August 2017 Formulary Updates - Aetna

Updated 08/2017 August 2017 Formulary Updates Generics Added CLINDAMYCIN/SODIUM CHLORIDE CLOFARABINE MELPHALAN ? PA OLOPATADINE HYDROCHLORIDE SEVELAMER CARBONATE PACK Brands Added ISENTRESS HD ? QL RITUXAN HYCELA ? PA SELZENTRY SOLN ? QL Prior Authorization Updates TYMLOS-CRITERIA REVISED Quantity Limit Updates DESVENLAFAXINE ER 25 mg--QL Increased Step Therapy Updates NONE Medications Removed from Formulary NONE

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 08/2017

July 2017 Formulary Updates Generics Added DOCETAXEL INJ 200MG/10ML EZETIMIBE-SIMVASTATIN TAB --QL FLUTICASONE PROPIONATE/SALMETEROL INH 55 --QL ROWEEPRA TABS 750MG; 1000MG ATOMOXETINE CAPS 10MG; 18MG; 25MG; 40MG; 60MG; 80MG; 100MG --PA, QL

Brands Added ALUNBRIG --PA, QL GAMMAPLEX INJ 5GM/50ML; 10GM/100ML; 20GM/200ML --PA HERCEPTIN INJ 150MG --PA IMFINZI --PA KISQALI FEMARA 200 DOSE; 400 DOSE; 600 DOSE --PA RYDAPT --PA STAMARIL TYMLOS --PA, QL XULTOPHY 100/3.6--ST, QL ZEJULA --PA, QL ZYTIGA TABS 500MG --PA, QL

Prior Authorization Updates NONE

Quantity Limit Updates NONE

Step Therapy Updates NONE

Medications Removed from Formulary NONE

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 08/2017

June 2017 Formulary Updates

Generics Added BUSULFAN TAZAROTENE CREAM Brands Added AUSTEDO TABS 6MG; 9MG; 12MG--PA, QL BAVENCIO--PA ESBRIET TABS 267MG; 801MG--PA, QL OCREVUS--PA, QL SYNJARDY XR--QL Prior Authorization Updates NITROFURANTOIN MACROCRYSTALS--PA removed NITROFURANTOIN MONOHYDRATE--PA removed NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS--PA removed NITROFURANTOIN SUSPENSION--PA removed Quantity Limit Updates KISQALI--QL increased Step Therapy Updates NONE Medications Removed from Formulary NONE

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 08/2017

May 2017 Formulary Updates

Generics Added DESVENLAFAXINE ER 10MG, 25MG, 100MG TABS (generic Pristiq?)--PA, QL PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION 10 MG/5ML; 20MG/5ML TACROLIMUS OINT 0.03%; 0.1%--QL

Brands Added GLEOSTINE 10MG, 40MG, 100MG CAPS ILARIS INJ 150MG/ML--PA, QL KISQALI --PA, QL

Over-the-Counter (OTC) Drugs Added 4-WAY FAST ACTING A THRU Z ADVANCED A THRU Z HIGH POTENCY A THRU Z SELECT A THRU Z SELECT 50+ MENS A THRU Z SELECT ADVANCED A THRU Z SELECT ULTIMATE A THRU Z ULTIMATE MENS ABC PLUS ABC PLUS SENIOR ADULTS 50 ACETA-GESIC ACETAMINOPHEN ACETAMINOPHEN EXTRA STREN ACID REDUCER ACIDOPHILUS PLUS PECTIN ACIDOPHILUS/CITRUS PECTIN ACIDOPHILUS/PECTIN ACTICAL ADULT ONE DAILY GUMMIES AFRIN SALINE NASAL MIST AIRBORNE AIRBORNE GUMMIES ALAHIST DM ALA-HIST PE ALIVE WOMENS ENERGY ALIVE WOMENS GUMMY VITAMI ALL DAY ALLERGY CHILDRENS ALL DAY ALLERGY D ALL DAY PAIN RELIEF ALLERGY 24-HR ALLERGY RELIEF

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

Updated 08/2017

ALLERGY RELIEF CHILDRENS ALMACONE ALOE VESTA PROTECTIVE ALTAMIST AMERICERIN ANTACID FAST ACTING ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI-GAS REL ANTI-DIARRHEAL ANTIFUNGAL ANTIOXIDANT ANTI-OXIDANT ANTIOXIDANT FORMULA ANTIOXIDANT FORMULA SG ANTIOXIDANT VITAMINS APATATE FORTE AP-HIST DM AQUADEKS ASPIRIN ASPIRIN ADULT LOW STRENGT ASPIRIN EC ASPIRIN LOW STRENGTH ATHLETES FOOT SPRAY AYR AYR NASAL DROPS AYR NASAL MIST ALLERGY & AYR SALINE NASAL AYR SALINE NASAL NO-DRIP BABY AYR SALINE BABY DARLINGS PEDIATRIC E BACITRACIN BACITRACIN ZINC BACITRACIN/NEOMYCIN/POLYM BANOPHEN BENZONATATE BEROCCA BETADINE BETADINE SKIN CLEANSER BIO-35 GLUTEN-FREE BIOCAL BIOSUPP BIOTECT PLUS BIOTIN PLUS/CALCIUM/VIT D BISACODYL EC

Key: PA ? Prior Authorization; ST ? Step Therapy; QL ? Quantity Limit

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