Drugs Not Covered — and Their Covered Alternatives for the Aetna Standard Formulary 2021 Formulary Exclusions Drug List

Covered and non-covered drugs

Drugs not covered — and their covered alternatives for the Aetna Standard Formulary 2021 Formulary Exclusions Drug List

05.03.948.1I (01/21) The drugs on this list have been removed from your Key plan’s formulary. If you continue using a drug listed under “formulary drug removals”, you may have to UPPERCASE Brand-name medicine pay the full cost. Ask your doctor to choose one of lowercase italics Generic medicine the generic or brand formulary options from the list.

Category Formulary drug removals Formulary options Drug class

Acromegaly SANDOSTATIN LAR1 SOMATULINE DEPOT SIGNIFOR LAR1 SOMAVERT1

Allergies dexchlorpheniramine levocetirizine Antihistamines Diphen Elixir RyClora CARBINOXAMINE TABLET 6 MG

Allergies BECONASE AQ flunisolide spray, fluticasone spray, mometasone Nasal Steroids / Combinations OMNARIS spray, DYMISTA QNASL ZETONNA

Anticonvulsants APTIOM carbamazepine, carbamazepine ext-rel, divalproex BRIVIACT sodium, divalproex sodium ext-rel, gabapentin, FYCOMPA lamotrigine, lamotrigine ext-rel, levetiracetam, ZONEGRAN levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

ONFI clobazam, lamotrigine, topiramate, TROKENDI XR

SABRIL1 vigabatrin

Anti-infectives, Antibacterials E.E.S. GRANULES erythromycins Erythromycins / Macrolides ERYPED

Anti-infectives, Antibacterials CoreMino doxycycline hyclate 20 mg, doxycycline hyclate Tetracyclines doxycycline hyclate delayed-rel capsule, minocycline, tetracycline tablet 200 mg doxycycline hyclate tablet 50 mg (NDC^ 72143021160 only) doxycycline hyclate tablet 75 mg doxycycline hyclate tablet 150 mg doxycycline monohydrate capsule 75 mg doxycycline monohydrate capsule 150 mg minocycline ext-rel Mondoxyne NL capsule 75 mg ACTICLATE DORYX DORYX MPC MINOCIN TARGADOX

Anti-infectives, Antibacterials MACRODANTIN nitrofurantoin Miscellaneous

Health benefits and health insurance plans are offered, underwritten and/or administered 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/or 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.

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Anti-infectives, Antifungals flucytosine capsule 500 mg fluconazole

posaconazole delayed-rel tablet fluconazole, itraconazole

Anti-infectives, Antivirals VALCYTE valganciclovir Cytomegalovirus*

Anti-infectives, Antivirals BARACLUDE TABLET1 entecavir, lamivudine, tenofovir disoproxil fumarate, 1 Hepatitis B* EPIVIR HBV BARACLUDE SOLUTION, VEMLIDY HEPSERA1

Anti-infectives, Antivirals MAVYRET1 EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), Hepatitis C* HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2 VIEKIRA PAK1 EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), ZEPATIER1 HARVONI (genotypes 1, 4, 5, 6)

Anti-infectives, Antivirals acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir Herpes* VALTREX

Anti-infectives, Antivirals COMPLERA1 ATRIPLA, BIKTARVY, GENVOYA, ODEFSEY, SYMFI, 1 HIV STRIBILD SYMFI LO, SYMTUZA, TRIUMEQ

Anti-infectives DARAPRIM pyrimethamine Miscellaneous

Antiobesity CONTRAVE SAXENDA QSYMIA

Anxiety* XANAX alprazolam, clonazepam, diazepam, lorazepam, Benzodiazepines XANAX XR oxazepam

Asthma* PROAIR HFA albuterol sulfate CFC-free aerosol, levalbuterol Beta Agonists, Short-Acting PROAIR RESPICLICK tartrate CFC-free aerosol PROVENTIL HFA VENTOLIN HFA XOPENEX HFA

Asthma* SINGULAIR montelukast, zafirlukast, zileuton ext-rel Leukotriene Modulators

Asthma* ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS, Steroid Inhalants ASMANEX FLOVENT HFA, PULMICORT FLEXHALER, ASMANEX HFA QVAR REDIHALER

Asthma* or Chronic Obstructive DULERA ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, Pulmonary Disease (COPD)* SYMBICORT Steroid / Beta Agonist Combinations

Attention Deficit Hyperactivity ADZENYS ER amphetamine-dextroamphetamine mixed salts Disorder* ADZENYS XR-ODT ext-rel †, methylphenidate ext-rel †, MYDAYIS, APTENSIO XR VYVANSE DAYTRANA

EVEKEO amphetamine-dextroamphetamine mixed salts, methylphenidate

INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel †, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Autoimmune Agents CIMZIA1 COSENTYX, ENBREL, HUMIRA 1 Ankylosing Spondylitis* SIMPONI TALTZ 1

Autoimmune Agents CIMZIA1 HUMIRA, STELARA SUBCUTANEOUS # 1 Crohn's Disease* ENTYVIO

Autoimmune Agents CIMZIA1 HUMIRA, OTEZLA, SKYRIZI, STELARA 1 Psoriasis* COSENTYX SUBCUTANEOUS, TALTZ, TREMFYA ENBREL1

Autoimmune Agents CIMZIA1 COSENTYX, ENBREL, HUMIRA, OTEZLA 1 Psoriatic Arthritis* ORENCIA CLICKJECT ORENCIA INTRAVENOUS1 ORENCIA SUBCUTANEOUS1 SIMPONI1 STELARA SUBCUTANEOUS1 TALTZ 1 TREMFYA1 XELJANZ1 XELJANZ XR1

Autoimmune Agents ACTEMRA1 ENBREL, HUMIRA, KEVZARA, ORENCIA 1 Rheumatoid Arthritis* CIMZIA CLICKJECT, ORENCIA SUBCUTANEOUS, KINERET1 RINVOQ, XELJANZ, XELJANZ XR ORENCIA INTRAVENOUS1 SIMPONI1

Autoimmune Agents ENTYVIO1 HUMIRA, STELARA SUBCUTANEOUS #, 1 Ulcerative Colitis* SIMPONI XELJANZ #, XELJANZ XR

Autoimmune Agents ACTEMRA1 ENBREL, HUMIRA 1 All Other Conditions* KINERET ORENCIA CLICKJECT1 ORENCIA INTRAVENOUS1 ORENCIA SUBCUTANEOUS1

Cancer GLEEVEC1 imatinib mesylate, BOSULIF, SPRYCEL 1 Chronic Myelogenous Leukemia* TASIGNA

Cancer BORTEZOMIB1 NINLARO, VELCADE 1 Multiple Myeloma* KYPROLIS Proteasome Inhibitors

Cancer ALIQOPA1 COPIKTRA 1 PI3K Inhibitors for ZYDELIG Follicular Lymphoma*

Cancer NILANDRON abiraterone, bicalutamide, XTANDI, YONSA 1 Prostate* ZYTIGA Hormonal Agents, Antiandrogens

Cancer LUPRON DEPOT1 ELIGARD Prostate* (For Prostate Cancer Only) Hormonal Agents, Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

Cardiovascular BETAPACE sotalol Antiarrhythmics BETAPACE AF

# after failure of HUMIRA Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Cardiovascular ZETIA ezetimibe Antilipemics Cholesterol Absorption Inhibitors

Cardiovascular fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg), Antilipemics FENOGLIDE TABLET 120 MG fenofibric acid delayed-rel TRICOR Fibrates

Cardiovascular ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, Antilipemics CRESTOR lovastatin, pravastatin, rosuvastatin, simvastatin LESCOL XL HMG-CoA Reductase Inhibitors LIPITOR 3 (HMGs or Statins) / Combinations LIVALO

Cardiovascular niacin tablet 500 mg niacin ext-rel Antilipemics Niacor Niacins

Cardiovascular REPATHA1 PRALUENT Antilipemics PCSK9 Inhibitors

Cardiovascular LANOXIN TABLET digoxin Digitalis Glycosides (125 MCG and 250 MCG only)

Cardiovascular DYRENIUM amiloride, triamterene Diuretics

Cardiovascular isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide Nitrates dinitrate 40 mg), isosorbide mononitrate

Cardiovascular LETAIRIS1 ambrisentan, bosentan, OPSUMIT 1 Pulmonary Arterial Hypertension TRACLEER Endothelin Receptor Antagonists

Cardiovascular ADCIRCA1 sildenafil, tadalafil 1 Pulmonary Arterial Hypertension* REVATIO Phosphodiesterase Inhibitors

Carnitine Deficiency CARNITOR levocarnitine CARNITOR SF

Chronic Obstructive Pulmonary INCRUSE ELLIPTA SPIRIVA, YUPELRI Disease (COPD)* TUDORZA Anticholinergics

Chronic Obstructive Pulmonary BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT Disease (COPD)* Anticholinergic / Beta Agonist Combinations Long Acting

Contraceptives BEYAZ ethinyl estradiol-drospirenone, Monophasic MINASTRIN 24 FE ethinyl estradiol-drospirenone-levomefolate, TAYTULLA ethinyl estradiol-norethindrone acetate, YAZ ethinyl estradiol-norethindrone acetate-iron

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Contraceptives NATAZIA ethinyl estradiol-drospirenone, Four Phase ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE

Contraceptives LILETTA1 KYLEENA, MIRENA, SKYLA Progestin Intrauterine Devices

Contraceptives NUVARING ethinyl estradiol-etonogestrel, ANNOVERA Vaginal

Cystic Fibrosis* TOBI1 tobramycin inhalation solution, BETHKIS 1 Inhaled Antibiotics TOBI PODHALER

Dental PREVIDENT Consult doctor Cavity/Caries Prevention

Depression* fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine Antidepressants, Selective Serotonin LEXAPRO (except fluoxetine tablet 60 mg, fluoxetine Reuptake Inhibitors (SSRIs) PAXIL tablet [generics for SARAFEM]), paroxetine HCl, PAXIL CR paroxetine HCl ext-rel, sertraline, TRINTELLIX PEXEVA PROZAC VIIBRYD

Depression* venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine, Antidepressants, Serotonin (except 225 mg) venlafaxine ext-rel capsule Norepinephrine Reuptake Inhibitors CYMBALTA (SNRIs) EFFEXOR XR PRISTIQ

Depression* bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel Antidepressants, APLENZIN (except bupropion ext-rel tablet 450 mg) Miscellaneous Agents OLEPTRO trazodone

Depression and/or Schizophrenia* ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, Antipsychotics, Atypicals FANAPT quetiapine ext-rel, risperidone, ziprasidone, SEROQUEL XR LATUDA, VRAYLAR

INVEGA SUSTENNA ABILIFY MAINTENA, PERSERIS

Dermatology clindamycin gel adapalene, benzoyl peroxide, clindamycin gel Acne* (NDC^ 68682046275 only) (except NDC^ 68682046275), clindamycin Vanoxide-HC solution, clindamycin-benzoyl peroxide, ACANYA erythromycin solution, erythromycin-benzoyl AZELEX peroxide, tretinoin, EPIDUO, ONEXTON BENZACLIN DIFFERIN LOTION FABIOR TAZORAC VELTIN ZIANA

Dermatology fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, Actinic Keratosis* CARAC imiquimod, PICATO, TOLAK, ZYCLARA

Dermatology mupirocin cream gentamicin, mupirocin ointment Antibiotics

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Dermatology calcipotriene cream calcipotriene ointment, calcipotriene solution Antipsoriatics calcitriol ointment SORILUX TAZORAC VECTICAL

calcipotriene-betamethasone calcipotriene ointment or calcipotriene solution WITH desoximetasone, fluocinonide (except fluocinonide cream 0.1%) or BRYHALI

Dermatology doxepin cream desonide, hydrocortisone, pimecrolimus, Atopic Dermatitis* tacrolimus, EUCRISA

Dermatology doxycycline monohydrate ORACEA Rosacea* delayed-rel capsule FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, MIRVASO SOOLANTRA NORITATE

Dermatology BEAU RX Consult doctor Scars CICATRACE POLYTOZA RECEDO SCARSILK PAD SIL-K PAD SILIVEX SILTREX

Dermatology ketoconazole foam 2% ketoconazole shampoo 2%, Seborrheic Dermatitis* Ketodan selenium sulfide lotion 2.5% XOLEGEL ciclopirox, ketoconazole cream 2%

Dermatology clobetasol spray clobetasol foam Skin Inflammation and Hives* CLOBEX SPRAY OLUX-E Corticosteroids fluocinonide cream 0.1% clobetasol cream

flurandrenolide lotion desonide, hydrocortisone (NDC^ 24470092112 only)

flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone hydrocortisone butyrate butyrate lotion, hydrocortisone butyrate ointment, lipophilic cream 0.1% hydrocortisone butyrate solution, mometasone, triamcinolone acetonide triamcinolone cream, triamcinolone lotion, aerosol 0.2% triamcinolone ointment CORDRAN OINTMENT

diflorasone cream desoximetasone, fluocinonide (except fluocinonide diflorasone ointment cream 0.1%), BRYHALI APEXICON E PSORCON

Dermatology VEREGEN imiquimod Warts

Dermatology ALEVICYN GEL desonide, hydrocortisone Wound Care Products ALEVICYN SG ALEVICYN SOLUTION

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Dermatology ALCORTIN A desonide, hydrocortisone Miscellaneous Skin Conditions ATOPADERM BENSAL HP EPICERAM KAMDOY NOVACORT SYNERDERM

oxiconazole (NDCs^ 0168035830, ciclopirox, clotrimazole, econazole, 51672135902 only) ketoconazole cream 2%, luliconazole

Diabetes* metformin ext-rel metformin, metformin ext-rel (except Biguanides (generics for FORTAMET generics for FORTAMET and GLUMETZA) and GLUMETZA only) FORTAMET GLUMETZA RIOMET

Diabetes* NESINA JANUVIA Dipeptidyl Peptidase-4 (DPP-4) ONGLYZA Inhibitors TRADJENTA

Diabetes* JENTADUETO JANUMET, JANUMET XR Dipeptidyl Peptidase-4 (DPP-4) JENTADUETO XR Inhibitor Combinations KAZANO KOMBIGLYZE XR

OSENI JANUMET, JANUMET XR; JANUVIA WITH pioglitazone

Diabetes* BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA Injectable Incretin Mimetics BYETTA

Diabetes* APIDRA FIASP, NOVOLOG Insulins HUMALOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/304 NOVOLIN 70/304

HUMULIN N4 NOVOLIN N4

HUMULIN R4 NOVOLIN R4

NOTE: Humulin R U-500 concentrate will not be subject to removal and will continue to be covered.

Diabetes* LANTUS BASAGLAR, LEVEMIR Long Acting Insulins5

Diabetes* ACTOS pioglitazone Insulin Sensitizers

Diabetes* INVOKANA FARXIGA, JARDIANCE Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Diabetes* INVOKAMET SYNJARDY, SYNJARDY XR, XIGDUO XR Sodium-Glucose INVOKAMET XR Co-transporter 2 (SGLT2) Inhibitor / Biguanide Combinations

Diabetes* QTERN GLYXAMBI Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor / Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations

Diabetes* NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES Supplies, Needles6 OWEN MUMFORD NEEDLES PERRIGO NEEDLES ULTIMED NEEDLES All other insulin needles that are not BD ULTRAFINE brand

Diabetes* ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES Supplies, Syringes6 INSULIN SYRINGES TRIVIDIA INSULIN SYRINGES ULTIMED INSULIN SYRINGES All other insulin syringes that are not BD ULTRAFINE brand

Diabetes* ACCU-CHEK AVIVA PLUS ONETOUCH ULTRA STRIPS AND KITS7, 7 Supplies, Test Strips and Kits7, 8 STRIPS AND KITS ONETOUCH VERIO STRIPS AND KITS ACCU-CHEK COMPACT PLUS STRIPS AND KITS ACCU-CHEK GUIDE STRIPS AND KITS ACCU-CHEK SMARTVIEW STRIPS AND KITS BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS All other test strips that are not ONETOUCH brand

ENLITE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE MONITORING MONITORING SYSTEM SYSTEM EVERSENSE CONTINUOUS GLUCOSE MONITORING SYSTEM FREESTYLE LIBRE CONTINUOUS GLUCOSE MONITORING SYSTEM GUARDIAN CONNECT CONTINUOUS GLUCOSE MONITORING SYSTEM

Dietary Supplements FOSTEUM alendronate, ibandronate, risedronate FOSTEUM PLUS

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Dietary Supplements Activite folic acid (continued) DaVite Dexifol Folvik-D Folvite-D Genicin Vita-S HylaVite Lorid TronVite Vitasure Xvite FERIVA 21/7 FOLIC-K NICADAN NICAPRIN NICAZEL NICAZEL FORTE NICOMIDE OMNIVEX ORTHO D ORTHO DF RHEUMATE RIBOZEL TALIVA XYZBAC ZYVIT

MultiPro Consult doctor PRODIGEN VASCULERA

Erectile Dysfunction* CIALIS sildenafil, tadalafil Phosphodiesterase Inhibitors STENDRA VIAGRA

Estrogen Replacement* MINIVELLE estradiol, DIVIGEL, EVAMIST VIVELLE-DOT

Fertility* FOLLISTIM AQ1 GONAL-F

CHORIONIC GONADOTROPIN1 OVIDREL NOVAREL1 PREGNYL1

Gastrointestinal chlordiazepoxide-clidinium dicyclomine Anticholinergics (NDC^ 42494040901 only) GLYCOPYRROLATE TABLET 1.5 MG

Gastrointestinal ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG Antidiarrheals MYTESI diphenoxylate-atropine, loperamide

Gastrointestinal TRANSDERM SCOP meclizine, scopolamine transdermal Antiemetics ZUPLENZ granisetron, ondansetron, SANCUSO

Gastrointestinal AMITIZA LINZESS, MOVANTIK, SYMPROIC Irritable Bowel Syndrome TRULANCE LINZESS

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Gastrointestinal LACTULOSE PAK lactulose solution Laxatives GOLYTELY peg 3350-electrolytes, CLENPIQ MOVIPREP OSMOPREP SUPREP

Gastrointestinal PROVAD Consult doctor Probiotics ZELAC

Gastrointestinal omeprazole-sodium bicarbonate esomeprazole, lansoprazole, omeprazole, Proton Pump Inhibitors (PPIs) ACIPHEX pantoprazole, DEXILANT ACIPHEX SPRINKLE NEXIUM PREVACID PROTONIX ZEGERID

Gastrointestinal sucralfate suspension sucralfate tablet Ulcer Treatment CARAFATE

Gaucher Disease ELELYSO1 CERDELGA, CEREZYME

Genitourinary RIMSO-50 Consult doctor Interstitial Cystitis

Gout* COLCRYS colchicine tablet

Growth Hormones GENOTROPIN1 NORDITROPIN HUMATROPE1 NUTROPIN AQ1 OMNITROPE1 SAIZEN1

Hematologic PRADAXA warfarin, ELIQUIS, XARELTO Anticoagulants (oral)

Hematologic EPOGEN1 ARANESP, RETACRIT 1 Erythropoiesis-Stimulating Agents PROCRIT

Hematologic ELOCTATE1 ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, Hemophilia A NOVOEIGHT, NUWIQ

Hematologic ALPROLIX1 Consult doctor Hemophilia B

Hematologic FULPHILA1 ZIEXTENZO 1 Neutropenia Colony NEULASTA NEULASTA ONPRO1 Stimulating Factors UDENYCA1

GRANIX1 NIVESTYM NEUPOGEN1 ZARXIO1

Hematologic PLAVIX clopidogrel, prasugrel, BRILINTA Platelet Aggregation Inhibitors ZONTIVITY Consult doctor

High Blood Pressure* ATACAND candesartan, irbesartan, losartan, olmesartan, Angiotensin II Receptor Antagonists BENICAR telmisartan, valsartan DIOVAN EDARBI

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

High Blood Pressure* ATACAND HCT candesartan, irbesartan, losartan, olmesartan, Angiotensin II Receptor BENICAR HCT telmisartan, valsartan DIOVAN HCT Antagonist / Diuretic Combinations EDARBYCLOR

High Blood Pressure* EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, Angiotensin II Receptor amlodipine-valsartan Antagonist / Calcium Channel Blocker Combinations

High Blood Pressure* EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, Angiotensin II Receptor olmesartan-amlodipine-hydrochlorothiazide Antagonist / Calcium Channel Blocker / Diuretic Combinations

High Blood Pressure* INDERAL LA atenolol, carvedilol, carvedilol phosphate ext-rel, Beta-blockers INDERAL XL metoprolol succinate ext-rel, metoprolol tartrate, INNOPRAN XL nadolol, pindolol, propranolol, propranolol ext-rel, TOPROL-XL BYSTOLIC

High Blood Pressure* DUTOPROL metoprolol succinate ext-rel WITH Beta-blocker Combinations hydrochlorothiazide

High Blood Pressure* NORVASC amlodipine Calcium Channel Blockers diltiazem ext-rel (generics diltiazem ext-rel (except generics for for CARDIZEM LA only) CARDIZEM LA) Matzim LA CARDIZEM CARDIZEM CD CARDIZEM LA

High Blood Pressure* CONSENSI amlodipine WITH celecoxib Calcium Channel Blocker / Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Combinations

Huntington's Disease XENAZINE1 tetrabenazine, AUSTEDO

Immunology CELLCEPT1 mycophenolate mofetil, mycophenolate sodium 1 Antimetabolites MYFORTIC

Immunology ASTAGRAF XL1 tacrolimus 1 Calcineurin Inhibitors ENVARSUS XR

Immunology OTREXUP1 RASUVO Disease Modifying Antirheumatic Agents

Immunology BERINERT1 FIRAZYR, RUCONEST Hereditary Angioedema*

Immunology RAPAMUNE1 everolimus, sirolimus 1 Rapamycin Derivatives ZORTRESS

Inflammatory Bowel Disease (IBD) ASACOL HD balsalazide, mesalamine delayed-rel, mesalamine Ulcerative Colitis* DELZICOL ext-rel, sulfasalazine, sulfasalazine delayed-rel, LIALDA PENTASA Aminosalicylates COLAZAL balsalazide

Interferons* PEGASYS1 Consult doctor

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Kidney Disease* lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA, Phosphate Binders FOSRENOL VELPHORO

Multiple Sclerosis AVONEX1 dimethyl fumarate delayed-rel, glatiramer, EXTAVIA1 AUBAGIO, BETASERON, COPAXONE, GILENYA, PLEGRIDY1 KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, TECFIDERA1 VUMERITY, ZEPOSIA

Musculoskeletal chlorzoxazone 375 mg cyclobenzaprine (except cyclobenzaprine chlorzoxazone 500 mg tablet 7.5 mg) (NDC^ 73007001303 only) chlorzoxazone 750 mg cyclobenzaprine ext-rel capsule cyclobenzaprine tablet 7.5 mg Fexmid Lorzone metaxalone 400 mg methocarbamol 500 mg (NDC^ 69036091010 only) methocarbamol 750 mg (NDCs^ 69036093090, 70868090190 only) orphenadrine-aspirin-caffeine Orphengesic Forte AMRIX CHLORZOXAZONE 250 MG NORGESIC FORTE

Narcolepsy NUVIGIL armodafinil, SUNOSI Wakefulness Promoters

Nephropathic Cystinosis PROCYSBI1 CYSTAGON

Ophthalmic ALREX azelastine, cromolyn sodium, olopatadine, Allergies BEPREVE LASTACAFT, PAZEO

Ophthalmic ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone, Anti-infective / Anti-inflammatory neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, TOBRADEX OINTMENT, TOBRADEX ST

Ophthalmic PROLENSA bromfenac, diclofenac, ketorolac, Anti-inflammatory, Nonsteroidal ACUVAIL, ILEVRO, NEVANAC

Ophthalmic FML LIQUIFILM dexamethasone, loteprednol, prednisolone Anti-inflammatory, Steroidal LOTEMAX acetate 1%, DUREZOL, FML FORTE, FML S.O.P., LOTEMAX SM MAXIDEX, PRED MILD PRED FORTE

Ophthalmic ZIRGAN trifluridine Antivirals

Ophthalmic LACRISERT RESTASIS, XIIDRA Artificial Tears

Ophthalmic bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN Glaucoma TIMOPTIC OCUDOSE timolol maleate solution, BETIMOL, BETOPTIC S

Ophthalmic AVENOVA Consult doctor Miscellaneous

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Opioid Dependency SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV

Opioid Reversal EVZIO naloxone injection, NARCAN NASAL SPRAY

Osteoarthritis* GEL-ONE1 DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX 1 Viscosupplements HYALGAN MONOVISC1 ORTHOVISC1 SYNVISC1 SYNVISC-ONE1 VISCO-31

Osteoporosis* MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, Calcium Regulators risedronate, FORTEO, PROLIA, TYMLOS MIACALCIN NASAL SPRAY calcitonin-salmon

Otic CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic Anti-infective / Anti-inflammatory CIPRODEX

Overactive Bladder / Incontinence* DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin, Urinary Antispasmodics ENABLEX tolterodine, tolterodine ext-rel, trospium, OXYTROL trospium ext-rel, MYRBETRIQ, TOVIAZ

Pain Bupap diclofenac sodium, ibuprofen, naproxen Headache* butalbital-acetaminophen (except naproxen CR or naproxen suspension) tablet 50-300 mg butalbital-acetaminophen- caffeine capsule Vanatol LQ Vanatol S BUTALBITAL-ACETAMINOPHEN (NDC^ 69499034230 only) CAMBIA FIORICET CAPSULE

dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, ergotamine-caffeine zolmitriptan, NURTEC ODT, ONZETRA XSAIL, Migergot REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, CAFERGOT ZOMIG NASAL SPRAY

sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen TREXIMET (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY

Pain BUTRANS buprenorphine transdermal, BELBUCA Opioid Analgesics LAZANDA fentanyl transmucosal lozenge, SUBSYS

levorphanol fentanyl transdermal, hydrocodone ext-rel, oxymorphone ext-rel hydromorphone ext-rel, methadone, morphine HYSINGLA ER ext-rel, NUCYNTA ER, XTAMPZA ER OXYCONTIN ZOHYDRO ER

PERCOCET hydrocodone-acetaminophen, hydromorphone, PRIMLEV morphine, oxycodone-acetaminophen, NUCYNTA

tramadol tramadol (except NDC^ 52817019610), (NDC^ 52817019610 only) tramadol ext-rel

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Pain LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine Topical Local Anesthetics (NDC^ 71800063115 only) LIDOTREX

Pain and Inflammation* MILLIPRED dexamethasone, hydrocortisone, Corticosteroids RAYOS methylprednisolone, prednisolone solution, prednisone

Pain and Inflammation* ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam Nonsteroidal Anti-inflammatory Drugs or naproxen (except naproxen CR or naproxen (NSAIDs) / Combinations suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT

Diclofex DC diclofenac sodium, diclofenac sodium gel 1%, (NDC^ 51021037201 only) diclofenac sodium solution, ibuprofen, Diclosaicin meloxicam, naproxen (except naproxen CR or Inflammacin naproxen suspension) NuDiclo SoluPak NuDiclo TabPak PENNSAID

fenoprofen diclofenac sodium, ibuprofen, meloxicam, naproxen indomethacin capsule 20 mg (except naproxen CR or naproxen suspension) ketoprofen capsule 25 mg ketoprofen ext-rel capsule mefenamic acid (NDC^ 69336012830 only) naproxen CR naproxen suspension FENOPROFEN CAPSULE INDOCIN NAPRELAN SPRIX ZORVOLEX

naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT

Parkinson’s Disease APOKYN1 INBRIJA

Postherpetic Neuralgia HORIZANT gabapentin, GRALISE

Prostate Condition JALYN dutasteride-tamsulosin; dutasteride or finasteride Benign Prostatic Hyperplasia* WITH alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin

RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, UROXATRAL terazosin

Respiratory ARALAST NP1 PROLASTIN-C 1 Alpha-1 Antitrypsin Deficiency GLASSIA ZEMAIRA1

Respiratory benzonatate (NDCs^ 69336012615, benzonatate (except NDCs^ 69336012615, Cough 69499032915 only) 69499032915)

Sleep Disorder quazepam doxepin, eszopiclone, ramelteon, zolpidem, Hypnotics, Non-benzodiazepines INTERMEZZO zolpidem ext-rel, zolpidem sublingual, BELSOMRA LUNESTA ROZEREM ZOLPIMIST

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Category Formulary drug removals Formulary options Drug class

Testosterone Replacement* testosterone gel 1% (authorized testosterone gel (except authorized generics for Androgens generics for TESTIM and TESTIM and VOGELXO), testosterone solution, VOGELXO only) ANDRODERM ANDROGEL 1% FORTESTA NATESTO TESTIM VOGELXO

Thyroid Supplements TIROSINT levothyroxine, SYNTHROID

Transplant* PROGRAF1 tacrolimus Immunosuppressants, Calcineurin Inhibitors

Urea Cycle Disorders BUPHENYL1 sodium phenylbutyrate RAVICTI1

Women’s Health MENEST estradiol Menopausal Symptom Agents OSPHENA PREMARIN Oral

Women’s Health ESTRING estradiol, IMVEXXY Menopausal Symptom Agents FEMRING INTRAROSA Vaginal PREMARIN CREAM

Women’s Health fluoxetine tablet fluoxetine (except fluoxetine tablet 60 mg, Premenstrual Dysphoric Disorder (generics for SARAFEM only) fluoxetine tablet [generics for SARAFEM]), (PMDD) paroxetine HCl ext-rel, sertraline

Women’s Health AZESCO prenatal vitamins, CITRANATAL Prenatal Vitamins ZALVIT

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) Drug class Other considerations

All Drugs On a quarterly basis, new and existing products - including limited source generics, products with significant cost inflation, and specialty and non-specialty products - may be re-evaluated to determine appropriate formulary placement. These evaluations will assess whether clinically appropriate and cost-effective options remain available on the formulary and may result in removal, addition or deletion of a product.

Autoimmune and For some clients, an Indication-Based Formulary will be utilized for products in these classes and may Hepatitis C* result in additional removals for certain conditions only.

Drugs for Infusion A drug that must be infused into a space other than the blood will generally not be covered under the Into Spaces Other prescription drug benefit. Than the Blood

New-to-Market Agents1 New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost- effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark® National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval.

The listed formulary options are subject to change.

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) List of formulary drug removals

ABILIFY BEPREVE CRESTOR EVERSENSE CONTINUOUS ACANYA BERINERT1 cyclobenzaprine ext-rel GLUCOSE MONITORING ACCU-CHEK AVIVA PLUS BETAPACE capsule SYSTEM STRIPS AND KITS8 BETAPACE AF cyclobenzaprine tablet 7.5 mg EVZIO ACCU-CHEK COMPACT PLUS BEVESPI AEROSPHERE CYMBALTA EXFORGE STRIPS AND KITS8 BEYAZ DARAPRIM EXFORGE HCT ACCU-CHEK GUIDE STRIPS bimatoprost solution 0.03% DaVite EXTAVIA1 1 AND KITS8 BORTEZOMIB DAYTRANA FABIOR 8 ACCU-CHEK SMARTVIEW BREEZE 2 STRIPS AND KITS DELZICOL FANAPT STRIPS AND KITS8 BRIVIACT DETROL LA FEMRING dexchlorpheniramine ACIPHEX Bupap fenofibrate tablet 120 mg BUPHENYL1 Dexifol ACIPHEX SPRINKLE FENOGLIDE TABLET 120 MG bupropion ext-rel Diclofex DC ACTEMRA1 fenoprofen tablet 450 mg (NDC^ 51021037201 only) FENOPROFEN CAPSULE ACTICLATE butalbital-acetaminophen Diclosaicin FERIVA 21/7 Activite tablet 50-300 mg DIFFERIN LOTION Fexmid ACTOS BUTALBITAL- diflorasone cream FINACEA GEL acyclovir cream ACETAMINOPHEN diflorasone ointment 1 FIORICET CAPSULE ADCIRCA dihydroergotamine spray (NDC^ 69499034230 only) flucytosine capsule 500 mg ADZENYS ER butalbital-acetaminophen- diltiazem ext-rel (generics fluocinonide cream 0.1% ADZENYS XR-ODT caffeine capsule for CARDIZEM LA only) fluorouracil cream 0.5% ALCORTIN A BUTRANS DIOVAN fluoxetine tablet generics( ALEVICYN GEL BYDUREON DIOVAN HCT for SARAFEM only) ALEVICYN SG BYETTA Diphen Elixir fluoxetine tablet 60 mg ALEVICYN SOLUTION CAFERGOT DORYX flurandrenolide lotion 1 (NDC^ 24470092112 only) ALIQOPA calcipotriene cream DORYX MPC flurandrenolide ointment ALLISON MEDICAL calcipotriene-betamethasone doxepin cream calcitriol ointment FML LIQUIFILM INSULIN SYRINGES6 doxycycline hyclate 1 CAMBIA delayed-rel tablet 200 mg FOLIC-K ALPROLIX 1 CARAC doxycycline hyclate FOLLISTIM AQ ALREX CARAFATE tablet 50 mg (NDC^ Folvik-D ALTOPREV CARBINOXAMINE 72143021160 only) Folvite-D ALVESCO TABLET 6 MG doxycycline hyclate FORTAMET AMITIZA CARDIZEM tablet 75 mg FORTESTA AMRIX CARDIZEM CD doxycycline hyclate FOSRENOL 1 tablet 150 mg ANDROGEL % CARDIZEM LA FOSTEUM doxycycline monohydrate APEXICON E CARNITOR FOSTEUM PLUS APIDRA capsule 75 mg FREESTYLE LIBRE CARNITOR SF doxycycline monohydrate APLENZIN CELLCEPT1 CONTINUOUS GLUCOSE 1 capsule 150 mg APOKYN chlordiazepoxide-clidinium doxycycline monohydrate MONITORING SYSTEM 8 APTENSIO XR (NDC^ 42494040901 only) delayed-rel capsule FREESTYLE STRIPS AND KITS 1 APTIOM CHLORZOXAZONE 250 MG DULERA FULPHILA 1 chlorzoxazone 375 mg ARALAST NP DUTOPROL FYCOMPA ARTHROTEC chlorzoxazone 500 mg (NDC^ GEL-ONE1 73007001303 only) DYRENIUM ASACOL HD Genicin Vita-S chlorzoxazone 750 mg EDARBI 1 ASMANEX 1 GENOTROPIN CHORIONIC GONADOTROPIN EDARBYCLOR 1 ASMANEX HFA GLASSIA CIALIS E.E.S. GRANULES 1 1 GLEEVEC ASTAGRAF XL CICATRACE EFFEXOR XR GLUMETZA ATACAND CIMZIA1 1 ELELYSO GLYCOPYRROLATE ATACAND HCT CIPRO HC 1 ELOCTATE TABLET 1.5 MG ATOPADERM CIPRODEX ENABLEX GOLYTELY AVENOVA clindamycin gel (NDC^ ENLITE CONTINUOUS 1 AVONEX1 68682046275 only) GRANIX GLUCOSE MONITORING AZELEX clobetasol spray GUARDIAN CONNECT SYSTEM AZESCO CLOBEX SPRAY CONTINUOUS GLUCOSE 1 COLAZAL ENTERAGAM MONITORING SYSTEM BARACLUDE TABLET 1 COLCRYS ENTYVIO HEPSERA1 BEAU RX 1 1 ENVARSUS XR BECONASE AQ COMPLERA HORIZANT BENICAR CONSENSI EPICERAM HUMALOG 1 BENICAR HCT CONTOUR NEXT STRIPS AND EPIVIR HBV HUMALOG MIX 50/50 1 BENSAL HP KITS 8 EPOGEN HUMALOG MIX 75/25 8 ergotamine-caffeine 1 BENZACLIN CONTOUR STRIPS AND KITS HUMATROPE 4 benzonatate CONTRAVE ERYPED HUMULIN 70/30 (NDCs^ 69336012615, CORDRAN OINTMENT ESTRING HUMULIN N4 69499032915 only) CoreMino EVEKEO HUMULIN R4

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) List of Formulary Drug Removals

HYALGAN1 metformin ext-rel Orphengesic Forte ROZEREM hydrocortisone butyrate (generics for FORTAMET ORTHO D RyClora lipophilic cream 0.1% and GLUMETZA only) ORTHO DF SABRIL1 HylaVite methocarbamol 500 mg ORTHOVISC1 SAIZEN1 (NDC^ 69036091010 only) 1 HYSINGLA ER OSENI SANDOSTATIN LAR INCRUSE ELLIPTA methocarbamol 750 mg (NDCs^ 69036093090, OSMOPREP SCARSILK PAD INDERAL LA 70868090190 only) OSPHENA SEROQUEL XR INDERAL XL 1 1 MIACALCIN INJECTION OTREXUP SIGNIFOR LAR INDOCIN MIACALCIN NASAL SPRAY OWEN MUMFORD NEEDLES6 SIL-K PAD indomethacin capsule 20 mg Migergot oxiconazole SILIVEX Inflammacin MILLIPRED (NDCs^ 00168035830, SILTREX INNOPRAN XL 1 MINASTRIN 24 FE 51672135902 only) SIMPONI INTERMEZZO MINIVELLE OXYCONTIN SINGULAIR INTRAROSA oxymorphone ext-rel 1 MINOCIN SOMAVERT INTUNIV minocycline ext-rel OXYTROL SORILUX INVEGA SUSTENNA MIRVASO PAXIL SPRIX INVOKAMET Mondoxyne NL capsule 75 mg PAXIL CR STENDRA 1 INVOKAMET XR MONOVISC1 PEGASYS STRIBILD1 INVOKANA MOVIPREP PENNSAID SUBOXONE isosorbide dinitrate 40 mg MultiPro PERCOCET sucralfate suspension JALYN mupirocin cream PERRIGO NEEDLES6 sumatriptan-naproxen JENTADUETO MYFORTIC1 PEXEVA SUPREP JENTADUETO XR MYTESI PLAVIX SYNERDERM KAMDOY NAPRELAN PLEGRIDY1 SYNVISC1 KAZANO naproxen-esomeprazole POLYTOZA SYNVISC-ONE1 ketoconazole foam 2% naproxen CR posaconazole TALIVA naproxen suspension Ketodan delayed-rel tablet TARGADOX ketoprofen capsule 25 mg NATAZIA 1 PRADAXA TASIGNA ketoprofen ext-rel capsule NATESTO PRED FORTE 1 TAYTULLA KINERET NESINA PREGNYL1 1 TAZORAC KOMBIGLYZE XR NEULASTA PREMARIN 1 1 1 TECFIDERA KYPROLIS NEULASTA ONPRO PREMARIN CREAM 1 TESTIM LACRISERT NEUPOGEN PREVACID testosterone gel 1% LACTULOSE PAK NEXIUM PREVIDENT (authorized generics for LANOXIN TABLET (125 MCG niacin tablet 500 mg PRIMLEV TESTIM and VOGELXO only) Niacor AND 250 MCG ONLY) PRISTIQ TIMOPTIC OCUDOSE lanthanum carbonate NICADAN PROAIR HFA TIROSINT LANTUS NICAPRIN 1 PROAIR RESPICLICK TOBI LAZANDA NICAZEL 1 PROCRIT1 TOBI PODHALER LESCOL XL NICAZEL FORTE 1 1 PROCYSBI TOPROL-XL LETAIRIS NICOMIDE 1 PRODIGEN TRACLEER levorphanol NILANDRON PROGRAF1 TRADJENTA LEXAPRO NORGESIC FORTE PROLENSA tramadol LIALDA NORITATE PROTONIX (NDC^ 52817019610 only) LIDOCAINE-TETRACAINE NORVASC PROVAD TRANSDERM SCOP CREAM (NDC^ NOVACORT PROVENTIL HFA TREXIMET 71800063115 only) NOVAREL1 triamcinolone PROZAC LIDOTREX NOVO NORDISK NEEDLES6 acetonide aerosol 0.2% PSORCON LILETTA1 NuDiclo SoluPak TRICOR QNASL 6 LIPITOR NuDiclo TabPak TRIVIDIA INSULIN SYRINGES 1 QSYMIA LIVALO NUTROPIN AQ TronVite Lorid NUVARING QTERN TRULANCE Lorzone NUVIGIL quazepam TUDORZA RAPAFLO 1 LOTEMAX OLEPTRO 1 UDENYCA RAPAMUNE 6 LOTEMAX SM OLUX-E 1 ULTIMED INSULIN SYRINGES RAVICTI 6 LUNESTA omeprazole-sodium ULTIMED NEEDLES 1 RAYOS LUPRON DEPOT bicarbonate UROXATRAL RECEDO MACRODANTIN OMNARIS VALCYTE 1 1 Matzim LA OMNITROPE REPATHA 1 VALTREX MAVYRET1 OMNIVEX REVATIO Vanatol LQ mefenamic acid ONFI RHEUMATE Vanatol S (NDC^ 69336012830 only) ONGLYZA RIBOZEL Vanoxide-HC MENEST ORENCIA INTRAVENOUS1 RIMSO-50 VASCULERA metaxalone 400 mg orphenadrine-aspirin-caffeine RIOMET VECTICAL

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) List of Formulary Drug Removals

VELTIN XENAZINE1 ZIANA venlafaxine ext-rel tablet XOLEGEL ZIRGAN (except 225 mg) XOPENEX HFA ZOHYDRO ER VENTOLIN HFA Xvite ZOLPIMIST VEREGEN XYZBAC ZONEGRAN VIAGRA YAZ ZONTIVITY VIEKIRA PAK1 ZALVIT ZORTRESS1 VIIBRYD ZARXIO1 ZORVOLEX VISCO-31 ZEGERID ZUPLENZ Vitasure ZELAC ZYDELIG1 VIVELLE-DOT ZEMAIRA1 ZYLET VOGELXO ZEPATIER1 ZYTIGA1 XANAX ZETIA ZYVIT XANAX XR ZETONNA

Aetna Standard Plan Formulary Exclusions Drug List (01/2021) * This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. † Listing does not include certain NDCs^. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size. 1 An exception process may exist for specific clinical or regulatory circumstances that may require coverage of a non-covered medication. If your doctor believes you have a specific clinical need for a non-covered product, he or she should fax an exception request to: 1-888-487-9257. 2 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). 3 If approved for coverage and prescribed for primary prevention of cardiovascular disease, may be covered without cost sharing through an exceptions process. 4 Rebranded or private label formulations are not covered (i.e., RELION). 5 Long Acting Insulins - First Generation. 6 BD ULTRAFINE syringes and needles are the only preferred options. 7 A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746. 8 ONETOUCH brand test strips are the only preferred options.

This is not a complete list of medications covered or excluded under your plan. We only list the most common ones. Certain drugs may not be covered by your particular pharmacy plan. Diabetic supplies may be covered under your medical plan. Information is believed to be accurate as of the production date; however, it is subject to change. To check coverage and copay information for a specific medicine, log into your member website. For questions, please call the toll free number on the back of your member ID card.