2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1

2016 Innovation Health Leap Drug Guide

Acamprosate CalciumProducts Affected

• acamprosate calcium

QL Criteria 6 tablets Per 1 day

Notes/References

Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

2016 Innovation Health Leap Drug GuideLast update 12/2016

Accu-Chek ActiveProducts Affected

• ACCU-CHEK ACTIVE

PA Criteria Criteria Details

Covered Uses Type II Diabetes Mellitus

Exclusion Criteria

Required Medical Information

There is documentation the member has a physical limitation that makes utilization of an Abbott or Lifescan product unsafe, inaccurate or otherwise not feasible. Such limitations may include, but are not limited to, manual dexterity or visual impairment issues not accommodated by the features and capabilities of the Abbott or Lifescan product lines, or the member has hematocrit levels which are chronically less than 30% or greater than 55%.

Age Restrictions

Prescriber Restrictions

Coverage Duration

3 Years, limit one meter per year

Other Criteria

QL Criteria 300 strips Per 1 month

Notes/References

Revision DatePrior Authorization: November 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

Accu-Chek AvivaProducts Affected

• ACCU-CHEK AVIVA IN VITRO STRIP

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Accu-Chek Aviva PlusProducts Affected

• ACCU-CHEK AVIVA PLUS IN VITRO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Accu-Chek Compact PlusProducts Affected

• ACCU-CHEK COMPACT PLUS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Accu-Chek Compact Test DrumProducts Affected

• ACCU-CHEK COMPACT TEST DRUM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Accu-Chek SmartViewProducts Affected

• ACCU-CHEK SMARTVIEW

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Accutrend GlucoseProducts Affected

• ACCUTREND GLUCOSE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AcitretinProducts Affected

• acitretin

QL Criteria 2 capsules Per 1 day

Notes/References

ActemraProducts Affected

• ACTEMRA INTRAVENOUS*

Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Refer to the clinical policy bulletin above for details.

Other Criteria

ST CriteriaRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/immunologicalagents_rheumatoid_arthritis.html

Notes/References

ActimmuneProducts Affected

• ACTIMMUNE

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/actimmune.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Revision DatePrior Authorization: September 28, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

Actoplus met XRProducts Affected

• ACTOPLUS MET XR

ST Criteria Documented step through METFORMIN 1500MG/day

Notes/References

Acura Blood Glucose TestProducts Affected

• ACURA BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AcuvailProducts Affected

• ACUVAIL

QL Criteria 1 vial Per 1 day

Notes/References

AdapaleneProducts Affected

• adapalene external lotion

ST Criteria Documented step through TRETINOIN

Notes/References

AdcircaProducts Affected

• ADCIRCA

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/pulmonaryhypertensionagents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Adefovir DipivoxilProducts Affected

• adefovir dipivoxil

QL Criteria 1 tablet Per 1 day

Notes/References

Advair DiskusProducts Affected

• ADVAIR DISKUS

ST Criteria Documented step through DULERA

QL Criteria 1 inhaler Per 1 month

Notes/References

Advair HFAProducts Affected

• ADVAIR HFA

ST Criteria Documented step through DULERA

Notes/References

Advance Intuition MeterProducts Affected

• ADVANCE INTUITION METER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 meter Per 1 year

Notes/References Annual Review: 04/2016

Advance Intuition TestProducts Affected

• ADVANCE INTUITION TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AdvateProducts Affected

• ADVATE

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/bloodproducts_coagulants.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AdvicorProducts Affected

• ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 1000-20 MG

ST Criteria Documented step through TWO of the following: ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN

Notes/References

• ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 750-20 MG

QL Criteria 1 tablet Per 1 Day

Notes/References

• ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 1000-40 MG, 500-20 MG

Notes/References

Advocate Blood Glucose MonitorProducts Affected

• ADVOCATE BLOOD GLUCOSE MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Advocate DuoProducts Affected

• ADVOCATE DUO DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Advocate Redi-CodeProducts Affected

• ADVOCATE REDI-CODE DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Advocate Redi-CodeProducts Affected

• ADVOCATE REDI-CODE IN VITRO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Advocate Redi-Code+Products Affected

• ADVOCATE REDI-CODE+

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Advocate Redi-Code+ TestProducts Affected

• ADVOCATE REDI-CODE+ TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Advocate TestProducts Affected

• ADVOCATE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AdynovateProducts Affected

• adynovate

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Afeditab CRProducts Affected

• AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG

Notes/References

Afeditab CRProducts Affected

• AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG

Notes/References

AfinitorProducts Affected

• AFINITOR

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Antineoplastics.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Revision DatePrior Authorization: May 27, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

AgaMatrix AMP TestProducts Affected

• AGAMATRIX AMP TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AgaMatrix Jazz TestProducts Affected

• AGAMATRIX JAZZ TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AgaMatrix KeyNote TestProducts Affected

• AGAMATRIX KEYNOTE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AgaMatrix Presto Pro MeterProducts Affected

• AGAMATRIX PRESTO PRO METER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

AgaMatrix Presto TestProducts Affected

• AGAMATRIX PRESTO TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AkynzeoProducts Affected

• AKYNZEO

Covered Uses Prophylaxis of nausea and vomiting associated with cancer chemotherapy

Exclusion Criteria

A documented diagnosis of nausea and vomiting associated with cancer chemotherapy

Age Restrictions

Coverage Duration

1 year

Other Criteria

QL Criteria 2 capsules Per 1 month

Revision DatePrior Authorization: October 21, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

AldurazymeProducts Affected

• ALDURAZYME

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/lysosomal_storage.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Alendronate SodiumProducts Affected

• alendronate sodium oral tablet 10 mg, 40 mg, 5 mg

Notes/References

Alendronate SodiumProducts Affected

• alendronate sodium oral tablet 70 mg, 35 mg

QL Criteria 4 tablets Per 1 month

Notes/References

Alfuzosin HCl ERProducts Affected

• alfuzosin hcl er

Notes/References

AlimtaProducts Affected

• ALIMTA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Almotriptan MalateProducts Affected

• almotriptan malate

ST Criteria Documented step through TWO of the following: SUMATRIPTAN, NARATRIPTAN, RIZATRIPTAN

QL Criteria 6 tablets Per 30 Days

Notes/References

Alogliptin BenzoateProducts Affected

• alogliptin benzoate

Notes/References

Alogliptin-Metformin HClProducts Affected

• alogliptin-metformin hcl

QL Criteria 2 tablets Per 1 Day

Notes/References

Alogliptin-PioglitazoneProducts Affected

• alogliptin-pioglitazone

Notes/References

AloxiProducts Affected

• ALOXI INTRAVENOUS* SOLUTION 0.25 MG/5ML

Covered Uses

Prevention of acute or delayed nausea or vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy and prevention of postoperative nausea and vomiting (PONV) for up to 24 hours following surgery

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

Alphanate/VWF Complex/HumanProducts Affected

• ALPHANATE/VWF COMPLEX/HUMAN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AlphaNine SDProducts Affected

• ALPHANINE SD

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ALPRAZolam ERProducts Affected

• alprazolam er

Notes/References

ALPRAZolam XRProducts Affected

• alprazolam xr

Notes/References

AlprolixProducts Affected

• ALPROLIX

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AltaveraProducts Affected

• ALTAVERA

QL Criteria 1.5 tablets Per 1 day

Notes/References

AltoprevProducts Affected

• ALTOPREV

Notes/References

AlvescoProducts Affected

• ALVESCO

ST Criteria Documented step through QVAR

Notes/References

Alyacen 1/35Products Affected

• alyacen 1/35

Notes/References

AmethiaProducts Affected

• AMETHIA

Notes/References

Amethia LoProducts Affected

• AMETHIA LO

Notes/References

AmethystProducts Affected

• AMETHYST

Notes/References

AmitizaProducts Affected

• AMITIZA

ST Criteria Documented step through LACTULOSE OR POLYETHYLENE GLYCOL

Notes/References

Amlodipine Besylate-ValsartanProducts Affected

• amlodipine besylate-valsartan

Notes/References

AmnesteemProducts Affected

• AMNESTEEM

ST Criteria Documented step through MINOCYCLINE OR DOXYCYCLINE

Amphetamine Salt ComboProducts Affected

• amphetamine salt combo

Notes/References

Amphetamine-Dextroamphet ERProducts Affected

• amphetamine-dextroamphet er

Covered UsesAttention Deficit Disorder(ADD), Attention Deficit Hyperactivity Disorder(ADHD)

Exclusion Criteria

Not covered as first-line treatment, not approved for reasons of convenience/compliance, either on the part of the patient or their provider, not covered in members with contraindications to stimulant therapy, and not covered for treatment of conditions other than ADD or ADHD including, but not limited to: cancer related fatigue, human immunodeficiency virus (HIV)-positive related fatigue, finding related to coordination/incoordination- impaired cognition (pediatrics), paraphilia (adjunct), shivering, postanesthesia (treatment and prophylaxis), traumatic brain injury

Documented diagnosis of adult ADD or ADHD OR documented diagnosis of childhood ADHD onset with history of previous treatment, with documentation of symptoms significantly impacting, impairing, or compromising the patient's ability to function normally (i.e., attend/maintain academic enrollment or employment), and either of the following: (1)for requests for Dextroamphetamine/Amphetamine ER, Methyphenidate CD, Daytrana, Dexmethylphenidate XR, Methylphenidate ER, Methylphenidate ER-LA, Quillivant XR: documentation of intolerance to appropriately dosed and administered regular/immediate acting stimulants, or (2) for requests for Vyvanse: documentation of intolerance to appropriately dosed and administered regular/immediate acting amphetamine salts and dextroamphetamine/amphetamine ER.

Age Restrictions 19 years and greater

Coverage Duration

1 Year

Other Criteria

QL Criteria 2 capsules Per 1 Day

Notes/References

Amphetamine-DextroamphetamineProducts Affected

• amphetamine-dextroamphetamine

Notes/References

AmpyraProducts Affected

• AMPYRA

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AndrodermProducts Affected

• ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR

Covered Uses Primary hypogonadism or hypogonadotropic hypogonadism

Exclusion CriteriaFemale patients, male patients with carcinoma of the breast or suspected carcinoma of the prostate, or in a patient who will be using therapy for muscle building purposes

Documented diagnosis of primary hypogonadism or hypogonadotropic hypogonadism as defined by either one of the following: (1) Member has undergone bilateral orchiectomy (no total fasting serum testosterone levels required), or (2) Having two consecutive low total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference ranges are not available), or for persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL), two consecutive low free or bioavailable fasting serum testosterone levels (below the testing laboratory's reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available), Note: Two morning samples drawn between 7:00 a.m. and 10:00 a.m. obtained on two different days is required for NEW starts only.

Age Restrictions

Coverage Duration

3 years

Other CriteriaNote: if there is conflict in the results of total testosterone and free testosterone testing, the free testosterone results will be used to evaluate the request.

QL Criteria 1 patch Per 1 day

AndroGelProducts Affected

• ANDROGEL TRANSDERMAL GEL 40.5 MG/2.5GM (1.62%)

Age Restrictions

Coverage Duration

3 years

QL Criteria 5 grams-2 packets Per 1 day

• ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%)

Age Restrictions

Coverage Duration

3 years

QL Criteria 1 1.25 gm packet Per 1 day

• ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%)

Age Restrictions

Coverage Duration

3 years

QL Criteria 1 25 gram packet Per 1 day

• ANDROGEL TRANSDERMAL GEL 50 MG/5GM (1%)

Age Restrictions

Coverage Duration

3 years

QL Criteria 2 10 gm packets Per 1 day

AndroGel PumpProducts Affected

• ANDROGEL PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%)

Age Restrictions

Coverage Duration

3 years

QL Criteria 10 grams Per 1 day

AndroGel PumpProducts Affected

• ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)

Age Restrictions

Coverage Duration

3 years

QL Criteria 4 pumps Per 1 day

AnzemetProducts Affected

• ANZEMET ORAL

Notes/References

ApidraProducts Affected

• APIDRA

ST Criteria Documented step through HUMALOG product

QL Criteria 1 SOLN Per 180 FILLs

Notes/References

Apidra SoloStarProducts Affected

• APIDRA SOLOSTAR SUBCUTANEOUS*

Notes/References

ApriProducts Affected

• APRI

Notes/References

AprisoProducts Affected

• APRISO

Notes/References

Aralast NPProducts Affected

• ARALAST NP

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/immunomodulators_CAP.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AranelleProducts Affected

• ARANELLE

Notes/References

Aranesp (Albumin Free)Products Affected

• ARANESP (ALBUMIN FREE) INJECTION SOLUTION 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 150 MCG/0.75ML, 10 MCG/0.4ML, 60 MCG/ML, 100 MCG/ML, 200 MCG/ML

• ARANESP (ALBUMIN FREE) INJECTION

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Erythropoiesis_Stimulating_Agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Aranesp (Albumin Free)Products Affected

• ARANESP (ALBUMIN FREE) INJECTION

Covered Uses

Anemia from myelodysplastic syndrome; or Anemia of prematurity; or Special circumstance members who will not or can not receive whole blood or components as replacement for traumatic or surgical loss; or Treatment of anemic members scheduled to undergo hi

Exclusion Criteria

Non-covered uses include the following-Acute renal injury, Anemia associated only with radiotherapy, Anemia associated with the treatment of acute and chronic myelogenous leukemia (AML, CML) or erythroid cancers, Anemia due to bleeding (other than indicatio

A. Treatment of anemia associated with chronic kidney disease (CKD) receiving dialysis: Requirement of laboratory evidence: 1) Initiation hemoglobin (g/dL) is less than 10g/dL and Hemoglobin is not maintained above 11g/dL. Maintenance of Hct > 36% or a

Age Restrictions

Coverage Duration

4 months

Other Criteria

1. Regardless of indication, member is experiencing symptomatic anemia, such as fatigue, weakness, shortness of breath, or lightheadedness that are significantly impacting the ability of the patient to perform necessary activities of daily living, Or if

Notes/References

ArcalystProducts Affected

• ARCALYST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Arcapta NeohalerProducts Affected

• ARCAPTA NEOHALER

QL Criteria 1 capsule Per 1 day

Notes/References

ARIPiprazoleProducts Affected

• aripiprazole oral tablet dispersible • aripiprazole oral tablet

Notes/References

ARIPiprazoleProducts Affected

• aripiprazole oral solution

QL Criteria 30 ml Per 1 Day

Notes/References

ArmodafinilProducts Affected

• armodafinil oral tablet 150 mg, 200 mg, 250 mg

Covered Uses excessive daytime sleepiness, Shift Work Sleep Disorder

Exclusion Criteria Nuvigil is not indicated to treat side effects caused by other medications.

FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH NARCOLEPSY: Documentation of diagnostic testing and clinical notations supporting diagnosis of Narcolepsy, such as MSLT, clinical progress notes, etc. (Failure to adequately support the diagnosis of narcolepsy may result in denial of coverage), and the patient has failed an adequate trial of at least TWO of the following immediate release stimulants (all available generically): Dexedrine, Ritalin, or Adderall, and the patient has stepped through an adequate trial of modafinil (modafinil requires prior authorization). FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH OBSTRUCTIVE SLEEP APNEA/HYPOPNEA SYNDROME: The prescribing physician is a sleep specialist, ear, nose and throat, neurologist or pulmonologist or has obtained a consult from a sleep specialist, and a standard diagnostic nocturnal polysomnography (NPSG) has confirmed the diagnosis of OSAHS, and the patient has received nasal continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) for at least 1 month, and CPAP or BIPAP therapy must be continued on a routine basis in combination with armodafinil therapy, and the daytime fatigue is significantly impacting, impairing, or compromising the patients ability to function normally, and the prescribing physician has established a patient care plan to treat the cause of OSAHS in conjunction with treating the daily fatigue, and the patient must be compliant with recommendations for OSAHS treatment, and the patient has stepped through an adequate trial of modafinil (modafinil requires prior authorization).

Age Restrictions

Coverage Duration

3 years

Other Criteria

Note: The plan also requires an unresponsive 2-week trial of 150mg per day dose before a 250mg per day dose is authorized. (Doses up to 250 mg/day can be used but there is no solid evidence that it provides additional benefit beyond 150 mg/day.)

Notes/References

ArmodafinilProducts Affected

• armodafinil oral tablet 50 mg

Covered Uses excessive daytime sleepiness, Shift Work Sleep Disorder

Exclusion Criteria Nuvigil is not indicated to treat side effects caused by other medications.

FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH NARCOLEPSY: Documentation of diagnostic testing and clinical notations supporting diagnosis of Narcolepsy, such as MSLT, clinical progress notes, etc. (Failure to adequately support the diagnosis of narcolepsy may result in denial of coverage), and the patient has failed an adequate trial of at least TWO of the following immediate release stimulants (all available generically): Dexedrine, Ritalin, or Adderall, and the patient has stepped through an adequate trial of modafinil (modafinil requires prior authorization). FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH OBSTRUCTIVE SLEEP APNEA/HYPOPNEA SYNDROME: The prescribing physician is a sleep specialist, ear, nose and throat, neurologist or pulmonologist or has obtained a consult from a sleep specialist, and a standard diagnostic nocturnal polysomnography (NPSG) has confirmed the diagnosis of OSAHS, and the patient has received nasal continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) for at least 1 month, and CPAP or BIPAP therapy must be continued on a routine basis in combination with armodafinil therapy, and the daytime fatigue is significantly impacting, impairing, or compromising the patients ability to function normally, and the prescribing physician has established a patient care plan to treat the cause of OSAHS in conjunction with treating the daily fatigue, and the patient must be compliant with recommendations for OSAHS treatment, and the patient has stepped through an adequate trial of modafinil (modafinil requires prior authorization).

Age Restrictions

Coverage Duration

3 years

Other Criteria

Note: The plan also requires an unresponsive 2-week trial of 150mg per day dose before a 250mg per day dose is authorized. (Doses up to 250 mg/day can be used but there is no solid evidence that it provides additional benefit beyond 150 mg/day.)

Notes/References

ArzerraProducts Affected

• ARZERRA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ascensia Autodisc TestProducts Affected

• ASCENSIA AUTODISC TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Asmanex 120 Metered DosesProducts Affected

• ASMANEX 120 METERED DOSES

Notes/References

Assure 3 TestProducts Affected

• ASSURE 3 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Assure 4 MeterProducts Affected

• ASSURE 4 METER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Assure 4 TestProducts Affected

• ASSURE 4 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Assure PlatinumProducts Affected

• ASSURE PLATINUM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Assure Platinum MeterProducts Affected

• ASSURE PLATINUM METER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Assure Pro Blood Glucose MeterProducts Affected

• ASSURE PRO BLOOD GLUCOSE METER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Assure Pro TestProducts Affected

• ASSURE PRO TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Atorvastatin CalciumProducts Affected

• atorvastatin calcium oral

Notes/References

AtriplaProducts Affected

• ATRIPLA

Notes/References

AubagioProducts Affected

• AUBAGIO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html

Notes/References

AvandametProducts Affected

• AVANDAMET ORAL TABLET 2-500 MG

Exclusion Criteria

Diagnosis of Type 1 Diabetes (IDDM), patients with symptomatic heart failure or those who develop signs and symptoms of heart failure after initiation of Avandia therapy, patients with established New York Heart Association (NYHA) Class III or IV heart failure, patients with a history of myocardial infarction, concurrent use with insulin or Symlin.

A documented diagnosis of type 2 diabetes mellitus in an adult patient who is unable to achieve adequate glycemic control (HbA1C lab value greater than 6.5%) despite the use of other medications, and who, after consultation with their healthcare provider, has decided not to take Actos (pioglitazone) for medical reasons.

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

AvandametProducts Affected

• AVANDAMET ORAL TABLET 2-1000 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

AvandiaProducts Affected

• AVANDIA

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

AvianeProducts Affected

• AVIANE

Notes/References

AvitaProducts Affected

• AVITA EXTERNAL CREAM

QL Criteria 50 grams Per 1 month

Notes/References

AvonexProducts Affected

• AVONEX

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 4 doses Per 1 month

Notes/References

Avonex PenProducts Affected

• AVONEX PEN INTRAMUSCULAR*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Avonex PrefilledProducts Affected

• AVONEX PREFILLED INTRAMUSCULAR*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AxironProducts Affected

• AXIRON

Age Restrictions

Coverage Duration

3 years

AzilectProducts Affected

• AZILECT

Notes/References

AzorProducts Affected

• AZOR

Notes/References

AzuretteProducts Affected

• AZURETTE

Notes/References

Balsalazide DisodiumProducts Affected

• balsalazide disodium

Notes/References

BalzivaProducts Affected

• BALZIVA

Notes/References

BanzelProducts Affected

• BANZEL ORAL TABLET

Covered Uses Adjunctive treatment of seizures associated with Lennox-Gastaut syndrome

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

BanzelProducts Affected

• BANZEL ORAL SUSPENSION

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

BaracludeProducts Affected

• BARACLUDE ORAL TABLET

Notes/References

Bayer Breeze 2 TestProducts Affected

• BAYER BREEZE 2 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Bayer Contour MonitorProducts Affected

• BAYER CONTOUR MONITOR DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Bayer Contour Next TestProducts Affected

• BAYER CONTOUR NEXT TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Bayer Contour TestProducts Affected

• BAYER CONTOUR TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

BebulinProducts Affected

• BEBULIN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Bebulin VHProducts Affected

• BEBULIN VH

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Beconase AQProducts Affected

• BECONASE AQ

ST Criteria Documented step through FLUTICASONE PROPIONATE AND FLUNISOLIDE

Notes/References

BenicarProducts Affected

• BENICAR

Notes/References

Benicar HCTProducts Affected

• BENICAR HCT

Notes/References

BenlystaProducts Affected

• BENLYSTA

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/benlysta.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

BetaseronProducts Affected

• BETASERON SUBCUTANEOUS* KIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 box (15 vials) Per 1 month

Notes/References

BexaroteneProducts Affected

• bexarotene

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

BG Star TestProducts Affected

• BG STAR TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

BicalutamideProducts Affected

• bicalutamide

Notes/References

BimatoprostProducts Affected

• bimatoprost ophthalmic

Covered Uses Glaucoma

Exclusion Criteria

Documented step through latanoprost.

Age Restrictions

Coverage Duration

3 years

Other Criteria

Notes/References

BivigamProducts Affected

• BIVIGAM

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/ivig.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

BosulifProducts Affected

• BOSULIF ORAL TABLET 100 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 4 EA Per 1 day

Notes/References

BosulifProducts Affected

• BOSULIF ORAL TABLET 500 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

BotoxProducts Affected

• BOTOX

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/botulinum_toxin.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

BravelleProducts Affected

• BRAVELLE

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/infertility.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Breeze 2 Blood Glucose SystemProducts Affected

• BREEZE 2 BLOOD GLUCOSE SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Brevicon (28)Products Affected

• BREVICON (28)

Notes/References

BriellynProducts Affected

• briellyn

Notes/References

BrilintaProducts Affected

• BRILINTA

ST Criteria Documented step through CLOPIDOGREL

Notes/References

BrovanaProducts Affected

• BROVANA

QL Criteria 4 milliliters Per 1 day

Notes/References

BudesonideProducts Affected

• budesonide inhalation

Covered Uses Asthma

Exclusion Criteria

Budesonide inhalation solution is NOT covered for members greater than 8 years of age, for children 5-8 years of age who are able to use metered-dose inhalers, for use in primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required, and for use in acute bronchospasms.

Covered for the maintenance treatment of asthma and as prophylactic therapy in children 1-4 years of age, or in children 5-8 years of age if unable to use metered dose inhalers.

Age Restrictions Less than 8 years of age

Coverage Duration

1 Year, up to the age of 8 years of age

Other CriteriaMedical Exception: Covered for topical steroid treatment of eosinophilic esophagitis for which other treatments have been unsatisfactory

Notes/References

BunavailProducts Affected

• BUNAVAIL

Covered UsesOpioid Dependence. NOTE: Prior Authorization does not apply to members residing in Massachusetts.

Exclusion Criteria

Medical literature does not support the concurrent use of opioids/Tramadol as part of opioid drug dependence treatment. Abstinence of opioids/Tramadol is required both during and following therapy with Suboxone/Subutex/Zubsolv/Bunavail/buprenorphine, and will only be covered when determined to be medically necessary (defined as short-term use during and following opioid dependence treatment for the treatment of acute pain related to surgery, dental procedure, or an emergency situation or for long-term use following opioid dependence treatment for the treatment of chronic pain. For long term use, the member must be treated by a single provider of their choice, opioids will only be covered when prescribed by this single provider, and this single provider is aware of past buprenorphine use for opioid dependence treatment in which an opioid dependence diagnosis). Physicians can contact (855) 746-0013 with any information related to the medical necessity for opioid/Tramadol therapy.

Prescriber provides verbal verification of patient's current and ongoing enrollment in an outpatient drug addiction treatment program/ counseling. If the member is currently enrolled, the approval will be 6 months. If the member is NOT enrolled (answer=no) and prescriber provides verbal verification of patient's agreed commitment to become enrolled in an acceptable drug addiction treatment program counseling, the approval will be for 2 months (Note: 1 time approval ONLY). If after 2 months member does not enroll in a program, then all future requests will be denied until member enrolls in a program.

Age Restrictions

Coverage Duration

6 months = current enrollement

Other Criteria

For coverage of additional quantities, the following conditions must be met: FOR BUPRENORPHONE SL: Member is pregnant or breastfeeding (Up to 120 tablets in 30 days)or member has a documented contraindication, intolerance, or allergy to buprenorphine-naloxone sublingual tablet or Suboxone (will allow up to 90 tablets per month for max length of approval of 6 months). FOR SUBOXONE OR BUPRENORPHINE-NALOXONE SUBLINGUAL TABLET 2mg/0.5mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 12 mg/daily for total of 42 tablets/films in 7 days). FOR ZUBSOLBV 1.4mg/0.36mg: Member's dose is being titrated by physician for 7 day induction therapy (max dose 8.4 mg/daily for total of 42 tablets/films in 7 days). Note: Aetna considers the following as acceptable programs: Outpatient drug addiction treatment programs and/or counseling, 12- step programs focused on "drug" addiction such as Narcotics Anonymous (N.A.), Other accepted programs can be found at http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx. Aetna considers the following as non-acceptable programs: On-line programs such as Here to Help, 12-step programs that are not focused on "drug" addiction (ex: Alcoholics Anonymous).

ST Criteria A documented step through one month each of the preferred alternatives, buprenorphine-naloxone sublingual tablet and Suboxone SL film

Revision DatePrior Authorization: April 20, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

BuphenylProducts Affected

• BUPHENYL ORAL TABLET

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/metabolic_agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Buprenorphine HClProducts Affected

• buprenorphine hcl sublingual tablet sublingual8 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Buprenorphine HClProducts Affected

• buprenorphine hcl sublingual tablet sublingual2 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Buprenorphine HCl-Naloxone HClProducts Affected

• buprenorphine hcl-naloxone hcl

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

BuprobanProducts Affected

• BUPROBAN

Notes/References

BuPROPion HClProducts Affected

• bupropion hcl oral

Notes/References

BuPROPion HCl ER (Smoking Det)Products Affected

• bupropion hcl er (smoking det)

Notes/References

BuPROPion HCl ER (SR)Products Affected

• bupropion hcl er (sr)

Notes/References

BuPROPion HCl ER (XL)Products Affected

• bupropion hcl er (xl)

Notes/References

Butorphanol TartrateProducts Affected

• butorphanol tartrate nasal

QL Criteria 2 bottles Per 1 month

Notes/References

ButransProducts Affected

• BUTRANS TRANSDERMAL PATCH WEEKLY 20 MCG/HR, 10 MCG/HR, 5 MCG/HR

Covered UsesChronic paid due to malignant condition or severe pain requiring long term opioid.

Exclusion CriteriaNo documented progression through the World Health Organization analgesic ladder

For new members with chronic pain due to a malignant condition (if previously stabilized) or for moderate to severe pain meeting the following criteria: documented progression through the World Health Organization analgesic ladder and documented step through extended release morphine sulfate tablets (MS Contin), or for the diagnosis of diabetic peripheral neuropathy (DPN) requesting Nucynta ER, a documented step through TWO (2) of the following drug/ drug classes (each agent must be from a different class): gabapentin, a tricyclic antidepressant (eg: amitriptyline), tramadol, Lyrica, a SNRI (e.g. venlafaxine, duloxetine) and documented step through extended release morphine sulfate tablets (MS Contin)

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

QL Criteria 1 box (4 patches) Per 1 month

Notes/References

BydureonProducts Affected

• BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED

Covered Uses Type 2 Diabetes Mellitus (NIDDM)

Exclusion Criteria

Diagnosis of metabolic syndrome or any other pre-diabetic diagnosis, diagnosis of Type 1 Diabetes, treatment of diabetic ketoacidosis, pediatric patients, patients with multiple endocrine neoplasia syndrome type 2 (MEN2), family history of medullary thyroid carcinoma (MTC), patients with a history of pancreatitis

Patient must an A1C level is greater than 6.5%, have failed to obtain adequate glycemic control on maximum tolerated dose of metformin (unless the patient is not a candidate for metformin therapy) and a second antidiabetic agent (either a sulfonylurea, a thiazolidinedione (TZD), a DPP4-inhibitor or basal insulin)

Age Restrictions

Coverage Duration

3 Years

Other Criteria

QL Criteria 4 vials Per 1 month

Notes/References

Byetta 10 MCG PenProducts Affected

• BYETTA 10 MCG PEN SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

3 Years

Other Criteria

QL Criteria 1 pen Per 1 month

Byetta 5 MCG PenProducts Affected

• BYETTA 5 MCG PEN SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

3 Years

Other Criteria

QL Criteria 1 pen Per 1 month

BystolicProducts Affected

• BYSTOLIC ORAL TABLET 20 MG

Notes/References

BystolicProducts Affected

• BYSTOLIC ORAL TABLET 2.5 MG, 5 MG, 10 MG

Notes/References

CalcipotrieneProducts Affected

• calcipotriene external

ST Criteria Documented step through of trial and failure of MEDIUM TO HIGH POTENCY TOPICAL STEROID

Notes/References

Calcipotriene-Betameth DipropProducts Affected

• calcipotriene-betameth diprop

ST Criteria Documented step through CALCIPOTRIENE AND MEDIUM TO HIGH POTENCY TOPICAL STEROID

Notes/References

Calcitonin (Salmon)Products Affected

• calcitonin (salmon)

Covered Uses Osteoporosis

Exclusion CriteriaNo failure of formulary bisphosphonates, use in combination with one or more bisphosphonates.

Documentation of a trial and failure of generic alendronate weekly (70mg weekly dose)

Age Restrictions

Coverage Duration

3 years

Other Criteria

QL Criteria 1 bottle Per 1 month

CalcitreneProducts Affected

• CALCITRENE

ST Criteria Documented step through of trial and failure of MEDIUM TO HIGH POTENCY TOPICAL STEROID

Notes/References

CamilaProducts Affected

• CAMILA

Notes/References

CamreseProducts Affected

• CAMRESE

Notes/References

Camrese LoProducts Affected

• CAMRESE LO

Notes/References

CanasaProducts Affected

• CANASA

ST Criteria Documented failure, contraindication or intolerance to Apriso

QL Criteria 1 suppository Per 1 Day

Notes/References

Candesartan CilexetilProducts Affected

• candesartan cilexetil oral tablet 4 mg, 8 mg, 16 mg

Notes/References

Candesartan Cilexetil-HCTZProducts Affected

• candesartan cilexetil-hctz

Notes/References

CapecitabineProducts Affected

• capecitabine

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

CaprelsaProducts Affected

• CAPRELSA ORAL TABLET 100 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

CaprelsaProducts Affected

• CAPRELSA ORAL TABLET 300 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

CarbagluProducts Affected

• CARBAGLU

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cardura XLProducts Affected

• CARDURA XL

Notes/References

CareSens N Glucose SystemProducts Affected

• CARESENS N GLUCOSE SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

CareSens N Glucose TestProducts Affected

• CARESENS N GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Carimune NFProducts Affected

• CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 6 GM, 12 GM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cartia XTProducts Affected

• CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 300 MG, 180 MG

Notes/References

Cartia XTProducts Affected

• CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG

Notes/References

CaystonProducts Affected

• CAYSTON

Notes/References

CaziantProducts Affected

• CAZIANT

Notes/References

CefiximeProducts Affected

• cefixime

QL Criteria 1 bottle Per 1 fill

Notes/References

CelecoxibProducts Affected

• celecoxib oral

ST Criteria Documented step through TWO NSAIDs

Notes/References

CerdelgaProducts Affected

• CERDELGA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 capsules Per 1 days

Notes/References

CerezymeProducts Affected

• CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

CesametProducts Affected

• CESAMET

Notes/References

CesiaProducts Affected

• CESIA

Notes/References

CetrotideProducts Affected

• CETROTIDE SUBCUTANEOUS* KIT 0.25 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cevimeline HClProducts Affected

• cevimeline hcl

Notes/References

ChantixProducts Affected

• CHANTIX

Notes/References

Chantix Continuing Month PakProducts Affected

• CHANTIX CONTINUING MONTH PAK

Notes/References

Chantix Starting Month PakProducts Affected

• CHANTIX STARTING MONTH PAK

Notes/References

ChatealProducts Affected

• CHATEAL

Notes/References

ChenodalProducts Affected

• CHENODAL

Covered Uses Cholesterol-type gallstones, Cerebrotendinous Xanthomatosis (CTX)

Exclusion CriteriaIntrahepatic duct calculus, Chronic constipation in patients with cholesterol gallstones, Prophylaxis of recurrent gallstones, Hyperlipidemia, Rheumatoid Arthritis

For treatment of cholesterol-type gallstones, documentation of trial and failure of 2 years of generic ursodiol therapy, and documentaion of inability to undergo surgery due to systemic disease or age.

Age Restrictions 18 Years of age or greater

Coverage Duration

1 month, extended approval after 3 months based on response and laboratory values

Other Criteria

Notes/References

Chorionic GonadotropinProducts Affected

• chorionic gonadotropin intramuscular*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

CialisProducts Affected

• CIALIS ORAL TABLET 5 MG

Covered Uses Benign Prostatic hyperplasia (BPH)

Exclusion Criteria Use solely for erectile dysfunction.

Diagnosis of benign prostatic hyperplasia, a trial and failure of two alpha blockers, and trial and failure of one 5-alpha reductase inhibitor

Age Restrictions

Coverage Duration

3 years

Other Criteria

CimziaProducts Affected

• CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Cimzia.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Cimzia.html

QL Criteria 1 kit Per 1 month

Notes/References

Cimzia PrefilledProducts Affected

• CIMZIA PREFILLED

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cimzia Starter KitProducts Affected

• CIMZIA STARTER KIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Citalopram HydrobromideProducts Affected

• citalopram hydrobromide oral tablet 10 mg, 20 mg

Notes/References

Citalopram HydrobromideProducts Affected

• citalopram hydrobromide oral tablet 40 mg

Notes/References

ClaravisProducts Affected

• CLARAVIS

Clever Chek Auto-CodeProducts Affected

• CLEVER CHEK AUTO-CODE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Clever Chek Auto-Code SystemProducts Affected

• CLEVER CHEK AUTO-CODE SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Clever Chek Auto-Code TestProducts Affected

• CLEVER CHEK AUTO-CODE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Clever Chek Auto-Code VoiceProducts Affected

• CLEVER CHEK AUTO-CODE VOICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Clever Chek Auto-Code VoiceProducts Affected

• CLEVER CHEK AUTO-CODE VOICE IN VITRO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Clever Chek TestProducts Affected

• CLEVER CHEK TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Clever Choice Auto-Code SystemProducts Affected

• CLEVER CHOICE AUTO-CODE SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Clever Choice Auto-Code TestProducts Affected

• CLEVER CHOICE AUTO-CODE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Clever Choice Micro TestProducts Affected

• CLEVER CHOICE MICRO TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Clever Choice Mini SystemProducts Affected

• CLEVER CHOICE MINI SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Climara ProProducts Affected

• CLIMARA PRO

Notes/References

CloNIDine HCl ERProducts Affected

• clonidine hcl er

ST Criteria Documented step through a STIMULANT

Notes/References

Clopidogrel BisulfateProducts Affected

• clopidogrel bisulfate

Notes/References

CloZAPineProducts Affected

• clozapine oral tablet 50 mg, 25 mg • clozapine oral tablet dispersible 25 mg

Notes/References

• clozapine oral tablet dispersible 100 mg • clozapine oral tablet 100 mg

Notes/References

• clozapine oral tablet dispersible 150 mg, 200 mg

Notes/References

• clozapine oral tablet dispersible 12.5 mg

Notes/References

• clozapine oral tablet 200 mg

Notes/References

CoagadexProducts Affected

• COAGADEX

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ColchicineProducts Affected

• colchicine oral tablet

Notes/References

Colyte with Flavor PacksProducts Affected

• COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 227.1 GM

QL Criteria 4 liters Per 1 fill

Notes/References

CombiPatchProducts Affected

• COMBIPATCH

QL Criteria 8 patches Per 1 month

Notes/References

Cometriq (100 mg Daily Dose)Products Affected

• COMETRIQ (100 MG DAILY DOSE)

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 kits Per 1 day

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 4 EA Per 1 day

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 3 kits Per 1 day

Notes/References

CompleraProducts Affected

• COMPLERA

Notes/References

Control ASTProducts Affected

• CONTROL AST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Control TestProducts Affected

• CONTROL TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

CopaxoneProducts Affected

• COPAXONE SUBCUTANEOUS* 40 MG/ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

CopaxoneProducts Affected

• COPAXONE SUBCUTANEOUS* 20 MG/ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

CordranProducts Affected

• CORDRAN EXTERNAL TAPE

QL Criteria 1 roll Per 1 month

Notes/References

Coreg CRProducts Affected

• COREG CR

ST Criteria Documented step through CARVEDILOL

Notes/References

CorifactProducts Affected

• CORIFACT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cosopt PFProducts Affected

• COSOPT PF

ST Criteria Documented step through DORZOLAMIDE/TIMOLOL

Notes/References

CreonProducts Affected

• CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 6000 UNIT

Covered Uses Exocrine pancreatic Insufficiency

Exclusion CriteriaUses not approved by the FDA, uses unapproved and not supported by the literature or evidence as an accepted off-label use. (see Off-Label Use Policy for determining accepted use).

Diagnosis of exocrine pancreatic insufficiency due to cystic fibrosis or other conditions and a documented trial of two weeks of Zenpep.

Age Restrictions

Coverage Duration

1 Year

Other Criteria

CrinoneProducts Affected

• CRINONE

Covered UsesART (Assisted Reproductive Technology), secondary amenorrhea, prevention of early pregnancy failure

Exclusion Criteria

Crinone, Endometrin, First Progesterone VGS is NOT covered for uses not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use).

Crinone, Endometrin, First Progesterone VGS are covered for members who meet the following criteria: (1) ART (Assisted Reproductive Technology): Crinone 8%, Endometrin, First Progesterone VGS: Documented diagnosis of progesterone deficiency in an infertile woman and member must have infertility coverage, or (2) Secondary amenorrhea: Crinone 4%, Crinone 8%: Documented diagnosis of progesterone deficiency in an infertile woman, and Crinone 8% is only for use in women who have failed to respond to treatment with Crinone 4%, and member must have infertility coverage, or (3) Prevention of early pregnancy failure

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

Cryselle-28Products Affected

• CRYSELLE-28

Notes/References

CuvposaProducts Affected

• CUVPOSA

Covered Uses neurologic conditions associated with drooling (e.g. cerebral palsy)

Exclusion Criteria

Documentaion of neurologic conditions associated with drooling (e.g. cerebral palsy) to reduce severe chronic drooling

Age Restrictions 3 years to 16 years

Coverage Duration

1 Year

Other Criteria

Cyclafem 1/35Products Affected

• CYCLAFEM 1/35

Notes/References

CyclessaProducts Affected

• CYCLESSA

Notes/References

CyclosetProducts Affected

• CYCLOSET

Notes/References

DacogenProducts Affected

• DACOGEN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

DaklinzaProducts Affected

• DAKLINZA

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/GI/hepatitis_c.html

Notes/References

DaklinzaProducts Affected

• DAKLINZA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 EA Per 1 Day

Notes/References

DalirespProducts Affected

• DALIRESP

Covered Uses Severe COPD

Exclusion Criteria Use for relief of acute bronchospasm

Diagnosis of severe COPD (FEV1 less than 50% predicted) associated with chronic bronchitis and at least one documented COPD exacerbation in the previous year, and an inadequate response or contraindication to a combination or single agent long-acting beta 2-agonist agent and Spiriva/Tudorza. An inadequate response to standard therapy shall include any exacerbation event requiring intervention with systemic glucocorticosteroids or hospitalization.

Age Restrictions

Coverage Duration

3 Years

Other Criteria

Notes/References

Darifenacin Hydrobromide ERProducts Affected

• darifenacin hydrobromide er

ST Criteria Documented step through OXYBUTYNIN or TROSPIUM AND VESICARE or MYRBETRIQ

Notes/References

Dasetta 1/35Products Affected

• DASETTA 1/35

Notes/References

DayseeProducts Affected

• DAYSEE

Notes/References

DaytranaProducts Affected

• DAYTRANA

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

DeblitaneProducts Affected

• DEBLITANE

Notes/References

DecitabineProducts Affected

• decitabine

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

DelzicolProducts Affected

• DELZICOL

QL Criteria 1 capsule Per 1 Day

Notes/References

DenavirProducts Affected

• DENAVIR

ST Criteria Documented step through ORAL ACYCLOVIR

Notes/References

Depo-ProveraProducts Affected

• DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 150 MG/ML

QL Criteria 1 syringe Per 90 dayss

Notes/References

Depo-SubQ Provera 104Products Affected

• DEPO-SUBQ PROVERA 104 SUBCUTANEOUS* SUSPENSION

Covered Uses Contraception/hormone therapy

Exclusion Criteria

A documented contraindication or intolerance or allergy or failure of an adequate trial of one month of one preferred oral generic alternative or a documented mental or physical handicap preventing the reasonable use of an oral contraceptive.

Age Restrictions

Coverage Duration

1 Year

Other Criteria

DescovyProducts Affected

• DESCOVY

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/antiviral_hiv.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

DesloratadineProducts Affected

• desloratadine

ST Criteria Documented step through TWO of the following: CLARITIN OTC, ZYRTEC OTC, ALLEGRA OTC

Notes/References

DesogenProducts Affected

• DESOGEN

Notes/References

Dexcom G4 Platinum ReceiverProducts Affected

• DEXCOM G4 PLATINUM RECEIVER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Dexcom G4 Platinum Sensor KitProducts Affected

• DEXCOM G4 PLATINUM SENSOR KIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Dexcom G4 Platinum TransmitterProducts Affected

• DEXCOM G4 PLATINUM TRANSMITTER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Dexcom G4 SensorProducts Affected

• DEXCOM G4 SENSOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

DexilantProducts Affected

• DEXILANT

Covered Uses

Diagnosis of Zollinger-Ellison syndrome, Uncomplicated gastroesophageal reflux desease (Gerd) with breakthrough symptoms, Complicated GERD and other higher risk conditions such as feflux-associated laryngitis, recent gastroinestinal bleed, grade 3 or 4 erosive esophagitis, or GERD exacerbated asthma.

Exclusion Criteria

Non-Covered uses include uses not approved by the FDA, or if use is unapproved and not supported by the literature or evidence as an accepted off-label use (see Off-Label Use Policy for determining accepted use). Quantity levels exceeding the quantity limitations on PPIs, Dexilant dosing exceeding 60mg/day

Rabeprazole up to 20 mg/day, Dexilant up to 60 mg/day, and Nexium up to 40 mg/day are available with prior-authorization when the following criteria is met: Step through Prilosec OTC/omeprazole, Prevacid 24H OTC, and pantoprazole. High Dose Nexium, Rabeprazole and Prevacid solutabs are available with prior-authorization when the following criteria is met: Nexium up to 80mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Rabeprazole up to 40mg/day with documentation of step through of one of the following high dose agents: 80 mg/day of Prilosec OTC/omeprazole or pantoprazole or 60mg/day of Prevacid 24H OTC, Prevacid solutabs up to 60mg/day for members greater than 1 year old with documentation of: inability to swallow tablets/capsules and step through ONE of the following: 80mg/day of omeprazole (capsules may be opened and sprinkled on 1 tablespoon of applesauce), or 60mg/day of Prevacid 24H OTC (capsule may be opened and sprinkled on 1 tablespoon of applesauce, Ensure pudding, cottage cheese, yogurt, or strained pears, or emptied into 60mL of apple juice, orange juice, or tomato juice )

Age Restrictions

Coverage Duration

Short Term course of high dose PPI 3-6 months. Long term course up to 1 Year.

Other Criteria

A step through one of these high dose therapies (80mg/day of Prilosec OTC/omeprazole or pantoprazole, OR 60mg/day of Prevacid 24H OTC) is required even if the member was previously approved for Rabeprazole, Prevacid solutabs, or Nexium at standard dosing. Exceptions may be considered if there is documentation of intolerance, e.g., side-effects or allergies to Prilosec OTC/omeprazole, pantoprazole, and Prevacid 24H OTC.

Dexmethylphenidate HClProducts Affected

• dexmethylphenidate hcl

Notes/References

Dexmethylphenidate HCl ERProducts Affected

• dexmethylphenidate hcl er

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

Dextroamphetamine SulfateProducts Affected

• dextroamphetamine sulfate oral solution

Notes/References

Dextroamphetamine SulfateProducts Affected

• dextroamphetamine sulfate oral tablet

Notes/References

Dextroamphetamine Sulfate ERProducts Affected

• dextroamphetamine sulfate er

Notes/References

DiazepamProducts Affected

• diazepam gel

QL Criteria 1 box Per 1 fill

Notes/References

Diclofenac SodiumProducts Affected

• diclofenac sodium transdermal gel 1 %

QL Criteria 200 grams Per 1 fill

Notes/References

DificidProducts Affected

• DIFICID

Covered Uses

Exclusion CriteriaInitial episodes of mild, moderate, or severe CDI.Severe complicated CDI (i.e. hypotension, ileus, megacolon, or shock).

Step through two courses of antibiotics: metronidazole and/or oral vancomycin

Age Restrictions

18 years old or greater

Coverage Duration

10 Days of therapy

Other Criteria

QL Criteria 20 tablets Per 1 fill

Notes/References

Diltiazem CDProducts Affected

• diltiazem cd oral capsule extended release 24 hour 240 mg

Notes/References

Diltiazem CDProducts Affected

• diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg

Notes/References

Diltiazem HCl ERProducts Affected

• diltiazem hcl er oral capsule extended release 24 hour 180 mg, 120 mg

• diltiazem hcl er oral capsule extended release 12 hour 120 mg

Notes/References

Diltiazem HCl ERProducts Affected

• diltiazem hcl er oral capsule extended release 24 hour 240 mg

Notes/References

Diltiazem HCl ER BeadsProducts Affected

• diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 300 mg, 360 mg, 120 mg, 420 mg

Notes/References

Diltiazem HCl ER BeadsProducts Affected

• diltiazem hcl er beads oral capsule extended release 24 hour 240 mg

Notes/References

Diltiazem HCl ER Coated BeadsProducts Affected

• diltiazem hcl er coated beads oral capsule extended release 24 hour 300 mg, 180 mg, 120 mg, 360 mg

Notes/References

Diltiazem HCl ER Coated BeadsProducts Affected

• diltiazem hcl er coated beads oral capsule extended release 24 hour 240 mg

Notes/References

Dilt-XRProducts Affected

• dilt-xr oral capsule extended release 24 hour180 mg, 120 mg

Notes/References

Dilt-XRProducts Affected

• dilt-xr oral capsule extended release 24 hour240 mg

Notes/References

DipentumProducts Affected

• DIPENTUM

Notes/References

Donepezil HClProducts Affected

• donepezil hcl oral tablet 23 mg

ST Criteria Documented step through DONEPEZIL 10MG

Notes/References

Donepezil HClProducts Affected

• donepezil hcl oral tablet 10 mg

Notes/References

DronabinolProducts Affected

• dronabinol

Covered UsesAnorexia associated with weight loss in patients with AIDS, Chemotherapy-induced nausea and vomiting

Exclusion Criteria Multiple sclerosis (spasticity), Fibromyalgia (Neuropathic Pain)

A diagnosis of anorexia associated with weight loss in patients with AIDS or for the treatment of chemotherapy induced nausea and vomiting who have failed to respond to conventional antiemetic therapies (such as prochlorperazine, chlorpromazine, haloperidol and metoclopramide)

Age Restrictions

Coverage Duration

Initial: 6 months. Continuation: 12 months if demonstrated adequate response to therapy.

Other Criteria

Notes/References

Drospiren-Eth Estrad-LevomefolProducts Affected

• drospiren-eth estrad-levomefol

QL Criteria 1.5 tablets Per 1 Day

Notes/References

Drospirenone-Ethinyl EstradiolProducts Affected

• drospirenone-ethinyl estradiol oral tablet3-0.03 mg

Notes/References

DuleraProducts Affected

• DULERA

Notes/References

DULoxetine HClProducts Affected

• duloxetine hcl oral capsule delayed release particles 30 mg, 60 mg

Notes/References

• duloxetine hcl oral capsule delayed release particles 40 mg

QL Criteria 1 cap Per 1 Day

Notes/References

• duloxetine hcl oral capsule delayed release particles 20 mg

Notes/References

DutasterideProducts Affected

• dutasteride

ST Criteria Documented step through FINASTERIDE

Notes/References

Easy Plus II Glucose SystemProducts Affected

• easy plus ii glucose system

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Easy Plus II Glucose TestProducts Affected

• easy plus ii glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Easy Step Glucose MonitorProducts Affected

• EASY STEP GLUCOSE MONITOR DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Easy Step TestProducts Affected

• EASY STEP TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Easy Talk Blood Glucose SystemProducts Affected

• easy talk blood glucose system device

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Easy Talk Blood Glucose TestProducts Affected

• easy talk blood glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Easy Touch TestProducts Affected

• EASY TOUCH TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Easy Trak Blood Glucose TestProducts Affected

• easy trak blood glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EasyGlucoProducts Affected

• EASYGLUCO IN VITRO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EasyMax 15 TestProducts Affected

• EASYMAX 15 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EasyMax L Blood GlucoseProducts Affected

• EASYMAX L BLOOD GLUCOSE DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

EasyMax N Blood GlucoseProducts Affected

• EASYMAX N BLOOD GLUCOSE DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

EasyMax NG Blood GlucoseProducts Affected

• EASYMAX NG BLOOD GLUCOSE DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

EASYMax TestProducts Affected

• EASYMAX TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EasyMax V Blood GlucoseProducts Affected

• EASYMAX V BLOOD GLUCOSE DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

EasyMax V2 Blood GlucoseProducts Affected

• EASYMAX V2 BLOOD GLUCOSE DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

EasyPlus Blood Glucose TestProducts Affected

• easyplus blood glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EasyPRO PlusProducts Affected

• EASYPRO PLUS IN VITRO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EdarbiProducts Affected

• EDARBI

Notes/References

EdarbyclorProducts Affected

• EDARBYCLOR

Notes/References

EdurantProducts Affected

• EDURANT

Notes/References

EffientProducts Affected

• EFFIENT

ST Criteria Documented step through CLOPIDOGREL

EgriftaProducts Affected

• EGRIFTA SUBCUTANEOUS* SOLUTION RECONSTITUTED 2 MG

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Antidotes.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ElapraseProducts Affected

• ELAPRASE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ElelysoProducts Affected

• ELELYSO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Element PlusProducts Affected

• ELEMENT PLUS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Element TestProducts Affected

• ELEMENT TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ElidelProducts Affected

• ELIDEL

Covered Uses Atopic Dermatitis

Exclusion Criteria

FOR CHILDREN LESS THAN 2 YEARS OF AGE: Covered for the treatment of mild to moderate atopic dermatitis (eczema) for short-term use (up to 3 months). FOR ADULTS: A documented diagnosis of atopic dermatitis (eczema) and the patient has a documented failure of an adequate trial of 2 weeks (14 days) of one preferred alternative topical corticosteroid indicated for the patient's condition or the patient is being treated for atopic dermatitis (eczema) in an area at high risk for skin atrophy such as face, eyelids, or genital areas.

Age Restrictions

Coverage Duration

1 year (3 months if less than 2 years old)

Other Criteria

ElinestProducts Affected

• ELINEST

Notes/References

EliquisProducts Affected

• ELIQUIS

ST Criteria A documented step through Xarelto and Pradaxa

Notes/References

EllaProducts Affected

• ELLA

Notes/References

EloctateProducts Affected

• ELOCTATE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EmbedaProducts Affected

• EMBEDA

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

Embrace Blood Glucose MonitorProducts Affected

• EMBRACE BLOOD GLUCOSE MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Embrace Blood Glucose TestProducts Affected

• EMBRACE BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EmendProducts Affected

• EMEND ORAL CAPSULE 80 & 125 MG

QL Criteria 3 tri-packs Per 30 months

Notes/References

EmendProducts Affected

• EMEND ORAL CAPSULE 125 MG, 80 MG, 40 MG

Notes/References

EmoquetteProducts Affected

• EMOQUETTE

Notes/References

EmsamProducts Affected

• EMSAM

Covered Uses Major Dispressive Disorder (MDD)

Exclusion CriteriaPatients taking products containing venlafaxine concomitantly, patients taking MAOIs concomitantly, for use in pediatrics.

Patient has documented failure or unresponsiveness to THREE different antidepressants from at least two different therapeutic subclasses, or patient is a new member and has been receiving Emsam therapy for more than 4 weeks.

Age Restrictions

Coverage Duration

3 years

Other CriteriaExamples of antidepressant trials from unique Therapeutic Subclass include SSRIs, SNRIs, NDRIs, TCAs, tetracyclic antidepressants, and MAOIs

Notes/References

EmtrivaProducts Affected

• EMTRIVA ORAL CAPSULE

Notes/References

EnbrelProducts Affected

• ENBREL SUBCUTANEOUS* 50 MG/ML • ENBREL SUBCUTANEOUS* KIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 8 syringes Per 1 month

Notes/References

EnbrelProducts Affected

• ENBREL SUBCUTANEOUS* 25 MG/0.5ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Enbrel SureClickProducts Affected

• ENBREL SURECLICK SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EndometrinProducts Affected

• ENDOMETRIN

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

EnjuviaProducts Affected

• ENJUVIA ORAL TABLET 0.9 MG, 0.45 MG, 0.625 MG, 0.3 MG

Notes/References

EnjuviaProducts Affected

• ENJUVIA ORAL TABLET 1.25 MG

Notes/References

Enoxaparin SodiumProducts Affected

• enoxaparin sodium

QL Criteria 2 syringes Per 1 day

Notes/References

Enpresse-28Products Affected

• ENPRESSE-28

Notes/References

EntecavirProducts Affected

• entecavir oral tablet 1 mg

Notes/References

EpclusaProducts Affected

• EPCLUSA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EpiduoProducts Affected

• EPIDUO

Notes/References

Epiduo ForteProducts Affected

• EPIDUO FORTE

QL Criteria 1 pump Per 1 month

Notes/References

EPINEPHrineProducts Affected

• epinephrine injection 0.3 mg/0.3ml, 0.15 mg/0.15ml

QL Criteria 2 pens Per 1 fill

Notes/References

EpiPen 2-PakProducts Affected

• EPIPEN 2-PAK INJECTION

Notes/References

EpogenProducts Affected

• EPOGEN INJECTION SOLUTION 3000 UNIT/ML, 20000 UNIT/ML, 4000 UNIT/ML, 10000 UNIT/ML, 2000 UNIT/ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Epoprostenol SodiumProducts Affected

• epoprostenol sodium

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Eprosartan MesylateProducts Affected

• eprosartan mesylate

Notes/References

ErivedgeProducts Affected

• ERIVEDGE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ErrinProducts Affected

• ERRIN

Notes/References

Escitalopram OxalateProducts Affected

• escitalopram oxalate oral tablet 5 mg, 20 mg

Notes/References

Escitalopram OxalateProducts Affected

• escitalopram oxalate oral tablet 10 mg

Notes/References

Esomeprazole MagnesiumProducts Affected

• esomeprazole magnesium

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EstradiolProducts Affected

• estradiol transdermal patch weekly

Notes/References

EstradiolProducts Affected

• estradiol transdermal patch biweekly

QL Criteria 8 patches Per 28 Days

Notes/References

Estradiol-Norethindrone AcetProducts Affected

• estradiol-norethindrone acet

Notes/References

EstrogelProducts Affected

• ESTROGEL

Notes/References

Estrostep FeProducts Affected

• ESTROSTEP FE

Notes/References

EszopicloneProducts Affected

• eszopiclone

Notes/References

EvamistProducts Affected

• EVAMIST

QL Criteria 2 bottles Per 1 fill

Notes/References

EvenCare + Blood Glucose TestProducts Affected

• EVENCARE + BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EvenCare Blood Glucose TestProducts Affected

• EVENCARE BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EvenCare G2 MonitorProducts Affected

• EVENCARE G2 MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

EvenCare G2 TestProducts Affected

• EVENCARE G2 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

EvenCare G3 MonitorProducts Affected

• EVENCARE G3 MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

EvenCare G3 TestProducts Affected

• EVENCARE G3 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Evolution AutocodeProducts Affected

• EVOLUTION AUTOCODE IN VITRO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Evolution AutocodeProducts Affected

• EVOLUTION AUTOCODE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ExjadeProducts Affected

• EXJADE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ExtaviaProducts Affected

• EXTAVIA SUBCUTANEOUS* KIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 box (15 vials) Per 1 month

Notes/References

Ez Smart Blood Glucose TestProducts Affected

• EZ SMART BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ez Smart Monitoring SystemProducts Affected

• EZ SMART MONITORING SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Ez Smart Plus Glucose TestProducts Affected

• EZ SMART PLUS GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ez Smart Plus Monitoring SysProducts Affected

• EZ SMART PLUS MONITORING SYS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

FabrazymeProducts Affected

• FABRAZYME

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FalminaProducts Affected

• FALMINA

Notes/References

FamciclovirProducts Affected

• famciclovir oral tablet 125 mg, 250 mg

Notes/References

FamciclovirProducts Affected

• famciclovir oral tablet 500 mg

Notes/References

FanaptProducts Affected

• FANAPT

ST Criteria Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE

Notes/References

Fanapt Titration PackProducts Affected

• FANAPT TITRATION PACK

Notes/References

Felodipine ERProducts Affected

• felodipine er

Notes/References

Femcon FeProducts Affected

• FEMCON FE

Notes/References

Femhrt Low DoseProducts Affected

• FEMHRT LOW DOSE

Notes/References

FemringProducts Affected

• FEMRING

QL Criteria 1 ring Per 90 dayss

Notes/References

FenofibrateProducts Affected

• fenofibrate oral

Notes/References

FenofibrateProducts Affected

• fenofibrate oral

Notes/References

Fenofibrate MicronizedProducts Affected

• fenofibrate micronized

Notes/References

Fenofibric AcidProducts Affected

• fenofibric acid oral tablet

Notes/References

FentaNYLProducts Affected

• fentanyl

Covered Uses moderate to severe pain

Exclusion Criteria

Documented diagnosis of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time

Age Restrictions

Coverage Duration

1 year

Other Criteria

QL Criteria 20 patches Per 1 fill

Notes/References

FentaNYLProducts Affected

• fentanyl

Covered Uses moderate to severe pain

Exclusion Criteria

Documented diagnosis of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time

Age Restrictions

Coverage Duration

1 year

Other Criteria

QL Criteria 20 patches Per 1 month

Notes/References

FentaNYL CitrateProducts Affected

• fentanyl citrate buccal

Covered Uses Pain due to malignant diagnosis only

Exclusion CriteriaNon-malignant pain, management of acute or postoperative or in patients not taking chronic opiates or not tolerant to opioid therapy.

Fentanyl citrate is covered for members with pain due to malignant diagnosis only, and who are already receiving and are tolerant to opioid therapy and who are intolerant of two (2) other immediate-release opioids including morphine, hydrocodone, oxycodone, or hydromorphone. (Patients who are considered opioid tolerant are those who are taking at least 60 mg morphine/day, 25 mcg transdermal fentanyl/hour, or an equianalgesic dose of another opioid for at least a week).

Age Restrictions

Coverage Duration

6 months

Other Criteria

QL Criteria 4 lozenges Per 1 day

Notes/References

FerriproxProducts Affected

• FERRIPROX

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Fifty50 Glucose Test 2.0Products Affected

• FIFTY50 GLUCOSE TEST 2.0

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FirazyrProducts Affected

• FIRAZYR

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/hereditary_angioedema.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 3 syringes Per 1 fill

Notes/References

First-Progesterone VGS 100Products Affected

• FIRST-PROGESTERONE VGS 100

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

Flebogamma DIFProducts Affected

• FLEBOGAMMA DIF

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Flovent DiskusProducts Affected

• FLOVENT DISKUS

Notes/References

Flovent HFAProducts Affected

• FLOVENT HFA

Notes/References

FlunisolideProducts Affected

• flunisolide nasal solution 25 mcg/act (0.025%)

Notes/References

FLUoxetine HClProducts Affected

• fluoxetine hcl oral tablet 20 mg

Notes/References

• fluoxetine hcl oral capsule delayed release

Notes/References

• fluoxetine hcl oral tablet 10 mg

Notes/References

• fluoxetine hcl oral capsule 20 mg

Notes/References

Fluvastatin SodiumProducts Affected

• fluvastatin sodium

Notes/References

Fluvastatin Sodium ERProducts Affected

• fluvastatin sodium er

Notes/References

FluvoxaMINE MaleateProducts Affected

• fluvoxamine maleate oral tablet 25 mg, 50 mg

Notes/References

FluvoxaMINE MaleateProducts Affected

• fluvoxamine maleate oral tablet 100 mg

Notes/References

Focalin XRProducts Affected

• FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 35 MG, 25 MG

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

Follistim AQProducts Affected

• FOLLISTIM AQ

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Fondaparinux SodiumProducts Affected

• fondaparinux sodium

QL Criteria 1 syringe Per 1 day

Notes/References

FORA D10 2-in-1 MonitorProducts Affected

• FORA D10 2-IN-1 MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FORA D10 Blood Glucose TestProducts Affected

• FORA D10 BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FORA D15g 2-in-1 MonitorProducts Affected

• FORA D15G 2-IN-1 MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FORA D15g Blood Glucose TestProducts Affected

• FORA D15G BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FORA D20 2-in-1 MonitorProducts Affected

• FORA D20 2-IN-1 MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FORA D20 Blood Glucose TestProducts Affected

• FORA D20 BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FORA G20 Blood Glucose TestProducts Affected

• FORA G20 BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FORA G30a Blood Glucose SystemProducts Affected

• FORA G30A BLOOD GLUCOSE SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

FORA G30a Blood Glucose TestProducts Affected

• FORA G30A BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Fora GD20 Blood Glucose SystemProducts Affected

• FORA GD20 BLOOD GLUCOSE SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Fora GD20 TestProducts Affected

• FORA GD20 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FORA V10 Blood Glucose SystemProducts Affected

• FORA V10 BLOOD GLUCOSE SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

FORA V10 Blood Glucose TestProducts Affected

• FORA V10 BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FORA V30a Blood Glucose SystemProducts Affected

• FORA V30A BLOOD GLUCOSE SYSTEM DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

FORA V30a Blood Glucose TestProducts Affected

• FORA V30A BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ForaCare GD40 MonitorProducts Affected

• FORACARE GD40 MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ForaCare GD40 TestProducts Affected

• FORACARE GD40 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ForaCare premium V10Products Affected

• FORACARE PREMIUM V10

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ForaCare premium V10 TestProducts Affected

• FORACARE PREMIUM V10 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Foradil AerolizerProducts Affected

• FORADIL AEROLIZER

Notes/References

ForteoProducts Affected

• FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/bone_disease_agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FortestaProducts Affected

• FORTESTA

Age Restrictions

Coverage Duration

3 years

ForticalProducts Affected

• FORTICAL

Age Restrictions

Coverage Duration

3 years

Other Criteria

Fosamax Plus DProducts Affected

• FOSAMAX PLUS D

Age Restrictions

Coverage Duration

3 years

Other Criteria

FragminProducts Affected

• FRAGMIN SUBCUTANEOUS* SOLUTION 5000 UNIT/0.2ML, 18000 UNT/0.72ML, 12500 UNIT/0.5ML, 2500 UNIT/0.2ML, 10000 UNIT/ML, 15000 UNIT/0.6ML

Notes/References

FragminProducts Affected

• FRAGMIN SUBCUTANEOUS* SOLUTION 95000 UNIT/3.8ML, 7500 UNIT/0.3ML, 25000 UNIT/ML

QL Criteria 1 syringe Per 1 Day

Notes/References

FreeStyle InsuLinx TestProducts Affected

• FREESTYLE INSULINX TEST

Notes/References

FreeStyle LiteProducts Affected

• FREESTYLE LITE

FreeStyle Lite TestProducts Affected

• FREESTYLE LITE TEST

Notes/References

FreeStyle TestProducts Affected

• FREESTYLE TEST

Notes/References

Frovatriptan SuccinateProducts Affected

• frovatriptan succinate

QL Criteria 9 tablets Per 30 Days

Notes/References

GabapentinProducts Affected

• gabapentin oral tablet

Notes/References

GabapentinProducts Affected

• gabapentin oral capsule

Notes/References

GammagardProducts Affected

• GAMMAGARD

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gammagard S/D Less IgAProducts Affected

• GAMMAGARD S/D LESS IGA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GammakedProducts Affected

• GAMMAKED

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GammaplexProducts Affected

• GAMMAPLEX INTRAVENOUS* SOLUTION 5 GM/100ML, 10 GM/200ML, 2.5 GM/50ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gamunex-CProducts Affected

• GAMUNEX-C

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ganirelix AcetateProducts Affected

• ganirelix acetate

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GatifloxacinProducts Affected

• gatifloxacin ophthalmic

Notes/References

GattexProducts Affected

• GATTEX

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Gattex.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GaviLyte-CProducts Affected

• GAVILYTE-C

Notes/References

GaviLyte-GProducts Affected

• GAVILYTE-G

Notes/References

GE100 Blood Glucose TestProducts Affected

• ge100 blood glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GelniqueProducts Affected

• GELNIQUE TRANSDERMAL GEL 10 %

Notes/References

GelniqueProducts Affected

• GELNIQUE TRANSDERMAL GEL 3 (28) % (MG/ACT)

QL Criteria 1 pump Per 1 month

Notes/References

Generess FEProducts Affected

• GENERESS FE

Notes/References

GianviProducts Affected

• GIANVI

Notes/References

GiazoProducts Affected

• GIAZO

ST Criteria Documented step through BALSALAZIDE

GildagiaProducts Affected

• GILDAGIA

Notes/References

Gildess 1.5/30Products Affected

• GILDESS 1.5/30

Notes/References

Gildess 1/20Products Affected

• GILDESS 1/20

Notes/References

Gildess FE 1.5/30Products Affected

• GILDESS FE 1.5/30

Notes/References

Gildess FE 1/20Products Affected

• GILDESS FE 1/20

Notes/References

GilenyaProducts Affected

• GILENYA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST CriteriaRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/multiple_sclerosis.html

Notes/References

GilotrifProducts Affected

• GILOTRIF

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GlatopaProducts Affected

• GLATOPA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GlucaGen DiagnosticProducts Affected

• GLUCAGEN DIAGNOSTIC

QL Criteria 1 vial Per 1 fill

Notes/References

GlucaGen HypoKitProducts Affected

• GLUCAGEN HYPOKIT

Notes/References

Glucocard 01 Blood GlucoseProducts Affected

• GLUCOCARD 01 BLOOD GLUCOSE DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Glucocard 01 Sensor PlusProducts Affected

• GLUCOCARD 01 SENSOR PLUS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Glucocard Expression TestProducts Affected

• GLUCOCARD EXPRESSION TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Glucocard Vital TestProducts Affected

• GLUCOCARD VITAL TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Glucocard X-SensorProducts Affected

• GLUCOCARD X-SENSOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GlucoCom Blood Glucose MonitorProducts Affected

• GLUCOCOM BLOOD GLUCOSE MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

GlucoCom TestProducts Affected

• GLUCOCOM TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gonal-fProducts Affected

• GONAL-F

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gonal-f RFFProducts Affected

• GONAL-F RFF

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gonal-f RFF PenProducts Affected

• GONAL-F RFF PEN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gonal-f RFF RedijectProducts Affected

• GONAL-F RFF REDIJECT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GraliseProducts Affected

• GRALISE ORAL TABLET 300 MG

ST Criteria Documented step through GABAPENTIN

GraliseProducts Affected

• GRALISE ORAL TABLET 600 MG

Gralise StarterProducts Affected

• GRALISE STARTER

QL Criteria 1 starter pack Per 1 month

Granisetron HClProducts Affected

• granisetron hcl oral

Notes/References

GuanFACINE HCl ERProducts Affected

• guanfacine hcl er

Notes/References

Guardian REAL-Time System PedProducts Affected

• GUARDIAN REAL-TIME SYSTEM PED

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

HalavenProducts Affected

• HALAVEN

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Halaven.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

HarvoniProducts Affected

• HARVONI

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Helixate FSProducts Affected

• HELIXATE FS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hemofil MProducts Affected

• HEMOFIL M INTRAVENOUS* SOLUTION RECONSTITUTED 220-400 UNIT, 250 UNIT, 1000 UNIT, 1700 UNIT, 500 UNIT, 1501-2000 UNIT, 801-1500 UNIT, 401-800 UNIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

HepseraProducts Affected

• HEPSERA

Notes/References

HizentraProducts Affected

• HIZENTRA SUBCUTANEOUS* SOLUTION 10 GM/50ML, 1 GM/5ML, 4 GM/20ML, 2 GM/10ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

HM NicotineProducts Affected

• hm nicotine transdermal patch 24 hr 7 mg/24hr

Notes/References

HorizantProducts Affected

• HORIZANT ORAL TABLET EXTENDEDRELEASE* 600 MG

ST CriteriaFOR POST-HERPTIC NEURALGIA: Documented step through gabapentin. FOR RESTLESS LESG SYNDROME: Documented step through gabapentin or ropinirole.

HorizantProducts Affected

• HORIZANT ORAL TABLET EXTENDEDRELEASE* 300 MG

ST CriteriaFOR POST-HERPTIC NEURALGIA: Documented step through gabapentin. FOR RESTLESS LESG SYNDROME: Documented step through gabapentin or ropinirole.

Humate-PProducts Affected

• HUMATE-P INTRAVENOUS* SOLUTION RECONSTITUTED 500-1200 UNIT, 1000-2400 UNIT, 250-600 UNIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

HumiraProducts Affected

• HUMIRA SUBCUTANEOUS* 10 MG/0.2ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 injections Per 28 kit (2 pens)s

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humira Pediatric Crohns StartProducts Affected

• HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 4 injections Per 21 months

Notes/References

Humira PenProducts Affected

• HUMIRA PEN SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humira Pen-Crohns StarterProducts Affected

• HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humira Pen-Psoriasis StarterProducts Affected

• HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

HycamtinProducts Affected

• HYCAMTIN ORAL

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hydrocod Polst-CPM Polst ERProducts Affected

• hydrocod polst-cpm polst er oral liquid extendedrelease*

QL Criteria 120 milliliters Per 1 fill

Notes/References

HYDROmorphone HCl ERProducts Affected

• hydromorphone hcl er

Notes/References

Ibandronate SodiumProducts Affected

• ibandronate sodium oral

Age Restrictions

Coverage Duration

3 years

Other Criteria

QL Criteria 1 tablet Per 1 month

Notes/References

IclusigProducts Affected

• ICLUSIG ORAL TABLET 45 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

IclusigProducts Affected

• ICLUSIG ORAL TABLET 15 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

IlarisProducts Affected

• ILARIS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Imatinib MesylateProducts Affected

• imatinib mesylate oral tablet 100 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Imatinib MesylateProducts Affected

• imatinib mesylate oral tablet 400 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ImiquimodProducts Affected

• imiquimod external

QL Criteria 48 packets Per 112 dayss

Notes/References

ImplanonProducts Affected

• IMPLANON

QL Criteria 1 implant Per 1 year

Notes/References

IncrelexProducts Affected

• INCRELEX

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/Increlex.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Infinity Blood Glucose TestProducts Affected

• INFINITY BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

InlytaProducts Affected

• INLYTA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

IntelenceProducts Affected

• INTELENCE ORAL TABLET 100 MG, 25 MG

Notes/References

IntelenceProducts Affected

• INTELENCE ORAL TABLET 200 MG

Notes/References

Intron AProducts Affected

• INTRON A

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

IntrovaleProducts Affected

• INTROVALE

Notes/References

InvokanaProducts Affected

• INVOKANA

Notes/References

Ipratropium BromideProducts Affected

• ipratropium bromide nasal

Notes/References

IrbesartanProducts Affected

• irbesartan

Notes/References

Irbesartan-HydrochlorothiazideProducts Affected

• irbesartan-hydrochlorothiazide

Notes/References

IsentressProducts Affected

• ISENTRESS ORAL TABLET

Notes/References

IsentressProducts Affected

• ISENTRESS ORAL TABLET CHEWABLE

Notes/References

IstodaxProducts Affected

• ISTODAX

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Istodax.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ItraconazoleProducts Affected

• itraconazole oral

Covered UsesOnychomycosis, invasive fungal infection, uther fungal infection, superficial mycoses

Exclusion Criteria

Cosmetic use, patients with evidence of ventricular dysfunction such as CHF or a history of CHF. Coadministration with certain drugs metabolized by the cytochrome P-450 3A4 isoenzyme system (CYP3A4), cisapride, oral midazolam, pimozide, quinidine, dofetilide, triazolam, HMG-CoA reductase inhibitors metabolized by CYP3A4, such as lovastatin and simvastatin, and ergot alkaloids metabolized by CYP3A4, such as dihydroergotamine, ergotamine, ergonovine, and methylergonovine.

Itraconazole Capsules are covered for members who meet the following criteria: (1) Invasive fungal infections in patients who are immunocompromised, such as histoplamosis, aspergillosis, and blastomycosis, (2) Treatment of tinea barbae, tinea capitis, tinea favosa with previous treatment with terbinafine, (3) Treatment of tinea corporis, tinea cruris, tinea faciei, tinea manuum, tinea pedis with previous treatment with a topical antifungal and terbinafine, (4) Treatment of tinea versicolor with previous treatment with selenium sulfide and a topcial antifungal, (5) a diagnosis of majocchi granuloma, (6) Onychomycosis in diabetic patients or patients with peripheral vascular disease and either a positive onychomycosis susceptible pathogen culture or a positive PAS stain performed by a laboratory and documented trial/failure of terbinafine (generic Lamisil), or (7) Onychomycosis with documented disabling pain or impairment and a positive onychomycosis susceptible pathogen culture and documented step through terbinafine.

Age Restrictions

Coverage Duration

Nail: 12 wk(toe),5 wk (finger) per year,Invasive: 1-3 mo based on severity, Other Dx: 1-6 wk

Other Criteria

Notes/References

JakafiProducts Affected

• JAKAFI

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

JanumetProducts Affected

• JANUMET

ST Criteria Documented step through METFORMIN ER (at least 1500mg/day) AND TRADJENTA/JENTADUETO or ONGLYZA/KOMBIGLYZE XR

Notes/References

Janumet XRProducts Affected

• JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 50-1000 MG

Notes/References

Janumet XRProducts Affected

• JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-500 MG

Notes/References

JanuviaProducts Affected

• JANUVIA

Notes/References

JentaduetoProducts Affected

• JENTADUETO

Jentadueto XRProducts Affected

• JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG

Jentadueto XRProducts Affected

• JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG

Jevantique LoProducts Affected

• jevantique lo

Notes/References

JinteliProducts Affected

• JINTELI

Notes/References

JolessaProducts Affected

• JOLESSA

Notes/References

JolivetteProducts Affected

• JOLIVETTE

Notes/References

Junel 1.5/30Products Affected

• JUNEL 1.5/30

Notes/References

Junel 1/20Products Affected

• JUNEL 1/20

Notes/References

Junel FE 1.5/30Products Affected

• JUNEL FE 1.5/30

Notes/References

Junel FE 1/20Products Affected

• JUNEL FE 1/20

Notes/References

JuxtapidProducts Affected

• JUXTAPID ORAL CAPSULE 60 MG, 40 MG, 30 MG

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/Antilipidemic Agents_HOFH.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

• JUXTAPID ORAL CAPSULE 20 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

• JUXTAPID ORAL CAPSULE 5 MG, 10 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

KadianProducts Affected

• KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 40 MG, 130 MG, 70 MG

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

Notes/References

KalydecoProducts Affected

• KALYDECO ORAL TABLET

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/cystic_fibrosis.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Revision DatePrior Authorization: December 21, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

KarivaProducts Affected

• KARIVA

Notes/References

Kelnor 1/35Products Affected

• KELNOR 1/35

Notes/References

KepivanceProducts Affected

• KEPIVANCE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

KetoconazoleProducts Affected

• ketoconazole oral

Notes/References

Ketorolac TromethamineProducts Affected

• ketorolac tromethamine ophthalmic

QL Criteria 1 vial Per 1 day

Notes/References

Ketorolac TromethamineProducts Affected

• ketorolac tromethamine oral

QL Criteria 20 tablets Per 28 dayss

Notes/References

KineretProducts Affected

• KINERET SUBCUTANEOUS*

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Kineret.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Kineret.html

Notes/References

Koate-DVIProducts Affected

• KOATE-DVI

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kogenate FSProducts Affected

• KOGENATE FS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kogenate FS Bio-SetProducts Affected

• KOGENATE FS BIO-SET

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kombiglyze XRProducts Affected

• KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG

Notes/References

Kombiglyze XRProducts Affected

• KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG, 5-500 MG

Notes/References

KorlymProducts Affected

• KORLYM

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/antidiabetic%20agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Revision DatePrior Authorization: February 10, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

KovaltryProducts Affected

• KOVALTRY

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kroger Blood Glucose TestProducts Affected

• kroger blood glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kroger Premium Glucose TestProducts Affected

• kroger premium glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kroger TestProducts Affected

• kroger test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

KurveloProducts Affected

• KURVELO

Notes/References

KuvanProducts Affected

• KUVAN ORAL PACKET 500 MG • KUVAN ORAL TABLET SOLUBLE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

LamISILProducts Affected

• LAMISIL ORAL PACKET 125 MG

QL Criteria 2 packs Per 1 day

Notes/References

LamISILProducts Affected

• LAMISIL ORAL PACKET 187.5 MG

Notes/References

LamoTRIgineProducts Affected

• lamotrigine oral tablet dispersible 100 mg, 200 mg

Covered UsesDiagnosis of epilepsy or Bipolar I disorder (Bipolar I disorder ONLY in the case of Lamictal ODT)

Exclusion Criteria

The member has a documented diagnosis of epilepsy or Bipolar I disorder (Bipolar I disorder ONLY in the case of Lamictal ODT) and either documentation of unsatisfactory effects with, intolerability to, or inability to take immediate-release lamotrigine, or in the case of Lamotrigine ER, the member is new to the health plan and has been established on therapy for longer than four weeks with Lamotrigine ER.

Age Restrictions

Coverage Duration

3 years for Lamotrigine ER. 1 year for Lamictal ODT.

Other Criteria

QL Criteria 2 TABS Per 1 DAYS

Notes/References

• lamotrigine oral tablet dispersible 50 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

• lamotrigine oral tablet dispersible 25 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

LamoTRIgine ERProducts Affected

• lamotrigine er oral tablet extended release 24 hr* 200 mg

Notes/References

• lamotrigine er oral tablet extended release 24 hr* 250 mg, 300 mg

Notes/References

• lamotrigine er oral tablet extended release 24 hr* 50 mg

QL Criteria 1 TB24 Per 1 DAYS

Notes/References

• lamotrigine er oral tablet extended release 24 hr* 100 mg, 25 mg

Notes/References

LansoprazoleProducts Affected

• lansoprazole oral capsule delayed release

Notes/References

LantusProducts Affected

• LANTUS

ST Criteria Documented step through LEVEMIR VIAL

Notes/References

Lantus SoloStarProducts Affected

• LANTUS SOLOSTAR SUBCUTANEOUS*

ST Criteria Documented step through LEVEMIR VIAL

Notes/References

Larin Fe 1.5/30Products Affected

• LARIN FE 1.5/30

Notes/References

LastacaftProducts Affected

• LASTACAFT

Notes/References

LatanoprostProducts Affected

• latanoprost ophthalmic

Notes/References

LatudaProducts Affected

• LATUDA ORAL TABLET 20 MG, 120 MG, 60 MG, 40 MG

Notes/References

LatudaProducts Affected

• LATUDA ORAL TABLET 80 MG

Notes/References

LeenaProducts Affected

• LEENA

Notes/References

LeflunomideProducts Affected

• leflunomide oral

Notes/References

LemtradaProducts Affected

• LEMTRADA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 6 ML Per 365 Days

Notes/References

LessinaProducts Affected

• LESSINA

Notes/References

LetairisProducts Affected

• LETAIRIS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

LeukineProducts Affected

• LEUKINE INTRAVENOUS*

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/GCSF.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Leuprolide AcetateProducts Affected

• leuprolide acetate injection

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Levalbuterol Tartrate HFAProducts Affected

• levalbuterol tartrate hfa

ST Criteria Documented step through VENTOLIN HFA

Notes/References

LevETIRAcetam ERProducts Affected

• levetiracetam er oral tablet extended release 24 hr* 500 mg

Notes/References

LevETIRAcetam ERProducts Affected

• levetiracetam er oral tablet extended release 24 hr* 750 mg

Notes/References

Levocetirizine DihydrochlorideProducts Affected

• levocetirizine dihydrochloride oral tablet

Notes/References

Levocetirizine DihydrochlorideProducts Affected

• levocetirizine dihydrochloride oral solution

Notes/References

LevonestProducts Affected

• LEVONEST

Notes/References

Levonorgest-Eth Estrad 91-DayProducts Affected

• levonorgest-eth estrad 91-day oral tablet0.15-0.03 mg, 0.1-0.02 & 0.01 mg

Notes/References

Levonorgestrel-Ethinyl EstradProducts Affected

• levonorgestrel-ethinyl estrad oral tablet0.15-30 mg-mcg

Notes/References

Levora 0.15/30 (28)Products Affected

• LEVORA 0.15/30 (28)

Notes/References

LialdaProducts Affected

• LIALDA

Notes/References

Liberty Blood Glucose MeterProducts Affected

• liberty blood glucose meter

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Liberty Blood Glucose MonitorProducts Affected

• liberty blood glucose monitor

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Liberty Next Generation TestProducts Affected

• LIBERTY NEXT GENERATION TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Liberty Nxt Generation MonitorProducts Affected

• LIBERTY NXT GENERATION MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Liberty TestProducts Affected

• liberty test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

LidocaineProducts Affected

• lidocaine external ointment

Covered Uses

***AUTHORIZATION IS NOT REQUIRED FOR LESS THAN 50 GRAMS OF LIDOCAINE EVERY 30 DAYS*** For quantities over 50 grams every 30 days, there must be a documented temporary need for anesthesia for any of the following: Accessible mucous membranes of the oropharynx, skin and mucous membranes or stomatitis, or pain associated with a minor burns, including sunburn, abrasions of the skin, and insect bites.

Exclusion Criteria

Documentation of any of the following: Planned area of application includes non-intact skin, sensitivity to amide-type local anesthetics or any other component of the product, planned use on large surface area of the body as this can lead to increased toxicity, planned area of application includes severely traumatized skin (e.g.,mucosal or skin abrasion, eczema, burns), the medication is being used in conjunction with a cosmetic procedure (i.e. hair removal), of if the product will be compounded with other products that would alter the total dose/dosage form being administered

A documented need for temporary anesthesia for any of the following: Accessible mucous membranes of the oropharynx, skin and mucous membranes or stomatitis, or pain associated with a minor burns, including sunburn, abrasions of the skin, and insect bites.

Age Restrictions

Coverage Duration

3 months

Other Criteria

*Topical lidocaine ointment is used for temporary anesthesia. Prescription renewals for longer than 3 months require clinical documentation of medical necessity. Due to Safety Concerns higher quantities and prolonged use are not recommended. Renewal Duration: 3 months *Approval can made up to an additional 50gms per 30 days. Higher additional quantities are not approvable *FOR ADULTS: A single application should not exceed 5 g of Lidocaine Ointment 5%, containing 250 mg of lidocaine base (equivalent chemically to approximately 300 mg of lidocaine hydrochloride). This is roughly equivalent to squeezing a six (6) inch length of ointment from the tube. In a 70 kg adult this dose equals 3.6 mg/kg (1.6 mg/lb) lidocaine base. No more than one-half tube, approximately 17-20 g of ointment or 850-1000 mg lidocaine base, should be administered in any one day. FOR CHILDREN: For children less than ten years who have a normal lean body mass and a normal lean body development, the maximum dose may be determined by the application of one of the standard pediatric drug formulas (e.g., Clark's rule). For example a child of five years weighing 50 lbs., the dose of lidocaine should not exceed 75-100 mg when calculated according to Clark's rule. In any case, the maximum amount of lidocaine administered should not exceed 4.5 mg/kg (2.0 mg/lb) of body weight ***Lidocaine toxicity resulting from transcutaneous absorption is theoretically possible. Signs and symptoms of systemic lidocaine toxicity include CNS excitation and/or depression, nervousness, confusion, dizziness, tinnitus, blurred or double vision, vomiting, twitching, tremors, seizures, unconsciousness, respiratory depression, bradycardia, hypotension, and cardiopulmonary arrest. If there is suspicion of lidocaine-related systemic toxicity, check lidocaine blood concentrations

QL Criteria 50 grams Per 30 Days

Notes/References

LidocaineProducts Affected

• lidocaine external patch 5 %

Covered Uses pain associated with post-herpetic neuralgia

Exclusion Criteria

Documented diagnosis of pain associated with post-herpetic neuralgia

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

Lidocaine-PrilocaineProducts Affected

• lidocaine-prilocaine external cream

Covered Uses

***AUTHORIZATION IS NOT REQUIRED FOR LESS THAN 50 GRAMS OF LIDOCAINE EVERY 30 DAYS*** For quantities over 50 grams every 30 days, there must be a documented temporary need for topical anesthetic in either of the following situations: Normal, intact skin for local analgesia, or Genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia

Exclusion Criteria

Documentation of any of the following: Planned area of application includes non-intact skin, Sensitivity to amide-type local anesthetics or any other component of the product, Planned use on large surface area of the body or for a period of time over 3 hours as this can lead to increased toxicity, the medication is being used in conjunction with a cosmetic procedure (i.e. hair removal), Use in situations where the drug may migrate into the middle ear, beyond the tympanic membrane, History of methemoglobinemia, or if the product will be compounded with other products that would alter the total dose/dosage form being administered

A documented need for topical anesthetic in either of the following situations: Normal, intact skin for local analgesia, or Genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia

Age Restrictions

Coverage Duration

3 months

Other Criteria

*Topical lidocaine/prilocaine cream is used for temporary anesthesia. Prescription renewals for longer than 3 months require clinical documentation of medical necessity.Due to Safety Concerns higher quantities and prolonged use are not recommended. Renewal Duration: 3 months *Up to an additional 30 grams per 30 days. Higher additional quantities are not approvable.

QL Criteria 30 grams Per 30 Days

Notes/References

LindaneProducts Affected

• lindane external lotion

Notes/References

LinezolidProducts Affected

• linezolid oral suspension reconstituted

QL Criteria 150 ml Per 1 fill

Notes/References

LinezolidProducts Affected

• linezolid oral tablet

Notes/References

LinzessProducts Affected

• LINZESS

ST Criteria Documented step through LACTULOSE OR POLYETHYLENE GLYCOL

Notes/References

LivaloProducts Affected

• LIVALO

Notes/References

Lo Loestrin FeProducts Affected

• LO LOESTRIN FE

Notes/References

Loestrin Fe 1.5/30Products Affected

• LOESTRIN FE 1.5/30

Notes/References

Loestrin Fe 1/20Products Affected

• LOESTRIN FE 1/20

Notes/References

Lomedia 24 FEProducts Affected

• LOMEDIA 24 FE

Notes/References

LorynaProducts Affected

• LORYNA

Notes/References

LoSeasoniqueProducts Affected

• LOSEASONIQUE

Notes/References

LovastatinProducts Affected

• lovastatin

Notes/References

Low-OgestrelProducts Affected

• LOW-OGESTREL

Notes/References

LumiganProducts Affected

• LUMIGAN OPHTHALMIC SOLUTION 0.01 %

Exclusion Criteria

Age Restrictions

Coverage Duration

3 years

Other Criteria

LumizymeProducts Affected

• LUMIZYME

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lupaneta PackProducts Affected

• LUPANETA PACK

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lupron DepotProducts Affected

• LUPRON DEPOT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lupron Depot-PedProducts Affected

• LUPRON DEPOT-PED

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

LuteraProducts Affected

• LUTERA

Notes/References

LyricaProducts Affected

• LYRICA

Covered UsesEpilepsy, Diabetic peripheral neuropathy, Post-herpetic neuropathy, Fibromyalgia, Neuropathic pain associated with spinal cord injury

Exclusion Criteria

Epilepsy as adjunct therapy, or diabetic peripheral neuropathy with documented failure of gabapentin, or post-herpetic neuropathy with documented failure of gabapentin, or documentation of the diagnosis of Fibromyalgia and documented failure of non-pharmacologic therapies (cognitive behavioral therapies, exercise etc.) and three (3) of the following drugs/drug classes: tricyclic antidepressant (eg: amitriptyline), muscle relaxant (eg: cyclobenzaprine), SSRI, SNRI, gabapentin, tramadol, or members with documented neuropathic pain associated with spinal cord injury with documented failure of three (3) of the following drugs/drug classes: tricyclic antidepressant (eg: amitriptyline), one muscle relaxant (eg: baclofen), SNRI, gabapentin, tramadol

Age Restrictions

Coverage Duration

3 Years

Other Criteria

Notes/References

LyzaProducts Affected

• LYZA

Notes/References

MalathionProducts Affected

• malathion external

Notes/References

MarlissaProducts Affected

• marlissa

Notes/References

Matzim LAProducts Affected

• MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 300 MG, 420 MG, 360 MG

Notes/References

Matzim LAProducts Affected

• MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 240 MG

Notes/References

Maxima Blood Glucose TestProducts Affected

• MAXIMA BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

MedroxyPROGESTERone AcetateProducts Affected

• medroxyprogesterone acetate intramuscular* suspension

Notes/References

Meijer Blood Glucose TestProducts Affected

• meijer blood glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Meijer Premium Glucose TestProducts Affected

• meijer premium glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Memantine HClProducts Affected

• memantine hcl oral tablet 10 mg, 5 mg

Notes/References

Memantine HClProducts Affected

• memantine hcl oral tablet 5 (28)-10 (21) mg

QL Criteria 1 pack Per 1 fill

Notes/References

MenopurProducts Affected

• MENOPUR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

MenostarProducts Affected

• MENOSTAR

Notes/References

MesalamineProducts Affected

• mesalamine oral

Notes/References

Metadate ERProducts Affected

• METADATE ER ORAL TABLET EXTENDEDRELEASE* 20 MG

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

MetaxaloneProducts Affected

• metaxalone oral tablet 400 mg

Notes/References

MetFORMIN HCl ER (MOD)Products Affected

• metformin hcl er (mod)

ST Criteria Documented trial and failure of both generic Glucophage and generic Glucophage XR

Notes/References

Methamphetamine HClProducts Affected

• methamphetamine hcl

Notes/References

MethylinProducts Affected

• METHYLIN ORAL TABLET CHEWABLE

Notes/References

Methylphenidate HClProducts Affected

• methylphenidate hcl oral solution 10 mg/5ml

Notes/References

• methylphenidate hcl oral solution 5 mg/5ml

Notes/References

• methylphenidate hcl oral tablet

Notes/References

Methylphenidate HCl ERProducts Affected

• methylphenidate hcl er oral tablet extended release 24 hr* 27 mg, 18 mg, 54 mg

Notes/References

• methylphenidate hcl er oral tablet extendedrelease* 27 mg, 18 mg, 54 mg

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

• methylphenidate hcl er oral tablet extendedrelease* 10 mg, 20 mg

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

• methylphenidate hcl er oral tablet extendedrelease* 36 mg

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

• methylphenidate hcl er oral tablet extended release 24 hr* 36 mg

Notes/References

Methylphenidate HCl ER (CD)Products Affected

• methylphenidate hcl er (cd)

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

Methylphenidate HCl ER (LA)Products Affected

• methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

Methylphenidate HCl ER (LA)Products Affected

• methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

Metoprolol Succinate ERProducts Affected

• metoprolol succinate er oral tablet extended release 24 hr* 200 mg

Notes/References

• metoprolol succinate er oral tablet extended release 24 hr* 25 mg

Notes/References

• metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 50 mg

Notes/References

MiacalcinProducts Affected

• MIACALCIN INJECTION

Age Restrictions

Coverage Duration

3 years

Other Criteria

Notes/References

Microdot TestProducts Affected

• MICRODOT TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Microgestin 1.5/30Products Affected

• MICROGESTIN 1.5/30

Notes/References

Microgestin 1/20Products Affected

• MICROGESTIN 1/20

Notes/References

Microgestin FE 1.5/30Products Affected

• MICROGESTIN FE 1.5/30

Notes/References

Microgestin FE 1/20Products Affected

• MICROGESTIN FE 1/20

Notes/References

MimveyProducts Affected

• MIMVEY

Notes/References

MircetteProducts Affected

• MIRCETTE

Notes/References

Mirena (52 MG)Products Affected

• MIRENA (52 MG)

QL Criteria 1 IUD Per 1 fill

Notes/References

MirtazapineProducts Affected

• mirtazapine oral

Notes/References

ModafinilProducts Affected

• modafinil

Covered UsesExcessive daytime sleepiness associated with narcolepsy, Excessive daytime sleepiness associated with obstructive sleep apnea/hypopnea syndrome (OSAHS), shift work sleep disorder (SWSD)

Exclusion Criteria Modafinil is not indicated to treat side effects caused by other medications.

FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH NARCOLEPSY: Documentation of diagnostic testing and clinical notations supporting diagnosis of Narcolepsy, such as MSLT, clinical progress notes, etc. (Failure to adequately support the diagnosis of narcolepsy may result in denial of coverage), and the patient has failed an adequate trial of at least TWO of the following immediate release stimulants (all available generically): Dexedrine, Ritalin, or Adderall. FOR THE TREATMENT OF EXCESSIVE DAYTIME SLEEPINESS ASSOCIATED WITH OBSTRUCTIVE SLEEP APNEA: The prescribing physician is a sleep specialist, ear, nose and throat, neurologist or pulmonologist or has obtained a consult from a sleep specialist, and a Standard Diagnostic Nocturnal Polysomnography (NPSG) has confirmed the diagnosis of OSA, and the patient has received nasal continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) for at least 1 month, and CPAP or BIPAP therapy will be continued on a routine basis in combination with modafinil therapy, and the daytime fatigue is significantly impacting, impairing, or compromising the patient's ability to function normally, and the prescribing physician has established a patient care plan to treat the cause of OSA in conjunction with treating the daily fatigue

Age Restrictions

Coverage Duration

3 years

Other Criteria

The plan also requires an unresponsive 2-week trial of 200mg per day dose before a 400mg per dose is authorized. (Doses up to 400mg/day given as a single dose have been well tolerated, but there is no consistent evidence that this dose confers additional benefit beyond that of the 200mg dose.)

Notes/References

Modicon (28)Products Affected

• MODICON (28)

Notes/References

Monoclate-PProducts Affected

• MONOCLATE-P

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Mono-LinyahProducts Affected

• MONO-LINYAH

Notes/References

Montelukast SodiumProducts Affected

• montelukast sodium oral

QL Criteria 1 pack Per 1 day

Notes/References

Montelukast SodiumProducts Affected

• montelukast sodium oral

Notes/References

Morphine Sulfate ERProducts Affected

• morphine sulfate er oral capsule extended release 24 hour

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

Notes/References

Morphine Sulfate ER BeadsProducts Affected

• morphine sulfate er beads oral capsule extended release 24 hour 90 mg, 120 mg, 75 mg, 45 mg

Notes/References

MozobilProducts Affected

• MOZOBIL

Covered UsesMobilizing hematopoeitic stem cells to peripheral blood for the purpose of collection and subsequent transplantation in patients with non-Hodgkins lymphoma and multiple myeloma

Exclusion Criteria

Age Restrictions

Coverage Duration

1 YEAR

Other Criteria

Notes/References

MultaqProducts Affected

• MULTAQ

Notes/References

MyGlucoHealth TestProducts Affected

• MYGLUCOHEALTH TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

MyoblocProducts Affected

• MYOBLOC

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

MyorisanProducts Affected

• MYORISAN ORAL CAPSULE 20 MG, 40 MG, 10 MG

MyrbetriqProducts Affected

• MYRBETRIQ

ST Criteria Documented step through OXYBUTYNIN OR TROSPIUM IR

Notes/References

MytesiProducts Affected

• MYTESI

Covered Uses Noninfectious diarrhea associated with HIV/AIDS infection

Exclusion CriteriaDiarrhea of infectious origin confirmed by diagnostic tests e.g. stool sample, blood culture, radiographic imaging, Diarrhea-predominant irritable bowel diseases such as Crohn's disease and ulcerative colitis

Diagnosis of noninfectious diarrhea associated with HIV/AIDS infection, currently taking antiviral therapy with adherence 80% or greater, and documentation of unsatisfactory effects with, intolerability to, or inability to take at least one antimotility agent such as Lomotil (atropine/diphenoxylate) or Imodium (loperamide).

Age Restrictions 18 Years of age or greater

Gastroenterologist

Coverage Duration

6 months

Other Criteria

Notes/References

MyzilraProducts Affected

• MYZILRA

Notes/References

Naftifine HClProducts Affected

• naftifine hcl

ST Criteria Documented step through CLOTRIMAZOLE AND ECONAZOLE 1%

Notes/References

NaftinProducts Affected

• NAFTIN EXTERNAL GEL 1 %

ST Criteria Documented step through CLOTRIMAZOLE AND ECONAZOLE 1%

Notes/References

NaglazymeProducts Affected

• NAGLAZYME

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Naratriptan HClProducts Affected

• naratriptan hcl

Notes/References

NataziaProducts Affected

• NATAZIA

Notes/References

Necon 0.5/35 (28)Products Affected

• NECON 0.5/35 (28)

Notes/References

Necon 1/35 (28)Products Affected

• NECON 1/35 (28)

Notes/References

• NECON 1/50 (28)

Notes/References

• NECON 10/11 (28)

Notes/References

NeulastaProducts Affected

• NEULASTA SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Neulasta Delivery KitProducts Affected

• NEULASTA DELIVERY KIT SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NeupogenProducts Affected

• NEUPOGEN INJECTION • NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML, 300 MCG/ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NeuproProducts Affected

• NEUPRO

ST Criteria Documented step through TWO of the following: GABAPENTIN, ROPINIROLE, PRAMIPEXOLE (covered without trials of Parkinson's)

Notes/References

Neutek 2Tek Glucose/PressureProducts Affected

• NEUTEK 2TEK GLUCOSE/PRESSURE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Neutek 2Tek TestProducts Affected

• NEUTEK 2TEK TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nevirapine ERProducts Affected

• nevirapine er oral tablet extended release 24 hr* 100 mg

Notes/References

Nevirapine ERProducts Affected

• nevirapine er oral tablet extended release 24 hr* 400 mg

Notes/References

NexAVARProducts Affected

• NEXAVAR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NexIUMProducts Affected

• NEXIUM ORAL PACKET

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nexium 24HRProducts Affected

• NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE

Notes/References

NexplanonProducts Affected

• NEXPLANON

QL Criteria 1 implant Per 1 year

Notes/References

Next Choice One DoseProducts Affected

• NEXT CHOICE ONE DOSE

QL Criteria 1 tablet Per 1 fill

Notes/References

Nicoderm CQProducts Affected

• NICODERM CQ

Notes/References

NicotineProducts Affected

• nicotine transdermal patch 24 hr

Notes/References

Nicotine Step 1Products Affected

• nicotine step 1

Notes/References

• nicotine step 2

Notes/References

• nicotine step 3

Notes/References

NicotrolProducts Affected

• NICOTROL

QL Criteria 3 boxes-504 crtrg Per 1 month

Notes/References

Nicotrol NSProducts Affected

• NICOTROL NS

QL Criteria 4 bottles Per 1 day

Notes/References

Nifediac CCProducts Affected

• NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG

Notes/References

Nifediac CCProducts Affected

• NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG

Notes/References

Nifedical XLProducts Affected

• NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG

Notes/References

Nifedical XLProducts Affected

• NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG

Notes/References

NIFEdipine ERProducts Affected

• nifedipine er oral tablet extended release 24 hr* 30 mg, 90 mg

Notes/References

NIFEdipine ERProducts Affected

• nifedipine er oral tablet extended release 24 hr* 60 mg

Notes/References

NIFEdipine ER Osmotic ReleaseProducts Affected

• nifedipine er osmotic release oral tablet extended release 24 hr* 90 mg, 30 mg

Notes/References

NIFEdipine ER Osmotic ReleaseProducts Affected

• nifedipine er osmotic release oral tablet extended release 24 hr* 60 mg

Notes/References

NikkiProducts Affected

• NIKKI

Notes/References

Nisoldipine ERProducts Affected

• nisoldipine er oral tablet extended release 24 hr* 20 mg, 25.5 mg, 40 mg, 8.5 mg, 17 mg, 34 mg

Notes/References

Nisoldipine ERProducts Affected

• nisoldipine er oral tablet extended release 24 hr* 30 mg

Notes/References

NitroglycerinProducts Affected

• nitroglycerin translingual solution

Notes/References

Nora-BEProducts Affected

• NORA-BE

Notes/References

NorethindroneProducts Affected

• norethindrone oral

Notes/References

Norinyl 1+35 (28)Products Affected

• NORINYL 1+35 (28)

Notes/References

Norinyl 1+50 (28)Products Affected

• NORINYL 1+50 (28)

Notes/References

NorlyrocProducts Affected

• NORLYROC

Notes/References

Nortrel 0.5/35 (28)Products Affected

• NORTREL 0.5/35 (28)

Notes/References

Nortrel 1/35 (21)Products Affected

• NORTREL 1/35 (21)

Notes/References

Nortrel 1/35 (28)Products Affected

• NORTREL 1/35 (28)

Notes/References

Nova Max Blood Glucose SystemProducts Affected

• NOVA MAX BLOOD GLUCOSE SYSTEM DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Nova Max Glucose TestProducts Affected

• NOVA MAX GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NovarelProducts Affected

• NOVAREL

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NovoeightProducts Affected

• NOVOEIGHT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NovoLIN 70/30Products Affected

• NOVOLIN 70/30

ST Criteria Documented step through HUMULIN Product

Notes/References

NovoLIN 70/30 ReliOnProducts Affected

• NOVOLIN 70/30 RELION

Notes/References

NovoLIN NProducts Affected

• NOVOLIN N

Notes/References

NovoLIN N ReliOnProducts Affected

• NOVOLIN N RELION

Notes/References

NovoLIN RProducts Affected

• NOVOLIN R

Notes/References

NovoLIN R ReliOnProducts Affected

• NOVOLIN R RELION

Notes/References

NovoLOGProducts Affected

• NOVOLOG

Notes/References

NovoLOG FlexPenProducts Affected

• NOVOLOG FLEXPEN SUBCUTANEOUS*

Notes/References

NovoLOG Mix 70/30Products Affected

• NOVOLOG MIX 70/30

Notes/References

NovoLOG Mix 70/30 FlexPenProducts Affected

• NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS*

Notes/References

NovoLOG PenFillProducts Affected

• NOVOLOG PENFILL SUBCUTANEOUS*

Notes/References

NovoSevenProducts Affected

• NOVOSEVEN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NovoSeven RTProducts Affected

• NOVOSEVEN RT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NoxafilProducts Affected

• NOXAFIL ORAL SUSPENSION

Covered UsesProphylaxis of Invasive Aspergillosis, prophylaxis of invasive candidiasis, treatment of oropharyngeal candidiasis in patients with disease refractory

Exclusion Criteria

Noxafil is NOT covered for members who are pursuing for prophylaxis of invasive aspergillosis or candidiasis who are not severely immunocompromised, for patients less that 13 years of age, patients without refractory disease to first-line antifungal agents, concomitant use with ergot alkaloids, simvastatin, or sirolimus, or concomitant use with CYP3A4 substrates such as, pimozide and quinidine.

Noxafil is covered for members who meet any ONE of the following criteria: (1) Prophylaxis of Invasive Aspergillosis in severely immunocompromised patients with active disease, (2) Prophylaxis of Invasive Candidiasis in severely immunocompromised patients with a history of developing invasive candidiasis refractory to fluconazole or who are intolerant to fluconazole, or (3) Treatment of Oropharyngeal Candidiasis in patients with disease refractory to fluconazole or itraconazole.

Age Restrictions 13 years of age or greater

Coverage Duration

Invasive Aspergillosis/Candidiasis prophylaxis- 3 months, Oropharyngeal Candidiasis-13 days

Other Criteria

Refractory fungal infection is defined as a previous occurrence of disease which failed to improve or respond to a standard course of antifungal therapy. Patients started on Noxafil as an inpatient will be allowed to continue therapy on an outpatient basis without interruption. Initial therapy of one 105ml bottle (7-day supply) will be covered to assure that therapy is not delayed while the prior authorization request is being reviewed.

Notes/References

NucyntaProducts Affected

• NUCYNTA

Covered Uses Moderate to severe pain

Exclusion Criteria Known or suspicious misuse of medications or illicit drug use.

Documented progression through the World Health Organization analgesic ladder, and step through, contraindication, or intolerance to two (2) alternative formulary immediate release opioids. Alternatives include morphine, oxycodone, hydromorphone.

Age Restrictions

Coverage Duration

up to 3 years

Other Criteria

Nucynta ERProducts Affected

• NUCYNTA ER

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

NuedextaProducts Affected

• NUEDEXTA

Covered UsesTreatment of pseudobulbar affect in patients with amyotrophic lateral sclerosis (ALS) OR multiple sclerosis (MS).

Exclusion CriteriaTreatment in other types of emotional lability (i.e. Alzheimers disease and other dementias).

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

NulojixProducts Affected

• NULOJIX

Covered UsesRefer to the clinical policy bulletin for details:http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/immunosuppressives.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NuvaRingProducts Affected

• NUVARING

QL Criteria 1 ring Per 28 dayss

Notes/References

NuwiqProducts Affected

• NUWIQ

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OcellaProducts Affected

• OCELLA

Notes/References

OctagamProducts Affected

• OCTAGAM INTRAVENOUS* SOLUTION 1 GM/20ML, 10 GM/200ML, 2 GM/20ML, 20 GM/200ML, 2.5 GM/50ML, 25 GM/500ML, 5 GM/100ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Octreotide AcetateProducts Affected

• octreotide acetate injection solution 500 mcg/ml, 100 mcg/ml, 1000 mcg/ml, 50 mcg/ml, 200 mcg/ml

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/Sandostatin.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OdefseyProducts Affected

• ODEFSEY

Notes/References

OgestrelProducts Affected

• OGESTREL

Notes/References

OLANZapineProducts Affected

• olanzapine oral tablet 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg

• olanzapine oral tablet dispersible

Notes/References

OLANZapineProducts Affected

• olanzapine oral tablet 2.5 mg

Notes/References

OLANZapine-FLUoxetine HClProducts Affected

• olanzapine-fluoxetine hcl

Notes/References

OleptroProducts Affected

• OLEPTRO

ST Criteria Documented step through TRAZADONE

Notes/References

Omega-3-acid Ethyl EstersProducts Affected

• omega-3-acid ethyl esters

Notes/References

Omeprazole-Sodium BicarbonateProducts Affected

• omeprazole-sodium bicarbonate oral capsule20-1100 mg

Notes/References

OmnarisProducts Affected

• OMNARIS

Notes/References

OmnitropeProducts Affected

• OMNITROPE

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/growthhormone.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

On Call Plus Blood GlucoseProducts Affected

• ON CALL PLUS BLOOD GLUCOSE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

On Call Vivid Blood GlucoseProducts Affected

• ON CALL VIVID BLOOD GLUCOSE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OndansetronProducts Affected

• ondansetron

Notes/References

Ondansetron HClProducts Affected

• ondansetron hcl oral tablet 8 mg

Notes/References

• ondansetron hcl oral solution

Notes/References

• ondansetron hcl oral tablet 24 mg, 4 mg

Notes/References

OneTouch TestProducts Affected

• ONETOUCH TEST

Notes/References

OneTouch Ultra BlueProducts Affected

• ONETOUCH ULTRA BLUE

Notes/References

OneTouch VerioProducts Affected

• ONETOUCH VERIO IN VITRO STRIP

Notes/References

OnfiProducts Affected

• ONFI ORAL SUSPENSION

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

OnfiProducts Affected

• ONFI ORAL TABLET 10 MG, 20 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

1 Year

Other Criteria

OnglyzaProducts Affected

• ONGLYZA

Notes/References

Opana ERProducts Affected

• OPANA ER ORAL

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

OpsumitProducts Affected

• OPSUMIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Optium TestProducts Affected

• OPTIUM TEST

Notes/References

OptiumEZ TestProducts Affected

• OPTIUMEZ TEST

Notes/References

OravigProducts Affected

• ORAVIG

Covered Uses Infection

Exclusion Criteria

Have documented step through fluconazole, AND nystatin or clotrimazole troche

Age Restrictions Less than 16 years old

Coverage Duration

6 months

Other Criteria

Notes/References

OrenciaProducts Affected

• ORENCIA SUBCUTANEOUS*

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Orencia.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Orencia.html

Notes/References

OrenciaProducts Affected

• ORENCIA INTRAVENOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Orencia ClickJectProducts Affected

• ORENCIA CLICKJECT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OrkambiProducts Affected

• ORKAMBI

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OrkambiProducts Affected

• ORKAMBI

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OrsythiaProducts Affected

• ORSYTHIA

Notes/References

Ortho MicronorProducts Affected

• ORTHO MICRONOR

Notes/References

Ortho Tri-Cyclen (28)Products Affected

• ORTHO TRI-CYCLEN (28)

Notes/References

Ortho Tri-Cyclen LoProducts Affected

• ORTHO TRI-CYCLEN LO

Notes/References

Ortho-Cept (28)Products Affected

• ORTHO-CEPT (28)

Notes/References

Ortho-Cyclen (28)Products Affected

• ORTHO-CYCLEN (28)

Notes/References

Ortho-Novum 1/35 (28)Products Affected

• ORTHO-NOVUM 1/35 (28)

Notes/References

Ortho-Novum 7/7/7 (28)Products Affected

• ORTHO-NOVUM 7/7/7 (28)

Notes/References

Ovcon-35 (28)Products Affected

• OVCON-35 (28)

Notes/References

OvidrelProducts Affected

• OVIDREL

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Oxtellar XRProducts Affected

• OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 600 MG

Notes/References

Oxtellar XRProducts Affected

• OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG

Notes/References

Oxybutynin ChlorideProducts Affected

• oxybutynin chloride oral tablet

Notes/References

Oxybutynin Chloride ERProducts Affected

• oxybutynin chloride er

Notes/References

Oxycodone-IbuprofenProducts Affected

• oxycodone-ibuprofen

Notes/References

OxyCONTINProducts Affected

• OXYCONTIN ORAL

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

Oxymorphone HClProducts Affected

• oxymorphone hcl

Covered Uses Moderate to severe pain

Exclusion Criteria

Oxymorphone is not covered for members with no documented progression through the World Health Organization analgesic ladder, who have not tried and failed three (2) alternative formulary opioids, or who have a known hypersensitivity to morphine analogs (e.g. codeine).

Documented progression through the World Health Organization analgesic ladder and step through, contraindication, or intolerance to two (2) alternative formulary immediate release opioids. Alternatives include morphine, oxycodone, hydromorphone.

Age Restrictions

Coverage Duration

3 years

Other Criteria

Notes/References

Oxymorphone HCl ERProducts Affected

• oxymorphone hcl er oral tablet extended release 12 hr* 10 mg

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

Notes/References

Oxymorphone HCl ERProducts Affected

• oxymorphone hcl er oral tablet extended release 12 hr* 40 mg, 5 mg, 7.5 mg, 15 mg, 20 mg

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

Notes/References

OxyMORphone HCl ERProducts Affected

• oxymorphone hcl er oral tablet extended release 12 hr* 30 mg

Age Restrictions

Coverage Duration

up to 1 year

Other Criteria

Notes/References

Paliperidone ERProducts Affected

• paliperidone er oral tablet extended release 24 hr* 1.5 mg, 9 mg, 3 mg

Notes/References

Paliperidone ERProducts Affected

• paliperidone er oral tablet extended release 24 hr* 6 mg

Notes/References

PancreazeProducts Affected

• PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 4200-10000 UNIT, 10500-25000 UNIT, 16800-40000 UNIT, 21000-37000 UNIT

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Pancrelipase (Lip-Prot-Amyl)Products Affected

• pancrelipase (lip-prot-amyl)

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Paragard Intrauterine CopperProducts Affected

• PARAGARD INTRAUTERINE COPPER

QL Criteria 1 IUD Per 1 fill

Notes/References

ParicalcitolProducts Affected

• paricalcitol oral

Notes/References

PARoxetine HClProducts Affected

• paroxetine hcl oral tablet 10 mg, 20 mg

Notes/References

PARoxetine HClProducts Affected

• paroxetine hcl oral tablet 30 mg, 40 mg

Notes/References

PARoxetine HCl ERProducts Affected

• paroxetine hcl er oral tablet extended release 24 hr* 25 mg

ST Criteria Documented step through paroxetine

Notes/References

PARoxetine HCl ERProducts Affected

• paroxetine hcl er oral tablet extended release 24 hr* 37.5 mg, 12.5 mg

ST Criteria Documented step through paroxetine

Notes/References

PEG 3350/ElectrolytesProducts Affected

• peg 3350/electrolytes

Notes/References

PEG-3350/ElectrolytesProducts Affected

• peg-3350/electrolytes

Notes/References

PegasysProducts Affected

• PEGASYS SUBCUTANEOUS* SOLUTION

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Pegasys ProClickProducts Affected

• PEGASYS PROCLICK

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Peg-IntronProducts Affected

• PEG-INTRON

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Peg-Intron RedipenProducts Affected

• PEG-INTRON REDIPEN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Peg-Intron Redipen Pak 4Products Affected

• PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS* KIT 50 MCG/0.5ML, 150 MCG/0.5ML, 120 MCG/0.5ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

PentasaProducts Affected

• PENTASA ORAL CAPSULE EXTENDED RELEASE* 250 MG

Notes/References

PentasaProducts Affected

• PENTASA ORAL CAPSULE EXTENDED RELEASE* 500 MG

Notes/References

PerforomistProducts Affected

• PERFOROMIST

Covered Uses Chronic Obstructive Pulmonary Disease (COPD)

Exclusion Criteria

Documented physical limitation that prevents the use of a non-nebulized long-acting bronchodilator with or without use of a spacer

Age Restrictions

Coverage Duration

3 years

Other Criteria

PertzyeProducts Affected

• PERTZYE

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Pharmacist Choice AutocodeProducts Affected

• PHARMACIST CHOICE AUTOCODE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

PhilithProducts Affected

• PHILITH

Notes/References

PicatoProducts Affected

• PICATO EXTERNAL GEL 0.05 %

QL Criteria 2 unit dose tubes Per 1 fill

Notes/References

PicatoProducts Affected

• PICATO EXTERNAL GEL 0.015 %

QL Criteria 3 unit dose tubes Per 1 fill

Notes/References

Pioglitazone HClProducts Affected

• pioglitazone hcl

Notes/References

Pioglitazone HCl-GlimepirideProducts Affected

• pioglitazone hcl-glimepiride

Notes/References

Pioglitazone HCl-Metformin HClProducts Affected

• pioglitazone hcl-metformin hcl

Notes/References

Plan B One-StepProducts Affected

• PLAN B ONE-STEP

Notes/References

PlegridyProducts Affected

• PLEGRIDY

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 inj Per 28 Days

Notes/References

Plegridy Starter PackProducts Affected

• PLEGRIDY STARTER PACK

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 inj Per 28 Days

Notes/References

PocketChem EZ TestProducts Affected

• POCKETCHEM EZ TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

PomalystProducts Affected

• POMALYST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Portia-28Products Affected

• PORTIA-28

Notes/References

PotigaProducts Affected

• POTIGA ORAL TABLET 200 MG, 400 MG, 300 MG

Covered Uses partial-onset seizures

Exclusion Criteria

documented diagnosis of partial-onset seizures

Age Restrictions

Coverage Duration

1 year

Other Criteria

PotigaProducts Affected

• POTIGA ORAL TABLET 50 MG

Exclusion Criteria

documented diagnosis of partial-onset seizures

Age Restrictions

Coverage Duration

1 year

Other Criteria

PraluentProducts Affected

• PRALUENT

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/PCSK9.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 syringes Per 28 Days

Notes/References

Pramipexole Dihydrochloride ERProducts Affected

• pramipexole dihydrochloride er

Notes/References

Pravastatin SodiumProducts Affected

• pravastatin sodium

Notes/References

Precision PCxProducts Affected

• PRECISION PCX

Notes/References

Precision PCX Plus TestProducts Affected

• PRECISION PCX PLUS TEST

Notes/References

Precision Point of Care TestProducts Affected

• PRECISION POINT OF CARE TEST

Notes/References

Precision QID TestProducts Affected

• PRECISION QID TEST

Notes/References

Precision Sof-Tact TestProducts Affected

• PRECISION SOF-TACT TEST

Notes/References

Precision XtraProducts Affected

• PRECISION XTRA DEVICE

Precision Xtra Blood GlucoseProducts Affected

• PRECISION XTRA BLOOD GLUCOSE

Notes/References

Precision Xtra MonitorProducts Affected

• PRECISION XTRA MONITOR

PrefestProducts Affected

• PREFEST

Notes/References

PregnylProducts Affected

• PREGNYL

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

PremarinProducts Affected

• PREMARIN ORAL

Notes/References

PremphaseProducts Affected

• PREMPHASE

Notes/References

PremproProducts Affected

• PREMPRO

Notes/References

PrevacidProducts Affected

• PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG

Notes/References

PrevifemProducts Affected

• PREVIFEM

Notes/References

PrezistaProducts Affected

• PREZISTA ORAL TABLET 600 MG, 75 MG, 150 MG

Notes/References

• PREZISTA ORAL TABLET 800 MG

Notes/References

• PREZISTA ORAL SUSPENSION

Notes/References

PristiqProducts Affected

• PRISTIQ

Covered Uses Major Depressive Disorder

Exclusion CriteriaPatients taking products containing venlafaxine concomitantly, patients taking MAOIs concomitantly, or for use in pediatrics.

Documentation of failure or unresponsiveness to THREE different antidepressants from at least two different therapeutic subclasses, or patient is a new member and has been receiving Pristiq therapy for more than 4 weeks.

Age Restrictions

Coverage Duration

3 Years

Other Criteria

Notes/References

PrivigenProducts Affected

• PRIVIGEN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ProAir HFAProducts Affected

• PROAIR HFA

QL Criteria 2 inhalers Per 1 fill

Notes/References

ProcritProducts Affected

• PROCRIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Prodigy AutoCode Blood GlucoseProducts Affected

• PRODIGY AUTOCODE BLOOD GLUCOSE DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Prodigy No Coding Blood GlucProducts Affected

• PRODIGY NO CODING BLOOD GLUC

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ProfilnineProducts Affected

• PROFILNINE INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Profilnine SDProducts Affected

• PROFILNINE SD

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Progesterone MicronizedProducts Affected

• progesterone micronized oral

Notes/References

Prolastin-CProducts Affected

• PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ProleukinProducts Affected

• PROLEUKIN

Covered UsesRefer to the clinical policy bulletin for details:: http://www.aetna.com/products/rxnonmedicare/data/2016/ANEOPL/Interleukin%202.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ProliaProducts Affected

• PROLIA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

PromactaProducts Affected

• PROMACTA ORAL TABLET 25 MG, 12.5 MG, 50 MG

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/promacta.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Propafenone HCl ERProducts Affected

• propafenone hcl er

Notes/References

Proventil HFAProducts Affected

• PROVENTIL HFA

QL Criteria 2 inhalers Per 1 month

Pulmicort FlexhalerProducts Affected

• PULMICORT FLEXHALER

Notes/References

PulmozymeProducts Affected

• PULMOZYME

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 ampules Per 1 day

Notes/References

QnaslProducts Affected

• QNASL

Notes/References

Qnasl ChildrensProducts Affected

• QNASL CHILDRENS

Notes/References

QuasenseProducts Affected

• QUASENSE

Notes/References

QUEtiapine FumarateProducts Affected

• quetiapine fumarate oral tablet 100 mg, 50 mg

Notes/References

• quetiapine fumarate oral tablet 25 mg

Notes/References

• quetiapine fumarate oral tablet 300 mg, 400 mg

Notes/References

• quetiapine fumarate oral tablet 200 mg

Notes/References

Quillivant XRProducts Affected

• QUILLIVANT XR

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

QuiNINE SulfateProducts Affected

• quinine sulfate oral

Covered Uses Malaria, babesiosis

Exclusion Criteria

Qualaquin is NOT covered for use for leg cramps, in women who are pregnant, or in patients with cerebral malaria in combination with doxycycline, tetracycline, or clindamycin (members should be treated with IV quinine per CDC (not oral).

Age Restrictions

Coverage Duration

MALARIA - 7 days (42 capsules). BABESIOSIS - 10 days (60 capsules).

Other Criteria

QL Criteria 42 capsules Per 1 fill

Notes/References

RA Blood Glucose MonitorProducts Affected

• ra blood glucose monitor

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

RA TRUEtest TestProducts Affected

• RA TRUETEST TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RABEprazole SodiumProducts Affected

• rabeprazole sodium

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RajaniProducts Affected

• RAJANI

QL Criteria 1.5 tablets Per 1 Day

Notes/References

RanexaProducts Affected

• RANEXA

Notes/References

RavictiProducts Affected

• RAVICTI

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RebetolProducts Affected

• REBETOL ORAL SOLUTION

Notes/References

RebifProducts Affected

• REBIF SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rebif RebidoseProducts Affected

• REBIF REBIDOSE SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rebif Rebidose Titration PackProducts Affected

• REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rebif Titration PackProducts Affected

• REBIF TITRATION PACK SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ReclastProducts Affected

• RECLAST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ReclipsenProducts Affected

• RECLIPSEN

Notes/References

RecombinateProducts Affected

• RECOMBINATE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RectivProducts Affected

• RECTIV

QL Criteria 1 tube Per 1 fill

Notes/References

RefuAH Plus Blood Glucose TestProducts Affected

• REFUAH PLUS BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Relenza DiskhalerProducts Affected

• RELENZA DISKHALER

QL Criteria 40 disks Per 1 year

Notes/References

ReliOn Confirm/micro TestProducts Affected

• RELION CONFIRM/MICRO TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ReliOn Prime MonitorProducts Affected

• RELION PRIME MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ReliOn Prime TestProducts Affected

• RELION PRIME TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ReliOn Ultima TestProducts Affected

• RELION ULTIMA TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RelistorProducts Affected

• RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML

Covered UsesOpioid-induced constipation (OIC) in adults with chronic non-cancer pain, OIC in adults with advanced illness

Exclusion Criteria

Patients with advanced illness who are receiving palliative care, for the treatment of opioid-induced constipation when response to laxative therapy has not been sufficient.

Age Restrictions

Coverage Duration

6 Months

Other Criteria

QL Criteria 0.6 ml Per 1 Day

Notes/References

RelistorProducts Affected

• RELISTOR SUBCUTANEOUS* SOLUTION 8 MG/0.4ML

Covered UsesOpioid-induced constipation (OIC) in adults with chronic non-cancer pain, OIC in adults with advanced illness

Exclusion Criteria

Patients with advanced illness who are receiving palliative care, for the treatment of opioid-induced constipation when response to laxative therapy has not been sufficient.

Age Restrictions

Coverage Duration

6 Months

Other Criteria

QL Criteria 0.4 ml Per 1 Day

Notes/References

RelpaxProducts Affected

• RELPAX

Notes/References

RemicadeProducts Affected

• REMICADE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RemodulinProducts Affected

• REMODULIN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST CriteriaRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/pulmonaryhypertensionagents.html

Notes/References

Repaglinide-Metformin HClProducts Affected

• repaglinide-metformin hcl

Notes/References

RepathaProducts Affected

• REPATHA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/PCSK9.html

Notes/References

Repatha Pushtronex SystemProducts Affected

• REPATHA PUSHTRONEX SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 syringe Per 1 month

Notes/References

Repatha SureClickProducts Affected

• REPATHA SURECLICK

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RepronexProducts Affected

• REPRONEX

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ResculaProducts Affected

• RESCULA

Exclusion Criteria

Age Restrictions

Coverage Duration

3 years

Other Criteria

Reveal Blood Glucose TestProducts Affected

• REVEAL BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RevlimidProducts Affected

• REVLIMID

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rexall Blood Glucose TestProducts Affected

• REXALL BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RexultiProducts Affected

• REXULTI

Covered Uses Major Depressive Disorder (MDD), Schizophrenia

Exclusion Criteria

Documented diagnosis of Major Depressive Disorder (MDD) or Schizophrenia

Age Restrictions

Coverage Duration

1 year

Other Criteria

ST Criteria Trial of two atypical generic antipsychotic medications (i.e. aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone)

ReyatazProducts Affected

• REYATAZ ORAL CAPSULE 200 MG

Notes/References

ReyatazProducts Affected

• REYATAZ ORAL CAPSULE 300 MG, 150 MG

Notes/References

RiaSTAPProducts Affected

• RIASTAP

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rightest GS100 Blood GlucoseProducts Affected

• RIGHTEST GS100 BLOOD GLUCOSE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Risedronate SodiumProducts Affected

• risedronate sodium oral tablet 5 mg, 30 mg, 35 mg

Age Restrictions

Coverage Duration

3 years

Other Criteria

Notes/References

• risedronate sodium oral tablet delayed release

Age Restrictions

Coverage Duration

3 years

Other Criteria

Notes/References

• risedronate sodium oral tablet 150 mg

Age Restrictions

Coverage Duration

3 years

Other Criteria

RisperiDONEProducts Affected

• risperidone oral tablet dispersible 4 mg • risperidone oral tablet 4 mg

Notes/References

• risperidone oral tablet 1 mg, 0.25 mg, 0.5 mg, 2 mg

• risperidone oral tablet dispersible 0.25 mg, 1 mg, 2 mg, 0.5 mg

Notes/References

• risperidone oral tablet 3 mg • risperidone oral tablet dispersible 3 mg

Notes/References

RisperiDONE M-TABProducts Affected

• RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 2 MG, 1 MG

Notes/References

• RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 3 MG

Notes/References

• RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 4 MG

Notes/References

RituxanProducts Affected

• RITUXAN INTRAVENOUS* SOLUTION

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RivastigmineProducts Affected

• rivastigmine

QL Criteria 1 patch Per 1 Day

Notes/References

Rizatriptan BenzoateProducts Affected

• rizatriptan benzoate

Notes/References

ROPINIRole HCl ERProducts Affected

• ropinirole hcl er oral tablet extended release 24 hr* 6 mg, 8 mg, 4 mg, 2 mg

Notes/References

ROPINIRole HCl ERProducts Affected

• ropinirole hcl er oral tablet extended release 24 hr* 12 mg

Notes/References

Rosuvastatin CalciumProducts Affected

• rosuvastatin calcium

Notes/References

RozeremProducts Affected

• ROZEREM

Covered Uses Insomnia

Exclusion Criteria

Step through either zolpidem tartrate or zalelpon, and through zolpidem tartrate extended-release

Age Restrictions 18 years of age or older

Coverage Duration

3 Years

Other Criteria

Notes/References

SabrilProducts Affected

• SABRIL

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/anticonvulasants.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SabrilProducts Affected

• SABRIL

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/anticonvulasants.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 6 packets Per 1 day

Notes/References

SafyralProducts Affected

• SAFYRAL

Notes/References

SamscaProducts Affected

• SAMSCA ORAL TABLET 30 MG

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/samsca.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SamscaProducts Affected

• SAMSCA ORAL TABLET 15 MG

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CV/samsca.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SancusoProducts Affected

• SANCUSO

Covered Uses Chemotherapy induced nausea and vomiting

Exclusion CriteriaCancer patients with non-chemotherapy related nausea and vomiting, patients with radiation-induced nausea and vomiting, patients with pregnancy-related nausea and vomiting, patients with post-operative nausea and vomiting

Patient is currently receiving chemotherapy and remains symptomatic despite treatment with oral ondansetron (Zofran) or oral granisetron (Kytril) or have documented inability to take oral antiemetics, including ODT formulations.

Age Restrictions

Coverage Duration

6 months

Other Criteria

QL Criteria 1 patch Per 1 month

Notes/References

SaphrisProducts Affected

• SAPHRIS

Notes/References

SaphrisProducts Affected

• SAPHRIS

Notes/References

SavellaProducts Affected

• SAVELLA

Covered Uses Fibromyalgia

Exclusion CriteriaPeripheral Neuropathy(s) (other than diabetic), General Anxiety Disorder or Panic Disorder, Post-operative pain

Documentation of trials of non-pharmacologic therapies (cognitive behavioral therapies, exercise etc.), and trial and failure of three (3) medications from the following drugs/drug classes: one tricyclic antidepressant (eg: amitriptyline), one muscle relaxant (eg: cyclobenzaprine), one SSRI, one SNRI, gabapentin, and tramadol

Age Restrictions

Coverage Duration

3 Years

Other Criteria

Savella Titration PackProducts Affected

• SAVELLA TITRATION PACK

Covered Uses Fibromyalgia

Exclusion CriteriaPeripheral Neuropathy(s) (other than diabetic), General Anxiety Disorder or Panic Disorder, Post-operative pain

Documentation of trials of non-pharmacologic therapies (cognitive behavioral therapies, exercise etc.), and trial and failure of three (3) medications from the following drugs/drug classes: one tricyclic antidepressant (eg: amitriptyline), one muscle relaxant (eg: cyclobenzaprine), one SSRI, one SNRI, gabapentin, and tramadol

Age Restrictions

Coverage Duration

3 Years

Other Criteria

SeasoniqueProducts Affected

• SEASONIQUE

Notes/References

SelzentryProducts Affected

• SELZENTRY

Notes/References

SensiparProducts Affected

• SENSIPAR

ST Criteria Documented step through CALCITRIOL (covered without trials for hyperparathyroidism and parathyroid carcinoma)

Notes/References

Serevent DiskusProducts Affected

• SEREVENT DISKUS

QL Criteria 2 blisters Per 1 day

Notes/References

SEROquel XRProducts Affected

• SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG

Covered Uses Major depressive disorder (MDD), Bipolar disorder or schizophrenia

Exclusion Criteria

Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE

Age Restrictions

Coverage Duration

3 Years

Other Criteria

Notes/References

SEROquel XRProducts Affected

• SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 300 MG, 400 MG, 50 MG

Covered Uses Major depressive disorder (MDD), Bipolar disorder or schizophrenia

Exclusion Criteria

Documented step through TWO of the following: RISPERIDONE, QUETIAPINE, ZIPRASIDONE, OLANZAPINE

Age Restrictions

Coverage Duration

3 Years

Other Criteria

Notes/References

Sertraline HClProducts Affected

• sertraline hcl oral tablet 25 mg

Notes/References

• sertraline hcl oral concentrate

QL Criteria 10 ml Per 1 day

Notes/References

SharobelProducts Affected

• SHAROBEL

Notes/References

Sildenafil CitrateProducts Affected

• sildenafil citrate oral

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SimcorProducts Affected

• SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR* 500-40 MG, 1000-40 MG

Notes/References

SimcorProducts Affected

• SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR* 750-20 MG, 500-20 MG, 1000-20 MG

Notes/References

SimponiProducts Affected

• SIMPONI SUBCUTANEOUS*

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Simponi.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Simponi AriaProducts Affected

• SIMPONI ARIA

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Simponi_Aria.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 vial Per 1 month

Notes/References

SimulectProducts Affected

• SIMULECT

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/Simulect.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Revision DatePrior Authorization: March 07, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

SimvastatinProducts Affected

• simvastatin oral

Notes/References

Smartest Blood Glucose TestProducts Affected

• SMARTEST BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Smartest EjectProducts Affected

• SMARTEST EJECT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Smartest ProtegeProducts Affected

• SMARTEST PROTEGE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Sodium PhenylbutyrateProducts Affected

• sodium phenylbutyrate • sodium phenylbutyrate oral powder 3 gm/tsp

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SoliaProducts Affected

• SOLIA

Notes/References

Solus V2 TestProducts Affected

• SOLUS V2 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Somatuline DepotProducts Affected

• SOMATULINE DEPOT

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/Sandostatin.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SomavertProducts Affected

• SOMAVERT

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/growthhormone.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SovaldiProducts Affected

• SOVALDI

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Spiriva HandiHalerProducts Affected

• SPIRIVA HANDIHALER

Notes/References

Spiriva RespimatProducts Affected

• SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 1.25 MCG/ACT

Notes/References

SporanoxProducts Affected

• SPORANOX ORAL SOLUTION

Covered UsesOnychomycosis, invasive fungal infection, uther fungal infection, superficial mycoses

Exclusion Criteria

Cosmetic use, patients with evidence of ventricular dysfunction such as CHF or a history of CHF. Coadministration with certain drugs metabolized by the cytochrome P-450 3A4 isoenzyme system (CYP3A4), cisapride, oral midazolam, pimozide, quinidine, dofetilide, triazolam, HMG-CoA reductase inhibitors metabolized by CYP3A4, such as lovastatin and simvastatin, and ergot alkaloids metabolized by CYP3A4, such as dihydroergotamine, ergotamine, ergonovine, and methylergonovine.

Itraconazole Capsules are covered for members who meet the following criteria: (1) Invasive fungal infections in patients who are immunocompromised, such as histoplamosis, aspergillosis, and blastomycosis, (2) Treatment of tinea barbae, tinea capitis, tinea favosa with previous treatment with terbinafine, (3) Treatment of tinea corporis, tinea cruris, tinea faciei, tinea manuum, tinea pedis with previous treatment with a topical antifungal and terbinafine, (4) Treatment of tinea versicolor with previous treatment with selenium sulfide and a topcial antifungal, (5) a diagnosis of majocchi granuloma, (6) Onychomycosis in diabetic patients or patients with peripheral vascular disease and either a positive onychomycosis susceptible pathogen culture or a positive PAS stain performed by a laboratory and documented trial/failure of terbinafine (generic Lamisil), or (7) Onychomycosis with documented disabling pain or impairment and a positive onychomycosis susceptible pathogen culture and documented step through terbinafine.

Age Restrictions

Coverage Duration

Nail: 12 wk(toe),5 wk (finger) per year,Invasive: 1-3 mo based on severity, Other Dx: 1-6 wk

Other Criteria

Notes/References

Sprintec 28Products Affected

• SPRINTEC 28

Notes/References

SprycelProducts Affected

• SPRYCEL ORAL TABLET 50 MG, 20 MG, 80 MG, 70 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SprycelProducts Affected

• SPRYCEL ORAL TABLET 140 MG, 100 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SronyxProducts Affected

• SRONYX

Notes/References

StavzorProducts Affected

• STAVZOR

Covered Uses Epilepsy, Bipolar disorder, Prophylaxis of migraine headaches

Exclusion Criteria

FOR EPILEPSY OR BIPOLAR DISORDER: documentation of step through valproic acid capsules or divalproex sodium delayed release tablets. FOR PROPHYLAXIS OF MIGRAINE HEADACHES: documentation of step through 2 of the following: valproic acid capsules or divalproex sodium delayed release tablets, propranolol, or topiramate.

Age Restrictions

Coverage Duration

3 years

Other Criteria

Notes/References

StelaraProducts Affected

• STELARA INTRAVENOUS*

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Stelara.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 4 vials Per 30 Days

Notes/References

StelaraProducts Affected

• STELARA SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

StimateProducts Affected

• STIMATE

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ENDO/miscendocrine.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Stiolto RespimatProducts Affected

• STIOLTO RESPIMAT

QL Criteria 1 inhaler Per 1 fill

Notes/References

StivargaProducts Affected

• STIVARGA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

StratteraProducts Affected

• STRATTERA

ST Criteria Documented step through a STIMULANT

Notes/References

StriantProducts Affected

• STRIANT

Age Restrictions

Coverage Duration

3 years

QL Criteria 2 buccal systems Per 1 day

StribildProducts Affected

• STRIBILD

Covered Uses

A documented diagnosis of human immunodeficiency virus (HIV), AND a documented viral load assay AND CD4 count indicating that the patient is stable on Stribild (stable or increase in CD4 counts AND viral load less than 50 copies/ml)(FOR renewals/continuations ONLY). For treatment naïve patients only, a documented resistance test within the past 3 months demonstrating virologic susceptibility to all of the following components of Stribild: elvitegravir, emtricitabine, and tenofovir AND a documented contraindication or intolerance or allergy or failure of an adequate trial of one month of one of the preferred regimens: Triumeq (dolutegravir/abacavir/lamivudine) OR Tivicay (dolutegravir) plus Truvada (tenofovir disoproxil fumarate/emtricitabine) OR Isentress (Raltegravir) plus Truvada (tenofovir disoproxil fumarate/emtricitabine) OR Prezista (Darunavir) plus Norvir (ritonavir) plus Truvada (tenofovir disoproxil fumarate/emtricitabine)

Exclusion Criteria

Age Restrictions

Coverage Duration

3 Years

Other Criteria

Notes/References

SuboxoneProducts Affected

• SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG, 2-0.5 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 3 films Per 1 day

SuboxoneProducts Affected

• SUBOXONE SUBLINGUAL FILM 12-3 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 films Per 1 day

SulfaSALAzineProducts Affected

• sulfasalazine oral

Notes/References

SulfazineProducts Affected

• SULFAZINE

Notes/References

Sulfazine ECProducts Affected

• SULFAZINE EC

Notes/References

SUMAtriptanProducts Affected

• sumatriptan nasal

QL Criteria 3 nasal sprays Per 1 month

Notes/References

SUMAtriptan SuccinateProducts Affected

• sumatriptan succinate subcutaneous* solution6 mg/0.5ml

QL Criteria 10 vials Per 30 Days

Notes/References

• sumatriptan succinate subcutaneous* 6 mg/0.5ml, 4 mg/0.5ml

• sumatriptan succinate subcutaneous* solution4 mg/0.5ml

QL Criteria 2 boxes (4 doses) Per 1 month

Notes/References

• sumatriptan succinate oral

Notes/References

SUMAtriptan Succinate RefillProducts Affected

• sumatriptan succinate refill subcutaneous*

QL Criteria 2 boxes (4 doses) Per 1 month

Notes/References

Supprelin LAProducts Affected

• SUPPRELIN LA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Sure Edge Glucose MonitorProducts Affected

• SURE EDGE GLUCOSE MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Sure Edge TestProducts Affected

• SURE EDGE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SureChek Blood Glucose MonitorProducts Affected

• SURECHEK BLOOD GLUCOSE MONITOR DEVICE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

SureChek Blood Glucose TestProducts Affected

• SURECHEK BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SureStep Pro LinearityProducts Affected

• SURESTEP PRO LINEARITY

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SureStep Pro TestProducts Affected

• SURESTEP PRO TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Sure-Test EasyPlus Mini MeterProducts Affected

• SURE-TEST EASYPLUS MINI METER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Sure-Test EasyPlus Mini TestProducts Affected

• SURE-TEST EASYPLUS MINI TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SutentProducts Affected

• SUTENT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SyedaProducts Affected

• SYEDA

Notes/References

SylatronProducts Affected

• SYLATRON SUBCUTANEOUS* KIT 300 MCG, 600 MCG, 4 X 300 MCG, 200 MCG, 4 X 200 MCG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SymbicortProducts Affected

• SYMBICORT

ST Criteria Documented step through DULERA (covered without trials for COPD)

Notes/References

SymlinPen 120Products Affected

• SYMLINPEN 120 SUBCUTANEOUS*

Covered Uses Type 1 and Type 2 diabetes

Exclusion Criteria

FOR TYPE 1 DIABETES: Patient must be using both basal insulin and short-acting insulin, and require three or more insulin injections daily, or using an insulin pump. FOR TYPE 2 DIABETES: Patient is receiving maximum tolerated doses of metformin, unless the patient is not a candidate for metformin therapy, and is using both basal insulin and short-acting insulin, and requires three or more insulin injections daily or is using an insulin pump, and failure to achieve adequate glycemic control despite individualized insulin management, defined as an A1C level is greater than 7% and less than 9%, and marked day-to-day variability in glucose levels (based on review of self-monitoring blood glucose levels), and home blood glucose monitoring is carried out three or more times per day, and is currently receiving individualized medical nutrition therapy by a registered dietician (requiring total daily carbohydrate intake monitoring), and is currently receiving ongoing care under the guidance of a healthcare professional skilled in the use of insulin and supported by the services of diabetes educators.

Age Restrictions

Coverage Duration

1 year

Other Criteria

Discontinuation Criteria includes recurrent unexplained hypoglycemia that requires medical assistance, persistent clinically significant nausea or associated abdominal pain, noncompliance with self-monitoring of blood glucose concentrations, noncompliance with insulin dose adjustments, or non compliance with scheduled health care professional contacts or recommended clinic visits

SymlinPen 60Products Affected

• SYMLINPEN 60 SUBCUTANEOUS*

Covered Uses Type 1 and Type 2 diabetes

Exclusion Criteria

FOR TYPE 1 DIABETES: Patient must be using both basal insulin and short-acting insulin, and require three or more insulin injections daily, or using an insulin pump. FOR TYPE 2 DIABETES: Patient is receiving maximum tolerated doses of metformin, unless the patient is not a candidate for metformin therapy, and is using both basal insulin and short-acting insulin, and requires three or more insulin injections daily or is using an insulin pump, and failure to achieve adequate glycemic control despite individualized insulin management, defined as an A1C level is greater than 7% and less than 9%, and marked day-to-day variability in glucose levels (based on review of self-monitoring blood glucose levels), and home blood glucose monitoring is carried out three or more times per day, and is currently receiving individualized medical nutrition therapy by a registered dietician (requiring total daily carbohydrate intake monitoring), and is currently receiving ongoing care under the guidance of a healthcare professional skilled in the use of insulin and supported by the services of diabetes educators.

Age Restrictions

Coverage Duration

1 year

Other Criteria

Discontinuation Criteria includes recurrent unexplained hypoglycemia that requires medical assistance, persistent clinically significant nausea or associated abdominal pain, noncompliance with self-monitoring of blood glucose concentrations, noncompliance with insulin dose adjustments, or non compliance with scheduled health care professional contacts or recommended clinic visits

SynagisProducts Affected

• SYNAGIS

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/Synagis.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SynriboProducts Affected

• SYNRIBO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TaclonexProducts Affected

• TACLONEX EXTERNAL SUSPENSION

ST Criteria Documented step through CALCIPOTRIENE AND MEDIUM TO HIGH POTENCY TOPICAL STEROID

Notes/References

Take ActionProducts Affected

• TAKE ACTION

Notes/References

TamifluProducts Affected

• TAMIFLU ORAL CAPSULE

QL Criteria 20 capsules Per 1 year

Notes/References

TamifluProducts Affected

• TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

Notes/References

TarcevaProducts Affected

• TARCEVA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TargretinProducts Affected

• TARGRETIN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TasignaProducts Affected

• TASIGNA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TaytullaProducts Affected

• TAYTULLA

QL Criteria 1.5 capsules Per 1 Day

Notes/References

TazoracProducts Affected

• TAZORAC

Notes/References

Taztia XTProducts Affected

• TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG

Notes/References

Taztia XTProducts Affected

• TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 360 MG, 180 MG, 120 MG

Notes/References

TechnivieProducts Affected

• TECHNIVIE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TekturnaProducts Affected

• TEKTURNA

Notes/References

Tekturna HCTProducts Affected

• TEKTURNA HCT

Notes/References

Telcare Blood Glucose TestProducts Affected

• TELCARE BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TelmisartanProducts Affected

• telmisartan

Notes/References

Telmisartan-AmlodipineProducts Affected

• telmisartan-amlodipine

Notes/References

Telmisartan-HCTZProducts Affected

• telmisartan-hctz

Notes/References

TemazepamProducts Affected

• temazepam oral capsule 7.5 mg, 22.5 mg

Notes/References

TemozolomideProducts Affected

• temozolomide

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TestimProducts Affected

• TESTIM

Age Restrictions

Coverage Duration

3 years

QL Criteria 2 10 gm packets Per 1 day

TestopelProducts Affected

• TESTOPEL

Age Restrictions

Coverage Duration

3 years

Notes/References

TestosteroneProducts Affected

• testosterone transdermal gel 50 mg/5gm (1%), 12.5 mg/act (1%)

Age Restrictions

Coverage Duration

3 years

Notes/References

TestosteroneProducts Affected

• testosterone transdermal gel 10 mg/act (2%)

Age Restrictions

Coverage Duration

3 years

Notes/References

Testosterone CypionateProducts Affected

• testosterone cypionate intramuscular* solution200 mg/ml

QL Criteria 10 vials Per 1 fill

Notes/References

Testosterone CypionateProducts Affected

• testosterone cypionate intramuscular* solution100 mg/ml

QL Criteria 10 ml Per 1 fill

Notes/References

TetrabenazineProducts Affected

• tetrabenazine oral tablet 12.5 mg

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MISC/huntingtons_xenazine.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TetrabenazineProducts Affected

• tetrabenazine oral tablet 25 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Teveten HCTProducts Affected

• TEVETEN HCT ORAL TABLET 600-25 MG

Notes/References

TGT Blood Glucose TestProducts Affected

• tgt blood glucose test

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ThalomidProducts Affected

• THALOMID

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TiaGABine HClProducts Affected

• tiagabine hcl oral tablet 4 mg

Notes/References

TiaGABine HClProducts Affected

• tiagabine hcl oral tablet 2 mg

Notes/References

Tilia FeProducts Affected

• TILIA FE

Notes/References

TirosintProducts Affected

• TIROSINT

Notes/References

TobramycinProducts Affected

• tobramycin inhalation

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/Aminoglycosides.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 10 ml Per 1 day

Notes/References

Tolterodine TartrateProducts Affected

• tolterodine tartrate

Notes/References

Tolterodine Tartrate ERProducts Affected

• tolterodine tartrate er

Notes/References

TopiramateProducts Affected

• topiramate oral capsule sprinkle

Notes/References

ToviazProducts Affected

• TOVIAZ

Notes/References

TracleerProducts Affected

• TRACLEER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TradjentaProducts Affected

• TRADJENTA

TraMADol HCl ERProducts Affected

• tramadol hcl er oral tablet extended release 24 hr*

ST Criteria Documented step through TRAMADOL

Notes/References

TraMADol HCl ER (Biphasic)Products Affected

• tramadol hcl er (biphasic)

ST Criteria Documented step through TRAMADOL

Notes/References

Tramadol-AcetaminophenProducts Affected

• tramadol-acetaminophen

Notes/References

Tranexamic AcidProducts Affected

• tranexamic acid oral

Notes/References

Travatan ZProducts Affected

• TRAVATAN Z

Exclusion Criteria

Age Restrictions

Coverage Duration

3 years

Other Criteria

Notes/References

TretinoinProducts Affected

• tretinoin external

Notes/References

Tretin-XProducts Affected

• TRETIN-X EXTERNAL CREAM 0.0375 %

Notes/References

TrettenProducts Affected

• TRETTEN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Triamcinolone AcetonideProducts Affected

• triamcinolone acetonide nasal aerosol†

Notes/References

TribenzorProducts Affected

• TRIBENZOR

Notes/References

Tri-Legest FeProducts Affected

• TRI-LEGEST FE

Notes/References

Tri-LinyahProducts Affected

• TRI-LINYAH

Notes/References

TriNessa (28)Products Affected

• TRINESSA (28)

Notes/References

Tri-Norinyl (28)Products Affected

• TRI-NORINYL (28)

Notes/References

Tri-PrevifemProducts Affected

• TRI-PREVIFEM

Notes/References

Tri-SprintecProducts Affected

• TRI-SPRINTEC

Notes/References

Trivora (28)Products Affected

• TRIVORA (28)

Notes/References

Trospium ChlorideProducts Affected

• trospium chloride

Notes/References

Trospium Chloride ERProducts Affected

• trospium chloride er

Notes/References

TRUEtest TestProducts Affected

• TRUETEST TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TrueTrack TestProducts Affected

• TRUETRACK TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TruvadaProducts Affected

• TRUVADA

Covered Uses HIV Infection, HIV Infection Pre-exposure Prophylaxis

Exclusion CriteriaTruvada is NOT covered for a use not approved by the FDA or if the use is unapproved and not supported by the literature or evidence as an accepted off-label use. (see Off-Label Use Policy for determining accepted use)

Truvada is covered for members who have a documented diagnosis of human immunodeficiency virus (HIV) OR a documented diagnosis of initiating therapy for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 in adults at high risk AND documentation of a negative HIV antibody test taken immediately before starting Truvada for PrEP AND every 3 months thereafter while on therapy. Confirmation that creatinine clearance value greater than or equal to 60 mL/min before initiating Truvada for PrEP AND Serum creatinine and calculate creatinine clearance checks performed at 3 months after initiation and then every 6 months thereafter. NOTE: Members may receive a 30 days' supply of medication upon initial request of Truvada for PrEP diagnosis. After 30 days, above criteria must be met.

Age Restrictions

Coverage Duration

HIV-1 infection: 3 years. Pre-exposure prophylaxis: 3 months.

Other Criteria

Notes/References

TruvadaProducts Affected

• TRUVADA

Covered Uses

A documented diagnosis of human immunodeficiency virus (HIV) in a patient who weighs 17KG or more OR initiating therapy for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 in adults at high risk who have documentation of all of the following: A negative HIV antibody test taken immediately before starting Truvada for PrEP and every 3 months thereafter while on therapy, confirmation that creatinine clearance value is greater than or equal to 60 mL/min before initiating Truvada for PrEP, and serum creatinine and calculate creatinine clearance checks performed at 3 months after initiation and then every 6 months thereafter. NOTE: Members may receive a 30 days' supply of medication upon initial request of Truvada for PrEP diagnosis. After 30 days, above criteria must be met.

Exclusion Criteria

Age Restrictions none

Coverage Duration

36 months HIV, 1 month initial PREP, 3 month PREP renewal

Other Criteria

4. Gilead Sciences, Inc.Truvada® (emtricitabine/tenofovir disoproxil fumarate) tablets, for oral use Foster City, CA: Gilead Sciences; 2004. Available at http://gilead.com/~/media/files/pdfs/medicines/hiv/truvada/truvada_pi.pdf Accessed June 9th,2016.

Notes/References

Revision DatePrior Authorization: July 07, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

Tudorza PressairProducts Affected

• TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT

Notes/References

TussiCapsProducts Affected

• TUSSICAPS

QL Criteria 20 capsules Per 1 fill

Notes/References

TykerbProducts Affected

• TYKERB

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TyzekaProducts Affected

• TYZEKA

Notes/References

UcerisProducts Affected

• UCERIS ORAL

Notes/References

UlesfiaProducts Affected

• ULESFIA

Notes/References

UloricProducts Affected

• ULORIC

ST Criteria Documented step through ALLOPURINOL

Notes/References

Ultima TestProducts Affected

• ULTIMA TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

UltraTRAK ActiveProducts Affected

• ULTRATRAK ACTIVE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

UltraTRAK PROProducts Affected

• ULTRATRAK PRO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

UltraTRAK PRO TestProducts Affected

• ULTRATRAK PRO TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

UltraTRAK Ultimate MonitorProducts Affected

• ULTRATRAK ULTIMATE MONITOR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

UltraTRAK Ultimate TestProducts Affected

• ULTRATRAK ULTIMATE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

UltresaProducts Affected

• ULTRESA

Age Restrictions

Coverage Duration

1 Year

Other Criteria

ValcyteProducts Affected

• VALCYTE

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/antiviraloraltopical.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ValGANciclovir HClProducts Affected

• valganciclovir hcl

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/ID/antiviraloraltopical.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ValsartanProducts Affected

• valsartan

Notes/References

Valsartan-HydrochlorothiazideProducts Affected

• valsartan-hydrochlorothiazide

Notes/References

VectibixProducts Affected

• VECTIBIX INTRAVENOUS* SOLUTION 400 MG/20ML, 100 MG/5ML

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

VelcadeProducts Affected

• VELCADE INJECTION

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

VelivetProducts Affected

• VELIVET

Notes/References

Venlafaxine HClProducts Affected

• venlafaxine hcl oral tablet 50 mg

Notes/References

• venlafaxine hcl oral tablet 100 mg, 25 mg

Notes/References

• venlafaxine hcl oral tablet 37.5 mg

Notes/References

• venlafaxine hcl oral tablet 75 mg

Notes/References

Venlafaxine HCl ERProducts Affected

• venlafaxine hcl er oral capsule extended release 24 hour 75 mg, 37.5 mg

Notes/References

Venlafaxine HCl ERProducts Affected

• venlafaxine hcl er oral capsule extended release 24 hour 150 mg

Notes/References

VeramystProducts Affected

• VERAMYST

Notes/References

Verapamil HCl ERProducts Affected

• verapamil hcl er oral capsule extended release 24 hour 300 mg, 100 mg

Notes/References

Verapamil HCl ERProducts Affected

• verapamil hcl er oral capsule extended release 24 hour 200 mg

Notes/References

VESIcareProducts Affected

• VESICARE

Notes/References

Victory AGM-4000 TestProducts Affected

• VICTORY AGM-4000 TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Victory Blood Glucose SystemProducts Affected

• VICTORY BLOOD GLUCOSE SYSTEM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

VictozaProducts Affected

• VICTOZA SUBCUTANEOUS*

Exclusion Criteria

Age Restrictions

Coverage Duration

3 Years

Other Criteria

QL Criteria 1 box-2 or 3 pens Per 1 month

Notes/References

VictrelisProducts Affected

• VICTRELIS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Viekira PakProducts Affected

• VIEKIRA PAK

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Viekira XRProducts Affected

• VIEKIRA XR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ViibrydProducts Affected

• VIIBRYD ORAL TABLET

Covered Uses Major depressive disorder

Exclusion Criteria

Documentation of failure or unresponsiveness to THREE different antidepressants from at least two different therapeutic subclasses

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

• VIIBRYD ORAL KIT

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

• VIIBRYD ORAL TABLET

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

Viibryd Starter PackProducts Affected

• VIIBRYD STARTER PACK

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

VimpatProducts Affected

• VIMPAT ORAL TABLET

Exclusion Criteria

A documented diagnosis of partial-onset seizures and documentation of a trial and failure with one of the following agents: carbamazepine, divalproex dr/er/sprinkle, gabapentin, lamotrigine, levetiracetam/ER, oxcarbazepine, phenytoin, topiramate, valproic acid, or zonisamide.

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

ViokaceProducts Affected

• VIOKACE

Age Restrictions

Coverage Duration

1 Year

Other Criteria

Notes/References

VioreleProducts Affected

• viorele

Notes/References

Viramune XRProducts Affected

• VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG

Notes/References

VireadProducts Affected

• VIREAD ORAL TABLET

Notes/References

VistogardProducts Affected

• VISTOGARD

QL Criteria 20 packs Per 1 prescription

Notes/References

Vocal Point Blood Glucose TestProducts Affected

• VOCAL POINT BLOOD GLUCOSE TEST

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

VoriconazoleProducts Affected

• voriconazole oral tablet

Covered Uses Fungal infections

Exclusion Criteria

Diagnosis of invasive aspergillosis or with a serious systemic fungal infection caused by Scedosporium apiospermum and Fusarium spp., for the treatment of esophageal candidiasis that is resistant to treatment with fluconazole and itraconazole, or for the treatment of candidemia in non-neutropenic patients and the following Candida infections: disseminated infections in skin and infections in abdomen, kidney, bladder wall, and wounds that are unresponsive to treatment with fluconazole (Continue therapy for 14 days after the patient is afebrile and blood cultures are negative).

Age Restrictions

Coverage Duration

Invasive aspergillosis: 12 weeks, Oral Candidiasis: 3 weeks MAX, Candidemia: 12 weeks

Other Criteria

Notes/References

VotrientProducts Affected

• VOTRIENT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

VprivProducts Affected

• VPRIV

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

VytorinProducts Affected

• VYTORIN

Notes/References

VyvanseProducts Affected

• VYVANSE

Exclusion Criteria

Coverage Duration

1 Year

Other Criteria

Notes/References

WaveSense KeyNote Pro MeterProducts Affected

• WAVESENSE KEYNOTE PRO METER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

WaveSense PrestoProducts Affected

• WAVESENSE PRESTO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

WelcholProducts Affected

• WELCHOL ORAL PACKET

Notes/References

WeraProducts Affected

• WERA

Notes/References

Wide-Seal Diaphragm 60Products Affected

• WIDE-SEAL DIAPHRAGM 60

QL Criteria 1 diaphram Per 1 year

Notes/References

WilateProducts Affected

• WILATE INTRAVENOUS* KIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Wymzya FeProducts Affected

• WYMZYA FE

Notes/References

XalkoriProducts Affected

• XALKORI

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

XeljanzProducts Affected

• XELJANZ

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Xeljanz_XeljanzXR.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Xeljanz_XeljanzXR.html

Notes/References

Xeljanz XRProducts Affected

• XELJANZ XR

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Xeljanz_XeljanzXR.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

ST Criteria http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/Xeljanz_XeljanzXR.html

Notes/References

XenazineProducts Affected

• XENAZINE ORAL TABLET 25 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

XenazineProducts Affected

• XENAZINE ORAL TABLET 12.5 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

XeominProducts Affected

• XEOMIN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

XgevaProducts Affected

• XGEVA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

XiaflexProducts Affected

• XIAFLEX

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/MUSC/dupuytrens_contracture_treatments.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

XifaxanProducts Affected

• XIFAXAN ORAL TABLET 550 MG

Covered Uses Hepatic Encephalopathy, Irritable Bowel Syndrome (IBS) with Diarrhea.

Exclusion Criteria Pregnancy, Severe hepatic impairment (child-Pugh C)

FOR HEPATIC ENCHEPHALOPATHY: Member must have a documented diagnosis and be 18 years and older. FOR IBS WITH DIARRHEA: Member must have a documented diagnosis and must have been prescribed a 14-day course of therapy with three times a day dosing. For reauthorization of 2nd or 3rd course of therapy, there must be at least a 10-week treatment free period from the previous course of therapy.

Age Restrictions 18 years or older

Coverage Duration

HEPATIC ENCEPHALOPATHY: 1 year. IBS: 14 days.

Other Criteria

Revision DatePrior Authorization: July 21, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

XifaxanProducts Affected

• XIFAXAN ORAL TABLET 200 MG

Notes/References

XtandiProducts Affected

• XTANDI

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

XulaneProducts Affected

• XULANE

Notes/References

XuridenProducts Affected

• XURIDEN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 4 packets Per 1 Day

Notes/References

XynthaProducts Affected

• XYNTHA INTRAVENOUS* KIT 2000 UNIT, 1000 UNIT, 250 UNIT, 500 UNIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xyntha SolofuseProducts Affected

• XYNTHA SOLOFUSE INTRAVENOUS* KIT 3000 UNIT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

XyremProducts Affected

• XYREM

Covered UsesRefer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2016/CNS/cataplexy-xyrem.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Yasmin 28Products Affected

• YASMIN 28

Notes/References

YAZProducts Affected

• YAZ

Notes/References

YervoyProducts Affected

• YERVOY

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ZaleplonProducts Affected

• zaleplon

Notes/References

ZarahProducts Affected

• ZARAH

Notes/References

ZavescaProducts Affected

• ZAVESCA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zegerid OTCProducts Affected

• ZEGERID OTC

Notes/References

ZelaparProducts Affected

• ZELAPAR

ST Criteria Documented step through SELEGILINE

Notes/References

ZelborafProducts Affected

• ZELBORAF

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ZemairaProducts Affected

• ZEMAIRA

Covered Uses pending

Exclusion Criteria

Age Restrictions

Coverage Duration

pending

Other Criteria

Notes/References

ZenataneProducts Affected

• ZENATANE

ZenchentProducts Affected

• ZENCHENT

Notes/References

Zenchent FEProducts Affected

• ZENCHENT FE

Notes/References

ZepatierProducts Affected

• ZEPATIER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ZetiaProducts Affected

• ZETIA

Notes/References

ZetonnaProducts Affected

• ZETONNA

Notes/References

ZioptanProducts Affected

• ZIOPTAN

Exclusion Criteria

Age Restrictions

Coverage Duration

3 years

Other Criteria

Ziprasidone HClProducts Affected

• ziprasidone hcl

Notes/References

ZirganProducts Affected

• ZIRGAN

Notes/References

Zoledronic AcidProducts Affected

• zoledronic acid intravenous* concentrate • zoledronic acid intravenous* solution

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ZolinzaProducts Affected

• ZOLINZA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ZOLMitriptanProducts Affected

• zolmitriptan oral

Notes/References

Zolpidem TartrateProducts Affected

• zolpidem tartrate oral

Notes/References

Zolpidem Tartrate ERProducts Affected

• zolpidem tartrate er

Notes/References

ZometaProducts Affected

• ZOMETA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ZomigProducts Affected

• ZOMIG NASAL SOLUTION 5 MG

QL Criteria 1 box (6 doses) Per 1 month

Notes/References

Zovia 1/35E (28)Products Affected

• ZOVIA 1/35E (28)

Notes/References

Zovia 1/50E (28)Products Affected

• ZOVIA 1/50E (28)

Notes/References

ZoviraxProducts Affected

• ZOVIRAX EXTERNAL CREAM

ST Criteria Documented step through ORAL ACYCLOVIR

Notes/References

ZytigaProducts Affected

• ZYTIGA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

acamprosate calcium .................................................................................. 1ACCU-CHEK ACTIVE .......................................................................... 2ACCU-CHEK AVIVA IN VITRO STRIP ..................... 3ACCU-CHEK AVIVA PLUS IN VITRO ....................... 4ACCU-CHEK COMPACT PLUS ............................................. 5ACCU-CHEK COMPACT TEST DRUM ...................... 6ACCU-CHEK SMARTVIEW ........................................................ 7ACCUTREND GLUCOSE ................................................................. 8acitretin ........................................................................................................................ 9ACTEMRA INTRAVENOUS* ................................................ 10ACTIMMUNE ................................................................................................ 11ACTOPLUS MET XR .......................................................................... 12ACURA BLOOD GLUCOSE TEST .................................. 13ACUVAIL ............................................................................................................ 14adapalene external lotion .................................................................. 15ADCIRCA ............................................................................................................ 16adefovir dipivoxil ......................................................................................... 17ADVAIR DISKUS ..................................................................................... 18ADVAIR HFA ................................................................................................ 19ADVANCE INTUITION METER ........................................ 20ADVANCE INTUITION TEST ............................................... 21ADVATE ............................................................................................................... 22ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 1000-20 MG ............................................ 23ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 1000-40 MG, 500-20 MG ...... 25ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR* 750-20 MG ................................................ 24ADVOCATE BLOOD GLUCOSE MONITOR.............................................................................................................................................. 26ADVOCATE DUO DEVICE ....................................................... 27ADVOCATE REDI-CODE DEVICE ............................... 28ADVOCATE REDI-CODE IN VITRO .......................... 29ADVOCATE REDI-CODE+ ........................................................ 30ADVOCATE REDI-CODE+ TEST .................................... 31ADVOCATE TEST .................................................................................. 32adynovate ............................................................................................................... 33AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG ............................................................. 35AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG ............................................................. 34AFINITOR ........................................................................................................... 36AGAMATRIX AMP TEST ........................................................... 37AGAMATRIX JAZZ TEST .......................................................... 38AGAMATRIX KEYNOTE TEST ......................................... 39AGAMATRIX PRESTO PRO METER ......................... 40AGAMATRIX PRESTO TEST ................................................ 41AKYNZEO .......................................................................................................... 42ALDURAZYME .......................................................................................... 43

alendronate sodium oral tablet 10 mg, 40 mg, 5 mg.............................................................................................................................................. 44alendronate sodium oral tablet 70 mg, 35 mg ......... 45alfuzosin hcl er ................................................................................................ 46ALIMTA ................................................................................................................. 47almotriptan malate ..................................................................................... 48alogliptin benzoate ..................................................................................... 49alogliptin-metformin hcl ..................................................................... 50alogliptin-pioglitazone .......................................................................... 51ALOXI INTRAVENOUS* SOLUTION 0.25 MG/5ML ................................................................................................................. 52ALPHANATE/VWF COMPLEX/HUMAN ............ 53ALPHANINE SD ........................................................................................ 54alprazolam er .................................................................................................... 55alprazolam xr .................................................................................................... 56ALPROLIX ......................................................................................................... 57ALTAVERA ...................................................................................................... 58ALTOPREV ....................................................................................................... 59ALVESCO ............................................................................................................ 60alyacen 1/35 ........................................................................................................ 61AMETHIA ............................................................................................................ 62AMETHIA LO ................................................................................................ 63AMETHYST ..................................................................................................... 64AMITIZA .............................................................................................................. 65amlodipine besylate-valsartan .................................................... 66AMNESTEEM ................................................................................................ 67amphetamine salt combo .................................................................... 68amphetamine-dextroamphet er ................................................... 69amphetamine-dextroamphetamine ......................................... 71AMPYRA .............................................................................................................. 72ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR ................................................................ 73ANDROGEL PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%) ................................................................................................ 78ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%) ..................................................................... 79ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%) ............................................................................. 75ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%) .......................................................................................... 76ANDROGEL TRANSDERMAL GEL 40.5 MG/2.5GM (1.62%) ................................................................................. 74ANDROGEL TRANSDERMAL GEL 50 MG/5GM (1%) ................................................................................................ 77ANZEMET ORAL ..................................................................................... 80APIDRA .................................................................................................................. 81APIDRA SOLOSTAR SUBCUTANEOUS* .......... 82APRI ............................................................................................................................. 83APRISO ................................................................................................................... 84

ARALAST NP ................................................................................................ 85ARANELLE ....................................................................................................... 86ARANESP (ALBUMIN FREE) INJECTION ........ 87ARANESP (ALBUMIN FREE) INJECTION ........ 88ARANESP (ALBUMIN FREE) INJECTION SOLUTION 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 150 MCG/0.75ML, 10 MCG/0.4ML, 60 MCG/ML, 100 MCG/ML, 200 MCG/ML ................... 87ARCALYST ....................................................................................................... 89ARCAPTA NEOHALER .................................................................. 90aripiprazole oral solution .................................................................. 92aripiprazole oral tablet ........................................................................ 91aripiprazole oral tablet dispersible ...................................... 91armodafinil oral tablet 150 mg, 200 mg, 250 mg.............................................................................................................................................. 93armodafinil oral tablet 50 mg ...................................................... 95ARZERRA ........................................................................................................... 97ASCENSIA AUTODISC TEST ............................................... 98ASMANEX 120 METERED DOSES ............................... 99ASMANEX 14 METERED DOSES ............................... 100ASMANEX 30 METERED DOSES ............................... 101ASMANEX 60 METERED DOSES ............................... 102ASSURE 3 TEST ..................................................................................... 103ASSURE 4 METER ............................................................................. 104ASSURE 4 TEST ..................................................................................... 105ASSURE PLATINUM ...................................................................... 106ASSURE PLATINUM METER ........................................... 107ASSURE PRO BLOOD GLUCOSE METER .... 108ASSURE PRO TEST .......................................................................... 109atorvastatin calcium oral ............................................................... 110ATRIPLA ........................................................................................................... 111AUBAGIO ........................................................................................................ 112AVANDAMET ORAL TABLET 2-1000 MG........................................................................................................................................... 114AVANDAMET ORAL TABLET 2-500 MG ...... 113AVANDIA ....................................................................................................... 115AVIANE .............................................................................................................. 116AVITA EXTERNAL CREAM .............................................. 117AVONEX ........................................................................................................... 118AVONEX PEN INTRAMUSCULAR* ...................... 119AVONEX PREFILLED INTRAMUSCULAR*........................................................................................................................................... 120AXIRON ............................................................................................................. 121AZILECT ........................................................................................................... 122AZOR ...................................................................................................................... 123AZURETTE .................................................................................................... 124balsalazide disodium ............................................................................ 125BALZIVA ......................................................................................................... 126BANZEL ORAL SUSPENSION ......................................... 128BANZEL ORAL TABLET ......................................................... 127BARACLUDE ORAL TABLET ......................................... 129

BAYER BREEZE 2 TEST .......................................................... 130BAYER CONTOUR MONITOR DEVICE ........... 131BAYER CONTOUR NEXT TEST ................................... 132BAYER CONTOUR TEST ........................................................ 133BEBULIN .......................................................................................................... 134BEBULIN VH ............................................................................................. 135BECONASE AQ ....................................................................................... 136BENICAR ......................................................................................................... 137BENICAR HCT ......................................................................................... 138BENLYSTA ................................................................................................... 139BETASERON SUBCUTANEOUS* KIT ................ 140bexarotene ......................................................................................................... 141BG STAR TEST ........................................................................................ 142bicalutamide ................................................................................................... 143bimatoprost ophthalmic ................................................................... 144BIVIGAM ......................................................................................................... 145BOSULIF ORAL TABLET 100 MG ............................. 146BOSULIF ORAL TABLET 500 MG ............................. 147BOTOX ................................................................................................................ 148BRAVELLE ................................................................................................... 149BREEZE 2 BLOOD GLUCOSE SYSTEM ........... 150BREVICON (28) ...................................................................................... 151briellyn ................................................................................................................... 152BRILINTA ....................................................................................................... 153BROVANA ..................................................................................................... 154budesonide inhalation ........................................................................ 155BUNAVAIL ................................................................................................... 156BUPHENYL ORAL TABLET ............................................... 158buprenorphine hcl sublingual tablet sublingual 2 mg ................................................................................................................................. 161buprenorphine hcl sublingual tablet sublingual 8 mg ................................................................................................................................. 159buprenorphine hcl-naloxone hcl ........................................... 163BUPROBAN .................................................................................................. 165bupropion hcl er (smoking det) .............................................. 167bupropion hcl er (sr) ............................................................................ 168bupropion hcl er (xl) ............................................................................ 169bupropion hcl oral .................................................................................. 166butorphanol tartrate nasal ........................................................... 170BUTRANS TRANSDERMAL PATCH WEEKLY 20 MCG/HR, 10 MCG/HR, 5 MCG/HR .................... 171BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED .............................................................................. 172BYETTA 10 MCG PEN SUBCUTANEOUS*........................................................................................................................................... 173BYETTA 5 MCG PEN SUBCUTANEOUS* ..... 174BYSTOLIC ORAL TABLET 2.5 MG, 5 MG, 10 MG .............................................................................................................................. 176BYSTOLIC ORAL TABLET 20 MG ........................... 175calcipotriene external ......................................................................... 177calcipotriene-betameth diprop ................................................ 178

calcitonin (salmon) ................................................................................ 179CALCITRENE ............................................................................................ 180CAMILA ............................................................................................................. 181CAMRESE ....................................................................................................... 182CAMRESE LO ........................................................................................... 183CANASA ............................................................................................................ 184candesartan cilexetil oral tablet 4 mg, 8 mg, 16 mg........................................................................................................................................... 185candesartan cilexetil-hctz .............................................................. 186capecitabine .................................................................................................... 187CAPRELSA ORAL TABLET 100 MG ...................... 188CAPRELSA ORAL TABLET 300 MG ...................... 189CARBAGLU ................................................................................................. 190CARDURA XL .......................................................................................... 191CARESENS N GLUCOSE SYSTEM ........................... 192CARESENS N GLUCOSE TEST ...................................... 193CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 6 GM, 12 GM .................................. 194CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 300 MG, 180 MG........................................................................................................................................... 195CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG ............................................... 196CAYSTON ....................................................................................................... 197CAZIANT ......................................................................................................... 198cefixime ................................................................................................................. 199celecoxib oral ................................................................................................ 200CERDELGA ................................................................................................... 201CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT .............................................. 202CESAMET ....................................................................................................... 203CESIA .................................................................................................................... 204CETROTIDE SUBCUTANEOUS* KIT 0.25 MG........................................................................................................................................... 205cevimeline hcl ................................................................................................ 206CHANTIX ......................................................................................................... 207CHANTIX CONTINUING MONTH PAK ............ 208CHANTIX STARTING MONTH PAK ..................... 209CHATEAL ....................................................................................................... 210CHENODAL ................................................................................................. 211chorionic gonadotropin intramuscular* ..................... 212CIALIS ORAL TABLET 5 MG ........................................... 213CIMZIA PREFILLED ....................................................................... 215CIMZIA STARTER KIT ............................................................... 216CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG........................................................................................................................................... 214citalopram hydrobromide oral tablet 10 mg, 20 mg........................................................................................................................................... 217citalopram hydrobromide oral tablet 40 mg .......... 218CLARAVIS ..................................................................................................... 219CLEVER CHEK AUTO-CODE ........................................... 220

CLEVER CHEK AUTO-CODE SYSTEM ............ 221CLEVER CHEK AUTO-CODE TEST ....................... 222CLEVER CHEK AUTO-CODE VOICE ................... 223CLEVER CHEK AUTO-CODE VOICE IN VITRO ................................................................................................................... 224CLEVER CHEK TEST .................................................................... 225CLEVER CHOICE AUTO-CODE SYSTEM ..... 226CLEVER CHOICE AUTO-CODE TEST ................ 227CLEVER CHOICE MICRO TEST ................................... 228CLEVER CHOICE MINI SYSTEM ............................... 229CLIMARA PRO ........................................................................................ 230clonidine hcl er ............................................................................................ 231clopidogrel bisulfate ............................................................................. 232clozapine oral tablet 100 mg ..................................................... 234clozapine oral tablet 200 mg ..................................................... 237clozapine oral tablet 50 mg, 25 mg ................................... 233clozapine oral tablet dispersible 100 mg ................... 234clozapine oral tablet dispersible 12.5 mg ................. 236clozapine oral tablet dispersible 150 mg, 200 mg........................................................................................................................................... 235clozapine oral tablet dispersible 25 mg ....................... 233COAGADEX ................................................................................................. 238colchicine oral tablet ........................................................................... 239COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 227.1 GM ....... 240COMBIPATCH .......................................................................................... 241COMETRIQ (100 MG DAILY DOSE) ...................... 242COMETRIQ (140 MG DAILY DOSE) ...................... 243COMETRIQ (60 MG DAILY DOSE) .......................... 244COMPLERA .................................................................................................. 245CONTROL AST ....................................................................................... 246CONTROL TEST .................................................................................... 247COPAXONE SUBCUTANEOUS* 20 MG/ML........................................................................................................................................... 249COPAXONE SUBCUTANEOUS* 40 MG/ML........................................................................................................................................... 248CORDRAN EXTERNAL TAPE ......................................... 250COREG CR ..................................................................................................... 251CORIFACT ..................................................................................................... 252COSOPT PF .................................................................................................... 253CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 6000 UNIT ................................................. 254CRINONE ......................................................................................................... 255CRYSELLE-28 ........................................................................................... 256CUVPOSA ....................................................................................................... 257CYCLAFEM 1/35 ................................................................................... 258CYCLESSA .................................................................................................... 259CYCLOSET .................................................................................................... 260DACOGEN ...................................................................................................... 261DAKLINZA .................................................................................................... 262

DAKLINZA .................................................................................................... 263DALIRESP ....................................................................................................... 264darifenacin hydrobromide er ..................................................... 265DASETTA 1/35 ......................................................................................... 266DAYSEE ............................................................................................................. 267DAYTRANA ................................................................................................. 268DEBLITANE ................................................................................................. 270decitabine ........................................................................................................... 271DELZICOL ...................................................................................................... 272DENAVIR ......................................................................................................... 273DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 150 MG/ML ...................................................... 274DEPO-SUBQ PROVERA 104 SUBCUTANEOUS* SUSPENSION ............................. 275DESCOVY ....................................................................................................... 276desloratadine ................................................................................................. 277DESOGEN ....................................................................................................... 278DEXCOM G4 PLATINUM RECEIVER .................. 279DEXCOM G4 PLATINUM SENSOR KIT ........... 280DEXCOM G4 PLATINUM TRANSMITTER........................................................................................................................................... 281DEXCOM G4 SENSOR ................................................................. 282DEXILANT ..................................................................................................... 283dexmethylphenidate hcl .................................................................... 285dexmethylphenidate hcl er ............................................................ 286dextroamphetamine sulfate er .................................................. 290dextroamphetamine sulfate oral solution .................. 288dextroamphetamine sulfate oral tablet ......................... 289diazepam gel ................................................................................................... 291diclofenac sodium transdermal gel 1 % ...................... 292DIFICID ............................................................................................................... 293diltiazem cd oral capsule extended release 24 hour120 mg, 180 mg .......................................................................................... 295diltiazem cd oral capsule extended release 24 hour240 mg .................................................................................................................... 294diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 300 mg, 360 mg, 120 mg, 420 mg .................................................................................................................... 298diltiazem hcl er beads oral capsule extended release 24 hour 240 mg .................................................................... 299diltiazem hcl er coated beads oral capsule extended release 24 hour 240 mg ........................................ 301diltiazem hcl er coated beads oral capsule extended release 24 hour 300 mg, 180 mg, 120 mg, 360 mg .................................................................................................................... 300diltiazem hcl er oral capsule extended release 12 hour 120 mg .................................................................................................... 296diltiazem hcl er oral capsule extended release 24 hour 180 mg, 120 mg ........................................................................... 296diltiazem hcl er oral capsule extended release 24 hour 240 mg .................................................................................................... 297

dilt-xr oral capsule extended release 24 hour 180 mg, 120 mg ....................................................................................................... 302dilt-xr oral capsule extended release 24 hour 240 mg ................................................................................................................................. 303DIPENTUM .................................................................................................... 304donepezil hcl oral tablet 10 mg .............................................. 306donepezil hcl oral tablet 23 mg .............................................. 305dronabinol ......................................................................................................... 307drospiren-eth estrad-levomefol ............................................... 308drospirenone-ethinyl estradiol oral tablet 3-0.03 mg ................................................................................................................................. 309DULERA ............................................................................................................ 310duloxetine hcl oral capsule delayed release particles 20 mg ............................................................................................ 313duloxetine hcl oral capsule delayed release particles 30 mg, 60 mg ...................................................................... 311duloxetine hcl oral capsule delayed release particles 40 mg ............................................................................................ 312dutasteride ......................................................................................................... 314easy plus ii glucose system ........................................................... 315easy plus ii glucose test .................................................................... 316EASY STEP GLUCOSE MONITOR DEVICE........................................................................................................................................... 317EASY STEP TEST ................................................................................ 318easy talk blood glucose system device ........................... 319easy talk blood glucose test ......................................................... 320EASY TOUCH TEST ........................................................................ 321easy trak blood glucose test ........................................................ 322EASYGLUCO IN VITRO ........................................................... 323EASYMAX 15 TEST ......................................................................... 324EASYMAX L BLOOD GLUCOSE DEVICE .... 325EASYMAX N BLOOD GLUCOSE DEVICE ... 326EASYMAX NG BLOOD GLUCOSE DEVICE........................................................................................................................................... 327EASYMAX TEST .................................................................................. 328EASYMAX V BLOOD GLUCOSE DEVICE ... 329EASYMAX V2 BLOOD GLUCOSE DEVICE........................................................................................................................................... 330easyplus blood glucose test .......................................................... 331EASYPRO PLUS IN VITRO ................................................... 332EDARBI .............................................................................................................. 333EDARBYCLOR ........................................................................................ 334EDURANT ....................................................................................................... 335EFFIENT ............................................................................................................ 336EGRIFTA SUBCUTANEOUS* SOLUTION RECONSTITUTED 2 MG ........................................................... 337ELAPRASE ..................................................................................................... 338ELELYSO ......................................................................................................... 339ELEMENT PLUS .................................................................................... 340ELEMENT TEST .................................................................................... 341ELIDEL ................................................................................................................ 342

ELINEST ............................................................................................................ 343ELIQUIS ............................................................................................................. 344ELLA ....................................................................................................................... 345ELOCTATE .................................................................................................... 346EMBEDA ........................................................................................................... 347EMBRACE BLOOD GLUCOSE MONITOR ... 348EMBRACE BLOOD GLUCOSE TEST .................... 349EMEND ORAL CAPSULE 125 MG, 80 MG, 40 MG .............................................................................................................................. 351EMEND ORAL CAPSULE 80 & 125 MG ............ 350EMOQUETTE ............................................................................................. 352EMSAM ............................................................................................................... 353EMTRIVA ORAL CAPSULE ................................................ 354ENBREL SUBCUTANEOUS* 25 MG/0.5ML........................................................................................................................................... 356ENBREL SUBCUTANEOUS* 50 MG/ML ......... 355ENBREL SUBCUTANEOUS* KIT ............................... 355ENBREL SURECLICK SUBCUTANEOUS*........................................................................................................................................... 357ENDOMETRIN ......................................................................................... 358ENJUVIA ORAL TABLET 0.9 MG, 0.45 MG, 0.625 MG, 0.3 MG ................................................................................. 359ENJUVIA ORAL TABLET 1.25 MG ........................... 360enoxaparin sodium ................................................................................. 361ENPRESSE-28 ............................................................................................ 362entecavir oral tablet 1 mg ............................................................. 363EPCLUSA ......................................................................................................... 364EPIDUO ............................................................................................................... 365EPIDUO FORTE ...................................................................................... 366epinephrine injection 0.3 mg/0.3ml, 0.15 mg/0.15ml ........................................................................................................... 367EPIPEN 2-PAK INJECTION ................................................... 368EPOGEN INJECTION SOLUTION 3000 UNIT/ML, 20000 UNIT/ML, 4000 UNIT/ML, 10000 UNIT/ML, 2000 UNIT/ML .................................... 369epoprostenol sodium ............................................................................ 370eprosartan mesylate .............................................................................. 371ERIVEDGE ..................................................................................................... 372ERRIN .................................................................................................................... 373escitalopram oxalate oral tablet 10 mg ....................... 375escitalopram oxalate oral tablet 5 mg, 20 mg ..... 374esomeprazole magnesium .............................................................. 376estradiol transdermal patch biweekly ............................ 379estradiol transdermal patch weekly .................................. 378estradiol-norethindrone acet ..................................................... 380ESTROGEL .................................................................................................... 381ESTROSTEP FE ....................................................................................... 382eszopiclone ....................................................................................................... 383EVAMIST ......................................................................................................... 384EVENCARE + BLOOD GLUCOSE TEST .......... 385EVENCARE BLOOD GLUCOSE TEST ................ 386

EVENCARE G2 MONITOR .................................................... 387EVENCARE G2 TEST .................................................................... 388EVENCARE G3 MONITOR .................................................... 389EVENCARE G3 TEST .................................................................... 390EVOLUTION AUTOCODE ..................................................... 392EVOLUTION AUTOCODE IN VITRO ................... 391EXJADE .............................................................................................................. 393EXTAVIA SUBCUTANEOUS* KIT ........................... 394EZ SMART BLOOD GLUCOSE TEST .................... 395EZ SMART MONITORING SYSTEM ...................... 396EZ SMART PLUS GLUCOSE TEST ........................... 397EZ SMART PLUS MONITORING SYS ................. 398FABRAZYME ............................................................................................ 399FALMINA ........................................................................................................ 400famciclovir oral tablet 125 mg, 250 mg ....................... 401famciclovir oral tablet 500 mg ................................................ 402FANAPT ............................................................................................................. 403FANAPT TITRATION PACK ............................................... 404felodipine er .................................................................................................... 405FEMCON FE ................................................................................................. 406FEMHRT LOW DOSE .................................................................... 407FEMRING ......................................................................................................... 408fenofibrate micronized ....................................................................... 411fenofibrate oral ........................................................................................... 409fenofibrate oral ........................................................................................... 410fenofibric acid oral tablet .............................................................. 412fentanyl .................................................................................................................. 413fentanyl .................................................................................................................. 414fentanyl citrate buccal ........................................................................ 415FERRIPROX ................................................................................................. 416FIFTY50 GLUCOSE TEST 2.0 ............................................ 417FIRAZYR .......................................................................................................... 418FIRST-PROGESTERONE VGS 100 ............................. 419FIRST-PROGESTERONE VGS 200 ............................. 420FIRST-PROGESTERONE VGS 25 ................................. 421FIRST-PROGESTERONE VGS 400 ............................. 422FIRST-PROGESTERONE VGS 50 ................................. 423FLEBOGAMMA DIF ........................................................................ 424FLOVENT DISKUS ............................................................................ 425FLOVENT HFA ........................................................................................ 426flunisolide nasal solution 25 mcg/act (0.025%)........................................................................................................................................... 427fluoxetine hcl oral capsule 10 mg ........................................ 433fluoxetine hcl oral capsule 20 mg ........................................ 431fluoxetine hcl oral capsule 40 mg ........................................ 432fluoxetine hcl oral capsule delayed release ............ 429fluoxetine hcl oral tablet 10 mg ............................................. 430fluoxetine hcl oral tablet 20 mg ............................................. 428fluvastatin sodium .................................................................................... 434fluvastatin sodium er ............................................................................ 435fluvoxamine maleate oral tablet 100 mg ..................... 437

fluvoxamine maleate oral tablet 25 mg, 50 mg........................................................................................................................................... 436FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 35 MG, 25 MG .......................... 438FOLLISTIM AQ ....................................................................................... 440fondaparinux sodium ........................................................................... 441FORA D10 2-IN-1 MONITOR .............................................. 442FORA D10 BLOOD GLUCOSE TEST ...................... 443FORA D15G 2-IN-1 MONITOR ......................................... 444FORA D15G BLOOD GLUCOSE TEST ................ 445FORA D20 2-IN-1 MONITOR .............................................. 446FORA D20 BLOOD GLUCOSE TEST ...................... 447FORA G20 BLOOD GLUCOSE TEST ...................... 448FORA G30A BLOOD GLUCOSE SYSTEM ..... 449FORA G30A BLOOD GLUCOSE TEST ................ 450FORA GD20 BLOOD GLUCOSE SYSTEM ..... 451FORA GD20 TEST ............................................................................... 452FORA V10 BLOOD GLUCOSE SYSTEM .......... 453FORA V10 BLOOD GLUCOSE TEST ...................... 454FORA V12 BLOOD GLUCOSE SYSTEM .......... 455FORA V12 BLOOD GLUCOSE TEST ...................... 456FORA V20 BLOOD GLUCOSE SYSTEM .......... 457FORA V20 BLOOD GLUCOSE TEST ...................... 458FORA V30A BLOOD GLUCOSE SYSTEM DEVICE ............................................................................................................... 459FORA V30A BLOOD GLUCOSE TEST ................ 460FORACARE GD40 MONITOR ........................................... 461FORACARE GD40 TEST ........................................................... 462FORACARE PREMIUM V10 ................................................ 463FORACARE PREMIUM V10 TEST ............................. 464FORADIL AEROLIZER ............................................................... 465FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML ................................................................................................... 466FORTESTA ..................................................................................................... 467FORTICAL ...................................................................................................... 468FOSAMAX PLUS D ........................................................................... 469FRAGMIN SUBCUTANEOUS* SOLUTION 5000 UNIT/0.2ML, 18000 UNT/0.72ML, 12500 UNIT/0.5ML, 2500 UNIT/0.2ML, 10000 UNIT/ML, 15000 UNIT/0.6ML ............................................ 470FRAGMIN SUBCUTANEOUS* SOLUTION 95000 UNIT/3.8ML, 7500 UNIT/0.3ML, 25000 UNIT/ML ........................................................................................................... 471FREESTYLE INSULINX TEST ......................................... 472FREESTYLE LITE ............................................................................... 473FREESTYLE LITE TEST ............................................................ 474FREESTYLE TEST .............................................................................. 475frovatriptan succinate ......................................................................... 476gabapentin oral capsule .................................................................. 478gabapentin oral tablet ........................................................................ 477GAMMAGARD ........................................................................................ 479

GAMMAGARD S/D LESS IGA ......................................... 480GAMMAKED .............................................................................................. 481GAMMAPLEX INTRAVENOUS* SOLUTION 5 GM/100ML, 10 GM/200ML, 2.5 GM/50ML ...... 482GAMUNEX-C ............................................................................................. 483ganirelix acetate ........................................................................................ 484gatifloxacin ophthalmic .................................................................... 485GATTEX ............................................................................................................ 486GAVILYTE-C ............................................................................................. 487GAVILYTE-G ............................................................................................. 488ge100 blood glucose test ................................................................. 489GELNIQUE TRANSDERMAL GEL 10 % ........... 490GELNIQUE TRANSDERMAL GEL 3 (28) % (MG/ACT) ........................................................................................................ 491GENERESS FE .......................................................................................... 492GIANVI ................................................................................................................ 493GIAZO ................................................................................................................... 494GILDAGIA ...................................................................................................... 495GILDESS 1.5/30 ....................................................................................... 496GILDESS 1/20 ............................................................................................. 497GILDESS FE 1.5/30 ............................................................................. 498GILDESS FE 1/20 .................................................................................. 499GILENYA ......................................................................................................... 500GILOTRIF ........................................................................................................ 501GLATOPA ....................................................................................................... 502GLUCAGEN DIAGNOSTIC ................................................... 503GLUCAGEN HYPOKIT ............................................................... 504GLUCOCARD 01 BLOOD GLUCOSE DEVICE........................................................................................................................................... 505GLUCOCARD 01 SENSOR PLUS ................................. 506GLUCOCARD EXPRESSION TEST .......................... 507GLUCOCARD VITAL TEST ................................................. 508GLUCOCARD X-SENSOR ...................................................... 509GLUCOCOM BLOOD GLUCOSE MONITOR........................................................................................................................................... 510GLUCOCOM TEST ............................................................................ 511GONAL-F ......................................................................................................... 512GONAL-F RFF ........................................................................................... 513GONAL-F RFF PEN ........................................................................... 514GONAL-F RFF REDIJECT ....................................................... 515GRALISE ORAL TABLET 300 MG ............................ 516GRALISE ORAL TABLET 600 MG ............................ 517GRALISE STARTER ........................................................................ 518granisetron hcl oral ............................................................................... 519guanfacine hcl er ...................................................................................... 520GUARDIAN REAL-TIME SYSTEM PED ........... 521HALAVEN ...................................................................................................... 522HARVONI ........................................................................................................ 523HELIXATE FS ........................................................................................... 524

HEMOFIL M INTRAVENOUS* SOLUTION RECONSTITUTED 220-400 UNIT, 250 UNIT, 1000 UNIT, 1700 UNIT, 500 UNIT, 1501-2000 UNIT, 801-1500 UNIT, 401-800 UNIT ...................... 525HEPSERA ......................................................................................................... 526HIZENTRA SUBCUTANEOUS* SOLUTION 10 GM/50ML, 1 GM/5ML, 4 GM/20ML, 2 GM/10ML ......................................................................................................... 527hm nicotine transdermal patch 24 hr 7 mg/24hr........................................................................................................................................... 528HORIZANT ORAL TABLET EXTENDEDRELEASE* 300 MG .................................... 530HORIZANT ORAL TABLET EXTENDEDRELEASE* 600 MG .................................... 529HUMATE-P INTRAVENOUS* SOLUTION RECONSTITUTED 500-1200 UNIT, 1000-2400 UNIT, 250-600 UNIT ......................................................................... 531HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML .............................. 535HUMIRA PEN SUBCUTANEOUS* ............................ 536HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* ........................................................................... 537HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* ........................................................................... 538HUMIRA SUBCUTANEOUS* 10 MG/0.2ML........................................................................................................................................... 532HUMIRA SUBCUTANEOUS* 20 MG/0.4ML........................................................................................................................................... 533HUMIRA SUBCUTANEOUS* 40 MG/0.8ML........................................................................................................................................... 534HYCAMTIN ORAL ............................................................................ 539hydrocod polst-cpm polst er oral liquid extendedrelease* ....................................................................................... 540hydromorphone hcl er ........................................................................ 541ibandronate sodium oral ................................................................. 542ICLUSIG ORAL TABLET 15 MG .................................. 544ICLUSIG ORAL TABLET 45 MG .................................. 543ILARIS .................................................................................................................. 545imatinib mesylate oral tablet 100 mg .............................. 546imatinib mesylate oral tablet 400 mg .............................. 547imiquimod external ................................................................................ 548IMPLANON ................................................................................................... 549INCRELEX ..................................................................................................... 550INFINITY BLOOD GLUCOSE TEST ........................ 551INLYTA .............................................................................................................. 552INTELENCE ORAL TABLET 100 MG, 25 MG........................................................................................................................................... 553INTELENCE ORAL TABLET 200 MG ................... 554INTRON A ....................................................................................................... 555INTROVALE ................................................................................................ 556INVOKANA .................................................................................................. 557

ipratropium bromide nasal .......................................................... 558irbesartan ........................................................................................................... 559irbesartan-hydrochlorothiazide ............................................. 560ISENTRESS ORAL TABLET ................................................ 561ISENTRESS ORAL TABLET CHEWABLE ..... 562ISTODAX ......................................................................................................... 563itraconazole oral ....................................................................................... 564JAKAFI ................................................................................................................ 566JANUMET ....................................................................................................... 567JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-500 MG........................................................................................................................................... 569JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 50-1000 MG ......................................... 568JANUVIA .......................................................................................................... 570JENTADUETO .......................................................................................... 571JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG ....................................... 572JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG ............................................ 573jevantique lo .................................................................................................... 574JINTELI ............................................................................................................... 575JOLESSA ........................................................................................................... 576JOLIVETTE ................................................................................................... 577JUNEL 1.5/30 ............................................................................................... 578JUNEL 1/20 .................................................................................................... 579JUNEL FE 1.5/30 ..................................................................................... 580JUNEL FE 1/20 .......................................................................................... 581JUXTAPID ORAL CAPSULE 20 MG ........................ 583JUXTAPID ORAL CAPSULE 5 MG, 10 MG ... 584JUXTAPID ORAL CAPSULE 60 MG, 40 MG, 30 MG .............................................................................................................................. 582KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 40 MG, 130 MG, 70 MG ........................................................................................ 585KALYDECO ORAL TABLET .............................................. 586KARIVA ............................................................................................................. 587KELNOR 1/35 ............................................................................................. 588KEPIVANCE ................................................................................................ 589ketoconazole oral ..................................................................................... 590ketorolac tromethamine ophthalmic ................................. 591ketorolac tromethamine oral ..................................................... 592KINERET SUBCUTANEOUS* .......................................... 593KOATE-DVI ................................................................................................. 594KOGENATE FS ........................................................................................ 595KOGENATE FS BIO-SET .......................................................... 596KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 2.5-1000 MG........................................................................................................................................... 597

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* 5-1000 MG, 5-500 MG ........................................................................................................... 598KORLYM .......................................................................................................... 599KOVALTRY ................................................................................................. 600kroger blood glucose test ............................................................... 601kroger premium glucose test ...................................................... 602kroger test .......................................................................................................... 603KURVELO ....................................................................................................... 604KUVAN ORAL PACKET 500 MG ................................. 605KUVAN ORAL TABLET SOLUBLE ......................... 605LAMISIL ORAL PACKET 125 MG ............................. 606LAMISIL ORAL PACKET 187.5 MG ........................ 607lamotrigine er oral tablet extended release 24 hr*100 mg, 25 mg .............................................................................................. 614lamotrigine er oral tablet extended release 24 hr*200 mg .................................................................................................................... 611lamotrigine er oral tablet extended release 24 hr*250 mg, 300 mg .......................................................................................... 612lamotrigine er oral tablet extended release 24 hr*50 mg ........................................................................................................................ 613lamotrigine oral tablet dispersible 100 mg, 200 mg........................................................................................................................................... 608lamotrigine oral tablet dispersible 25 mg ................. 610lamotrigine oral tablet dispersible 50 mg ................. 609lansoprazole oral capsule delayed release .............. 615LANTUS ............................................................................................................. 616LANTUS SOLOSTAR SUBCUTANEOUS* ..... 617LARIN FE 1.5/30 ..................................................................................... 618LASTACAFT ............................................................................................... 619latanoprost ophthalmic ..................................................................... 620LATUDA ORAL TABLET 20 MG, 120 MG, 60 MG, 40 MG ..................................................................................................... 621LATUDA ORAL TABLET 80 MG ................................. 622LEENA .................................................................................................................. 623leflunomide oral ......................................................................................... 624LEMTRADA ................................................................................................. 625LESSINA ............................................................................................................ 626LETAIRIS ......................................................................................................... 627LEUKINE INTRAVENOUS* ................................................ 628leuprolide acetate injection ......................................................... 629levalbuterol tartrate hfa ................................................................... 630levetiracetam er oral tablet extended release 24 hr* 500 mg ........................................................................................................ 631levetiracetam er oral tablet extended release 24 hr* 750 mg ........................................................................................................ 632levocetirizine dihydrochloride oral solution .......... 634levocetirizine dihydrochloride oral tablet ................ 633LEVONEST .................................................................................................... 635levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg, 0.1-0.02 & 0.01 mg .................................................................... 636

levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg .................................................................................................................. 637LEVORA 0.15/30 (28) ...................................................................... 638LIALDA .............................................................................................................. 639liberty blood glucose meter ......................................................... 640liberty blood glucose monitor ................................................... 641LIBERTY NEXT GENERATION TEST ................. 642LIBERTY NXT GENERATION MONITOR ..... 643liberty test ........................................................................................................... 644lidocaine external ointment ......................................................... 645lidocaine external patch 5 % ..................................................... 647lidocaine-prilocaine external cream ................................ 648lindane external lotion ....................................................................... 650linezolid oral suspension reconstituted ........................ 651linezolid oral tablet ................................................................................ 652LINZESS ............................................................................................................ 653LIVALO .............................................................................................................. 654LO LOESTRIN FE ................................................................................ 655LOESTRIN FE 1.5/30 ....................................................................... 656LOESTRIN FE 1/20 ............................................................................. 657LOMEDIA 24 FE .................................................................................... 658LORYNA ........................................................................................................... 659LOSEASONIQUE .................................................................................. 660lovastatin ............................................................................................................. 661LOW-OGESTREL ................................................................................. 662LUMIGAN OPHTHALMIC SOLUTION 0.01 %........................................................................................................................................... 663LUMIZYME .................................................................................................. 664LUPANETA PACK .............................................................................. 665LUPRON DEPOT ................................................................................... 666LUPRON DEPOT-PED ................................................................... 667LUTERA ............................................................................................................. 668LYRICA .............................................................................................................. 669LYZA ...................................................................................................................... 670malathion external .................................................................................. 671marlissa ................................................................................................................ 672MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 300 MG, 420 MG, 360 MG ................................................................................................................. 673MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 240 MG ...................................................... 674MAXIMA BLOOD GLUCOSE TEST ........................ 675medroxyprogesterone acetate intramuscular* suspension ......................................................................................................... 676meijer blood glucose test ................................................................ 677meijer premium glucose test ....................................................... 678memantine hcl oral tablet 10 mg, 5 mg ........................ 679memantine hcl oral tablet 5 (28)-10 (21) mg ........ 680MENOPUR ...................................................................................................... 681MENOSTAR ................................................................................................. 682mesalamine oral ......................................................................................... 683

METADATE ER ORAL TABLET EXTENDEDRELEASE* 20 MG ........................................ 684metaxalone oral tablet 400 mg ................................................ 686metformin hcl er (mod) ..................................................................... 687methamphetamine hcl ......................................................................... 688METHYLIN ORAL TABLET CHEWABLE ..... 689methylphenidate hcl er (cd) ......................................................... 701methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg .................................................. 703methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg ........................................................................ 705methylphenidate hcl er oral tablet extended release 24 hr* 27 mg, 18 mg, 54 mg ....................................................... 693methylphenidate hcl er oral tablet extended release 24 hr* 36 mg .................................................................................................. 700methylphenidate hcl er oral tablet extendedrelease* 10 mg, 20 mg ............................................. 696methylphenidate hcl er oral tablet extendedrelease* 27 mg, 18 mg, 54 mg ....................... 694methylphenidate hcl er oral tablet extendedrelease* 36 mg ................................................................... 698methylphenidate hcl oral solution 10 mg/5ml ...... 690methylphenidate hcl oral solution 5 mg/5ml .......... 691methylphenidate hcl oral tablet .............................................. 692metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 50 mg .................................................. 709metoprolol succinate er oral tablet extended release 24 hr* 200 mg ........................................................................ 707metoprolol succinate er oral tablet extended release 24 hr* 25 mg ........................................................................... 708MIACALCIN INJECTION ......................................................... 710MICRODOT TEST ............................................................................... 711MICROGESTIN 1.5/30 ................................................................... 712MICROGESTIN 1/20 ......................................................................... 713MICROGESTIN FE 1.5/30 ......................................................... 714MICROGESTIN FE 1/20 .............................................................. 715MIMVEY ........................................................................................................... 716MIRCETTE ..................................................................................................... 717MIRENA (52 MG) ................................................................................. 718mirtazapine oral ......................................................................................... 719modafinil .............................................................................................................. 720MODICON (28) ......................................................................................... 722MONOCLATE-P ..................................................................................... 723MONO-LINYAH ..................................................................................... 724montelukast sodium oral ................................................................. 725montelukast sodium oral ................................................................. 726morphine sulfate er beads oral capsule extended release 24 hour 90 mg, 120 mg, 75 mg, 45 mg ... 728morphine sulfate er oral capsule extended release 24 hour ................................................................................................................... 727MOZOBIL ........................................................................................................ 729

MULTAQ .......................................................................................................... 730MYGLUCOHEALTH TEST .................................................... 731MYOBLOC ..................................................................................................... 732MYORISAN ORAL CAPSULE 20 MG, 40 MG, 10 MG ..................................................................................................................... 733MYRBETRIQ .............................................................................................. 734MYTESI .............................................................................................................. 735MYZILRA ........................................................................................................ 736naftifine hcl ...................................................................................................... 737NAFTIN EXTERNAL GEL 1 % ......................................... 738NAGLAZYME ........................................................................................... 739naratriptan hcl ............................................................................................. 740NATAZIA ......................................................................................................... 741NECON 0.5/35 (28) .............................................................................. 742NECON 1/35 (28) ................................................................................... 743NECON 1/50 (28) ................................................................................... 744NECON 10/11 (28) ................................................................................ 745NEULASTA DELIVERY KIT SUBCUTANEOUS* ........................................................................... 747NEULASTA SUBCUTANEOUS* ................................... 746NEUPOGEN INJECTION ........................................................... 748NEUPOGEN INJECTION SOLUTION 480 MCG/1.6ML, 300 MCG/ML ..................................................... 748NEUPRO ............................................................................................................ 749NEUTEK 2TEK GLUCOSE/PRESSURE ............... 750NEUTEK 2TEK TEST ..................................................................... 751nevirapine er oral tablet extended release 24 hr*100 mg .................................................................................................................... 752nevirapine er oral tablet extended release 24 hr*400 mg .................................................................................................................... 753NEXAVAR ...................................................................................................... 754NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE ......................................................................................................... 757NEXIUM ORAL PACKET ........................................................ 755NEXPLANON ............................................................................................. 758NEXT CHOICE ONE DOSE ................................................... 759NICODERM CQ ....................................................................................... 760nicotine step 1 ............................................................................................... 762nicotine step 2 ............................................................................................... 763nicotine step 3 ............................................................................................... 764nicotine transdermal patch 24 hr ......................................... 761NICOTROL ..................................................................................................... 765NICOTROL NS ......................................................................................... 766NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG .......................................................... 767NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG .......................................................... 768NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG .......................................................... 769NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 60 MG .......................................................... 770

nifedipine er oral tablet extended release 24 hr* 30 mg, 90 mg ........................................................................................................... 771nifedipine er oral tablet extended release 24 hr* 60 mg ................................................................................................................................. 772nifedipine er osmotic release oral tablet extended release 24 hr* 60 mg ........................................................................... 774nifedipine er osmotic release oral tablet extended release 24 hr* 90 mg, 30 mg ...................................................... 773NIKKI ..................................................................................................................... 775nisoldipine er oral tablet extended release 24 hr*20 mg, 25.5 mg, 40 mg, 8.5 mg, 17 mg, 34 mg ... 776nisoldipine er oral tablet extended release 24 hr*30 mg ........................................................................................................................ 777nitroglycerin translingual solution .................................... 778NORA-BE ......................................................................................................... 779norethindrone oral .................................................................................. 780NORINYL 1+35 (28) .......................................................................... 781NORINYL 1+50 (28) .......................................................................... 782NORLYROC ................................................................................................. 783NORTREL 0.5/35 (28) ..................................................................... 784NORTREL 1/35 (21) ........................................................................... 785NORTREL 1/35 (28) ........................................................................... 786NOVA MAX BLOOD GLUCOSE SYSTEM DEVICE ............................................................................................................... 787NOVA MAX GLUCOSE TEST ........................................... 788NOVAREL ....................................................................................................... 789NOVOEIGHT .............................................................................................. 790NOVOLIN 70/30 ...................................................................................... 791NOVOLIN 70/30 RELION ......................................................... 792NOVOLIN N ................................................................................................. 793NOVOLIN N RELION .................................................................... 794NOVOLIN R .................................................................................................. 795NOVOLIN R RELION ..................................................................... 796NOVOLOG ..................................................................................................... 797NOVOLOG FLEXPEN SUBCUTANEOUS* ... 798NOVOLOG MIX 70/30 ................................................................... 799NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* ........................................................................... 800NOVOLOG PENFILL SUBCUTANEOUS* ...... 801NOVOSEVEN ............................................................................................. 802NOVOSEVEN RT .................................................................................. 803NOXAFIL ORAL SUSPENSION ..................................... 804NUCYNTA ...................................................................................................... 805NUCYNTA ER ........................................................................................... 806NUEDEXTA .................................................................................................. 807NULOJIX ........................................................................................................... 808NUVARING ................................................................................................... 809NUWIQ ................................................................................................................ 810OCELLA ............................................................................................................. 811

OCTAGAM INTRAVENOUS* SOLUTION 1 GM/20ML, 10 GM/200ML, 2 GM/20ML, 20 GM/200ML, 2.5 GM/50ML, 25 GM/500ML, 5 GM/100ML ...................................................................................................... 812octreotide acetate injection solution 500 mcg/ml, 100 mcg/ml, 1000 mcg/ml, 50 mcg/ml, 200 mcg/ml........................................................................................................................................... 813ODEFSEY ......................................................................................................... 814OGESTREL .................................................................................................... 815olanzapine oral tablet 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg ...................................................................................................................... 816olanzapine oral tablet 2.5 mg ................................................... 817olanzapine oral tablet dispersible ....................................... 816olanzapine-fluoxetine hcl ............................................................... 818OLEPTRO ......................................................................................................... 819omega-3-acid ethyl esters .............................................................. 820omeprazole-sodium bicarbonate oral capsule20-1100 mg ...................................................................................................... 821OMNARIS ........................................................................................................ 822OMNITROPE ............................................................................................... 823ON CALL PLUS BLOOD GLUCOSE ........................ 824ON CALL VIVID BLOOD GLUCOSE ..................... 825ondansetron ..................................................................................................... 826ondansetron hcl oral solution ................................................... 828ondansetron hcl oral tablet 24 mg, 4 mg .................... 829ondansetron hcl oral tablet 8 mg ......................................... 827ONETOUCH TEST .............................................................................. 830ONETOUCH ULTRA BLUE .................................................. 831ONETOUCH VERIO IN VITRO STRIP ................. 832ONFI ORAL SUSPENSION ..................................................... 833ONFI ORAL TABLET 10 MG, 20 MG ..................... 834ONGLYZA ...................................................................................................... 835OPANA ER ORAL ............................................................................... 836OPSUMIT ......................................................................................................... 837OPTIUM TEST .......................................................................................... 838OPTIUMEZ TEST ................................................................................. 839ORAVIG ............................................................................................................. 840ORENCIA CLICKJECT ................................................................. 843ORENCIA INTRAVENOUS* ............................................... 842ORENCIA SUBCUTANEOUS* ......................................... 841ORKAMBI ....................................................................................................... 844ORKAMBI ....................................................................................................... 845ORSYTHIA ..................................................................................................... 846ORTHO MICRONOR ....................................................................... 847ORTHO TRI-CYCLEN (28) ..................................................... 848ORTHO TRI-CYCLEN LO ....................................................... 849ORTHO-CEPT (28) .............................................................................. 850ORTHO-CYCLEN (28) ................................................................... 851ORTHO-NOVUM 1/35 (28) ..................................................... 852ORTHO-NOVUM 7/7/7 (28) ................................................... 853OVCON-35 (28) ........................................................................................ 854

OVIDREL ......................................................................................................... 855OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG .......................... 857OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR* 600 MG ...................................................... 856oxybutynin chloride er ....................................................................... 859oxybutynin chloride oral tablet ............................................... 858oxycodone-ibuprofen ........................................................................... 860OXYCONTIN ORAL ........................................................................ 861oxymorphone hcl ....................................................................................... 862oxymorphone hcl er oral tablet extended release 12 hr* 10 mg ............................................................................................................ 863oxymorphone hcl er oral tablet extended release 12 hr* 30 mg ............................................................................................................ 865oxymorphone hcl er oral tablet extended release 12 hr* 40 mg, 5 mg, 7.5 mg, 15 mg, 20 mg ...................... 864paliperidone er oral tablet extended release 24 hr*1.5 mg, 9 mg, 3 mg ................................................................................. 866paliperidone er oral tablet extended release 24 hr*6 mg ........................................................................................................................... 867PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 4200-10000 UNIT, 10500-25000 UNIT, 16800-40000 UNIT, 21000-37000 UNIT ............................................................................... 868pancrelipase (lip-prot-amyl) ...................................................... 869PARAGARD INTRAUTERINE COPPER ............ 870paricalcitol oral ......................................................................................... 871paroxetine hcl er oral tablet extended release 24 hr* 25 mg ............................................................................................................ 874paroxetine hcl er oral tablet extended release 24 hr* 37.5 mg, 12.5 mg ........................................................................... 875paroxetine hcl oral tablet 10 mg, 20 mg ..................... 872paroxetine hcl oral tablet 30 mg, 40 mg ..................... 873peg 3350/electrolytes ........................................................................... 876peg-3350/electrolytes .......................................................................... 877PEGASYS PROCLICK ................................................................... 879PEGASYS SUBCUTANEOUS* SOLUTION........................................................................................................................................... 878PEG-INTRON .............................................................................................. 880PEG-INTRON REDIPEN ............................................................. 881PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS* KIT 50 MCG/0.5ML, 150 MCG/0.5ML, 120 MCG/0.5ML ........................................... 882PENTASA ORAL CAPSULE EXTENDED RELEASE* 250 MG ........................................................................... 883PENTASA ORAL CAPSULE EXTENDED RELEASE* 500 MG ........................................................................... 884PERFOROMIST ....................................................................................... 885PERTZYE ......................................................................................................... 886PHARMACIST CHOICE AUTOCODE ................... 887PHILITH ............................................................................................................. 888

PICATO EXTERNAL GEL 0.015 % ............................ 890PICATO EXTERNAL GEL 0.05 % ................................ 889pioglitazone hcl ........................................................................................... 891pioglitazone hcl-glimepiride ...................................................... 892pioglitazone hcl-metformin hcl ............................................... 893PLAN B ONE-STEP ........................................................................... 894PLEGRIDY ..................................................................................................... 895PLEGRIDY STARTER PACK .............................................. 896POCKETCHEM EZ TEST .......................................................... 897POMALYST .................................................................................................. 898PORTIA-28 ..................................................................................................... 899POTIGA ORAL TABLET 200 MG, 400 MG, 300 MG .............................................................................................................................. 900POTIGA ORAL TABLET 50 MG .................................... 901PRALUENT ................................................................................................... 902pramipexole dihydrochloride er ............................................ 903pravastatin sodium ................................................................................. 904PRECISION PCX .................................................................................... 905PRECISION PCX PLUS TEST ............................................. 906PRECISION POINT OF CARE TEST ........................ 907PRECISION QID TEST .................................................................. 908PRECISION SOF-TACT TEST ............................................ 909PRECISION XTRA BLOOD GLUCOSE ............... 911PRECISION XTRA DEVICE ................................................. 910PRECISION XTRA MONITOR .......................................... 912PREFEST ........................................................................................................... 913PREGNYL ........................................................................................................ 914PREMARIN ORAL .............................................................................. 915PREMPHASE .............................................................................................. 916PREMPRO ....................................................................................................... 917PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG ................................................................................... 918PREVIFEM ..................................................................................................... 919PREZISTA ORAL SUSPENSION ................................... 922PREZISTA ORAL TABLET 600 MG, 75 MG, 150 MG .............................................................................................................................. 920PREZISTA ORAL TABLET 800 MG ......................... 921PRISTIQ .............................................................................................................. 923PRIVIGEN ....................................................................................................... 924PROAIR HFA .............................................................................................. 925PROCRIT ........................................................................................................... 926PRODIGY AUTOCODE BLOOD GLUCOSE DEVICE ............................................................................................................... 927PRODIGY NO CODING BLOOD GLUC ............. 928PROFILNINE INTRAVENOUS* SOLUTION RECONSTITUTED 1000 UNIT .......................................... 929PROFILNINE SD .................................................................................... 930progesterone micronized oral .................................................. 931PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG ................................................ 932PROLEUKIN ................................................................................................ 933

PROLIA ............................................................................................................... 934PROMACTA ORAL TABLET 25 MG, 12.5 MG, 50 MG ..................................................................................................................... 935propafenone hcl er .................................................................................. 936PROVENTIL HFA ................................................................................ 937PULMICORT FLEXHALER ................................................... 938PULMOZYME ........................................................................................... 939QNASL ................................................................................................................. 940QNASL CHILDRENS ...................................................................... 941QUASENSE ................................................................................................... 942quetiapine fumarate oral tablet 100 mg, 50 mg........................................................................................................................................... 943quetiapine fumarate oral tablet 200 mg ...................... 946quetiapine fumarate oral tablet 25 mg .......................... 944quetiapine fumarate oral tablet 300 mg, 400 mg........................................................................................................................................... 945QUILLIVANT XR ................................................................................. 947quinine sulfate oral ................................................................................ 949ra blood glucose monitor ............................................................... 950RA TRUETEST TEST ...................................................................... 951rabeprazole sodium ............................................................................... 952RAJANI ................................................................................................................ 954RANEXA ........................................................................................................... 955RAVICTI ............................................................................................................ 956REBETOL ORAL SOLUTION ............................................ 957REBIF REBIDOSE SUBCUTANEOUS* ............... 959REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* ........................................................................... 960REBIF SUBCUTANEOUS* ..................................................... 958REBIF TITRATION PACK SUBCUTANEOUS*........................................................................................................................................... 961RECLAST ......................................................................................................... 962RECLIPSEN ................................................................................................... 963RECOMBINATE ..................................................................................... 964RECTIV ............................................................................................................... 965REFUAH PLUS BLOOD GLUCOSE TEST ...... 966RELENZA DISKHALER ............................................................. 967RELION CONFIRM/MICRO TEST .............................. 968RELION PRIME MONITOR .................................................. 969RELION PRIME TEST ................................................................... 970RELION ULTIMA TEST ............................................................. 971RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML ........................................................................................................ 972RELISTOR SUBCUTANEOUS* SOLUTION 8 MG/0.4ML ........................................................................................................ 973RELPAX ............................................................................................................. 974REMICADE ................................................................................................... 975REMODULIN .............................................................................................. 976repaglinide-metformin hcl ............................................................ 977REPATHA ........................................................................................................ 978REPATHA PUSHTRONEX SYSTEM ....................... 979

REPATHA SURECLICK ............................................................. 980REPRONEX ................................................................................................... 981RESCULA ........................................................................................................ 982REVEAL BLOOD GLUCOSE TEST ........................... 983REVLIMID ...................................................................................................... 984REXALL BLOOD GLUCOSE TEST ........................... 985REXULTI .......................................................................................................... 986REYATAZ ORAL CAPSULE 200 MG ..................... 987REYATAZ ORAL CAPSULE 300 MG, 150 MG........................................................................................................................................... 988RIASTAP ........................................................................................................... 989RIGHTEST GS100 BLOOD GLUCOSE ................. 990RIGHTEST GS300 BLOOD GLUCOSE ................. 991RIGHTEST GS550 BLOOD GLUCOSE ................. 992risedronate sodium oral tablet 150 mg ......................... 995risedronate sodium oral tablet 5 mg, 30 mg, 35 mg........................................................................................................................................... 993risedronate sodium oral tablet delayed release........................................................................................................................................... 994RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 2 MG, 1 MG ......................... 999RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 3 MG ..................................................................... 1000RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 4 MG ..................................................................... 1001risperidone oral tablet 1 mg, 0.25 mg, 0.5 mg, 2 mg........................................................................................................................................... 997risperidone oral tablet 3 mg ....................................................... 998risperidone oral tablet 4 mg ....................................................... 996risperidone oral tablet dispersible 0.25 mg, 1 mg, 2 mg, 0.5 mg ......................................................................................................... 997risperidone oral tablet dispersible 3 mg ..................... 998risperidone oral tablet dispersible 4 mg ..................... 996RITUXAN INTRAVENOUS* SOLUTION ..... 1002rivastigmine ................................................................................................. 1003rizatriptan benzoate ........................................................................... 1004ropinirole hcl er oral tablet extended release 24 hr* 12 mg ........................................................................................................ 1006ropinirole hcl er oral tablet extended release 24 hr* 6 mg, 8 mg, 4 mg, 2 mg ..................................................... 1005rosuvastatin calcium ......................................................................... 1007ROZEREM ................................................................................................... 1008SABRIL ............................................................................................................ 1009SABRIL ............................................................................................................ 1010SAFYRAL ..................................................................................................... 1011SAMSCA ORAL TABLET 15 MG ............................. 1013SAMSCA ORAL TABLET 30 MG ............................. 1012SANCUSO .................................................................................................... 1014SAPHRIS ........................................................................................................ 1015SAPHRIS ........................................................................................................ 1016SAVELLA ..................................................................................................... 1017

SAVELLA TITRATION PACK ...................................... 1018SEASONIQUE ........................................................................................ 1019SELZENTRY ............................................................................................ 1020SENSIPAR ................................................................................................... 1021SEREVENT DISKUS .................................................................... 1022SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG ...................... 1023SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 300 MG, 400 MG, 50 MG....................................................................................................................................... 1024sertraline hcl oral concentrate ............................................ 1026sertraline hcl oral tablet 100 mg ...................................... 1028sertraline hcl oral tablet 25 mg .......................................... 1025sertraline hcl oral tablet 50 mg .......................................... 1027SHAROBEL ............................................................................................... 1029sildenafil citrate oral ........................................................................ 1030SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR* 500-40 MG, 1000-40 MG....................................................................................................................................... 1031SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR* 750-20 MG, 500-20 MG, 1000-20 MG ................................................................................................ 1032SIMPONI ARIA .................................................................................... 1034SIMPONI SUBCUTANEOUS* ........................................ 1033SIMULECT ................................................................................................. 1035simvastatin oral ....................................................................................... 1036SMARTEST BLOOD GLUCOSE TEST .............. 1037SMARTEST EJECT ......................................................................... 1038SMARTEST PROTEGE ............................................................. 1039sodium phenylbutyrate ................................................................. 1040sodium phenylbutyrate oral powder 3 gm/tsp....................................................................................................................................... 1040SOLIA ................................................................................................................ 1041SOLUS V2 TEST ................................................................................. 1042SOMATULINE DEPOT ............................................................. 1043SOMAVERT .............................................................................................. 1044SOVALDI ...................................................................................................... 1045SPIRIVA HANDIHALER ........................................................ 1046SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 1.25 MCG/ACT ............................................... 1047SPORANOX ORAL SOLUTION .................................. 1048SPRINTEC 28 .......................................................................................... 1050SPRYCEL ORAL TABLET 140 MG, 100 MG....................................................................................................................................... 1052SPRYCEL ORAL TABLET 50 MG, 20 MG, 80 MG, 70 MG .................................................................................................. 1051SRONYX ........................................................................................................ 1053STAVZOR .................................................................................................... 1054STELARA INTRAVENOUS* ........................................... 1055STELARA SUBCUTANEOUS* ..................................... 1056STIMATE ...................................................................................................... 1057

STIOLTO RESPIMAT ................................................................. 1058STIVARGA ................................................................................................. 1059STRATTERA ............................................................................................ 1060STRIANT ....................................................................................................... 1061STRIBILD ..................................................................................................... 1062SUBOXONE SUBLINGUAL FILM 12-3 MG....................................................................................................................................... 1065SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG, 2-0.5 MG .......................................................................................... 1063sulfasalazine oral .................................................................................. 1067SULFAZINE .............................................................................................. 1068SULFAZINE EC ................................................................................... 1069sumatriptan nasal ................................................................................. 1070sumatriptan succinate oral ....................................................... 1073sumatriptan succinate refill subcutaneous* ........ 1074sumatriptan succinate subcutaneous* 6 mg/0.5ml, 4 mg/0.5ml ..................................................................................................... 1072sumatriptan succinate subcutaneous* solution 4 mg/0.5ml ........................................................................................................... 1072sumatriptan succinate subcutaneous* solution 6 mg/0.5ml ........................................................................................................... 1071SUPPRELIN LA ................................................................................... 1075SURE EDGE GLUCOSE MONITOR ...................... 1076SURE EDGE TEST ........................................................................... 1077SURECHEK BLOOD GLUCOSE MONITOR DEVICE ........................................................................................................... 1078SURECHEK BLOOD GLUCOSE TEST ............. 1079SURESTEP PRO LINEARITY ......................................... 1080SURESTEP PRO TEST ............................................................... 1081SURE-TEST EASYPLUS MINI METER ........... 1082SURE-TEST EASYPLUS MINI TEST .................. 1083SUTENT .......................................................................................................... 1084SYEDA .............................................................................................................. 1085SYLATRON SUBCUTANEOUS* KIT 300 MCG, 600 MCG, 4 X 300 MCG, 200 MCG, 4 X 200 MCG ..................................................................................................................... 1086SYMBICORT ........................................................................................... 1087SYMLINPEN 120 SUBCUTANEOUS* ............... 1088SYMLINPEN 60 SUBCUTANEOUS* ................... 1090SYNAGIS ...................................................................................................... 1092SYNRIBO ...................................................................................................... 1093TACLONEX EXTERNAL SUSPENSION ........ 1094TAKE ACTION ..................................................................................... 1095TAMIFLU ORAL CAPSULE ............................................. 1096TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML .......................................... 1097TARCEVA ................................................................................................... 1098TARGRETIN ............................................................................................ 1099TASIGNA ...................................................................................................... 1100TAYTULLA ............................................................................................... 1101TAZORAC ................................................................................................... 1102

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 240 MG ............................................ 1103TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 300 MG, 360 MG, 180 MG, 120 MG ............................................................................................................. 1104TECHNIVIE ............................................................................................... 1105TEKTURNA .............................................................................................. 1106TEKTURNA HCT .............................................................................. 1107TELCARE BLOOD GLUCOSE TEST ................... 1108telmisartan ..................................................................................................... 1109telmisartan-amlodipine ................................................................. 1110telmisartan-hctz ...................................................................................... 1111temazepam oral capsule 7.5 mg, 22.5 mg .............. 1112temozolomide ............................................................................................. 1113TESTIM ............................................................................................................ 1114TESTOPEL .................................................................................................. 1115testosterone cypionate intramuscular* solution 100 mg/ml .................................................................................................................... 1119testosterone cypionate intramuscular* solution 200 mg/ml .................................................................................................................... 1118testosterone transdermal gel 10 mg/act (2%) ... 1117testosterone transdermal gel 50 mg/5gm (1%), 12.5 mg/act (1%) .................................................................................................. 1116tetrabenazine oral tablet 12.5 mg .................................... 1120tetrabenazine oral tablet 25 mg .......................................... 1121TEVETEN HCT ORAL TABLET 600-25 MG....................................................................................................................................... 1122tgt blood glucose test ....................................................................... 1123THALOMID ............................................................................................... 1124tiagabine hcl oral tablet 2 mg ............................................... 1126tiagabine hcl oral tablet 4 mg ............................................... 1125TILIA FE ........................................................................................................ 1127TIROSINT ..................................................................................................... 1128tobramycin inhalation ..................................................................... 1129tolterodine tartrate .............................................................................. 1130tolterodine tartrate er ...................................................................... 1131topiramate oral capsule sprinkle ...................................... 1132TOVIAZ ........................................................................................................... 1133TRACLEER ................................................................................................ 1134TRADJENTA ............................................................................................ 1135tramadol hcl er (biphasic) ......................................................... 1137tramadol hcl er oral tablet extended release 24 hr*....................................................................................................................................... 1136tramadol-acetaminophen ............................................................ 1138tranexamic acid oral ........................................................................ 1139TRAVATAN Z ....................................................................................... 1140tretinoin external ................................................................................... 1141TRETIN-X EXTERNAL CREAM 0.0375 %....................................................................................................................................... 1142TRETTEN ..................................................................................................... 1143triamcinolone acetonide nasal aerosol† ................. 1144

TRIBENZOR ............................................................................................. 1145TRI-LEGEST FE .................................................................................. 1146TRI-LINYAH ............................................................................................ 1147TRINESSA (28) ..................................................................................... 1148TRI-NORINYL (28) ......................................................................... 1149TRI-PREVIFEM ................................................................................... 1150TRI-SPRINTEC ..................................................................................... 1151TRIVORA (28) ....................................................................................... 1152trospium chloride .................................................................................. 1153trospium chloride er .......................................................................... 1154TRUETEST TEST .............................................................................. 1155TRUETRACK TEST ....................................................................... 1156TRUVADA .................................................................................................. 1157TRUVADA .................................................................................................. 1158TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT ........................................................................................ 1159TUSSICAPS ............................................................................................... 1160TYKERB ......................................................................................................... 1161TYZEKA ......................................................................................................... 1162UCERIS ORAL ...................................................................................... 1163ULESFIA ........................................................................................................ 1164ULORIC ........................................................................................................... 1165ULTIMA TEST ...................................................................................... 1166ULTRATRAK ACTIVE ............................................................. 1167ULTRATRAK PRO .......................................................................... 1168ULTRATRAK PRO TEST ...................................................... 1169ULTRATRAK ULTIMATE MONITOR .............. 1170ULTRATRAK ULTIMATE TEST ............................... 1171ULTRESA ..................................................................................................... 1172VALCYTE .................................................................................................... 1173valganciclovir hcl ................................................................................. 1174valsartan .......................................................................................................... 1175valsartan-hydrochlorothiazide ............................................ 1176VECTIBIX INTRAVENOUS* SOLUTION 400 MG/20ML, 100 MG/5ML ......................................................... 1177VELCADE INJECTION ............................................................ 1178VELIVET ....................................................................................................... 1179venlafaxine hcl er oral capsule extended release 24 hour 150 mg ................................................................................................. 1185venlafaxine hcl er oral capsule extended release 24 hour 75 mg, 37.5 mg ......................................................................... 1184venlafaxine hcl oral tablet 100 mg, 25 mg ........... 1181venlafaxine hcl oral tablet 37.5 mg ............................... 1182venlafaxine hcl oral tablet 50 mg ..................................... 1180venlafaxine hcl oral tablet 75 mg ..................................... 1183VERAMYST .............................................................................................. 1186verapamil hcl er oral capsule extended release 24 hour 200 mg ................................................................................................. 1188verapamil hcl er oral capsule extended release 24 hour 300 mg, 100 mg ....................................................................... 1187

VESICARE .................................................................................................. 1189VICTORY AGM-4000 TEST .............................................. 1190VICTORY BLOOD GLUCOSE SYSTEM ........ 1191VICTOZA SUBCUTANEOUS* ...................................... 1192VICTRELIS ................................................................................................. 1193VIEKIRA PAK ....................................................................................... 1194VIEKIRA XR ............................................................................................ 1195VIIBRYD ORAL KIT .................................................................... 1197VIIBRYD ORAL TABLET .................................................... 1196VIIBRYD ORAL TABLET .................................................... 1198VIIBRYD STARTER PACK ................................................ 1199VIMPAT ORAL TABLET ...................................................... 1200VIOKACE ..................................................................................................... 1201viorele .................................................................................................................. 1202VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG .................................................. 1203VIREAD ORAL TABLET ....................................................... 1204VISTOGARD ............................................................................................ 1205VOCAL POINT BLOOD GLUCOSE TEST ... 1206voriconazole oral tablet ................................................................ 1207VOTRIENT ................................................................................................. 1208VPRIV ................................................................................................................ 1209VYTORIN ..................................................................................................... 1210VYVANSE ................................................................................................... 1211WAVESENSE KEYNOTE PRO METER .......... 1213WAVESENSE PRESTO ............................................................ 1214WELCHOL ORAL PACKET .............................................. 1215WERA ................................................................................................................ 1216WIDE-SEAL DIAPHRAGM 60 ....................................... 1217WIDE-SEAL DIAPHRAGM 65 ....................................... 1218WIDE-SEAL DIAPHRAGM 70 ....................................... 1219WIDE-SEAL DIAPHRAGM 75 ....................................... 1220WIDE-SEAL DIAPHRAGM 80 ....................................... 1221WIDE-SEAL DIAPHRAGM 85 ....................................... 1222WIDE-SEAL DIAPHRAGM 90 ....................................... 1223WIDE-SEAL DIAPHRAGM 95 ....................................... 1224WILATE INTRAVENOUS* KIT .................................. 1225WYMZYA FE .......................................................................................... 1226XALKORI ..................................................................................................... 1227XELJANZ ...................................................................................................... 1228XELJANZ XR .......................................................................................... 1229XENAZINE ORAL TABLET 12.5 MG ................. 1231XENAZINE ORAL TABLET 25 MG ...................... 1230XEOMIN ......................................................................................................... 1232XGEVA ............................................................................................................ 1233XIAFLEX ....................................................................................................... 1234XIFAXAN ORAL TABLET 200 MG ....................... 1236XIFAXAN ORAL TABLET 550 MG ....................... 1235XTANDI .......................................................................................................... 1237XULANE ........................................................................................................ 1238XURIDEN ..................................................................................................... 1239

XYNTHA INTRAVENOUS* KIT 2000 UNIT, 1000 UNIT, 250 UNIT, 500 UNIT ................................ 1240XYNTHA SOLOFUSE INTRAVENOUS* KIT 3000 UNIT .................................................................................................... 1241XYREM ............................................................................................................ 1242YASMIN 28 ................................................................................................ 1243YAZ ....................................................................................................................... 1244YERVOY ....................................................................................................... 1245zaleplon ............................................................................................................. 1246ZARAH ............................................................................................................. 1247ZAVESCA .................................................................................................... 1248ZEGERID OTC ...................................................................................... 1249ZELAPAR ..................................................................................................... 1250ZELBORAF ................................................................................................ 1251ZEMAIRA ..................................................................................................... 1252ZENATANE ............................................................................................... 1253ZENCHENT ............................................................................................... 1254ZENCHENT FE ..................................................................................... 1255ZEPATIER ................................................................................................... 1256ZETIA ................................................................................................................. 1257ZETONNA ................................................................................................... 1258ZIOPTAN ....................................................................................................... 1259ziprasidone hcl ......................................................................................... 1260ZIRGAN .......................................................................................................... 1261zoledronic acid intravenous* concentrate ............ 1262zoledronic acid intravenous* solution ....................... 1262ZOLINZA ...................................................................................................... 1263zolmitriptan oral .................................................................................... 1264zolpidem tartrate er ........................................................................... 1266zolpidem tartrate oral ..................................................................... 1265ZOMETA ....................................................................................................... 1267ZOMIG NASAL SOLUTION 5 MG .......................... 1268ZOVIA 1/35E (28) .............................................................................. 1269ZOVIA 1/50E (28) .............................................................................. 1270ZOVIRAX EXTERNAL CREAM ................................. 1271ZYTIGA ........................................................................................................... 1272

2016 Innovation Health Leap Drug Guide Acamprosate Calcium · 2020-05-28 · Quantity Limits: August 25, 2015. 2016 Innovation Health Leap Drug Guide. Last update 12/2016. 1

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