2018 Aetna Premier Plus Plan

Absorica

Products Affected• ABSORICA

PA Criteria Criteria Details

Covered Uses Severe recalcitrant nodular or cystic acne

Exclusion Criteria

Required Medical Information

Member is enrolled in the FDA iPLEDGE program and, because of significant adverse reactions associated with its use, should be reserved for patients with multiple severe nodular acne who are unresponsive to conventional therapy, including topical acne products and systemic antibiotics

Age Restrictions

Prescriber Restrictions

Coverage Duration

1 year

Other Criteria

QL Criteria 2 capsules Per 1 Day

Notes/References

Annual Review: 02/2017

Revision DatePrior Authorization: August 22, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

2018 Aetna Premier Plus Plan01/01/2018

Abstral

Products Affected• ABSTRAL

Covered Uses Breakthrough cancer pain, General anesthesia

Exclusion Criteria

A documented diagnosis of cancer and concomitant use of long acting opioid therapy or member's resident state or contract state is California and the member is terminally ill

Age Restrictions

Coverage Duration

1 year

Other Criteria

For coverage of additional quantities, member must meet the following requirements: A Documented diagnosis of cancer and prescription is written by an oncologist or pain specialist, or member is enrolled in a hospice program or meets hospice criteria, or member's resident state or contract state is California and the member is terminally ill, or the patient has signed opioid agreement in support of clinical guidelines by the American Pain Society and the American Academy of Pain Medicine, Healthcare Provider verbal confirmation that an agreement has been signed by the patient meets the criteria requirement.*Exceptions to requiring the signed opioid agreement for additional quantities are only for those patients that have a diagnosis of cancer or that are enrolled in a hospice program and documentation of one of the following: Member has current diagnosis of cancer(*see exception to opioid agreement above) as the primary cause of the pain and is currently on long-acting opioid and is being titrated on the long-acting opioid by physician, and member has tried and failed an adequate trial of two weeks of a single entity or combination pain medication containing an immediate release acting opioid (ex. oxycodone, morphine sulfate oral(Roxanol), oxymorphone(Opana), hydromorphone(Dilaudid), oxycodone/apap(Percocet))

QL Criteria 120 tablets Per 30 Days

Notes/References

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

Acetaminophen-Codeine

Products Affected• acetaminophen-codeine

Covered Uses All FDA approved indications

Exclusion Criteria

(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.

Age Restrictions

Coverage Duration

Length of Therapy; see required medical information

Other Criteria

QL Criteria 90 MME Per 1 Day

Notes/References

Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

Acetaminophen-Codeine #2

Products Affected• acetaminophen-codeine #2

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Actemra

Products Affected• ACTEMRA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Actemra.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Refer to the clinical policy bulletin above for details.

Other Criteria

Notes/References

Actimmune

Products Affected• ACTIMMUNE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/actimmune.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• ACTIQ

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

QL Criteria 120 lozenges Per 30 Days

Notes/References

Adcirca

Products Affected• ADCIRCA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 tablets Per 1 Day

Notes/References

Adderall

Products Affected• ADDERALL

Notes/References

Adderall XR

Products Affected• ADDERALL XR

Notes/References

Adempas

Products Affected• ADEMPAS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Advate

Products Affected• ADVATE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Adynovate

Products Affected• adynovate

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Adzenys XR-ODT

Products Affected• ADZENYS XR-ODT

QL Criteria 1 tablet Per 1 Day

Notes/References

Afinitor

Products Affected• AFINITOR

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 30 days maximum Per 1 fill

Notes/References

Afinitor Disperz

Products Affected• AFINITOR DISPERZ

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Afstyla

Products Affected• AFSTYLA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Aldurazyme

Products Affected• ALDURAZYME

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Alecensa

Products Affected• ALECENSA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Alphanate/VWF Complex/Human

Products Affected• ALPHANATE/VWF COMPLEX/HUMAN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AlphaNine SD

Products Affected• ALPHANINE SD

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Alprolix

Products Affected• ALPROLIX

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Alunbrig

Products Affected• ALUNBRIG

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Alunbrig.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Amnesteem

Products Affected• AMNESTEEM

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

Amphetamine-Dextroamphet ER

Products Affected• amphetamine-dextroamphet er

Notes/References

Amphetamine-Dextroamphetamine

Products Affected• amphetamine-dextroamphetamine

Notes/References

Ampyra

Products Affected• AMPYRA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Ampyra.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

APAP-Caff-Dihydrocodeine

Products Affected• apap-caff-dihydrocodeine oral capsule• apap-caff-dihydrocodeine oral tablet 325-30-

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Aptensio XR

Products Affected• APTENSIO XR

QL Criteria 1 capsule Per 1 Day

Notes/References

Aralast NP

Products Affected• ARALAST NP

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Alpha-1 Antitrypsin Inhibitor Therapy.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Aranesp (Albumin Free)

Products Affected• ARANESP (ALBUMIN FREE) INJECTION

SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 150 MCG/0.75ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

• ARANESP (ALBUMIN FREE) INJECTION

SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Erythropoiesis_Stimulating_Agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Arcalyst

Products Affected• ARCALYST

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Arcalyst.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Arymo ER

Products Affected• ARYMO ER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ascomp-Codeine

Products Affected• ASCOMP-CODEINE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Aspirin-Caff-Dihydrocodeine

Products Affected• aspirin-caff-dihydrocodeine

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Atomoxetine HCl

Products Affected• atomoxetine hcl oral capsule 10 mg, 18 mg,

25 mg, 40 mg, 60 mg

Notes/References

Atomoxetine HCl

Products Affected• atomoxetine hcl oral capsule 100 mg, 80 mg

Notes/References

Aubagio

Products Affected• AUBAGIO

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Aubagio.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Austedo

Products Affected• AUSTEDO

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Austedo.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

AVINza

Products Affected• AVINZA ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 60 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Avonex

Products Affected• AVONEX

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Avonex Pen

Products Affected• AVONEX PEN INTRAMUSCULAR

AUTO-INJECTOR KIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Avonex Prefilled

Products Affected• AVONEX PREFILLED

INTRAMUSCULAR PREFILLED SYRINGE KIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Bebulin

Products Affected• BEBULIN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Bebulin VH

Products Affected• BEBULIN VH

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Belbuca

Products Affected• BELBUCA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

BeneFIX

Products Affected• BENEFIX INTRAVENOUS SOLUTION

RECONSTITUTED

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Benlysta

Products Affected• BENLYSTA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/benlysta.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Berinert

Products Affected• BERINERT

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/hereditary_angioedema.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Betaseron

Products Affected• BETASERON SUBCUTANEOUS KIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 15 vials Per 1 fill

Notes/References

Bexarotene

Products Affected• bexarotene

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Targretin.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Bivigam

Products Affected• BIVIGAM

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Bosulif

Products Affected• BOSULIF

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• BOTOX

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/botulinum_toxin.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Bravelle

Products Affected• BRAVELLE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Bunavail

Products Affected• BUNAVAIL BUCCAL FILM 2.1-0.3 MG

QL Criteria 6 films Per 1 Day

Notes/References

Bunavail

Products Affected• BUNAVAIL BUCCAL FILM 4.2-0.7 MG

Notes/References

Bunavail

Products Affected• BUNAVAIL BUCCAL FILM 6.3-1 MG

Notes/References

Buphenyl

Products Affected• BUPHENYL ORAL POWDER 3 GM/TSP • BUPHENYL ORAL TABLET

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Buprenorphine

Products Affected• buprenorphine

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 4 patches Per 28 Days

Notes/References

Buprenorphine HCl

Products Affected• buprenorphine hcl sublingual

Notes/References

Buprenorphine HCl-Naloxone HCl

Products Affected• buprenorphine hcl-naloxone hcl

Notes/References

Butalbital-APAP-Caff-Cod

Products Affected• butalbital-apap-caff-cod

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Butalbital-ASA-Caff-Codeine

Products Affected• butalbital-asa-caff-codeine

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Butorphanol Tartrate

Products Affected• butorphanol tartrate nasal

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Butrans

Products Affected• BUTRANS

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 4 patches Per 28 Days

Notes/References

Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: October 04, 2017

Cabometyx

Products Affected• CABOMETYX

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Capecitabine

Products Affected• capecitabine

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Capital/Codeine

Products Affected• CAPITAL/CODEINE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Caprelsa

Products Affected• CAPRELSA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Carbaglu

Products Affected• CARBAGLU

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Carimune NF

Products Affected• CARIMUNE NF INTRAVENOUS

SOLUTION RECONSTITUTED 12 GM, 6 GM

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cerdelga

Products Affected• CERDELGA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/gaucher_disease.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 2 caps Per 1 Day

Notes/References

Cerezyme

Products Affected• CEREZYME

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cetrotide

Products Affected• CETROTIDE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cholbam

Products Affected• CHOLBAM

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Cholbam.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Chorionic Gonadotropin

Products Affected• chorionic gonadotropin intramuscular

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cimzia

Products Affected• CIMZIA SUBCUTANEOUS KIT 2 X 200

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Cimzia.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 kit Per 1 month

Notes/References

Cimzia Prefilled

Products Affected• CIMZIA PREFILLED

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 kit Per 1 month

Notes/References

Cimzia Starter Kit

Products Affected• CIMZIA STARTER KIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 kit Per 1 year

Notes/References

Cinqair

Products Affected• CINQAIR

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/RESP/Cinqair.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cinryze

Products Affected• CINRYZE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Claravis

Products Affected• CLARAVIS

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

CloNIDine HCl ER

Products Affected• clonidine hcl er

Notes/References

Coagadex

Products Affected• COAGADEX

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Codeine Sulfate

Products Affected• codeine sulfate oral tablet

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cometriq (100 mg Daily Dose)

Products Affected• COMETRIQ (100 MG DAILY DOSE)

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Concerta

Products Affected• CONCERTA ORAL TABLET EXTENDED

RELEASE 18 MG, 27 MG, 54 MG

Notes/References

Concerta

Products Affected• CONCERTA ORAL TABLET EXTENDED

RELEASE 36 MG

Notes/References

ConZip

Products Affected• CONZIP

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Copaxone

Products Affected• COPAXONE SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/glatiramer.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Corifact

Products Affected• CORIFACT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cosentyx

Products Affected• COSENTYX

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Cosentyx.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cosentyx Sensoready Pen

Products Affected• COSENTYX SENSOREADY PEN

SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Cosentyx.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cotellic

Products Affected• COTELLIC

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cotempla XR-ODT

Products Affected• COTEMPLA XR-ODT

Notes/References

Cuprimine

Products Affected• CUPRIMINE ORAL CAPSULE 250 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cuvitru

Products Affected• CUVITRU

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cystadane

Products Affected• CYSTADANE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Cystaran

Products Affected• CYSTARAN

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/EYE/ophthalmic_agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Daklinza

Products Affected• DAKLINZA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Daytrana

Products Affected• DAYTRANA

QL Criteria 1 patch Per 1 Day

Notes/References

Demerol

Products Affected• DEMEROL ORAL

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Depen Titratabs

Products Affected• DEPEN TITRATABS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Descovy

Products Affected• DESCOVY

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antiviral_hiv.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Desoxyn

Products Affected• DESOXYN

Notes/References

Dexedrine

Products Affected• DEXEDRINE ORAL CAPSULE

EXTENDED RELEASE 24 HOUR

Notes/References

Dexedrine

Products Affected• DEXEDRINE ORAL TABLET

Notes/References

Dexmethylphenidate HCl

Products Affected• dexmethylphenidate hcl

Notes/References

Dexmethylphenidate HCl ER

Products Affected• dexmethylphenidate hcl er oral capsule

extended release 24 hour 10 mg, 20 mg, 30 mg

• dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 40 mg, 5 mg

Notes/References

Dextroamphetamine Sulfate

Products Affected• dextroamphetamine sulfate oral solution

QL Criteria 40 ML Per 1 Day

Notes/References

Dextroamphetamine Sulfate

Products Affected• dextroamphetamine sulfate oral tablet

Notes/References

Dextroamphetamine Sulfate ER

Products Affected• dextroamphetamine sulfate er

Notes/References

Dibenzyline

Products Affected• DIBENZYLINE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/antihypertensive_misc.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Diclofenac Sodium

Products Affected• diclofenac sodium transdermal gel 1 %

QL Criteria 200 grams Per 30 Days

Notes/References

Diclofenac Sodium

Products Affected• diclofenac sodium transdermal gel 3 %

Covered Uses Actinic keratoses (AK)

Exclusion Criteria

Documentation of any of the following patients/situations: use in treatment of postoperative pain after coronary artery bypass graft (CABG) surgery, any known hypersensitivity to diclofenac or any component of the formulation, any history of Asthma and aspirin triad, the planned area of application includes non-intact skin, or if the medication will be compounded with other products that would alter the total dose/dosage form being administered

Documentation that sun avoidance is indicated during therapy

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

Dilaudid

Products Affected• DILAUDID ORAL

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Dolophine

Products Affected• DOLOPHINE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Doxepin HCl

Products Affected• doxepin hcl external

Notes/References

Dupixent

Products Affected• DUPIXENT

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Dupixent.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Duragesic-100

Products Affected• DURAGESIC-100

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Duragesic-12

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Duragesic-25

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Duragesic-50

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Duragesic-75

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Dyanavel XR

Products Affected• DYANAVEL XR

QL Criteria 240 ml Per 30 Days

Notes/References

Dysport

Products Affected• DYSPORT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Elaprase

Products Affected• ELAPRASE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Elelyso

Products Affected• ELELYSO

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Eligard

Products Affected• ELIGARD

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• ELLA

QL Criteria 2 tablets Per 1 fill

Notes/References

Eloctate

Products Affected• ELOCTATE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Embeda

Products Affected• EMBEDA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Emflaza

Products Affected• EMFLAZA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Emflaza.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• EMLA

Covered Uses

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

Exclusion Criteria

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

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

Age Restrictions

Coverage Duration

3 months

Other Criteria

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

Notes/References

Revision DatePrior Authorization: October 03, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

Enbrel

Products Affected• ENBREL SUBCUTANEOUS KIT• ENBREL SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 25 MG/0.5ML

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Enbrel.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 8 units Per 28 Days

Notes/References

Enbrel

Products Affected• ENBREL SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 50 MG/ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Enbrel SureClick

Products Affected• ENBREL SURECLICK SUBCUTANEOUS

SOLUTION AUTO-INJECTOR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Endocet

Products Affected• ENDOCET ORAL TABLET 10-325 MG,

2.5-325 MG, 5-325 MG, 7.5-325 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Entecavir

Products Affected• entecavir

Notes/References

Entyvio

Products Affected• ENTYVIO

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Entyvio.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Epclusa

Products Affected• EPCLUSA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Epogen

Products Affected• EPOGEN INJECTION SOLUTION 10000

UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Epoprostenol Sodium

Products Affected• epoprostenol sodium

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Erivedge

Products Affected• ERIVEDGE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Esbriet

Products Affected• ESBRIET ORAL CAPSULE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Idiopathic_Pulmonary_Fibrosis.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Esbriet

Products Affected• ESBRIET ORAL TABLET

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Euflexxa

Products Affected• EUFLEXXA INTRA-ARTICULAR

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Evekeo

Products Affected• EVEKEO

Notes/References

Exalgo

Products Affected• EXALGO ORAL TABLET ER 24 HOUR

ABUSE-DETERRENT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Exjade

Products Affected• EXJADE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Anitdotes.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Extavia

Products Affected• EXTAVIA SUBCUTANEOUS KIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 15 vials Per 1 fill

Notes/References

Products Affected• EYLEA INTRAOCULAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Fabrazyme

Products Affected• FABRAZYME

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Falmina

Products Affected• FALMINA

QL Criteria 1.5 tablets Per 1 Day

Notes/References

Farydak

Products Affected• FARYDAK

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 12 capsules Per 30 Days

Notes/References

Faslodex

Products Affected• FASLODEX INTRAMUSCULAR

SOLUTION 250 MG/5ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• FEIBA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Feiba NF

Products Affected• FEIBA NF

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Feiba VH Immuno

Products Affected• FEIBA VH IMMUNO

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FentaNYL

Products Affected• fentanyl

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

FentaNYL Citrate

Products Affected• fentanyl citrate buccal

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

QL Criteria 120 lozenges Per 30 Days

Notes/References

Fentora

Products Affected• FENTORA BUCCAL TABLET 100 MCG,

200 MCG, 400 MCG, 600 MCG, 800 MCG

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

Ferriprox

Products Affected• FERRIPROX

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Fioricet/Codeine

Products Affected• FIORICET/CODEINE ORAL CAPSULE

50-300-40-30 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Fiorinal/Codeine #3

Products Affected• FIORINAL/CODEINE #3

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Firazyr

Products Affected• FIRAZYR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Firmagon

Products Affected• FIRMAGON

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Flebogamma

Products Affected• FLEBOGAMMA INTRAVENOUS

SOLUTION 0.5 GM/10ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Flebogamma DIF

Products Affected• FLEBOGAMMA DIF

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Flolan

Products Affected• FLOLAN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Focalin

Products Affected• FOCALIN

Notes/References

Focalin XR

Products Affected• FOCALIN XR

Notes/References

Follistim AQ

Products Affected• FOLLISTIM AQ

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Fuzeon

Products Affected• FUZEON

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gammagard

Products Affected• GAMMAGARD

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gammagard S/D

Products Affected• GAMMAGARD S/D INTRAVENOUS

SOLUTION RECONSTITUTED 10 GM, 5 GM

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gammaked

Products Affected• GAMMAKED

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gammaplex

Products Affected• GAMMAPLEX INTRAVENOUS

SOLUTION 10 GM/200ML, 2.5 GM/50ML, 20 GM/400ML, 5 GM/100ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gamunex-C

Products Affected• GAMUNEX-C

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ganirelix Acetate

Products Affected• ganirelix acetate

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gattex

Products Affected• GATTEX

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gattex.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gel-One

Products Affected• GEL-ONE INTRA-ARTICULAR

PREFILLED SYRINGE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gelsyn-3

Products Affected• GELSYN-3

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Genotropin

Products Affected• GENOTROPIN

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Genotropin MiniQuick

Products Affected• GENOTROPIN MINIQUICK

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gildagia

Products Affected• GILDAGIA

Notes/References

Gildess FE 1.5/30

Products Affected• GILDESS FE 1.5/30

Notes/References

Gildess FE 1/20

Products Affected• GILDESS FE 1/20

Notes/References

Gilenya

Products Affected• GILENYA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Gilenya.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gilotrif

Products Affected• GILOTRIF

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Glassia

Products Affected• GLASSIA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Glatopa

Products Affected• GLATOPA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/glatiramer.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gleevec

Products Affected• GLEEVEC

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gonal-f

Products Affected• GONAL-F

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gonal-f RFF

Products Affected• GONAL-F RFF

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gonal-f RFF Pen

Products Affected• GONAL-F RFF PEN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Gonal-f RFF Rediject

Products Affected• GONAL-F RFF REDIJECT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Granix

Products Affected• GRANIX

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/G-CSF.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

GuanFACINE HCl ER

Products Affected• guanfacine hcl er

Notes/References

Haegarda

Products Affected• HAEGARDA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Harvoni

Products Affected• HARVONI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Helixate FS

Products Affected• HELIXATE FS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hemofil M

Products Affected• HEMOFIL M INTRAVENOUS SOLUTION

RECONSTITUTED 1000 UNIT, 1501-2000 UNIT, 1700 UNIT, 220-400 UNIT, 250 UNIT, 401-800 UNIT, 500 UNIT, 801-1500 UNIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hetlioz

Products Affected• HETLIOZ

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/sedative-hypnotics.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hizentra

Products Affected• HIZENTRA SUBCUTANEOUS

SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

HP Acthar

Products Affected• HP ACTHAR

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/acthar.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humate-P

Products Affected• HUMATE-P INTRAVENOUS SOLUTION

RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humatrope

Products Affected• HUMATROPE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humira

Products Affected• HUMIRA SUBCUTANEOUS PREFILLED

SYRINGE KIT

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Humira.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humira Pediatric Crohns Start

Products Affected• HUMIRA PEDIATRIC CROHNS START

SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humira Pen

Products Affected• HUMIRA PEN SUBCUTANEOUS PEN-

INJECTOR KIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humira Pen-Crohns Starter

Products Affected• HUMIRA PEN-CROHNS STARTER

SUBCUTANEOUS PEN-INJECTOR KIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Humira Pen-Psoriasis Starter

Products Affected• HUMIRA PEN-PSORIASIS STARTER

SUBCUTANEOUS PEN-INJECTOR KIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hyalgan

Products Affected• HYALGAN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hycamtin

Products Affected• HYCAMTIN ORAL

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• HYCET

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hydrocodone-Acetaminophen

Products Affected• hydrocodone-acetaminophen oral solution

10-325 mg/15ml, 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

• hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hydrocodone-Ibuprofen

Products Affected• hydrocodone-ibuprofen

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

HYDROmorphone HCl

Products Affected• hydromorphone hcl oral • hydromorphone hcl rectal

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

HYDROmorphone HCl ER

Products Affected• hydromorphone hcl er

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hymovis

Products Affected• HYMOVIS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hyqvia

Products Affected• HYQVIA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Hysingla ER

Products Affected• HYSINGLA ER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ibrance

Products Affected• IBRANCE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ibudone

Products Affected• IBUDONE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Iclusig

Products Affected• ICLUSIG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Idelvion

Products Affected• IDELVION

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

IDHIFA

Products Affected• IDHIFA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Idhifa.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ilaris

Products Affected• ILARIS

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Ilaris.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ilaris (150mg Delivered)

Products Affected• ILARIS (150MG DELIVERED)

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Ilaris.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Imatinib Mesylate

Products Affected• imatinib mesylate

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Imbruvica

Products Affected• IMBRUVICA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Increlex

Products Affected• INCRELEX

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Increlex.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Infergen

Products Affected• INFERGEN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Inflectra

Products Affected• INFLECTRA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Inflectra.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ingrezza

Products Affected• INGREZZA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Ingrezza.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Inlyta

Products Affected• INLYTA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Intron A

Products Affected• INTRON A

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Intuniv

Products Affected• INTUNIV

Notes/References

Iressa

Products Affected• IRESSA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Iressa.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ixinity

Products Affected• IXINITY

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Jadenu

Products Affected• JADENU

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Jadenu Sprinkle

Products Affected• JADENU SPRINKLE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Jakafi

Products Affected• JAKAFI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Jetrea

Products Affected• JETREA INTRAOCULAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Junel 1.5/30

Products Affected• JUNEL 1.5/30

Notes/References

Junel 1/20

Products Affected• JUNEL 1/20

Notes/References

Junel FE 1.5/30

Products Affected• JUNEL FE 1.5/30

Notes/References

Junel FE 1/20

Products Affected• JUNEL FE 1/20

Notes/References

Juxtapid

Products Affected• JUXTAPID ORAL CAPSULE 10 MG

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Antilipidemic Agents_HOFH.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 28 capsules Per 1 fill

Notes/References

Juxtapid

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Juxtapid

Products Affected• JUXTAPID ORAL CAPSULE 30 MG, 40

MG, 60 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Juxtapid

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kadian

Products Affected• KADIAN ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG

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

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kalbitor

Products Affected• KALBITOR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kalydeco

Products Affected• KALYDECO ORAL PACKET

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/cystic_fibrosis.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kalydeco

Products Affected• KALYDECO ORAL TABLET

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kanuma

Products Affected• KANUMA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kapvay

Products Affected• KAPVAY ORAL

QL Criteria 2 EA Per 1 Day

Notes/References

Kapvay

Products Affected• KAPVAY ORAL TABLET EXTENDED

RELEASE 12 HOUR

Notes/References

Kariva

Products Affected• KARIVA

Notes/References

Kelnor 1/35

Products Affected• KELNOR 1/35

Notes/References

Keveyis

Products Affected• KEVEYIS

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/carbonic_anhydrase_inhibitor.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kevzara

Products Affected• KEVZARA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Kevzara.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kineret

Products Affected• KINERET SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Kineret.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kisqali 200 Dose

Products Affected• KISQALI 200 DOSE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Kisqali.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kisqali 400 Dose

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kisqali 600 Dose

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kisqali Femara 200 Dose

Products Affected• KISQALI FEMARA 200 DOSE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• KOATE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Koate-DVI

Products Affected• KOATE-DVI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kogenate FS

Products Affected• KOGENATE FS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kogenate FS Bio-Set

Products Affected• KOGENATE FS BIO-SET

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Korlym

Products Affected• KORLYM

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/antidiabetic agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kovaltry

Products Affected• KOVALTRY

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Krystexxa

Products Affected• KRYSTEXXA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/gout.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kurvelo

Products Affected• KURVELO

Notes/References

Products Affected• KUVAN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Kynamro

Products Affected• KYNAMRO SUBCUTANEOUS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lazanda

Products Affected• LAZANDA

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

QL Criteria 4 bottles Per 30 Days

Notes/References

Lazanda

Products Affected• LAZANDA

Exclusion Criteria

Documentation that member is terminally ill or has a documented diagnosis of cancer with concomitant use of around the clock long acting opioid therapy for cancer pain, requiring management of breakthrough pain and is intolerant of two (2) immediate-release opioids including morphine, hydrocodone, oxycodone, or hydromorphone.

Age Restrictions

Coverage Duration

1 year

Other Criteria Step therapy may apply

Notes/References

Revision DatePrior Authorization: December 29, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015

Products Affected• LEENA

Notes/References

Lemtrada

Products Affected• LEMTRADA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Lemtrada.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 5 vials Per 365 Days

Notes/References

Lenvima 10 MG Daily Dose

Products Affected• LENVIMA 10 MG DAILY DOSE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 30 day supply Per 1 fill

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lessina

Products Affected• LESSINA

Notes/References

Letairis

Products Affected• LETAIRIS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Leukine

Products Affected• LEUKINE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Leuprolide Acetate

Products Affected• leuprolide acetate injection

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Levonest

Products Affected• LEVONEST

Notes/References

Levonorgestrel-Ethinyl Estrad

Products Affected• levonorgestrel-ethinyl estrad oral tablet

0.15-30 mg-mcg

Notes/References

Levora 0.15/30 (28)

Products Affected• LEVORA 0.15/30 (28)

Notes/References

Levorphanol Tartrate

Products Affected• levorphanol tartrate oral

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lidocaine

Products Affected• lidocaine external ointment

Covered Uses

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

Exclusion Criteria

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

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

Age Restrictions

Coverage Duration

3 months

Other Criteria

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

Notes/References

Lidocaine-Prilocaine

Products Affected• lidocaine-prilocaine external cream

Covered Uses

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

Exclusion Criteria

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

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

Age Restrictions

Coverage Duration

3 months

Other Criteria

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

Notes/References

Lonsurf

Products Affected• LONSURF

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lorcet

Products Affected• LORCET

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lorcet HD

Products Affected• LORCET HD

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lorcet Plus

Products Affected• LORCET PLUS ORAL TABLET 7.5-325

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lortab

Products Affected• LORTAB ORAL ELIXIR 10-300 MG/15ML• LORTAB ORAL TABLET 10-325 MG, 5-

325 MG, 7.5-325 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Low-Ogestrel

Products Affected• LOW-OGESTREL

Notes/References

Lucentis

Products Affected• LUCENTIS INTRAOCULAR• LUCENTIS INTRAVITREAL SOLUTION

PREFILLED SYRINGE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lumizyme

Products Affected• LUMIZYME

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lupaneta Pack

Products Affected• LUPANETA PACK

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lupron Depot (1-Month)

Products Affected• LUPRON DEPOT (1-MONTH)

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lupron Depot-Ped (1-Month)

Products Affected• LUPRON DEPOT-PED (1-MONTH)

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lupron Depot-Ped (3-Month)

Products Affected• LUPRON DEPOT-PED (3-MONTH)

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lutera

Products Affected• LUTERA

QL Criteria 1.5 tablet Per 1 Day

Notes/References

Lynparza

Products Affected• LYNPARZA ORAL CAPSULE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Lynparza

Products Affected• LYNPARZA ORAL TABLET

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Macugen

Products Affected• MACUGEN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Makena

Products Affected• MAKENA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/hydroxyprogesterone.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Marlissa

Products Affected• marlissa

Notes/References

Mavyret

Products Affected• MAVYRET

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Mekinist

Products Affected• MEKINIST

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Menopur

Products Affected• MENOPUR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Meperidine HCl

Products Affected• meperidine hcl oral

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Metadate CD

Products Affected• METADATE CD

Notes/References

Metadate ER

Products Affected• METADATE ER ORAL TABLET

EXTENDED RELEASE 20 MG

Notes/References

Methadone HCl

Products Affected• methadone hcl oral

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Methadone HCl Intensol

Products Affected• METHADONE HCL INTENSOL

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Methadose

Products Affected• METHADOSE ORAL CONCENTRATE 10

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Methadose Sugar-Free

Products Affected• METHADOSE SUGAR-FREE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Methamphetamine HCl

Products Affected• methamphetamine hcl

Notes/References

Methylin

Products Affected• METHYLIN ORAL SOLUTION 10

MG/5ML

Notes/References

Methylin

Products Affected• METHYLIN ORAL SOLUTION 5

MG/5ML

Notes/References

Methylin

Products Affected• METHYLIN ORAL TABLET CHEWABLE

Notes/References

Methylphenidate HCl

Products Affected• methylphenidate hcl oral solution 10 mg/5ml

Notes/References

Methylphenidate HCl

Products Affected• methylphenidate hcl oral solution 5 mg/5ml

Notes/References

Methylphenidate HCl

Products Affected• methylphenidate hcl oral tablet • methylphenidate hcl oral tablet chewable

Notes/References

Methylphenidate HCl ER

Products Affected• methylphenidate hcl er oral tablet extended

release 10 mg

Notes/References

release 18 mg, 27 mg, 54 mg

Notes/References

release 20 mg

Notes/References

release 36 mg

Notes/References

release 24 hour 18 mg, 27 mg, 54 mg

Notes/References

release 24 hour 36 mg

Notes/References

Methylphenidate HCl ER (CD)

Products Affected• methylphenidate hcl er (cd)

Notes/References

Methylphenidate HCl ER (LA)

Products Affected• methylphenidate hcl er (la) oral capsule

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

extended release 24 hour 40 mg

Notes/References

Microgestin 1.5/30

Products Affected• MICROGESTIN 1.5/30

Notes/References

Microgestin 1/20

Products Affected• MICROGESTIN 1/20

Notes/References

Microgestin FE 1.5/30

Products Affected• MICROGESTIN FE 1.5/30

Notes/References

Microgestin FE 1/20

Products Affected• MICROGESTIN FE 1/20

Notes/References

Mircera

Products Affected• MIRCERA INJECTION SOLUTION

PREFILLED SYRINGE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Monoclate-P

Products Affected• MONOCLATE-P

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Mononine

Products Affected• MONONINE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Monovisc

Products Affected• MONOVISC

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

MorphaBond ER

Products Affected• MORPHABOND ER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Morphine Sulfate

Products Affected• morphine sulfate oral • morphine sulfate rectal

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Morphine Sulfate (Concentrate)

Products Affected• morphine sulfate (concentrate) oral solution

100 mg/5ml, 20 mg/ml

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Morphine Sulfate ER

Products Affected• morphine sulfate er oral capsule extended

release 24 hour• morphine sulfate er oral tablet extended

release

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Morphine Sulfate ER Beads

Products Affected• morphine sulfate er beads

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

MS Contin

Products Affected• MS CONTIN ORAL TABLET EXTENDED

RELEASE

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Myalept

Products Affected• MYALEPT

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/myalept.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Mydayis

Products Affected• MYDAYIS

Notes/References

Myorisan

Products Affected• MYORISAN

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

Myorisan

Products Affected• MYORISAN

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

Myozyme

Products Affected• MYOZYME

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Naglazyme

Products Affected• NAGLAZYME

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Natpara

Products Affected• NATPARA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/bone_disease_agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Necon 0.5/35 (28)

Products Affected• NECON 0.5/35 (28)

Notes/References

Necon 1/35 (28)

Products Affected• NECON 1/35 (28)

Notes/References

Necon 10/11 (28)

Products Affected• NECON 10/11 (28)

Notes/References

Nerlynx

Products Affected• NERLYNX

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Nerlynx.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Neulasta

Products Affected• NEULASTA SUBCUTANEOUS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Neulasta Delivery Kit

Products Affected• NEULASTA DELIVERY KIT

SUBCUTANEOUS PREFILLED SYRINGE KIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Neumega

Products Affected• NEUMEGA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Neumega.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Neupogen

Products Affected• NEUPOGEN INJECTION SOLUTION 300

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

PREFILLED SYRINGE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NexAVAR

Products Affected• NEXAVAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ninlaro

Products Affected• NINLARO

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• NITYR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• NORCO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Norditropin FlexPro

Products Affected• NORDITROPIN FLEXPRO

SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Norditropin NordiFlex Pen

Products Affected• NORDITROPIN NORDIFLEX PEN

SUBCUTANEOUS SOLUTION 30 MG/3ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Norgestrel-Ethinyl Estradiol

Products Affected• norgestrel-ethinyl estradiol

Notes/References

Northera

Products Affected• NORTHERA ORAL CAPSULE 100 MG

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Northera.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Northera

Products Affected• NORTHERA ORAL CAPSULE 200 MG,

300 MG

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Northera.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nortrel 0.5/35 (28)

Products Affected• NORTREL 0.5/35 (28)

Notes/References

Nortrel 1/35 (21)

Products Affected• NORTREL 1/35 (21)

Notes/References

Nortrel 1/35 (28)

Products Affected• NORTREL 1/35 (28)

Notes/References

Novarel

Products Affected• novarel intramuscular solution reconstituted

10000 unit

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Novoeight

Products Affected• NOVOEIGHT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

NovoSeven RT

Products Affected• NOVOSEVEN RT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nplate

Products Affected• NPLATE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Neumega.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nucala

Products Affected• NUCALA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/RESP/Interleukin Antagonist.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nucynta

Products Affected• NUCYNTA

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nucynta ER

Products Affected• NUCYNTA ER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nuplazid

Products Affected• NUPLAZID

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Nuplazid.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nutropin

Products Affected• NUTROPIN SUBCUTANEOUS

SOLUTION RECONSTITUTED 10 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nutropin AQ

Products Affected• NUTROPIN AQ

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nutropin AQ NuSpin 10

Products Affected• NUTROPIN AQ NUSPIN 10

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Nutropin AQ Pen

Products Affected• NUTROPIN AQ PEN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• NUWIQ INTRAVENOUS KIT 1000 UNIT,

2000 UNIT, 250 UNIT, 500 UNIT• NUWIQ INTRAVENOUS SOLUTION

RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ocaliva

Products Affected• OCALIVA ORAL TABLET 5 MG

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/Primary_Biliary_Cholagitis.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Octagam

Products Affected• OCTAGAM

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Octreotide Acetate

Products Affected• octreotide acetate

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Sandostatin.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Odomzo

Products Affected• ODOMZO

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Odomzo.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• OFEV

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Olysio

Products Affected• OLYSIO

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Omnitrope

Products Affected• OMNITROPE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• OPANA ORAL

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Opana ER

Products Affected• OPANA ER ORAL TABLET ER 12 HOUR

ABUSE-DETERRENT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Opsumit

Products Affected• OPSUMIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Orencia

Products Affected• ORENCIA INTRAVENOUS• ORENCIA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Orencia.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Orencia

Products Affected• ORENCIA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 125 MG/ML

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 4 syringes Per 1 fill

Notes/References

Orencia ClickJect

Products Affected• ORENCIA CLICKJECT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Orenitram

Products Affected• ORENITRAM

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Orfadin

Products Affected• ORFADIN ORAL CAPSULE 10 MG, 2

MG, 5 MG• ORFADIN ORAL SUSPENSION

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Orkambi

Products Affected• ORKAMBI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Orsythia

Products Affected• ORSYTHIA

Notes/References

OrthoVisc

Products Affected• ORTHOVISC INTRA-ARTICULAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Otezla

Products Affected• OTEZLA ORAL TABLET• OTEZLA ORAL TABLET THERAPY

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Otezla.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ovidrel

Products Affected• OVIDREL

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Oxaydo

Products Affected• OXAYDO

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OxyCODONE HCl

Products Affected• oxycodone hcl oral capsule• oxycodone hcl oral concentrate 100 mg/5ml• oxycodone hcl oral concentrate 20 mg/ml

• oxycodone hcl oral solution• oxycodone hcl oral tablet

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OxyCODONE HCl ER

Products Affected• oxycodone hcl er oral tablet er 12 hour

abuse-deterrent

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OxyCODONE HCl ER

Products Affected• oxycodone hcl er oral tablet er 12 hour

abuse-deterrent

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Oxycodone-Acetaminophen

Products Affected• oxycodone-acetaminophen oral solution• oxycodone-acetaminophen oral tablet 10-325

mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Oxycodone-Aspirin

Products Affected• oxycodone-aspirin oral tablet 4.8355-325 mg

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Oxycodone-Ibuprofen

Products Affected• oxycodone-ibuprofen

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OxyCONTIN

Products Affected• OXYCONTIN ORAL TABLET ER 12

HOUR ABUSE-DETERRENT

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Oxymorphone HCl

Products Affected• oxymorphone hcl

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

OxyMORphone HCl ER

Products Affected• oxymorphone hcl er

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ozurdex

Products Affected• OZURDEX INTRAOCULAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Pegasys

Products Affected• PEGASYS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Pegasys ProClick

Products Affected• PEGASYS PROCLICK

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

PegIntron

Products Affected• PEGINTRON

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Peg-Intron

Products Affected• PEG-INTRON

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Peg-Intron Redipen

Products Affected• PEG-INTRON REDIPEN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Peg-Intron Redipen Pak 4

Products Affected• PEG-INTRON REDIPEN PAK 4

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Pentazocine-Naloxone HCl

Products Affected• pentazocine-naloxone hcl

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Percocet

Products Affected• PERCOCET ORAL TABLET 10-325 MG,

2.5-325 MG, 5-325 MG, 7.5-325 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Phenoxybenzamine HCl

Products Affected• phenoxybenzamine hcl oral

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Philith

Products Affected• PHILITH

Notes/References

Plegridy

Products Affected• PLEGRIDY

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 ML Per 28 Days

Notes/References

Plegridy Starter Pack

Products Affected• PLEGRIDY STARTER PACK

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 ML Per 28 Days

Notes/References

Pomalyst

Products Affected• POMALYST

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Portia-28

Products Affected• PORTIA-28

Notes/References

Praluent

Products Affected• PRALUENT

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/PCSK9.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Pregnyl

Products Affected• pregnyl

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Primlev

Products Affected• PRIMLEV

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Privigen

Products Affected• PRIVIGEN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ProCentra

Products Affected• PROCENTRA

Notes/References

Procrit

Products Affected• PROCRIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Procysbi

Products Affected• PROCYSBI ORAL CAPSULE DELAYED

RELEASE 25 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Procysbi

Products Affected• PROCYSBI ORAL CAPSULE DELAYED

RELEASE 75 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Profilnine SD

Products Affected• PROFILNINE SD

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Prolastin-C

Products Affected• PROLASTIN-C INTRAVENOUS

SOLUTION RECONSTITUTED 1000 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Prolia

Products Affected• PROLIA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Promacta

Products Affected• PROMACTA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Promacta.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Prudoxin

Products Affected• PRUDOXIN

Notes/References

Pulmozyme

Products Affected• PULMOZYME

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Purixan

Products Affected• PURIXAN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

QuilliChew ER

Products Affected• QUILLICHEW ER ORAL TABLET

CHEWABLE EXTENDED RELEASE 20 MG, 40 MG

Notes/References

QuilliChew ER

Products Affected• QUILLICHEW ER ORAL TABLET

CHEWABLE EXTENDED RELEASE 30 MG

Notes/References

Quillivant XR

Products Affected• QUILLIVANT XR

Notes/References

Ravicti

Products Affected• RAVICTI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• REBIF SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rebif Rebidose

Products Affected• REBIF REBIDOSE SUBCUTANEOUS

SOLUTION AUTO-INJECTOR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rebif Rebidose Titration Pack

Products Affected• REBIF REBIDOSE TITRATION PACK

SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rebif Titration Pack

Products Affected• REBIF TITRATION PACK

SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Reclipsen

Products Affected• RECLIPSEN

Notes/References

Recombinate

Products Affected• RECOMBINATE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Remicade

Products Affected• REMICADE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Remicade.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Remodulin

Products Affected• REMODULIN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Renflexis

Products Affected• RENFLEXIS

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Renflexis.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Repatha

Products Affected• REPATHA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Repatha Pushtronex System

Products Affected• REPATHA PUSHTRONEX SYSTEM

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Repatha SureClick

Products Affected• REPATHA SURECLICK

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Reprexain

Products Affected• REPREXAIN ORAL TABLET 10-200 MG,

5-200 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Repronex

Products Affected• REPRONEX

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Revatio

Products Affected• REVATIO INTRAVENOUS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Revatio

Products Affected• REVATIO ORAL SUSPENSION

RECONSTITUTED

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Revatio

Products Affected• REVATIO ORAL TABLET

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Revlimid

Products Affected• REVLIMID

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

RiaSTAP

Products Affected• RIASTAP

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Riastap.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ritalin

Products Affected• RITALIN

Notes/References

Ritalin LA

Products Affected• RITALIN LA ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 60 MG

Notes/References

Ritalin LA

Products Affected• RITALIN LA ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 30 MG

Notes/References

Rixubis

Products Affected• RIXUBIS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rosuvastatin Calcium

Products Affected• rosuvastatin calcium

Notes/References

Roxicet

Products Affected• ROXICET ORAL SOLUTION

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Roxicodone

Products Affected• ROXICODONE ORAL TABLET

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rubraca

Products Affected• RUBRACA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Rubraca.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ruconest

Products Affected• RUCONEST

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Rydapt

Products Affected• RYDAPT

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Rydapt.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Sabril

Products Affected• SABRIL

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/anticonvulsants.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Saizen

Products Affected• SAIZEN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Saizen Click.Easy

Products Affected• SAIZEN CLICK.EASY

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Samsca

Products Affected• SAMSCA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/samsca.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SandoSTATIN

Products Affected• SANDOSTATIN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

SandoSTATIN LAR Depot

Products Affected• SANDOSTATIN LAR DEPOT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Serostim

Products Affected• SEROSTIM SUBCUTANEOUS

SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Signifor

Products Affected• SIGNIFOR

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Signifor.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 10 ampules Per 30 Days

Notes/References

Signifor LAR

Products Affected• SIGNIFOR LAR INTRAMUSCULAR

SUSPENSION RECONSTITUTED

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Signifor.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 injection Per 28 Days

Notes/References

Sildenafil Citrate

Products Affected• sildenafil citrate oral

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• SILIQ

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Siliq.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Simponi

Products Affected• SIMPONI SUBCUTANEOUS SOLUTION

AUTO-INJECTOR• SIMPONI SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Simponi.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 syringe Per 30 Days

Notes/References

Simponi Aria

Products Affected• SIMPONI ARIA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Simponi_Aria.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Sirturo

Products Affected• SIRTURO

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antimycobacterial_agents.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Sodium Phenylbutyrate

Products Affected• sodium phenylbutyrate oral powder 3 gm/tsp

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Solaraze

Products Affected• SOLARAZE

Covered Uses Actinic keratoses (AK)

Exclusion Criteria

Documentation of any of the following patients/situations: use in treatment of postoperative pain after coronary artery bypass graft (CABG) surgery, any known hypersensitivity to diclofenac or any component of the formulation, any history of Asthma and aspirin triad, the planned area of application includes non-intact skin, or if the medication will be compounded with other products that would alter the total dose/dosage form being administered

Documentation that sun avoidance is indicated during therapy

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

Soliris

Products Affected• SOLIRIS

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/soliris.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Somatuline Depot

Products Affected• SOMATULINE DEPOT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Somavert

Products Affected• SOMAVERT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Sovaldi

Products Affected• SOVALDI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 tab Per 1 fill

Notes/References

Sprycel

Products Affected• SPRYCEL

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 30 days Per 1 fill

Notes/References

Sronyx

Products Affected• SRONYX

Notes/References

Stelara

Products Affected• STELARA INTRAVENOUS• STELARA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Stelara.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Stiolto Respimat

Products Affected• STIOLTO RESPIMAT

QL Criteria 1 inhaler Per 30 Days

Notes/References

Stivarga

Products Affected• STIVARGA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Strattera

Products Affected• STRATTERA ORAL CAPSULE 10 MG, 18

MG, 25 MG, 40 MG, 60 MG

Notes/References

Strattera

Products Affected• STRATTERA ORAL CAPSULE 100 MG,

Notes/References

Strensiq

Products Affected• STRENSIQ

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Suboxone

Products Affected• SUBOXONE SUBLINGUAL FILM 12-3

Notes/References

Suboxone

Products Affected• SUBOXONE SUBLINGUAL FILM 2-0.5

MG, 4-1 MG, 8-2 MG

QL Criteria 90 films Per 30 Days

Notes/References

Suboxone

Products Affected• SUBOXONE SUBLINGUAL TABLET

SUBLINGUAL

Notes/References

Subsys

Products Affected• SUBSYS

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

QL Criteria 120 sprays Per 30 Days

Notes/References

Supartz

Products Affected• SUPARTZ INTRA-ARTICULAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Supprelin LA

Products Affected• SUPPRELIN LA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Sutent

Products Affected• SUTENT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Sylatron

Products Affected• SYLATRON SUBCUTANEOUS KIT 200

MCG, 300 MCG, 4 X 200 MCG, 4 X 300 MCG, 600 MCG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Synagis

Products Affected• SYNAGIS

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Synagis.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Synalgos-DC

Products Affected• SYNALGOS-DC

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Synarel

Products Affected• SYNAREL

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Synvisc

Products Affected• SYNVISC INTRA-ARTICULAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Synvisc One

Products Affected• SYNVISC ONE INTRA-ARTICULAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Syprine

Products Affected• SYPRINE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tacrolimus

Products Affected• tacrolimus external

QL Criteria 60 GM Per 1 fill

Notes/References

Tafinlar

Products Affected• TAFINLAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tagrisso

Products Affected• TAGRISSO

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Tagrisso.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• TALTZ

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Taltz.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tarceva

Products Affected• TARCEVA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Targretin

Products Affected• TARGRETIN ORAL

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Targretin.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tasigna

Products Affected• TASIGNA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tecfidera

Products Affected• TECFIDERA ORAL

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Tecfidera.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 starter pack Per 30 Days

Notes/References

Tecfidera

Products Affected• TECFIDERA ORAL CAPSULE DELAYED

RELEASE 120 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tecfidera

Products Affected• TECFIDERA ORAL CAPSULE DELAYED

RELEASE 240 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Technivie

Products Affected• TECHNIVIE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Temodar

Products Affected• TEMODAR ORAL

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Temozolomide

Products Affected• temozolomide

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tetrabenazine

Products Affected• tetrabenazine

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/xenazine.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tev-Tropin

Products Affected• TEV-TROPIN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Thalomid

Products Affected• THALOMID

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Thiola

Products Affected• THIOLA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tilia Fe

Products Affected• TILIA FE

Notes/References

Tracleer

Products Affected• TRACLEER

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TraMADol HCl

Products Affected• tramadol hcl oral

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TraMADol HCl ER

Products Affected• tramadol hcl er

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

TraMADol HCl ER (Biphasic)

Products Affected• tramadol hcl er (biphasic)

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tramadol-Acetaminophen

Products Affected• tramadol-acetaminophen

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Trelstar

Products Affected• TRELSTAR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Trelstar Mixject

Products Affected• TRELSTAR MIXJECT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tremfya

Products Affected• TREMFYA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Tremfya.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tretten

Products Affected• TRETTEN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Trezix

Products Affected• TREZIX ORAL CAPSULE 320.5-30-16 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tri-Legest Fe

Products Affected• TRI-LEGEST FE

Notes/References

Trivora (28)

Products Affected• TRIVORA (28)

Notes/References

Truvada

Products Affected• TRUVADA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tykerb

Products Affected• TYKERB

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tylenol with Codeine #3

Products Affected• TYLENOL WITH CODEINE #3

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tylenol with Codeine #4

Products Affected• TYLENOL WITH CODEINE #4

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tymlos

Products Affected• TYMLOS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 pen Per 1 month

Notes/References

Tysabri

Products Affected• TYSABRI

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Tysabri.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tyvaso

Products Affected• TYVASO

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tyvaso Refill

Products Affected• TYVASO REFILL

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Tyvaso Starter

Products Affected• TYVASO STARTER

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ultracet

Products Affected• ULTRACET

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ultram

Products Affected• ULTRAM

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Ultram ER

Products Affected• ULTRAM ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 100 MG, 300 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Uptravi

Products Affected• UPTRAVI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Valchlor

Products Affected• VALCHLOR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Valcyte

Products Affected• VALCYTE

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antiviraloraltopical.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

ValGANciclovir HCl

Products Affected• valganciclovir hcl

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antiviraloraltopical.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Vantas

Products Affected• VANTAS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Vecamyl

Products Affected• VECAMYL

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Veletri

Products Affected• VELETRI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Velivet

Products Affected• VELIVET

Notes/References

Veltassa

Products Affected• VELTASSA

Covered Uses Treatment of hyperkalemia

Exclusion Criteria

Documentation that a member (at least 18 years of age) has a diagnosis of chronic kidney disease (CKD) and has hyperkalemia (serum potassium level of 5.1 to greater than 6.5 mEq/L), that the member is stable on an angiotensin converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), or an aldosterone antagonist (e.g. spironolactone, eplerenone)(if taking one of the medications), the patient has been counseled to take all other oral medications 3 hours before or 3 hours after Veltassa, Veltassa will not be used as an emergency treatment for life-threatening hyperkalemia, and the member is following a low potassium diet (less than or equal to 3 grams per day).

Age Restrictions

Coverage Duration

1 year

Other Criteria

Reauthorization criteria: Use of Veltassa has been effective in treating hyperkalemia (e.g. current serum potassium level is lower than the pretreatment baseline serum potassium level), the member continues to require treatment for hyperkalemia, the member is stable on an angiotensin converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), or an aldosterone antagonist (e.g. spironolactone, eplerenone)(if taking one of the medications) and the member continues to follow a low potassium diet (less than or equal to 3 grams per day).

Notes/References

Vemlidy

Products Affected• VEMLIDY

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/Vemlidy.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Venclexta

Products Affected• VENCLEXTA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Venclexta.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Venclexta Starting Pack

Products Affected• VENCLEXTA STARTING PACK

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Venclexta.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

QL Criteria 1 pack Per 28 Days

Notes/References

Ventavis

Products Affected• VENTAVIS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Verdrocet

Products Affected• VERDROCET

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Vicodin

Products Affected• VICODIN ORAL TABLET 5-300 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Vicodin ES

Products Affected• VICODIN ES ORAL TABLET 7.5-300 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Vicodin HP

Products Affected• VICODIN HP ORAL TABLET 10-300 MG

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Vicoprofen

Products Affected• VICOPROFEN

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Victrelis

Products Affected• VICTRELIS

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Viekira Pak

Products Affected• VIEKIRA PAK

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Viekira XR

Products Affected• VIEKIRA XR

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Vimizim

Products Affected• VIMIZIM

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Visudyne

Products Affected• VISUDYNE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Voltaren

Products Affected• VOLTAREN TRANSDERMAL

Notes/References

Vonvendi

Products Affected• VONVENDI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Vosevi

Products Affected• VOSEVI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Votrient

Products Affected• VOTRIENT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• VPRIV

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Vyvanse

Products Affected• VYVANSE

Notes/References

Vyvanse

Products Affected• VYVANSE

Notes/References

Products Affected• WERA

Notes/References

Wilate

Products Affected• WILATE INTRAVENOUS KIT• WILATE INTRAVENOUS SOLUTION

RECONSTITUTED 1000-1000 UNIT, 500-500 UNIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xalkori

Products Affected• XALKORI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xartemis XR

Products Affected• XARTEMIS XR

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xeljanz

Products Affected• XELJANZ

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Xeljanz_XeljanzXR.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xeljanz XR

Products Affected• XELJANZ XR

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Xeljanz_XeljanzXR.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xeloda

Products Affected• XELODA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xenazine

Products Affected• XENAZINE ORAL TABLET 12.5 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xenazine

Products Affected• XENAZINE ORAL TABLET 25 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xeomin

Products Affected• XEOMIN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xermelo

Products Affected• XERMELO

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Xermelo.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• XGEVA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• XODOL

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xolair

Products Affected• XOLAIR

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/RESP/Xolair.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xtampza ER

Products Affected• XTAMPZA ER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xtandi

Products Affected• XTANDI

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xuriden

Products Affected• XURIDEN

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xyntha

Products Affected• XYNTHA INTRAVENOUS KIT 1000

UNIT, 2000 UNIT, 250 UNIT, 500 UNIT

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Xyntha Solofuse

Products Affected• XYNTHA SOLOFUSE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Products Affected• XYREM

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/cataplexy-xyrem.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zamicet

Products Affected• ZAMICET

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zarxio

Products Affected• ZARXIO

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zavesca

Products Affected• ZAVESCA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zejula

Products Affected• ZEJULA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Zejula.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zelboraf

Products Affected• ZELBORAF

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zemaira

Products Affected• ZEMAIRA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zenatane

Products Affected• ZENATANE

Exclusion Criteria

Age Restrictions

Coverage Duration

1 year

Other Criteria

Notes/References

Zenchent

Products Affected• ZENCHENT

Notes/References

Zenzedi

Products Affected• ZENZEDI

Notes/References

Zepatier

Products Affected• ZEPATIER

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zinbryta

Products Affected• ZINBRYTA

Covered Uses

Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Zinbryta.html

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zohydro ER

Products Affected• ZOHYDRO ER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zohydro ER

Products Affected• ZOHYDRO ER

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zoladex

Products Affected• ZOLADEX

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zolinza

Products Affected• ZOLINZA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zomacton

Products Affected• ZOMACTON

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zonalon

Products Affected• ZONALON

Notes/References

Zorbtive

Products Affected• ZORBTIVE

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zovia 1/35E (28)

Products Affected• ZOVIA 1/35E (28)

Notes/References

Zovia 1/50E (28)

Products Affected• ZOVIA 1/50E (28)

Notes/References

Zubsolv

Products Affected• ZUBSOLV SUBLINGUAL TABLET

SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG

Notes/References

Zubsolv

SUBLINGUAL 11.4-2.9 MG

Notes/References

Zubsolv

Notes/References

Zubsolv

Notes/References

Zydelig

Products Affected• ZYDELIG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zykadia

Products Affected• ZYKADIA

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zytiga

Products Affected• ZYTIGA ORAL TABLET 250 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

Zytiga

Products Affected• ZYTIGA ORAL TABLET 500 MG

Covered Uses

Exclusion Criteria

Age Restrictions

Coverage Duration

Other Criteria

Notes/References

IndexIndex

ABSORICA................................................1ABSTRAL..................................................2acetaminophen-codeine ................................ 4acetaminophen-codeine #2 ...........................6acetaminophen-codeine #3 ...........................8acetaminophen-codeine #4 ......................... 10ACTEMRA..............................................12ACTIMMUNE........................................ 13ACTIQ..................................................... 14ADCIRCA............................................... 16ADDERALL............................................17ADDERALL XR..................................... 18ADEMPAS...............................................19ADVATE................................................. 20adynovate .................................................. 21ADZENYS XR-ODT...............................22AFINITOR.............................................. 23AFINITOR DISPERZ.............................24AFSTYLA................................................25ALDURAZYME..................................... 26ALECENSA.............................................27ALPHANATE/VWF COMPLEX/HUMAN..............................28ALPHANINE SD.................................... 29ALPROLIX..............................................30ALUNBRIG............................................ 31AMNESTEEM.........................................32amphetamine-dextroamphet er ...................33amphetamine-dextroamphetamine ..............34AMPYRA................................................ 35apap-caff-dihydrocodeine oral capsule ........36apap-caff-dihydrocodeine oral tablet 325-30-16 mg ................................................... 36APTENSIO XR........................................38ARALAST NP......................................... 39ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 150 MCG/0.75ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML.............................................40

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML............................................ 40ARCALYST.............................................41ARYMO ER............................................ 42ASCOMP-CODEINE.............................. 44aspirin-caff-dihydrocodeine ........................46atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg, 60 mg ..................................48atomoxetine hcl oral capsule 100 mg, 80 mg .............................................................49AUBAGIO............................................... 50AUSTEDO...............................................51AVINZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 60 MG...........................................................52AVONEX.................................................54AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT.......................... 55AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT........................................ 56BEBULIN................................................ 57BEBULIN VH..........................................58BELBUCA............................................... 59BENEFIX INTRAVENOUS SOLUTION RECONSTITUTED........... 61BENLYSTA............................................. 62BERINERT..............................................63BETASERON SUBCUTANEOUS KIT. 64bexarotene .................................................65BIVIGAM................................................ 66BOSULIF.................................................67BOTOX.................................................... 68BRAVELLE............................................. 69BUNAVAIL BUCCAL FILM 2.1-0.3 MG...........................................................70

BUNAVAIL BUCCAL FILM 4.2-0.7 MG...........................................................71BUNAVAIL BUCCAL FILM 6.3-1 MG.72BUPHENYL ORAL POWDER 3 GM/TSP................................................... 73BUPHENYL ORAL TABLET................ 73buprenorphine ............................................74buprenorphine hcl sublingual ...................... 76buprenorphine hcl-naloxone hcl ..................77butalbital-apap-caff-cod .............................78butalbital-asa-caff-codeine .........................80butorphanol tartrate nasal ..........................82BUTRANS...............................................84CABOMETYX.........................................86capecitabine ...............................................87CAPITAL/CODEINE..............................88CAPRELSA............................................. 90CARBAGLU........................................... 91CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM................................................92CERDELGA............................................93CEREZYME............................................94CETROTIDE........................................... 95CHOLBAM..............................................96chorionic gonadotropin intramuscular ........ 97CIMZIA PREFILLED............................ 99CIMZIA STARTER KIT.......................100CIMZIA SUBCUTANEOUS KIT 2 X 200 MG.................................................... 98CINQAIR...............................................101CINRYZE.............................................. 102CLARAVIS............................................ 103clonidine hcl er .........................................104COAGADEX......................................... 105codeine sulfate oral tablet .........................106COMETRIQ (100 MG DAILY DOSE). 108COMETRIQ (140 MG DAILY DOSE). 109COMETRIQ (60 MG DAILY DOSE)... 110CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 54 MG............................................111

CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG........... 112CONZIP................................................. 113COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 115CORIFACT............................................116COSENTYX...........................................117COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML....................... 118COTELLIC............................................ 119COTEMPLA XR-ODT.......................... 120CUPRIMINE ORAL CAPSULE 250 MG......................................................... 121CUVITRU..............................................122CYSTADANE........................................123CYSTARAN.......................................... 124DAKLINZA...........................................125DAYTRANA......................................... 126DEMEROL ORAL................................ 127DEPEN TITRATABS............................129DESCOVY............................................. 130DESOXYN.............................................131DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR...... 132DEXEDRINE ORAL TABLET............ 133dexmethylphenidate hcl ............................134dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg ........................................................... 135dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 40 mg, 5 mg ........................................................... 135dextroamphetamine sulfate er .................. 138dextroamphetamine sulfate oral solution .. 136dextroamphetamine sulfate oral tablet ......137DIBENZYLINE.....................................139diclofenac sodium transdermal gel 1 % ..... 140diclofenac sodium transdermal gel 3 % ..... 141DILAUDID ORAL................................142DOLOPHINE........................................ 144doxepin hcl external .................................146DUPIXENT........................................... 147

DURAGESIC-100..................................148DURAGESIC-12................................... 150DURAGESIC-25................................... 152DURAGESIC-50................................... 154DURAGESIC-75................................... 156DYANAVEL XR................................... 158DYSPORT............................................. 159ELAPRASE............................................160ELELYSO.............................................. 161ELIGARD..............................................162ELLA......................................................163ELOCTATE........................................... 164EMBEDA...............................................165EMFLAZA.............................................167EMLA.................................................... 168ENBREL SUBCUTANEOUS KIT....... 170ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML............................................. 170ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML..................................................171ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR............................................ 172ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG......................................................... 173entecavir .................................................. 175ENTYVIO.............................................. 176EPCLUSA.............................................. 177EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML...............................................178epoprostenol sodium .................................179ERIVEDGE........................................... 180ESBRIET ORAL CAPSULE................. 181ESBRIET ORAL TABLET....................182EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 183EVEKEO................................................184

EXALGO ORAL TABLET ER 24 HOUR ABUSE-DETERRENT............. 185EXJADE.................................................187EXTAVIA SUBCUTANEOUS KIT......188EYLEA INTRAOCULAR.................... 189FABRAZYME.......................................190FALMINA............................................. 191FARYDAK............................................192FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML.....................193FEIBA.................................................... 194FEIBA NF..............................................195FEIBA VH IMMUNO........................... 196fentanyl ................................................... 197fentanyl citrate buccal ..............................199FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG................................................ 201FERRIPROX......................................... 203FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG................. 204FIORINAL/CODEINE #3.................... 206FIRAZYR.............................................. 208FIRMAGON..........................................209FLEBOGAMMA DIF........................... 211FLEBOGAMMA INTRAVENOUS SOLUTION 0.5 GM/10ML....................210FLOLAN................................................212FOCALIN.............................................. 213FOCALIN XR....................................... 214FOLLISTIM AQ.................................... 215FUZEON............................................... 216GAMMAGARD.................................... 217GAMMAGARD S/D INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM..............................................218GAMMAKED....................................... 219GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/200ML, 2.5 GM/50ML, 20 GM/400ML, 5 GM/100ML............................................ 220GAMUNEX-C....................................... 221ganirelix acetate ...................................... 222

GATTEX................................................223GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE....................... 224GELSYN-3.............................................225GENOTROPIN......................................226GENOTROPIN MINIQUICK.............. 227GILDAGIA............................................228GILDESS FE 1.5/30............................... 229GILDESS FE 1/20.................................. 230GILENYA..............................................231GILOTRIF.............................................232GLASSIA............................................... 233GLATOPA............................................. 234GLEEVEC..............................................235GONAL-F..............................................236GONAL-F RFF..................................... 237GONAL-F RFF PEN.............................238GONAL-F RFF REDIJECT................. 239GRANIX................................................240guanfacine hcl er ......................................241HAEGARDA.........................................242HARVONI............................................. 243HELIXATE FS...................................... 244HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1501-2000 UNIT, 1700 UNIT, 220-400 UNIT, 250 UNIT, 401-800 UNIT, 500 UNIT, 801-1500 UNIT.........245HETLIOZ...............................................246HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML..................... 247HP ACTHAR.........................................248HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT......................................................249HUMATROPE...................................... 250HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML............................................. 252

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT............................253HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT.........................................................254HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT.........................................................255HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT............... 251HYALGAN............................................256HYCAMTIN ORAL..............................257HYCET.................................................. 258hydrocodone-acetaminophen oral solution10-325 mg/15ml, 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml ....................... 260hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg ............260hydrocodone-ibuprofen .............................262hydromorphone hcl er ...............................266hydromorphone hcl oral ........................... 264hydromorphone hcl rectal .........................264HYMOVIS............................................. 268HYQVIA................................................ 269HYSINGLA ER.....................................270IBRANCE.............................................. 272IBUDONE............................................. 273ICLUSIG................................................275IDELVION............................................ 276IDHIFA..................................................277ILARIS...................................................278ILARIS (150MG DELIVERED)........... 279imatinib mesylate .....................................280IMBRUVICA.........................................281INCRELEX............................................282INFERGEN........................................... 283INFLECTRA......................................... 284INGREZZA........................................... 285INLYTA.................................................286INTRON A............................................ 287INTUNIV...............................................288IRESSA.................................................. 289

IXINITY................................................ 290JADENU................................................291JADENU SPRINKLE........................... 292JAKAFI..................................................293JETREA INTRAOCULAR...................294JUNEL 1.5/30.........................................295JUNEL 1/20............................................296JUNEL FE 1.5/30................................... 297JUNEL FE 1/20......................................298JUXTAPID ORAL CAPSULE 10 MG. 299JUXTAPID ORAL CAPSULE 20 MG. 300JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG....................................... 301JUXTAPID ORAL CAPSULE 5 MG... 302KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG....................................... 303KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG, 40 MG, 70 MG...............................303KALBITOR........................................... 305KALYDECO ORAL PACKET............. 306KALYDECO ORAL TABLET..............307KANUMA............................................. 308KAPVAY ORAL................................... 309KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR...... 310KARIVA................................................ 311KELNOR 1/35........................................312KEVEYIS...............................................313KEVZARA.............................................314KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 315KISQALI 200 DOSE.............................. 316KISQALI 400 DOSE.............................. 317KISQALI 600 DOSE.............................. 318KISQALI FEMARA 200 DOSE............319KISQALI FEMARA 400 DOSE............320KISQALI FEMARA 600 DOSE............321KOATE.................................................. 322KOATE-DVI..........................................323KOGENATE FS.................................... 324

KOGENATE FS BIO-SET.................... 325KORLYM.............................................. 326KOVALTRY..........................................327KRYSTEXXA........................................328KURVELO............................................ 329KUVAN................................................. 330KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 331LAZANDA............................................ 332LAZANDA............................................ 334LEENA...................................................335LEMTRADA......................................... 336LENVIMA 10 MG DAILY DOSE........ 337LENVIMA 14 MG DAILY DOSE........ 338LENVIMA 18 MG DAILY DOSE........ 339LENVIMA 20 MG DAILY DOSE........ 340LENVIMA 24 MG DAILY DOSE........ 341LENVIMA 8 MG DAILY DOSE.......... 342LESSINA............................................... 343LETAIRIS..............................................344LEUKINE..............................................345leuprolide acetate injection .......................346LEVONEST........................................... 347levonorgestrel-ethinyl estrad oral tablet0.15-30 mg-mcg ....................................... 348LEVORA 0.15/30 (28)............................ 349levorphanol tartrate oral .......................... 350lidocaine external ointment ...................... 352lidocaine-prilocaine external cream .......... 354LONSURF............................................. 356LORCET................................................ 357LORCET HD......................................... 359LORCET PLUS ORAL TABLET 7.5-325 MG...................................................361LORTAB ORAL ELIXIR 10-300 MG/15ML.............................................. 363LORTAB ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG...........................363LOW-OGESTREL................................. 365LUCENTIS INTRAOCULAR.............. 366LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE.. 366LUMIZYME..........................................367

LUPANETA PACK...............................368LUPRON DEPOT (1-MONTH)............369LUPRON DEPOT (3-MONTH)............370LUPRON DEPOT (4-MONTH)............371LUPRON DEPOT (6-MONTH)............372LUPRON DEPOT-PED (1-MONTH)...373LUPRON DEPOT-PED (3-MONTH)...374LUTERA................................................375LYNPARZA ORAL CAPSULE............376LYNPARZA ORAL TABLET.............. 377MACUGEN........................................... 378MAKENA..............................................379marlissa ................................................... 380MAVYRET............................................ 381MEKINIST............................................ 382MENOPUR............................................383meperidine hcl oral ...................................384METADATE CD................................... 386METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG........... 387METHADONE HCL INTENSOL........ 390methadone hcl oral ...................................388METHADOSE ORAL CONCENTRATE 10 MG/ML...............392METHADOSE SUGAR-FREE.............394methamphetamine hcl .............................. 396METHYLIN ORAL SOLUTION 10 MG/5ML................................................ 397METHYLIN ORAL SOLUTION 5 MG/5ML................................................ 398METHYLIN ORAL TABLET CHEWABLE..........................................399methylphenidate hcl er (cd) ..................... 409methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg ................ 410methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg ................ 411methylphenidate hcl er (la) oral capsule extended release 24 hour 40 mg ................ 410methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg ................ 412methylphenidate hcl er oral tablet extended release 10 mg ........................................... 403

methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg .....................404methylphenidate hcl er oral tablet extended release 20 mg ........................................... 405methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg ........ 407methylphenidate hcl er oral tablet extended release 24 hour 36 mg ...............................408methylphenidate hcl er oral tablet extended release 36 mg ........................................... 406methylphenidate hcl oral solution 10 mg/5ml .................................................... 400methylphenidate hcl oral solution 5 mg/5ml................................................................ 401methylphenidate hcl oral tablet .................402methylphenidate hcl oral tablet chewable ..402MICROGESTIN 1.5/30..........................413MICROGESTIN 1/20............................ 414MICROGESTIN FE 1.5/30....................415MICROGESTIN FE 1/20.......................416MIRCERA INJECTION SOLUTION PREFILLED SYRINGE....................... 417MONOCLATE-P................................... 418MONONINE......................................... 419MONOVISC...........................................420MORPHABOND ER.............................421morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml .................425morphine sulfate er beads ......................... 429morphine sulfate er oral capsule extended release 24 hour .........................................427morphine sulfate er oral tablet extended release ..................................................... 427morphine sulfate oral ............................... 423morphine sulfate rectal .............................423MS CONTIN ORAL TABLET EXTENDED RELEASE....................... 431MYALEPT.............................................433MYDAYIS............................................. 434MYORISAN.......................................... 435MYORISAN.......................................... 436MYOZYME........................................... 437NAGLAZYME...................................... 438

NATPARA.............................................439NECON 0.5/35 (28)................................ 440NECON 1/35 (28)................................... 441NECON 10/11 (28)................................. 442NERLYNX............................................ 443NEULASTA DELIVERY KIT SUBCUTANEOUS PREFILLED SYRINGE KIT...................................... 445NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 444NEUMEGA........................................... 446NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML........... 447NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE....................... 447NEXAVAR............................................ 448NINLARO............................................. 449NITYR................................................... 450NORCO..................................................451NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML............................................. 453NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS SOLUTION 30 MG/3ML................................................ 454norgestrel-ethinyl estradiol .......................455NORTHERA ORAL CAPSULE 100 MG......................................................... 456NORTHERA ORAL CAPSULE 200 MG, 300 MG.......................................... 457NORTREL 0.5/35 (28)........................... 458NORTREL 1/35 (21).............................. 459NORTREL 1/35 (28).............................. 460novarel intramuscular solution reconstituted 10000 unit ........................... 461NOVOEIGHT........................................ 462NOVOSEVEN RT..................................463NPLATE................................................ 464NUCALA...............................................465NUCYNTA............................................466NUCYNTA ER......................................468NUPLAZID........................................... 470

NUTROPIN AQ.................................... 472NUTROPIN AQ NUSPIN 10................473NUTROPIN AQ NUSPIN 20................474NUTROPIN AQ NUSPIN 5..................475NUTROPIN AQ PEN............................476NUTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG......................................................... 471NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT......................................................477NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT................. 477OCALIVA ORAL TABLET 5 MG........478OCTAGAM........................................... 479octreotide acetate .....................................480ODOMZO.............................................. 481OFEV..................................................... 482OLYSIO................................................. 483OMNITROPE........................................ 484OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT............. 487OPANA ORAL...................................... 485OPSUMIT.............................................. 489ORENCIA CLICKJECT....................... 492ORENCIA INTRAVENOUS................ 490ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML........................................... 491ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML................. 490ORENITRAM....................................... 493ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG..............................................494ORFADIN ORAL SUSPENSION........ 494ORKAMBI.............................................495ORSYTHIA........................................... 496ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 497OTEZLA ORAL TABLET.................... 498

OTEZLA ORAL TABLET THERAPY PACK..................................................... 498OVIDREL.............................................. 499OXAYDO...............................................500oxycodone hcl er oral tablet er 12 hour abuse-deterrent ........................................ 504oxycodone hcl er oral tablet er 12 hour abuse-deterrent ........................................ 506oxycodone hcl oral capsule .......................502oxycodone hcl oral concentrate 100 mg/5ml................................................................ 502oxycodone hcl oral concentrate 20 mg/ml . 502oxycodone hcl oral solution ...................... 502oxycodone hcl oral tablet ......................... 502oxycodone-acetaminophen oral solution ... 508oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg................................................................ 508oxycodone-aspirin oral tablet 4.8355-325 mg ........................................................... 510oxycodone-ibuprofen ................................512OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT............. 514oxymorphone hcl ......................................516oxymorphone hcl er ..................................518OZURDEX INTRAOCULAR.............. 520PEGASYS.............................................. 521PEGASYS PROCLICK......................... 522PEGINTRON........................................ 523PEG-INTRON....................................... 524PEG-INTRON REDIPEN.....................525PEG-INTRON REDIPEN PAK 4......... 526pentazocine-naloxone hcl ......................... 527PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG......................................................... 529phenoxybenzamine hcl oral ...................... 531PHILITH................................................532PLEGRIDY........................................... 533PLEGRIDY STARTER PACK.............534POMALYST.......................................... 535PORTIA-28............................................ 536PRALUENT.......................................... 537

pregnyl .................................................... 538PRIMLEV.............................................. 539PRIVIGEN.............................................541PROCENTRA........................................542PROCRIT.............................................. 543PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG..............544PROCYSBI ORAL CAPSULE DELAYED RELEASE 75 MG..............545PROFILNINE SD..................................546PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG......................................................... 547PROLIA................................................. 548PROMACTA......................................... 549PRUDOXIN.......................................... 550PULMOZYME...................................... 551PURIXAN..............................................552QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 40 MG....................................... 553QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 30 MG.................................................... 554QUILLIVANT XR.................................555RAVICTI............................................... 556REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR........... 558REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR................................ 559REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE....................... 557REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE....................... 560RECLIPSEN.......................................... 561RECOMBINATE...................................562REMICADE.......................................... 563REMODULIN....................................... 564RENFLEXIS..........................................565REPATHA............................................. 566REPATHA PUSHTRONEX SYSTEM.567

REPATHA SURECLICK......................568REPREXAIN ORAL TABLET 10-200 MG, 5-200 MG....................................... 569REPRONEX.......................................... 571REVATIO INTRAVENOUS.................572REVATIO ORAL SUSPENSION RECONSTITUTED...............................573REVATIO ORAL TABLET.................. 574REVLIMID............................................575RIASTAP............................................... 576RITALIN............................................... 577RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 60 MG................. 578RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 30 MG......................................................... 579RIXUBIS................................................580rosuvastatin calcium .................................581ROXICET ORAL SOLUTION............. 582ROXICODONE ORAL TABLET......... 584RUBRACA............................................ 586RUCONEST.......................................... 587RYDAPT................................................588SABRIL..................................................589SAIZEN..................................................590SAIZEN CLICK.EASY......................... 591SAMSCA................................................592SANDOSTATIN....................................593SANDOSTATIN LAR DEPOT.............594SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG........................................... 595SIGNIFOR.............................................596SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED..... 597sildenafil citrate oral ................................ 598SILIQ......................................................599SIMPONI ARIA.................................... 601SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR........... 600SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 600

SIRTURO.............................................. 602sodium phenylbutyrate oral powder 3 gm/tsp ......................................................603SOLARAZE........................................... 604SOLIRIS.................................................605SOMATULINE DEPOT........................606SOMAVERT.......................................... 607SOVALDI.............................................. 608SPRYCEL.............................................. 609SRONYX............................................... 610STELARA INTRAVENOUS................ 611STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 611STIOLTO RESPIMAT.......................... 612STIVARGA............................................613STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG, 60 MG.... 614STRATTERA ORAL CAPSULE 100 MG, 80 MG............................................615STRENSIQ.............................................616SUBOXONE SUBLINGUAL FILM 12-3 MG...................................................... 617SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG.......................618SUBOXONE SUBLINGUAL TABLET SUBLINGUAL...................................... 619SUBSYS................................................. 620SUPARTZ INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 622SUPPRELIN LA....................................623SUTENT................................................ 624SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 4 X 200 MCG, 4 X 300 MCG, 600 MCG.............................. 625SYNAGIS...............................................626SYNALGOS-DC....................................627SYNAREL............................................. 629SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 630SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 631SYPRINE...............................................632tacrolimus external .................................. 633

TAFINLAR........................................... 634TAGRISSO............................................ 635TALTZ................................................... 636TARCEVA............................................. 637TARGRETIN ORAL............................ 638TASIGNA.............................................. 639TECFIDERA ORAL............................. 640TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG............ 641TECFIDERA ORAL CAPSULE DELAYED RELEASE 240 MG............ 642TECHNIVIE.......................................... 643TEMODAR ORAL................................644temozolomide ...........................................645tetrabenazine ........................................... 646TEV-TROPIN........................................ 647THALOMID.......................................... 648THIOLA.................................................649TILIA FE............................................... 650TRACLEER...........................................651tramadol hcl er .........................................654tramadol hcl er (biphasic) ........................656tramadol hcl oral ..................................... 652tramadol-acetaminophen ..........................658TRELSTAR........................................... 660TRELSTAR MIXJECT......................... 661TREMFYA............................................ 662TRETTEN..............................................663TREZIX ORAL CAPSULE 320.5-30-16 MG......................................................... 664TRI-LEGEST FE................................... 666TRIVORA (28).......................................667TRUVADA............................................ 668TYKERB................................................669TYLENOL WITH CODEINE #3..........670TYLENOL WITH CODEINE #4..........672TYMLOS............................................... 674TYSABRI...............................................675TYVASO................................................ 676TYVASO REFILL................................. 677TYVASO STARTER............................. 678ULTRACET...........................................679ULTRAM.............................................. 681

ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 300 MG.......................................... 683UPTRAVI.............................................. 685VALCHLOR.......................................... 686VALCYTE............................................. 687valganciclovir hcl ..................................... 688VANTAS................................................689VECAMYL............................................ 690VELETRI............................................... 691VELIVET............................................... 692VELTASSA............................................ 693VEMLIDY............................................. 695VENCLEXTA........................................696VENCLEXTA STARTING PACK....... 697VENTAVIS............................................ 698VERDROCET........................................699VICODIN ES ORAL TABLET 7.5-300 MG......................................................... 703VICODIN HP ORAL TABLET 10-300 MG......................................................... 705VICODIN ORAL TABLET 5-300 MG..701VICOPROFEN...................................... 707VICTRELIS........................................... 709VIEKIRA PAK...................................... 710VIEKIRA XR........................................ 711VIMIZIM............................................... 712VISUDYNE........................................... 713VOLTAREN TRANSDERMAL...........714VONVENDI...........................................715VOSEVI..................................................716VOTRIENT............................................717VPRIV.................................................... 718VYVANSE............................................. 719VYVANSE............................................. 720WERA.................................................... 721WILATE INTRAVENOUS KIT........... 722WILATE INTRAVENOUS SOLUTION RECONSTITUTED 1000-1000 UNIT, 500-500 UNIT.........................................722XALKORI............................................. 723XARTEMIS XR.....................................724XELJANZ.............................................. 726

XELJANZ XR....................................... 727XELODA............................................... 728XENAZINE ORAL TABLET 12.5 MG 729XENAZINE ORAL TABLET 25 MG... 730XEOMIN................................................731XERMELO............................................ 732XGEVA..................................................733XODOL..................................................734XOLAIR.................................................736XTAMPZA ER...................................... 737XTANDI................................................ 739XURIDEN............................................. 740XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT......................................................741XYNTHA SOLOFUSE..........................742XYREM................................................. 743ZAMICET..............................................744ZARXIO.................................................746ZAVESCA..............................................747ZEJULA.................................................748ZELBORAF...........................................749ZEMAIRA............................................. 750ZENATANE.......................................... 751ZENCHENT.......................................... 752ZENZEDI.............................................. 753ZEPATIER.............................................754ZINBRYTA........................................... 755ZOHYDRO ER......................................756ZOHYDRO ER......................................758ZOLADEX.............................................760ZOLINZA.............................................. 761ZOMACTON......................................... 762ZONALON............................................ 763ZORBTIVE............................................ 764ZOVIA 1/35E (28)...................................765ZOVIA 1/50E (28)...................................766ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG......................................................... 767ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG................. 768

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 2.9-0.71 MG................. 769ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6-2.1 MG...................770ZYDELIG.............................................. 771ZYKADIA............................................. 772ZYTIGA ORAL TABLET 250 MG.......773ZYTIGA ORAL TABLET 500 MG.......774

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Distributed By Aetna Plastics €¦ · Distributed By Aetna Plastics Aetna Plastics - Phone 800.634.3074 - Fax 216.524.2280 - Email sales@aetnaplastics.com @?>=

AARP Essential Premier Health Insurance · AARP® Essential Premier Health Insurance Plan is the name of the plan underwritten for AARP members by Aetna Life Insurance Company. In

AETNA BETTER HEALTH PREMIER PLAN · 2020-05-06 · MANUAL PARA MIEMBROS de Aetna Better Health Premier Plan . Índice. Capítulo 1: Primeros pasos como miembro A. Bienvenido a Aetna

Make Aetna the choice for your health! of New Jersey...The Aetna companies that offer or underwrite benefits coverage include: Aetna Health Inc., Aetna Health of California Inc., Aetna

2020 List of Covered Drugs/Formulary · 2019-10-21 · 2020 List of Covered Drugs/Formulary Aetna Better HealthSM Premier Plan Aetna Better Health Premier Plan (Medicare-Medicaid

Aetna Assure Premier Plus (HMO D-SNP)

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Aetna Premier Care Network (APCN) Aetna Premier Care Plus ... · APCN Plus is a network program that can be added to the Choice POS II or Open Access Aetna ... only those claims for

WILLIAM LEE, M.D.WILLIAM LEE, M.D.WILLIAM LEE, M.D.WILLIAM LEE, M.D. HEALTH PLAN TOLL FREE # PROVIDER HEALTH PLAN ID # Aetna and US Healthcare 800.282.5366 RMG- 408611 LMG- 686903

Aetna IndividualUnderwritingGuide

Pennsylvania - Aetna

Your Benefits - Aetna · submit claim forms – your provider does it for you. The Aetna PPO plan uses the Aetna Choice POS II network. Aetna EPO The Aetna EPO plan is an Exclusive

Florida 2017 Application for Aetna Individual Health …Florida 2017 Application for Aetna Individual Health Insurance Aetna Life Insurance Company and Aetna Health Inc. Primary Applicant’s

Aetna medical plans€¦ · ©2016 Aetna Inc. 00.25.051.1 A (03/16) AETNA / MMC/ October 5, 2016 Aetna medical plans Marsh & McLennan Companies 2017 Benefits Overview

AETNA BETTER HEALTH PREMIER PLAN MMAI€¦ · Aetna Better Health Premier Plan MMAI (plan de Medicare y Medicaid): Resumen de beneicios para 2021 ! A. Descargos de responsabilidad

January1,2015–December31,2015 Summary ofBenefits Part D 2015 PDP Summary o… · January1,2015–December31,2015 Aetna Medicare Rx Saver (PDP) Aetna Medicare Rx Premier (PDP) MONTHLY

Aetna Assure Premier Plus (HMO D-SNP) · 2021. 1. 19. · Model of Care ... Assure Premier Plus (HMO D-SNP) for approved facilities and/or contracted Providers. However, Members are

Summaryof · 2016. 11. 16. · This isa summaryofservices covered by Aetna Medicare Premier Plan (PPO) January 1,2017-December31, 2017 Aetna Medicare Premier Plan (PPO) isa Medicare

Administrative Handbook · Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or ... Thank you for choosing Aetna for