July 2017 Formulary Updates - Aetna Medicaid

Updated 07/2017

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 07/2017

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 07/2017

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 07/2017

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

Updated 07/2017

BISCOLAX BODY/HAIR/SKIN/NAILS CALCARB 600 CAL-CARB FORTE CALCET PLUS CALCI-CHEW CHERRY CALCIDOL CALCIFEROL CALCI-MIX CALCIONATE CALCITRATE CAL-CITRATE PLUS VITAMIN CALCIUM CALCIUM + D3 CALCIUM 1000 + D CALCIUM 1200 CALCIUM 500 + D CALCIUM 500 +D CALCIUM 500/D CALCIUM 500/VITAMIN D CALCIUM 500/VITAMIN D3 CALCIUM 500+D CALCIUM 500+D HIGH POTENC CALCIUM 600 CALCIUM 600 + D CALCIUM 600 HIGH POTENCY CALCIUM 600 WITH VITAMIN CALCIUM 600/VITAMIN D CALCIUM 600/VITAMIN D3 CALCIUM 600+D CALCIUM 600+D HIGH POTENC CALCIUM 600+D PLUS MINERA CALCIUM 600+D3 CALCIUM 600+D3 PLUS MINER CALCIUM 600-D CALCIUM CARBONATE CALCIUM CARBONATE/D3 CALCIUM CARBONATE/VITAMIN CALCIUM CITRATE CALCIUM CITRATE + D CALCIUM CITRATE + D3 CALCIUM CITRATE + D3 MAXI CALCIUM CITRATE +D CALCIUM CITRATE MAXIMUM/V

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

Updated 07/2017

CALCIUM CITRATE PETITE/VI CALCIUM CITRATE W/D CALCIUM CITRATE/VITAMIN D CALCIUM CITRATE+ D CALCIUM CITRATE+D CALCIUM CITRATE+D3 CALCIUM CITRATE+D3 PETITE CALCIUM GUMMIES CALCIUM HIGH POTENCY CALCIUM HIGH POTENCY + VI CALCIUM LACTATE CALCIUM OYSTER SHELL CALCIUM PLUS VITAMIN D3 CALCIUM POLYCARBOPHIL CALCIUM/D CALCIUM/D3 LIQUID CALCIUM/VITAMIN D CALCIUM/VITAMIN D/MINERAL CALCIUM/VITAMIN D3 CALCIUM+D3 CAL-MINT CAL-QUICK CALTRATE 600 CALTRATE 600+D CALTRATE 600+D PLUS MINER CALTRATE 600+D SOFT CHEWS CALTRATE 600+D3 SOFT CHEW CALTRATE MINIS PLUS MIN CAPSAICIN CARDENZ CARRAVITE CARRINGTON MOISTURE BARRI CASTOR OIL STIMULANT LAXA CENTAMIN CENTAVITE CENTAVITE A-Z COMPLETE MU CENTRAVITES CENTRAVITES 50 PLUS CENTRUM CENTRUM ADULTS CENTRUM CARDIO CENTRUM FLAVOR BURST ADUL CENTRUM FLAVOR BURST KIDS CENTRUM SILVER

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

Updated 07/2017

CENTRUM SILVER ADULT 50+ CENTRUM SILVER ULTRA MENS CENTRUM SILVER ULTRA WOME CENTRUM SPECIALIST HEART CENTRUM SPECIALIST VISION CENTRUM ULTRA MENS CENTRUM ULTRA WOMENS CENTURY CENTURY MATURE CERALYTE 70 CEROVITE ADVANCED FORMULA CEROVITE SENIOR CERTA PLUS CERTAGEN CERTA-VITE CERTAVITE SENIOR/ANTIOXID CERTAVITE/ANTIOXIDANTS CHEST CONGESTION RELIEF P CHEWABLE CALCIUM CHILDRENS ALLERGY CHILDRENS COLD & ALLERGY CHILDRENS IBUPROFEN CHLORPHENIRAMINE MALEATE CITRACAL + D3 MAXIMUM CITRACAL CALCIUM GUMMIES CITRACAL MAXIMUM CITRACAL PETITES/VITAMIN CITRACAL/VITAMIN D CITRACAL+D3 CITRUCEL CITRUS CALCIUM +D CITRUS CALCIUM/VITAMIN D CLEARLAX COLACE COLACE CLEAR COLD & ALLERGY COMPANION COMPETE COMPLETE COMPLETE FORMULATION MULT COMPLETE MULTIVITAMIN/MUL COMPLETE SENIOR CONCEPTIONXR MOTILITY SUP CONEX COLD/ALLERGY

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

Updated 07/2017

COUGH & COLD COUGH DM CRITIC-AID CLEAR AF CRITIC-AID CLEAR MOISTURE CVS CALCIUM CVS CALCIUM 600 & VITAMIN CVS CALCIUM 600 + D/MINER CVS CALCIUM 600+D CVS CALCIUM CARBONATE CVS CALCIUM CITRATE CVS CALCIUM CITRATE + D CVS CALCIUM CITRATE +D3 M CVS D3 CVS DAILY ENERGY CVS DAILY GUMMIES CVS DAILY MULTIPLE CVS DAILY MULTIPLE FOR ME CVS DAILY MULTIPLE FOR WO CVS DAILY MULTIPLE PLUS I CVS DIABETES HEALTH SUPPO CVS ELECTROLYTE SOLUTION CVS FISH OIL CVS FOLIC ACID CVS GLUCOSE CVS IRON CVS MAGNESIUM CVS MENS DAILY GUMMIES CVS NASAL MIST CVS NATURAL FISH OIL CVS OMEGA-3 GUMMY FISH/DH CVS OYSTER SHELL CALCIUM CVS PEDIATRIC ELECTROLYTE CVS SALINE NASAL SPRAY CVS SALINE NOSE SPRAY CVS SLOW RELEASE IRON CVS SPECTRAVITE ADULT 50+ CVS SPECTRAVITE ADULT GUM CVS SPECTRAVITE ADVANCED CVS SPECTRAVITE PERFORMAN CVS SPECTRAVITE SENIOR CVS SPECTRAVITE ULTRA HEA CVS SPECTRAVITE ULTRA MEN CVS SPECTRAVITE ULTRA WOM CVS VISION FORMULA

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

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