2018 Aetna Premier Plus Plan - Lee County, Florida

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

1

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


2


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


3

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


4

QL Criteria 90 MME Per 1 Day

Notes/References

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


5

Acetaminophen-Codeine #2

Products Affected• acetaminophen-codeine #2



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


6


Notes/References



7





Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


8


Notes/References



9





Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


10


Notes/References



11

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



12

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



13

Actiq

Products Affected• ACTIQ



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year


14


Other Criteria


QL Criteria 120 lozenges Per 30 Days

Notes/References




15

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



16

Adderall

Products Affected• ADDERALL


Notes/References



17

Adderall XR

Products Affected• ADDERALL XR


Notes/References




18

Adempas

Products Affected• ADEMPAS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



19

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



20

Adynovate

Products Affected• adynovate


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



21

Adzenys XR-ODT

Products Affected• ADZENYS XR-ODT

QL Criteria 1 tablet Per 1 Day

Notes/References



22

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



23

Afinitor Disperz

Products Affected• AFINITOR DISPERZ


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



24

Afstyla

Products Affected• AFSTYLA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



25

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



26

Alecensa

Products Affected• ALECENSA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



27

Alphanate/VWF Complex/Human

Products Affected• ALPHANATE/VWF COMPLEX/HUMAN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



28

AlphaNine SD

Products Affected• ALPHANINE SD


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



29

Alprolix

Products Affected• ALPROLIX


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



30

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



31

Amnesteem

Products Affected• AMNESTEEM



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year

Other Criteria


Notes/References




32

Amphetamine-Dextroamphet ER

Products Affected• amphetamine-dextroamphet er


Notes/References




33

Amphetamine-Dextroamphetamine

Products Affected• amphetamine-dextroamphetamine


Notes/References



34

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



35

APAP-Caff-Dihydrocodeine

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

16 mg



Exclusion Criteria



Age Restrictions


Coverage Duration



36


Other Criteria


Notes/References



37

Aptensio XR

Products Affected• APTENSIO XR

QL Criteria 1 capsule Per 1 Day

Notes/References




38

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



39

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



40

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



41

Arymo ER

Products Affected• ARYMO ER



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


42


Notes/References




43

Ascomp-Codeine

Products Affected• ASCOMP-CODEINE



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


44


Notes/References



45

Aspirin-Caff-Dihydrocodeine

Products Affected• aspirin-caff-dihydrocodeine



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


46


Notes/References



47

Atomoxetine HCl

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

25 mg, 40 mg, 60 mg


Notes/References



48

Atomoxetine HCl

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


Notes/References



49

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



50

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



51

AVINza

Products Affected• AVINZA ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 60 MG



Exclusion Criteria



Age Restrictions


Coverage Duration



52


Other Criteria


Notes/References



53

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



54

Avonex Pen

Products Affected• AVONEX PEN INTRAMUSCULAR

AUTO-INJECTOR KIT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



55

Avonex Prefilled

Products Affected• AVONEX PREFILLED

INTRAMUSCULAR PREFILLED SYRINGE KIT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



56

Bebulin

Products Affected• BEBULIN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



57

Bebulin VH

Products Affected• BEBULIN VH


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



58

Belbuca

Products Affected• BELBUCA



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


59


Notes/References



60

BeneFIX

Products Affected• BENEFIX INTRAVENOUS SOLUTION

RECONSTITUTED


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



61

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



62

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



63

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



64

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



65

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



66

Bosulif

Products Affected• BOSULIF


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



67

Botox

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



68

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



69

Bunavail

Products Affected• BUNAVAIL BUCCAL FILM 2.1-0.3 MG

QL Criteria 6 films Per 1 Day

Notes/References




70

Bunavail

Products Affected• BUNAVAIL BUCCAL FILM 4.2-0.7 MG


Notes/References




71

Bunavail

Products Affected• BUNAVAIL BUCCAL FILM 6.3-1 MG


Notes/References




72

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



73

Buprenorphine

Products Affected• buprenorphine



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


74

QL Criteria 4 patches Per 28 Days

Notes/References



75

Buprenorphine HCl

Products Affected• buprenorphine hcl sublingual


Notes/References




76

Buprenorphine HCl-Naloxone HCl

Products Affected• buprenorphine hcl-naloxone hcl


Notes/References




77

Butalbital-APAP-Caff-Cod

Products Affected• butalbital-apap-caff-cod



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


78


Notes/References



79

Butalbital-ASA-Caff-Codeine

Products Affected• butalbital-asa-caff-codeine



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


80


Notes/References



81

Butorphanol Tartrate

Products Affected• butorphanol tartrate nasal



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


82


Notes/References



83

Butrans

Products Affected• BUTRANS



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


84

QL Criteria 4 patches Per 28 Days

Notes/References

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


85

Cabometyx

Products Affected• CABOMETYX


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



86

Capecitabine

Products Affected• capecitabine


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



87

Capital/Codeine

Products Affected• CAPITAL/CODEINE



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


88


Notes/References



89

Caprelsa

Products Affected• CAPRELSA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



90

Carbaglu

Products Affected• CARBAGLU


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



91

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



92

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



93

Cerezyme

Products Affected• CEREZYME


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



94

Cetrotide

Products Affected• CETROTIDE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



95

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



96

Chorionic Gonadotropin

Products Affected• chorionic gonadotropin intramuscular


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



97

Cimzia

Products Affected• CIMZIA SUBCUTANEOUS KIT 2 X 200

MG


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



98

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



99

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



100

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



101

Cinryze

Products Affected• CINRYZE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



102

Claravis

Products Affected• CLARAVIS



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year

Other Criteria


Notes/References




103

CloNIDine HCl ER

Products Affected• clonidine hcl er


Notes/References




104

Coagadex

Products Affected• COAGADEX


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



105

Codeine Sulfate

Products Affected• codeine sulfate oral tablet



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


106


Notes/References



107

Cometriq (100 mg Daily Dose)

Products Affected• COMETRIQ (100 MG DAILY DOSE)


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



108




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



109




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



110

Concerta

Products Affected• CONCERTA ORAL TABLET EXTENDED

RELEASE 18 MG, 27 MG, 54 MG


Notes/References




111

Concerta

Products Affected• CONCERTA ORAL TABLET EXTENDED

RELEASE 36 MG


Notes/References




112

ConZip

Products Affected• CONZIP



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


113


Notes/References



114

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



115

Corifact

Products Affected• CORIFACT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



116

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



117

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



118

Cotellic

Products Affected• COTELLIC


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



119

Cotempla XR-ODT

Products Affected• COTEMPLA XR-ODT


Notes/References



120

Cuprimine

Products Affected• CUPRIMINE ORAL CAPSULE 250 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



121

Cuvitru

Products Affected• CUVITRU


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



122

Cystadane

Products Affected• CYSTADANE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



123

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



124

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



125

Daytrana

Products Affected• DAYTRANA

QL Criteria 1 patch Per 1 Day

Notes/References




126

Demerol

Products Affected• DEMEROL ORAL



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


127


Notes/References



128

Depen Titratabs

Products Affected• DEPEN TITRATABS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



129

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



130

Desoxyn

Products Affected• DESOXYN


Notes/References




131

Dexedrine

Products Affected• DEXEDRINE ORAL CAPSULE

EXTENDED RELEASE 24 HOUR


Notes/References



132

Dexedrine

Products Affected• DEXEDRINE ORAL TABLET


Notes/References



133

Dexmethylphenidate HCl

Products Affected• dexmethylphenidate hcl


Notes/References



134

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




135

Dextroamphetamine Sulfate

Products Affected• dextroamphetamine sulfate oral solution

QL Criteria 40 ML Per 1 Day

Notes/References




136

Dextroamphetamine Sulfate

Products Affected• dextroamphetamine sulfate oral tablet


Notes/References



137

Dextroamphetamine Sulfate ER

Products Affected• dextroamphetamine sulfate er


Notes/References



138

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



139

Diclofenac Sodium

Products Affected• diclofenac sodium transdermal gel 1 %

QL Criteria 200 grams Per 30 Days

Notes/References



140

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



141

Dilaudid

Products Affected• DILAUDID ORAL



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


142


Notes/References



143

Dolophine

Products Affected• DOLOPHINE



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


144


Notes/References



145

Doxepin HCl

Products Affected• doxepin hcl external


Notes/References



146

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



147

Duragesic-100

Products Affected• DURAGESIC-100



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


148


Notes/References




149

Duragesic-12




Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


150


Notes/References




151

Duragesic-25




Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


152


Notes/References




153

Duragesic-50




Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


154


Notes/References




155

Duragesic-75




Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


156


Notes/References




157

Dyanavel XR

Products Affected• DYANAVEL XR

QL Criteria 240 ml Per 30 Days

Notes/References



158

Dysport

Products Affected• DYSPORT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



159

Elaprase

Products Affected• ELAPRASE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



160

Elelyso

Products Affected• ELELYSO


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



161

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



162

Ella

Products Affected• ELLA

QL Criteria 2 tablets Per 1 fill

Notes/References



163

Eloctate

Products Affected• ELOCTATE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



164

Embeda

Products Affected• EMBEDA



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


165


Notes/References




166

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



167

EMLA

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


168


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


169

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



170

Enbrel

Products Affected• ENBREL SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 50 MG/ML


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



171

Enbrel SureClick

Products Affected• ENBREL SURECLICK SUBCUTANEOUS

SOLUTION AUTO-INJECTOR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



172

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



173


Other Criteria


Notes/References



174

Entecavir

Products Affected• entecavir


Notes/References



175

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



176

Epclusa

Products Affected• EPCLUSA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



177

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



178

Epoprostenol Sodium

Products Affected• epoprostenol sodium


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



179

Erivedge

Products Affected• ERIVEDGE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



180

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



181

Esbriet

Products Affected• ESBRIET ORAL TABLET


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



182

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



183

Evekeo

Products Affected• EVEKEO


Notes/References




184

Exalgo

Products Affected• EXALGO ORAL TABLET ER 24 HOUR

ABUSE-DETERRENT



Exclusion Criteria



Age Restrictions


Coverage Duration



185


Other Criteria


Notes/References



186

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



187

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



188

Eylea

Products Affected• EYLEA INTRAOCULAR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



189

Fabrazyme

Products Affected• FABRAZYME


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



190

Falmina

Products Affected• FALMINA

QL Criteria 1.5 tablets Per 1 Day

Notes/References



191

Farydak

Products Affected• FARYDAK


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

QL Criteria 12 capsules Per 30 Days

Notes/References



192

Faslodex

Products Affected• FASLODEX INTRAMUSCULAR

SOLUTION 250 MG/5ML


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



193

Feiba

Products Affected• FEIBA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



194

Feiba NF

Products Affected• FEIBA NF


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



195

Feiba VH Immuno

Products Affected• FEIBA VH IMMUNO


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



196

FentaNYL

Products Affected• fentanyl



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


197


Notes/References




198

FentaNYL Citrate

Products Affected• fentanyl citrate buccal



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year


199


Other Criteria


QL Criteria 120 lozenges Per 30 Days

Notes/References




200

Fentora

Products Affected• FENTORA BUCCAL TABLET 100 MCG,

200 MCG, 400 MCG, 600 MCG, 800 MCG



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year


201


Other Criteria



Notes/References




202

Ferriprox

Products Affected• FERRIPROX


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



203

Fioricet/Codeine

Products Affected• FIORICET/CODEINE ORAL CAPSULE

50-300-40-30 MG



Exclusion Criteria



Age Restrictions


Coverage Duration



204


Other Criteria


Notes/References



205

Fiorinal/Codeine #3

Products Affected• FIORINAL/CODEINE #3



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


206


Notes/References



207

Firazyr

Products Affected• FIRAZYR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



208

Firmagon

Products Affected• FIRMAGON


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



209

Flebogamma

Products Affected• FLEBOGAMMA INTRAVENOUS

SOLUTION 0.5 GM/10ML


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



210

Flebogamma DIF

Products Affected• FLEBOGAMMA DIF


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



211

Flolan

Products Affected• FLOLAN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



212

Focalin

Products Affected• FOCALIN


Notes/References



213

Focalin XR

Products Affected• FOCALIN XR


Notes/References




214

Follistim AQ

Products Affected• FOLLISTIM AQ


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



215

Fuzeon

Products Affected• FUZEON


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



216

Gammagard

Products Affected• GAMMAGARD


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



217

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



218

Gammaked

Products Affected• GAMMAKED


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



219

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



220

Gamunex-C

Products Affected• GAMUNEX-C


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



221

Ganirelix Acetate

Products Affected• ganirelix acetate


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



222

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



223

Gel-One

Products Affected• GEL-ONE INTRA-ARTICULAR

PREFILLED SYRINGE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



224

Gelsyn-3

Products Affected• GELSYN-3


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



225

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



226

Genotropin MiniQuick

Products Affected• GENOTROPIN MINIQUICK


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



227

Gildagia

Products Affected• GILDAGIA


Notes/References



228

Gildess FE 1.5/30

Products Affected• GILDESS FE 1.5/30


Notes/References



229

Gildess FE 1/20

Products Affected• GILDESS FE 1/20


Notes/References



230

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



231

Gilotrif

Products Affected• GILOTRIF


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



232

Glassia

Products Affected• GLASSIA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



233

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



234

Gleevec

Products Affected• GLEEVEC


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



235

Gonal-f

Products Affected• GONAL-F


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



236

Gonal-f RFF

Products Affected• GONAL-F RFF


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



237

Gonal-f RFF Pen

Products Affected• GONAL-F RFF PEN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



238

Gonal-f RFF Rediject

Products Affected• GONAL-F RFF REDIJECT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



239

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



240

GuanFACINE HCl ER

Products Affected• guanfacine hcl er


Notes/References




241

Haegarda

Products Affected• HAEGARDA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



242

Harvoni

Products Affected• HARVONI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



243

Helixate FS

Products Affected• HELIXATE FS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



244

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



245

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



246

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



247

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



248

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



249

Humatrope

Products Affected• HUMATROPE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



250

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



251

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



252

Humira Pen

Products Affected• HUMIRA PEN SUBCUTANEOUS PEN-

INJECTOR KIT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



253

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



254

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



255

Hyalgan

Products Affected• HYALGAN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



256

Hycamtin

Products Affected• HYCAMTIN ORAL


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



257

Hycet

Products Affected• HYCET



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


258


Notes/References



259

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



260


Other Criteria


Notes/References



261

Hydrocodone-Ibuprofen

Products Affected• hydrocodone-ibuprofen



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


262


Notes/References



263

HYDROmorphone HCl

Products Affected• hydromorphone hcl oral • hydromorphone hcl rectal



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


264


Notes/References



265

HYDROmorphone HCl ER

Products Affected• hydromorphone hcl er



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


266


Notes/References



267

Hymovis

Products Affected• HYMOVIS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



268

Hyqvia

Products Affected• HYQVIA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



269

Hysingla ER

Products Affected• HYSINGLA ER



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


270


Notes/References



271

Ibrance

Products Affected• IBRANCE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



272

Ibudone

Products Affected• IBUDONE



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


273


Notes/References



274

Iclusig

Products Affected• ICLUSIG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



275

Idelvion

Products Affected• IDELVION


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



276

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



277

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



278

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



279

Imatinib Mesylate

Products Affected• imatinib mesylate


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



280

Imbruvica

Products Affected• IMBRUVICA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



281

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



282

Infergen

Products Affected• INFERGEN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



283

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



284

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



285

Inlyta

Products Affected• INLYTA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



286

Intron A

Products Affected• INTRON A


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



287

Intuniv

Products Affected• INTUNIV


Notes/References




288

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



289

Ixinity

Products Affected• IXINITY


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



290

Jadenu

Products Affected• JADENU


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



291

Jadenu Sprinkle

Products Affected• JADENU SPRINKLE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



292

Jakafi

Products Affected• JAKAFI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



293

Jetrea

Products Affected• JETREA INTRAOCULAR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



294

Junel 1.5/30

Products Affected• JUNEL 1.5/30


Notes/References



295

Junel 1/20

Products Affected• JUNEL 1/20


Notes/References



296

Junel FE 1.5/30

Products Affected• JUNEL FE 1.5/30


Notes/References



297

Junel FE 1/20

Products Affected• JUNEL FE 1/20


Notes/References



298

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



299

Juxtapid



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



300

Juxtapid

Products Affected• JUXTAPID ORAL CAPSULE 30 MG, 40

MG, 60 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



301

Juxtapid



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



302

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



303


Other Criteria


Notes/References



304

Kalbitor

Products Affected• KALBITOR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



305

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



306

Kalydeco

Products Affected• KALYDECO ORAL TABLET


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



307

Kanuma

Products Affected• KANUMA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



308

Kapvay

Products Affected• KAPVAY ORAL

QL Criteria 2 EA Per 1 Day

Notes/References



309

Kapvay

Products Affected• KAPVAY ORAL TABLET EXTENDED

RELEASE 12 HOUR


Notes/References




310

Kariva

Products Affected• KARIVA


Notes/References



311

Kelnor 1/35

Products Affected• KELNOR 1/35


Notes/References



312

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



313

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



314

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



315

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



316

Kisqali 400 Dose



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



317

Kisqali 600 Dose



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



318

Kisqali Femara 200 Dose

Products Affected• KISQALI FEMARA 200 DOSE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



319




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



320




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



321

Koate

Products Affected• KOATE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



322

Koate-DVI

Products Affected• KOATE-DVI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



323

Kogenate FS

Products Affected• KOGENATE FS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



324

Kogenate FS Bio-Set

Products Affected• KOGENATE FS BIO-SET


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



325

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



326

Kovaltry

Products Affected• KOVALTRY


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



327

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



328

Kurvelo

Products Affected• KURVELO


Notes/References



329

Kuvan

Products Affected• KUVAN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



330

Kynamro

Products Affected• KYNAMRO SUBCUTANEOUS



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



331

Lazanda

Products Affected• LAZANDA



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year


332


Other Criteria


QL Criteria 4 bottles Per 30 Days

Notes/References




333

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


334

Leena

Products Affected• LEENA


Notes/References



335

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



336

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



337




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



338




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



339




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



340




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



341




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



342

Lessina

Products Affected• LESSINA


Notes/References



343

Letairis

Products Affected• LETAIRIS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



344

Leukine

Products Affected• LEUKINE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



345

Leuprolide Acetate

Products Affected• leuprolide acetate injection


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



346

Levonest

Products Affected• LEVONEST


Notes/References



347

Levonorgestrel-Ethinyl Estrad

Products Affected• levonorgestrel-ethinyl estrad oral tablet

0.15-30 mg-mcg


Notes/References



348

Levora 0.15/30 (28)

Products Affected• LEVORA 0.15/30 (28)


Notes/References



349

Levorphanol Tartrate

Products Affected• levorphanol tartrate oral



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


350


Notes/References



351

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


352


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



353

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


354


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



355

Lonsurf

Products Affected• LONSURF


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



356

Lorcet

Products Affected• LORCET



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


357


Notes/References



358

Lorcet HD

Products Affected• LORCET HD



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


359


Notes/References



360

Lorcet Plus

Products Affected• LORCET PLUS ORAL TABLET 7.5-325

MG



Exclusion Criteria



Age Restrictions


Coverage Duration



361


Other Criteria


Notes/References



362

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



363


Other Criteria


Notes/References



364

Low-Ogestrel

Products Affected• LOW-OGESTREL


Notes/References



365

Lucentis

Products Affected• LUCENTIS INTRAOCULAR• LUCENTIS INTRAVITREAL SOLUTION

PREFILLED SYRINGE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



366

Lumizyme

Products Affected• LUMIZYME


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



367

Lupaneta Pack

Products Affected• LUPANETA PACK


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



368

Lupron Depot (1-Month)

Products Affected• LUPRON DEPOT (1-MONTH)


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



369




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



370




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



371




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



372

Lupron Depot-Ped (1-Month)

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


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



373

Lupron Depot-Ped (3-Month)

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


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



374

Lutera

Products Affected• LUTERA

QL Criteria 1.5 tablet Per 1 Day

Notes/References



375

Lynparza

Products Affected• LYNPARZA ORAL CAPSULE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



376

Lynparza

Products Affected• LYNPARZA ORAL TABLET


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



377

Macugen

Products Affected• MACUGEN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



378

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



379

Marlissa

Products Affected• marlissa


Notes/References



380

Mavyret

Products Affected• MAVYRET


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



381

Mekinist

Products Affected• MEKINIST


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



382

Menopur

Products Affected• MENOPUR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



383

Meperidine HCl

Products Affected• meperidine hcl oral



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


384


Notes/References



385

Metadate CD

Products Affected• METADATE CD


Notes/References




386

Metadate ER

Products Affected• METADATE ER ORAL TABLET

EXTENDED RELEASE 20 MG


Notes/References




387

Methadone HCl

Products Affected• methadone hcl oral



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


388


Notes/References



389

Methadone HCl Intensol

Products Affected• METHADONE HCL INTENSOL



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


390


Notes/References



391

Methadose

Products Affected• METHADOSE ORAL CONCENTRATE 10

MG/ML



Exclusion Criteria



Age Restrictions


Coverage Duration



392


Other Criteria


Notes/References



393

Methadose Sugar-Free

Products Affected• METHADOSE SUGAR-FREE



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


394


Notes/References



395

Methamphetamine HCl

Products Affected• methamphetamine hcl


Notes/References




396

Methylin

Products Affected• METHYLIN ORAL SOLUTION 10

MG/5ML


Notes/References




397

Methylin

Products Affected• METHYLIN ORAL SOLUTION 5

MG/5ML


Notes/References




398

Methylin

Products Affected• METHYLIN ORAL TABLET CHEWABLE


Notes/References




399

Methylphenidate HCl

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


Notes/References




400

Methylphenidate HCl

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


Notes/References




401

Methylphenidate HCl

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


Notes/References




402

Methylphenidate HCl ER

Products Affected• methylphenidate hcl er oral tablet extended

release 10 mg


Notes/References



403



release 18 mg, 27 mg, 54 mg


Notes/References




404



release 20 mg


Notes/References




405



release 36 mg


Notes/References




406



release 24 hour 18 mg, 27 mg, 54 mg


Notes/References



407



release 24 hour 36 mg


Notes/References



408

Methylphenidate HCl ER (CD)

Products Affected• methylphenidate hcl er (cd)


Notes/References




409

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




410





Notes/References




411





Notes/References



412

Microgestin 1.5/30

Products Affected• MICROGESTIN 1.5/30


Notes/References



413

Microgestin 1/20

Products Affected• MICROGESTIN 1/20


Notes/References



414

Microgestin FE 1.5/30

Products Affected• MICROGESTIN FE 1.5/30


Notes/References



415

Microgestin FE 1/20

Products Affected• MICROGESTIN FE 1/20


Notes/References



416

Mircera

Products Affected• MIRCERA INJECTION SOLUTION

PREFILLED SYRINGE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



417

Monoclate-P

Products Affected• MONOCLATE-P


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



418

Mononine

Products Affected• MONONINE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



419

Monovisc

Products Affected• MONOVISC


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



420

MorphaBond ER

Products Affected• MORPHABOND ER



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


421


Notes/References



422

Morphine Sulfate

Products Affected• morphine sulfate oral • morphine sulfate rectal



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


423


Notes/References



424

Morphine Sulfate (Concentrate)

Products Affected• morphine sulfate (concentrate) oral solution

100 mg/5ml, 20 mg/ml



Exclusion Criteria



Age Restrictions


Coverage Duration



425


Other Criteria


Notes/References



426

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



427


Other Criteria


Notes/References



428

Morphine Sulfate ER Beads

Products Affected• morphine sulfate er beads



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


429


Notes/References



430

MS Contin

Products Affected• MS CONTIN ORAL TABLET EXTENDED

RELEASE



Exclusion Criteria



Age Restrictions


Coverage Duration



431


Other Criteria


Notes/References



432

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



433

Mydayis

Products Affected• MYDAYIS


Notes/References



434

Myorisan

Products Affected• MYORISAN



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year

Other Criteria


Notes/References



435

Myorisan

Products Affected• MYORISAN



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year

Other Criteria


Notes/References




436

Myozyme

Products Affected• MYOZYME


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



437

Naglazyme

Products Affected• NAGLAZYME


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



438

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



439

Necon 0.5/35 (28)

Products Affected• NECON 0.5/35 (28)


Notes/References



440

Necon 1/35 (28)

Products Affected• NECON 1/35 (28)


Notes/References



441

Necon 10/11 (28)

Products Affected• NECON 10/11 (28)


Notes/References



442

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



443

Neulasta

Products Affected• NEULASTA SUBCUTANEOUS



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



444

Neulasta Delivery Kit

Products Affected• NEULASTA DELIVERY KIT

SUBCUTANEOUS PREFILLED SYRINGE KIT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



445

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



446

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



447

NexAVAR

Products Affected• NEXAVAR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



448

Ninlaro

Products Affected• NINLARO


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



449

Nityr

Products Affected• NITYR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



450

Norco

Products Affected• NORCO



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


451


Notes/References



452

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



453

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



454

Norgestrel-Ethinyl Estradiol

Products Affected• norgestrel-ethinyl estradiol


Notes/References



455

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



456

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



457

Nortrel 0.5/35 (28)

Products Affected• NORTREL 0.5/35 (28)


Notes/References



458

Nortrel 1/35 (21)

Products Affected• NORTREL 1/35 (21)


Notes/References



459

Nortrel 1/35 (28)

Products Affected• NORTREL 1/35 (28)


Notes/References



460

Novarel

Products Affected• novarel intramuscular solution reconstituted

10000 unit


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



461

Novoeight

Products Affected• NOVOEIGHT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



462

NovoSeven RT

Products Affected• NOVOSEVEN RT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



463

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



464

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



465

Nucynta

Products Affected• NUCYNTA



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


466


Notes/References




467

Nucynta ER

Products Affected• NUCYNTA ER



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


468


Notes/References




469

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



470

Nutropin

Products Affected• NUTROPIN SUBCUTANEOUS

SOLUTION RECONSTITUTED 10 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



471

Nutropin AQ

Products Affected• NUTROPIN AQ


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



472

Nutropin AQ NuSpin 10

Products Affected• NUTROPIN AQ NUSPIN 10


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



473




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



474




Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



475

Nutropin AQ Pen

Products Affected• NUTROPIN AQ PEN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



476

Nuwiq

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



477

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



478

Octagam

Products Affected• OCTAGAM


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



479

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



480

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



481

Ofev

Products Affected• OFEV


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



482

Olysio

Products Affected• OLYSIO


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



483

Omnitrope

Products Affected• OMNITROPE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



484

Opana

Products Affected• OPANA ORAL



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


485


Notes/References



486

Opana ER

Products Affected• OPANA ER ORAL TABLET ER 12 HOUR

ABUSE-DETERRENT



Exclusion Criteria



Age Restrictions


Coverage Duration



487


Other Criteria


Notes/References




488

Opsumit

Products Affected• OPSUMIT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



489

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



490

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



491

Orencia ClickJect

Products Affected• ORENCIA CLICKJECT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



492

Orenitram

Products Affected• ORENITRAM


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



493

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



494

Orkambi

Products Affected• ORKAMBI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



495

Orsythia

Products Affected• ORSYTHIA


Notes/References



496

OrthoVisc

Products Affected• ORTHOVISC INTRA-ARTICULAR



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



497

Otezla

Products Affected• OTEZLA ORAL TABLET• OTEZLA ORAL TABLET THERAPY

PACK


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



498

Ovidrel

Products Affected• OVIDREL


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



499

Oxaydo

Products Affected• OXAYDO



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


500


Notes/References



501

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



502


Other Criteria


Notes/References



503

OxyCODONE HCl ER

Products Affected• oxycodone hcl er oral tablet er 12 hour

abuse-deterrent



Exclusion Criteria



Age Restrictions


Coverage Duration



504


Other Criteria


Notes/References



505

OxyCODONE HCl ER

Products Affected• oxycodone hcl er oral tablet er 12 hour

abuse-deterrent



Exclusion Criteria



Age Restrictions


Coverage Duration



506


Other Criteria


Notes/References




507

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



508


Other Criteria


Notes/References



509

Oxycodone-Aspirin

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



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


510


Notes/References



511

Oxycodone-Ibuprofen

Products Affected• oxycodone-ibuprofen



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


512


Notes/References



513

OxyCONTIN

Products Affected• OXYCONTIN ORAL TABLET ER 12

HOUR ABUSE-DETERRENT



Exclusion Criteria



Age Restrictions


Coverage Duration



514


Other Criteria


Notes/References




515

Oxymorphone HCl

Products Affected• oxymorphone hcl



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


516


Notes/References



517

OxyMORphone HCl ER

Products Affected• oxymorphone hcl er



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


518


Notes/References



519

Ozurdex

Products Affected• OZURDEX INTRAOCULAR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



520

Pegasys

Products Affected• PEGASYS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



521

Pegasys ProClick

Products Affected• PEGASYS PROCLICK


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



522

PegIntron

Products Affected• PEGINTRON


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



523

Peg-Intron

Products Affected• PEG-INTRON


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



524

Peg-Intron Redipen

Products Affected• PEG-INTRON REDIPEN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



525

Peg-Intron Redipen Pak 4

Products Affected• PEG-INTRON REDIPEN PAK 4


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



526

Pentazocine-Naloxone HCl

Products Affected• pentazocine-naloxone hcl



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


527


Notes/References



528

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



529


Other Criteria


Notes/References



530

Phenoxybenzamine HCl

Products Affected• phenoxybenzamine hcl oral


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



531

Philith

Products Affected• PHILITH


Notes/References



532

Plegridy

Products Affected• PLEGRIDY


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

QL Criteria 1 ML Per 28 Days

Notes/References



533

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



534

Pomalyst

Products Affected• POMALYST


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



535

Portia-28

Products Affected• PORTIA-28


Notes/References



536

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



537

Pregnyl

Products Affected• pregnyl


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



538

Primlev

Products Affected• PRIMLEV



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


539


Notes/References



540

Privigen

Products Affected• PRIVIGEN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



541

ProCentra

Products Affected• PROCENTRA


Notes/References




542

Procrit

Products Affected• PROCRIT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



543

Procysbi

Products Affected• PROCYSBI ORAL CAPSULE DELAYED

RELEASE 25 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



544

Procysbi

Products Affected• PROCYSBI ORAL CAPSULE DELAYED

RELEASE 75 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



545

Profilnine SD

Products Affected• PROFILNINE SD


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



546

Prolastin-C

Products Affected• PROLASTIN-C INTRAVENOUS

SOLUTION RECONSTITUTED 1000 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



547

Prolia

Products Affected• PROLIA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



548

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



549

Prudoxin

Products Affected• PRUDOXIN


Notes/References



550

Pulmozyme

Products Affected• PULMOZYME


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



551

Purixan

Products Affected• PURIXAN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



552

QuilliChew ER

Products Affected• QUILLICHEW ER ORAL TABLET

CHEWABLE EXTENDED RELEASE 20 MG, 40 MG


Notes/References



553

QuilliChew ER

Products Affected• QUILLICHEW ER ORAL TABLET

CHEWABLE EXTENDED RELEASE 30 MG


Notes/References



554

Quillivant XR

Products Affected• QUILLIVANT XR


Notes/References




555

Ravicti

Products Affected• RAVICTI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



556

Rebif

Products Affected• REBIF SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



557

Rebif Rebidose

Products Affected• REBIF REBIDOSE SUBCUTANEOUS

SOLUTION AUTO-INJECTOR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



558

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



559

Rebif Titration Pack

Products Affected• REBIF TITRATION PACK

SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



560

Reclipsen

Products Affected• RECLIPSEN


Notes/References



561

Recombinate

Products Affected• RECOMBINATE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



562

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



563

Remodulin

Products Affected• REMODULIN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



564

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



565

Repatha

Products Affected• REPATHA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



566

Repatha Pushtronex System

Products Affected• REPATHA PUSHTRONEX SYSTEM


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



567

Repatha SureClick

Products Affected• REPATHA SURECLICK


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



568

Reprexain

Products Affected• REPREXAIN ORAL TABLET 10-200 MG,

5-200 MG



Exclusion Criteria



Age Restrictions


Coverage Duration



569


Other Criteria


Notes/References



570

Repronex

Products Affected• REPRONEX


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



571

Revatio

Products Affected• REVATIO INTRAVENOUS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



572

Revatio

Products Affected• REVATIO ORAL SUSPENSION

RECONSTITUTED


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



573

Revatio

Products Affected• REVATIO ORAL TABLET


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



574

Revlimid

Products Affected• REVLIMID


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



575

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



576

Ritalin

Products Affected• RITALIN


Notes/References



577

Ritalin LA

Products Affected• RITALIN LA ORAL CAPSULE

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


Notes/References




578

Ritalin LA

Products Affected• RITALIN LA ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 30 MG


Notes/References




579

Rixubis

Products Affected• RIXUBIS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



580

Rosuvastatin Calcium

Products Affected• rosuvastatin calcium


Notes/References



581

Roxicet

Products Affected• ROXICET ORAL SOLUTION



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


582


Notes/References



583

Roxicodone

Products Affected• ROXICODONE ORAL TABLET



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


584


Notes/References



585

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



586

Ruconest

Products Affected• RUCONEST


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



587

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



588

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



589

Saizen

Products Affected• SAIZEN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



590

Saizen Click.Easy

Products Affected• SAIZEN CLICK.EASY


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



591

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



592

SandoSTATIN

Products Affected• SANDOSTATIN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



593

SandoSTATIN LAR Depot

Products Affected• SANDOSTATIN LAR DEPOT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



594

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



595

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



596

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



597

Sildenafil Citrate

Products Affected• sildenafil citrate oral


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



598

Siliq

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



599

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



600

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



601

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



602

Sodium Phenylbutyrate

Products Affected• sodium phenylbutyrate oral powder 3 gm/tsp


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



603

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



604

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



605

Somatuline Depot

Products Affected• SOMATULINE DEPOT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



606

Somavert

Products Affected• SOMAVERT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



607

Sovaldi

Products Affected• SOVALDI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

QL Criteria 1 tab Per 1 fill

Notes/References



608

Sprycel

Products Affected• SPRYCEL


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

QL Criteria 30 days Per 1 fill

Notes/References



609

Sronyx

Products Affected• SRONYX


Notes/References



610

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



611

Stiolto Respimat

Products Affected• STIOLTO RESPIMAT

QL Criteria 1 inhaler Per 30 Days

Notes/References



612

Stivarga

Products Affected• STIVARGA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



613

Strattera

Products Affected• STRATTERA ORAL CAPSULE 10 MG, 18

MG, 25 MG, 40 MG, 60 MG


Notes/References



614

Strattera

Products Affected• STRATTERA ORAL CAPSULE 100 MG,

80 MG


Notes/References



615

Strensiq

Products Affected• STRENSIQ


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



616

Suboxone

Products Affected• SUBOXONE SUBLINGUAL FILM 12-3

MG


Notes/References




617

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




618

Suboxone

Products Affected• SUBOXONE SUBLINGUAL TABLET

SUBLINGUAL


Notes/References




619

Subsys

Products Affected• SUBSYS



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year


620


Other Criteria


QL Criteria 120 sprays Per 30 Days

Notes/References




621

Supartz

Products Affected• SUPARTZ INTRA-ARTICULAR



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



622

Supprelin LA

Products Affected• SUPPRELIN LA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



623

Sutent

Products Affected• SUTENT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



624

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



625

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



626

Synalgos-DC

Products Affected• SYNALGOS-DC



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


627


Notes/References



628

Synarel

Products Affected• SYNAREL


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



629

Synvisc

Products Affected• SYNVISC INTRA-ARTICULAR



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



630

Synvisc One

Products Affected• SYNVISC ONE INTRA-ARTICULAR



Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



631

Syprine

Products Affected• SYPRINE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



632

Tacrolimus

Products Affected• tacrolimus external

QL Criteria 60 GM Per 1 fill

Notes/References




633

Tafinlar

Products Affected• TAFINLAR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



634

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



635

Taltz

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



636

Tarceva

Products Affected• TARCEVA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



637

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



638

Tasigna

Products Affected• TASIGNA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



639

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



640

Tecfidera

Products Affected• TECFIDERA ORAL CAPSULE DELAYED

RELEASE 120 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



641

Tecfidera

Products Affected• TECFIDERA ORAL CAPSULE DELAYED

RELEASE 240 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



642

Technivie

Products Affected• TECHNIVIE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



643

Temodar

Products Affected• TEMODAR ORAL


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



644

Temozolomide

Products Affected• temozolomide


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



645

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



646

Tev-Tropin

Products Affected• TEV-TROPIN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



647

Thalomid

Products Affected• THALOMID


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



648

Thiola

Products Affected• THIOLA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



649

Tilia Fe

Products Affected• TILIA FE


Notes/References



650

Tracleer

Products Affected• TRACLEER


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



651

TraMADol HCl

Products Affected• tramadol hcl oral



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


652


Notes/References



653

TraMADol HCl ER

Products Affected• tramadol hcl er



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


654


Notes/References



655

TraMADol HCl ER (Biphasic)

Products Affected• tramadol hcl er (biphasic)



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


656


Notes/References



657

Tramadol-Acetaminophen

Products Affected• tramadol-acetaminophen



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


658


Notes/References



659

Trelstar

Products Affected• TRELSTAR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



660

Trelstar Mixject

Products Affected• TRELSTAR MIXJECT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



661

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



662

Tretten

Products Affected• TRETTEN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



663

Trezix

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



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


664


Notes/References



665

Tri-Legest Fe

Products Affected• TRI-LEGEST FE


Notes/References



666

Trivora (28)

Products Affected• TRIVORA (28)


Notes/References



667

Truvada

Products Affected• TRUVADA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



668

Tykerb

Products Affected• TYKERB


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



669

Tylenol with Codeine #3

Products Affected• TYLENOL WITH CODEINE #3



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


670


Notes/References



671

Tylenol with Codeine #4

Products Affected• TYLENOL WITH CODEINE #4



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


672


Notes/References



673

Tymlos

Products Affected• TYMLOS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

QL Criteria 1 pen Per 1 month

Notes/References



674

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



675

Tyvaso

Products Affected• TYVASO


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



676

Tyvaso Refill

Products Affected• TYVASO REFILL


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



677

Tyvaso Starter

Products Affected• TYVASO STARTER


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



678

Ultracet

Products Affected• ULTRACET



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


679


Notes/References



680

Ultram

Products Affected• ULTRAM



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


681


Notes/References



682

Ultram ER

Products Affected• ULTRAM ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 100 MG, 300 MG



Exclusion Criteria



Age Restrictions


Coverage Duration



683


Other Criteria


Notes/References



684

Uptravi

Products Affected• UPTRAVI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



685

Valchlor

Products Affected• VALCHLOR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



686

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



687

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



688

Vantas

Products Affected• VANTAS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



689

Vecamyl

Products Affected• VECAMYL


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



690

Veletri

Products Affected• VELETRI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



691

Velivet

Products Affected• VELIVET


Notes/References



692

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


693



694

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



695

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



696

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



697

Ventavis

Products Affected• VENTAVIS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



698

Verdrocet

Products Affected• VERDROCET



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


699


Notes/References



700

Vicodin

Products Affected• VICODIN ORAL TABLET 5-300 MG



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


701


Notes/References



702

Vicodin ES

Products Affected• VICODIN ES ORAL TABLET 7.5-300 MG



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


703


Notes/References



704

Vicodin HP

Products Affected• VICODIN HP ORAL TABLET 10-300 MG



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


705


Notes/References



706

Vicoprofen

Products Affected• VICOPROFEN



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


707


Notes/References



708

Victrelis

Products Affected• VICTRELIS


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



709

Viekira Pak

Products Affected• VIEKIRA PAK


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



710

Viekira XR

Products Affected• VIEKIRA XR


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



711

Vimizim

Products Affected• VIMIZIM


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



712

Visudyne

Products Affected• VISUDYNE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



713

Voltaren

Products Affected• VOLTAREN TRANSDERMAL


Notes/References



714

Vonvendi

Products Affected• VONVENDI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



715

Vosevi

Products Affected• VOSEVI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



716

Votrient

Products Affected• VOTRIENT


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



717

Vpriv

Products Affected• VPRIV


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



718

Vyvanse

Products Affected• VYVANSE


Notes/References



719

Vyvanse

Products Affected• VYVANSE


Notes/References



720

Wera

Products Affected• WERA


Notes/References



721

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



722

Xalkori

Products Affected• XALKORI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



723

Xartemis XR

Products Affected• XARTEMIS XR



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


724


Notes/References



725

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



726

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



727

Xeloda

Products Affected• XELODA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



728

Xenazine

Products Affected• XENAZINE ORAL TABLET 12.5 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



729

Xenazine

Products Affected• XENAZINE ORAL TABLET 25 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



730

Xeomin

Products Affected• XEOMIN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



731

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



732

Xgeva

Products Affected• XGEVA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



733

Xodol

Products Affected• XODOL



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


734


Notes/References



735

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



736

Xtampza ER

Products Affected• XTAMPZA ER



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


737


Notes/References



738

Xtandi

Products Affected• XTANDI


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



739

Xuriden

Products Affected• XURIDEN


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



740

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



741

Xyntha Solofuse

Products Affected• XYNTHA SOLOFUSE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



742

Xyrem

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



743

Zamicet

Products Affected• ZAMICET



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


744


Notes/References



745

Zarxio

Products Affected• ZARXIO


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



746

Zavesca

Products Affected• ZAVESCA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



747

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



748

Zelboraf

Products Affected• ZELBORAF


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



749

Zemaira

Products Affected• ZEMAIRA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



750

Zenatane

Products Affected• ZENATANE



Exclusion Criteria



Age Restrictions


Coverage Duration

1 year

Other Criteria


Notes/References




751

Zenchent

Products Affected• ZENCHENT


Notes/References



752

Zenzedi

Products Affected• ZENZEDI


Notes/References



753

Zepatier

Products Affected• ZEPATIER


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



754

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



755

Zohydro ER

Products Affected• ZOHYDRO ER



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


756


Notes/References




757

Zohydro ER

Products Affected• ZOHYDRO ER



Exclusion Criteria



Age Restrictions


Coverage Duration


Other Criteria


758


Notes/References




759

Zoladex

Products Affected• ZOLADEX


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



760

Zolinza

Products Affected• ZOLINZA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



761

Zomacton

Products Affected• ZOMACTON


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



762

Zonalon

Products Affected• ZONALON


Notes/References



763

Zorbtive

Products Affected• ZORBTIVE


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



764

Zovia 1/35E (28)

Products Affected• ZOVIA 1/35E (28)


Notes/References



765

Zovia 1/50E (28)

Products Affected• ZOVIA 1/50E (28)


Notes/References



766

Zubsolv

Products Affected• ZUBSOLV SUBLINGUAL TABLET

SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG


Notes/References




767

Zubsolv


SUBLINGUAL 11.4-2.9 MG


Notes/References




768

Zubsolv




Notes/References




769

Zubsolv




Notes/References




770

Zydelig

Products Affected• ZYDELIG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



771

Zykadia

Products Affected• ZYKADIA


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



772

Zytiga

Products Affected• ZYTIGA ORAL TABLET 250 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria


Notes/References



773

Zytiga

Products Affected• ZYTIGA ORAL TABLET 500 MG


Covered Uses


Exclusion Criteria


Age Restrictions


Coverage Duration


Other Criteria

Notes/References



774

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

Index

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


775

Index

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

Index

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


776

Index

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

Index

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


777

Index

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

Index

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


778

Index

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

Index

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


779

Index

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

Index

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


780

Index

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

Index

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


781

Index

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

Index

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


782

Index

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

Index

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


783

Index

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

Index

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


784

Index

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

Index

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


785

Documents

2018 Aetna Premier Plus Plan - Lee County, Florida