEMBA...... 59 COAGUCHEK LANCETS..181 CONDYLOX...... 115 CRESTOR...... 61 coal tar...... 115 CONSENSI...... 91 CRINONE...... 265 COARTEM...... 69 constulose...... 170 CRIXIVAN...... 85 cocoa butter...... 250 CONTOUR MONITOR...... 181 cromolyn sodium...... 38, 154, 241 coconut oil...... 95 CONTOUR NEXT EZ...... 182 CROTAN...... 115 cod liver oil...... 227 CONTOUR NEXT LINK.... 182 Cryselle-28...... 98 codeine sulfate...... 28 CONTOUR NEXT CURITY ALCOHOL PREPS COLAZAL...... 154 MONITOR...... 182 ...... 182 colchicine...... 158 CONTOUR NEXT ONE...... 182 CURITY ALCOHOL colchicine-probenecid...... 158 CONTOUR NEXT TEST.....135 SWABS...... 182 COLCRYS...... 158 CONTOUR TEST...... 135 CURITY AMD colesevelam hcl...... 61 CONTRAST ALLERGY ANTIMICROBIAL SPNGE 182 colestipol hcl...... 61 PREMED PACK...... 106 CURITY AMD COLLATYL...... 115 CONTRAVE...... 17 ANTIMICROBIAL STRIP.. 182 COMBIGAN...... 241 CONVENIENCE PAK...... 253 CURITY HYPERTONIC COMBIPATCH...... 152 CONZIP...... 28 NACL STRIP...... 115 COMBIVENT RESPIMAT....38 COOL BLOOD GLUCOSE CURITY IODOFORM COMETRIQ (100 MG TEST STRIPS...... 135 PACKING STRIP...... 182 DAILY DOSE)...... 71 COOL MONITOR...... 182 CURITY NACL DRESSING COMETRIQ (140 MG COOL MONITOR KIT...... 182 6"X6-3/4"...... 116 DAILY DOSE)...... 71 COPASIL...... 115 Curity Sterile Saline...... 157 COMETRIQ (60 MG DAILY COPAXONE...... 253 CURITY WOUND DOSE)...... 71 COPIKTRA...... 71 CLOSURE 1/2"X4"...... 182 COMFORT ASSIST CORDRAN...... 115 CURITY WOUND INSULIN SYRINGE...... 181 COREG CR...... 89 CLOSURE 1/4"X1.5"...... 182 comfort assured lancets 28g.... 181 Coremino...... 259 CURITY WOUND comfort assured lancets 33g.... 181 CORLANOR...... 93 CLOSURE 1/4"X3"...... 182 COMFORT EZ INSULIN corn (syrup)...... 250 CURITY WOUND SYRINGE...... 181 correct...... 170 CLOSURE 1/4"X4"...... 182 COMFORT EZ MICRO CORRECTOL...... 170 CURITY WOUND PEN NEEDLES...... 181 CORTIFOAM...... 33 CLOSURE 1/8"X3"...... 182 COMFORT EZ PEN cortisone acetate...... 106 CUROSURF...... 258 NEEDLES...... 181 CORTISPORIN...... 115 CUTAQUIG...... 247 COMFORT EZ SHORT CORTISPORIN-TC...... 247 CUTIVATE...... 116 PEN NEEDLES...... 181 CORVITA...... 227 CUVITRU...... 247 comfort lancets...... 181 Corvita 150...... 163 CUVPOSA...... 262 COMFORT SHORT INF CORVITE 150...... 163 CVS ADVANCED SET 23"/13MM...... 181 corvite fe...... 163 GLUCOSE TEST...... 135 COMFORT SHORT INF COSENTYX...... 115 cvs aspirin low dose...... 26 SET 31"/13MM...... 181 COSENTYX (300 MG cvs aspirin low strength...... 26 COMFORT SHORT INF DOSE)...... 115 CVS BLOOD GLUCOSE SET 43"/13MM...... 181 COSENTYX METER...... 182 COMPLERA...... 85 SENSOREADY (300 MG)... 115 cvs c-lax laxative...... 170 complete natal dha...... 227 COSENTYX cvs folic acid...... 163 completenate...... 227 SENSOREADY PEN...... 115 cvs glucose meter test strips.... 135 Compro...... 81 COTELLIC...... 71 CVS KETONE CARE...... 135 276 cvs lancets 21g...... 182 DAURISMO...... 71 DERMACINRX cvs lancets micro thin 33g...... 182 DAYPRO...... 20 THERAZOLE PAK...... 116 cvs lancets original...... 182 Daysee...... 98 DERMACINRX cvs lancets thin 26g...... 182 DAYTRANA...... 17 TICANASE PAK...... 238 cvs lancets ultra thin 30g...... 182 D-CARE BLOOD DERMACINRX ZRM...... 116 cvs lancets ultra-thin 30g...... 182 GLUCOSE...... 135 DERMULCERA...... 116 cvs lancing device...... 182 D-CARE GLUCOMETER.. 183 DESCOVY...... 85 cvs nicotine...... 253 DDAVP RHINAL TUBE.....147 DESFERAL...... 57 cvs nicotine polacrilex...... 253 Deblitane...... 98 desflurane...... 156 cvs prenatal gummy...... 227 Decadron...... 106 desipramine hcl...... 47 cvs prep...... 182 deferasirox...... 57 desloratadine...... 60 cvs ultra thin lancets...... 182 deferoxamine mesylate...... 57 desmopressin ace spray refrig. 147 cyanocobalamin...... 163 DEFITELIO...... 160 desmopressin acetate...... 147 Cyclafem 1/35...... 98 DELESTROGEN...... 152 desmopressin acetate spray..... 147 Cyclafem 7/7/7...... 98 DELSTRIGO...... 85 desogestrel-ethinyl estradiol...... 98 cyclo/gaba 10/300...... 236 DELTEC COZMO CLEO DESONATE...... 116 cyclobenzaprine hcl...... 236 SET 42" 6MM...... 183 desonide...... 116 cyclobenzaprine hcl er...... 236 DELTEC COZMO CLEO desoximetasone...... 116 CYCLOMYDRIL...... 241 SET 42" 9MM...... 183 desvenlafaxine er...... 47 cyclopentolate hcl...... 241 Delyla...... 98 desvenlafaxine succinate er...... 47 CYCLOPHENE RAPIDPAQ DELZICOL...... 154 DETROL LA...... 264 ...... 236 demeclocycline hcl...... 259 dexamethasone...... 106, 107 cyclophosphamide...... 71 DEMSER...... 64 dexamethasone (la)...... 106 cycloserine...... 69 DENAVIR...... 116 DEXAMETHASONE CYCLOSET...... 51 Denta 5000 Plus...... 225 INTENSOL...... 106 cyclosporine...... 223 Dentagel...... 225 dexamethasone sodium CYCLOSPORINE IN DEPEN TITRATABS...... 223 phosphate...... 241 KLARITY...... 241 DEPO-ESTRADIOL...... 152 dexchlorpheniramine maleate... 60 cyclosporine modified...... 222 DEPO-SUBQ PROVERA DEXCOM G4 PLAT PED CYMBALTA...... 47 104...... 98 RCV/SHARE...... 183 cyproheptadine hcl...... 60 DEPO-TESTOSTERONE...... 32 DEXCOM G4 PLAT PED CYRAMZA...... 71 dermacinrx analgesic RECEIVER...... 183 Cyred...... 98 combopak...... 20 DEXCOM G4 PLATINUM Cyred Eq...... 98 DERMACINRX AZENASE RCV/SHARE...... 183 CYSTAGON...... 157 PAK...... 238 DEXCOM G4 PLATINUM CYSTOGRAFIN...... 135 DERMACINRX RECEIVER...... 183 CYSTOGRAFIN-DILUTE..135 CLORHEXACIN...... 116 DEXCOM G4 PLATINUM CYSVIEW...... 135 DERMACINRX TRANSMITTER...... 183 CYTOMEL...... 261 DUOPATCH DEXCOM G4 SENSOR...... 183 cytra k crystals...... 157 PHARMAPAK...... 116 DEXCOM G5 MOB/G4 dalfampridine er...... 253 DERMACINRX PLAT SENSOR...... 183 DALIRESP...... 38 LEXITRAL PHARMAPAK 116 DEXCOM G5 MOBILE danazol...... 32 DERMACINRX RECEIVER...... 183 dantrolene sodium...... 236 NEUROTRAL DEXCOM G5 MOBILE dapsone...... 67, 116 PHARMAPAK...... 116 TRANSMITTER...... 183 DARAPRIM...... 69 DERMACINRX PHN...... 116 DEXCOM G5 RECEIVER darifenacin hydrobromide er... 264 dermacinrx surgical combopak116 KIT...... 183 DARZALEX FASPRO...... 71 DERMACINRX DEXCOM G6 RECEIVER.. 183 Dasetta 1/35...... 98 SURGICAL PHARMAPAK116 DEXCOM G6 SENSOR...... 183 Dasetta 7/7/7...... 98 277 DEXCOM G6 diclovix...... 117 doxazosin mesylate...... 64 TRANSMITTER...... 183 dicloxacillin sodium...... 249 doxepin hcl...... 47, 117, 168 DEXERYL...... 117 diclozor...... 117 doxercalciferol...... 147 Dexifol...... 228 dicyclomine hcl...... 262 doxycycline...... 117 DEXILANT...... 262 didanosine...... 85 doxycycline hyclate...... 259, 260 dexmethylphenidate hcl...... 17 DIFFERIN...... 117 doxycycline monohydrate...... 260 dexmethylphenidate hcl er...... 17 DIFICID...... 172 doxylamine-pyridoxine...... 59 DEXONTO 0.4%...... 107 DIFIL-G FORTE...... 38 DRCAPS SIZE 0...... 250 DEXTENZA...... 241 diflorasone diacetate...... 117 DRCAPS SIZE 00...... 250 dextroamphetamine sulfate...... 17 diflunisal...... 26 DRCAPS SIZE 1...... 250 dextroamphetamine sulfate er...17 Digitek...... 92 dronabinol...... 59 DEXYCU...... 241 Digox...... 92 DROPLET INSULIN dfs dr/ms/menth/cap pak...... 20 digoxin...... 92 SYRINGE...... 184 dfs/ms/menth/cap pak...... 117 dihydroergotamine mesylate... 219 DROPLET LANCETS DIAB...... 117 DILANTIN...... 43 ULTRA THIN 30G...... 184 DIAB F.D.G. FREEZE- DILATRATE-SR...... 34 DROPLET LANCING DRIED...... 117 DILAUDID...... 28 DEVICE...... 184 DIACOMIT...... 43 diltiazem hcl...... 91 DROPLET MICRON...... 184 DIASTAT ACUDIAL...... 43 diltiazem hcl er...... 91 DROPLET PEN NEEDLES 184 DIASTAT PEDIATRIC...... 43 diltiazem hcl er beads...... 91 dropsafe safety pen needles..... 184 DIASTIX...... 135 diltiazem hcl er coated beads.... 91 drospiren-eth estrad-levomefol..98 DIATHRIVE BLOOD dilt-xr...... 91 drospirenone-ethinyl estradiol...98 GLUCOSE METER...... 183 dimentho...... 117 DROXIA...... 164 DIATHRIVE BLOOD DIOVAN...... 64 drug mart lancets thin 26g...... 184 GLUCOSE TEST...... 135 DIOVAN HCT...... 64 DRUG MART ON-THE-GO DIATHRIVE GLUCOSE DIPENTUM...... 154 LANCET 30G...... 184 TEST...... 135 diphen...... 60 drug mart unifine pentips...... 184 DIATHRIVE LANCET diphenhydramine hcl...... 60 drug mart unifine pentips plus. 184 ULTRA THIN 30...... 183 diphenoxylate-atropine...... 57 DRYSOL...... 117 DIATHRIVE LANCETS..... 183 DIPROLENE AF...... 117 DSUVIA...... 28 DIATHRIVE LANCING dipyridamole...... 160 DUAVEE...... 152 DEVICE...... 183 disopyramide phosphate...... 36 ducodyl...... 170 DIATHRIVE PEN NEEDLE disulfiram...... 253 DUET DHA 400...... 228 ...... 183 DIURIL...... 145 DUET DHA BALANCED...228 DIATHRIVE+ GLUCOSE divalproex sodium...... 43 DUEXIS...... 20 MONITOR...... 184 divalproex sodium er...... 43 DULERA...... 38 DIATHRIVE+ GLUCOSE DIVIGEL...... 152 duloxetine hcl...... 47 TEST...... 135 DMT SUIK...... 107 DUOBRII...... 117 diatrue plus blood glucose...... 184 dofetilide...... 36 DUO-CARE TEST...... 135 diatrue plus test...... 135 DOLOPHINE...... 28 DUOPA...... 80 diazepam...... 35, 43 donepezil hcl...... 253 DUPIXENT...... 117 DICLEGIS...... 58 DOPTELET...... 163 durachol...... 164 diclofenac epolamine...... 117 DORYX...... 259 DURAGESIC-100...... 28 diclofenac potassium...... 20 DORYX MPC...... 259 DURAGESIC-12...... 28 diclofenac sodium...... 20, 117, 241 dorzolamide hcl...... 241 DURAGESIC-25...... 28 diclofenac sodium er...... 20 dorzolamide hcl-timolol mal....241 DURAGESIC-50...... 28 diclofenac-misoprostol...... 20 dorzolamide hcl-timolol mal pf241 DURAGESIC-75...... 28 DICLOFONO...... 117 Dotti...... 152 DUREZOL...... 242 diclopr...... 117 double pm...... 242 DUROLANE...... 236 diclosaicin...... 117 DOVATO...... 85 dutasteride...... 157 278 dutasteride-tamsulosin hcl...... 157 EASY TOUCH SAFETY ELEMENT AUTOCODE DUTOPROL...... 64 PEN NEEDLES...... 185 SYSTEM...... 186 DXEVO 11-DAY...... 107 EASY TOUCH element compact glucose d-xylose...... 135 SHEATHLOCK SYRINGE.185 system...... 186 DYANAVEL XR...... 17 EASY TOUCH TEST...... 135 element compact test...... 136 DYMISTA...... 238 easy trak blood glucose system185 element compact v glucose sys.186 DYRENIUM...... 145 easy trak blood glucose test.... 135 ELEMENT PLUS...... 186 DYSPORT...... 239 easy trak ii blood glucose sys.. 185 ELEMENT TEST...... 136 E.E.S. 400...... 172 easy trak ii glucose test...... 135 ELESTRIN...... 152 E.E.S. GRANULES...... 172 EASYGEL...... 225 ELETONE...... 118 easy comfort alcohol pads...... 184 EASYGLUCO...... 135, 185 eletriptan hydrobromide...... 219 easy comfort insulin syringe....184 EASYGLUCO PLUS...... 135 ELFOLATE PLUS...... 143 easy comfort lancets...... 184 EASYMAX 15 LEVEL 2-3 ELIDEL...... 118 easy comfort lancets twist top. 184 CONTROL...... 186 ELIGARD...... 71 easy comfort pen needles...... 184 EASYMAX 15 TEST...... 135 Elinest...... 99 easy glide pen needles...... 184 EASYMAX CONTROL ELIQUIS...... 41 easy mini eject lancing device..184 NORMAL/HIGH...... 186 ELIQUIS DVT/PE easy mini lancing device...... 184 EASYMAX NG BLOOD STARTER PACK...... 41 easy plus ii glucose system...... 184 GLUCOSE...... 186 ELITE-OB...... 228 easy plus ii glucose test...... 135 EASYMAX TEST...... 136 ELIXOPHYLLIN...... 38 EASY STEP GLUCOSE EASYMAX V BLOOD ELLA...... 99 MONITOR...... 185 GLUCOSE...... 186 ELLZIA PAK...... 118 EASY STEP TEST...... 135 EASYPRO BLOOD ELMIRON...... 157 easy talk blood glucose system 185 GLUCOSE MONITOR...... 186 ELOCTATE...... 160 easy talk blood glucose test.....135 EASYPRO BLOOD Eluryng...... 99 EASY TOUCH ALCOHOL GLUCOSE TEST...... 136 EMBRACE BLOOD PREP MEDIUM...... 185 EASYPRO PLUS...... 136, 186 GLUCOSE MONITOR...... 186 EASY TOUCH FLIPLOCK econazole nitrate...... 117 EMBRACE BLOOD INSULIN SY...... 185 ECONTRA EZ...... 98 GLUCOSE TEST...... 136 EASY TOUCH GLUCOSE ECONTRA ONE-STEP...... 98 EMBRACE EVO BLOOD SYSTEM...... 185 ECOTRIN LOW GLUCOSE TEST...... 136 EASY TOUCH INSULIN STRENGTH...... 26 EMBRACE EVO GLUCOSE SAFETY SYR...... 185 ECOZA...... 117 MONITORING...... 186 EASY TOUCH INSULIN EC-RX DHEA...... 19 EMBRACE LANCETS SYRINGE...... 185 ec-rx estradiol...... 152 ULTRA THIN 30G...... 186 EASY TOUCH LANCETS ec-rx progesterone...... 252 EMBRACE PRO GLUCOSE 21G...... 185 ec-rx testosterone...... 32 METER...... 186 EASY TOUCH LANCETS EDARBI...... 64 EMBRACE PRO GLUCOSE 23G...... 185 EDARBYCLOR...... 64 TEST...... 136 EASY TOUCH LANCETS EDLUAR...... 169 EMBRACE TALK BLOOD 28G...... 185 ed-spaz...... 262 GLUCOSE...... 186 EASY TOUCH LANCETS EDURANT...... 85 EMBRACE TALK 30G...... 185 efavirenz...... 85 GLUCOSE TEST...... 136 EASY TOUCH LANCETS EFFER-K...... 220 EMBRACE TALK 32G...... 185 Effer-K...... 220 MONITORING SYSTEM... 186 EASY TOUCH LANCING EFFEXOR XR...... 48 EMCYT...... 72 DEVICE...... 185 EGRIFTA SV...... 147 EMEND...... 59 EASY TOUCH PEN ELAPRASE...... 147 EMEND TRI-PACK...... 59 NEEDLES...... 185 ELCYS...... 239 EMFLAZA...... 107 ELELYSO...... 164 EMGALITY...... 219 279 EMGALITY (300 MG EPIDUO FORTE...... 118 ERYTHROCIN STEARATE DOSE)...... 219 EPIFOAM...... 118 ...... 172 Emoquette...... 99 epinastine hcl...... 242 erythromycin...... 118, 173, 242 empty capsule size 0 white/opa 250 epinephrine...... 267 erythromycin base...... 172 empty capsule size 00 clear..... 250 epinephrine professional...... 267 erythromycin ethylsuccinate....173 empty capsule size 1 clear...... 250 EPINEPHRINESNAP-EMS 267 ESBRIET...... 258 empty capsule size 1 veg clear. 250 EPINEPHRINESNAP-V...... 267 escitalopram oxalate...... 48 empty capsule size 2 clear...... 250 EPISNAP...... 267 Esgic...... 26 empty capsule size 3 clear...... 250 Epitol...... 43 ESGIC...... 26 empty capsule size 4 clear...... 250 EPIVIR HBV...... 85 ESKATA...... 118 empty capsule size 5 clear...... 250 eplerenone...... 65 ESOMEP-EZS...... 262 empty capsule size 7 clear...... 250 EPOGEN...... 164 esomeprazole magnesium...... 262 EMSAM...... 48 epoprostenol sodium...... 93 essentra wipes 9x9"...... 118 EMTRIVA...... 85 eq blood glucose test...... 136 Estarylla...... 99 EMULSION SB...... 118 eq childrens aspirin...... 26 estazolam...... 169 EMVERM...... 34 eq famotidine max st...... 262 estradiol...... 152, 265 ENABLEX...... 264 eq nicotine...... 253, 254 estradiol valerate...... 152 enalapril maleate...... 64 eq nicotine polacrilex...... 253 estradiol-norethindrone acet... 152 enalapril-hydrochlorothiazide... 64 eq nicotine step 3...... 253 ESTRING...... 266 ENBRACE HR...... 228 eq womens laxative...... 170 estriol-progesterone micro...... 152 ENBREL...... 20 eql alcohol swabs...... 186 ESTROGEL...... 152 ENBREL MINI...... 20 eql aspirin low dose...... 26 eszopiclone...... 169 ENBREL SURECLICK...... 20 eql color lancets 21g...... 186 ethacrynic acid...... 145 ENCARE...... 265 eql color lancets micro 33g...... 187 ethambutol hcl...... 69 Endocet...... 28 eql gentle laxative...... 170 ethosuximide...... 43 ENDOMETRIN...... 265 eql insulin syringe...... 187 ethynodiol diac-eth estradiol..... 99 ENLITE GLUCOSE eql laxative...... 170 etodolac...... 21 SENSOR...... 186 eql nicotine polacrilex...... 254 etodolac er...... 21 ENLITE SERTER...... 186 eql super thin lancets 30g...... 187 etonogestrel-ethinyl estradiol....99 enovarx-diclofenac sodium...... 118 eql thin lancets 26g...... 187 etoposide...... 72 enoxaparin sodium...... 41 equapax/atorvastatin/coq10...... 61 EUCRISA...... 118 Enpresse-28...... 99 equapax/ibuprofen/minrex...... 20 EUFLEXXA...... 236 Enskyce...... 99 EQUETRO...... 81 Euthyrox...... 261 ENSPRYNG...... 223 ergocal...... 267 EVAMIST...... 152 ENSTILAR...... 118 ergocalciferol...... 267 EVEKEO...... 17 entacapone...... 80 ergoloid mesylates...... 254 EVEKEO ODT...... 17 entecavir...... 85 ERGOMAR...... 219 EVENCARE + BLOOD ENTERAGAM...... 143 ergotamine-caffeine...... 219 GLUCOSE TEST...... 136 ENTEREG...... 154 ERIVEDGE...... 72 EVENCARE BLOOD ENTRESTO...... 93 ERLEADA...... 72 GLUCOSE TEST...... 136 ENTTY SPRAY...... 118 erlotinib hcl...... 72 EVENCARE G2 MONITOR ENTYVIO...... 154 EROS-CTD...... 187 ...... 187 enulose...... 154 Errin...... 99 EVENCARE G2 TEST...... 136 ENVARSUS XR...... 223 ERTACZO...... 118 EVENCARE G3 MONITOR enzadyne...... 145 ERWINAZE...... 72 ...... 187 EPANED...... 65 ery...... 118 EVENCARE G3 TEST...... 136 EPCLUSA...... 85 ERYPED 200...... 172 EVENCARE GLUCOSE EPICERAM...... 118 ERYPED 400...... 172 MONITORING...... 187 EPICYN...... 118 Ery-Tab...... 172 EVENCARE MINI EPIDIOLEX...... 43 GLUCOSE TEST...... 136 280 EVENCARE MINI ezetimibe...... 61 FERRIPROX...... 57, 58 MONITOR...... 187 ezetimibe-simvastatin...... 61 FERRIPROX TWICE-A- EVENCARE PROVIEW E-Z-HD...... 136 DAY...... 58 GLUCOSE TEST...... 136 EZ-LETS LANCETS 21G.... 188 Ferrocite Plus...... 164 EVENITY...... 147 EZ-LETS LANCETS 26G.... 188 FERRO-PLEX EVERSENSE EZ-LETS LANCETS 28G.... 188 HEMATINIC...... 164 SENSOR/HOLDER...... 187 EZ-LETS LANCETS 30G.... 188 FERROTRIN...... 164 EVERSENSE SMART E-Z-PAQUE...... 137 FETROJA...... 95 TRANSMITTER...... 187 FA-8...... 164 FETZIMA...... 48 EVOLUTION AUTOCODE fabb...... 164 FETZIMA TITRATION...... 48 ...... 136, 187 FABIOR...... 118 FEXMID...... 236 EVOMELA...... 72 FABRAZYME...... 147 FIASP...... 51 EVOTAZ...... 85 Falmina...... 99 FIASP FLEXTOUCH...... 51 EVRYSDI...... 239 famciclovir...... 85 FIASP PENFILL...... 51 EXACTECH R-S-G TEST... 136 famotidine...... 262 FIBRICOR...... 62 EXACTECH TEST...... 136 FANAPT...... 81 FIFTY50 GLUCOSE EXCILON AMD DRAIN FANAPT TITRATION METER 2.0...... 188 SPONGES...... 187 PACK...... 82 FIFTY50 GLUCOSE TEST EXEL COMFORT POINT FANATREX FUSEPAQ...... 43 2.0...... 137 INSULIN SYR...... 187 FARXIGA...... 51 FIFTY50 PEN NEEDLES... 188 EXEL COMFORT POINT FARYDAK...... 72 FIFTY50 SUPERIOR PEN NEEDLE...... 187 FASENRA...... 38 COMFORT SYR...... 188 EXELDERM...... 118 FASENRA PEN...... 38 FIFTY50 UNILET exemestane...... 72 favipiravir...... 85 LANCETS 33G...... 188 EXFORGE...... 65 fa-vitamin b-6-vitamin b-12.....164 FINACEA...... 118 EXFORGE HCT...... 65 Fayosim...... 99 finasteride...... 157 EXJADE...... 57 FC FEMALE CONDOM..... 188 FINGERSTIX LANCETS... 188 EXODERM...... 118 FC2 FEMALE CONDOM... 188 FINTEPLA...... 43 EXTAVIA...... 254 febuxostat...... 158 FIORICET...... 26 EXTINA...... 118 FEENAMINT...... 170 FIORINAL...... 26 EYLEA...... 242 FEIBA...... 160 FIORINAL/CODEINE #3.....29 E-Z JECT LANCET felbamate...... 43 FIRAZYR...... 160 MICRO-THIN 33G...... 187 felodipine er...... 91 FIRDAPSE...... 69 E-Z JECT LANCET SUPER FEMCAP...... 188 FIRMAGON...... 72 THIN 30G...... 187 FEMRING...... 266 FIRMAGON (240 MG E-Z JECT LANCETS...... 187 Femynor...... 99 DOSE)...... 72 E-Z JECT LANCETS 21G....187 fenofibrate...... 62 FIRST - METOPROLOL...... 89 E-Z JECT LANCETS THIN fenofibrate micronized...... 62 FIRST-ATENOLOL...... 89 26G...... 187 fenofibric acid...... 62 FIRST-BACLOFEN...... 236 EZ SMART BLOOD FENOGLIDE...... 62 FIRST-METRONIDAZOLE.67 GLUCOSE LANCETS...... 187 fenoprofen calcium...... 21 FIRVANQ...... 67 EZ SMART BLOOD FENORTHO...... 21 Flac...... 247 GLUCOSE TEST...... 136 FENSOLVI (6 MONTH)...... 147 FLAREX...... 242 EZ SMART MONITORING fentanyl...... 29 FLAVOR BLEND...... 251 SYSTEM...... 188 fentanyl citrate...... 28, 29 flavor plus...... 251 EZ SMART PLUS FENTORA...... 29 flavor sweet...... 251 GLUCOSE TEST...... 136 FERIVA 21/7...... 164 flavor sweet-sf...... 251 EZ SMART PLUS ferocon...... 164 flavoxate hcl...... 264 MONITORING SYS...... 188 ferotrinsic...... 164 FLEBOGAMMA DIF...... 248 EZALLOR SPRINKLE...... 61 ferraplus 90...... 164 flecainide acetate...... 36 281 flexin...... 119 FOLBEE PLUS CZ...... 228 FORA GTEL BLOOD FLOLAN...... 93 FOLGARD OS...... 228 GLUCOSE TEST...... 137 flolipid...... 62 folic acid...... 164 FORA GTEL BLOOD FLORIVA...... 220, 228 folic-k...... 228 KETONE TEST...... 137 FLORIVA PLUS...... 228 FOLI-D...... 164 FORA LANCETS...... 189 FLOVENT DISKUS...... 38 folite...... 164 FORA LANCING DEVICE 189 FLOVENT HFA...... 38 FOLIVANE-F...... 164 FORA PREMIUM V10 BLE fluconazole...... 59, 60 FOLIVANE-OB...... 228 SYSTEM...... 189 flucytosine...... 60 FOLIVANE-PLUS...... 164 FORA TEST N' GO fludrocortisone acetate...... 107 FOLLISTIM AQ...... 147 MONITOR...... 189 flunisolide...... 238 folplex 2.2...... 164 FORA TN'G VOICE...... 189 fluocinolone acetonide..... 119, 247 foltrin...... 164 FORA TN'G/TN'G VOICE.. 137 fluocinolone acetonide body.... 119 Folvite-D...... 165 FORA V10 BLOOD fluocinolone acetonide scalp....119 fondaparinux sodium...... 41 GLUCOSE SYSTEM...... 189 fluocinonide...... 119 FORA 6 CONNECT...... 137 FORA V10 BLOOD fluocinonide emulsified base....119 FORA BLOOD GLUCOSE GLUCOSE TEST...... 137 FLUORABON...... 220 TEST...... 137 FORA V10/V12/D10/D20 fluorescein-benoxinate...... 242 FORA D10 2-IN-1 TEST...... 189 Fluoridex Daily Renewal...... 225 MONITOR...... 188 FORA V12 BLOOD Fluoridex Enhanced FORA D15G 2-IN-1 GLUCOSE SYSTEM...... 189 Whitening...... 225 MONITOR...... 188 FORA V12 BLOOD Fluoridex Sensitivity Relief....225 FORA D15G BLOOD GLUCOSE TEST...... 137 Fluor-I-Strips A.T...... 242 GLUCOSE TEST...... 137 FORA V20 BLOOD fluoritab...... 220 FORA D20 2-IN-1 GLUCOSE SYSTEM...... 189 fluorometholone...... 242 MONITOR...... 188 FORA V20 BLOOD FLUOROPLEX...... 119 FORA D20 BLOOD GLUCOSE TEST...... 137 fluorouracil...... 119 GLUCOSE TEST...... 137 FORA V30A BLOOD fluovix...... 119 FORA D40 GLUCOSE SYSTEM...... 189 fluoxetine hcl...... 48 GLUCOSE/PRESSURE...... 188 FORA V30A BLOOD fluoxetine hcl (pmdd)...... 254 FORA D40/G31 BLOOD GLUCOSE TEST...... 137 fluphenazine decanoate...... 82 GLUCOSE...... 137 FORACARE GD40 fluphenazine hcl...... 82 FORA D40G MONITOR...... 189 FLURA-DROPS...... 220 GLUCOSE/PRESSURE...... 188 FORACARE GD40 TEST....137 flurandrenolide...... 119 FORA G20 BLOOD FORACARE PREMIUM FLURA-SAFE...... 242 GLUCOSE SYSTEM...... 188 V10...... 189 flurazepam hcl...... 169 FORA G20 BLOOD FORACARE PREMIUM flurbiprofen...... 21 GLUCOSE TEST...... 137 V10 TEST...... 137 flurbiprofen sodium...... 242 FORA G30/PREM V10 FORACARE TEST N GO flutamide...... 72 GLUCOSE TEST...... 137 MONITOR...... 189 fluticasone propionate..... 119, 238 FORA G30A BLOOD FORACARE TEST N GO fluticasone-salmeterol...... 38 GLUCOSE SYSTEM...... 188 TEST...... 138 fluvastatin sodium...... 62 FORA GD20 BLOOD formaldehyde...... 84 fluvastatin sodium er...... 62 GLUCOSE SYSTEM...... 188 FORTAMET...... 51 fluvoxamine maleate...... 48 FORA GD20 TEST...... 137 FORTEO...... 147 fluvoxamine maleate er...... 48 FORA GD50 BLOOD FORTESTA...... 32 FML...... 242 GLUCOSE SYSTEM...... 189 FORTISCARE GLUCOSE FML FORTE...... 242 FORA GD50 BLOOD SYSTEM...... 189 FML LIQUIFILM...... 242 GLUCOSE TEST...... 137 FORTISCARE T1 folbee...... 164 FORA GTEL BLOOD GLUCOSE SYSTEM...... 189 folbee plus...... 228 GLUCOSE SYSTEM...... 189 FORTISCARE TEST...... 138 282 FOSAMAX PLUS D...... 147 furosemide...... 145, 146 Genicin Vita-S...... 228 fosamprenavir calcium...... 85 FUSION PLUS...... 165 GENOTROPIN...... 147 fosinopril sodium...... 65 FUZEON...... 85 GENOTROPIN fosinopril sodium-hctz...... 65 Fyavolv...... 152 MINIQUICK...... 147 FOSRENOL...... 154 FYCOMPA...... 43, 44 GENTAK...... 242 FOSTEUM...... 143 g tussin ac...... 109 gentamicin sulfate...... 120, 242 FOSTEUM PLUS...... 143 gabapentin...... 44 GENTEEL BUTTERFLY FRAGMIN...... 41 galantamine hydrobromide..... 254 TOUCH LANCET...... 191 freds pharmacy autolet lancing189 galantamine hydrobromide er..254 GENTEEL CONTACT TIPS freds pharmacy unifine pentip+ GALAXTRA...... 143 (BLUE)...... 191 ...... 190 GALZIN...... 220 GENTEEL CONTACT TIPS freds pharmacy unifine pentips 190 GAMMACORE...... 190 (CLEAR)...... 191 FREESTYLE FLASH GAMMACORE SAPPHIRE GENTEEL CONTACT TIPS SYSTEM...... 190 31-DAY...... 190 (GREEN)...... 191 FREESTYLE FREEDOM... 190 GAMMACORE SAPPHIRE GENTEEL CONTACT TIPS FREESTYLE FREEDOM REFILL KIT...... 190 (ORANGE)...... 191 LITE...... 190 GAMMAGARD...... 248 GENTEEL CONTACT TIPS FREESTYLE INSULINX GAMMAGARD S/D LESS (RAINBOW)...... 191 SYSTEM...... 190 IGA...... 248 GENTEEL CONTACT TIPS FREESTYLE INSULINX GAMMAKED...... 248 (VIOLET)...... 191 TEST...... 138 GAMMAPLEX...... 248 GENTEEL CONTACT TIPS FREESTYLE LIBRE 14 GAMUNEX-C...... 248 (YELLOW)...... 191 DAY READER...... 190 gatifloxacin...... 242 GENTEEL LANCING FREESTYLE LIBRE 14 GATTEX...... 155 DEVICE (BLACK)...... 191 DAY SENSOR...... 190 GAVILYTE-C...... 170 GENTEEL LANCING FREESTYLE LIBRE 2 Gavilyte-G...... 170 DEVICE (BLUE)...... 191 READER SYSTM...... 190 Gavilyte-H...... 170 GENTEEL LANCING FREESTYLE LIBRE 2 Gavilyte-N With Flavor Pack170 DEVICE (PINK)...... 191 SENSOR SYSTM...... 190 ge100 blood glucose system GENTEEL LANCING FREESTYLE LIBRE ...... 190, 191 DEVICE (WHITE)...... 191 READER...... 190 ge100 blood glucose test...... 138 GENTEEL LANCING FREESTYLE LIBRE GEBAUERS PAIN EASE.... 119 DEVICE(PURPLE)...... 191 SENSOR SYSTEM...... 190 GEBAUERS SPRAY AND GENTEEL LANCING KIT FREESTYLE LITE...... 190 STRETCH...... 119 (BLUE)...... 191 FREESTYLE LITE TEST....138 GELCLAIR...... 225 GENTEEL NOZZLES...... 191 FREESTYLE PRECISION GELFILM...... 242 gentle laxative...... 170 INS SYR...... 190 GEL-FLOW...... 168 GENTLE-LET GP FREESTYLE PRECISION GELFOAM-JMI POWDER.168 LANCETS...... 191 NEO SYSTEM...... 190 GELFOAM-JMI SPONGE.. 168 GENTLE-LET LANCETS...191 FREESTYLE PRECISION GELNIQUE...... 264 GENTLE-LET NEO TEST...... 138 GEL-ONE...... 236 PLATFORMS...... 191 FREESTYLE SIDEKICK II 190 GELSYN-3...... 236 GENULTIMATE TEST...... 138 FREESTYLE SYSTEM...... 190 gemfibrozil...... 62 GENVISC 850...... 236 FREESTYLE TEST...... 138 gen7t...... 119 GENVOYA...... 85 FREESTYLE UNISTICK II gen7t plus...... 119 GEODON...... 82 LANCETS...... 190 GENADUR...... 120 ght blood glucose monitor...... 191 FROTEK...... 119 generlac...... 155 ght test...... 138 frovatriptan succinate...... 219 Gengraf...... 223 GIALAX...... 170 FULPHILA...... 165 GENICIN VITA-D...... 165 Gianvi...... 99 fungimez...... 119 GENICIN VITA-Q...... 228 GIAPREZA...... 267 283 GILENYA...... 254 GLUCOCARD X-METER.. 192 gnp lancets 21g...... 193 GILPHEX TR...... 109 GLUCOCARD X-SENSOR.138 gnp lancets micro thin 33g...... 193 GILTUSS TR...... 109 GLUCOCOM BLOOD gnp lancets thin...... 193 GLASSIA...... 258 GLUCOSE MONITOR...... 192 gnp lancets thin 26g...... 193 glatiramer acetate...... 254 GLUCOCOM LANCETS gnp laxative...... 170 Glatopa...... 254 28G...... 192 gnp micro thin lancets 33g...... 193 GLEEVEC...... 72 GLUCOCOM LANCETS gnp nicotine...... 254 GLEOLAN...... 138 30G...... 192 gnp nicotine mini...... 254 GLEOSTINE...... 72 GLUCOCOM LANCETS gnp nicotine polacrilex...... 254 GLIADEL WAFER...... 72 33G...... 192 gnp super thin lancets 30g...... 193 glimepiride...... 51 GLUCOCOM MONITOR... 192 gnp ulticare pen needles...... 193 glipizide...... 51 GLUCOCOM TEST...... 138 gnp ultra com insulin syringe...193 glipizide er...... 51 GLUCONAVII BLOOD gnp womens gentle laxative.....170 glipizide xl...... 51 GLUCOSE SYS...... 192 GOCOVRI...... 80 glipizide-metformin hcl...... 51 GLUCONAVII BLOOD GOJJI LANCING global alcohol prep ease...... 191 GLUCOSE TEST...... 138 DEVICE/CLEAR CAP...... 193 global ease inject pen needles.. 191 GLUCOPRO INSULIN GOJJI STERILE LANCETS 193 global easy glide insulin syr.....191 SYRINGE...... 192 GOLYTELY...... 170 global easy glide pen needles... 191 GLUCOPRO SYR RES 3ML GONAL-F...... 147 global inject ease insulin syr....191 22GX3/8"...... 192 GONAL-F RFF...... 148 global inject ease lancets 28g.. 191 glucose meter test...... 138 GONAL-F RFF REDIJECT 148 global inject ease lancets 30g.. 191 GLUMETZA...... 51 GONITRO...... 34 global insulin syringes...... 191 glutaraldehyde...... 84 goodsense blood glucose.. 138, 193 global lancing device...... 191 glyburide...... 51 goodsense clickfine pen needle.193 GLUCAGEN HYPOKIT...... 51 glyburide micronized...... 51 goodsense lancets 26g univ...... 193 glucagon emergency...... 51 glyburide-metformin...... 51 goodsense lancets 30g univ...... 193 GLUCO PERFECT 3 GLYCATE...... 262 goodsense lancets 33g...... 193 METER...... 192 glycine...... 157 goodsense lancets 33g univ...... 193 GLUCO PERFECT 3 TEST.138 glycine soya protein...... 95 goodsense lancing device...... 193 GLUCOCARD 01 BLOOD glycolic acid...... 120 goodsense nicotine...... 254 GLUCOSE...... 192 glycopyrrolate...... 262 GOODSENSE PEN GLUCOCARD 01 SENSOR Glydo...... 120 NEEDLE PENFINE...... 193 PLUS...... 138 GLYRX-PF...... 262 goprelto...... 238 GLUCOCARD 01-MINI GLYTACTIN BUILD 10PE.143 GORDOFILM...... 120 GLUCOSE...... 192 GLYTACTIN BURST...... 143 GRALISE...... 254 GLUCOCARD GLYTACTIN COMPLETE granisetron hcl...... 59 EXPRESSION MONITOR.. 192 10PE...... 143 GRANIX...... 165 GLUCOCARD GLYTACTIN SWIRL 15PE.143 GRASTEK...... 19 EXPRESSION TEST...... 138 GLYXAMBI...... 51 griseofulvin microsize...... 60 GLUCOCARD SHINE gnp adult aspirin low strength... 26 griseofulvin ultramicrosize...... 60 CONNEX...... 192 gnp alcohol swabs...... 192 guaiatussin ac...... 109 GLUCOCARD SHINE gnp aspirin...... 26 guaifenesin-codeine...... 109 EXPRESS...... 192 GNP BISA-LAX...... 170 guanfacine hcl...... 65 GLUCOCARD SHINE gnp clickfine pen needles...... 193 guanfacine hcl er...... 17 TEST...... 138 GNP EASY TOUCH guanidine hcl...... 69 GLUCOCARD SHINE XL..192 GLUCOSE METER...... 193 GUARDIAN CONNECT GLUCOCARD VITAL gnp easy touch glucose test..... 138 TRANSMITTER...... 193 MONITOR...... 192 gnp gentle laxative...... 170 GUARDIAN LINK 3 GLUCOCARD VITAL gnp insulin syringe...... 193 TRANSMITTER...... 193 TEST...... 138 gnp lancets...... 193 284 GUARDIAN REAL-TIME HEMLIBRA...... 160 HUMULIN N KWIKPEN.....52 CHARGER...... 194 HEMOCYTE PLUS...... 165 HUMULIN R...... 52 GUARDIAN REAL-TIME Hemocyte-F...... 165 HUMULIN R U-500 REPLACE PED...... 194 hemocyte-plus...... 165 (CONCENTRATED)...... 52 GUARDIAN REAL-TIME HEMOFIL M...... 160 HUMULIN R U-500 TEST PLUG...... 194 HEPAGAM B...... 248 KWIKPEN...... 53 GUARDIAN SENSOR (3)...194 heparin sodium (porcine)...... 41 HW EMBRACE PRO GVOKE HYPOPEN 1- heparin sodium (porcine) pf..... 41 GLUCOSE METER...... 195 PACK...... 52 hepmed...... 42 HW EMBRACE PRO GVOKE HYPOPEN 2- HEPSERA...... 86 GLUCOSE TEST...... 138 PACK...... 52 HERCEPTIN HYLECTA...... 72 HW EMBRACE TALK GVOKE PFS...... 52 HERZUMA...... 72 BLOOD GLUCOSE...... 195 GYNAZOLE-1...... 266 Hidex 6-Day...... 107 HW EMBRACE TALK HAEGARDA...... 160 HIZENTRA...... 248 GLUCOSE TEST...... 139 Hailey 1.5/30...... 99 hm aspirin...... 26 HYALGAN...... 236 Hailey 24 Fe...... 99 HM EMBRACE TALK hyalucil-4...... 120 halcinonide...... 120 SYSTEM...... 194 HYCAMTIN...... 72 halobetasol propionate...... 120 hm laxative...... 170, 171 HYCLODEX...... 120 HALOG...... 120 hm nicotine...... 254 hydralazine hcl...... 65 haloperidol...... 82 hm nicotine polacrilex...... 254 hydrochlorothiazide...... 146 haloperidol decanoate...... 82 hm sterile alcohol prep...... 194 hydrocod polst-cpm polst er.... 109 haloperidol lactate...... 82 HM ULTICARE INSULIN hydrocodone bitartrate er...... 29 HARMONY BLOOD SYRINGE...... 194 hydrocodone-acetaminophen.....29 GLUCOSE TEST...... 138 HM ULTICARE SHORT hydrocodone-homatropine...... 109 HARVONI...... 85, 86 PEN NEEDLES...... 194 hydrocodone-ibuprofen...... 29 HCU EASY...... 143 HORIZANT...... 254 hydrocortisone...... 33, 107, 120 HEALTH CARE LANCING HPR PLUS...... 120 hydrocortisone (perianal)...... 33 DEVICE...... 194 HPR PLUS HYDROGEL.... 120 hydrocortisone ace-pramoxine.. 33 healthwise insulin syr/needle... 194 HUMALOG...... 52 hydrocortisone butyr lipo base 120 healthwise micron pen needles.194 HUMALOG KWIKPEN...... 52 hydrocortisone butyrate...... 120 healthwise mini pen needles.....194 HUMALOG MIX 50/50...... 52 hydrocortisone valerate...... 120 healthwise pen needles...... 194 HUMALOG MIX 50/50 hydrocortisone-acetic acid...... 247 healthwise short pen needles....194 KWIKPEN...... 52 HYDROFERA BLUE 6"X6"121 healthwise unifine pentips...... 194 HUMALOG MIX 75/25...... 52 HYDROFERA BLUE healthy accents lancing device.194 HUMALOG MIX 75/25 FOAM DRESSING...... 121 healthy accents unifine pentip. 194 KWIKPEN...... 52 HYDROFERA BLUE healthy accents unilet lancets.. 194 HUMATE-P...... 160 FOAM/TUNNELING...... 121 Heather...... 99 HUMATROPE...... 148 HYDROFERA BLUE MRF h-e-b aspirin...... 26 HUMIRA...... 21 DRESSING...... 121 h-e-b incontrol adv lancing...... 194 HUMIRA PEDIATRIC HYDROFERA BLUE h-e-b incontrol alcohol...... 194 CROHNS START...... 21 READY FOAM...... 121 h-e-b incontrol lancets 28g...... 194 HUMIRA PEN...... 21 hydrogen peroxide...... 84 h-e-b incontrol lancets 30g...... 194 HUMIRA PEN-CD/UC/HS hydromet...... 109 h-e-b incontrol lancets 33g...... 194 STARTER...... 21 hydromorphone hcl...... 29 h-e-b incontrol pen needles...... 194 HUMIRA PEN- hydromorphone hcl er...... 29 H-E-B INCONTROL PS/UV/ADOL HS START..... 21 hydroxocobalamin acetate...... 165 UNIFINE PENTIP...... 194 HUMULIN 70/30...... 52 hydroxychloroquine sulfate...... 69 HEMANGEOL...... 90 HUMULIN 70/30 hydroxyprogesterone caproate hematinic plus vit/minerals...... 165 KWIKPEN...... 52 ...... 96, 252 hematinic/folic acid...... 165 HUMULIN N...... 52 hydroxyurea...... 72 285 hydroxyzine hcl...... 35 IN TOUCH STERILE INTRALIPID...... 239 hydroxyzine pamoate...... 35 LANCETS 30G...... 195 INTRAROSA...... 266 hygel...... 121 INATAL GT...... 228 INTRON A...... 73 HYLATOPIC PLUS...... 121 INBRIJA...... 80 Introvale...... 99 hylavite...... 228 Incassia...... 99 INTUNIV...... 17 HYMOVIS...... 236 INCRELEX...... 148 INVEGA SUSTENNA...... 82 HYOPHEN...... 67 INCRUSE ELLIPTA...... 38 INVEGA TRINZA...... 82 hyoscyamine sulfate...... 263 indapamide...... 146 INVELTYS...... 242 hyoscyamine sulfate er...... 263 INDERAL LA...... 90 INVIRASE...... 86 HYPERSAL...... 109 INDERAL XL...... 90 INVOKAMET...... 53 HYPOCYN...... 121 INDOCIN...... 21 INVOKAMET XR...... 53 HYQVIA...... 248 indomethacin...... 21 INVOKANA...... 53 HYSINGLA ER...... 29 indomethacin er...... 21 iodine strong...... 221 HY-VEE LANCETS...... 195 INFASURF...... 258 iodine tincture...... 84 hy-vee thin lancets...... 195 INFINITY BLOOD IOPIDINE...... 242 ibandronate sodium...... 148 GLUCOSE SYSTEM...... 195 ipratropium bromide...... 39, 238 IBG STAR BLOOD INFINITY BLOOD ipratropium-albuterol...... 39 GLUCOSE SYSTEM...... 195 GLUCOSE TEST...... 139 irbesartan...... 65 IBRANCE...... 72 INFINITY VOICE...... 139, 195 irbesartan-hydrochlorothiazide. 65 Ibu...... 21 Inflammacin...... 21 IRESSA...... 73 ibuprofen...... 21 INFLATHERM...... 22 ISENTRESS...... 86 ICAR-C PLUS...... 165 INFLECTRA...... 155 ISENTRESS HD...... 86 icatibant acetate...... 160 INFUGEM...... 73 Isibloom...... 99 IDELVION...... 160 infusion catheter soft 23"...... 195 isoflurane...... 156 IDHIFA...... 73 infusion catheter soft 31"...... 195 isoniazid...... 69 Iferex 150 Forte...... 165 infusion catheter soft 43"...... 195 ISOPTO ATROPINE...... 242 IGLUCOSE MONITORING INFUVITE ADULT...... 228 ISORDIL TITRADOSE...... 34 SYSTEM...... 195 INFUVITE PEDIATRIC..... 228 isosorbide dinitrate...... 34 IGLUCOSE TEST STRIPS.. 139 INGREZZA...... 254 isosorbide mononitrate...... 34 ILARIS...... 21 INLYTA...... 73 isosorbide mononitrate er...... 34 ILEVRO...... 242 INNOPRAN XL...... 90 isotretinoin...... 121 ILUMYA...... 121 INPEN 100-BLUE-LILLY... 195 isradipine...... 91 imatinib mesylate...... 73 INPEN 100-BLUE-NOVO... 195 itraconazole...... 60 imipramine hcl...... 48 INPEN 100-GRAY-LILLY.. 195 ivermectin...... 34 imipramine pamoate...... 48 INPEN 100-GREY-NOVO...195 IXINITY...... 160 imiquimod...... 121 INPEN 100-PINK-LILLY....195 JADENU...... 58 imiquimod pump...... 121 INPEN 100-PINK-NOVO.... 195 JADENU SPRINKLE...... 58 IMLYGIC...... 73 INQOVI...... 73 JAKAFI...... 73 IMPAVIDO...... 67 INREBIC...... 73 JALYN...... 157 IMPOYZ...... 121 insulin cartridge 3ml...... 195 Jantoven...... 42 IMVEXXY insulin syringe...... 196 JANUMET...... 53 MAINTENANCE PACK.....266 insulin syringe/needle...... 196 JANUMET XR...... 53 IMVEXXY STARTER insulin syringe-needle u-100.... 196 JANUVIA...... 53 PACK...... 266 insupen pen needles...... 196 JARDIANCE...... 53 IN TOUCH...... 195 INSUPEN SENSITIVE...... 196 Jasmiel...... 99 IN TOUCH BLOOD INSUPEN ULTRAFIN...... 196 JELMYTO...... 73 GLUCOSE TEST...... 139 INTEGRA F...... 165 Jencycla...... 99 IN TOUCH LANCING INTEGRA PLUS...... 165 JENTADUETO...... 53 DEVICE...... 195 INTELENCE...... 86 JENTADUETO XR...... 53 INTERMEZZO...... 169 Jinteli...... 153 286 JIVI...... 161 KERAMATRIX KLS QUIT4...... 255 Jolessa...... 100 REPLICINE 10CMX10CM..122 kmart valu insulin syringe 29g.196 JORNAY PM...... 17 KERAMATRIX kmart valu insulin syringe 30g.196 JUBLIA...... 121 REPLICINE 5CMX5CM..... 122 KOATE...... 161 Juleber...... 100 KERLIX AMD KOATE-DVI...... 161 JULUCA...... 86 ANTIMICROBIAL...... 196 KOGENATE FS...... 161 Junel 1.5/30...... 100 KERLIX AMD SUPER KOMBIGLYZE XR...... 53 Junel 1/20...... 100 SPONGES...... 196 KOSELUGO...... 74 Junel Fe 1.5/30...... 100 KERYDIN...... 122 kosher prenatal plus iron...... 228 Junel Fe 1/20...... 100 KESIMPTA...... 254 KOVALTRY...... 161 Junel Fe 24...... 100 ketoconazole...... 60, 122 kp aspirin...... 26 JUXTAPID...... 62 Ketodan...... 122 kp bisacodyl...... 171 JYNARQUE...... 148 KETO-DIASTIX...... 139 K-PHOS...... 221 KADIAN...... 29 ketone test...... 139 K-PHOS NO 2...... 157 Kaitlib Fe...... 100 KETOPHENE RAPIDPAQ. 122 K-Prime...... 221 KALETRA...... 86 ketoprofen...... 22 KRINTAFEL...... 69 Kalliga...... 100 ketoprofen er...... 22 KRISTALOSE...... 171 KALYDECO...... 258 ketorolac tromethamine.... 22, 242 KROGER AUTOLET KAMDOY...... 121 KETOSTIX...... 139 LANCING DEVICE...... 196 KANJINTI...... 73 KETOVIE...... 144 kroger blood glucose...... 196 KANUMA...... 148 KETOVIE PEPTIDE...... 144 kroger blood glucose test...... 139 KAPSPARGO SPRINKLE....90 KEVZARA...... 22 kroger insulin syringe...... 196 KARBINAL ER...... 60 KHAPZORY...... 73 kroger lancets...... 196 Kariva...... 100 KINERET...... 22 kroger lancets super thin...... 196 KATERZIA...... 91 kinney lancets...... 196 kroger lancets thin...... 196 KAZANO...... 53 kinney thin lancets...... 196 kroger pen needles...... 196 KELARX...... 121 kinray insulin syringe...... 196 kroger premium blood glucose.197 Kelnor 1/35...... 100 Kionex...... 223 kroger premium glucose test... 139 Kelnor 1/50...... 100 KISQALI (200 MG DOSE).... 73 kroger test...... 139 KENDALL ALGINATE 12" KISQALI (400 MG DOSE).... 73 KRYSTEXXA...... 158 ROPE...... 121 KISQALI (600 MG DOSE).... 73 K-TAB...... 221 KENDALL ALGINATE KISQALI FEMARA (400 K-Tan Plus...... 165 DRESS 2"X2"...... 121 MG DOSE)...... 73 Kurvelo...... 100 KENDALL ALGINATE KISQALI FEMARA (600 KUVAN...... 148 DRESS 4"X4"...... 121 MG DOSE)...... 74 KYLEENA...... 100 KENDALL ALGINATE KISQALI FEMARA(200 KYPROLIS...... 74 DRESS 4"X8"...... 121 MG DOSE)...... 74 L.E.T...... 122 KENDALL AMORPHOUS KITABIS PAK...... 19 labetalol hcl...... 90 WOUND...... 121 KIVIK...... 122 LACRISERT...... 243 KENDALL HYDROGEL KLARITY-A...... 243 lactated ringers...... 223 GAUZE 2"X2"...... 122 KLARITY-L...... 243 lactic acid...... 122 KENDALL HYDROGEL Klor-Con...... 221 lactic acid e...... 122 GAUZE 4"X4"...... 122 Klor-Con 10...... 221 lactulose...... 171 KENDALL HYDROGEL Klor-Con M10...... 221 lactulose encephalopathy...... 155 GAUZE 4"X8"...... 122 KLOR-CON M15...... 221 LAMICTAL...... 44 KENDALL HYDROGEL Klor-Con M20...... 221 LAMICTAL ODT...... 44 WOUND DRESS...... 122 Klor-Con Sprinkle...... 221 LAMICTAL STARTER...... 44 KENGREAL...... 161 Klor-Con/Ef...... 221 LAMICTAL XR...... 44 KERAGEL...... 122 kls aspirin low dose...... 26 lamivudine...... 86 KERAGELT...... 122 KLS QUIT2...... 255 lamivudine-zidovudine...... 86 287 lamotrigine...... 44 LENVIMA (12 MG DAILY LEXETTE...... 122 lamotrigine er...... 44 DOSE)...... 74 LEXIVA...... 86 lamotrigine starter kit-blue...... 44 LENVIMA (14 MG DAILY LIALDA...... 155 lamotrigine starter kit-green.....44 DOSE)...... 74 liberty blood glucose meter..... 197 lamotrigine starter kit-orange...44 LENVIMA (18 MG DAILY LIBERTY NEXT LAMPIT...... 67 DOSE)...... 74 GENERATION TEST...... 139 lancet device...... 197 LENVIMA (20 MG DAILY LIBERTY NXT lancet device with ejector...... 197 DOSE)...... 74 GENERATION MONITOR 197 lancet transporter case...... 197 LENVIMA (24 MG DAILY liberty test...... 139 lancets...... 197 DOSE)...... 74 lidocaine...... 122, 123 lancets 30g...... 197 LENVIMA (4 MG DAILY lidocaine hcl...... 123, 225 lancets micro thin 33g...... 197 DOSE)...... 74 lidocaine hcl urethral/mucosal.123 lancets thin...... 197 LENVIMA (8 MG DAILY lidocaine in dextrose...... 172 LANCETS ULTRA FINE....197 DOSE)...... 74 lidocaine viscous hcl...... 225 lancets ultra thin 30g...... 197 LESCOL XL...... 62 lidocaine-prilocaine...... 123 lancing device...... 197 Lessina...... 101 lidocaine-tetracaine...... 123 LANOXIN...... 92 LETAIRIS...... 93 lidocidex i...... 107 lansoprazole...... 263 letrozole...... 74 LIDODERM...... 123 lanthanum carbonate...... 155 LEU TECHNELITE...... 139 lidomark 2/5...... 172 LANTUS...... 53 leucovorin calcium...... 74, 96 lidopac...... 123 LANTUS SOLOSTAR...... 53 LEUKERAN...... 74 LIDOPURE PATCH...... 123 LANZO...... 197 LEUKINE...... 165 LIDOTHOL...... 123 Larin 1.5/30...... 100 leuprolide acetate...... 74 LIDOTRAL...... 123 Larin 1/20...... 100 levalbuterol hcl...... 39 LIDOTREX...... 123 Larin 24 Fe...... 100 levalbuterol tartrate...... 39 LIFESCAN UNISTIK 2...... 197 Larin Fe 1.5/30...... 100 levatio...... 122 LIFESCAN UNISTIK II Larin Fe 1/20...... 100 LEVEMIR...... 53 LANCETS...... 197 Larissia...... 101 LEVEMIR FLEXTOUCH..... 53 LILETTA (52 MG)...... 101 LASTACAFT...... 243 levetiracetam...... 44 Lillow...... 101 latanoprost...... 243 levetiracetam er...... 44 lindane...... 123 LATUDA...... 82 LEVICYN...... 122 linezolid...... 67 laxative...... 171 LEVICYN DERMAL linseed oil...... 96 Layolis Fe...... 101 SPRAY...... 122 LINZESS...... 155 LAZANDA...... 29 levobunolol hcl...... 243 liothyronine sodium...... 261 LDL CARE...... 144 levocarnitine...... 148 LIPITOR...... 62 LDO PLUS...... 122 levocetirizine dihydrochloride lipo-c...... 239 ldr blood glucose truetest...... 197 ...... 60, 61 LIQUID E-Z-PAQUE...... 139 leader insulin syringe...... 197 levofloxacin...... 153, 243 lisinopril...... 65 LEADER UNIFINE Levonest...... 101 lisinopril-hydrochlorothiazide... 65 PENTIPS...... 197 levonorgest-eth est & eth est....101 lissamine green...... 243 LEADER UNIFINE levonorgest-eth estrad 91-day. 101 lite touch lancets...... 197 PENTIPS PLUS...... 197 levonorgestrel...... 101 LITE TOUCH LANCING lecithin...... 239 levonorgestrel-ethinyl estrad... 101 PEN...... 197 ledipasvir-sofosbuvir...... 86 levonorg-eth estrad triphasic...101 LITETOUCH INSULIN Leena...... 101 Levora 0.15/30 (28)...... 101 SYRINGE...... 197 leflunomide...... 22 levorphanol tartrate...... 29 LITETOUCH LANCETS.....197 LEMTRADA...... 255 Levo-T...... 261 LITETOUCH PEN LENVIMA (10 MG DAILY levothyroxine sodium...... 261 NEEDLES...... 198 DOSE)...... 74 Levoxyl...... 261 lithium...... 82 LEXAPRO...... 48 lithium carbonate...... 82 288 lithium carbonate er...... 82 LUPRON DEPOT (3- MAXI-COMFORT SAFETY LITHOSTAT...... 157 MONTH)...... 75 PEN NEEDLE...... 198 LIVALO...... 62 LUPRON DEPOT (4- MAXICOMFORT SYR 27G live better adv lancing device...198 MONTH)...... 75 X 1/2"...... 198 live better lancet ultra thin...... 198 LUPRON DEPOT (6- MAXIDEX...... 243 LMR PLUS...... 123 MONTH)...... 75 MAXITROL...... 243 LO LOESTRIN FE...... 101 LUPRON DEPOT-PED (1- MAYZENT...... 255 LODINE...... 22 MONTH)...... 148 MAYZENT STARTER LOKELMA...... 223 LUPRON DEPOT-PED (3- PACK...... 255 LOMAIRA...... 17 MONTH)...... 148 Md-Gastroview...... 139 longs insulin syringe...... 198 Lutera...... 101 me/naphos/mb/hyo1...... 67 longs lancets standard...... 198 LUXAMEND...... 123 meclizine hcl...... 59 longs lancets thin...... 198 LYNPARZA...... 75 meclofenamate sodium...... 22 longs lancets ultra thin...... 198 LYRICA...... 44 medic insulin syringe...... 198 LONHALA MAGNAIR LYRICA CR...... 255 medichoice safety lancet extra 198 REFILL KIT...... 39 Lysiplex Plus...... 228 medicine shoppe pen needles....198 LONHALA MAGNAIR LYSODREN...... 75 MEDISENSE THIN STARTER KIT...... 39 Lyza...... 101 LANCETS...... 198 LONSURF...... 74 M.V.I. ADULT...... 228 MEDLANCE PLUS EXTRA loperamide hcl...... 57 M.V.I. PEDIATRIC...... 229 21G...... 198 lopinavir-ritonavir...... 86 macadamia nut oil...... 96 MEDLANCE PLUS LOPROX...... 123 MACI...... 236 LANCETS...... 198 lorazepam...... 35 MACRILEN...... 139 MEDLANCE PLUS LITE LORBRENA...... 74 MACRODANTIN...... 67 25G...... 198 lorid...... 228 mafenide acetate...... 123 MEDLANCE PLUS LORTAB...... 29 MAGELLAN INSULIN SPECIAL 0.8MM...... 198 Loryna...... 101 SAFETY SYR...... 198 MEDLANCE PLUS Lorzone...... 236 MAKENA...... 252 SUPERLITE 30G...... 198 losartan potassium...... 65 malathion...... 123 MEDLANCE PLUS losartan potassium-hctz...... 65 maprotiline hcl...... 48 UNIVERSAL 21G...... 198 LOTEMAX...... 243 MARATHON MEDICAL MEDROL...... 107 LOTEMAX SM...... 243 PENTIPS...... 198 MEDROLOAN II SUIK...... 107 loteprednol etabonate...... 243 MARINOL...... 59 MEDROLOAN SUIK...... 107 LOTRONEX...... 155 marlissa...... 101 medroxyprogesterone acetate lovastatin...... 62 MARNATAL-F...... 229 ...... 101, 102, 252 LOVENOX...... 42 MARPLAN...... 48 mefenamic acid...... 22 Low-Ogestrel...... 101 MATULANE...... 75 mefloquine hcl...... 69 loxapine succinate...... 82 Matzim La...... 91 megestrol acetate...... 75, 252 LOYON...... 123 MAVENCLAD (10 TABS)...255 meijer blood glucose...... 198 Lo-Zumandimine...... 101 MAVENCLAD (4 TABS).....255 meijer blood glucose test...... 139 LUCEMYRA...... 255 MAVENCLAD (5 TABS).....255 meijer essential blood glucose..198 LUCENTIS...... 243 MAVENCLAD (6 TABS).....255 meijer essential glucose test.... 139 luliconazole...... 123 MAVENCLAD (7 TABS).....255 MEIJER LANCETS THIN.. 199 LUMIGAN...... 243 MAVENCLAD (8 TABS).....255 MEIJER LANCETS LUMIZYME...... 148 MAVENCLAD (9 TABS).....255 UNIVERSAL 21G...... 199 LUMOXITI...... 74 MAVYRET...... 86 MEIJER LANCETS LUNESTA...... 169 MAXICOMFORT II PEN UNIVERSAL 30G...... 199 LUPANETA PACK...... 148 NEEDLE...... 198 MEIJER LANCETS LUPRON DEPOT (1- MAXI-COMFORT UNIVERSAL 33G...... 199 MONTH)...... 74 INSULIN SYRINGE...... 198 meijer pen needles...... 199 289 meijer premium blood glucose. 199 Methergine...... 247 miglitol...... 54 meijer premium glucose test.... 139 methimazole...... 261 miglustat...... 165 MEIJER SUPER THIN methitest...... 32 MIGRAINE PACK...... 219 LANCETS...... 199 methocarbamol...... 237 MIGRANAL...... 219 MEIJER TRUE2GO methotrexate sodium...... 75 MIGRANOW...... 219 BLOOD GLUCOSE...... 199 methotrexate sodium (pf)...... 75 Mili...... 102 MEIJER TRUERESULT methoxsalen rapid...... 123 MILLIPRED...... 107 GLUCOSE SYS...... 199 methscopolamine bromide...... 263 MILLIPRED DP 12-DAY....107 MEIJER TRUETEST TEST 139 methyldopa...... 65 Mimvey...... 153 MEIJER TRUETRACK methyldopa- MIMYX...... 124 GLUCOSE SYS...... 199 hydrochlorothiazide...... 65 MINASTRIN 24 FE...... 102 MEIJER TRUETRACK methylergonovine maleate...... 247 mineral oil heavy...... 171 TEST...... 139 methylphenidate hcl...... 18 mini lancing device...... 199 MEKINIST...... 75 methylphenidate hcl er...... 18 MINILINK REAL-TIME Melodetta 24 Fe...... 102 methylphenidate hcl er (cd)...... 17 TRANSMITTER...... 199 meloxicam...... 22 methylphenidate hcl er (la)...... 18 MINIMED 630G melphalan...... 75 methylprednisolone...... 107 GUARDIAN PRESS...... 199 memantine hcl...... 255 methyltestosterone...... 32 MINIMED GUARDIAN memantine hcl er...... 255 metoclopramide hcl...... 155 LINK 3...... 199 MENEST...... 153 metolazone...... 146 MINIMED GUARDIAN MENOPUR...... 148 METOPIRONE...... 139 SENSOR 3...... 199 MENOSTAR...... 153 metoprolol succinate er...... 90 MINIMED PUMP MENQUADFI...... 265 metoprolol tartrate...... 90 RESERVOIR 3ML...... 199 MENTAX...... 123 metoprolol-hydrochlorothiazide 65 MINIMED RESERVOIR meperidine hcl...... 29 metronidazole.... 67, 123, 124, 266 1.8ML...... 199 meprobamate...... 35 METRONIDAZOLE MINIMED RESERVOIR mercaptopurine...... 75 BENZO+SYRSPEND...... 67 3ML...... 199 mesalamine...... 155 mexiletine hcl...... 36 MINIPRIN LOW DOSE...... 26 mesalamine er...... 155 MI PASTE...... 199 Minitran...... 34 mesalamine-cleanser...... 155 MI PASTE PLUS...... 199 MINIVELLE...... 153 MESNEX...... 75 MIACALCIN...... 148 MINOCIN...... 260 MESTINON...... 69 Mibelas 24 Fe...... 102 minocycline hcl...... 260 Metadate Er...... 17 miconazole 3...... 266 minocycline hcl er...... 260 METAXALL CP...... 236 miconazole-zinc oxide-petrolat124 MINOLIRA...... 260 metaxalone...... 236, 237 MICROCYN...... 124 minoxidil...... 65 metformin hcl...... 54 MICRODOT BLOOD MIO INFUSION SET 18" metformin hcl er...... 54 GLUCOSE SYSTEM...... 199 6MM...... 199 metformin hcl er (mod)...... 54 MICRODOT TEST...... 139 MIO INFUSION SET 23" metformin hcl er (osm)...... 54 Microgestin 1.5/30...... 102 6MM...... 200 methadone hcl...... 30 Microgestin 1/20...... 102 MIO INFUSION SET 32" Methadone Hcl Intensol...... 29 Microgestin Fe 1.5/30...... 102 6MM...... 200 methadone hcl-nacl...... 30 Microgestin Fe 1/20...... 102 MIO INFUSION SET 32" METHADOSE...... 30 MICROLET LANCETS...... 199 9MM...... 200 Methadose...... 30 MICROLET NEXT MIRCERA...... 166 METHADOSE SUGAR- LANCING DEVICE...... 199 MIRCETTE...... 102 FREE...... 30 midazolam hcl...... 169 MIRENA (52 MG)...... 102 methamphetamine hcl...... 17 MIDAZOLAM+SYRSPEN mirtazapine...... 48 methazolamide...... 146 D SF...... 169 MIRVASO...... 124 methenamine hippurate...... 67 midodrine hcl...... 267 misoprostol...... 263 methenamine mandelate...... 67 MIGERGOT...... 219 MITOSOL...... 243 290 mko melt dose pack...... 169 MULPLETA...... 166 nalocet...... 30 MM EASY TOUCH MULTAQ...... 36 naloxone hcl...... 58 GLUCOSE...... 140 MULTIGEN...... 166 naltrexone hcl...... 58 MM EASY TOUCH MULTIGEN FOLIC...... 166 NAMENDA XR GLUCOSE METER...... 200 MULTIGEN PLUS...... 166 TITRATION PACK...... 256 mm insulin syringe/needle...... 200 MULTI-LANCET DEVICE NAMZARIC...... 256 MM PEN NEEDLES...... 200 2...... 200 NAPRELAN...... 22 m-natal plus...... 229 multipro...... 229 naproxen...... 22 MOBIC...... 22 multi-vit/iron/fluoride...... 229 naproxen dr...... 22 modafinil...... 18 multivitamin/fluoride...... 229 naproxen sodium...... 22 moexipril hcl...... 65 multi-vitamin/fluoride...... 229 naproxen sodium er...... 22 molindone hcl...... 82 multi-vitamin/fluoride/iron...... 229 naproxen-esomeprazole...... 22 mometasone furoate...... 124, 238 mupirocin...... 124 naratriptan hcl...... 219 Mondoxyne Nl...... 260 mupirocin calcium...... 124 NARCAN...... 58 MONOJECT INSULIN MVASI...... 75 NASCOBAL...... 166 SYRINGE...... 200 MY CHOICE...... 102 NATACHEW...... 229 MONOJECT ULTRA MY WAY...... 102 NATACYN...... 243 COMFORT SYRINGE...... 200 mycophenolate mofetil...... 223 NATALVIT...... 229 MONOLET LANCETS...... 200 mycophenolate sodium...... 223 NATAZIA...... 102 MONOLET OPD LANCETS MYDAYIS...... 18 nateglinide...... 54 ...... 200 MYFORTIC...... 223 NATESTO...... 32 MONOLETTOR SAFETY MYGLUCOHEALTH NATPARA...... 149 LANCETS...... 200 BLOOD GLUCOSE...... 200 NATURE-THROID...... 261 Mono-Linyah...... 102 MYGLUCOHEALTH NAYZILAM...... 45 MONONINE...... 161 LANCETS 30G...... 201 NEBUPENT...... 67 MONOVISC...... 237 MYGLUCOHEALTH TEST Necon 0.5/35 (28)...... 102 montelukast sodium...... 39 ...... 140 NEEVO DHA...... 229 MONUROL...... 67 MYLERAN...... 75 nefazodone hcl...... 48 Morgidox...... 260 MYLOTARG...... 75 NEOCERA...... 124 morphine sulfate...... 30 MYNATAL...... 229 NEOKE ALCAR...... 239 morphine sulfate (concentrate).30 mynatal plus...... 229 neoke bhb...... 144 morphine sulfate er...... 30 mynatal-z...... 229 NEOKE MCT70...... 239 morphine sulfate er beads...... 30 Myorisan...... 124 NEOKE RA LIPOIC...... 19 MOTEGRITY...... 155 MYRBETRIQ...... 264 neomycin sulfate...... 19 MOTOFEN...... 57 MYTESI...... 57 neomycin-bacitracin zn- mouth wash-gp...... 251 MYXREDLIN...... 54 polymyx...... 244 mouthwash-af...... 251 nabumetone...... 22 neomycin-polymyxin b gu...... 157 mouthwash-om...... 251 n-acetyl-l-cysteine...... 239 neomycin-polymyxin-dexameth MOVANTIK...... 155 nadolol...... 90 ...... 244 MOVIPREP...... 171 Nafrinse...... 221 neomycin-polymyxin- MOXEZA...... 243 NAFRINSE DAILY gramicidin...... 244 moxifloxacin hcl...... 153, 243 ACIDULATED...... 225 neomycin-polymyxin-hc.. 244, 247 mpd safety lancet 21g...... 200 NAFRINSE NEONATAL PLUS...... 229 mpd safety lancet 23g...... 200 DAILY/NEUTRAL...... 225 Neo-Polycin...... 244 mpd safety lancet 28g...... 200 Nafrinse Drops...... 221 Neo-Polycin Hc...... 244 mpd safety lancet 30g...... 200 NAFRINSE WEEKLY...... 225 NEOSALUS...... 124 MS CONTIN...... 30 naftifine hcl...... 124 NEOSALUS CP...... 124 ms insulin syringe...... 200 NAFTIN...... 124 NEO-SYNALAR...... 124 MSUD EASY...... 144 NAGLAZYME...... 148 NEOTUSS PLUS...... 109 MUCOSITISRX...... 225 NALFON...... 22 Nephronex...... 229 291 NERLYNX...... 75 NINLARO...... 75 NOVA MAX GLUCOSE NESINA...... 54 NIPRIDE RTU...... 65 TEST...... 140 NESTABS...... 229 nisoldipine er...... 92 NOVA MAX PLUS NESTABS DHA...... 229 NITRO-BID...... 34 KETONE TEST...... 140 NESTABS ONE...... 229 NITRO-DUR...... 34 NOVA SAFETY LANCETS Neuac...... 124 nitrofurantoin...... 67 23G...... 201 NEULASTA...... 166 nitrofurantoin macrocrystal...... 67 NOVA SAFETY LANCETS NEULASTA ONPRO...... 166 nitrofurantoin monohyd macro. 67 28G...... 201 NEUPOGEN...... 166 nitroglycerin...... 35 NOVA SUREFLEX NEUPRO...... 80 NITROLINGUAL...... 35 LANCETS...... 201 NEURAPTINE...... 124 NITROMIST...... 35 NOVA SUREFLEX NEURONTIN...... 45 NIVA-PLUS...... 230 LANCING DEVICE...... 201 NEUTEK 2TEK NIVATOPIC PLUS...... 124 NOVACORT...... 125 GLUCOSE/PRESSURE...... 201 NIVESTYM...... 166 NOVOEIGHT...... 161 NEUTEK 2TEK TEST...... 140 nizatidine...... 263 NOVOFINE...... 201 NEUTRASAL...... 225 NOCDURNA...... 149 NOVOFINE AUTOCOVER 201 NEVANAC...... 244 Nolix...... 124 NOVOFINE PLUS...... 201 nevirapine...... 86 Nora-Be...... 102 NOVOLIN 70/30...... 54 nevirapine er...... 86 NORCO...... 30 NOVOLIN 70/30 FLEXPEN..54 NEW DAY...... 102 NORDIPEN 5 INJECTION NOVOLIN 70/30 FLEXPEN NEXAVAR...... 75 DEVICE...... 201 RELION...... 54 NEXIUM...... 263 NORDIPEN DELIVERY NOVOLIN 70/30 RELION.....54 NEXLETOL...... 62 SYSTEM...... 201 NOVOLIN N...... 54 NEXLIZET...... 62 NORDITROPIN FLEXPRO149 NOVOLIN N FLEXPEN...... 54 niacin (antihyperlipidemic)...... 62 norethin ace-eth estrad-fe...... 102 NOVOLIN N FLEXPEN niacin er (antihyperlipidemic).. 62 norethindrone...... 103 RELION...... 54 NIACOR...... 62 norethindrone acetate...... 252 NOVOLIN N RELION...... 54 NICADAN...... 229 norethindrone acet-ethinyl est. 102 NOVOLIN R...... 55 NICAPRIN...... 144 norethindrone-eth estradiol..... 153 NOVOLIN R FLEXPEN...... 54 nicardipine hcl...... 91 norethin-eth estradiol-fe...... 103 NOVOLIN R FLEXPEN NICAZEL...... 229 norgesic forte...... 237 RELION...... 55 NICAZEL FORTE...... 229 norgestimate-eth estradiol...... 103 NOVOLIN R RELION...... 55 nicazyme...... 144 norgestim-eth estrad triphasic.103 NOVOLOG...... 55 NICOMIDE...... 229 NORITATE...... 124 NOVOLOG FLEXPEN...... 55 NICORELIEF...... 256 Norlyda...... 103 NOVOLOG MIX 70/30...... 55 nicotine...... 256 Norlyroc...... 103 NOVOLOG MIX 70/30 nicotine mini...... 256 NORPACE CR...... 36 FLEXPEN...... 55 nicotine polacrilex...... 256 NORTHERA...... 267 NOVOLOG PENFILL...... 55 nicotine step 1...... 256 Nortrel 0.5/35 (28)...... 103 NOVOPEN ECHO...... 201 nicotine step 2...... 256 Nortrel 1/35 (21)...... 103 NOVOSEVEN RT...... 161 nicotine step 3...... 256 Nortrel 1/35 (28)...... 103 NOVOTWIST...... 201 NICOTROL...... 256 Nortrel 7/7/7...... 103 NOXAFIL...... 60 NICOTROL NS...... 256 nortriptyline hcl...... 48 np thyroid...... 261 nifedipine...... 92 NORVASC...... 92 NPLATE...... 166 nifedipine er...... 92 NORVIR...... 86 NUBEQA...... 75 nifedipine er osmotic release..... 92 NOURIANZ...... 80 NUCALA...... 39 Nikki...... 102 NOURISH...... 144 NUCARACLINPAK...... 125 NILANDRON...... 75 NOVA MAX BLOOD NUCARARXPAK...... 125 nilutamide...... 75 GLUCOSE SYSTEM...... 201 NUCYNTA...... 30 nimodipine...... 92 NUCYNTA ER...... 30 292 NUDERMRXPAK 120...... 125 O-CAL PRENATAL...... 230 ONE-A-DAY WOMENS NUDERMRXPAK 60...... 125 OCALIVA...... 155 PRENATAL 1...... 230 Nudiclo Solupak...... 125 Ocella...... 103 ONETOUCH CLUB Nudiclo Tabpak...... 22 OCREVUS...... 256 LANCETS FINE PT...... 201 NUDROXIPAK...... 22 OCTAGAM...... 248 ONETOUCH DELICA NUDROXIPAK DSDR-50.... 22 octreotide acetate...... 149 LANCETS 30G...... 201 NUDROXIPAK DSDR-75.... 23 ODACTRA...... 19 ONETOUCH DELICA NUDROXIPAK E-400...... 23 ODEFSEY...... 86 LANCETS 33G...... 201 NUDROXIPAK I-800...... 23 ODOMZO...... 76 ONETOUCH DELICA NUDROXIPAK M-15...... 23 OFEV...... 258 LANCING DEV...... 201 NUDROXIPAK N-500...... 23 ofloxacin...... 153, 244, 247 ONETOUCH DELICA NUEDEXTA...... 256 OGIVRI...... 76 PLUS LANCET30G...... 201 NUFERA...... 166 olanzapine...... 83 ONETOUCH DELICA Nufol...... 166 olanzapine-fluoxetine hcl...... 256 PLUS LANCET33G...... 201 Nulev...... 263 olive oil...... 96 ONETOUCH DELICA NUMOISYN...... 225 olmesartan medoxomil...... 65 PLUS LANCING...... 201 NUPLAZID...... 82 olmesartan medoxomil-hctz...... 65 ONETOUCH SURESOFT NURTEC...... 219 olmesartan-amlodipine-hctz...... 66 LANCING DEV...... 201 NUSURGEPAK olopatadine hcl...... 238, 244 ONETOUCH ULTRA...... 140 SURGICAL PREP/CARE....125 OLUMIANT...... 23 ONETOUCH ULTRA 2...... 202 NUTRASEB...... 125 OLUX-E...... 125 ONETOUCH ULTRA MINI NUTRICAP...... 230 OMECLAMOX-PAK...... 263 ...... 202 Nutrifac Zx...... 230 omega-3 rx complete...... 62 ONETOUCH ULTRALINK202 NUTRILIPID...... 239 OMEGA-3/D-3 WELLNESS ONETOUCH ULTRASOFT NUTRIVIT...... 230 PACK...... 62 LANCETS...... 202 NUTROPIN AQ NUSPIN 10 omega-3-acid ethyl esters...... 62 ONETOUCH VERIO... 140, 202 ...... 149 OMEGAVEN...... 240 ONETOUCH VERIO FLEX NUTROPIN AQ NUSPIN 20 omeprazole...... 263 SYSTEM...... 202 ...... 149 omeprazole-sodium ONETOUCH VERIO IQ NUTROPIN AQ NUSPIN 5 149 bicarbonate...... 263 SYSTEM...... 202 NUVAIL...... 125 OMNARIS...... 238 ONETOUCH VERIO NUVARING...... 103 OMNIFLEX DIAPHRAGM201 REFLECT...... 202 NUVESSA...... 266 OMNIPAQUE...... 140 ONETOUCH VERIO SYNC NUVIGIL...... 18 OMNIPOD DASH 5 PACK SYSTEM...... 202 NUWIQ...... 161 PODS...... 201 onevite...... 230 NUZYRA...... 260 OMNIPOD STARTER...... 201 ONEXTON...... 125 Nyamyc...... 125 OMNITROPE...... 149 ONFI...... 45 NYMALIZE...... 92 OMNITROPE PEN 10 INJ ONGLYZA...... 55 nystatin...... 60, 125, 225 DEVICE...... 201 ONUREG...... 76 nystatin-triamcinolone...... 125 OMNITROPE PEN 5 INJ ONZETRA XSAIL...... 219 Nystop...... 125 DEVICE...... 201 OPANA...... 30 OB COMPLETE...... 230 omnivex...... 144 OPCICON ONE-STEP...... 103 OB COMPLETE ONE...... 230 ONCASPAR...... 76 opium...... 57 OB COMPLETE PETITE.... 230 ondansetron...... 59 OPSUMIT...... 93 OB COMPLETE PREMIER 230 ondansetron hcl...... 59 OPTION 2...... 103 OB COMPLETE/DHA...... 230 ONE A DAY PRENATAL.. 230 OPTIONS GYNOL II obizur...... 161 one drop blood glucose monitor CONTRACEPTIVE...... 266 OBSTETRIX DHA...... 230 ...... 201 OPTIUM BLOOD OBSTETRIX EC...... 230 one drop test...... 140 GLUCOSE MONITOR...... 202 OBSTETRIX ONE...... 230 293 OPTIUM GLUCOSE OXTELLAR XR...... 45 PARADIGM SILHOUETTE MONITOR SYSTEM...... 202 oxybutynin chloride...... 264 COMBO 23"...... 203 OPTIUM TEST...... 140 oxybutynin chloride er...... 264 PARADIGM SILHOUETTE OPTIUMEZ TEST...... 140 oxycodone hcl...... 31 FULL 23"...... 203 ORA-BLEND...... 251 oxycodone hcl er...... 31 PARADIGM SURE-T 23" ORA-BLEND SF...... 251 oxycodone-acetaminophen...... 31 6MM...... 203 ORACEA...... 125 oxycodone-aspirin...... 31 PARADIGM SURE-T 23" ORACIT...... 157 OXYCONTIN...... 31 8MM...... 203 ORAFATE...... 225 oxymorphone hcl...... 31 PARAGARD ORALAIR...... 19 oxymorphone hcl er...... 31 INTRAUTERINE COPPER 103 Oralone...... 225 OXYTROL...... 265 PARAPLATIN...... 76 ORA-PLUS...... 251 OZEMPIC (0.25 OR 0.5 PAREMYD...... 244 ORA-SWEET...... 251 MG/DOSE)...... 55 paricalcitol...... 149 ORA-SWEET SF...... 251 OZEMPIC (1 MG/DOSE)...... 55 Paroex...... 225 ORAVIG...... 225 OZURDEX...... 244 paromomycin sulfate...... 19 ORENCIA...... 23 Pacerone...... 36 paroxetine hcl...... 48 ORENCIA CLICKJECT...... 23 paclitaxel...... 76 paroxetine hcl er...... 48 ORENITRAM...... 93 paingo kft...... 126 paroxetine mesylate...... 256 ORFADIN...... 149 paliperidone er...... 83 PARSABIV...... 149 ORIAHNN...... 153 PALYNZIQ...... 149 PASER...... 69 ORILISSA...... 149 PANCREAZE...... 145 PAXIL...... 49 ORKAMBI...... 259 PANDEL...... 126 PAXIL CR...... 49 ORMECA...... 125 PANRETIN...... 126 PAZEO...... 244 orphenadrine citrate er...... 237 pantoprazole sodium...... 263 pc lancets super thin 30g...... 203 orphenadrine-asa-caffeine...... 237 PANZYGA...... 248 pc unifine pentips...... 203 Orphengesic Forte...... 237 PARADIGM PUMP PCCA SWEET-SF...... 251 Orsythia...... 103 RESERVOIR 1.8ML...... 202 PCCA SYRUP VEHICLE.... 251 ortho df...... 166 PARADIGM PUMP PCCA-PLUS...... 251 ORTHO TRI-CYCLEN LO. 103 RESERVOIR 3ML...... 202 PCP 100...... 171 ORTHOVISC...... 237 PARADIGM QUICK-SET peanut oil...... 96 oscimin...... 263 18" 6MM...... 202 peg 3350-kcl-na bicarb-nacl.... 171 oscimin sr...... 263 PARADIGM QUICK-SET peg-3350/electrolytes...... 171 oseltamivir phosphate...... 86, 87 23" 6MM...... 202 PEGASYS...... 87 OSENI...... 55 PARADIGM QUICK-SET PEGINTRON...... 87 OSMOLEX ER...... 80 23" 9MM...... 202 Peg-Prep...... 171 OSMOPREP...... 171 PARADIGM QUICK-SET pen needles...... 203 OSPHENA...... 149 32" 6MM...... 202 pen needles 1/2"...... 203 OTEZLA...... 23 PARADIGM QUICK-SET pen needles 3/16"...... 203 OTIPRIO...... 247 32" 9MM...... 202 pen needles 5/16"...... 203 OTOVEL...... 247 PARADIGM QUICK-SET penicillamine...... 223 OTREXUP...... 23 43" 6MM...... 202 penicillin v potassium...... 249 OVACE PLUS...... 125 PARADIGM QUICK-SET PENLEN...... 126 OVIDREL...... 149 43" 9MM...... 203 PENLET II BLOOD oxandrolone...... 33 PARADIGM REAL-TIME SAMPLER...... 203 oxaprozin...... 23 TRANSMITTER...... 203 PENLET II OXAYDO...... 30 PARADIGM SILHOUETTE REPLACEMENT CAP...... 203 oxazepam...... 35 18" 13MM...... 203 PENNSAID...... 126 oxcarbazepine...... 45 PARADIGM SILHOUETTE PENTASA...... 155 oxiconazole nitrate...... 125 32" 17MM...... 203 pentazocine-naloxone hcl...... 31 OXISTAT...... 125 PENTIPS...... 203 294 pentoxifylline er...... 161 PICATO...... 126 POLY-VI-FLOR/IRON...... 231 PERCOCET...... 31 PICO WOUND THERAPY POMALYST...... 76 PERFECT LANCETS 28G.. 203 SYSTEM...... 126 Portia-28...... 104 PERFECT LANCETS 30G.. 203 PIFELTRO...... 87 PORTRAZZA...... 76 PERFOROMIST...... 39 pilocarpine hcl...... 225, 244 posaconazole...... 60 perindopril erbumine...... 66 pimecrolimus...... 126 pot & sod cit-cit ac...... 157 Periogard...... 225 pimozide...... 256 POTABA...... 268 PERJETA...... 76 Pimtrea...... 103 potassium chloride...... 221, 222 permethrin...... 126 pindolol...... 90 potassium chloride crys er...... 221 perphenazine...... 83 pioglitazone hcl...... 55 potassium chloride er...... 221 perphenazine-amitriptyline..... 256 pioglitazone hcl-glimepiride...... 55 potassium citrate er...... 157 PERSERIS...... 83 pioglitazone hcl-metformin hcl..55 potassium citrate-citric acid....157 PERTZYE...... 145 pip lancets 28g...... 204 povidone-iodine...... 244 PEXEVA...... 49 pip lancets 30g...... 204 PR BENZOYL PEROXIDE.126 PFIZERPEN...... 250 PIQRAY (200 MG DAILY Pr Benzoyl Peroxide Wash.....126 ph strips...... 140 DOSE)...... 76 PR CREAM...... 126 PHARMACIST CHOICE PIQRAY (250 MG DAILY PRADAXA...... 42 AUTOCODE...... 140 DOSE)...... 76 PRALUENT...... 63 PHARMACIST CHOICE PIQRAY (300 MG DAILY pramipexole dihydrochloride.....80 AUTOCODE SYS...... 203 DOSE)...... 76 pramipexole dihydrochloride er.80 PHARMACIST CHOICE Pirmella 1/35...... 103 PRAMOX...... 126 LANCETS...... 203 Pirmella 7/7/7...... 103 prasugrel hcl...... 161 PHARMACIST CHOICE piroxicam...... 23 pravastatin sodium...... 63 MINI SYSTEM...... 203 PKU EASY...... 144 praziquantel...... 34 pharmacist choice no coding... 140 PLAQUENIL...... 69 prazosin hcl...... 66 PHARMACY COUNTER PLAVIX...... 161 PRE & POST SX POUCH.... 126 LANCETS...... 204 PLEGRIDY...... 256, 257 PRECEDEX...... 169 Phenazo...... 157 PLEGRIDY STARTER PRECISION LINK...... 204 phenelzine sulfate...... 49 PACK...... 256 PRECISION PCX...... 140 phenobarbital...... 169 PLENVU...... 171 PRECISION PCX PLUS phenoxybenzamine hcl...... 66 PLIAGLIS...... 126 TEST...... 140 phenylephrine hcl...... 244, 267 pnv tabs 29-1...... 230 PRECISION POINT OF phenylephrine hcl (pressors)...267 pnv-dha...... 230 CARE TEST...... 140 phenytoin...... 45 pnv-dha+docusate...... 230 PRECISION QID phenytoin sodium extended...... 45 pnv-omega...... 230 MONITOR...... 204 PHESGO...... 76 pnv-select...... 230 PRECISION QID TEST...... 140 Philith...... 103 POCKETCHEM EZ PRECISION SOF-TACT PHLAG SPRAY...... 126 SYSTEM...... 204 MONITOR...... 204 PHOSLYRA...... 155 POCKETCHEM EZ TEST...140 PRECISION SOF-TACT Phospha 250 Neutral...... 221 pod-care 100c...... 107 TEST...... 140 Phosphasal...... 67 podofilox...... 126 PRECISION SUREDOSE PHOSPHOLINE IODIDE....244 POLIVY...... 76 PLUS SYR...... 204 phosphorous...... 221 Polycin...... 244 PRECISION SURE-DOSE Phospho-Trin 250 Neutral.....221 poly-iron 150 forte...... 166 SYRINGE...... 204 PHOTREXA VISCOUS...... 244 polymyxin b-trimethoprim...... 244 PRECISION XTRA...... 204 PHOTREXA-PHOTREXA polypeg...... 251 PRECISION XTRA BLOOD VISCOUS KIT...... 244 polysaccharide iron forte...... 166 GLUCOSE...... 140 Physiolyte...... 223 polytoza patch...... 204 PRECISION XTRA Physiosol Irrigation...... 223 POLY-VI-FLOR...... 231 KETONE...... 140 phytonadione...... 267 POLY-VI-FLOR FS...... 230, 231 295 PRECISION XTRA PRENATE RESTORE...... 232 pro voice v9 glucose system.....205 MONITOR...... 204 PREPIDIL...... 247 PROAIR DIGIHALER...... 39 PRED FORTE...... 245 prepiv supply...... 126 PROAIR HFA...... 39 PRED MILD...... 245 preplus...... 232 PROAIR RESPICLICK...... 39 PRED-G...... 245 PRESERA...... 126 probenecid...... 158 PRED-G S.O.P...... 245 pressure activat safety lancet.. 204 probichew...... 57 prednicarbate...... 126 PRESTALIA...... 66 PROBUPHINE IMPLANT prednisolone...... 107 pretab...... 232 KIT...... 31 prednisolone acetate...... 245 pretomanid...... 69 PRO-C-DURE 6...... 108 prednisolone acetate p-f...... 245 PREVACID...... 263 prochlorperazine...... 83 prednisolone sodium phosphate Prevalite...... 63 prochlorperazine edisylate...... 83 ...... 107, 245 PREVENT SAFETY PEN prochlorperazine maleate...... 83 prednisolone-gatifloxacin...... 245 NEEDLES...... 204 PROCORT...... 34 prednisone...... 108 PREVENTEZA...... 104 PROCRIT...... 167 PREDNISONE INTENSOL 108 PREVIDENT...... 226 pro-critic...... 144 preferred plus insulin syringe...204 PREVIDENT 5000 PROCTOFOAM HC...... 34 preferred plus lancets colored..204 BOOSTER PLUS...... 226 Procto-Med Hc...... 34 preferred plus lancets thin...... 204 PREVIDENT 5000 DRY Procto-Pak...... 34 preferred plus unifine pentips.. 204 MOUTH...... 226 Proctozone-Hc...... 34 PREFEST...... 153 PREVIDENT 5000 PROCYSBI...... 157, 158 pregabalin...... 45 ENAMEL PROTECT...... 226 prodigen...... 57 pregenna...... 231 PREVIDENT 5000 ORTHO PRODIGY AUTOCODE PREMARIN...... 153, 266 DEFENSE...... 226 BLOOD GLUCOSE...... 205 PREMESISRX...... 231 PREVIDENT 5000 PLUS.....226 PRODIGY INSULIN premium blood glucose test..... 140 PREVIDENT 5000 SYRINGE...... 205 premium scar...... 126 SENSITIVE...... 226 PRODIGY LANCETS 28G..205 PREMPHASE...... 153 PREVIDOLRX PRODIGY LANCING PREMPRO...... 153 ANALGESIC...... 23 DEVICE...... 205 prena 1 true...... 231 Previfem...... 104 PRODIGY NO CODING prena1...... 231 PREVYMIS...... 87 BLOOD GLUC...... 141 prena1 pearl...... 231 PREZCOBIX...... 87 PRODIGY POCKET prenaissance...... 231 PREZISTA...... 87 BLOOD GLUCOSE...... 205 prenaissance plus...... 231 PRIFTIN...... 70 PRODIGY SAFETY PRENATABS RX...... 231 PRILOSEC...... 263 LANCETS 26G...... 205 prenatal...... 231 PRIMACARE...... 232 PRODIGY VOICE BLOOD prenatal + complete multi...... 231 primaquine phosphate...... 69 GLUCOSE...... 205 prenatal 19...... 231 primidone...... 45 PROFILNINE...... 162 prenatal gummies/dha & fa..... 231 PRIMLEV...... 31 progesterone...... 252 prenatal multi +dha...... 231 PRIMSOL...... 68 progesterone compounding kit.252 prenatal plus iron...... 231 PRISTIQ...... 49 progesterone micronized...... 252 prenatal vitamin plus low iron. 231 PRIVIGEN...... 249 PROGLYCEM...... 55 PRENATAL-U...... 231 PRIZOTRAL...... 126 PROGRAF...... 223 PRENATE...... 232 pro comfort alcohol...... 204 PROLASTIN-C...... 259 PRENATE AM...... 231 PRO COMFORT INSULIN PROLENSA...... 245 PRENATE DHA...... 232 SYRINGE...... 204 PROLEUKIN...... 76 PRENATE ELITE...... 232 pro comfort lancets 30g...... 205 PROLIA...... 149 PRENATE ENHANCE...... 232 pro comfort lancets 31g...... 205 PROMACTA...... 167 PRENATE ESSENTIAL...... 232 pro comfort pen needles...... 205 PROMACTIN AA PLUS PRENATE MINI...... 232 pro voice v8 glucose system.....205 20PE...... 144 PRENATE PIXIE...... 232 pro voice v8/v9 glucose...... 140 promethazine hcl...... 61 296 promethazine-codeine...... 109 px enteric aspirin...... 26 quinine sulfate...... 69 promethazine-dm...... 109 px extra short pen needles...... 205 QUINIXIL...... 127 promethazine-phenyleph- px insulin syringe...... 205 QUINJA...... 127 codeine...... 109 px lancet auto injector...... 205 QUINTET AC BLOOD promethazine-phenylephrine... 109 px lancets ultra thin...... 205 GLUCOSE...... 206 Promethegan...... 61 px mini pen needles...... 205 QUINTET AC BLOOD PROMETHEGAN...... 61 px pen needle...... 205 GLUCOSE TEST...... 141 PROMISEB...... 127 px shortlength pen needles...... 205 QUINTET BLOOD propafenone hcl...... 36 PYLERA...... 264 GLUCOSE SYSTEM...... 206 propafenone hcl er...... 36 pyrazinamide...... 70 QUINTET BLOOD propantheline bromide...... 263 pyridostigmine bromide...... 69 GLUCOSE TEST...... 141 proparacaine hcl...... 245 pyridostigmine bromide er...... 69 QUTENZA...... 127 proparacaine-fluorescein...... 245 pyridoxine hcl...... 268 QUTENZA (2 PATCH)...... 127 propranolol hcl...... 90 pyrimethamine...... 69, 96 QVAR REDIHALER...... 39 propranolol hcl er...... 90 pyrogallic acid...... 127 ra alcohol swabs...... 206 propranolol-hctz...... 66 QBRELIS...... 66 ra aspirin adult low dose...... 26 propylthiouracil...... 261 QBREXZA...... 127 ra aspirin childrens...... 26 PROSTIN E2...... 247 qc advanced lancing device...... 205 ra aspirin ec adult low st...... 26 PROTHELIAL...... 226 qc alcohol swabs...... 205 ra blood glucose monitor...... 206 PROTONIX...... 263, 264 qc childrens aspirin...... 26 ra childrens aspirin...... 26 PROTOPIC...... 127 qc gentle laxative...... 171 RA E-ZJECT COLOR protriptyline hcl...... 49 qc lancets super thin 30g...... 205 LANCETS 33G...... 206 PROTYL AG...... 127 qc lancets ultra thin...... 206 RA E-ZJECT LANCETS provad...... 57 qc pen needles...... 206 28G...... 206 PROVAYBLUE...... 58 qc unifine pentips...... 206 RA E-ZJECT LANCETS PROVENTIL HFA...... 39 qc unilet lancets 28g...... 206 THIN 26G...... 206 PROVERA...... 252 qc unilet lancets micro thin..... 206 RA E-ZJECT LANCETS PROVIDA OB...... 232 QMIIZ ODT...... 23 THIN 28G...... 206 PROVOCHOLINE...... 141 QNASL...... 238 RA E-ZJECT LANCETS PROZAC...... 49 QNASL CHILDRENS...... 238 ULTRA THIN...... 206 PRUCLAIR...... 127 QSYMIA...... 18 ra fast relief laxative...... 171 PRUMYX...... 127 QTERN...... 55 ra insulin syringe...... 206 pseudoeph-bromphen-dm...... 109 quad-mix...... 93 ra laxative...... 171 psorcon...... 127 quazepam...... 169 ra mini nicotine...... 257 PSS SELECT GP LANCETS205 quetiapine fumarate...... 83 ra nicotine...... 257 PSS SELECT PLATFORMS 205 quetiapine fumarate er...... 83 ra nicotine polacrilex...... 257 PSS SELECT SAFETY QUFLORA FE...... 232 ra pen needles...... 206 LANCETS...... 205 QUFLORA FE PEDIATRIC ra stimulant laxative...... 171 PTS PANELS GLUCOSE ...... 232 RA TRUE2GO BLOOD TEST...... 141 QUFLORA GUMMIES...... 232 GLUCOSE...... 206 PTS PANELS KETONE QUFLORA PEDIATRIC.....232 RA TRUERESULT BLOOD TEST...... 141 QUICKTEK...... 206 GLUCOSE...... 206 PULMICORT QUICKTEK TEST...... 141 RA TRUETEST TEST...... 141 FLEXHALER...... 39 QUICKTEK/METER...... 206 rabeprazole sodium...... 264 PULMOZYME...... 259 QUILLICHEW ER...... 18 RADIAGEL...... 127 purified water...... 251 QUILLIVANT XR...... 18 RADIOGARDASE...... 58 PURIXAN...... 76 quinapril hcl...... 66 RAGWITEK...... 19 push button safety lancets...... 205 quinapril-hydrochlorothiazide...66 raloxifene hcl...... 149 push button safety lancets 28g.205 quinidine gluconate er...... 36 ramelteon...... 169 px aspirin...... 26 quinidine sulfate...... 36 ramipril...... 66 297 ranolazine er...... 35 REFUAH PLUS BLOOD RELION ULTIMA RAPAFLO...... 158 GLUCOSE TEST...... 141 GLUCOSE SYSTEM...... 208 RAPAMUNE...... 223 REFUAH PLUS RELION ULTIMA TEST.... 141 RAPIVAB...... 87 MONITORING SYSTEM... 206 RELION ULTRA THIN RAPPORT RLS...... 206 REGENECARE...... 127 LANCETS 30G...... 208 RAPPORT VTD...... 206 REGIOCIT...... 42 RELION ULTRA THIN rasagiline mesylate...... 80 REGRANEX...... 127 PLUS LANCETS...... 208 RASUVO...... 24 RELENZA DISKHALER...... 87 RELISTOR...... 155 RAVICTI...... 150 RELEXXII...... 18 relnate dha...... 232 RAYALDEE...... 150 RELION ALL-IN-ONE...... 207 remdesivir...... 87 RAYOS...... 108 RELION BLOOD REMERON...... 49 REACT...... 104 GLUCOSE TEST...... 141 REMESENSE...... 208 READI-CAT 2...... 141 RELION CONFIRM REMICADE...... 156 READYLANCE SAFETY GLUCOSE MONITOR...... 207 remigen...... 127 LANCETS...... 206 RELION REMODULIN...... 93 READYSHARP ANESTH + CONFIRM/MICRO TEST...141 RENACIDIN...... 158 DEXAMETH...... 108 RELION INSULIN RENATABS...... 232 READYSHARP ANESTH + SYRINGE...... 207 RENATABS WITH IRON...232 KETOROLAC...... 24 RELI-ON INSULIN RENFLEXIS...... 156 READYSHARP ANESTH + SYRINGE...... 207 reno caps...... 232 METHYLPRED...... 108 RELION KETONE...... 141 repaglinide...... 55 READYSHARP RELION KETONE TEST....141 REPATHA...... 63 BETAMETHASONE...... 108 RELION LANCET REPATHA PUSHTRONEX READYSHARP DEVICES 30G...... 207 SYSTEM...... 63 DEXAMETHASONE...... 108 RELION LANCETS REPATHA SURECLICK...... 63 READYSHARP MICRO-THIN 33G...... 207 REQ 49+...... 233 KETOROLAC...... 24 RELION LANCETS RESECTISOL...... 158 READYSHARP-A...... 172 STANDARD 21G...... 207 RESET FOR IOS OR reality insulin syringe...... 206 RELION LANCETS THIN ANDROID APP...... 223 reality lancets...... 206 26G...... 207 RESET-O FOR IOS OR reality swabs...... 206 RELION LANCETS ANDROID APP...... 223 reality trigger lancets...... 206 ULTRA-THIN 30G...... 207 resorcinol-sulfur...... 127 REBIF...... 257 RELION LANCING RESTASIS...... 245 REBIF REBIDOSE...... 257 DEVICE...... 207 RESTASIS MULTIDOSE....245 REBIF REBIDOSE RELION MICRO...... 207 RESTORA RX...... 57 TITRATION PACK...... 257 RELION MINI PEN RESTORE SILVER REBIF TITRATION PACK 257 NEEDLES...... 207 DRESSING...... 127 REBINYN...... 162 RELION PEN NEEDLES....207 RETACRIT...... 167 REBLOZYL...... 167 RELION PREMIER BLU RETAVASE...... 162 RECARBRIO...... 68 MONITOR...... 207 RETAVASE HALF-KIT...... 162 RECEDO...... 127 RELION PREMIER RETEVMO...... 76 reck...... 172 COMPACT SYSTEM...... 207 RETIN-A MICRO...... 127 RECLAST...... 150 RELION PREMIER VOICE RETIN-A MICRO PUMP....128 Reclipsen...... 104 MONITOR...... 207 REVATIO...... 93 RECOMBINATE...... 162 RELION PRIME revesta...... 167 RECOTHROM...... 168 MONITOR...... 207 REVLIMID...... 223 RECOTHROM SPRAY KIT RELION PRIME TEST...... 141 REXALL BLOOD ...... 168 RELION SHORT PEN GLUCOSE SYSTEM...... 208 RECTIV...... 34 NEEDLES...... 207 REXALL BLOOD RECURA...... 127 GLUCOSE TEST...... 141 298 REXASIL PATCH & ROCKLATAN...... 245 SAPHRIS...... 83 VITAMIN E LIQ...... 128 romidepsin...... 76 saps care alcohol prep...... 208 REXULTI...... 83 ROPIDEX...... 108 saps health care alcohol prep...208 REYATAZ...... 87 ropinirole hcl...... 80 saps health twist top lancets....208 REYVOW...... 219 ropinirole hcl er...... 80 saps twist top lancets...... 208 RHEUMATE...... 144 Rosadan...... 128 sapscare twist top lancets...... 208 RHOFADE...... 128 ROSE GLO...... 245 SARCLISA...... 77 RHOPHYLAC...... 249 rosuvastatin calcium...... 63 SAVAYSA...... 42 RHOPRESSA...... 245 ROTARIX...... 265 SAVELLA...... 257 RIAX...... 128 ROTATEQ...... 265 SAVELLA TITRATION ribavirin...... 87 Roweepra...... 45 PACK...... 257 ribozel...... 144 ROXICODONE...... 31 sb alcohol prep...... 208 RIDAURA...... 24 ROZEREM...... 169 sb bisacodyl laxative ec...... 171 rifabutin...... 70 ROZLYTREK...... 76 sb childrens aspirin...... 27 rifampin...... 70 RTD WOUND CARE sb insulin syringe...... 208 RIFAMPIN+SYRSPEND DRESSING...... 128 sb lancets thin...... 209 SF...... 70 RUBRACA...... 76 sb lancets ultra thin...... 209 RIGHTEST ALTERNATE RUCONEST...... 162 sb laxative...... 171 SITE ADAPT...... 208 RUZURGI...... 69 scarcin...... 128 RIGHTEST GD500 RYBELSUS...... 55 scarsilk...... 128 LANCING DEVICE...... 208 RYCLORA...... 61 SCARZEN SKIN REPAIR.. 128 RIGHTEST GL300 RYDAPT...... 77 SCENESSE...... 128 LANCETS...... 208 RYTARY...... 80 scopolamine...... 59 RIGHTEST GM100 BLOOD RYVENT...... 61 SEBUDERM...... 128 GLUCOSE...... 208 SABRIL...... 45 SECONAL...... 169 RIGHTEST GM300 BLOOD SAFESNAP INSULIN SEEBRI NEOHALER...... 40 GLUCOSE...... 208 SYRINGE...... 208 SEGLUROMET...... 56 RIGHTEST GM550 BLOOD SAFE-T-LANCE...... 208 select-lite lancing device...... 209 GLUCOSE...... 208 SAFE-T-LANCE PLUS...... 208 SELECT-OB...... 233 RIGHTEST GS100 BLOOD safety insulin syringes...... 208 SELECT-OB+DHA...... 233 GLUCOSE...... 141 safety lancet 23g/pressure act. 208 selegiline hcl...... 80 RIGHTEST GS300 BLOOD safety lancet 30g/pressure act. 208 selenium sulfide...... 128 GLUCOSE...... 141 SAFETY LET LANCETS.... 208 SELZENTRY...... 87 RIGHTEST GS550 BLOOD SAFETY SEAL LANCETS..208 SEMPREX-D...... 109 GLUCOSE...... 141 safflower oil...... 96 se-natal 19...... 233 riluzole...... 239 SAFYRAL...... 104 SENSIPAR...... 150 rimantadine hcl...... 87 SAIZEN...... 150 SEREVENT DISKUS...... 40 RIMSO-50...... 158 SAIZENPREP...... 150 SERNIVO...... 128 ringers irrigation...... 223 SALAGEN...... 226 SEROQUEL XR...... 83 RINVOQ...... 24 salimez...... 128 SEROSTIM...... 150 RIOMET...... 55 salimez forte...... 128 sertraline hcl...... 49 risedronate sodium...... 150 SALIVAMAX...... 226 sesame oil...... 96 RISPERDAL CONSTA...... 83 salsalate...... 27 Setlakin...... 104 risperidone...... 83 SAMSCA...... 150 sevelamer carbonate...... 156 ritonavir...... 87 SANCUSO...... 59 sevelamer hcl...... 156 rivastigmine...... 257 SANDIMMUNE...... 224 SEVENFACT...... 162 rivastigmine tartrate...... 257 SANDOSTATIN...... 150 sevoflurane...... 156 Rivelsa...... 104 SANDOSTATIN LAR SEYSARA...... 260 rixubis...... 162 DEPOT...... 150 sf...... 226 rizatriptan benzoate...... 219 SANTYL...... 128 sf 5000 plus...... 226 299 SFROWASA...... 156 SLYND...... 104 sodium polystyrene sulfonate.. 224 Sharobel...... 104 sm alcohol prep...... 209 sodium saccharin...... 144 SHOPKO ALCOHOL sm aspirin adult low strength.... 27 sodium sulfacetamide wash..... 128 SWABS...... 209 sm childrens aspirin...... 27 sofosbuvir-velpatasvir...... 87 SHOPKO AUTOLET sm folic acid...... 167 solifenacin succinate...... 265 LANCING DEVICE...... 209 sm gentle laxative...... 171 SOLIQUA...... 56 SHOPKO UNIFINE sm lancets 33g...... 209 SOLIRIS...... 162 PENTIPS...... 209 sm laxative...... 171 SOLOSEC...... 19 SHOPKO UNIFINE sm nicotine...... 257 SOLTAMOX...... 77 PENTIPS PLUS...... 209 sm nicotine polacrilex...... 257 SOLUS V2 BLOOD SHUR-SEAL SM TRUEDRAW GLUCOSE SYSTEM...... 210 CONTRACEPTIVE...... 266 LANCING DEVICE...... 209 SOLUS V2 LANCETS 28G.. 210 side button safety lancet...... 209 SMART DIABETES SOLUS V2 LANCING SIDEROL...... 233 VANTAGE LANCING...... 209 DEVICE...... 210 SIGNIFOR...... 150 SMART SENSE COLOR SOLUS V2 TEST...... 142 SIGNIFOR LAR...... 150 LANCETS 33G...... 209 SOLUS V2 TWIST SIKLOS...... 167 SMART SENSE PREMIUM LANCETS 30G...... 210 sildenafil citrate...... 93 SYSTEM...... 209 SOMATULINE DEPOT...... 150 SILENOR...... 169 SMART SENSE PREMIUM SOMAVERT...... 150 SILHOUETTE 13MM...... 209 TEST...... 141 SOOLANTRA...... 129 SILHOUETTE 17MM...... 209 SMART SENSE SOOTHEE...... 129 SILHOUETTE INFUSION STANDARD LANCETS..... 209 sorbitol...... 158, 251 SET 23"...... 209 SMART SENSE SUPER sorbitol-mannitol...... 158 SILHOUETTE INFUSION THIN LANCETS...... 209 SORIATANE...... 129 SET 43"...... 209 SMART SENSE THIN SORILUX...... 129 silipac...... 128 LANCETS 26G...... 209 Sorine...... 90 SILIQ...... 128 SMART SENSE VALUE sorrel/dock mix...... 19 silivex...... 209 GLUCOSE SYS...... 209 sotalol hcl...... 90 silodosin...... 158 SMART SENSE VALUE sotalol hcl (af)...... 90 SILTREX...... 209 TEST...... 142 SOTYLIZE...... 90 silver sulfadiazine...... 128 SMARTEST BLOOD SOVALDI...... 87 SIMBRINZA...... 245 GLUCOSE TEST...... 142 soybean oil...... 96 Simliya...... 104 SMARTEST EJECT...... 209 spg supposi-base...... 251 Simpesse...... 104 SMARTEST EJECT spinosad...... 129 SIMPLE DIAGNOSTICS STARTER...... 210 SPIRIVA HANDIHALER.....40 LANCING DEV...... 209 SMARTEST LANCETS 28G SPIRIVA RESPIMAT...... 40 simple syrup...... 251 ...... 210 spironolactone...... 146 SIMPONI...... 24 SMARTEST PERSONA spironolactone-hctz...... 146 SIMPONI ARIA...... 24 STARTER...... 210 SPRAVATO (56 MG DOSE). 49 simvastatin...... 63 SMARTEST PRONTO SPRAVATO (84 MG DOSE). 49 SINGLE-LET...... 209 STARTER...... 210 Sprintec 28...... 104 SINGULAIR...... 40 SMARTEST PROTEGE...... 210 SPRITAM...... 45 SINUVA...... 238 SMARTEST PROTEGE SPRIX...... 24 sirolimus...... 224 STARTER...... 210 SPRYCEL...... 77 SIRTURO...... 70 sod citrate-citric acid...... 158 Sps...... 224 SITAVIG...... 87 sodium bicarbonate...... 34 sr nicotine...... 257 SIVEXTRO...... 68 sodium chloride...... 109, 158 Sronyx...... 104 SKLICE...... 128 sodium fluoride...... 222 Ssd...... 129 SKYLA...... 104 sodium hyaluronate...... 128, 237 ST JOSEPH LOW DOSE...... 27 SKYRIZI (150 MG DOSE).. 128 sodium phenylbutyrate...... 150 stavudine...... 87 300 STEGLATRO...... 56 SUPRAX...... 95 SUSPENDRX STEGLUJAN...... 56 SUPREME TEST...... 142 W/BITTERBLOC STELARA...... 129, 156 SUPREP BOWEL PREP KIT UNSWEET...... 251 STENDRA...... 94 ...... 171 suspension vehicle...... 251 STERILANCE PA...... 210 sure comfort alcohol prep...... 210 SUSTOL...... 59 STERILANCE TL...... 210 sure comfort insulin syringe.... 210 SUTENT...... 77 sterile water for irrigation...... 224 sure comfort lancets 18g...... 210 suvicort...... 129 STIMATE...... 150 sure comfort lancets 21g...... 210 SX1 MEDICATED POST- STIOLTO RESPIMAT...... 40 sure comfort lancets 23g...... 210 OPERATIVE...... 129 STIVARGA...... 77 sure comfort lancets 30g...... 210 Syeda...... 104 STRIBILD...... 88 sure comfort lancing pen...... 210 SYLVANT...... 224 STRIVERDI RESPIMAT...... 40 sure comfort pen needles...... 210 SYMAX DUOTAB...... 264 STROVITE FORTE...... 233 SURE EDGE GLUCOSE Symax-Sr...... 264 SUBLOCADE...... 31 MONITOR...... 211 SYMBICORT...... 40 SUBOXONE...... 31 SURE EDGE TEST...... 142 SYMDEKO...... 259 SUBSYS...... 31 sure result o3d3 system...... 63 SYMFI...... 88 Subvenite...... 45 SURECHEK BLOOD SYMFI LO...... 88 Subvenite Starter Kit-Blue...... 45 GLUCOSE MONITOR...... 211 SYMJEPI...... 267 Subvenite Starter Kit-Green....45 SURECHEK BLOOD SYMLINPEN 120...... 56 Subvenite Starter Kit-Orange.. 45 GLUCOSE TEST...... 142 SYMLINPEN 60...... 56 SUCRAID...... 145 SURE-FINE PEN SYMPAZAN...... 45 sucralfate...... 264 NEEDLES...... 211 SYMPROIC...... 156 sulconazole nitrate...... 129 SURE-JECT INSULIN SYMTUZA...... 88 sulfacetamide sodium...... 245 SYRINGE...... 211 SYNAGEX...... 233 sulfacetamide sodium (acne).. 129 SURE-LANCE FLAT SYNAGIS...... 249 sulfacetamide sodium-sulfur....129 LANCETS...... 211 SYNALAR...... 129 sulfacetamide-prednisolone..... 245 SURE-LANCE LANCETS SYNAREL...... 151 sulfadiazine...... 259 26G...... 211 SYNDROS...... 59 sulfamethoxazole-trimethoprim 68 SURELITE LANCETS...... 211 SYNERA...... 129 sulfamez wash...... 129 SURE-PEN...... 211 SYNERDERM...... 129 SULFAMYLON...... 129 SURE-T INFUSION SET SYNJARDY...... 56 sulfasalazine...... 156 18"...... 211 SYNJARDY XR...... 56 Sulfatrim Pediatric...... 68 SURE-T INFUSION SET SYNRIBO...... 77 sulfurated lime...... 129 23"...... 211 SYNVISC...... 237 sulindac...... 24 SURE-T INFUSION SET SYNVISC ONE...... 237 sumatriptan...... 219 32"...... 211 syrpalta...... 251 sumatriptan succinate...... 219, 220 SURE-T INFUSION SET SYRPALTA (RED)...... 251 sumatriptan succinate refill.....220 6MM...... 211 SYRSPEND SF...... 251 sumatriptan-naproxen sodium.220 SURE-T INFUSION SET SYRSPEND SF PH4...... 251 SUNOSI...... 18 8MM...... 211 syrup vehicle...... 251 SUPARTZ FX...... 237 SURE-TEST EASYPLUS syrup vehicle sf...... 251 super bi-mix...... 94 MINI METER...... 211 T:FLEX T:LOCK super quad-mix...... 94 SURE-TEST EASYPLUS CARTRIDGE 4.8ML...... 211 super thin lancets...... 210 MINI TEST...... 142 T:SLIM T:LOCK INSULIN super tri-mix...... 94 SURE-TOUCH LANCETS CART 3ML...... 211 SUPERVITE...... 233 UNIVERSAL...... 211 TABLOID...... 77 support...... 233 SURVANTA...... 259 TABRADOL FUSEPAQ...... 237 SUPPORT-500...... 233 SUSPENDRX TABRADOL RAPIDPAQ... 237 suppository blend...... 251 W/BITTERBLOC SWEET... 251 TACLONEX...... 130 SUPPRELIN LA...... 151 tacrolimus...... 130, 224 301 tadalafil (pah)...... 94 telmisartan-hctz...... 66 thrivite rx...... 233 TAFINLAR...... 77 temazepam...... 169 THROMBIN-JMI...... 168 TAGITOL V...... 142 TEMIXYS...... 88 THROMBIN-JMI TAGRISSO...... 77 TEMODAR...... 77 EPISTAXIS...... 168 TAKE ACTION...... 104 TEMOVATE...... 130 THROMBOGEN...... 168 TAKHZYRO...... 162 temozolomide...... 77 THYROGEN...... 142 TALICIA...... 264 TENCON...... 27 tiagabine hcl...... 45 TALIVA...... 167 tenofovir disoproxil fumarate....88 TICE BCG...... 77 TALTZ...... 130 TEPEZZA...... 151 TIGLUTIK...... 239 TALZENNA...... 77 terazosin hcl...... 66 TIKOSYN...... 36 tamoxifen citrate...... 77 terbinafine hcl...... 60 Tilia Fe...... 105 tamsulosin hcl...... 158 terbutaline sulfate...... 40 timolol maleate...... 90, 245 TAPERDEX 12-DAY...... 108 terconazole...... 266 TIMOPTIC OCUDOSE...... 245 Taperdex 6-Day...... 108 teriparatide (recombinant).....151 tinidazole...... 68 TAPERDEX 7-DAY...... 108 Terrell...... 156 TIROSINT...... 261 TARCEVA...... 77 TESTIM...... 33 TIROSINT-SOL...... 261 TARGADOX...... 260 TESTONE CIK...... 33 TISSEEL...... 168 TARGRETIN...... 77, 130 TESTOPEL...... 33 Tis-U-Sol...... 224 Tarina 24 Fe...... 104 testosterone...... 33 TIVICAY...... 88 Tarina Fe 1/20...... 104 testosterone compounding kit....33 TIVICAY PD...... 88 Tarina Fe 1/20 Eq...... 104 testosterone cypionate...... 33 TIVORBEX...... 24 taron forte...... 167 testosterone enanthate...... 33 tizanidine hcl...... 237 TARON-C DHA...... 233 tetrabenazine...... 258 tl-hem 150...... 167 Taron-Crystals...... 158 tetracaine hcl...... 245 TOBAKIENT...... 144 TARON-PREX...... 233 tetracycline hcl...... 260 TOBI...... 19 TASIGNA...... 77 TETRIX...... 130 TOBI PODHALER...... 19 TAVALISSE...... 162 TEXACORT...... 130 TOBRADEX...... 246 TAYTULLA...... 104 tgt blood glucose monitoring... 212 TOBRADEX ST...... 246 tazarotene...... 130 tgt blood glucose test...... 142 tobramycin...... 19, 246 TAZORAC...... 130 tgt lancet micro thin 33g...... 212 tobramycin-dexamethasone.... 246 Taztia Xt...... 92 tgt lancet thin 26g...... 212 TOBREX...... 246 TECARTUS...... 77 tgt lancet ultra thin 30g...... 212 todays health mini pen needles 212 TECFIDERA...... 257 tgt lancing device...... 212 todays health pen needles...... 212 techlite insulin syringe...... 211 THALOMID...... 224 todays health short pen needle.212 TECHLITE PEN NEEDLES212 THE LIQUILIFT TRACE... 222 TOLAK...... 130 TECHNELITE...... 142 THE MAGIC BULLET...... 171 tolbutamide...... 56 TEGADERM AG MESH.....130 THEO-24...... 40 tolcapone...... 80 TEGSEDI...... 258 theophylline...... 40 tolmetin sodium...... 24 TEKTURNA...... 66 theophylline er...... 40 tolsura...... 60 TEKTURNA HCT...... 66 THERAHONEY...... 130 tolterodine tartrate...... 265 TELCARE BLOOD THERANATAL ONE...... 233 tolterodine tartrate er...... 265 GLUCOSE SYSTEM...... 212 thiamine hcl...... 268 topcare clickfine pen needles... 212 TELCARE BLOOD THINLETS GP LANCETS..212 topcare lancets micro-thin 33g 212 GLUCOSE TEST...... 142 THIOLA EC...... 158 topcare ultra comfort ins syr...212 TELFA AMD ISLAND thioridazine hcl...... 83 TOPICORT...... 130 DRESSING...... 212 thiothixene...... 83 topiramate...... 46 TELFA AMD NON- thrivacin 30...... 144 topiramate er...... 45 ADHERENT...... 212 thrivacin detox...... 144 TOPROL XL...... 90 telmisartan...... 66 THRIVE...... 258 toremifene citrate...... 77 telmisartan-amlodipine...... 66 thrivite 19...... 233 TORONOVA II SUIK...... 24 302 TORONOVA SUIK...... 24 Trianex...... 131 TRIVISC...... 237 torsemide...... 146 triazolam...... 169 tri-vite/fluoride...... 234 TOSYMRA...... 220 TRICARE...... 233 Trivora (28)...... 105 TOTECT...... 78 TRICARE PRENATAL Tri-Vylibra...... 105 TOUJEO MAX SOLOSTAR. 56 DHA ONE...... 233 Tri-Vylibra Lo...... 105 TOUJEO SOLOSTAR...... 56 TRICITRASOL...... 42 TRODELVY...... 78 TOVIAZ...... 265 tricitrates...... 158 TROKENDI XR...... 46 TOXICOLOGY MED Tricon...... 167 tronvite...... 234 COLLECTION SYS...... 142 TRICOR...... 63 tropicamide...... 246 TRACLEER...... 94 Triderm...... 131 trospium chloride...... 265 TRADJENTA...... 56 trientine hcl...... 224 trospium chloride er...... 265 tramadol hcl...... 32 Tri-Estarylla...... 105 true comfort insulin syringe.....212 tramadol hcl er...... 31, 32 TRIFERIC...... 167 true comfort pen needles...... 212 tramadol hcl er (biphasic)...... 31 trifluoperazine hcl...... 83 true comfort twist top lancets..212 tramadol-acetaminophen...... 32 trifluridine...... 246 TRUE FOCUS BLOOD trandolapril...... 66 trigels-f forte...... 167 GLUCOSE METER...... 212 trandolapril-verapamil hcl er.... 66 trihexyphenidyl hcl...... 80 true focus blood glucose strip.. 142 tranexamic acid...... 168 TRIJARDY XR...... 56 TRUE METRIX AIR TRANSDERM SCOP (1.5 TRIKAFTA...... 259 GLUCOSE METER...... 212 MG)...... 59 Tri-Legest Fe...... 105 TRUE METRIX BLOOD TRANSDERM-SCOP (1.5 Tri-Linyah...... 105 GLUCOSE TEST...... 142 MG)...... 59 Tri-Lo-Estarylla...... 105 TRUE METRIX GO tranylcypromine sulfate...... 49 Tri-Lo-Marzia...... 105 GLUCOSE METER...... 213 TRAVATAN Z...... 246 Tri-Lo-Mili...... 105 TRUE METRIX METER.... 213 travel lancets...... 212 Tri-Lo-Sprintec...... 105 TRUEDRAW LANCING TRAVEL LANCETS TRILURON...... 237 DEVICE...... 213 ADVANCED 28G...... 212 Trilyte...... 171 TRUEPLUS 5-BEVEL PEN travoprost (bak free)...... 246 trimethobenzamide hcl...... 59 NEEDLES...... 213 trazodone hcl...... 49 trimethoprim...... 68 TRUEPLUS INSULIN TREANDA...... 78 Tri-Mili...... 105 SYRINGE...... 213 TRECATOR...... 70 trimipramine maleate...... 49 TRUEPLUS LANCETS 26G213 TRELEGY ELLIPTA...... 40 tri-mix...... 94 TRUEPLUS LANCETS 28G213 TRELSTAR MIXJECT...... 78 TRIMO-SAN...... 266 TRUEPLUS LANCETS 30G213 TREMFYA...... 130 trinatal rx 1...... 233 TRUEPLUS LANCETS 33G213 treprostinil...... 94 TRINATE...... 233 TRUEPLUS PEN NEEDLES TRESIBA...... 56 trinaz...... 233 ...... 213 TRESIBA FLEXTOUCH...... 56 TRINTELLIX...... 49 TRUEPLUS SAFETY tretinoin...... 78, 130, 131 triphrocaps...... 233 LANCETS 28G...... 213 tretinoin microsphere...... 131 triple complex formula 3 kit....131 TRUERESULT BLOOD tretinoin microsphere pump.....131 triple pmb...... 246 GLUCOSE...... 213 TREXALL...... 78 triple pmk...... 246 TRUETEST TEST...... 142 TREXIMET...... 220 Tri-Previfem...... 105 TRUETRACK BLOOD TREZIX...... 32 TRIPTODUR...... 151 GLUCOSE...... 213 Tri Femynor...... 105 Tri-Sprintec...... 105 TRUETRACK SMART triamcinolone acetonide...131, 226 tristart dha...... 233 SYSTEM...... 213 tri-amino...... 240 TRISTART ONE...... 233 TRUETRACK TEST...... 142 TRIAMSIL COMBIPAK..... 131 tri-tabs dha...... 234 TRULANCE...... 156 triamsil multipak...... 131 TRIUMEQ...... 88 TRULICITY...... 56 triamterene...... 146 TRI-VI-FLOR...... 234 TRUSTEEL INFUSION triamterene-hctz...... 146 tri-vi-floro...... 234 SET...... 213 303 TRUVADA...... 88 ULTILET INSULIN UNILET COMFORTOUCH TRUXIMA...... 78 SYRINGE SHORT...... 214 LANCET...... 216 tryptophan...... 240 ULTILET LANCETS...... 214 UNILET EXCELITE...... 216 TUDORZA PRESSAIR...... 40 ULTILET PEN NEEDLE.... 214 UNILET EXCELITE II...... 216 TUKYSA...... 78 ULTILET SAFETY UNILET G.P. LANCET...... 216 Tulana...... 105 LANCETS...... 214 UNILET G.P. SUPERLITE TURALIO...... 78 ULTILET SAFETY LANCET...... 216 turpentine...... 131 LANCETS 23G...... 214 UNILET GP 28 ULTRA TUSSICAPS...... 109 ULTIMA...... 214 THIN...... 216 TUXARIN ER...... 109 ULTIMA TEST...... 142 UNILET LANCET...... 216 TUZISTRA XR...... 109 ULTOMIRIS...... 162 UNILET MICRO-THIN 33G TYBOST...... 88 ultra comfort insulin syringe... 214 ...... 216 Tydemy...... 105 ultra thin lancets 31g...... 214 UNILET SUPERLITE TYGACIL...... 260 ULTRA THIN PEN LANCET...... 216 TYKERB...... 78 NEEDLES...... 215 UNILET SUPER-THIN 30G TYLACTIN COMPLETE 15 ULTRA TRAK PRO ...... 216 PE...... 144 BLOOD GLUCOSE...... 215 UNILET ULTRA-THIN TYMLOS...... 151 ultracare insulin syringe...... 215 28G...... 216 TYR EASY...... 144 ultra-care lancets 30g...... 215 UNISTIK 1...... 216 TYSABRI...... 258 ultracare pen needles...... 215 UNISTIK 2...... 216 TYVASO...... 94 ULTRACET...... 32 UNISTIK 2 COMFORT...... 216 TYVASO REFILL...... 94 ultra-comfort insulin syringe...215 UNISTIK 2 EXTRA...... 216 TYVASO STARTER...... 94 ULTRALANCE...... 215 UNISTIK 2 NEONATAL.... 216 UBRELVY...... 220 ULTRAM...... 32 UNISTIK 2 NORMAL...... 216 UCERIS...... 34 ULTRA-THIN II AUTO UNISTIK 2 SUPER...... 216 UDAMIN SP...... 234 LANCET...... 215 UNISTIK 3...... 216 UDENYCA...... 167 ULTRA-THIN II INS SYR UNISTIK 3 COMFORT...... 216 ULORIC...... 158 SHORT...... 215 UNISTIK 3 EXTRA...... 216 ULTICARE ALCOHOL ULTRA-THIN II INSULIN UNISTIK 3 GENTLE...... 216 SWABS...... 213 SYRINGE...... 215 UNISTIK 3 NEONATAL.... 216 ULTICARE INSULIN ULTRA-THIN II LANCETS UNISTIK 3 NORMAL...... 216 SAFETY SYR...... 213 ...... 215 UNISTIK CZT COMFORT.216 ULTICARE INSULIN ULTRA-THIN II MINI PEN UNISTIK CZT NORMAL...216 SYRINGE...... 214 NEEDLE...... 215 UNISTIK PRO SAFETY ULTICARE MICRO PEN ULTRA-THIN II PEN LANCET...... 216 NEEDLES...... 214 NEEDLE SHORT...... 215 UNISTIK SAFETY ULTICARE MINI PEN ULTRA-THIN II PEN LANCETS 28G...... 216 NEEDLES...... 214 NEEDLES...... 215 UNISTIK SAFETY ULTICARE PEN NEEDLES ULTRATRAK ACTIVE...... 215 LANCETS 30G...... 216 ...... 214 ULTRATRAK PRO...... 215 UNISTIK TOUCH SAFETY ULTICARE SHORT PEN ULTRATRAK PRO TEST.. 142 LANC 21G...... 217 NEEDLES...... 214 ULTRATRAK ULTIMATE UNISTIK TOUCH SAFETY ultiguard safepack pen needle..214 MONITOR...... 215 LANC 23G...... 217 ULTI-LANCE ULTRATRAK ULTIMATE UNISTIK TOUCH SAFETY AUTOMATIC...... 214 TEST...... 142 LANC 28G...... 217 ultilet alcohol swabs...... 214 ULTRAVATE...... 131 UNISTIK TOUCH SAFETY ULTILET CLASSIC UNIFINE PENTIPS...... 215 LANC 30G...... 217 LANCETS...... 214 UNIFINE PENTIPS PLUS.. 216 UNISTRIP1 GENERIC...... 142 ULTILET INSULIN UNIFINE SAFECONTROL Unithroid...... 261 SYRINGE...... 214 PEN NEEDLE...... 216 304 UNIVERSAL 1 LANCETS VARIBAR PUDDING...... 142 V-GO 20...... 217 THIN 26G...... 217 VARIBAR THIN HONEY.. 143 V-GO 30...... 217 UNIVERSAL 1 LANCETS VARIBAR THIN LIQUID.. 143 V-GO 40...... 217 THIN 33G...... 217 VARISOFT INFUSION SET VIAGRA...... 94 UNIVERSAL 1 LANCETS ...... 217 VIBERZI...... 156 ULTRA THIN...... 217 VAROPHEN...... 131 VIBRAMYCIN...... 260 UPTRAVI...... 94 VARUBI (180 MG DOSE)..... 59 Vic-Forte...... 234 Uredeb...... 131 VASCEPA...... 63 VICTOZA...... 56 URESOL...... 131 VASCULERA...... 144 VIDA MIA UNIFINE Uribel...... 68 VAXCHORA...... 265 PENTIPS...... 217 URIMAR-T...... 68 vb6 p5p...... 144 VIEKIRA PAK...... 88 uro-458...... 68 v-c forte...... 234 Vienva...... 105 uro-mp...... 68 VCF VAGINAL vigabatrin...... 46 urosex...... 234 CONTRACEPTIVE...... 266 Vigadrone...... 46 UROXATRAL...... 158 VECAMYL...... 66 VIIBRYD...... 49 ursodiol...... 156 VECTICAL...... 131 VIIBRYD STARTER PACK.49 URSODIOL+SYRSPEND vegetable capsule #0 green...... 251 Vilamit Mb...... 68 SF...... 156 vegetable capsule #0 white...... 252 Vilevev Mb...... 68 Ustell...... 68 vegetable capsule #00 white....252 VIMIZIM...... 151 UTIBRON NEOHALER...... 40 vegetable capsule #1 white...... 252 VIMOVO...... 24 uticap...... 68 vegetable capsule #2 white...... 252 VIMPAT...... 46 Utira-C...... 68 vegetable capsule #3 white...... 252 VINATE DHA RF...... 234 Utrona-C...... 68 vegetable capsule #4 white...... 252 VINATE II...... 234 valacyclovir hcl...... 88 VELCADE...... 78 VINATE ONE...... 234 VALCYTE...... 88 VELETRI...... 94 VIOKACE...... 145 valganciclovir hcl...... 88 Velivet...... 105 viorele...... 106 valproic acid...... 46 VELPHORO...... 156 VIRACEPT...... 88 valsartan...... 66 VELTASSA...... 224 VIREAD...... 88, 89 valsartan-hydrochlorothiazide...66 VELTIN...... 131 virt-c dha...... 234 VALTOCO 10 MG DOSE...... 46 VEMLIDY...... 88 virt-caps...... 234 VALTOCO 15 MG DOSE...... 46 VENELEX...... 131 virt-fefa plus...... 167 VALTOCO 20 MG DOSE...... 46 VENIPUNCTURE PX1 Virt-Gard...... 167 VALTOCO 5 MG DOSE...... 46 PHLEBOTOMY...... 131 virt-nate dha...... 234 VALTREX...... 88 venlafaxine hcl...... 49 virt-phos 250 neutral...... 222 value health insulin syringe..... 217 venlafaxine hcl er...... 49 virt-pn dha...... 234 value plus lancet standard 21g.217 VENTAVIS...... 94 virt-pn plus...... 234 value plus lancets super thin.... 217 VENTOLIN HFA...... 41 virtussin a/c...... 109 valumark lancet ultra thin 28g 217 veracolate...... 172 virtussin dac...... 110 valumark pen needles...... 217 verapamil hcl...... 92 VISCO-3...... 237 Vanatol Lq...... 27 verapamil hcl er...... 92 Vita S Forte...... 234 vancomycin hcl...... 68 verasens blood glucose meter...217 Vitacel...... 234 VANCOMYCIN+SYRSPEN verasens blood glucose system.217 VITAFOL GUMMIES...... 234 D SF...... 68 verasens blood glucose test...... 143 VITAFOL STRIPS...... 234 Vandazole...... 266 VERDESO...... 131 VITAFOL ULTRA...... 234 VANISHPOINT INSULIN VEREGEN...... 131 VITAFOL-NANO...... 234 SYRINGE...... 217 VERSACLOZ...... 83 VITAFOL-OB...... 234 Vanoxide-Hc...... 131 VERSAFREE...... 252 VITAFOL-OB+DHA...... 234 VANTAS...... 78 VERSAPLUS...... 252 VITAFOL-ONE...... 235 VARIBAR HONEY...... 142 VERZENIO...... 78 Vitamax Pediatric...... 235 VARIBAR NECTAR...... 142 vexasyn...... 131 305 VITAMEDMD ONE VYLEESI...... 258 XALIX...... 132 RX/QUATREFOLIC...... 235 Vylibra...... 106 XALKORI...... 78 VITAMEDMD REDICHEW VYNDAMAX...... 94 XANAX...... 35 RX...... 235 VYNDAQEL...... 94 XANAX XR...... 36 VITAMEZ...... 167 VYVANSE...... 18 XAQUIL XR...... 144 vita-min...... 235 VYXEOS...... 78 XARELTO...... 42 vitamin d (ergocalciferol)...... 268 VYZULTA...... 246 XARELTO STARTER vitamin k1...... 268 walgreens adv travel lancets....217 PACK...... 42 vitamins acd-fluoride...... 235 WALGREENS LANCETS...217 XCOPRI...... 46 VITAPEARL...... 235 walgreens lancets micro thin... 217 XCOPRI (250 MG DAILY vitasure...... 235 walgreens lancets super thin....217 DOSE)...... 46 VITATRUE...... 235 WALGREENS THIN XCOPRI (350 MG DAILY VITRAKVI...... 78 LANCETS...... 218 DOSE)...... 46 VIVA DHA...... 235 WALGREENS ULTRA XELJANZ...... 24, 25 VIVAGUARD INO THIN LANCETS...... 218 XELJANZ XR...... 25 GLUCOSE METER...... 217 warfarin sodium...... 42 XELODA...... 78 VIVAGUARD INO TEST WAVESENSE AMP...... 218 XELPROS...... 246 STRIPS...... 143 WEBCOL ALCOHOL PREP XEMBIFY...... 249 VIVAGUARD LANCETS... 217 LARGE...... 218 XENAZINE...... 258 VIVAGUARD LANCING WEBCOL ALCOHOL PREP XENLETA...... 68 DEVICE...... 217 MEDIUM...... 218 xenon xe 133...... 143 VIVELLE-DOT...... 153 wegmans unifine pentips plus.. 218 XEOMIN...... 239 VIVITROL...... 58 WELLMIND VERTIGO...... 224 XEPI...... 132 VIVLODEX...... 24 Wera...... 106 XERAC AC...... 132 VIVOTIF...... 265 WESTHROID...... 261 XERALUX...... 132 VIZIMPRO...... 78 wheat germ oil...... 268 XERAVA...... 260 VOCAL POINT BLOOD WIDE-SEAL DIAPHRAGM XERESE...... 132 GLUCOSE SYS...... 217 60...... 218 XEROFORM OIL VOCAL POINT BLOOD WIDE-SEAL DIAPHRAGM EMULSION 2"X2"...... 132 GLUCOSE TEST...... 143 65...... 218 XEROFORM OIL VOGELXO...... 33 WIDE-SEAL DIAPHRAGM EMULSION GAUZE...... 132 VOGELXO PUMP...... 33 70...... 218 XEROFORM OIL vol-plus...... 235 WIDE-SEAL DIAPHRAGM EMULSION STRIP...... 132 vol-tab rx...... 235 75...... 218 XEROFORM OIL ROLL VOLTAREN...... 131 WIDE-SEAL DIAPHRAGM 4"X9'...... 132 VONVENDI...... 162 80...... 218 XEROFORM PETROLAT voriconazole...... 60 WIDE-SEAL DIAPHRAGM GAUZE 1"X8"...... 132 VOSEVI...... 89 85...... 218 XEROFORM PETROLAT VOTRIENT...... 78 WIDE-SEAL DIAPHRAGM GAUZE 5"X9"...... 132 vp gkl kit...... 132 90...... 218 XEROFORM PETROLAT vp insulin syringe...... 217 WIDE-SEAL DIAPHRAGM PATCH 2"X2"...... 132 vp-heme ob + dha...... 235 95...... 218 XEROFORM PETROLAT vp-pnv-dha...... 235 WILATE...... 162 PATCH 4"X4"...... 132 VPRIV...... 167 WINRHO SDF...... 249 XEROFORM vp-vite rx...... 235 WITEPSOL...... 252 PETROLATUM ROLL VRAYLAR...... 84 womans laxative...... 172 4"X9'...... 132 VSL#3 DS...... 57 WP THYROID...... 262 XEROSTOMIA RELIEF VUMERITY...... 258 wpr plus wound healing system132 SPRAY...... 226 VUSION...... 132 Wymzya Fe...... 106 XGEVA...... 151 Vyfemla...... 106 XADAGO...... 80 XHANCE...... 238 306 XIFAXAN...... 68 ZEJULA...... 79 Zovia 1/35E (28)...... 106 XIGDUO XR...... 57 zelac...... 57 ZTLIDO...... 133 XIIDRA...... 246 ZELAPAR...... 81 ZUBSOLV...... 32 XIMINO...... 260 ZELBORAF...... 79 ZULRESSO...... 50 XOFIGO...... 78 ZELNORM...... 156 Zumandimine...... 106 XOFLUZA (40 MG DOSE)... 89 ZEMAIRA...... 259 ZUPLENZ...... 59 XOFLUZA (80 MG DOSE)... 89 ZEMBRACE SYMTOUCH. 220 ZYCLARA...... 133 XOLAIR...... 41 Zenatane...... 133 ZYCLARA PUMP...... 133 XOLEGEL...... 132 ZENPEP...... 145 ZYDELIG...... 79 XOPENEX HFA...... 41 Zenzedi...... 18 ZYFLO...... 41 XOSPATA...... 78 ZENZEDI...... 18 ZYKADIA...... 79 XPOVIO (100 MG ONCE ZEPATIER...... 89 ZYLET...... 246 WEEKLY)...... 78 ZEPOSIA...... 258 ZYLOPRIM...... 158 XPOVIO (60 MG ONCE ZEPOSIA 7-DAY STARTER ZYPITAMAG...... 63 WEEKLY)...... 79 PACK...... 258 ZYPREXA RELPREVV...... 84 XPOVIO (80 MG ONCE ZEPOSIA STARTER KIT... 258 ZYTIGA...... 79 WEEKLY)...... 79 ZERVIATE...... 246 zyvit...... 144 XPOVIO (80 MG TWICE ZETIA...... 63 WEEKLY)...... 79 ZETONNA...... 238 XRYLIX...... 132 ZIANA...... 133 XTAMPZA ER...... 32 zidovudine...... 89 XTANDI...... 79 ZIEXTENZO...... 168 XULANE...... 106 ZILACAINE PATCH...... 133 XULTOPHY...... 57 zileuton er...... 41 xvite...... 235 ZILRETTA...... 108 XYNTHA...... 162 zinc sulfate...... 222 XYNTHA SOLOFUSE...... 162 ZINPLAVA...... 249 XYOSTED...... 33 ZIOPTAN...... 246 xyzbac...... 144 ziprasidone hcl...... 84 YAZ...... 106 ZIPSOR...... 25 yl folic acid...... 167 ZIRGAN...... 246 YONSA...... 79 ZITHROMAX...... 173 YOSPRALA...... 163 ZOHYDRO ER...... 32 YUPELRI...... 41 ZOLADEX...... 79 YUTIQ...... 246 zoledronic acid...... 151 Yuvafem...... 266 ZOLINZA...... 79 zaclir cleansing...... 132 zolmitriptan...... 220 zafirlukast...... 41 zolpidem tartrate...... 169 zaleplon...... 169 zolpidem tartrate er...... 169 zalvit...... 235 ZOLPIMIST...... 169 zanabin hydrogel...... 132 ZOMACTON...... 151 ZANAFLEX...... 237 ZOMACTON (FOR ZOMA- Zarah...... 106 JET 10)...... 151 ZARONTIN...... 46 ZOMIG...... 220 ZARXIO...... 167 ZONEGRAN...... 46 ZATEAN-PN DHA...... 235 zonisamide...... 46 ZATEAN-PN PLUS...... 235 ZONTIVITY...... 163 ZAVESCA...... 168 ZORBTIVE...... 151 Zebutal...... 27 ZORTRESS...... 224 ZEGERID...... 264 ZORVOLEX...... 25 307