This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available
covered options. For a summary of your coverage or benefits plan log in to your secure member site at www.aetna.com
. Or call the toll-free number on your member ID card.
. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this
information and any health-related questions you haveThis list is subject to change.
Subject to applicable laws and regulations.
†
This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.
* Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and
package size.
** Listing does not include certain NDCs*.
1
An exception process may exist for specific clinical or regulatory circumstances that may require coverage of a non-covered medication. If your doctor believes you have a specific
clinical need for a non-covered product, they should fax an exception request to: 1-888-487-9257.
2
For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).
3
QVAR REDIHALER covered for members 5 years of age and under.
4
If approved for coverage and prescribed for primary prevention of cardiovascular disease, may be covered without cost sharing through an exceptions process.
5
Rebranded or private label formulations are not covered (i.e., RELION).
6
Long Acting Insulins - First Generation.
7
BD ULTRAFINE syringes and needles are the only preferred options.
8
An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK or
ONETOUCH. For more information on how to obtain a blood glucose meter, call: 1-877-418-4746.
9
ACCU-CHEK or ONETOUCH brand test strips are the only preferred options.
10
Generic multivitamins (except Activite, Dexifol, Folvite-D, Genicin Vita-S, HylaVite, Multipro, TronVite, Vitasure) are the only preferred options.
11
Generic prenatal vitamins are the only preferred options.
Please note that if your prescription drug benefits plan changes, the information here may no longer apply. Medications on the A
etna Drug Guide, precertification, step-therapy and
quantity limits lists are subject to change. Not all health services are covered. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking
cessation. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are
subject to change. The drugs on the Pharmacy Drug Guide (formulary), Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and step
therapy drug coverage review programs are not available in all service areas. However, these programs are available to self-funded plans. In accordance with state law, commercial fully
insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the
Pharmacy Drug Guide (formulary), Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level
until their plan’s renewal date. In Texas, precertification approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law,
certain fully insured commercial California members (except Federal Employee Health Benefit Plan members) who obtained approval from an Aetna plan for coverage of drugs that are
later added to the Preauthorization or Step Therapy Lists or removed from the Pharmacy Drug Guide will continue to have those drugs covered, for as long as the treating in-network
provider continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. Aetna reserves
the right to periodically request clinical information from your provider to assess your medical condition and the appropriateness of your ongoing treatment. Failure to provide clinical
information could result in subsequent denial of coverage for this medication. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO)
members (except Federal Employee Health Benefit Plan members) who are receiving coverage for drugs that are added to the Precertification or Step-Therapy Lists will continue to have
those drugs covered for as long as the prescriber prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this
section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be
construed to prohibit generic drug substitutions. In certain states, including Arkansas, Colorado, Connecticut, Delaware, Georgia, Illinois, Louisiana, Maryland, Minnesota, North Dakota,
Pennsylvania and Texas, step therapy programs do not apply to fully insured members utilizing prescription drugs for the treatment of stage-four advanced, metastatic cancer. This
material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete
description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent
contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to
change. CVS Caremark Mail Service Pharmacy is part of the CVS Health family of companies.
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