www.aetnabetterhealth.com/newyork List of Covered Drugs/Formulary AETNA BETTER HEALTH SM FIDA PLAN Aetna Better Health FIDA plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. H8056_14_007R5 CMS APPROVED Last Updated 08/2015 Effective 8/1/2015 Participant Services 55 W. 125th St., Suite 1300 New York, NY 10027 1-855-494-9945 (toll-free) TTY: New York Relay 711 Non-Emergency Transportation 1-866-334-8919
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www.aetnabetterhealth.com/newyork
List of Covered Drugs/FormularyAETNA BETTER HEALTHSM FIDA PLAN
Aetna Better Health FIDA plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.
H8056_14_007R5 CMS APPROVED Last Updated 08/2015 Effective 8/1/2015
ParticipantServices55 W. 125th St., Suite 1300New York, NY 100271-855-494-9945 (toll-free)TTY: New York Relay 711Non-EmergencyTransportation1-866-334-8919
AddressAetna Better Health FIDA Plan 55 W. 125th St., Suite 1300New York, NY 10027
Personal information
My ID number
My PCP (primary care provider)
My PCP’s phone number
My care manager’s name and phone number
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 1
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H8056_14_007R5
Aetna Better Health FIDA Plan | 2015 List of Covered Drugs (Formulary) This is a list of drugs that Participants can get in Aetna Better Health FIDA Plan.
Aetna Better Health FIDA Plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.
Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year.
You can always check Aetna Better Health FIDA Plan’s up-to-date List of Covered Drugs online at www.aetnabetterhealth.com/newyork or by calling Aetna Better Health FIDA Plan Participant Services at 1-855-494-9945 (TTY 711).
Limitations and restrictions may apply. For more information, call Aetna Better Health FIDA Plan Participant Services or read the Aetna Better Health FIDA Plan Participant Handbook.
There are no copays for any covered drugs.
You can get this information for free in other formats, such as Braille or large print. Call 1-855-494-9945 (TTY 711). The call is free.
You can get this information for free in other languages. Call 1-855-494-9945 and 711 for TTY/TDD, 24 hours a day, 7 days a week. The call is free.
Usted puede recibir esta información en otros idiomas en forma gratuita. Llame al 1-855-494-9945 ó al 711 para TTY/TDD, 24 horas al día, 7 días de la semana. La llamada es gratuita.
È possibile ottenere queste informazioni gratuitamente in altre lingue. Chiamare il numero 1-855-494-9945 e il numero 711 per il servizio TTY/TDD per i non udenti, 24 ore al giorno 7 giorni alla settimana. La chiamata è gratuita.
Ou kapab jwenn enfòmasyon sa a pou gratis nan lòt lang. Rele 1-855-494-9945 ak 711 pou TTY/TDD, 24 èdtan chak jou, 7 jou pa semèn. Apèl la gratis.
Вы можете бесплатно получить эту информацию в переводе на другой язык. Позвоните по телефону 1-855-494-9945. Линия работает круглосуточно и без выходных. Звонки бесплатные. Если вы пользуетесь устройством TTY/TDD, звоните по телефону 711.
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 2
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다른 언어로 이 정보를 무료로 받으실 수 있습니다. 연중 무휴 24시간 1-855-494-9945 번 또는 TTY/TDD의 경우 711 번으로 전화해 주십시오. 통화는 무료입니다.
The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by Aetna Better Health FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at www.icannys.org.
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 3
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Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.
1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 11 are the drugs covered by Aetna Better Health FIDA Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”
→ Aetna Better Health FIDA Plan will cover all drugs on the Drug List if:
• your doctor or other network prescriber says you need them to get better or stay healthy,
• the drug is medically necessary for your condition, and
• you fill the prescription at an Aetna Better Health FIDA Plan network pharmacy.
→ Aetna Better Health FIDA Plan may have additional steps to access certain drugs (see question 5). In some cases, you may have to do something before you can get a drug, like try other drugs first.
You can also see an up-to-date list of drugs that we cover on our website at www.aetnabetterhealth.com/newyork or call Participant Services at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week.
2. Does the Drug List ever change?
Yes. Aetna Better Health FIDA Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if:
• a new drug comes along that works as well as a drug on the Drug List now, or
• we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
• Decide to require or not require prior approval for a drug. (Prior approval is permission from Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) before you can get a drug.)
• Add or change the amount of a drug you can get (called “quantity limits”).
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 4
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• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)
(For more information on these drug rules, see page 5.)
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes.
→ You can always check Aetna Better Health FIDA Plan’s up to date Drug List online at www.aetnabetterhealth.com/newyork. You can also call Participant Services to check the current Drug List at 1-855-494-9945 (TTY 711).
3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now?
If a cheaper drug becomes available, that works as well as a drug on the Drug List now:
• Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now.
• Aetna Better Health FIDA Plan may decide to take the more expensive drug off of the Drug List. If you are taking a drug that we remove from the Drug List because a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. You will be notified by mail if a drug list change will affect you. You can also search for your drug with the online searchable formulary tool as it is updated to reflect current coverage.
4. What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the Drug List. Please contact your doctor if a drug you are taking is removed from the drug list.
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 5
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5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example:
• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) before you fill your prescription. If you don’t get approval, Aetna Better Health FIDA Plan may not cover the drug.
• Quantity limits: Sometimes Aetna Better Health FIDA Plan limits the amount of a drug you can get.
• Step therapy: Sometimes Aetna Better Health FIDA Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 11. You can also get more information by visiting our web site at www.aetnabetterhealth.com/newyork. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.
You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions.
→ If you are in a nursing facility or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Aetna Better Health FIDA Plan Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions.
6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?
The List of Covered Drugs on page 11 has a column labeled “Necessary actions, restrictions, or limits on use.”
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 6
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7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next.
8. How can you find a drug on the Drug List?
There are two ways to find a drug:
• You can search alphabetically (if you know how to spell the drug), or
• You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section (Index) on page 143. Then look for the name of your drug in the list.
To search by medical condition, find the section labeled “List of drugs by medical condition” on page 11. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.
9. What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Participant Services at 1-855-494-9945 and ask about it. If you learn that Aetna Better Health FIDA Plan will not cover the drug, you can do one of these things:
• Ask Participant Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or
• You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions.
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 7
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10. What if you are a new Aetna Better Health FIDA Plan Participant and can’t find your drug on the Drug List or have a problem getting your drug?
We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of Aetna Better Health FIDA Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.
We will cover up to 90 days of temporary supplies of your drug if:
• you are taking a drug that is not on our Drug List, or
• health plan rules do not let you get the amount ordered by your prescriber, or
• the drug requires prior approval by Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT), or
• you are taking a drug that is part of a step therapy restriction.
If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 91 and may be up to 98 days. You may refill the drug multiple times during the 91 and may be up to 98 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.
If you are a current participant and you have a change in your level of care (e.g. you are discharged from a hospital to your home or admitted to, or discharged from, a long-term care facility, your pharmacy may obtain an override up to a 90-day supply from Aetna Better Health FIDA Plan.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.
11. Can you ask for an exception to cover your drug?
Yes. You can ask Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List.
You can also ask Aetna Better Health FIDA Plan or your IDT to change the rules on your drug.
• For example, Aetna Better Health FIDA Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more.
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 8
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• Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements.
12. How long does it take to get an exception?
First, Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get a decision on your exception request within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of receiving your prescriber’s supporting statement.
13. How can you ask for an exception?
To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception.
14. What are generic drugs?
Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).
Aetna Better Health FIDA Plan covers both brand name drugs and generic drugs.
15. What are OTC drugs?
OTC stands for “over-the-counter”. Aetna Better Health FIDA Plan covers some OTC drugs when they are written as prescriptions by your provider.
You can read the Aetna Better Health FIDA Plan Drug List to see what OTC drugs are covered.
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 9
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16. Does Aetna Better Health FIDA Plan cover OTC non-drug products?
Aetna Better Health FIDA Plan covers some OTC non-drug products when they are written as prescriptions by your provider.
You can read the Aetna Better Health FIDA Plan Drug List to see what OTC non-drug products are covered.
17. What is your copay?
You will not be charged a copay for drugs on the Drug List.
18. What are drug tiers?
Tiers are groups of drugs with the same copay.
Tier 1 drugs are Medicare Part D prescription generic drugs.
Tier 2 drugs are Medicare Part D prescription brand name drugs.
Tier 3 drugs are Non-Medicare Part D prescription generic and brand name drugs.
All tiers have no copay.
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 10
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List of Covered Drugs The list of covered drugs that begins on the next page gives you information about the drugs covered by Aetna Better Health FIDA Plan If you have trouble finding your drug in the list, turn to the Index that begins on page 143.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., amoxicillin).
The information in the necessary actions, restrictions, or limits on use column tells you if Aetna Better Health FIDA Plan has any rules for covering your drug. Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column: Note: The * next to a drug means the drug is not a “Part D drug.” These drugs have different rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was a mistake. For example, Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at 1-855-494-9945 or the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800. You can also read the Participant Handbook to learn how to appeal a decision.
Abbreviation Necessary actions, restrictions, or limits on use ( * ) Non Medicare Part D drugs, or OTC items that are covered by Medicaid B/D Covered under Medicare B or D PA Prior Authorization QL Quantity Limits ST Step Therapy NM Not available at mail-order LA Limited Access
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
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NY_MMP_CY15_2T_STANDARD eff 08/01/2015 Drug Name Drug
Tier WHAT THE DRUG
WILL COST YOU
NECESSARY ACTIONS
RESTRICTIONS OR LIMITS ON USE
ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab 100 mg 1 $0
allopurinol tab 300 mg 1 $0
colchicine w/ probenecid tab
0.5-500 mg
1 $0
COLCRYS TAB 0.6MG 2 $0 QL (120 tabs / 30 days)
probenecid tab 500 mg 1 $0
ULORIC TAB 40MG 2 $0 ST
ULORIC TAB 80MG 2 $0 ST
MISCELLANEOUS acetamin jr tab 160mg rt 3 $0 NM; *
ACETAMINOPHE TAB 650MG 3 $0 NM; *
acetaminophen soln 160 mg/5ml 3 $0 NM; *
ADULT ASA TAB 81MG QM 3 $0 NM; *
ADVIL JR ST TAB 100MG 3 $0 NM; *
all day pain tab 220mg 3 $0 NM; *
APAP 500 LIQ 500/5ML 3 $0 NM; *
ASCRIPTIN TAB 3 $0 NM; *
ASPIRIN SUP 60MG 3 $0 NM; *
ASPIRIN SUP 120MG 3 $0 NM; *
ASPIRIN SUP 200MG 3 $0 NM; *
aspirin suppos 300 mg 3 $0 NM; *
aspirin suppos 600 mg 3 $0 NM; *
aspirin tab 81 mg 3 $0 NM; *
aspirin tab 325 mg 3 $0 NM; *
ASPIRIN TAB 650MG EC 3 $0 NM; *
aspirin tab delayed release 325 mg 3 $0 NM; *
aspirin tab delayed release 500 mg 3 $0 NM; *
aspirin tab delayed release 650 mg 3 $0 NM; *
bayer low chw 81mg 3 $0 NM; *
BUFFERIN TAB 81MG 3 $0 NM; *
BUFFERIN TAB 500MG 3 $0 NM; *
CHILD MOTRIN CHW 50MG 3 $0 NM; *
chld asafree elx 80/2.5ml 3 $0 NM; *
doans ex st tab 580mg 3 $0 NM; *
ed-apap liq 80mg/2.5 3 $0 NM; *
ELIXSURE GEL F/P BGUM 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
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Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
eq aspirin tab 500mg ec 3 $0 NM; *
FEBROL SOL 325/5ML 3 $0 NM; *
FEVERALL INF SUP 80MG 3 $0 NM; *
FEVERALL SUP 120MG 3 $0 NM; *
FEVERALL SUP 325MG 3 $0 NM; *
FEVERALL SUP 650MG 3 $0 NM; *
8 hour pain tab 650mg 3 $0 NM; *
ibuprofen cap 200 mg 3 $0 NM; *
ibuprofen dro 50/1.25 3 $0 NM; *
ibuprofen jr chw 100mg 3 $0 NM; *
ibuprofen sus 100/5ml 3 $0 NM; *
motrin ib tab 200mg 3 $0 NM; *
NAPROXEN SODIUM CAP 220 MG 3 $0 NM; *
non-asa jr tab 160mg 3 $0 NM; *
non-aspirin chw 80mg 3 $0 NM; *
non-aspirin chw 160mg jr 3 $0 NM; *
NON-ASPIRIN TAB 500MG QM 3 $0 NM; *
pain relief dro 80/0.8ml 3 $0 NM; *
pain relief liq 500/15ml 3 $0 NM; *
pain relief sus 160/5ml 3 $0 NM; *
pain relief tab 325mg 3 $0 NM; *
pain relief tab 500mg 3 $0 NM; *
pain relievr tab 325mg 3 $0 NM; *
q-pap infant dro 80/0.8ml 3 $0 NM; *
ra aspirin tab 500mg 3 $0 NM; *
st joseph as chw 81mg 3 $0 NM; *
ST JOSEPH CHW 75MG ADU 3 $0 NM; *
STANBACK AF POW 950MG 3 $0 NM; *
tri-buff asa tab 325mg 3 $0 NM; *
TRIAMINIC SYP INFANT 3 $0 NM; *
tylenol chld tab 80mg 3 $0 NM; *
NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib cap 50 mg 1 $0 QL (60 caps / 30 days)
celecoxib cap 100 mg 1 $0 QL (60 caps / 30 days)
celecoxib cap 200 mg 1 $0 QL (60 caps / 30 days)
celecoxib cap 400 mg 1 $0 QL (60 caps / 30 days)
diclofenac potassium tab 50 mg 1 $0
diclofenac sodium tab delayed
release 25 mg
1 $0
diclofenac sodium tab delayed
release 50 mg
1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
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Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
morphine sulfate beads cap sr 24hr
45 mg
1 $0 QL (60 caps / 30 days)
morphine sulfate beads cap sr 24hr
60 mg
1 $0 QL (60 caps / 30 days)
morphine sulfate beads cap sr 24hr
75 mg
1 $0 QL (60 caps / 30 days)
morphine sulfate beads cap sr 24hr
90 mg
1 $0 QL (60 caps / 30 days)
morphine sulfate beads cap sr 24hr
120 mg
1 $0 QL (60 caps / 30 days)
morphine sulfate cap sr 24hr 10 mg 1 $0 QL (60 caps / 30 days)
morphine sulfate cap sr 24hr 20 mg 1 $0 QL (60 caps / 30 days)
morphine sulfate cap sr 24hr 30 mg 1 $0 QL (60 caps / 30 days)
morphine sulfate cap sr 24hr 50 mg 1 $0 QL (60 caps / 30 days)
morphine sulfate cap sr 24hr 60 mg 1 $0 QL (60 caps / 30 days)
morphine sulfate cap sr 24hr 80 mg 2 $0 QL (60 caps / 30 days)
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
19
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
clindamycin phosphate iv soln 600
mg/4ml
1 $0
clindamycin phosphate iv soln 900
mg/6ml
1 $0
colistimethate sodium for inj 150
mg
1 $0
CUBICIN SOL 500MG 2 $0
dapsone tab 25 mg 1 $0
dapsone tab 100 mg 1 $0
DARAPRIM TAB 25MG 2 $0
imipenem-cilastatin intravenous for soln 250 mg
1 $0
imipenem-cilastatin intravenous for soln 500 mg
1 $0
INVANZ INJ 1GM 2 $0
ivermectin tab 3 mg 1 $0
linezolid iv soln 2 mg/ml 2 $0
meropenem iv for soln 1 gm 1 $0
meropenem iv for soln 500 mg 1 $0
methenamine hippurate tab 1 gm 1 $0
metronidazole in nacl 0.79% iv soln 500 mg/100ml
1 $0
metronidazole tab 250 mg 1 $0
metronidazole tab 500 mg 1 $0
NEBUPENT INH 300MG 2 $0 B/D
nitrofurantoin macrocrystalline cap
50 mg
2 $0 PA; 90 day limit if >64
yr
nitrofurantoin macrocrystalline cap
100 mg
2 $0 PA; 90 day limit if >64
yr
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
2 $0 PA; 90 day limit if >64
yr
PENTAM 300 INJ 300MG 2 $0
SIVEXTRO INJ 200MG 2 $0
SIVEXTRO TAB 200MG 2 $0
sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml
1 $0
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml
1 $0
sulfamethoxazole-trimethoprim tab 400-80 mg
1 $0
sulfamethoxazole-trimethoprim tab 800-160 mg
1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl tab
62.5-25 mg 1 $0
atovaquone-proguanil hcl tab 250-100 mg
1 $0
chloroquine phosphate tab 250 mg 1 $0
chloroquine phosphate tab 500 mg 1 $0
COARTEM TAB 20-120MG 2 $0
mefloquine hcl tab 250 mg 1 $0
PRIMAQUINE TAB 26.3MG 2 $0
quinine sulfate cap 324 mg 1 $0 PA
ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS
INFECTION abacavir sulfate tab 300 mg (base
equiv)
1 $0
APTIVUS CAP 250MG 2 $0
APTIVUS SOL 2 $0
CRIXIVAN CAP 200MG 2 $0
CRIXIVAN CAP 400MG 2 $0
didanosine delayed release capsule 125 mg
1 $0
didanosine delayed release capsule 200 mg
1 $0
didanosine delayed release capsule 250 mg
1 $0
didanosine delayed release capsule 400 mg
1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
22
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
EDURANT TAB 25MG 2 $0
EMTRIVA CAP 200MG 2 $0
EMTRIVA SOL 10MG/ML 2 $0
EPIVIR SOL 10MG/ML 2 $0
FUZEON INJ 90MG 2 $0 NM
INTELENCE TAB 25MG 2 $0
INTELENCE TAB 100MG 2 $0
INTELENCE TAB 200MG 2 $0
INVIRASE CAP 200MG 2 $0
INVIRASE TAB 500MG 2 $0
ISENTRESS CHW 25MG 2 $0
ISENTRESS CHW 100MG 2 $0
ISENTRESS POW 100MG 1 $0
ISENTRESS TAB 400MG 2 $0
lamivudine oral soln 10 mg/ml 1 $0
lamivudine tab 150 mg 1 $0
lamivudine tab 300 mg 1 $0
LEXIVA SUS 50MG/ML 2 $0
LEXIVA TAB 700MG 2 $0
NEVIRAPINE SUSP 50 MG/5ML 1 $0
nevirapine tab 200 mg 1 $0
nevirapine tab sr 24hr 400 mg 1 $0
NORVIR CAP 100MG 2 $0
NORVIR SOL 80MG/ML 2 $0
NORVIR TAB 100MG 2 $0
PREZISTA SUS 100MG/ML 2 $0
PREZISTA TAB 75MG 2 $0
PREZISTA TAB 150MG 2 $0
PREZISTA TAB 600MG 2 $0
PREZISTA TAB 800MG 2 $0
RESCRIPTOR TAB 100 MG 2 $0
RESCRIPTOR TAB 200MG 2 $0
RETROVIR INJ 10MG/ML 2 $0
REYATAZ CAP 150MG 2 $0
REYATAZ CAP 200MG 2 $0
REYATAZ CAP 300MG 2 $0
REYATAZ POW 50MG 2 $0
SELZENTRY TAB 150MG 2 $0
SELZENTRY TAB 300MG 2 $0
stavudine cap 15 mg 1 $0
stavudine cap 20 mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
23
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
stavudine cap 30 mg 1 $0
stavudine cap 40 mg 1 $0
stavudine for oral soln 1 mg/ml 1 $0
SUSTIVA CAP 50MG 2 $0
SUSTIVA CAP 200MG 2 $0
SUSTIVA TAB 600MG 2 $0
TIVICAY TAB 50MG 2 $0
TYBOST TAB 150MG 2 $0
VIDEX SOL 2GM 2 $0
VIDEX SOL 4GM 2 $0
VIRACEPT TAB 250MG 2 $0
VIRACEPT TAB 625MG 2 $0
VIRAMUNE XR TAB 100MG 2 $0
VIREAD POW 40MG/GM 2 $0
VIREAD TAB 150MG 2 $0
VIREAD TAB 200MG 2 $0
VIREAD TAB 250MG 2 $0
VIREAD TAB 300MG 2 $0
VITEKTA TAB 85MG 2 $0
VITEKTA TAB 150MG 2 $0
ZIAGEN SOL 20MG/ML 2 $0
zidovudine cap 100 mg 1 $0
zidovudine syrup 10 mg/ml 1 $0
zidovudine tab 300 mg 1 $0
ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS
HIV/AIDS INFECTION abacavir
sulfate-lamivudine-zidovudine tab
300-150-300 mg
2 $0
ATRIPLA TAB 2 $0
COMPLERA TAB 2 $0
EPZICOM TAB 600-300 2 $0
EVOTAZ TAB 300-150 2 $0
KALETRA SOL 2 $0
KALETRA TAB 100-25MG 2 $0
KALETRA TAB 200-50MG 2 $0
lamivudine-zidovudine tab 150-300
mg
2 $0
PREZCOBIX TAB 800-150 2 $0
STRIBILD TAB 2 $0
TRIUMEQ TAB 2 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
24
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
TRUVADA TAB 200-300 2 $0 QL (30 tabs / 30 days)
ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SUL INJ 1GM 2 $0
cycloserine cap 250 mg 1 $0
ethambutol hcl tab 100 mg 1 $0
ethambutol hcl tab 400 mg 1 $0
isoniazid inj 100 mg/ml 1 $0
isoniazid syrup 50 mg/5ml 1 $0
isoniazid tab 100 mg 1 $0
isoniazid tab 300 mg 1 $0
paser gra 4gm 2 $0
PRIFTIN TAB 150MG 2 $0
pyrazinamide tab 500 mg 1 $0
rifabutin cap 150 mg 1 $0
rifampin cap 150 mg 1 $0
rifampin cap 300 mg 1 $0
rifampin for inj 600 mg 1 $0
RIFATER TAB 2 $0
SIRTURO TAB 100MG 2 $0 LA, PA
TRECATOR TAB 250MG 2 $0
ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir cap 200 mg 1 $0
acyclovir sodium for inj 500 mg 1 $0 B/D
acyclovir sodium for inj 1000 mg 1 $0 B/D
acyclovir sodium iv soln 50 mg/ml 1 $0 B/D
acyclovir susp 200 mg/5ml 1 $0
acyclovir tab 400 mg 1 $0
acyclovir tab 800 mg 1 $0
adefovir dipivoxil tab 10 mg 2 $0
BARACLUDE SOL .05MG/ML 2 $0
entecavir tab 0.5 mg 2 $0
entecavir tab 1 mg 2 $0
EPIVIR HBV SOL 5MG/ML 2 $0
famciclovir tab 125 mg 1 $0
famciclovir tab 250 mg 1 $0
famciclovir tab 500 mg 1 $0
foscarnet sodium inj 24 mg/ml 1 $0
ganciclovir sodium for inj 500 mg 1 $0 B/D
HARVONI TAB 90-400MG 2 $0 NM, PA
lamivudine tab 100 mg (hbv) 1 $0
moderiba pak 600/day 2 $0 NM, PA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
25
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
moderiba pak 800/day 2 $0 NM, PA
moderiba pak 1000/day 2 $0 NM, PA
moderiba pak 1200/day 2 $0 NM, PA
OLYSIO CAP 150MG 2 $0 NM, PA
REBETOL SOL 40MG/ML 2 $0 NM, PA
RELENZA MIS DISKHALE 2 $0
ribapak pak 600/day 2 $0 NM, PA
ribapak pak 800/day 2 $0 NM, PA
ribapak pak 1000/day 2 $0 NM, PA
ribapak pak 1200/day 2 $0 NM, PA
ribasphere cap 200mg 1 $0 NM, PA
ribasphere tab 200mg 1 $0 NM, PA
ribasphere tab 400mg 1 $0 NM, PA
ribasphere tab 600mg 2 $0 NM, PA
ribavirin cap 200 mg 1 $0 NM, PA
ribavirin tab 200 mg 1 $0 NM, PA
rimantadine hydrochloride tab 100 mg
1 $0
SOVALDI TAB 400MG 2 $0 NM, PA
TAMIFLU CAP 30MG 2 $0
TAMIFLU CAP 45MG 2 $0
TAMIFLU CAP 75MG 2 $0
TAMIFLU SUS 6MG/ML 2 $0
TYZEKA TAB 600MG 2 $0
valacyclovir hcl tab 1 gm 1 $0
valacyclovir hcl tab 500 mg 1 $0
VALCYTE SOL 50MG/ML 2 $0
valganciclovir hcl tab 450 mg (base
equivalent)
2 $0
VICTRELIS CAP 200MG 2 $0 NM, PA
CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor cap 250 mg 1 $0
cefaclor cap 500 mg 1 $0
cefaclor er tab 500mg 2 $0
cefaclor for susp 125 mg/5ml 1 $0
cefaclor for susp 250 mg/5ml 1 $0
cefaclor for susp 375 mg/5ml 1 $0
cefadroxil cap 500 mg 1 $0
cefadroxil for susp 250 mg/5ml 1 $0
cefadroxil for susp 500 mg/5ml 1 $0
cefadroxil tab 1 gm 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
26
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
cefazolin inj 1gm/50ml 2 $0
cefazolin sodium for inj 1 gm 1 $0
cefazolin sodium for inj 10 gm 1 $0
cefazolin sodium for inj 20 gm 1 $0
cefazolin sodium for inj 500 mg 1 $0
cefazolin sodium for iv soln 1 gm 1 $0
cefdinir cap 300 mg 1 $0
cefdinir for susp 125 mg/5ml 1 $0
cefdinir for susp 250 mg/5ml 1 $0
cefepime hcl for inj 1 gm 1 $0
cefepime hcl for inj 2 gm 1 $0
cefixime for susp 100 mg/5ml 1 $0
cefixime for susp 200 mg/5ml 1 $0
cefotaxime sodium for inj 1 gm 1 $0
cefotaxime sodium for inj 2 gm 1 $0
cefotaxime sodium for inj 500 mg 1 $0
cefoxitin sodium for inj 10 gm 1 $0
cefoxitin sodium for iv soln 1 gm 1 $0
cefoxitin sodium for iv soln 2 gm 1 $0
cefpodoxime proxetil for susp 50
mg/5ml
1 $0
cefpodoxime proxetil for susp 100
mg/5ml
1 $0
cefpodoxime proxetil tab 100 mg 1 $0
cefpodoxime proxetil tab 200 mg 1 $0
cefprozil for susp 125 mg/5ml 1 $0
cefprozil for susp 250 mg/5ml 1 $0
cefprozil tab 250 mg 1 $0
cefprozil tab 500 mg 1 $0
ceftazidime for inj 1 gm 1 $0
ceftazidime for inj 2 gm 1 $0
ceftazidime for inj 6 gm 1 $0
CEFTAZIDIME/ SOL D5W 1GM 2 $0
CEFTAZIDIME/ SOL D5W 2GM 2 $0
ceftriaxone sodium for inj 1 gm 1 $0
ceftriaxone sodium for inj 2 gm 1 $0
ceftriaxone sodium for inj 10 gm 1 $0
ceftriaxone sodium for inj 250 mg 1 $0
ceftriaxone sodium for inj 500 mg 1 $0
ceftriaxone sodium for iv soln 1 gm 1 $0
ceftriaxone sodium for iv soln 2 gm 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
27
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
cefuroxime axetil tab 250 mg 1 $0
cefuroxime axetil tab 500 mg 1 $0
cefuroxime inj 7.5gm 1 $0
cefuroxime sodium for inj 1.5 gm 1 $0
cefuroxime sodium for inj 7.5 gm 1 $0
cefuroxime sodium for inj 750 mg 1 $0
cefuroxime sodium for iv soln 1.5
gm
1 $0
cephalexin cap 250 mg 1 $0
cephalexin cap 500 mg 1 $0
cephalexin for susp 125 mg/5ml 1 $0
cephalexin for susp 250 mg/5ml 1 $0
SUPRAX CAP 400MG 2 $0
suprax chw 100mg 2 $0
suprax chw 200mg 2 $0
suprax sus 100/5ml 2 $0
suprax sus 200/5ml 2 $0
SUPRAX SUS 500/5ML 2 $0
tazicef inj 1gm 1 $0
tazicef inj 2gm 1 $0
tazicef inj 6gm 1 $0
TEFLARO INJ 400MG 2 $0
TEFLARO INJ 600MG 2 $0
ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin for susp 100 mg/5ml 1 $0
azithromycin for susp 200 mg/5ml 1 $0
azithromycin iv for soln 500 mg 1 $0
AZITHROMYCIN POWD PACK FOR SUSP 1 GM
1 $0
azithromycin tab 250 mg 1 $0
azithromycin tab 500 mg 1 $0
azithromycin tab 600 mg 1 $0
clarithromycin for susp 125 mg/5ml 1 $0
clarithromycin for susp 250 mg/5ml 1 $0
clarithromycin tab 250 mg 1 $0
clarithromycin tab 500 mg 1 $0
clarithromycin tab sr 24hr 500 mg 1 $0
DIFICID TAB 200MG 2 $0
e.e.s. 400 tab 400mg 1 $0
E.E.S. GRAN SUS 200/5ML 2 $0
ery-tab tab 250mg ec 2 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
28
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
ery-tab tab 333mg ec 2 $0
ery-tab tab 500mg ec 2 $0
ERYPED SUS 200/5ML 2 $0
ERYPED SUS 400/5ML 2 $0
erythrocin inj 500mg 2 $0
erythrocin tab 250mg 1 $0
erythromycin ethylsuccinate tab
400 mg
1 $0
erythromycin tab 250 mg 1 $0
erythromycin tab 500 mg 1 $0
erythromycin w/ delayed release particles cap 250 mg
1 $0
ZMAX SUS 2GM 2 $0
FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin 200 mg/100ml in d5w 1 $0
ciprofloxacin 400 mg/200ml in d5w 1 $0
ciprofloxacin for oral susp 250
mg/5ml (5%) (5 gm/100ml)
1 $0
ciprofloxacin for oral susp 500
mg/5ml (10%) (10 gm/100ml)
1 $0
ciprofloxacin hcl tab 100 mg (base
equiv)
1 $0
ciprofloxacin hcl tab 250 mg (base
equiv)
1 $0
ciprofloxacin hcl tab 500 mg (base
equiv)
1 $0
ciprofloxacin hcl tab 750 mg (base
equiv)
1 $0
ciprofloxacin iv soln 200 mg/20ml
(1%)
1 $0
ciprofloxacin iv soln 400 mg/40ml
(1%)
1 $0
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 500 mg (base eq)
1 $0
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 1000 mg(base eq)
1 $0
levofloxacin in d5w iv soln 250
mg/50ml
1 $0
levofloxacin in d5w iv soln 500
mg/100ml
1 $0
levofloxacin in d5w iv soln 750
mg/150ml
1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
29
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
levofloxacin iv soln 25 mg/ml 1 $0
levofloxacin oral soln 25 mg/ml 1 $0
levofloxacin tab 250 mg 1 $0
levofloxacin tab 500 mg 1 $0
levofloxacin tab 750 mg 1 $0
PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin & k clavulanate chew tab
200-28.5 mg 1 $0
amoxicillin & k clavulanate chew tab 400-57 mg
1 $0
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
1 $0
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
1 $0
amoxicillin & k clavulanate for susp
400-57 mg/5ml
1 $0
amoxicillin & k clavulanate for susp
600-42.9 mg/5ml
1 $0
amoxicillin & k clavulanate tab
250-125 mg
1 $0
amoxicillin & k clavulanate tab
500-125 mg
1 $0
amoxicillin & k clavulanate tab
875-125 mg
1 $0
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg
1 $0
amoxicillin (trihydrate) cap 250 mg 1 $0
amoxicillin (trihydrate) cap 500 mg 1 $0
amoxicillin (trihydrate) chew tab 125 mg
1 $0
amoxicillin (trihydrate) chew tab 250 mg
1 $0
amoxicillin (trihydrate) for susp 125 mg/5ml
1 $0
amoxicillin (trihydrate) for susp 200 mg/5ml
1 $0
amoxicillin (trihydrate) for susp 250 mg/5ml
1 $0
amoxicillin (trihydrate) for susp 400 mg/5ml
1 $0
amoxicillin (trihydrate) tab 500 mg 1 $0
amoxicillin (trihydrate) tab 875 mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
30
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
ampicillin & sulbactam sodium for
inj 1-0.5 gm
1 $0
ampicillin & sulbactam sodium for
inj 2-1 gm
1 $0
ampicillin & sulbactam sodium for
inj 10-5 gm
1 $0
ampicillin & sulbactam sodium for iv
soln 1-0.5 gm
1 $0
ampicillin & sulbactam sodium for iv
soln 2-1 gm
1 $0
ampicillin & sulbactam sodium for iv
soln 10-5 gm
1 $0
ampicillin cap 250 mg 1 $0
ampicillin cap 500 mg 1 $0
ampicillin for susp 125 mg/5ml 1 $0
ampicillin for susp 250 mg/5ml 1 $0
ampicillin sodium for inj 1 gm 1 $0
ampicillin sodium for inj 2 gm 1 $0
ampicillin sodium for inj 125 mg 1 $0
ampicillin sodium for inj 250 mg 1 $0
ampicillin sodium for inj 500 mg 1 $0
ampicillin sodium for iv soln 1 gm 1 $0
ampicillin sodium for iv soln 2 gm 1 $0
ampicillin sodium for iv soln 10 gm 1 $0
BICILLIN L-A INJ 600000 2 $0
BICILLIN L-A INJ 1200000 2 $0
BICILLIN L-A INJ 2400000 2 $0
dicloxacillin sodium cap 250 mg 1 $0
dicloxacillin sodium cap 500 mg 1 $0
nafcillin sodium for inj 1 gm 1 $0
nafcillin sodium for inj 2 gm 2 $0
nafcillin sodium for inj 10 gm 2 $0
nafcillin sodium for iv soln 1 gm 1 $0
nafcillin sodium for iv soln 2 gm 2 $0
oxacillin sodium for inj 1 gm 1 $0
oxacillin sodium for inj 2 gm 1 $0
oxacillin sodium for inj 10 gm 2 $0
pen g proc inj 600000 2 $0
PENICILL GK/ INJ DEX 2MU 2 $0
PENICILL GK/ INJ DEX 3MU 2 $0
penicillin g potassium for inj 5000000 unit
1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
31
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
penicillin g potassium for inj
20000000 unit
1 $0
penicillin g sodium for inj 5000000
unit
1 $0
penicillin v potassium for soln 125
mg/5ml
1 $0
penicillin v potassium for soln 250
mg/5ml
1 $0
penicillin v potassium tab 250 mg 1 $0
penicillin v potassium tab 500 mg 1 $0
piperacillin sodium-tazobactam sodium for inj 2-0.25 gm
1 $0
piperacillin sodium-tazobactam
sodium for inj 3-0.375 gm
1 $0
piperacillin sodium-tazobactam
sodium for inj 4-0.5 gm
1 $0
piperacillin sodium-tazobactam
sodium for inj 36-4.5 gm
1 $0
TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxycycline hyclate cap 50 mg 1 $0
doxycycline hyclate cap 100 mg 1 $0
doxycycline hyclate for inj 100 mg 1 $0
doxycycline hyclate tab 20 mg 1 $0
doxycycline hyclate tab 100 mg 1 $0
doxycycline monohydrate cap 50 mg
1 $0
doxycycline monohydrate cap 100 mg
1 $0
doxycycline monohydrate tab 50 mg
1 $0
doxycycline monohydrate tab 75 mg
1 $0
doxycycline monohydrate tab 100 mg
1 $0
doxycycline monohydrate tab 150 mg
1 $0
minocycline hcl cap 50 mg 1 $0
minocycline hcl cap 75 mg 1 $0
minocycline hcl cap 100 mg 1 $0
VIBRAMYCIN SYP 50MG/5ML 2 $0
ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
32
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
BICNU INJ 100MG 2 $0 B/D
BUSULFEX INJ 6MG/ML 2 $0 B/D
CYCLOPHOSPH CAP 25MG 2 $0 B/D
CYCLOPHOSPH CAP 50MG 2 $0 B/D
cyclophosphamide for inj 1 gm 1 $0 B/D
cyclophosphamide for inj 2 gm 1 $0 B/D
cyclophosphamide for inj 500 mg 1 $0 B/D
dacarbazine for inj 200 mg 1 $0 B/D
EMCYT CAP 140MG 2 $0
HEXALEN CAP 50MG 2 $0
IFEX INJ 3GM 2 $0 B/D
ifosfamide for inj 1 gm 1 $0 B/D
IFOSFAMIDE INJ 3GM 2 $0 B/D
ifosfamide iv inj 1 gm/20ml (50
mg/ml)
1 $0 B/D
ifosfamide iv inj 3 gm/60ml (50
mg/ml)
1 $0 B/D
LEUKERAN TAB 2MG 2 $0
LOMUSTINE CAP 10 MG 1 $0
LOMUSTINE CAP 40 MG 1 $0
LOMUSTINE CAP 100 MG 1 $0
melphalan hcl for inj 50 mg (base equiv)
2 $0 B/D
MUSTARGEN INJ 10MG 2 $0 B/D
TREANDA INJ 25MG 2 $0 B/D, NM
TREANDA INJ 45/0.5ML 2 $0 B/D, NM
TREANDA INJ 100MG 2 $0 B/D, NM
TREANDA INJ 180/2ML 2 $0 B/D, NM
ANTHRACYCLINES adriamyc inj 50mg 1 $0 B/D
daunorubicin hcl inj 5 mg/ml (base
equiv)
1 $0 B/D
doxorubicin hcl for inj 50 mg 1 $0 B/D
doxorubicin hcl inj 2 mg/ml 1 $0 B/D
doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml
2 $0 B/D
epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)
1 $0 B/D
epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)
1 $0 B/D
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)
2 $0 B/D
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
33
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
idarubicin hcl iv inj 10 mg/10ml (1
mg/ml)
2 $0 B/D
idarubicin hcl iv inj 20 mg/20ml (1
mg/ml)
2 $0 B/D
ANTIBIOTICS bleomycin sulfate for inj 15 unit 1 $0 B/D
bleomycin sulfate for inj 30 unit 1 $0 B/D
mitomycin for iv soln 5 mg 1 $0 B/D
mitomycin for iv soln 20 mg 1 $0 B/D
mitomycin for iv soln 40 mg 1 $0 B/D
ANTIMETABOLITES adrucil inj 500/10ml 1 $0 B/D
ALIMTA INJ 100MG 2 $0 B/D
ALIMTA INJ 500MG 2 $0 B/D
azacitidine for inj 100 mg 2 $0 B/D, NM
cladribine inj 1 mg/ml 2 $0 B/D
cytarabine inj 20 mg/ml 1 $0 B/D
fludarabine phosphate for inj 50 mg 1 $0 B/D
fludarabine phosphate inj 25 mg/ml 1 $0 B/D
fluorouracil inj 1 gm/20ml (50
mg/ml)
1 $0 B/D
fluorouracil inj 2.5 gm/50ml (50
mg/ml)
1 $0 B/D
fluorouracil inj 5 gm/100ml (50
mg/ml)
1 $0 B/D
fluorouracil inj 500 mg/10ml (50
mg/ml)
1 $0 B/D
gemcitabine hcl for inj 1 gm 2 $0 B/D
gemcitabine hcl for inj 2 gm 2 $0 B/D
gemcitabine hcl for inj 200 mg 2 $0 B/D
GEMCITABINE INJ 1GM 2 $0 B/D
GEMCITABINE INJ 2GM 2 $0 B/D
GEMCITABINE INJ 200MG 2 $0 B/D
mercaptopurine tab 50 mg 1 $0
methotrexate sodium for inj 1 gm 1 $0 B/D
methotrexate sodium inj 25 mg/ml 1 $0 B/D
methotrexate sodium inj pf 25 mg/ml
1 $0 B/D
NIPENT INJ 10MG 2 $0 B/D
PURIXAN SUS 20MG/ML 2 $0
TABLOID TAB 40MG 2 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
KINASE INHIBITORS AFINITOR DIS TAB 2MG 2 $0 NM, PA
AFINITOR DIS TAB 3MG 2 $0 NM, PA
AFINITOR DIS TAB 5MG 2 $0 NM, PA
AFINITOR TAB 2.5MG 2 $0 NM, PA
AFINITOR TAB 5MG 2 $0 NM, PA
AFINITOR TAB 7.5MG 2 $0 NM, PA
AFINITOR TAB 10MG 2 $0 NM, PA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
36
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
BOSULIF TAB 100MG 2 $0 NM, PA
BOSULIF TAB 500MG 2 $0 NM, PA
CAPRELSA TAB 100MG 2 $0 NM, LA, PA
CAPRELSA TAB 300MG 2 $0 NM, LA, PA
COMETRIQ KIT 60MG 2 $0 NM, PA
COMETRIQ KIT 100MG 2 $0 NM, PA
COMETRIQ KIT 140MG 2 $0 NM, PA
GILOTRIF TAB 20MG 2 $0 NM, LA, PA
GILOTRIF TAB 30MG 2 $0 NM, LA, PA
GILOTRIF TAB 40MG 2 $0 NM, LA, PA
GLEEVEC TAB 100MG 2 $0 NM, PA
GLEEVEC TAB 400MG 2 $0 NM, PA
ICLUSIG TAB 15MG 2 $0 NM, LA, PA
ICLUSIG TAB 45MG 2 $0 NM, LA, PA
IMBRUVICA CAP 140MG 2 $0 NM, LA, PA
INLYTA TAB 1MG 2 $0 NM, LA, PA
INLYTA TAB 5MG 2 $0 NM, LA, PA
JAKAFI TAB 5MG 2 $0 NM, LA, PA
JAKAFI TAB 10MG 2 $0 NM, LA, PA
JAKAFI TAB 15MG 2 $0 NM, LA, PA
JAKAFI TAB 20MG 2 $0 NM, LA, PA
JAKAFI TAB 25MG 2 $0 NM, LA, PA
LENVIMA CAP 10MG 2 $0 NM, LA, PA
LENVIMA CAP 14MG 2 $0 NM, LA, PA
LENVIMA CAP 20MG 2 $0 NM, LA, PA
LENVIMA CAP 24MG 2 $0 NM, LA, PA
MEKINIST TAB 0.5MG 2 $0 NM, PA
MEKINIST TAB 2MG 2 $0 NM, PA
NEXAVAR TAB 200MG 2 $0 NM, LA, PA
SPRYCEL TAB 20MG 2 $0 NM, PA
SPRYCEL TAB 50MG 2 $0 NM, PA
SPRYCEL TAB 70MG 2 $0 NM, PA
SPRYCEL TAB 80MG 2 $0 NM, PA
SPRYCEL TAB 100MG 2 $0 NM, PA
SPRYCEL TAB 140MG 2 $0 NM, PA
STIVARGA TAB 40MG 2 $0 NM, LA, PA
SUTENT CAP 12.5MG 2 $0 NM, PA
SUTENT CAP 25MG 2 $0 NM, PA
SUTENT CAP 37.5MG 2 $0 NM, PA
SUTENT CAP 50MG 2 $0 NM, PA
TAFINLAR CAP 50MG 2 $0 NM, PA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
37
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
TAFINLAR CAP 75MG 2 $0 NM, PA
TARCEVA TAB 25MG 2 $0 NM, PA
TARCEVA TAB 100MG 2 $0 NM, PA
TARCEVA TAB 150MG 2 $0 NM, PA
TASIGNA CAP 150MG 2 $0 NM, PA
TASIGNA CAP 200MG 2 $0 NM, PA
TYKERB TAB 250MG 2 $0 NM, LA, PA
VOTRIENT TAB 200MG 2 $0 NM, PA
XALKORI CAP 200MG 2 $0 NM, LA, PA
XALKORI CAP 250MG 2 $0 NM, LA, PA
ZELBORAF TAB 240MG 2 $0 NM, LA, PA
ZYDELIG TAB 100MG 2 $0 NM, LA, PA
ZYDELIG TAB 150MG 2 $0 NM, LA, PA
ZYKADIA CAP 150MG 1 $0 NM, LA, PA
MISCELLANEOUS DROXIA CAP 200MG 2 $0
DROXIA CAP 300MG 2 $0
DROXIA CAP 400MG 2 $0
hydroxyurea cap 500 mg 1 $0
MATULANE CAP 50MG 2 $0
mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml)
1 $0 B/D, NM
mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)
1 $0 B/D, NM
mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml)
1 $0 B/D, NM
POMALYST CAP 1MG 2 $0 NM, LA, PA
POMALYST CAP 2MG 2 $0 NM, LA, PA
POMALYST CAP 3MG 2 $0 NM, LA, PA
POMALYST CAP 4MG 2 $0 NM, LA, PA
SYLATRON KIT 200MCG 2 $0 NM, PA
SYLATRON KIT 300MCG 2 $0 NM, PA
SYLATRON KIT 600MCG 2 $0 NM, PA
TARGRETIN CAP 75MG 2 $0 NM, PA
tretinoin cap 10 mg 2 $0
TRISENOX SOL 10MG/10M 2 $0 B/D
PLATINUM-BASED AGENTS carboplatin iv soln 50 mg/5ml 1 $0 B/D
carboplatin iv soln 150 mg/15ml 1 $0 B/D
carboplatin iv soln 450 mg/45ml 1 $0 B/D
carboplatin iv soln 600 mg/60ml 1 $0 B/D
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION
CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD
PRESSURE
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
40
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
moexipril-hydrochlorothiazide tab
7.5-12.5 mg
1 $0
moexipril-hydrochlorothiazide tab
15-12.5 mg
1 $0
moexipril-hydrochlorothiazide tab
15-25 mg
1 $0
quinapril-hydrochlorothiazide tab
10-12.5 mg
1 $0
quinapril-hydrochlorothiazide tab
20-12.5 mg
1 $0
quinapril-hydrochlorothiazide tab
20-25 mg
1 $0
ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl tab 5 mg 1 $0
benazepril hcl tab 10 mg 1 $0
benazepril hcl tab 20 mg 1 $0
benazepril hcl tab 40 mg 1 $0
captopril tab 12.5 mg 1 $0
captopril tab 25 mg 1 $0
captopril tab 50 mg 1 $0
captopril tab 100 mg 1 $0
enalapril maleate tab 2.5 mg 1 $0
enalapril maleate tab 5 mg 1 $0
enalapril maleate tab 10 mg 1 $0
enalapril maleate tab 20 mg 1 $0
fosinopril sodium tab 10 mg 1 $0
fosinopril sodium tab 20 mg 1 $0
fosinopril sodium tab 40 mg 1 $0
lisinopril tab 2.5 mg 1 $0
lisinopril tab 5 mg 1 $0
lisinopril tab 10 mg 1 $0
lisinopril tab 20 mg 1 $0
lisinopril tab 30 mg 1 $0
lisinopril tab 40 mg 1 $0
moexipril hcl tab 7.5 mg 1 $0
moexipril hcl tab 15 mg 1 $0
perindopril erbumine tab 2 mg 1 $0
perindopril erbumine tab 4 mg 1 $0
perindopril erbumine tab 8 mg 1 $0
quinapril hcl tab 5 mg 1 $0
quinapril hcl tab 10 mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
41
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
quinapril hcl tab 20 mg 1 $0
quinapril hcl tab 40 mg 1 $0
ramipril cap 1.25 mg 1 $0
ramipril cap 2.5 mg 1 $0
ramipril cap 5 mg 1 $0
ramipril cap 10 mg 1 $0
trandolapril tab 1 mg 1 $0
trandolapril tab 2 mg 1 $0
trandolapril tab 4 mg 1 $0
ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS
TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-valsartan tab
5-160 mg
1 $0 QL (30 tabs / 30 days)
amlodipine besylate-valsartan tab
5-320 mg
1 $0 QL (30 tabs / 30 days)
amlodipine besylate-valsartan tab
10-160 mg
1 $0 QL (30 tabs / 30 days)
amlodipine besylate-valsartan tab
10-320 mg
1 $0
amlodipine-valsartan-hydrochlorot
hiazide tab 5-160-12.5 mg
1 $0 QL (30 tabs / 30 days)
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl inj 150 mg/3ml (50
mg/ml) 1 $0
amiodarone hcl inj 450 mg/9ml (50 mg/ml)
1 $0
amiodarone hcl inj 900 mg/18ml (50 mg/ml)
1 $0
amiodarone hcl tab 100 mg 1 $0
amiodarone hcl tab 200 mg 1 $0
amiodarone hcl tab 400 mg 1 $0
disopyramide phosphate cap 100
mg
2 $0 PA
disopyramide phosphate cap 150
mg
2 $0 PA
flecainide acetate tab 50 mg 1 $0
flecainide acetate tab 100 mg 1 $0
flecainide acetate tab 150 mg 1 $0
mexiletine hcl cap 150 mg 1 $0
mexiletine hcl cap 200 mg 1 $0
mexiletine hcl cap 250 mg 1 $0
MULTAQ TAB 400MG 2 $0
NORPACE CAP 100MG CR 2 $0 PA
NORPACE CAP 150MG CR 2 $0 PA
pacerone tab 100mg 1 $0
pacerone tab 200mg 1 $0
pacerone tab 400mg 1 $0
propafenone hcl cap sr 12hr 225 mg 1 $0
propafenone hcl cap sr 12hr 325 mg 1 $0
propafenone hcl cap sr 12hr 425 mg 1 $0
propafenone hcl tab 150 mg 1 $0
propafenone hcl tab 225 mg 1 $0
propafenone hcl tab 300 mg 1 $0
quinidine gluconate tab cr 324 mg 1 $0
quinidine sulfate tab 200 mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
44
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
quinidine sulfate tab 300 mg 1 $0
sorine tab 80mg 1 $0
sorine tab 120mg 1 $0
sorine tab 160mg 1 $0
sorine tab 240mg 1 $0
sotalol hcl (afib/afl) tab 80 mg 1 $0
sotalol hcl (afib/afl) tab 120 mg 1 $0
sotalol hcl (afib/afl) tab 160 mg 1 $0
sotalol hcl tab 80 mg 1 $0
sotalol hcl tab 120 mg 1 $0
sotalol hcl tab 160 mg 1 $0
sotalol hcl tab 240 mg 1 $0
TIKOSYN CAP 125MCG 2 $0 NM
TIKOSYN CAP 250MCG 2 $0 NM
TIKOSYN CAP 500MCG 2 $0 NM
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO
TREAT HIGH CHOLESTEROL atorvastatin calcium tab 10 mg
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
45
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH
CHOLESTEROL cholestyramine light powder
packets 4 gm
1 $0
cholestyramine powder 4 gm/dose 1 $0
cholestyramine powder packets 4
gm
1 $0
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv)
1 $0
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv)
1 $0
colestipol hcl granule packets 5 gm 1 $0
colestipol hcl granules 5 gm 1 $0
colestipol hcl tab 1 gm 1 $0
fenofibrate micronized cap 43 mg 1 $0
fenofibrate micronized cap 67 mg 1 $0
fenofibrate micronized cap 130 mg 1 $0
fenofibrate micronized cap 134 mg 1 $0
fenofibrate micronized cap 200 mg 1 $0
fenofibrate tab 48 mg 1 $0
fenofibrate tab 54 mg 1 $0
fenofibrate tab 145 mg 1 $0
fenofibrate tab 160 mg 1 $0
gemfibrozil tab 600 mg 1 $0
niacin tab cr 500 mg
(antihyperlipidemic)
1 $0 QL (90 tabs / 30 days)
niacin tab cr 750 mg
(antihyperlipidemic)
1 $0
niacin tab cr 1000 mg
(antihyperlipidemic)
1 $0
niacor tab 500mg 1 $0
omega-3-acid ethyl esters cap 1 gm 1 $0
prevalite pow 4gm 1 $0
VASCEPA CAP 1GM 2 $0
WELCHOL PAK 3.75GM 2 $0
WELCHOL TAB 625MG 2 $0
ZETIA TAB 10MG 2 $0
BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH
BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone tab 50-25
mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
46
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
atenolol & chlorthalidone tab
100-25 mg
1 $0
bisoprolol & hydrochlorothiazide tab
2.5-6.25 mg
1 $0
bisoprolol & hydrochlorothiazide tab
5-6.25 mg
1 $0
bisoprolol & hydrochlorothiazide tab
10-6.25 mg
1 $0
metoprolol & hydrochlorothiazide
tab 50-25 mg
1 $0
metoprolol & hydrochlorothiazide
tab 100-25 mg
1 $0
metoprolol & hydrochlorothiazide
tab 100-50 mg
1 $0
propranolol & hydrochlorothiazide
tab 40-25 mg
1 $0
propranolol & hydrochlorothiazide
tab 80-25 mg
1 $0
BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND
HEART CONDITIONS acebutolol hcl cap 200 mg 1 $0
acebutolol hcl cap 400 mg 1 $0
atenolol tab 25 mg 1 $0
atenolol tab 50 mg 1 $0
atenolol tab 100 mg 1 $0
bisoprolol fumarate tab 5 mg 1 $0
bisoprolol fumarate tab 10 mg 1 $0
BYSTOLIC TAB 2.5MG 2 $0
BYSTOLIC TAB 5MG 2 $0
BYSTOLIC TAB 10MG 2 $0
BYSTOLIC TAB 20MG 2 $0
carvedilol tab 3.125 mg 1 $0
carvedilol tab 6.25 mg 1 $0
carvedilol tab 12.5 mg 1 $0
carvedilol tab 25 mg 1 $0
labetalol hcl tab 100 mg 1 $0
labetalol hcl tab 200 mg 1 $0
labetalol hcl tab 300 mg 1 $0
metoprolol succinate tab sr 24hr 25 mg
1 $0 QL (60 tabs / 30 days)
metoprolol succinate tab sr 24hr 50 mg
1 $0 QL (60 tabs / 30 days)
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
47
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
metoprolol succinate tab sr 24hr
100 mg
1 $0 QL (45 tabs / 30 days)
metoprolol succinate tab sr 24hr
200 mg
1 $0
metoprolol tartrate inj 1 mg/ml 1 $0
metoprolol tartrate tab 25 mg 1 $0
metoprolol tartrate tab 50 mg 1 $0
metoprolol tartrate tab 100 mg 1 $0
nadolol tab 20 mg 1 $0
nadolol tab 40 mg 1 $0
nadolol tab 80 mg 1 $0
pindolol tab 5 mg 1 $0
pindolol tab 10 mg 1 $0
propranolol hcl cap sr 24hr 60 mg 1 $0
propranolol hcl cap sr 24hr 80 mg 1 $0
propranolol hcl cap sr 24hr 120 mg 1 $0
propranolol hcl cap sr 24hr 160 mg 1 $0
propranolol hcl inj 1 mg/ml 1 $0
propranolol hcl oral soln 20 mg/5ml 1 $0
propranolol hcl oral soln 40 mg/5ml 1 $0
propranolol hcl tab 10 mg 1 $0
propranolol hcl tab 20 mg 1 $0
propranolol hcl tab 40 mg 1 $0
propranolol hcl tab 60 mg 1 $0
propranolol hcl tab 80 mg 1 $0
timolol maleate tab 5 mg 1 $0
timolol maleate tab 10 mg 1 $0
timolol maleate tab 20 mg 1 $0
CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
48
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
diltiazem hcl coated beads cap sr
24hr 120 mg
1 $0
diltiazem hcl coated beads cap sr
24hr 180 mg
1 $0
diltiazem hcl coated beads cap sr
24hr 240 mg
1 $0
diltiazem hcl coated beads cap sr
24hr 300 mg
1 $0
diltiazem hcl coated beads cap sr
24hr 360 mg
1 $0
diltiazem hcl extended release
beads cap sr 24hr 120 mg
1 $0
diltiazem hcl extended release
beads cap sr 24hr 180 mg
1 $0
diltiazem hcl extended release
beads cap sr 24hr 240 mg
1 $0
diltiazem hcl extended release
beads cap sr 24hr 300 mg
1 $0
diltiazem hcl extended release beads cap sr 24hr 360 mg
1 $0
diltiazem hcl extended release beads cap sr 24hr 420 mg
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
50
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
LANOXIN TAB 0.25MG 2 $0 PA
LANOXIN TAB 0.125MG 2 $0 QL (30 tabs / 30 days)
DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT
DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide cap sr 12hr 500 mg 1 $0
acetazolamide tab 125 mg 1 $0
acetazolamide tab 250 mg 1 $0
amiloride & hydrochlorothiazide tab 5-50 mg
1 $0
amiloride hcl tab 5 mg 1 $0
bumetanide inj 0.25 mg/ml 1 $0
bumetanide tab 0.5 mg 1 $0
bumetanide tab 1 mg 1 $0
bumetanide tab 2 mg 1 $0
chlorothiazide tab 250 mg 1 $0
chlorothiazide tab 500 mg 1 $0
chlorthalidone tab 25 mg 1 $0
chlorthalidone tab 50 mg 1 $0
DIURIL SUS 250/5ML 2 $0
DYRENIUM CAP 50MG 2 $0
DYRENIUM CAP 100MG 2 $0
EDECRIN TAB 25MG 2 $0
furosemide inj 10 mg/ml 1 $0
furosemide oral soln 10 mg/ml 1 $0
furosemide sol 8mg/ml 1 $0
furosemide tab 20 mg 1 $0
furosemide tab 40 mg 1 $0
furosemide tab 80 mg 1 $0
hydrochlorothiazide cap 12.5 mg 1 $0
hydrochlorothiazide tab 12.5 mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
51
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
hydrochlorothiazide tab 25 mg 1 $0
hydrochlorothiazide tab 50 mg 1 $0
indapamide tab 1.25 mg 1 $0
indapamide tab 2.5 mg 1 $0
methazolamide tab 25 mg 1 $0
methazolamide tab 50 mg 1 $0
methyclothiazide tab 5 mg 1 $0
metolazone tab 2.5 mg 1 $0
metolazone tab 5 mg 1 $0
metolazone tab 10 mg 1 $0
spironolactone & hydrochlorothiazide tab 25-25 mg
1 $0
torsemide inj 20mg/2ml 1 $0
torsemide inj 50mg/5ml 1 $0
torsemide tab 5 mg 1 $0
torsemide tab 10 mg 1 $0
torsemide tab 20 mg 1 $0
torsemide tab 100 mg 1 $0
triamterene & hydrochlorothiazide cap 37.5-25 mg
1 $0
triamterene & hydrochlorothiazide tab 37.5-25 mg
1 $0
triamterene & hydrochlorothiazide tab 75-50 mg
1 $0
MISCELLANEOUS clonidine hcl tab 0.1 mg 1 $0
clonidine hcl tab 0.2 mg 1 $0
clonidine hcl tab 0.3 mg 1 $0
clonidine hcl td patch weekly 0.1 mg/24hr
1 $0
clonidine hcl td patch weekly 0.2 mg/24hr
1 $0
clonidine hcl td patch weekly 0.3 mg/24hr
1 $0
DEMSER CAP 250MG 2 $0
hydralazine hcl inj 20 mg/ml 1 $0
hydralazine hcl tab 10 mg 1 $0
hydralazine hcl tab 25 mg 1 $0
hydralazine hcl tab 50 mg 1 $0
hydralazine hcl tab 100 mg 1 $0
midodrine hcl tab 2.5 mg 1 $0
midodrine hcl tab 5 mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
53
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
ADCIRCA TAB 20MG 2 $0 QL (60 tabs / 30 days),
NM, PA
ADEMPAS TAB 0.5MG 2 $0 QL (90 tabs / 30 days),
NM, PA
ADEMPAS TAB 1.5MG 2 $0 QL (90 tabs / 30 days),
NM, PA
ADEMPAS TAB 1MG 2 $0 QL (90 tabs / 30 days),
NM, PA
ADEMPAS TAB 2.5MG 2 $0 QL (90 tabs / 30 days),
NM, PA
ADEMPAS TAB 2MG 2 $0 QL (90 tabs / 30 days),
NM, PA
LETAIRIS TAB 5MG 2 $0 QL (30 tabs / 30 days),
NM, LA, PA
LETAIRIS TAB 10MG 2 $0 QL (30 tabs / 30 days),
NM, LA, PA
REMODULIN INJ 1MG/ML 2 $0 B/D, NM, LA
REMODULIN INJ 2.5MG/ML 2 $0 B/D, NM, LA
REMODULIN INJ 5MG/ML 2 $0 B/D, NM, LA
REMODULIN INJ 10MG/ML 2 $0 B/D, NM, LA
REVATIO SUS 10MG/ML 2 $0 QL (2 bottles / 30 days), NM, PA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
57
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
levetiracetam tab 500 mg 1 $0
levetiracetam tab 750 mg 1 $0
levetiracetam tab 1000 mg 1 $0
levetiracetam tab sr 24hr 500 mg 1 $0
levetiracetam tab sr 24hr 750 mg 1 $0
LYRICA CAP 25MG 2 $0 QL (120 caps / 30 days)
LYRICA CAP 50MG 2 $0 QL (120 caps / 30 days)
LYRICA CAP 75MG 2 $0 QL (120 caps / 30 days)
LYRICA CAP 100MG 2 $0 QL (120 caps / 30 days)
LYRICA CAP 150MG 2 $0 QL (120 caps / 30 days)
LYRICA CAP 200MG 2 $0 QL (90 caps / 30 days)
LYRICA CAP 225MG 2 $0 QL (60 caps / 30 days)
LYRICA CAP 300MG 2 $0 QL (60 caps / 30 days)
LYRICA SOL 20MG/ML 2 $0 QL (946 mL / 30 days)
ONFI SUS 2.5MG/ML 2 $0 PA
ONFI TAB 10MG 2 $0 PA
ONFI TAB 20MG 2 $0 PA
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
1 $0
oxcarbazepine tab 150 mg 1 $0
oxcarbazepine tab 300 mg 1 $0
oxcarbazepine tab 600 mg 1 $0
PEGANONE TAB 250MG 2 $0
PHENOBARB INJ 65MG/ML 2 $0 PA
phenobarbital elixir 20 mg/5ml 2 $0 PA
phenobarbital sodium inj 130 mg/ml
2 $0 PA
phenobarbital tab 15 mg 2 $0 PA
phenobarbital tab 16.2 mg 2 $0 PA
phenobarbital tab 30 mg 2 $0 PA
phenobarbital tab 32.4 mg 2 $0 PA
phenobarbital tab 60 mg 2 $0 PA
phenobarbital tab 64.8 mg 2 $0 PA
phenobarbital tab 97.2 mg 2 $0 PA
phenobarbital tab 100 mg 2 $0 PA
phenytek cap 200mg 2 $0
phenytek cap 300mg 2 $0
phenytoin chew tab 50 mg 1 $0
phenytoin sodium extended cap 100 mg
1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
58
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
phenytoin sodium extended cap
200 mg
1 $0
phenytoin sodium extended cap
300 mg
1 $0
phenytoin sodium inj 50 mg/ml 1 $0
phenytoin susp 125 mg/5ml 1 $0
POTIGA TAB 50MG 2 $0
POTIGA TAB 200MG 2 $0 QL (180 tabs / 30 days)
POTIGA TAB 300MG 2 $0 QL (90 tabs / 30 days)
POTIGA TAB 400MG 2 $0 QL (90 tabs / 30 days)
primidone tab 50 mg 1 $0
primidone tab 250 mg 1 $0
SABRIL POW 500MG 2 $0 QL (180 packets / 30
days), NM, LA, PA
SABRIL TAB 500MG 2 $0 QL (180 tabs / 30 days),
NM, LA, PA
TEGRETOL SUS 100/5ML 2 $0
TEGRETOL TAB 200MG 2 $0
TEGRETOL-XR TAB 100MG 2 $0
TEGRETOL-XR TAB 200MG 2 $0
TEGRETOL-XR TAB 400MG 2 $0
tiagabine hcl tab 2 mg 1 $0
tiagabine hcl tab 4 mg 1 $0
topiramate sprinkle cap 15 mg 1 $0
topiramate sprinkle cap 25 mg 1 $0
topiramate tab 25 mg 1 $0
topiramate tab 50 mg 1 $0
topiramate tab 100 mg 1 $0
topiramate tab 200 mg 1 $0
valproate sodium inj 100 mg/ml 1 $0
valproate sodium syrup 250 mg/5ml (base equiv)
1 $0
valproic acid cap 250 mg 1 $0
VIMPAT INJ 200MG/20 2 $0
VIMPAT SOL 10MG/ML 2 $0 QL (1200 mL / 30 days)
VIMPAT TAB 50MG 2 $0 QL (180 tabs / 30 days)
VIMPAT TAB 100MG 2 $0 QL (60 tabs / 30 days)
VIMPAT TAB 150MG 2 $0 QL (60 tabs / 30 days)
VIMPAT TAB 200MG 2 $0 QL (60 tabs / 30 days)
zonisamide cap 25 mg 1 $0
zonisamide cap 50 mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
59
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
zonisamide cap 100 mg 1 $0
ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride orally
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
SURMONTIL CAP 25MG 2 $0 QL (240 caps / 30 days), PA
SURMONTIL CAP 50MG 2 $0 QL (120 caps / 30 days), PA
SURMONTIL CAP 100MG 2 $0 QL (60 caps / 30 days), PA
tranylcypromine sulfate tab 10 mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
63
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
trazodone hcl tab 50 mg 1 $0
trazodone hcl tab 100 mg 1 $0
trazodone hcl tab 150 mg 1 $0
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
1 $0 QL (30 caps / 30 days)
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
1 $0 QL (30 caps / 30 days)
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
1 $0 QL (60 caps / 30 days)
venlafaxine hcl tab 25 mg 1 $0
venlafaxine hcl tab 37.5 mg 1 $0
venlafaxine hcl tab 50 mg 1 $0
venlafaxine hcl tab 75 mg 1 $0
venlafaxine hcl tab 100 mg 1 $0
VIIBRYD KIT 2 $0
VIIBRYD TAB 10MG 2 $0 QL (30 tabs / 30 days)
VIIBRYD TAB 20MG 2 $0 QL (30 tabs / 30 days)
VIIBRYD TAB 40MG 2 $0 QL (30 tabs / 30 days)
ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
64
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
carbidopa & levodopa tab 25-100
mg
1 $0
carbidopa & levodopa tab 25-250
mg
1 $0
carbidopa & levodopa tab cr 25-100
mg
1 $0
carbidopa & levodopa tab cr 50-200
mg
1 $0
CARBIDOPA-LEVODOPA-ENTACAPO
NE TABS 12.5-50-200 MG
1 $0
CARBIDOPA-LEVODOPA-ENTACAPO
NE TABS 18.75-75-200 MG
1 $0
CARBIDOPA-LEVODOPA-ENTACAPO
NE TABS 25-100-200 MG
1 $0
CARBIDOPA-LEVODOPA-ENTACAPO
NE TABS 31.25-125-200 MG
1 $0
CARBIDOPA-LEVODOPA-ENTACAPO
NE TABS 37.5-150-200 MG
1 $0
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG
1 $0
entacapone tab 200 mg 1 $0
NEUPRO DIS 1MG/24HR 2 $0
NEUPRO DIS 2MG/24HR 2 $0
NEUPRO DIS 3MG/24HR 2 $0
NEUPRO DIS 4MG/24HR 2 $0
NEUPRO DIS 6MG/24HR 2 $0
NEUPRO DIS 8MG/24HR 2 $0
pramipexole dihydrochloride tab
0.5 mg
1 $0
pramipexole dihydrochloride tab
0.25 mg
1 $0
pramipexole dihydrochloride tab
0.75 mg
1 $0
pramipexole dihydrochloride tab
0.125 mg
1 $0
pramipexole dihydrochloride tab 1 mg
1 $0
pramipexole dihydrochloride tab 1.5 mg
1 $0
ropinirole hydrochloride tab 0.5 mg 1 $0
ropinirole hydrochloride tab 0.25
mg
1 $0
ropinirole hydrochloride tab 1 mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
66
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
CLOZAPINE ORALLY
DISINTEGRATING TAB 150 MG
1 $0 QL (180 tabs / 30 days),
PA
CLOZAPINE ORALLY
DISINTEGRATING TAB 200 MG
1 $0 QL (135 tabs / 30 days),
PA
clozapine tab 25 mg 1 $0
clozapine tab 50 mg 1 $0
clozapine tab 100 mg 1 $0 QL (270 tabs / 30 days)
clozapine tab 200 mg 1 $0 QL (135 tabs / 30 days)
FANAPT PAK 2 $0 ST
FANAPT TAB 1MG 2 $0 QL (60 tabs / 30 days), ST
FANAPT TAB 2MG 2 $0 QL (60 tabs / 30 days), ST
FANAPT TAB 4MG 2 $0 QL (60 tabs / 30 days), ST
FANAPT TAB 6MG 2 $0 QL (60 tabs / 30 days), ST
FANAPT TAB 8MG 2 $0 QL (60 tabs / 30 days), ST
FANAPT TAB 10MG 2 $0 QL (60 tabs / 30 days), ST
FANAPT TAB 12MG 2 $0 QL (60 tabs / 30 days), ST
FAZACLO TAB 12.5/ODT 2 $0 PA
FAZACLO TAB 25MG ODT 2 $0 PA
FAZACLO TAB 100/ODT 2 $0 QL (270 tabs / 30 days),
PA
FAZACLO TAB 150MG 2 $0 QL (180 tabs / 30 days),
PA
FAZACLO TAB 200MG 2 $0 QL (135 tabs / 30 days),
PA
fluphenazine decanoate inj 25
mg/ml
1 $0
fluphenazine hcl elixir 2.5 mg/5ml 1 $0
fluphenazine hcl inj 2.5 mg/ml 1 $0
fluphenazine hcl oral conc 5 mg/ml 1 $0
fluphenazine hcl tab 1 mg 1 $0
fluphenazine hcl tab 2.5 mg 1 $0
fluphenazine hcl tab 5 mg 1 $0
fluphenazine hcl tab 10 mg 1 $0
GEODON INJ 20MG 2 $0 QL (6 mL / 3 days)
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
olanzapine for im inj 10 mg 1 $0 QL (3 vials / 1 day)
olanzapine orally disintegrating tab
5 mg
1 $0 QL (30 tabs / 30 days)
olanzapine orally disintegrating tab
10 mg
1 $0 QL (60 tabs / 30 days)
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT
ADHD amphetamine-dextroamphetamine
cap sr 24hr 5 mg
1 $0 QL (90 caps / 30 days)
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
73
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
COPAXONE INJ 40MG/ML 2 $0 QL (12 syringes / 28
days), NM, PA
GILENYA CAP 0.5MG 2 $0 QL (28 caps / 28 days),
NM, PA
TYSABRI INJ 300/15ML 2 $0 NM, LA, PA
MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
SUBOXONE MIS 2-0.5MG 2 $0 QL (4 boxes / 30 days), PA
SUBOXONE MIS 4-1MG 2 $0 QL (4 boxes / 30 days), PA
SUBOXONE MIS 8-2MG 2 $0 QL (4 boxes / 30 days), PA
SUBOXONE MIS 12-3MG 2 $0 QL (2 boxes / 30 days), PA
thrive gum 2mg mint 3 $0 NM; *
thrive gum 4mg mint 3 $0 NM; *
wal-som cap 50mg 3 $0 NM; *
ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND
REGULATE HORMONES
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
75
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANDRODERM DIS 2MG/24HR 2 $0 QL (30 patches / 30
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
78
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
kionex sus 15gm/60 1 $0
sodium polystyrene sulfonate oral
susp 15 gm/60ml
1 $0
sps sus 15gm/60 1 $0
SYPRINE CAP 250MG 2 $0
CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL altavera tab 1 $0
apri tab 1 $0
aranelle tab 1 $0
aubra tab 0.1-0.02 1 $0
aviane tab 1 $0
balziva tab 1 $0
briellyn tab 1 $0
camila tab 0.35mg 1 $0
cryselle-28 tab 28 tabs 1 $0
cyclafem tab 1/35 1 $0
cyclafem tab 7/7/7 1 $0
deblitane tab 0.35mg 1 $0
delyla tab 0.1-0.02 1 $0
desogest-eth estrad & eth estrad
tab 0.15-0.02/0.01 mg(21/5)
1 $0
drospirenone-ethinyl estradiol tab
3-0.02 mg
1 $0
DROSPIRENONE-ETHINYL
ESTRADIOL TAB 3-0.02 MG
1 $0
drospirenone-ethinyl estradiol tab
3-0.03 mg
1 $0
DROSPIRENONE-ETHINYL
ESTRADIOL TAB 3-0.03 MG
1 $0
ELLA TAB 30MG 2 $0
emoquette tab 1 $0
enpresse-28 tab 1 $0
errin tab 0.35mg 1 $0
falmina tab 1 $0
gildagia tab 0.4-35 1 $0
gildess tab 1.5/30 1 $0
heather tab 0.35mg 1 $0
introvale tab 1 $0
JOLIVETTE TAB 0.35MG 1 $0
junel 1.5/30 tab 1 $0
junel 1/20 tab 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
1 $0
levonorgestrel tab 0.75 mg 1 $0
levonorgestrel tab 1.5 mg 1 $0
levora-28 tab 0.15/30 1 $0
loryna tab 3-0.02mg 1 $0
low-ogestrel tab 1 $0
lutera tab 1 $0
lyza tab 0.35mg 1 $0
marlissa tab 0.15/30 1 $0
medroxyprogesterone acetate im
susp 150 mg/ml
1 $0
microgestin tab 1.5/30 1 $0
microgestin tab 1/20 1 $0
microgestin tab fe1.5/30 1 $0
microgestin tab fe 1/20 1 $0
MONONESSA TAB 1 $0
my way tab 1.5mg 1 $0
my way tab 1.5mg 3 $0 NM; *
myzilra tab 1 $0
necon tab 0.5/35 1 $0
necon tab 1/35 1 $0
NECON TAB 1/50-28 1 $0
NECON TAB 7/7/7 1 $0
necon tab 10/11-28 2 $0
next choice tab 1.5mg 1 $0
nikki tab 3-0.02mg 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
81
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
danazol cap 200 mg 1 $0
SYNAREL SOL 2MG/ML 2 $0
ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ADAGEN INJ 250/ML 2 $0 NM, LA, PA
ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES COMBIPATCH DIS .05/.14 2 $0 PA
COMBIPATCH DIS .05/.25 2 $0 PA
estradiol tab 0.5 mg 2 $0 PA
estradiol tab 1 mg 2 $0 PA
estradiol tab 2 mg 2 $0 PA
estradiol td patch weekly 0.1 mg/24hr
2 $0 PA
estradiol td patch weekly 0.05 mg/24hr
2 $0 PA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD
SUGAR GLUCAGEN INJ HYPOKIT 2 $0
GLUCAGON KIT 1MG 2 $0
PROGLYCEM SUS 50MG/ML 2 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
84
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
85
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
PARATHYROID HORMONES - DRUGS TO REGULATE PARATHYROID
PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab
2.5 mg 1 $0
medroxyprogesterone acetate tab 5
mg
1 $0
medroxyprogesterone acetate tab
10 mg
1 $0
norethindrone acetate tab 5 mg 1 $0
THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS levothyroxine sodium tab 25 mcg 1 $0
levothyroxine sodium tab 50 mcg 1 $0
levothyroxine sodium tab 75 mcg 1 $0
levothyroxine sodium tab 88 mcg 1 $0
levothyroxine sodium tab 100 mcg 1 $0
levothyroxine sodium tab 112 mcg 1 $0
levothyroxine sodium tab 125 mcg 1 $0
levothyroxine sodium tab 137 mcg 1 $0
levothyroxine sodium tab 150 mcg 1 $0
levothyroxine sodium tab 175 mcg 1 $0
levothyroxine sodium tab 200 mcg 1 $0
levothyroxine sodium tab 300 mcg 1 $0
LEVOXYL TAB 25MCG 1 $0
LEVOXYL TAB 50MCG 1 $0
LEVOXYL TAB 75MCG 1 $0
LEVOXYL TAB 88MCG 1 $0
LEVOXYL TAB 100MCG 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
87
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
desmopressin acetate nasal spray
soln 0.01% (refrigerated)
1 $0
desmopressin acetate tab 0.1 mg 1 $0
desmopressin acetate tab 0.2 mg 1 $0
GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
88
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
anti-diarrhe tab 2mg 3 $0 NM; *
diges probio cap 250mg 3 $0 NM; *
floranex gra 3 $0 NM; *
FLORASTOR PAK KIDS 3 $0 NM; *
kaopectate sus 262/15ml 3 $0 NM; *
lactobacillus tab 3 $0 NM; *
loperamide hcl liq 1 mg/7.5ml 3 $0 NM; *
peptic relf chw 262mg 3 $0 NM; *
probiotic cap 3 $0 NM; *
PROBIOTIC CAP FORMULA 3 $0 NM; *
RISA-BID TAB PROBIO 3 $0 NM; *
soothe tab 262mg 3 $0 NM; *
stomach relf sus 525/15ml 3 $0 NM; *
ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING compro sup 25mg 1 $0
dramamine tab 25mg 3 $0 NM; *
dronabinol cap 2.5 mg 1 $0 B/D, QL (60 caps / 30
days)
dronabinol cap 5 mg 1 $0 B/D, QL (60 caps / 30
days)
dronabinol cap 10 mg 2 $0 B/D, QL (60 caps / 30
days)
EMEND CAP 40MG 1 $0 B/D
EMEND CAP 80MG 2 $0 B/D
EMEND CAP 125MG 2 $0 B/D
EMEND PAK 80 & 125 2 $0 B/D
granisetron hcl inj 0.1 mg/ml 1 $0
granisetron hcl inj 1 mg/ml 1 $0
granisetron hcl inj 4 mg/4ml (1 mg/ml)
1 $0
granisetron hcl tab 1 mg 1 $0 B/D
meclizine hcl tab 12.5 mg 1 $0
meclizine hcl tab 25 mg 1 $0
metoclopramide hcl inj 5 mg/ml 1 $0
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
1 $0
metoclopramide hcl tab 5 mg 1 $0
metoclopramide hcl tab 10 mg 1 $0
motion sick chw 25mg 3 $0 NM; *
motion sick tab 50mg 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
ANTISPASMODICS - DRUGS FOR STOMACH SPASMS CUVPOSA SOL 1MG/5ML 2 $0
dicyclomine hcl cap 10 mg 1 $0
dicyclomine hcl oral soln 10 mg/5ml 1 $0
dicyclomine hcl tab 20 mg 1 $0
glycopyrrolate inj 4 mg/20ml (0.2
mg/ml)
1 $0
glycopyrrolate tab 1 mg 1 $0
glycopyrrolate tab 2 mg 1 $0
H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH
ACID acid reducer tab 10mg 3 $0 NM; *
acid reducer tab 150mg 3 $0 NM; *
AXID AR TAB 75MG 3 $0 NM; *
cimetidine tab 200 mg 3 $0 NM; *
famotidine for susp 40 mg/5ml 1 $0
famotidine in nacl 0.9% iv soln 20
mg/50ml
1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
90
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
famotidine inj 20 mg/2ml 1 $0
famotidine inj 40 mg/4ml 1 $0
famotidine inj 200 mg/20ml 1 $0
famotidine tab 20 mg 1 $0
famotidine tab 20mg 3 $0 NM; *
famotidine tab 40 mg 1 $0
PEPCID AC CHW 10MG 3 $0 NM; *
ranitidine hcl inj 50 mg/2ml (25
mg/ml)
1 $0
ranitidine hcl inj 150 mg/6ml (25
mg/ml)
1 $0
ranitidine hcl syrup 15 mg/ml (75
mg/5ml)
1 $0
ranitidine hcl tab 75 mg 3 $0 NM; *
ranitidine hcl tab 150 mg 1 $0
ranitidine hcl tab 300 mg 1 $0
ranitidine tab 75mg 3 $0 NM; *
INFLAMMATORY BOWEL DISEASE APRISO CAP 0.375GM 2 $0
ASACOL HD TAB 800MG 2 $0
balsalazide disodium cap 750 mg 1 $0
budesonide cap sr 24hr 3 mg 2 $0
CANASA SUP 1000MG 2 $0
DELZICOL CAP 400MG 2 $0
DIPENTUM CAP 250MG 2 $0
hydrocortisone enema 100 mg/60ml
1 $0
HYDROCORTISONE ENEMA 100 MG/60ML
1 $0
LIALDA TAB 1.2GM 2 $0
mesalamine enema 4 gm 1 $0
mesalamine rectal enema 4 gm & cleanser wipe kit
1 $0
PENTASA CAP 250MG CR 2 $0
PENTASA CAP 500MG CR 2 $0
sulfasalazine tab 500 mg 1 $0
sulfazine ec tab 500mg 1 $0
UCERIS TAB 9MG 2 $0
LAXATIVES ALOE VERA LIQ JUICE DR 3 $0 NM; *
BENEFIBER CHW 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
91
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
BENEFIBER POW 3 $0 NM; *
bisacodyl tab & peg 3350-kcl-sod
bicarb-nacl for soln kit
1 $0
BLK DRAUGHT CHW 10MG 3 $0 NM; *
BLK DRAUGHT SYP 90/15ML 3 $0 NM; *
constulose sol 10gm/15 1 $0
corn dextrin oral powder 3 $0 NM; *
cvs fiber chw gummies 3 $0 NM; *
d.o.s. cap 250mg 3 $0 NM; *
docusate sodium liquid 150
mg/15ml
3 $0 NM; *
dok tab 100mg 3 $0 NM; *
DULCOLAX KIT BOWEL 3 $0 NM; *
easy fiber/ chw calcium 3 $0 NM; *
enemeez mini ene 3 $0 NM; *
enemeez plus ene 20-283 3 $0 NM; *
enulose sol 10gm/15 1 $0
epsom salt gra 3 $0 NM; *
EQL NATURAL POW FIBER 3 $0 NM; *
EQUALACTIN CHW 625MG 3 $0 NM; *
ex-lax ultra tab 5mg ec 3 $0 NM; *
FIBER CHW 3 $0 NM; *
fiber laxatv tab 625mg 3 $0 NM; *
fiber oral powder 3 $0 NM; *
FIBER POW 3 $0 NM; *
FLEET BISACO ENE 10/30ML 3 $0 NM; *
gavilyte-c sol 1 $0
gavilyte-g sol 1 $0
gavilyte-n sol flav pk 1 $0
generlac sol 10gm/15 1 $0
gentle laxat sup 10mg 3 $0 NM; *
GOLYTELY SOL 2 $0
HYDROCIL INS POW 95% 3 $0 NM; *
konsyl cap 520mg 3 $0 NM; *
konsyl pow 28.3% 3 $0 NM; *
KONSYL POW 28.3% 3 $0 NM; *
konsyl pow 30.9% 3 $0 NM; *
KONSYL POW 60.3% 3 $0 NM; *
KONSYL POW 71.67% 3 $0 NM; *
KONSYL POW 100% 3 $0 NM; *
KONSYL-D POW 52.3% 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
92
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
lactulose (encephalopathy) solution
10 gm/15ml
1 $0
lactulose solution 10 gm/15ml 1 $0
lax diet sup tab 500mg 3 $0 NM; *
laxative chw 15mg 3 $0 NM; *
magnesium citrate soln 3 $0 NM; *
METAMUCIL POW 28% 3 $0 NM; *
METAMUCIL POW 63% 3 $0 NM; *
METAMUCIL WAF 3 $0 NM; *
MILK OF MAGN SUS 800/5ML 3 $0 NM; *
MILK OF MAGN SUS 2400MG 3 $0 NM; *
milk of magn sus frsh mnt 3 $0 NM; *
MINERAL OIL 3 $0 NM; *
mineral oil enema 3 $0 NM; *
MOVIPREP SOL 2 $0
nat fiber pow therapy 3 $0 NM; *
naturl fiber pow 68% 3 $0 NM; *
NULYTELY SOL FLAV PKS 2 $0
NUTRISOURCE PAK FIBER 3 $0 NM; *
oral saline sol laxative 3 $0 NM; *
PEDIA-LAX LIQ 50MG 3 $0 NM; *
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 236 gm
1 $0
PEG 3350-KCL-NA
BICARB-NACL-NA SULFATE FOR SOLN 240 GM
1 $0
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
1 $0
perdiem over tab 15mg 3 $0 NM; *
polyethylene glycol 3350 oral packet
1 $0
polyethylene glycol 3350 oral powder
1 $0
psyldex pow 30% 3 $0 NM; *
psyllium powder 100% 3 $0 NM; *
qc natural pow vegetabl 3 $0 NM; *
ra col-rite cap 50mg 3 $0 NM; *
ra fiber tab 500mg 3 $0 NM; *
reguloid pow 48.57% 3 $0 NM; *
reguloid pow 58.6% 3 $0 NM; *
RELISTOR INJ 8/0.4ML 2 $0 PA
RELISTOR INJ 12/0.6ML 2 $0 PA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
93
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
RELISTOR KIT 12/0.6ML 2 $0 PA
sb fib lax pow 33% 3 $0 NM; *
SB NAT FIBER POW 49% 3 $0 NM; *
sen-o-tabs tab 187mg 3 $0 NM; *
SENNA PROMPT CAP 9-500MG 3 $0 NM; *
SENNA SYP 3 $0 NM; *
SENNA TAB 8.6MG 3 $0 NM; *
senna tab 25mg 3 $0 NM; *
senna-extra tab 17.2mg 3 $0 NM; *
sennosides cap 8.6 mg 3 $0 NM; *
sennosides syrup 8.8 mg/5ml 3 $0 NM; *
sennosides tab 8.6 mg 3 $0 NM; *
sennosides-docusate sodium tab
8.6-50 mg
3 $0 NM; *
sodium phosphates - enema 3 $0 NM; *
soluble fib pow therapy 3 $0 NM; *
sorbulax pow 100% 3 $0 NM; *
stool softnr cap 50mg 3 $0 NM; *
stool softnr cap 100mg 3 $0 NM; *
stool softnr cap 240mg 3 $0 NM; *
stool softnr syp 60/15ml 3 $0 NM; *
stool softnr tab 8.6-50mg 3 $0 NM; *
SUPREP BOWEL SOL PREP 2 $0
total fiber pow 3 $0 NM; *
trilyte sol 1 $0
MISCELLANEOUS alosetron hcl tab 0.5 mg (base
equiv)
2 $0 PA
alosetron hcl tab 1 mg (base equiv) 2 $0 PA
AMITIZA CAP 8MCG 2 $0 QL (60 caps / 30 days)
AMITIZA CAP 24MCG 2 $0 QL (60 caps / 30 days)
cromolyn sodium oral conc 100 mg/5ml
2 $0
diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml
1 $0
diphenoxylate w/ atropine tab 2.5-0.025 mg
1 $0
LINZESS CAP 145MCG 2 $0 QL (60 caps / 30 days)
LINZESS CAP 290MCG 2 $0 QL (30 caps / 30 days)
loperamide hcl cap 2 mg 1 $0
LOTRONEX TAB 0.5MG 2 $0 PA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
94
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
LOTRONEX TAB 1MG 2 $0 PA
misoprostol tab 100 mcg 1 $0
misoprostol tab 200 mcg 1 $0
MOVANTIK TAB 12.5MG 2 $0 QL (60 tabs / 30 days)
MOVANTIK TAB 25MG 2 $0 QL (30 tabs / 30 days)
SUCRAID SOL 8500/ML 2 $0
sucralfate tab 1 gm 1 $0
ursodiol cap 300 mg 1 $0
ursodiol tab 250 mg 1 $0
ursodiol tab 500 mg 1 $0
XIFAXAN TAB 550MG 2 $0 PA
PANCREATIC ENZYMES CREON CAP 3000UNIT 2 $0
CREON CAP 6000UNIT 2 $0
CREON CAP 12000UNT 2 $0
CREON CAP 24000UNT 2 $0
CREON CAP 36000UNT 2 $0
ZENPEP CAP 3000UNIT 2 $0
ZENPEP CAP 5000UNIT 2 $0
ZENPEP CAP 10000UNT 2 $0
ZENPEP CAP 15000UNT 2 $0
ZENPEP CAP 20000UNT 2 $0
ZENPEP CAP 25000UNT 2 $0
ZENPEP CAP 40000UNT 2 $0
PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH
ACID DEXILANT CAP 30MG DR 2 $0 QL (30 caps / 30 days)
DEXILANT CAP 60MG DR 2 $0 QL (30 caps / 30 days)
dual action chw complete 3 $0 NM; *
esomeprazole sodium for intravenous soln 20 mg (base
equiv)
1 $0
esomeprazole sodium for intravenous soln 40 mg (base
equiv)
1 $0
lansoprazole cap 15mg dr 3 $0 NM; *
NEXIUM CAP 20MG 2 $0 QL (30 caps / 30 days)
NEXIUM CAP 40MG 2 $0 QL (30 caps / 30 days)
NEXIUM GRA 2.5MG DR 2 $0
NEXIUM GRA 5MG DR 2 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
95
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
NEXIUM GRA 10MG DR 2 $0 QL (30 packets / 30
days)
NEXIUM GRA 20MG DR 2 $0 QL (30 packets / 30
days)
NEXIUM GRA 40MG DR 2 $0 QL (30 packets / 30
days)
omeprazole cap 20.6mgdr 3 $0 NM; *
omeprazole cap delayed release 10
mg
1 $0 QL (30 caps / 30 days)
omeprazole cap delayed release 20
mg
1 $0 QL (60 caps / 30 days)
omeprazole cap delayed release 40
mg
1 $0 QL (30 caps / 30 days)
OMEPRAZOLE TAB 20MG 3 $0 NM; *
omeprazole-sodium bicarbonate
cap 20-1100 mg
3 $0 NM; *
pantoprazole sodium ec tab 20 mg
(base equiv)
1 $0 QL (30 tabs / 30 days)
pantoprazole sodium ec tab 40 mg
(base equiv)
1 $0 QL (30 tabs / 30 days)
PRILOSEC OTC TAB 20MG 3 $0 NM; *
GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT
CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
98
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
HEPARIN SODIUM (PORCINE) 40
UNIT/ML IN D5W
2 $0
heparin sodium (porcine) inj 1000
unit/ml
1 $0 B/D
heparin sodium (porcine) inj 5000
unit/ml
1 $0 B/D
heparin sodium (porcine) inj 10000
unit/ml
1 $0 B/D
heparin sodium (porcine) inj 20000
unit/ml
1 $0 B/D
jantoven tab 1mg 1 $0
jantoven tab 2.5mg 1 $0
jantoven tab 2mg 1 $0
jantoven tab 3mg 1 $0
jantoven tab 4mg 1 $0
jantoven tab 5mg 1 $0
jantoven tab 6mg 1 $0
jantoven tab 7.5mg 1 $0
jantoven tab 10mg 1 $0
PRADAXA CAP 75MG 2 $0
PRADAXA CAP 150MG 2 $0
warfarin sodium tab 1 mg 1 $0
warfarin sodium tab 2 mg 1 $0
warfarin sodium tab 2.5 mg 1 $0
warfarin sodium tab 3 mg 1 $0
warfarin sodium tab 4 mg 1 $0
warfarin sodium tab 5 mg 1 $0
warfarin sodium tab 6 mg 1 $0
warfarin sodium tab 7.5 mg 1 $0
warfarin sodium tab 10 mg 1 $0
XARELTO STAR TAB 15/20MG 2 $0
XARELTO TAB 10MG 2 $0
XARELTO TAB 15MG 2 $0
XARELTO TAB 20MG 2 $0
HEMATOPOIETIC GROWTH FACTORS GRANIX INJ 300/0.5 2 $0 NM, PA
GRANIX INJ 480/0.8 2 $0 NM, PA
LEUKINE INJ 250MCG 2 $0 NM, PA
MOZOBIL INJ 2 $0 NM, PA
NEUMEGA INJ 5MG 2 $0 NM
NEUPOGEN INJ 300/0.5 2 $0 NM, PA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
ferrous sulfate tab ec 325 mg (65 mg fe equivalent)
3 $0 NM; *
FOLGARD TAB 3 $0 NM; *
FOLITAB 500 TAB 3 $0 NM; *
foltabs 800 tab 3 $0 NM; *
gnp iron tab 45mg 3 $0 NM; *
INTEGRA CAP 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
101
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
tranexamic acid tab 650 mg 1 $0
PLATELET AGGREGATION INHIBITORS AGGRENOX CAP 25-200MG 2 $0
BRILINTA TAB 90MG 2 $0
clopidogrel bisulfate tab 75 mg
(base equiv)
1 $0 QL (30 tabs / 30 days)
EFFIENT TAB 5MG 2 $0
EFFIENT TAB 10MG 2 $0
ZONTIVITY TAB 2.08MG 2 $0
IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE
IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS
TO TREAT RHEUMATOID ARTHRITIS CIMZIA KIT 2 $0 NM, PA
CIMZIA KIT STARTER 2 $0 NM, PA
CIMZIA PREFL KIT 200MG/ML 2 $0 NM, PA
HUMIRA INJ 10MG/0.2 2 $0 NM, PA
HUMIRA INJ 40MG/0.8 1 $0 NM, PA
HUMIRA KIT 20MG/0.4 2 $0 NM, PA
HUMIRA PEN INJ 40MG/0.8 2 $0 NM, PA
HUMIRA PEN INJ CROHNS 2 $0 NM, PA
HUMIRA PEN INJ PSORIASI 2 $0 NM, PA
hydroxychloroquine sulfate tab 200 mg
1 $0
leflunomide tab 10 mg 1 $0
leflunomide tab 20 mg 1 $0
methotrexate sodium tab 2.5 mg (base equiv)
1 $0
REMICADE INJ 100MG 2 $0 NM, PA
IMMUNOGLOBULINS BIVIGAM INJ 10% 2 $0 NM, PA
CARIMUNE NF INJ 3GM 2 $0 NM, PA
CARIMUNE NF INJ 6GM 2 $0 NM, PA
CARIMUNE NF INJ 12GM 2 $0 NM, PA
FLEBOGAMMA INJ 5% 2 $0 NM, PA
FLEBOGAMMA INJ 10/200ML 2 $0 NM, PA
FLEBOGAMMA INJ 20/400ML 2 $0 NM, PA
FLEBOGAMMA INJ DIF 5% 2 $0 NM, PA
FLEBOGAMMA INJ DIF 10% 2 $0 NM, PA
GAMASTAN S/D INJ 2 $0 B/D, NM
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
102
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
GAMMAGARD INJ 1GM/10ML 2 $0 NM, PA
GAMMAGARD INJ 2.5GM/25 2 $0 NM, PA
GAMMAGARD INJ 5GM/50ML 2 $0 NM, PA
GAMMAGARD INJ 10GM/100 2 $0 NM, PA
GAMMAGARD INJ 20GM/200 2 $0 NM, PA
GAMMAGARD INJ 30GM/300 2 $0 NM, PA
GAMMAGARD SD INJ 2.5GM HU 2 $0 NM, PA
GAMMAGARD SD INJ 5GM HU 2 $0 NM, PA
GAMMAGARD SD INJ 10GM HU 2 $0 NM, PA
GAMMAKED INJ 1GM/10ML 2 $0 NM, PA
GAMMAKED INJ 2.5GM/25 2 $0 NM, PA
GAMMAKED INJ 5GM/50ML 2 $0 NM, PA
GAMMAKED INJ 10GM/100 2 $0 NM, PA
GAMMAKED INJ 20GM/200 2 $0 NM, PA
GAMMAPLEX INJ 2.5GM 2 $0 NM, PA
GAMMAPLEX INJ 5GM 2 $0 NM, PA
GAMMAPLEX INJ 10GM 2 $0 NM, PA
GAMUNEX-C INJ 1GM/10ML 2 $0 NM, PA
GAMUNEX-C INJ 2.5GM/25 2 $0 NM, PA
GAMUNEX-C INJ 5GM/50ML 2 $0 NM, PA
GAMUNEX-C INJ 10GM/100 2 $0 NM, PA
GAMUNEX-C INJ 20GM/200 2 $0 NM, PA
GAMUNEX-C INJ 40/400ML 2 $0 NM, PA
OCTAGAM INJ 1GM 2 $0 NM, PA
OCTAGAM INJ 2.5GM 2 $0 NM, PA
OCTAGAM INJ 2GM/20ML 2 $0 NM, PA
OCTAGAM INJ 5GM 2 $0 NM, PA
OCTAGAM INJ 10GM 2 $0 NM, PA
OCTAGAM INJ 25GM 2 $0 NM, PA
PRIVIGEN INJ 5 GRAMS 2 $0 NM, PA
PRIVIGEN INJ 10GRAMS 2 $0 NM, PA
PRIVIGEN INJ 20GRAMS 2 $0 NM, PA
PRIVIGEN INJ 40GRAMS 2 $0 NM, PA
IMMUNOMODULATORS ACTIMMUNE INJ 2MU/0.5 2 $0 NM, LA, PA
ARCALYST INJ 220MG 2 $0 NM, PA
INTRON A INJ 10MU 2 $0 B/D, NM
INTRON A INJ 18MU 2 $0 B/D, NM
INTRON A INJ 25MU 2 $0 B/D, NM
INTRON A INJ 50MU 2 $0 B/D, NM
PEG-INTRON KIT 50MCG 2 $0 NM, PA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
104
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
NULOJIX INJ 250MG 2 $0 B/D
PROGRAF CAP 0.5MG 2 $0 B/D
PROGRAF CAP 1MG 2 $0 B/D
PROGRAF CAP 5MG 2 $0 B/D
RAPAMUNE SOL 1MG/ML 2 $0 B/D
SANDIMMUNE CAP 25MG 2 $0 B/D
SANDIMMUNE CAP 100MG 2 $0 B/D
SANDIMMUNE SOL 100MG/ML 2 $0 B/D
sirolimus tab 0.5 mg 1 $0 B/D
SIROLIMUS TAB 1 MG 1 $0 B/D
SIROLIMUS TAB 2 MG 2 $0 B/D
tacrolimus cap 0.5 mg 1 $0 B/D
tacrolimus cap 1 mg 1 $0 B/D
tacrolimus cap 5 mg 2 $0 B/D
ZORTRESS TAB 0.5MG 2 $0 B/D
ZORTRESS TAB 0.25MG 2 $0 B/D
ZORTRESS TAB 0.75MG 2 $0 B/D
VACCINES ACTHIB INJ 2 $0
ADACEL INJ 2 $0
BCG VACCINE INJ 2 $0
BEXSERO INJ 2 $0
BOOSTRIX INJ 2 $0
CERVARIX INJ 2 $0
COMVAX INJ 2 $0
DAPTACEL INJ 2 $0
DIP/TET PED INJ 25-5LFU 2 $0 B/D
ENGERIX-B INJ 10/0.5ML 2 $0 B/D
ENGERIX-B INJ 20MCG/ML 2 $0 B/D
GARDASIL 9 INJ 2 $0
GARDASIL INJ 2 $0
HAVRIX INJ 720UNIT 2 $0
HAVRIX INJ 1440UNIT 2 $0
HIBERIX SOL 10MCG 2 $0
IMOVAX RABIE INJ 2.5/ML 2 $0
INFANRIX INJ 2 $0
IPOL INJ INACTIVE 2 $0
IXIARO INJ 2 $0
M-M-R II INJ LIVE 2 $0
MENACTRA INJ 2 $0
MENOMUNE INJ A/C/Y/W 2 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
105
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
MENVEO INJ 2 $0
PEDVAX HIB INJ 2 $0
PROQUAD INJ 2 $0
RABAVERT INJ 2 $0
RECOMBIVA HB INJ 5MCG/0.5 2 $0 B/D
RECOMBIVA HB INJ 10MCG/ML 2 $0 B/D
RECOMBIVA-HB INJ 40MCG/ML 2 $0 B/D
ROTARIX SUS 2 $0
ROTATEQ SOL 2 $0
SYNAGIS INJ 50MG 2 $0 NM
SYNAGIS INJ 100MG/ML 2 $0 NM
TENIVAC INJ 5-2LF 2 $0 B/D
TET/DIP TOX INJ 2-2 LF 2 $0 B/D
TETANUS TOX INJ 5LF ADS 2 $0 B/D
TRUMENBA INJ 2 $0
TWINRIX INJ 2 $0
TYPHIM VI INJ 2 $0
VAQTA INJ 25/0.5ML 2 $0
VAQTA INJ 50UNT/ML 2 $0
VARIVAX INJ 2 $0
YF-VAX INJ 2 $0
ZOSTAVAX INJ 2 $0 QL (1 vial per lifetime)
NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES KLOR-CON 8 TAB 8MEQ ER 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
106
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
potassium chloride
microencapsulated crys cr tab 20 meq
1 $0
potassium chloride oral liq 10% (20 meq/15ml)
1 $0
potassium chloride oral liq 20% (40 meq/15ml)
1 $0
potassium chloride tab cr 8 meq (600 mg)
1 $0
POTASSIUM CHLORIDE TAB CR 10 MEQ
1 $0
POTASSIUM CHLORIDE TAB CR 20 MEQ (1500 MG)
1 $0
rehydralyte sol 3 $0 NM; *
SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)
1 $0
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN
1 $0
TPN ELECTROL INJ 2 $0 B/D
IV NUTRITION amino acid infusion 6% 1 $0 B/D
AMINOSYN 7% INJ /LYTES 2 $0 B/D
AMINOSYN II INJ 7% 2 $0 B/D
AMINOSYN II INJ 8.5% 2 $0 B/D
AMINOSYN II INJ 8.5/LYTE 2 $0 B/D
AMINOSYN II INJ 10% 2 $0 B/D
AMINOSYN INJ 8.5% 2 $0 B/D
AMINOSYN INJ 8.5/LYTE 2 $0 B/D
AMINOSYN INJ 10% 2 $0 B/D
AMINOSYN M INJ 3.5% 2 $0 B/D
AMINOSYN-HBC INJ 7% 2 $0 B/D
AMINOSYN-PF INJ 7% 2 $0 B/D
AMINOSYN-PF INJ 10% 2 $0 B/D
AMINOSYN-RF INJ 5.2% 2 $0 B/D
CLINIMIX INJ 2.75/D5W 2 $0 B/D
CLINIMIX INJ 4.25/D5W 2 $0 B/D
CLINIMIX INJ 4.25/D10 2 $0 B/D
CLINIMIX INJ 4.25/D20 2 $0 B/D
CLINIMIX INJ 4.25/D25 2 $0 B/D
CLINIMIX INJ 5%/D15W 2 $0 B/D
CLINIMIX INJ 5%/D20W 2 $0 B/D
CLINIMIX INJ 5%/D25W 2 $0 B/D
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
107
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
FAT EMULSION IV SOLN 20% 2 $0 B/D
FREAMINE HBC INJ 6.9% 2 $0 B/D
FREAMINE III INJ 10% 2 $0 B/D
HEPATAMINE SOL 8% 2 $0 B/D
INTRALIPID INJ 20% 2 $0 B/D
INTRALIPID INJ 30% 2 $0 B/D
NEPHRAMINE INJ 5.4% 2 $0 B/D
premasol sol 10% 2 $0 B/D
PROCALAMINE INJ 3% 2 $0 B/D
PROSOL INJ 20% 2 $0 B/D
travasol inj 10% 2 $0 B/D
TROPHAMINE INJ 10% 2 $0 B/D
IV REPLACEMENT SOLUTIONS D5W/LYTES INJ #48 2 $0
D5W/NACL INJ 0.3% 1 $0
D10W/NACL INJ 0.2% 2 $0
DEXTROSE 2.5% W/ SODIUM
CHLORIDE 0.45%
1 $0
DEXTROSE 5% IN LACTATED
RINGERS
1 $0
DEXTROSE 5% W/ SODIUM
CHLORIDE 0.2%
1 $0
DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%
1 $0
DEXTROSE 5% W/ SODIUM CHLORIDE 0.33%
1 $0
DEXTROSE 5% W/ SODIUM CHLORIDE 0.45%
1 $0
DEXTROSE 5% W/ SODIUM CHLORIDE 0.225%
1 $0
DEXTROSE 10% W/ SODIUM CHLORIDE 0.45%
1 $0
DEXTROSE INJ 5% 1 $0
DEXTROSE INJ 10% 1 $0
DEXTROSE INJ 50% 1 $0
dextrose inj 70% 1 $0
IONOSOL-B/ INJ D5W 2 $0
IONOSOL-MB INJ /D5W 2 $0
ISOLYTE-P INJ /D5W 2 $0
isolyte-s inj 2 $0
KCL 10 MEQ/L (0.075%) IN
DEXTROSE 5% & NACL 0.45% INJ
1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
108
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL 0.2% INJ
1 $0
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL 0.9% INJ
1 $0
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL 0.33% INJ
1 $0
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL 0.45% INJ
1 $0
KCL 20 MEQ/L (0.15%) IN NACL
0.9% INJ
1 $0
kcl 20 meq/l (0.15%) in nacl 0.45%
inj
1 $0
KCL 20 MEQ/L (0.15%) IN NACL
0.45% INJ
1 $0
KCL 30 MEQ/L (0.224%) IN
DEXTROSE 5% & NACL 0.45% INJ
1 $0
KCL 40 MEQ/L (0.3%) IN
DEXTROSE 5% & NACL 0.45% INJ
1 $0
KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ
1 $0
KCL/D5W/NACL INJ 0.3/0.9% 1 $0
KCL/D5W/NACL INJ 0.15/0.2 2 $0
LACTATED RINGER'S SOLUTION 1 $0
normosol -m inj /d5w 1 $0
NORMOSOL -R INJ /D5W 2 $0
NORMOSOL-R INJ PH 7.4 2 $0
PLASMA-LYTE INJ 56/D5W 2 $0
PLASMA-LYTE INJ -148 2 $0
PLASMA-LYTE INJ -A 2 $0
POTASSIUM CHLORIDE 20 MEQ/L
(0.15%) IN DEXTROSE 5% INJ
1 $0
POTASSIUM CHLORIDE 40 MEQ/L
(0.3%) IN DEXTROSE 5% INJ
1 $0
potassium chloride inj 2 meq/ml 1 $0
potassium chloride inj 10 meq/50 ml
1 $0
POTASSIUM CHLORIDE INJ 10 MEQ/100 ML
1 $0
potassium chloride inj 20 meq/50 ml
1 $0
POTASSIUM CHLORIDE INJ 20 MEQ/100 ML
1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
109
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
potassium chloride inj 40 meq/100
ml
1 $0
RINGER'S SOLUTION 1 $0
SODIUM CHLORIDE INJ 0.45% 1 $0
SODIUM CHLORIDE INJ 3% 1 $0
SODIUM CHLORIDE INJ 5% 1 $0
SODIUM CHLORIDE IV SOLN 0.9% 1 $0
MINERALS BEELITH TAB 3 $0 NM; *
BONE DENSITY TAB 3 $0 NM; *
bone meal w/ vitamin d tab 3 $0 NM; *
buffered tab salt 3 $0 NM; *
CA CITRATE TAB 250MG 3 $0 NM; *
ca citrate tab + d 3 $0 NM; *
CA GLUCONATE TAB 50MG 3 $0 NM; *
CA LACTATE TAB 100MG 3 $0 NM; *
CA/MG TAB 3 $0 NM; *
CA/MG/ZN TAB 3 $0 NM; *
CAL CIT MAL/ TAB VITAMIND 3 $0 NM; *
CAL-CITRATE TAB PLUS D 3 $0 NM; *
CAL-GLU CAP 500MG 3 $0 NM; *
cal-mag aspa tab 333-167 3 $0 NM; *
CAL-QUICK LIQ 500-400 3 $0 NM; *
CAL/MAG TAB CHEW 3 $0 NM; *
CAL/MAG/VITD TAB 3 $0 NM; *
CALC CITRATE TAB 200MG 3 $0 NM; *
calc citrate tab +d 3 $0 NM; *
CALC GUMMIES CHW CHILD 3 $0 NM; *
CALCET CHW BITES 3 $0 NM; *
CALCET PETIT TAB 200-250 3 $0 NM; *
CALCI-MIX CAP 1250MG 3 $0 NM; *
CALCIONATE SYP 1.8GM/5 3 $0 NM; *
CALCIUM 500 TAB 3 $0 NM; *
calcium 500 tab +d 3 $0 NM; *
calcium 600 chw +d/mnrls 3 $0 NM; *
calcium 600 tab 3 $0 NM; *
calcium 600 tab vit d/mi 3 $0 NM; *
CALCIUM 1000 TAB + D 3 $0 NM; *
calcium 1200 chw 3 $0 NM; *
CALCIUM &MAG TAB 3 $0 NM; *
calcium + d chw 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
calcium carbonate-cholecalciferol tab 500 mg-400 unit
3 $0 NM; *
calcium carbonate-cholecalciferol tab 600 mg-200 unit
3 $0 NM; *
calcium carbonate-cholecalciferol tab 600 mg-400 unit
3 $0 NM; *
calcium carbonate-vitamin d tab
500 mg-125 unit
3 $0 NM; *
calcium carbonate-vitamin d tab
500 mg-400 unit
3 $0 NM; *
calcium carbonate-vitamin d tab
600 mg-125 unit
3 $0 NM; *
calcium carbonate-vitamin d tab
600 mg-200 unit
3 $0 NM; *
calcium carbonate-vitamin d tab
600 mg-400 unit
3 $0 NM; *
CALCIUM CHW GUMMIES 3 $0 NM; *
CALCIUM CIT/ TAB VIT D 3 $0 NM; *
calcium citrate tab 950 mg (200 mg elemental ca)
3 $0 NM; *
calcium citrate-vitamin d tab 200 mg-250 unit (elemental ca)
3 $0 NM; *
calcium for chw women 3 $0 NM; *
CALCIUM GLUC TAB 500MG 3 $0 NM; *
calcium gluconate tab 500 mg 3 $0 NM; *
CALCIUM GRA CITRATE 3 $0 NM; *
CALCIUM LACT TAB 648MG 3 $0 NM; *
calcium lactate tab 650 mg 3 $0 NM; *
calcium soft chw chocolat 3 $0 NM; *
calcium tab 500 mg 3 $0 NM; *
calcium tab 600 mg 3 $0 NM; *
CALCIUM TAB FORMULA 3 $0 NM; *
calcium w/ magnesium tab 500-250
mg
3 $0 NM; *
calcium w/ vitamin d tab 600
mg-125 unit
3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
111
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
calcium+d3 tab 600-800 3 $0 NM; *
calcium+d3 tab grad rel 3 $0 NM; *
CALCIUM/C/D CHW 500MG 3 $0 NM; *
CALCIUM/D3 TAB 3 $0 NM; *
calcium/d3 tab 600-800 3 $0 NM; *
calcium/d chw 500-400 3 $0 NM; *
calcium/magn tab zinc 3 $0 NM; *
CALMAG THINS TAB 200-50MG 3 $0 NM; *
caltrate 600 chw 600-800 3 $0 NM; *
CALTRATE 600 CHW +D PLUS 3 $0 NM; *
caltrate 600 tab 3 $0 NM; *
calvite p&d tab 3 $0 NM; *
CHELATED CA TAB 200MG 3 $0 NM; *
cit calc/d tab 315-250 3 $0 NM; *
CITRACAL CAL CHW GUMMIES 3 $0 NM; *
CITRACAL HRT TAB HEALTH 3 $0 NM; *
CORAL CALCIU CAP 3 $0 NM; *
CORAL CALCIU CAP 1000MG 3 $0 NM; *
CORAL CALCIU CAP PLUS 3 $0 NM; *
CORAL CAP CALCIUM 3 $0 NM; *
elite magnes tab 100mg 3 $0 NM; *
EQL CALCIUM CAP VIT D 3 $0 NM; *
kp ca/mg/zn tab 3 $0 NM; *
kp calcium cap 600+d 3 $0 NM; *
kp calcium tab 600+d 3 $0 NM; *
liq ca/vit d cap 600mg 3 $0 NM; *
LIQUID CALCI CAP WITH D3 3 $0 NM; *
LOCALNESIUM TAB 3 $0 NM; *
LOCALNESIUM TAB -C 3 $0 NM; *
MAG CITRATE TAB 100MG 3 $0 NM; *
MAG-200 TAB 3 $0 NM; *
mag-delay tab 3 $0 NM; *
MAG-TAB SR TAB 84MG 3 $0 NM; *
MAGINEX TAB 615 MG 3 $0 NM; *
MAGN SULFATE CAP 70MG 3 $0 NM; *
magnacaps cap 100mg 3 $0 NM; *
MAGNEBIND TAB 200 3 $0 NM; *
MAGNEBIND TAB 300 3 $0 NM; *
MAGNESIUM CAP 300MG 3 $0 NM; *
MAGNESIUM CAP 400MG 3 $0 NM; *
MAGNESIUM GL TAB 550MG 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
112
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
magnesium oxide tab 400 mg (240
mg elemental mg)
3 $0 NM; *
magnesium oxide tab 400 mg
(241.3 mg elemental mg)
3 $0 NM; *
magnesium oxide tab 500 mg (mg
supplement)
3 $0 NM; *
MAGNESIUM TAB 30MG 3 $0 NM; *
magnesium tab 200 mg 3 $0 NM; *
magnesium tab 250 mg 3 $0 NM; *
MG GLUCONATE TAB 250MG 3 $0 NM; *
os-cal + d3 tab 500-200 3 $0 NM; *
OSTEO-PORETI TAB 3 $0 NM; *
oys shell+d tab 250-125 3 $0 NM; *
oysco 500 tab 500mg 3 $0 NM; *
OYSCO 500+D CHW 3 $0 NM; *
oyst shell/d tab 500-200 3 $0 NM; *
oyst shell/d tab 500mg 3 $0 NM; *
oyst-cal d tab 250mg 3 $0 NM; *
PARVA-CAL TAB 250-100 3 $0 NM; *
PARVA-CAL TAB 500MG 3 $0 NM; *
PHOS-NAK POW CONCENTR 3 $0 NM; *
RA CA/BORON TAB 3 $0 NM; *
ra coral cap calcium 3 $0 NM; *
ra magnesium cap 500mg 3 $0 NM; *
RA OYS SHL/D TAB 250MG 3 $0 NM; *
ra oys shl/d tab 500mg 3 $0 NM; *
selenium tab 100 mcg 3 $0 NM; *
SELENIUM TAB 200MCG 3 $0 NM; *
slow magnes/ tab calcium 3 $0 NM; *
SLOW-MAG TAB 3 $0 NM; *
sm ca/mg/zn tab 3 $0 NM; *
SM CORAL CAL TAB 1000MG 3 $0 NM; *
sm magnesium tab 250mg 3 $0 NM; *
UPCAL D POW 3 $0 NM; *
VITAMINS A-25 CAP 25000UNT 3 $0 NM; *
ACEROLA C WAF 500MG 3 $0 NM; *
ANTIOXIDANT CAP 3 $0 NM; *
APATATE LIQ 3 $0 NM; *
AQUA-E LIQ 3 $0 NM; *
aquadeks dro 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
113
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
ASCORBIC ACD POW 3 $0 NM; *
ascorbic acid cap cr 500 mg 3 $0 NM; *
ascorbic acid chew tab 250 mg 3 $0 NM; *
ascorbic acid syrup 500 mg/5ml 3 $0 NM; *
ascorbic acid tab 100 mg 3 $0 NM; *
ascorbic acid tab 250 mg 3 $0 NM; *
ascorbic acid tab 500 mg 3 $0 NM; *
ascorbic acid tab 1000 mg 3 $0 NM; *
ascorbic acid tab cr 500 mg 3 $0 NM; *
b complex tab form 1 3 $0 NM; *
B-1 TAB 500MG 3 $0 NM; *
B-12 DOTS TAB 500MCG 3 $0 NM; *
B-12 TAB 2500MCG 3 $0 NM; *
B-12 TAB 5000MCG 3 $0 NM; *
b-50 tr tab 3 $0 NM; *
b-100 complx tab 3 $0 NM; *
b-complex tab 50 tr 3 $0 NM; *
b-complex vitamin cap 3 $0 NM; *
b-complex vitamin sublingual liquid 3 $0 NM; *
b-complex vitamin tab 3 $0 NM; *
b-complex w/ c & calcium tab 3 $0 NM; *
b-complex w/ c cap 3 $0 NM; *
B-NATAL LOZ 25MG 3 $0 NM; *
bee zee tab 3 $0 NM; *
beta carotene cap 25000 unit 3 $0 NM; *
bio-d-mulsio liq 400unit 3 $0 NM; *
bio-d-mulsio liq 2000unit 3 $0 NM; *
biotin tab 300 mcg 3 $0 NM; *
brewers yeast tab 3 $0 NM; *
c-500 chw 500mg 3 $0 NM; *
calciferol dro 8000/ml 3 $0 NM; *
calcitriol cap 0.5 mcg 1 $0 B/D
calcitriol cap 0.25 mcg 1 $0 B/D
calcitriol inj 1 mcg/ml 1 $0 B/D
calcitriol oral soln 1 mcg/ml 1 $0 B/D
calcium ascorbate tab 500 mg 3 $0 NM; *
calcium pantothenate tab 500 mg 3 $0 NM; *
CALNA TAB 3 $0 NM; *
central-vite tab performa 3 $0 NM; *
CENTRUM CHW SILVER 3 $0 NM; *
centrum kids chw complete 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
114
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
cerovite adv liq formula 3 $0 NM; *
chewabl vite chw childrns 3 $0 NM; *
child chew/ chw extra c 3 $0 NM; *
CHILD-MULTI CHW VITAMINS 3 $0 NM; *
CHOLECALCIFEROL CAP 400 UNIT 3 $0 NM; *
cholecalciferol cap 2000 unit 3 $0 NM; *
cholecalciferol cap 5000 unit 3 $0 NM; *
cholecalciferol drops 5000 unit/ml
(1000 unit/0.2ml)
3 $0 NM; *
cholecalciferol oral liquid 400
unit/ml
3 $0 NM; *
cholecalciferol tab 400 unit 3 $0 NM; *
cholecalciferol tab 1000 unit 3 $0 NM; *
cholecalciferol tab 2000 unit 3 $0 NM; *
CL PRENATAL TAB 28-0.8MG 3 $0 NM; *
COD LIVER OIL 3 $0 NM; *
cod liver oil cap 3 $0 NM; *
cvs vit b-6 tab 200mg 3 $0 NM; *
cyanocobalamin inj 1000 mcg/ml 3 $0 NM; *
cyanocobalamin liquid 1000 mcg/15ml
3 $0 NM; *
cyanocobalamin tab 50 mcg 3 $0 NM; *
cyanocobalamin tab 100 mcg 3 $0 NM; *
cyanocobalamin tab 250 mcg 3 $0 NM; *
cyanocobalamin tab 500 mcg 3 $0 NM; *
cyanocobalamin tab 1000 mcg 3 $0 NM; *
cyanocobalamin tab 2000 mcg 3 $0 NM; *
cyanocobalamin tab cr 1000 mcg 3 $0 NM; *
cyanocobalamin tab sl 1000 mcg 3 $0 NM; *
cyanocobalamin tab sl 2500 mcg 3 $0 NM; *
CYTO B2 POW 3 $0 NM; *
D3 DOTS TAB 2000UNIT 3 $0 NM; *
daily-vite/ tab iron 3 $0 NM; *
DECARA CAP 25000UNT 3 $0 NM; *
DIALYVITE 80 TAB ZINC 15 3 $0 NM; *
dialyvite tab 800 3 $0 NM; *
e-oil oil 30000unt 3 $0 NM; *
ecee plus tab 3 $0 NM; *
ELDERTONIC ELX 3 $0 NM; *
energy b-12 tab 1500mcg 3 $0 NM; *
ergocalciferol cap 50000 unit 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
115
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
EZFE FORTE CAP 3 $0 NM; *
FA-8 CAP 800MCG 3 $0 NM; *
fa-8 tab 0.8mg 3 $0 NM; *
FOLIC ACID CAP 5MG 3 $0 NM; *
FOLIC ACID CAP 20MG 3 $0 NM; *
folic acid inj 5 mg/ml 3 $0 NM; *
folic acid tab 1 mg 3 $0 NM; *
FOLIC ACID TAB 1 MG 3 $0 NM; *
folic acid tab 400 mcg 3 $0 NM; *
folic acid tab 800 mcg 3 $0 NM; *
folic acid tab 800mcg 3 $0 NM; *
fruit c-100 chw 3 $0 NM; *
geravim liq 3 $0 NM; *
GERIATRIC LIQ VITAMIN 3 $0 NM; *
GNP DAILY MIS PRENATAL 3 $0 NM; *
gummi bear chw multivit 3 $0 NM; *
HONEY BEARS CHW 3 $0 NM; *
HONEY BEARS CHW IRON-ZIN 3 $0 NM; *
hydroxocobalamin inj 1000 mcg/ml 3 $0 NM; *
icaps cap 3 $0 NM; *
ICAPS LUTEIN TAB ZEAXANTH 3 $0 NM; *
icaps mv tab 3 $0 NM; *
iromin-g tab 3 $0 NM; *
kp vitamin e cap 100unit 3 $0 NM; *
KPN PRENATAL TAB 3 $0 NM; *
LUMITENE CAP 30MG 3 $0 NM; *
mega-maratho tab 100 tr 3 $0 NM; *
MEPHYTON TAB 5MG 3 $0 NM; *
meribin cap 5mg 3 $0 NM; *
MISSION PREN TAB 3 $0 NM; *
MISSION PREN TAB HP 3 $0 NM; *
multi-delyn liq 3 $0 NM; *
MULTI-DELYN LIQ /IRON 3 $0 NM; *
multi-vit tab 3 $0 NM; *
MYKIDZ IRON SUS 10MG/2ML 3 $0 NM; *
nail-ex tab 2.5mg 3 $0 NM; *
NASCOBAL SPR 500MCG 3 $0 NM; *
NEPHRONEX LIQ 3 $0 NM; *
neuro-k-250 tab 250mg 3 $0 NM; *
neuro-k-500 tab 3 $0 NM; *
niacin cap cr 250 mg 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
116
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
niacin cap cr 500 mg 3 $0 NM; *
niacin tab 50 mg 3 $0 NM; *
niacin tab 100 mg 3 $0 NM; *
niacin tab 250 mg 3 $0 NM; *
niacin tab 500 mg 3 $0 NM; *
niacin tab cr 500 mg 3 $0 NM; *
niacin tab cr 750 mg 3 $0 NM; *
NIACIN TR TAB 1000MG 3 $0 NM; *
niacinamide tab 100 mg 3 $0 NM; *
niacinamide tab 500 mg 3 $0 NM; *
nutr-e-sol liq 400/15ml 3 $0 NM; *
NUTRICION TAB PORVIDA 3 $0 NM; *
pantothenic acid tab 100 mg 3 $0 NM; *
pantothenic acid tab 500 mg 3 $0 NM; *
paricalcitol cap 1 mcg 1 $0 B/D
paricalcitol cap 2 mcg 1 $0 B/D
paricalcitol cap 4 mcg 1 $0 B/D
PERRY PRENAT CAP 3 $0 NM; *
phytonadione inj 1 mg/0.5ml (2
mg/ml)
3 $0 NM; *
phytonadione inj 10 mg/ml 3 $0 NM; *
phytonadione tab 100 mcg 3 $0 NM; *
polyvitamin dro 3 $0 NM; *
polyvitamin dro /iron 3 $0 NM; *
PRENATAL TAB 3 $0 NM; *
PRENATAL TAB 27-0.8MG 3 $0 NM; *
PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)
1 $0
PROTEXIN SYP 3 $0 NM; *
pyridoxine hcl inj 100 mg/ml 3 $0 NM; *
pyridoxine hcl tab 25 mg 3 $0 NM; *
pyridoxine hcl tab 50 mg 3 $0 NM; *
pyridoxine hcl tab 100 mg 3 $0 NM; *
pyridoxine hcl tab cr 200 mg 3 $0 NM; *
ra b-complex tab vit c tr 3 $0 NM; *
ra beta caro cap 15mg 3 $0 NM; *
ra vit c loz 60mg 3 $0 NM; *
ra vitamin c tab 1000mg 3 $0 NM; *
riboflavin tab 25 mg 3 $0 NM; *
riboflavin tab 50 mg 3 $0 NM; *
riboflavin tab 100 mg 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
117
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
ROCALTROL CAP 0.5MCG 2 $0 B/D
ROCALTROL CAP 0.25MCG 2 $0 B/D
ROCALTROL SOL 1MCG/ML 2 $0 B/D
SCOOBY-DOO CHW 3 $0 NM; *
slo-niacin tab 250mg cr 3 $0 NM; *
STUART PRENA PAK + DHA 3 $0 NM; *
super b-100 tab 3 $0 NM; *
SUPER POW NU-THERA 3 $0 NM; *
TAB-A-VITE TAB WOMENS 3 $0 NM; *
THERA BETA- TAB CAROTENE 3 $0 NM; *
THERA-D TAB 4000UNIT 3 $0 NM; *
THERANATAL TAB 27-1 3 $0 NM; *
thiamine hcl inj 100 mg/ml 3 $0 NM; *
thiamine hcl tab 50 mg 3 $0 NM; *
thiamine hcl tab 100 mg 3 $0 NM; *
thiamine hcl tab 250 mg 3 $0 NM; *
thiamine mononitrate tab 100 mg 3 $0 NM; *
total b/c tab 3 $0 NM; *
TRI-VI-SOL DRO /IRON 3 $0 NM; *
TRI-VI-SOL SOL 3 $0 NM; *
tri-vita sol 3 $0 NM; *
tri-vitamin dro 3 $0 NM; *
vit c & e cap combo 3 $0 NM; *
vita-bee/c tab 3 $0 NM; *
VITA-MAG TAB 3 $0 NM; *
vita-plus e cap 400unit 3 $0 NM; *
VITALETS CHW 3 $0 NM; *
vitalize liq ginseng 3 $0 NM; *
vitamin a cap 8000unit 3 $0 NM; *
vitamin a cap 10000 unit 3 $0 NM; *
VITAMIN A TAB 3 $0 NM; *
vitamin a tab 10000 unit 3 $0 NM; *
VITAMIN A TAB 15000UNT 3 $0 NM; *
vitamin b12 tab 2000mcg 3 $0 NM; *
VITAMIN C CHW 1000MG 3 $0 NM; *
VITAMIN C SOL 3 $0 NM; *
VITAMIN D2 TAB 400UNIT 3 $0 NM; *
VITAMIN D2 TAB 2000UNIT 3 $0 NM; *
VITAMIN D3 CAP 4000UNIT 3 $0 NM; *
vitamin d3 cap 10000unt 3 $0 NM; *
vitamin d3 cap 50000unt 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
118
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
VITAMIN D3 LIQ 1200UNIT 3 $0 NM; *
VITAMIN D3 TAB 3000UNIT 3 $0 NM; *
vitamin d3 tab 5000unit 3 $0 NM; *
VITAMIN D3 TAB 50000UNT 3 $0 NM; *
vitamin d cap 1000unit 3 $0 NM; *
vitamin d chw 400unit 3 $0 NM; *
vitamin d chw 1000unit 3 $0 NM; *
vitamin e cap 200 unit 3 $0 NM; *
vitamin e cap 600 unit 3 $0 NM; *
vitamin e cap 1000 unit 3 $0 NM; *
VITAMIN E CHW 400UNIT 3 $0 NM; *
vitamin e soln 15 unit/0.3ml (50 unit/ml)
3 $0 NM; *
VITAMIN E TAB 100UNIT 3 $0 NM; *
VITAMIN E TAB 200UNIT 3 $0 NM; *
vitamin e tab 400 unit 3 $0 NM; *
VITAMIN K TAB 100MCG 3 $0 NM; *
vitamin mixture cap 3 $0 NM; *
vitamins a & d cap 3 $0 NM; *
vitatrum chw 3 $0 NM; *
vite/iron chw children 3 $0 NM; *
yl folic aci tab 400mcg 3 $0 NM; *
ZOO FRIENDS CHW COMPLETE 3 $0 NM; *
OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT
INFECTIONS AND INFLAMMATION bacitracin-polymyxin-neomycin-hc
ophth oint 1% 1 $0
blephamide oin s.o.p. 2 $0
neomycin-polymyxin-dexamethasone ophth oint 0.1%
1 $0
neomycin-polymyxin-dexamethasone ophth susp 0.1%
1 $0
neomycin-polymyxin-hc ophth susp 1 $0
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)%
1 $0
TOBRADEX OIN 0.3-0.1% 2 $0
TOBRADEX ST SUS 0.3-0.05 2 $0
tobramycin-dexamethasone ophth
susp 0.3-0.1%
1 $0
ZYLET SUS 0.5-0.3% 2 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
120
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
flurbiprofen sodium ophth soln
0.03%
1 $0
ILEVRO DRO 0.3% OP 2 $0
ketorolac tromethamine ophth soln
0.4%
1 $0
ketorolac tromethamine ophth soln
0.5%
1 $0
LOTEMAX GEL 0.5% 2 $0
LOTEMAX OIN 0.5% 2 $0
LOTEMAX SUS 0.5% 2 $0
MAXIDEX SUS 0.1% OP 2 $0
NEVANAC SUS 0.1% 2 $0
pred sod pho sol 1% op 2 $0
PREDNISOLONE ACETATE OPHTH
SUSP 1%
1 $0
ANTIALLERGICS - DRUGS TO TREAT ALLERGIES altafrin sol 0.12% 3 $0 NM; *
azelastine hcl ophth soln 0.05% 1 $0
BEPREVE DRO 1.5% 2 $0
cromolyn sodium ophth soln 4% 1 $0
EYE ALLERGY SOL RELIEF 3 $0 NM; *
eye drops sol 0.05% op 3 $0 NM; *
eye drops sol a/r 3 $0 NM; *
ketotif fum dro 0.025%op 3 $0 NM; *
LASTACAFT SOL 0.25% 2 $0
PATADAY SOL 0.2% 2 $0
PATANOL SOL 0.1% OP 2 $0
PAZEO DRO 0.7% 2 $0
VASOCLEAR A SOL OP 3 $0 NM; *
visine-a sol op 3 $0 NM; *
VISINE-LR SOL 0.025% 3 $0 NM; *
ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% 2 $0
AZOPT SUS 1% OP 2 $0
betaxolol hcl ophth soln 0.5% 1 $0
BETOPTIC-S SUS 0.25% OP 2 $0
brimonidine tartrate ophth soln
0.2%
1 $0
BRIMONIDINE TARTRATE OPHTH
SOLN 0.15%
1 $0
carteolol hcl ophth soln 1% 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
122
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
MURO 128 SOL 2% OP 3 $0 NM; *
naphazoline hcl ophth soln 0.1% 1 $0
natures tear sol 0.4% 3 $0 NM; *
NUTRATEAR SOL 0.6% 3 $0 NM; *
optics mini dro 3 $0 NM; *
PROLENSA SOL 0.07% 2 $0
proparacaine hcl ophth soln 0.5% 1 $0
pure & gentl dro 0.3% 3 $0 NM; *
ra lubricant dro 0.4-0.3% 3 $0 NM; *
REFRESH CELL DRO 1% OP 3 $0 NM; *
refresh p.m. oin op 3 $0 NM; *
REFRESH SOL OPTIVE 3 $0 NM; *
RESTASIS EMU 0.05% 2 $0 QL (64 vials / 30 days)
RETAINE MGD EMU 0.5-0.5% 3 $0 NM; *
sodium chloride hypertonic ophth
oint 5%
3 $0 NM; *
sodium chloride hypertonic ophth
soln 5%
3 $0 NM; *
SOOTHE DRO 0.6-0.6% 3 $0 NM; *
STERILE LUBR DRO 0.7% 3 $0 NM; *
SYSTANE BAL SOL RESTOR 3 $0 NM; *
systane dro contacts 3 $0 NM; *
SYSTANE GEL 0.3% 3 $0 NM; *
SYSTANE LIQ DRO 0.4-0.3% 3 $0 NM; *
systane oin 3 $0 NM; *
TEARS AGAIN GEL NGHT/DAY 3 $0 NM; *
tgt lubricnt dro eye 3 $0 NM; *
th eye tears dro 3 $0 NM; *
THERATEARS SOL OP 3 $0 NM; *
VIVA DROPS DRO 1% 3 $0 NM; *
RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES ALA-HIST IR TAB 2MG 3 $0 NM; *
ALDEX AN CHW 5MG 3 $0 NM; *
all day allg tab 10mg 3 $0 NM; *
ALLEGRA ALRG SUS 30MG/5ML 3 $0 NM; *
ALLEGRA ALRG TAB 30MG 3 $0 NM; *
aller-ease tab 60mg 3 $0 NM; *
allergy chld liq 12.5/5ml 3 $0 NM; *
allergy relf cap 25mg 3 $0 NM; *
allergy relf tab 10mg 3 $0 NM; *
allergy relf tab 25mg 3 $0 NM; *
allrgy relf tab 12.5mg 3 $0 NM; *
altaryl elx 12.5/5ml 3 $0 NM; *
ASTEPRO SPR 0.15% 2 $0
azelastine hcl nasal spray 0.1%
(137 mcg/spray)
1 $0
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray)
1 $0
cetirizine hcl chew tab 5 mg 3 $0 NM; *
cetirizine hcl chew tab 10 mg 3 $0 NM; *
cetirizine hcl oral soln 1 mg/ml (5
mg/5ml)
1 $0
cetirizine hcl tab 5 mg 3 $0 NM; *
cetirizine sol 5mg/5ml 3 $0 NM; *
child comple chw allergy 3 $0 NM; *
chlorpheniramine maleate tab 4 mg 3 $0 NM; *
chlorpheniramine maleate tab cr 12 mg
3 $0 NM; *
CLARITIN CAP 10MG 3 $0 NM; *
CLARITIN CHW 5MG 3 $0 NM; *
CLARITIN RDT TAB 5MG 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
126
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
childrens sus plus cld 3 $0 NM; *
chld decongs liq 15mg/5ml 3 $0 NM; *
CHLO TUSS EX LIQ 12.5-100 3 $0 NM; *
cld/cgh/sore liq throat 3 $0 NM; *
CLOFERA LIQ 3 $0 NM; *
CNTC CLD/FLU PAK DAY/NGHT 3 $0 NM; *
CNTC CLD/FLU TAB MAX ST 3 $0 NM; *
CODAR AR LIQ 3 $0 NM; *
CODAR D LIQ 3 $0 NM; *
CODAR GF LIQ 3 $0 NM; *
CODITUSS DM SYP 3 $0 NM; *
cold head tab cong dt 3 $0 NM; *
cold medicin cap plus 3 $0 NM; *
cold multi pak day/nght 3 $0 NM; *
cold multi-s tab night 3 $0 NM; *
cold relief tab plus 3 $0 NM; *
cold/allergy elx children 3 $0 NM; *
cold/allery sus child 3 $0 NM; *
cold/cough elx child 3 $0 NM; *
cold/sinus tab relief 3 $0 NM; *
COMPLETE SIN TAB RELIEF 3 $0 NM; *
comtrex sev pak cld/sinu 3 $0 NM; *
CONEX SOL CLD/ALRG 3 $0 NM; *
CONEX TAB 2-60MG 3 $0 NM; *
contac tab cold+flu 3 $0 NM; *
coricidin cap cong/cgh 3 $0 NM; *
coricidin liq hbp 3 $0 NM; *
cough & cold tab 3 $0 NM; *
cough & sore liq thrt day 3 $0 NM; *
cough cont liq dm max 3 $0 NM; *
COUGH D SYP 3 $0 NM; *
cough dm liq 30mg/5ml 3 $0 NM; *
12.5cpd/1dcp liq m/30pse 3 $0 NM; *
cromolyn sodium nasal aerosol soln
5.2 mg/act (4%)
3 $0 NM; *
cvs nasal spr mist 3 $0 NM; *
DALLERGY SYP 3 $0 NM; *
day time liq cough 3 $0 NM; *
day-time cap sinus 3 $0 NM; *
day/nite mis cold/flu 3 $0 NM; *
de-chlor dm liq liquid 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
127
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
DECON-A LIQ DROPS 3 $0 NM; *
decongestant tab 120mg er 3 $0 NM; *
delsym child liq cgh/cold 3 $0 NM; *
DELTUSS DP LIQ 1-30/5ML 3 $0 NM; *
DEX-TUSS LIQ 300-10/5 3 $0 NM; *
DEXATREX D ELX CF-NASAL 3 $0 NM; *
dextromethorphan-guaifenesin tab
20-400 mg
3 $0 NM; *
DIABETIC CAP COLD/FLU 3 $0 NM; *
DICEL CD LIQ 3 $0 NM; *
dimetane dx syp 3 $0 NM; *
dimetapp liq nighttim 3 $0 NM; *
DIMETAPP SYP CGH/COLD 3 $0 NM; *
DONATUSSIN SYP 3 $0 NM; *
DRYMAX AF TAB 15-4-25 3 $0 NM; *
DURAFLU TAB 3 $0 NM; *
ed a-hist dm liq 3 $0 NM; *
ed bron gp liq 3 $0 NM; *
ED CHLORPED DRO D 3 $0 NM; *
entre-b sus 6-10mg/5 3 $0 NM; *
entre-cough liq 3 $0 NM; *
entre-hist liq 0.938-10 3 $0 NM; *
ENTSOL NASAL GEL 3 $0 NM; *
exefen dmx tab 3 $0 NM; *
exefen-ir tab 60-400mg 3 $0 NM; *
father johns syp 10mg/5ml 3 $0 NM; *
fexofenadine-pseudoephedrine tab sr 24hr 180-240 mg
3 $0 NM; *
flu/cold/cgh pow daytime 3 $0 NM; *
flu/severe pow cold/cgh 3 $0 NM; *
gnp day time liq cold/flu 3 $0 NM; *
gnp ibuprofn tab cold/sin 3 $0 NM; *
gnp tussin liq nighttim 3 $0 NM; *
guaifenesin syrup 100 mg/5ml 3 $0 NM; *
guaifenesin-codeine soln 100-10 mg/5ml
3 $0 NM; *
intense cold tab /flu med 3 $0 NM; *
intense coug liq reliever 3 $0 NM; *
J-MAX SYP 5-200MG 3 $0 NM; *
J-TAN D PD DRO 1-7.5MG 3 $0 NM; *
kidkare liq cgh/cold 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
128
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
liquituss gg liq 200/5ml 3 $0 NM; *
LITTLE NOSES DRO 0.125% 3 $0 NM; *
LODRANE D CAP 4-60MG 3 $0 NM; *
LOHIST-D LIQ 3 $0 NM; *
lohist-dm syp 5-2-10mg 3 $0 NM; *
lohist-peb liq 4-10/5ml 3 $0 NM; *
loratadine & pseudoephedrine tab
sr 24hr 10-240 mg
3 $0 NM; *
LORTUSS DM LIQ 3 $0 NM; *
LORTUSS EX LIQ 3 $0 NM; *
LORTUSS LQ LIQ 3 $0 NM; *
LUSAIR LIQ 3 $0 NM; *
m-clear wc liq 3 $0 NM; *
m-end dm liq 3 $0 NM; *
M-END DMX LIQ 3 $0 NM; *
M-END MAX D LIQ 3 $0 NM; *
M-END PE LIQ 3 $0 NM; *
m-end wc liq 3 $0 NM; *
mapap cold tab 10-5-325 3 $0 NM; *
MAR-COF BP LIQ 3 $0 NM; *
MEDI-GRAINE TAB 3 $0 NM; *
mucaphed tab 10-400mg 3 $0 NM; *
MUCINEX CGH GRA 5-100MG 3 $0 NM; *
mucinex cold tab sinus 3 $0 NM; *
MUCINEX D TAB 60-600MG 3 $0 NM; *
MUCINEX D TAB 120-1200 3 $0 NM; *
MUCINEX TAB 1200MG 3 $0 NM; *
MUCINEX/KIDS GRA 50MG 3 $0 NM; *
MUCINEX/KIDS GRA 100MG 3 $0 NM; *
mucus relief liq 5-100mg 3 $0 NM; *
mucus relief liq cold/sin 3 $0 NM; *
mucus relief tab 400mg 3 $0 NM; *
mucus+chst liq 100/5ml 3 $0 NM; *
mucus-dm max tab 60-1200 3 $0 NM; *
mucus-dm tab 30-600mg 3 $0 NM; *
mucus-er tab 600mg 3 $0 NM; *
multi-sympt liq cld nght 3 $0 NM; *
multi-sympt pak day/nght 3 $0 NM; *
multsym cold liq childrns 3 $0 NM; *
nasal decon liq 15mg/5ml 3 $0 NM; *
nasal decon syp 30mg/5ml 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
131
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
THERAFLU FLU PAK SORE THR 3 $0 NM; *
theraflu nt liq warm rlf 3 $0 NM; *
THERAFLU POW 3 $0 NM; *
THERAFLU POW MAX-D 3 $0 NM; *
triacting dt liq cold/cgh 3 $0 NM; *
triaminic liq 3 $0 NM; *
TRIAMINIC NT MIS COLD/CGH 3 $0 NM; *
TRIAMINIC SOL COLD/CGH 3 $0 NM; *
TRIAMINIC SYP CHST/NSL 3 $0 NM; *
TRIAMINIC SYP COLD/ALL 3 $0 NM; *
TRIAMINIC SYP COLD/CGH 3 $0 NM; *
TRIAMINIC SYP FEVER 3 $0 NM; *
TRICODE AR LIQ 3 $0 NM; *
TRICODE GF LIQ 3 $0 NM; *
trymine cg liq 225-7.5 3 $0 NM; *
tusnel c syp 3 $0 NM; *
TUSNEL LIQ 3 $0 NM; *
TUSNEL PED DRO 7.5-50 3 $0 NM; *
TUSNEL PEDI LIQ 15-5-50 3 $0 NM; *
TUSNEL-DM DRO PEDIATRC 3 $0 NM; *
tussi-pres liq pe ped 3 $0 NM; *
tussin cf liq cgh/cold 3 $0 NM; *
tussin dm syp 100-10/5 3 $0 NM; *
vcks dayquil liq mucus dm 3 $0 NM; *
VICK VAPORUB OIN 3 $0 NM; *
wal-act tab 2.5-60mg 3 $0 NM; *
wal-dryl all tab sinus 3 $0 NM; *
wal-dryl-d tab alrg/sin 3 $0 NM; *
wal-fex d tab 12 hour 3 $0 NM; *
wal-flu cold pak daytime 3 $0 NM; *
wal-itin d tab 5-120mg 3 $0 NM; *
wal-phed pe tab 4-10mg 3 $0 NM; *
wal-phed tab 4-60mg 3 $0 NM; *
4-way fast spr 1% 3 $0 NM; *
z-cof 12dm liq 3 $0 NM; *
Z-TUSS AC LIQ 2-9/5ML 3 $0 NM; *
Z-TUSS E LIQ 3 $0 NM; *
ZODRYL AC 25 SUS 3 $0 NM; *
ZODRYL AC 30 SUS 3 $0 NM; *
ZODRYL AC 35 SUS 3 $0 NM; *
ZODRYL AC 40 SUS 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
132
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
ZODRYL DAC SUS 25 3 $0 NM; *
ZODRYL DAC SUS 30 3 $0 NM; *
ZODRYL DAC SUS 35 3 $0 NM; *
ZODRYL DAC SUS 40 3 $0 NM; *
ZODRYL DEC25 SUS 3 $0 NM; *
ZODRYL DEC30 SUS 3 $0 NM; *
ZODRYL DEC35 SUS 3 $0 NM; *
ZODRYL DEC40 SUS 3 $0 NM; *
zonatuss cap 150mg 3 $0 NM; *
LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT ASTHMA
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE adapalene cream 0.1% 1 $0
adapalene gel 0.1% 1 $0
amnesteem cap 10mg 1 $0
amnesteem cap 20mg 1 $0
amnesteem cap 40mg 1 $0
AVITA CRE 0.025% 1 $0
AVITA GEL 0.025% 1 $0
benzoyl peroxide-erythromycin gel
5-3%
1 $0
claravis cap 10mg 1 $0
claravis cap 20mg 1 $0
claravis cap 30mg 1 $0
claravis cap 40mg 1 $0
clindamax gel 1% 1 $0
clindamycin phosphate gel 1% 1 $0
clindamycin phosphate lotion 1% 1 $0
clindamycin phosphate soln 1% 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
135
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
clindamycin phosphate swab 1% 1 $0
erythromycin gel 2% 1 $0
erythromycin pads 2% 1 $0
erythromycin soln 2% 1 $0
myorisan cap 10mg 1 $0
myorisan cap 20mg 1 $0
myorisan cap 40mg 1 $0
sulfacetamide sodium lotion 10%
(acne)
1 $0
tretinoin cream 0.1% 1 $0
tretinoin cream 0.05% 1 $0
tretinoin cream 0.025% 1 $0
tretinoin gel 0.01% 1 $0
tretinoin gel 0.025% 1 $0
zenatane cap 10mg 1 $0
zenatane cap 20mg 1 $0
zenatane cap 30mg 1 $0
zenatane cap 40mg 1 $0
DERMATOLOGY, ANTIBIOTICS ACNE MEDICAT LOT 5% 3 $0 NM; *
ACNE MEDICAT LOT 10% 3 $0 NM; *
antibiotic cre plus 3 $0 NM; *
bacitracin oint 500 unit/gm 3 $0 NM; *
bacitracin zinc oint 500 unit/gm 3 $0 NM; *
BENZOYL PER GEL 2.5% 3 $0 NM; *
benzoyl per gel 5% 3 $0 NM; *
benzoyl per gel 10% 3 $0 NM; *
benzoyl per liq 5% wash 3 $0 NM; *
benzoyl per lot 6% 3 $0 NM; *
BP CLEANSING LOT 4% 3 $0 NM; *
bp wash liq 5.25% 3 $0 NM; *
clean&clear cre 10% 3 $0 NM; *
double antib oin 3 $0 NM; *
gentamicin sulfate cream 0.1% 1 $0
gentamicin sulfate oint 0.1% 1 $0
mupirocin oint 2% 1 $0
neosporin+pn oin relf max 3 $0 NM; *
PANOXYL BAR 10% 3 $0 NM; *
panoxyl wash liq 10% 3 $0 NM; *
PANOXYL-4 LIQ CREM WSH 3 $0 NM; *
PANOXYL-8 LIQ CREM WSH 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
138
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
betamethasone dipropionate
augmented lotion 0.05%
1 $0
betamethasone dipropionate
augmented oint 0.05%
1 $0
betamethasone dipropionate cream
0.05%
1 $0
betamethasone dipropionate lotion
0.05%
1 $0
betamethasone dipropionate oint
0.05%
1 $0
betamethasone valerate cream
0.1%
1 $0
betamethasone valerate lotion
0.1%
1 $0
betamethasone valerate oint 0.1% 1 $0
clobetasol e cre 0.05% 1 $0
clobetasol propionate cream 0.05% 1 $0
clobetasol propionate gel 0.05% 1 $0
clobetasol propionate oint 0.05% 1 $0
clobetasol propionate soln 0.05% 1 $0
cormax scalp sol 0.05% 1 $0
cortaid spr 1% 3 $0 NM; *
cortizone-10 gel 1% 3 $0 NM; *
demarest cre dricort 3 $0 NM; *
DESONIDE CREAM 0.05% 1 $0
desonide lotion 0.05% 1 $0
desonide oint 0.05% 1 $0
desoximetasone cream 0.05% 1 $0
desoximetasone cream 0.25% 1 $0
desoximetasone gel 0.05% 1 $0
DESOXIMETASONE OINT 0.05% 1 $0
desoximetasone oint 0.25% 1 $0
diflorasone diacetate cream 0.05% 1 $0
diflorasone diacetate oint 0.05% 1 $0
fluocin acet oil scalp 1 $0
fluocinolone acetonide cream
0.01%
1 $0
fluocinolone acetonide cream
0.025%
1 $0
fluocinolone acetonide oil 0.01%
(body oil)
1 $0
fluocinolone acetonide oint 0.025% 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
139
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
fluocinolone acetonide soln 0.01% 1 $0
fluocinonide cream 0.05% 1 $0
fluocinonide emulsified base cream 0.05%
1 $0
fluocinonide gel 0.05% 1 $0
fluocinonide oint 0.05% 1 $0
fluocinonide soln 0.05% 1 $0
fluticasone propionate cream 0.05%
1 $0
fluticasone propionate oint 0.005% 1 $0
halobetasol propionate cream
0.05%
1 $0
halobetasol propionate oint 0.05% 1 $0
hc-1% hemorr oin 1% 3 $0 NM; *
HYDROCORT AC CRE 0.5% 3 $0 NM; *
HYDROCORT/ OIN ALOE 1% 3 $0 NM; *
hydrocortisone butyrate cream 0.1%
1 $0
hydrocortisone butyrate oint 0.1% 1 $0
hydrocortisone butyrate soln 0.1% 1 $0
hydrocortisone cream 0.5% 3 $0 NM; *
hydrocortisone cream 1% 1 $0
hydrocortisone cream 1% 3 $0 NM; *
hydrocortisone cream 2.5% 1 $0
hydrocortisone lotion 2.5% 1 $0
hydrocortisone oint 0.5% 3 $0 NM; *
hydrocortisone oint 1% 1 $0
hydrocortisone oint 2.5% 1 $0
hydrocortisone valerate cream
0.2%
1 $0
hydrocortisone valerate oint 0.2% 1 $0
hydrocortisone-aloe vera cream
0.5%
3 $0 NM; *
hydrocortisone-aloe vera cream 1% 3 $0 NM; *
LOKARA LOT 0.05% 1 $0
mometasone furoate cream 0.1% 1 $0
mometasone furoate oint 0.1% 1 $0
mometasone furoate solution 0.1% (lotion)
1 $0
ra anti-itch oin 1% 3 $0 NM; *
ra hydrocort cre 0.5% 3 $0 NM; *
texacort sol 2.5% 2 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
140
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
triamcinolone acetonide cream
0.1%
1 $0
triamcinolone acetonide cream
0.5%
1 $0
triamcinolone acetonide cream
0.025%
1 $0
triamcinolone acetonide lotion
0.1%
1 $0
triamcinolone acetonide lotion
0.025%
1 $0
triamcinolone acetonide oint 0.1% 1 $0
triamcinolone acetonide oint 0.5% 1 $0
triamcinolone acetonide oint
0.025%
1 $0
triderm cre 0.1% 1 $0
TUCKS OIN 1% 3 $0 NM; *
DERMATOLOGY, LOCAL ANESTHETICS lidocaine hcl gel 2% 1 $0
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
141
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
metronidazole lotion 0.75% 1 $0
MEXSANA POW 3 $0 NM; *
PANRETIN GEL 0.1% 2 $0
podofilox soln 0.5% 1 $0
RA CALAMINE LOT 3 $0 NM; *
risamine oin 3 $0 NM; *
rosadan cre 0.75% 1 $0
SECURA CRE 30.6% 3 $0 NM; *
secura prote cre 10% 3 $0 NM; *
SENSI-CARE OIN 49-15% 3 $0 NM; *
TARGRETIN GEL 1% 2 $0 NM, PA
TRIPLE PASTE OIN 12.8% 3 $0 NM; *
VALCHLOR GEL 0.016% 2 $0 NM, LA, PA
VOLTAREN GEL 1% 2 $0
zinc oxide oint 20% 3 $0 NM; *
ZINC OXIDE PST 25% 3 $0 NM; *
DERMATOLOGY, SCABICIDES AND PEDICULIDES A-200 GEL 0.33-4% 3 $0 NM; *
If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11
142
Drug Name Drug Tier
WHAT THE DRUG WILL
COST YOU
NECESSARY ACTIONS RESTRICTIONS OR
LIMITS ON USE
SODIUM CHLORIDE IRRIGATION
SOLN 0.9%
1 $0
WATER FOR IRRIGATION, STERILE
IRRIGATION SOLN
1 $0
MOUTH/THROAT/DENTAL AGENTS cevimeline hcl cap 30 mg 1 $0
chlorhexidine gluconate soln 0.12% 1 $0
clotrimazole troche 10 mg 1 $0
lidocaine hcl viscous soln 2% 1 $0
nystatin susp 100000 unit/ml 1 $0
periogard sol 0.12% 1 $0
pilocarpine hcl tab 5 mg 1 $0
pilocarpine hcl tab 7.5 mg 1 $0
triamcinolone acetonide dental paste 0.1%
1 $0
OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid 2% in aluminum acetate