Covered and non-covered drugs - Drugs not covered - and their covered alternatives for the Aetna Standard Formulary
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Covered and non-covered drugs Drugs not covered — and their covered alternatives for the Aetna Standard Formulary 2021 Formulary Exclusions Drug List 05.03.948.1I (01/21)
The drugs on this list have been removed from your
Key
plan’s formulary. If you continue using a drug listed
under “formulary drug removals”, you may have to UPPERCASE Brand-name medicine
pay the full cost. Ask your doctor to choose one of
lowercase italics Generic medicine
the generic or brand formulary options from the list.
Category
Formulary drug removals Formulary options
Drug class
Acromegaly SANDOSTATIN LAR1 SOMATULINE DEPOT
SIGNIFOR LAR1
SOMAVERT1
Allergies dexchlorpheniramine levocetirizine
Antihistamines Diphen Elixir
RyClora
CARBINOXAMINE TABLET 6 MG
Allergies BECONASE AQ flunisolide spray, fluticasone spray, mometasone
Nasal Steroids / Combinations OMNARIS spray, DYMISTA
QNASL
ZETONNA
Anticonvulsants APTIOM carbamazepine, carbamazepine ext-rel, divalproex
BRIVIACT sodium, divalproex sodium ext-rel, gabapentin,
FYCOMPA lamotrigine, lamotrigine ext-rel, levetiracetam,
ZONEGRAN levetiracetam ext-rel, oxcarbazepine, phenobarbital,
phenytoin, phenytoin sodium extended, primidone,
tiagabine, topiramate, valproic acid, zonisamide,
OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI
ONFI clobazam, lamotrigine, topiramate, TROKENDI XR
SABRIL1 vigabatrin
Anti-infectives, Antibacterials E.E.S. GRANULES erythromycins
Erythromycins / Macrolides ERYPED
Anti-infectives, Antibacterials CoreMino doxycycline hyclate 20 mg, doxycycline hyclate
Tetracyclines doxycycline hyclate delayed-rel capsule, minocycline, tetracycline
tablet 200 mg
doxycycline hyclate tablet 50 mg
(NDC^ 72143021160 only)
doxycycline hyclate tablet 75 mg
doxycycline hyclate tablet 150 mg
doxycycline monohydrate
capsule 75 mg
doxycycline monohydrate
capsule 150 mg
minocycline ext-rel
Mondoxyne NL capsule 75 mg
ACTICLATE
DORYX
DORYX MPC
MINOCIN
TARGADOX
Anti-infectives, Antibacterials MACRODANTIN nitrofurantoin
Miscellaneous
Health benefits and health insurance plans are offered, underwritten and/or administered by Aetna Health Inc.,
Aetna Health Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna Health
Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida by Aetna Health Inc. and/or Aetna
Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and/or Aetna Life Insurance
Company. In Maryland by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole
financial responsibility for its own products.
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Anti-infectives, Antifungals flucytosine capsule 500 mg fluconazole
posaconazole delayed-rel tablet fluconazole, itraconazole
Anti-infectives, Antivirals VALCYTE valganciclovir
Cytomegalovirus*
Anti-infectives, Antivirals BARACLUDE TABLET1 entecavir, lamivudine, tenofovir disoproxil fumarate,
Hepatitis B* EPIVIR HBV1 BARACLUDE SOLUTION, VEMLIDY
HEPSERA1
Anti-infectives, Antivirals MAVYRET1 EPCLUSA (genotypes 1, 2, 3, 4, 5, 6),
Hepatitis C* HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2
VIEKIRA PAK1 EPCLUSA (genotypes 1, 2, 3, 4, 5, 6),
ZEPATIER1 HARVONI (genotypes 1, 4, 5, 6)
Anti-infectives, Antivirals acyclovir cream acyclovir capsule, acyclovir tablet, valacyclovir
Herpes* VALTREX
Anti-infectives, Antivirals COMPLERA1 ATRIPLA, BIKTARVY, GENVOYA, ODEFSEY, SYMFI,
HIV STRIBILD1 SYMFI LO, SYMTUZA, TRIUMEQ
Anti-infectives DARAPRIM pyrimethamine
Miscellaneous
Antiobesity CONTRAVE SAXENDA
QSYMIA
Anxiety* XANAX alprazolam, clonazepam, diazepam, lorazepam,
Benzodiazepines XANAX XR oxazepam
Asthma* PROAIR HFA albuterol sulfate CFC-free aerosol, levalbuterol
Beta Agonists, Short-Acting PROAIR RESPICLICK tartrate CFC-free aerosol
PROVENTIL HFA
VENTOLIN HFA
XOPENEX HFA
Asthma* SINGULAIR montelukast, zafirlukast, zileuton ext-rel
Leukotriene Modulators
Asthma* ALVESCO ARNUITY ELLIPTA, FLOVENT DISKUS,
Steroid Inhalants ASMANEX FLOVENT HFA, PULMICORT FLEXHALER,
ASMANEX HFA QVAR REDIHALER
Asthma* or Chronic Obstructive DULERA ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA,
Pulmonary Disease (COPD)* SYMBICORT
Steroid / Beta Agonist Combinations
Attention Deficit Hyperactivity ADZENYS ER amphetamine-dextroamphetamine mixed salts
Disorder* ADZENYS XR-ODT ext-rel †, methylphenidate ext-rel †, MYDAYIS,
APTENSIO XR VYVANSE
DAYTRANA
EVEKEO amphetamine-dextroamphetamine mixed salts,
methylphenidate
INTUNIV amphetamine-dextroamphetamine mixed
salts ext-rel †, atomoxetine, guanfacine ext-rel,
methylphenidate ext-rel †, MYDAYIS, VYVANSE
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Autoimmune Agents CIMZIA1 COSENTYX, ENBREL, HUMIRA
Ankylosing Spondylitis* SIMPONI1
TALTZ1
Autoimmune Agents CIMZIA1 HUMIRA, STELARA SUBCUTANEOUS #
Crohn's Disease* ENTYVIO1
Autoimmune Agents CIMZIA1 HUMIRA, OTEZLA, SKYRIZI, STELARA
Psoriasis* COSENTYX1 SUBCUTANEOUS, TALTZ, TREMFYA
ENBREL1
Autoimmune Agents CIMZIA1 COSENTYX, ENBREL, HUMIRA, OTEZLA
Psoriatic Arthritis* ORENCIA CLICKJECT1
ORENCIA INTRAVENOUS1
ORENCIA SUBCUTANEOUS1
SIMPONI1
STELARA SUBCUTANEOUS1
TALTZ1
TREMFYA1
XELJANZ1
XELJANZ XR1
Autoimmune Agents ACTEMRA1 ENBREL, HUMIRA, KEVZARA, ORENCIA
Rheumatoid Arthritis* CIMZIA1 CLICKJECT, ORENCIA SUBCUTANEOUS,
KINERET1 RINVOQ, XELJANZ, XELJANZ XR
ORENCIA INTRAVENOUS1
SIMPONI1
Autoimmune Agents ENTYVIO1 HUMIRA, STELARA SUBCUTANEOUS #,
Ulcerative Colitis* SIMPONI1 XELJANZ #, XELJANZ XR
Autoimmune Agents ACTEMRA1 ENBREL, HUMIRA
All Other Conditions* KINERET1
ORENCIA CLICKJECT1
ORENCIA INTRAVENOUS1
ORENCIA SUBCUTANEOUS1
Cancer GLEEVEC1 imatinib mesylate, BOSULIF, SPRYCEL
Chronic Myelogenous Leukemia* TASIGNA1
Cancer BORTEZOMIB1 NINLARO, VELCADE
Multiple Myeloma* KYPROLIS1
Proteasome Inhibitors
Cancer ALIQOPA1 COPIKTRA
PI3K Inhibitors for ZYDELIG1
Follicular Lymphoma*
Cancer NILANDRON abiraterone, bicalutamide, XTANDI, YONSA
Prostate* ZYTIGA1
Hormonal Agents, Antiandrogens
Cancer LUPRON DEPOT1 ELIGARD
Prostate* (For Prostate Cancer Only)
Hormonal Agents,
Luteinizing Hormone-Releasing
Hormone (LHRH) Agonists
Cardiovascular BETAPACE sotalol
Antiarrhythmics BETAPACE AF
# after failure of HUMIRA
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Cardiovascular ZETIA ezetimibe
Antilipemics
Cholesterol Absorption Inhibitors
Cardiovascular fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg),
Antilipemics FENOGLIDE TABLET 120 MG fenofibric acid delayed-rel
TRICOR
Fibrates
Cardiovascular ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin,
Antilipemics CRESTOR lovastatin, pravastatin, rosuvastatin, simvastatin
LESCOL XL
HMG-CoA Reductase Inhibitors LIPITOR
(HMGs or Statins) / Combinations3 LIVALO
Cardiovascular niacin tablet 500 mg niacin ext-rel
Antilipemics Niacor
Niacins
Cardiovascular REPATHA1 PRALUENT
Antilipemics
PCSK9 Inhibitors
Cardiovascular LANOXIN TABLET digoxin
Digitalis Glycosides (125 MCG and 250 MCG only)
Cardiovascular DYRENIUM amiloride, triamterene
Diuretics
Cardiovascular isosorbide dinitrate 40 mg isosorbide dinitrate (except isosorbide
Nitrates dinitrate 40 mg), isosorbide mononitrate
Cardiovascular LETAIRIS1 ambrisentan, bosentan, OPSUMIT
Pulmonary Arterial Hypertension TRACLEER1
Endothelin Receptor Antagonists
Cardiovascular ADCIRCA1 sildenafil, tadalafil
Pulmonary Arterial Hypertension* REVATIO1
Phosphodiesterase Inhibitors
Carnitine Deficiency CARNITOR levocarnitine
CARNITOR SF
Chronic Obstructive Pulmonary INCRUSE ELLIPTA SPIRIVA, YUPELRI
Disease (COPD)* TUDORZA
Anticholinergics
Chronic Obstructive Pulmonary BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT
Disease (COPD)*
Anticholinergic / Beta Agonist
Combinations
Long Acting
Contraceptives BEYAZ ethinyl estradiol-drospirenone,
Monophasic MINASTRIN 24 FE ethinyl estradiol-drospirenone-levomefolate,
TAYTULLA ethinyl estradiol-norethindrone acetate,
YAZ ethinyl estradiol-norethindrone acetate-iron
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Contraceptives NATAZIA ethinyl estradiol-drospirenone,
Four Phase ethinyl estradiol-drospirenone-levomefolate,
ethinyl estradiol-levonorgestrel,
ethinyl estradiol-norethindrone acetate,
ethinyl estradiol-norethindrone acetate-iron,
ethinyl estradiol-norgestimate, LO LOESTRIN FE
Contraceptives LILETTA1 KYLEENA, MIRENA, SKYLA
Progestin Intrauterine Devices
Contraceptives NUVARING ethinyl estradiol-etonogestrel, ANNOVERA
Vaginal
Cystic Fibrosis* TOBI1 tobramycin inhalation solution, BETHKIS
Inhaled Antibiotics TOBI PODHALER1
Dental PREVIDENT Consult doctor
Cavity/Caries Prevention
Depression* fluoxetine tablet 60 mg citalopram, escitalopram, fluoxetine
Antidepressants, Selective Serotonin LEXAPRO (except fluoxetine tablet 60 mg, fluoxetine
Reuptake Inhibitors (SSRIs) PAXIL tablet [generics for SARAFEM]), paroxetine HCl,
PAXIL CR paroxetine HCl ext-rel, sertraline, TRINTELLIX
PEXEVA
PROZAC
VIIBRYD
Depression* venlafaxine ext-rel tablet desvenlafaxine ext-rel, duloxetine, venlafaxine,
Antidepressants, Serotonin (except 225 mg) venlafaxine ext-rel capsule
Norepinephrine Reuptake Inhibitors CYMBALTA
(SNRIs) EFFEXOR XR
PRISTIQ
Depression* bupropion ext-rel tablet 450 mg bupropion, bupropion ext-rel
Antidepressants, APLENZIN (except bupropion ext-rel tablet 450 mg)
Miscellaneous Agents OLEPTRO trazodone
Depression and/or Schizophrenia* ABILIFY aripiprazole, clozapine, olanzapine, quetiapine,
Antipsychotics, Atypicals FANAPT quetiapine ext-rel, risperidone, ziprasidone,
SEROQUEL XR LATUDA, VRAYLAR
INVEGA SUSTENNA ABILIFY MAINTENA, PERSERIS
Dermatology clindamycin gel adapalene, benzoyl peroxide, clindamycin gel
Acne* (NDC^ 68682046275 only) (except NDC^ 68682046275), clindamycin
Vanoxide-HC solution, clindamycin-benzoyl peroxide,
ACANYA erythromycin solution, erythromycin-benzoyl
AZELEX peroxide, tretinoin, EPIDUO, ONEXTON
BENZACLIN
DIFFERIN LOTION
FABIOR
TAZORAC
VELTIN
ZIANA
Dermatology fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution,
Actinic Keratosis* CARAC imiquimod, PICATO, TOLAK, ZYCLARA
Dermatology mupirocin cream gentamicin, mupirocin ointment
Antibiotics
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Dermatology calcipotriene cream calcipotriene ointment, calcipotriene solution
Antipsoriatics calcitriol ointment
SORILUX
TAZORAC
VECTICAL
calcipotriene-betamethasone calcipotriene ointment or calcipotriene solution
WITH desoximetasone, fluocinonide (except
fluocinonide cream 0.1%) or BRYHALI
Dermatology doxepin cream desonide, hydrocortisone, pimecrolimus,
Atopic Dermatitis* tacrolimus, EUCRISA
Dermatology doxycycline monohydrate ORACEA
Rosacea* delayed-rel capsule
FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM,
MIRVASO SOOLANTRA
NORITATE
Dermatology BEAU RX Consult doctor
Scars CICATRACE
POLYTOZA
RECEDO
SCARSILK PAD
SIL-K PAD
SILIVEX
SILTREX
Dermatology ketoconazole foam 2% ketoconazole shampoo 2%,
Seborrheic Dermatitis* Ketodan selenium sulfide lotion 2.5%
XOLEGEL ciclopirox, ketoconazole cream 2%
Dermatology clobetasol spray clobetasol foam
Skin Inflammation and Hives* CLOBEX SPRAY
OLUX-E
Corticosteroids
fluocinonide cream 0.1% clobetasol cream
flurandrenolide lotion desonide, hydrocortisone
(NDC^ 24470092112 only)
flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone
hydrocortisone butyrate butyrate lotion, hydrocortisone butyrate ointment,
lipophilic cream 0.1% hydrocortisone butyrate solution, mometasone,
triamcinolone acetonide triamcinolone cream, triamcinolone lotion,
aerosol 0.2% triamcinolone ointment
CORDRAN OINTMENT
diflorasone cream desoximetasone, fluocinonide (except fluocinonide
diflorasone ointment cream 0.1%), BRYHALI
APEXICON E
PSORCON
Dermatology VEREGEN imiquimod
Warts
Dermatology ALEVICYN GEL desonide, hydrocortisone
Wound Care Products ALEVICYN SG
ALEVICYN SOLUTION
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Dermatology ALCORTIN A desonide, hydrocortisone
Miscellaneous Skin Conditions ATOPADERM
BENSAL HP
EPICERAM
KAMDOY
NOVACORT
SYNERDERM
oxiconazole (NDCs^ 0168035830, ciclopirox, clotrimazole, econazole,
51672135902 only) ketoconazole cream 2%, luliconazole
Diabetes* metformin ext-rel metformin, metformin ext-rel (except
Biguanides (generics for FORTAMET generics for FORTAMET and GLUMETZA)
and GLUMETZA only)
FORTAMET
GLUMETZA
RIOMET
Diabetes* NESINA JANUVIA
Dipeptidyl Peptidase-4 (DPP-4) ONGLYZA
Inhibitors TRADJENTA
Diabetes* JENTADUETO JANUMET, JANUMET XR
Dipeptidyl Peptidase-4 (DPP-4) JENTADUETO XR
Inhibitor Combinations KAZANO
KOMBIGLYZE XR
OSENI JANUMET, JANUMET XR; JANUVIA WITH
pioglitazone
Diabetes* BYDUREON OZEMPIC, RYBELSUS, TRULICITY, VICTOZA
Injectable Incretin Mimetics BYETTA
Diabetes* APIDRA FIASP, NOVOLOG
Insulins HUMALOG
HUMALOG MIX 50/50 NOVOLOG MIX 70/30
HUMALOG MIX 75/25 NOVOLOG MIX 70/30
HUMULIN 70/304 NOVOLIN 70/304
HUMULIN N4 NOVOLIN N4
HUMULIN R4 NOVOLIN R4
NOTE: Humulin R U-500
concentrate will not be
subject to removal and will
continue to be covered.
Diabetes* LANTUS BASAGLAR, LEVEMIR
Long Acting Insulins 5
Diabetes* ACTOS pioglitazone
Insulin Sensitizers
Diabetes* INVOKANA FARXIGA, JARDIANCE
Sodium-Glucose
Co-transporter 2 (SGLT2) Inhibitors
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Diabetes* INVOKAMET SYNJARDY, SYNJARDY XR, XIGDUO XR
Sodium-Glucose INVOKAMET XR
Co-transporter 2 (SGLT2) Inhibitor /
Biguanide Combinations
Diabetes* QTERN GLYXAMBI
Sodium-Glucose
Co-transporter 2 (SGLT2) Inhibitor /
Dipeptidyl Peptidase-4 (DPP-4)
Inhibitor Combinations
Diabetes* NOVO NORDISK NEEDLES BD ULTRAFINE NEEDLES
Supplies, Needles6 OWEN MUMFORD NEEDLES
PERRIGO NEEDLES
ULTIMED NEEDLES
All other insulin needles that are
not BD ULTRAFINE brand
Diabetes* ALLISON MEDICAL BD ULTRAFINE INSULIN SYRINGES
Supplies, Syringes6 INSULIN SYRINGES
TRIVIDIA INSULIN SYRINGES
ULTIMED INSULIN SYRINGES
All other insulin syringes that are
not BD ULTRAFINE brand
Diabetes* ACCU-CHEK AVIVA PLUS ONETOUCH ULTRA STRIPS AND KITS7,
Supplies, Test Strips and Kits
7, 8 STRIPS AND KITS ONETOUCH VERIO STRIPS AND KITS7
ACCU-CHEK COMPACT
PLUS STRIPS AND KITS
ACCU-CHEK GUIDE STRIPS
AND KITS
ACCU-CHEK SMARTVIEW
STRIPS AND KITS
BREEZE 2 STRIPS AND KITS
CONTOUR NEXT STRIPS AND KITS
CONTOUR STRIPS AND KITS
FREESTYLE STRIPS AND KITS
All other test strips that are not
ONETOUCH brand
ENLITE CONTINUOUS GLUCOSE DEXCOM CONTINUOUS GLUCOSE MONITORING
MONITORING SYSTEM SYSTEM
EVERSENSE CONTINUOUS
GLUCOSE MONITORING
SYSTEM
FREESTYLE LIBRE CONTINUOUS
GLUCOSE MONITORING
SYSTEM
GUARDIAN CONNECT
CONTINUOUS GLUCOSE
MONITORING SYSTEM
Dietary Supplements FOSTEUM alendronate, ibandronate, risedronate
FOSTEUM PLUS
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Dietary Supplements Activite folic acid
(continued) DaVite
Dexifol
Folvik-D
Folvite-D
Genicin Vita-S
HylaVite
Lorid
TronVite
Vitasure
Xvite
FERIVA 21/7
FOLIC-K
NICADAN
NICAPRIN
NICAZEL
NICAZEL FORTE
NICOMIDE
OMNIVEX
ORTHO D
ORTHO DF
RHEUMATE
RIBOZEL
TALIVA
XYZBAC
ZYVIT
MultiPro Consult doctor
PRODIGEN
VASCULERA
Erectile Dysfunction* CIALIS sildenafil, tadalafil
Phosphodiesterase Inhibitors STENDRA
VIAGRA
Estrogen Replacement* MINIVELLE estradiol, DIVIGEL, EVAMIST
VIVELLE-DOT
Fertility* FOLLISTIM AQ1 GONAL-F
CHORIONIC GONADOTROPIN1 OVIDREL
NOVAREL1
PREGNYL1
Gastrointestinal chlordiazepoxide-clidinium dicyclomine
Anticholinergics (NDC^ 42494040901 only)
GLYCOPYRROLATE
TABLET 1.5 MG
Gastrointestinal ENTERAGAM alosetron, VIBERZI, XIFAXAN 550 MG
Antidiarrheals
MYTESI diphenoxylate-atropine, loperamide
Gastrointestinal TRANSDERM SCOP meclizine, scopolamine transdermal
Antiemetics
ZUPLENZ granisetron, ondansetron, SANCUSO
Gastrointestinal AMITIZA LINZESS, MOVANTIK, SYMPROIC
Irritable Bowel Syndrome
TRULANCE LINZESS
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Gastrointestinal LACTULOSE PAK lactulose solution
Laxatives
GOLYTELY peg 3350-electrolytes, CLENPIQ
MOVIPREP
OSMOPREP
SUPREP
Gastrointestinal PROVAD Consult doctor
Probiotics ZELAC
Gastrointestinal omeprazole-sodium bicarbonate esomeprazole, lansoprazole, omeprazole,
Proton Pump Inhibitors (PPIs) ACIPHEX pantoprazole, DEXILANT
ACIPHEX SPRINKLE
NEXIUM
PREVACID
PROTONIX
ZEGERID
Gastrointestinal sucralfate suspension sucralfate tablet
Ulcer Treatment CARAFATE
Gaucher Disease ELELYSO1 CERDELGA, CEREZYME
Genitourinary RIMSO-50 Consult doctor
Interstitial Cystitis
Gout* COLCRYS colchicine tablet
Growth Hormones GENOTROPIN1 NORDITROPIN
HUMATROPE1
NUTROPIN AQ1
OMNITROPE1
SAIZEN1
Hematologic PRADAXA warfarin, ELIQUIS, XARELTO
Anticoagulants (oral)
Hematologic EPOGEN1 ARANESP, RETACRIT
Erythropoiesis-Stimulating Agents PROCRIT1
Hematologic ELOCTATE1 ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY,
Hemophilia A NOVOEIGHT, NUWIQ
Hematologic ALPROLIX1 Consult doctor
Hemophilia B
Hematologic FULPHILA1 ZIEXTENZO
Neutropenia Colony NEULASTA1
NEULASTA ONPRO1
Stimulating Factors UDENYCA1
GRANIX1 NIVESTYM
NEUPOGEN1
ZARXIO1
Hematologic PLAVIX clopidogrel, prasugrel, BRILINTA
Platelet Aggregation Inhibitors
ZONTIVITY Consult doctor
High Blood Pressure* ATACAND candesartan, irbesartan, losartan, olmesartan,
Angiotensin II Receptor Antagonists BENICAR telmisartan, valsartan
DIOVAN
EDARBI
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
High Blood Pressure* ATACAND HCT candesartan, irbesartan, losartan, olmesartan,
Angiotensin II Receptor BENICAR HCT telmisartan, valsartan
DIOVAN HCT
Antagonist / Diuretic Combinations EDARBYCLOR
High Blood Pressure* EXFORGE amlodipine-olmesartan, amlodipine-telmisartan,
Angiotensin II Receptor amlodipine-valsartan
Antagonist / Calcium Channel Blocker
Combinations
High Blood Pressure* EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide,
Angiotensin II Receptor olmesartan-amlodipine-hydrochlorothiazide
Antagonist / Calcium Channel Blocker /
Diuretic Combinations
High Blood Pressure* INDERAL LA atenolol, carvedilol, carvedilol phosphate ext-rel,
Beta-blockers INDERAL XL metoprolol succinate ext-rel, metoprolol tartrate,
INNOPRAN XL nadolol, pindolol, propranolol, propranolol ext-rel,
TOPROL-XL BYSTOLIC
High Blood Pressure* DUTOPROL metoprolol succinate ext-rel WITH
Beta-blocker Combinations hydrochlorothiazide
High Blood Pressure* NORVASC amlodipine
Calcium Channel Blockers
diltiazem ext-rel (generics diltiazem ext-rel (except generics for
for CARDIZEM LA only) CARDIZEM LA)
Matzim LA
CARDIZEM
CARDIZEM CD
CARDIZEM LA
High Blood Pressure* CONSENSI amlodipine WITH celecoxib
Calcium Channel Blocker /
Nonsteroidal Anti-inflammatory
Drugs (NSAIDs) Combinations
Huntington's Disease XENAZINE1 tetrabenazine, AUSTEDO
Immunology CELLCEPT1 mycophenolate mofetil, mycophenolate sodium
Antimetabolites MYFORTIC1
Immunology ASTAGRAF XL1 tacrolimus
Calcineurin Inhibitors ENVARSUS XR1
Immunology OTREXUP1 RASUVO
Disease Modifying
Antirheumatic Agents
Immunology BERINERT1 FIRAZYR, RUCONEST
Hereditary Angioedema*
Immunology RAPAMUNE1 everolimus, sirolimus
Rapamycin Derivatives ZORTRESS1
Inflammatory Bowel Disease (IBD) ASACOL HD balsalazide, mesalamine delayed-rel, mesalamine
Ulcerative Colitis* DELZICOL ext-rel, sulfasalazine, sulfasalazine delayed-rel,
LIALDA PENTASA
Aminosalicylates
COLAZAL balsalazide
Interferons* PEGASYS1 Consult doctor
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Kidney Disease* lanthanum carbonate calcium acetate, sevelamer carbonate, PHOSLYRA,
Phosphate Binders FOSRENOL VELPHORO
Multiple Sclerosis AVONEX1 dimethyl fumarate delayed-rel, glatiramer,
EXTAVIA1 AUBAGIO, BETASERON, COPAXONE, GILENYA,
PLEGRIDY1 KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI,
TECFIDERA1 VUMERITY, ZEPOSIA
Musculoskeletal chlorzoxazone 375 mg cyclobenzaprine (except cyclobenzaprine
chlorzoxazone 500 mg tablet 7.5 mg)
(NDC^ 73007001303 only)
chlorzoxazone 750 mg
cyclobenzaprine ext-rel capsule
cyclobenzaprine tablet 7.5 mg
Fexmid
Lorzone
metaxalone 400 mg
methocarbamol 500 mg
(NDC^ 69036091010 only)
methocarbamol 750 mg
(NDCs^ 69036093090,
70868090190 only)
orphenadrine-aspirin-caffeine
Orphengesic Forte
AMRIX
CHLORZOXAZONE 250 MG
NORGESIC FORTE
Narcolepsy NUVIGIL armodafinil, SUNOSI
Wakefulness Promoters
Nephropathic Cystinosis PROCYSBI1 CYSTAGON
Ophthalmic ALREX azelastine, cromolyn sodium, olopatadine,
Allergies BEPREVE LASTACAFT, PAZEO
Ophthalmic ZYLET neomycin-polymyxin B-bacitracin-hydrocortisone,
Anti-infective / Anti-inflammatory neomycin-polymyxin B-dexamethasone,
tobramycin-dexamethasone, TOBRADEX
OINTMENT, TOBRADEX ST
Ophthalmic PROLENSA bromfenac, diclofenac, ketorolac,
Anti-inflammatory, Nonsteroidal ACUVAIL, ILEVRO, NEVANAC
Ophthalmic FML LIQUIFILM dexamethasone, loteprednol, prednisolone
Anti-inflammatory, Steroidal LOTEMAX acetate 1%, DUREZOL, FML FORTE, FML S.O.P.,
LOTEMAX SM MAXIDEX, PRED MILD
PRED FORTE
Ophthalmic ZIRGAN trifluridine
Antivirals
Ophthalmic LACRISERT RESTASIS, XIIDRA
Artificial Tears
Ophthalmic bimatoprost solution 0.03% latanoprost, travoprost, LUMIGAN, ZIOPTAN
Glaucoma
TIMOPTIC OCUDOSE timolol maleate solution, BETIMOL, BETOPTIC S
Ophthalmic AVENOVA Consult doctor
Miscellaneous
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Opioid Dependency SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV
Opioid Reversal EVZIO naloxone injection, NARCAN NASAL SPRAY
Osteoarthritis* GEL-ONE1 DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX
Viscosupplements HYALGAN1
MONOVISC1
ORTHOVISC1
SYNVISC1
SYNVISC-ONE1
VISCO-31
Osteoporosis* MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate,
Calcium Regulators risedronate, FORTEO, PROLIA, TYMLOS
MIACALCIN NASAL SPRAY calcitonin-salmon
Otic CIPRO HC ciprofloxacin-dexamethasone, ofloxacin otic
Anti-infective / Anti-inflammatory CIPRODEX
Overactive Bladder / Incontinence* DETROL LA darifenacin ext-rel, oxybutynin ext-rel, solifenacin,
Urinary Antispasmodics ENABLEX tolterodine, tolterodine ext-rel, trospium,
OXYTROL trospium ext-rel, MYRBETRIQ, TOVIAZ
Pain Bupap diclofenac sodium, ibuprofen, naproxen
Headache* butalbital-acetaminophen (except naproxen CR or naproxen suspension)
tablet 50-300 mg
butalbital-acetaminophen-
caffeine capsule
Vanatol LQ
Vanatol S
BUTALBITAL-ACETAMINOPHEN
(NDC^ 69499034230 only)
CAMBIA
FIORICET CAPSULE
dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan,
ergotamine-caffeine zolmitriptan, NURTEC ODT, ONZETRA XSAIL,
Migergot REYVOW, UBRELVY, ZEMBRACE SYMTOUCH,
CAFERGOT ZOMIG NASAL SPRAY
sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen
TREXIMET (except naproxen CR or naproxen suspension)
WITH eletriptan, naratriptan, rizatriptan,
sumatriptan, zolmitriptan, NURTEC ODT,
ONZETRA XSAIL, REYVOW, UBRELVY,
ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY
Pain BUTRANS buprenorphine transdermal, BELBUCA
Opioid Analgesics
LAZANDA fentanyl transmucosal lozenge, SUBSYS
levorphanol fentanyl transdermal, hydrocodone ext-rel,
oxymorphone ext-rel hydromorphone ext-rel, methadone, morphine
HYSINGLA ER ext-rel, NUCYNTA ER, XTAMPZA ER
OXYCONTIN
ZOHYDRO ER
PERCOCET hydrocodone-acetaminophen, hydromorphone,
PRIMLEV morphine, oxycodone-acetaminophen, NUCYNTA
tramadol tramadol (except NDC^ 52817019610),
(NDC^ 52817019610 only) tramadol ext-rel
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Pain LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine
Topical Local Anesthetics (NDC^ 71800063115 only)
LIDOTREX
Pain and Inflammation* MILLIPRED dexamethasone, hydrocortisone,
Corticosteroids RAYOS methylprednisolone, prednisolone solution,
prednisone
Pain and Inflammation* ARTHROTEC celecoxib; diclofenac sodium, ibuprofen, meloxicam
Nonsteroidal Anti-inflammatory Drugs or naproxen (except naproxen CR or naproxen
(NSAIDs) / Combinations suspension) WITH esomeprazole, lansoprazole,
omeprazole, pantoprazole or DEXILANT
Diclofex DC diclofenac sodium, diclofenac sodium gel 1%,
(NDC^ 51021037201 only) diclofenac sodium solution, ibuprofen,
Diclosaicin meloxicam, naproxen (except naproxen CR or
Inflammacin naproxen suspension)
NuDiclo SoluPak
NuDiclo TabPak
PENNSAID
fenoprofen diclofenac sodium, ibuprofen, meloxicam, naproxen
indomethacin capsule 20 mg (except naproxen CR or naproxen suspension)
ketoprofen capsule 25 mg
ketoprofen ext-rel capsule
mefenamic acid
(NDC^ 69336012830 only)
naproxen CR
naproxen suspension
FENOPROFEN CAPSULE
INDOCIN
NAPRELAN
SPRIX
ZORVOLEX
naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam or
naproxen (except naproxen CR or naproxen
suspension) WITH esomeprazole, lansoprazole,
omeprazole, pantoprazole or DEXILANT
Parkinson’s Disease APOKYN1 INBRIJA
Postherpetic Neuralgia HORIZANT gabapentin, GRALISE
Prostate Condition JALYN dutasteride-tamsulosin; dutasteride or finasteride
Benign Prostatic Hyperplasia* WITH alfuzosin ext-rel, doxazosin, silodosin,
tamsulosin or terazosin
RAPAFLO alfuzosin ext-rel, doxazosin, silodosin, tamsulosin,
UROXATRAL terazosin
Respiratory ARALAST NP1 PROLASTIN-C
Alpha-1 Antitrypsin Deficiency GLASSIA1
ZEMAIRA1
Respiratory benzonatate (NDCs^ 69336012615, benzonatate (except NDCs^ 69336012615,
Cough 69499032915 only) 69499032915)
Sleep Disorder quazepam doxepin, eszopiclone, ramelteon, zolpidem,
Hypnotics, Non-benzodiazepines INTERMEZZO zolpidem ext-rel, zolpidem sublingual, BELSOMRA
LUNESTA
ROZEREM
ZOLPIMIST
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Category
Formulary drug removals Formulary options
Drug class
Testosterone Replacement* testosterone gel 1% (authorized testosterone gel (except authorized generics for
Androgens generics for TESTIM and TESTIM and VOGELXO), testosterone solution,
VOGELXO only) ANDRODERM
ANDROGEL 1%
FORTESTA
NATESTO
TESTIM
VOGELXO
Thyroid Supplements TIROSINT levothyroxine, SYNTHROID
Transplant* PROGRAF1 tacrolimus
Immunosuppressants,
Calcineurin Inhibitors
Urea Cycle Disorders BUPHENYL1 sodium phenylbutyrate
RAVICTI1
Women’s Health MENEST estradiol
Menopausal Symptom Agents OSPHENA
PREMARIN
Oral
Women’s Health ESTRING estradiol, IMVEXXY
Menopausal Symptom Agents FEMRING
INTRAROSA
Vaginal PREMARIN CREAM
Women’s Health fluoxetine tablet fluoxetine (except fluoxetine tablet 60 mg,
Premenstrual Dysphoric Disorder (generics for SARAFEM only) fluoxetine tablet [generics for SARAFEM]),
(PMDD) paroxetine HCl ext-rel, sertraline
Women’s Health AZESCO prenatal vitamins, CITRANATAL
Prenatal Vitamins ZALVIT
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)Drug class Other considerations
All Drugs On a quarterly basis, new and existing products - including limited source generics, products
with significant cost inflation, and specialty and non-specialty products - may be re-evaluated
to determine appropriate formulary placement. These evaluations will assess whether clinically
appropriate and cost-effective options remain available on the formulary and may result in removal,
addition or deletion of a product.
Autoimmune and For some clients, an Indication-Based Formulary will be utilized for products in these classes and may
Hepatitis C* result in additional removals for certain conditions only.
Drugs for Infusion A drug that must be infused into a space other than the blood will generally not be covered under the
Into Spaces Other prescription drug benefit.
Than the Blood
New-to-Market Agents1 New-to-market products and new variations of products already in the marketplace will not be added
to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-
effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark®
National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review
and approval.
The listed formulary options are subject to change.
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)List of formulary drug removals
ABILIFY BEPREVE CRESTOR EVERSENSE CONTINUOUS
ACANYA BERINERT1 cyclobenzaprine ext-rel GLUCOSE MONITORING
ACCU-CHEK AVIVA PLUS BETAPACE capsule SYSTEM
STRIPS AND KITS8 BETAPACE AF cyclobenzaprine tablet 7.5 mg EVZIO
ACCU-CHEK COMPACT PLUS BEVESPI AEROSPHERE CYMBALTA EXFORGE
STRIPS AND KITS8 BEYAZ DARAPRIM EXFORGE HCT
ACCU-CHEK GUIDE STRIPS bimatoprost solution 0.03% DaVite EXTAVIA1
AND KITS8 BORTEZOMIB1 DAYTRANA FABIOR
ACCU-CHEK SMARTVIEW BREEZE 2 STRIPS AND KITS8 DELZICOL FANAPT
STRIPS AND KITS8 BRIVIACT DETROL LA FEMRING
Bupap dexchlorpheniramine fenofibrate tablet 120 mg
ACIPHEX
BUPHENYL1 Dexifol FENOGLIDE TABLET 120 MG
ACIPHEX SPRINKLE Diclofex DC
bupropion ext-rel fenoprofen
ACTEMRA1 tablet 450 mg (NDC^ 51021037201 only)
ACTICLATE FENOPROFEN CAPSULE
butalbital-acetaminophen Diclosaicin
Activite FERIVA 21/7
tablet 50-300 mg DIFFERIN LOTION Fexmid
ACTOS BUTALBITAL- diflorasone cream
acyclovir cream FINACEA GEL
ACETAMINOPHEN diflorasone ointment
ADCIRCA1 FIORICET CAPSULE
(NDC^ 69499034230 only) dihydroergotamine spray
flucytosine capsule 500 mg
ADZENYS ER butalbital-acetaminophen- diltiazem ext-rel (generics fluocinonide cream 0.1%
ADZENYS XR-ODT caffeine capsule for CARDIZEM LA only) fluorouracil cream 0.5%
ALCORTIN A BUTRANS DIOVAN fluoxetine tablet (generics
ALEVICYN GEL BYDUREON DIOVAN HCT for SARAFEM only)
ALEVICYN SG BYETTA Diphen Elixir fluoxetine tablet 60 mg
ALEVICYN SOLUTION CAFERGOT DORYX flurandrenolide lotion
calcipotriene cream DORYX MPC (NDC^ 24470092112 only)
ALIQOPA1
calcipotriene-betamethasone doxepin cream flurandrenolide ointment
ALLISON MEDICAL
calcitriol ointment doxycycline hyclate FML LIQUIFILM
INSULIN SYRINGES6
CAMBIA delayed-rel tablet 200 mg FOLIC-K
ALPROLIX1 FOLLISTIM AQ1
CARAC doxycycline hyclate
ALREX tablet 50 mg (NDC^ Folvik-D
CARAFATE
ALTOPREV CARBINOXAMINE 72143021160 only) Folvite-D
ALVESCO TABLET 6 MG doxycycline hyclate FORTAMET
AMITIZA CARDIZEM tablet 75 mg FORTESTA
AMRIX CARDIZEM CD doxycycline hyclate FOSRENOL
ANDROGEL1% tablet 150 mg FOSTEUM
CARDIZEM LA
APEXICON E doxycycline monohydrate FOSTEUM PLUS
CARNITOR capsule 75 mg
APIDRA CARNITOR SF FREESTYLE LIBRE
doxycycline monohydrate
APLENZIN CELLCEPT1 CONTINUOUS GLUCOSE
capsule 150 mg
APOKYN1 chlordiazepoxide-clidinium doxycycline monohydrate MONITORING SYSTEM
APTENSIO XR (NDC^ 42494040901 only) delayed-rel capsule FREESTYLE STRIPS AND KITS8
APTIOM CHLORZOXAZONE 250 MG DULERA FULPHILA1
ARALAST NP1 chlorzoxazone 375 mg FYCOMPA
DUTOPROL
ARTHROTEC chlorzoxazone 500 mg (NDC^ GEL-ONE1
73007001303 only) DYRENIUM
ASACOL HD Genicin Vita-S
chlorzoxazone 750 mg EDARBI
ASMANEX GENOTROPIN1
CHORIONIC GONADOTROPIN1 EDARBYCLOR
ASMANEX HFA GLASSIA1
CIALIS E.E.S. GRANULES
ASTAGRAF XL1 GLEEVEC1
CICATRACE EFFEXOR XR
ATACAND GLUMETZA
CIMZIA1 ELELYSO1
ATACAND HCT GLYCOPYRROLATE
CIPRO HC ELOCTATE1
ATOPADERM TABLET 1.5 MG
CIPRODEX ENABLEX
AVENOVA GOLYTELY
clindamycin gel (NDC^ ENLITE CONTINUOUS
AVONEX1 68682046275 only) GRANIX1
GLUCOSE MONITORING GUARDIAN CONNECT
AZELEX clobetasol spray
CLOBEX SPRAY SYSTEM CONTINUOUS GLUCOSE
AZESCO
COLAZAL ENTERAGAM MONITORING SYSTEM
BARACLUDE TABLET1
COLCRYS ENTYVIO1 HEPSERA1
BEAU RX
COMPLERA1 ENVARSUS XR1 HORIZANT
BECONASE AQ
BENICAR CONSENSI EPICERAM HUMALOG
BENICAR HCT CONTOUR NEXT STRIPS AND EPIVIR HBV1 HUMALOG MIX 50/50
BENSAL HP KITS 8 EPOGEN1 HUMALOG MIX 75/25
CONTOUR STRIPS AND KITS8 ergotamine-caffeine HUMATROPE1
BENZACLIN
benzonatate CONTRAVE ERYPED HUMULIN 70/304
(NDCs^ 69336012615, CORDRAN OINTMENT ESTRING HUMULIN N4
69499032915 only) CoreMino EVEKEO HUMULIN R4
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)List of Formulary Drug Removals
HYALGAN1 metformin ext-rel Orphengesic Forte ROZEREM
hydrocortisone butyrate (generics for FORTAMET ORTHO D RyClora
lipophilic cream 0.1% and GLUMETZA only) ORTHO DF SABRIL1
HylaVite methocarbamol 500 mg ORTHOVISC1 SAIZEN1
HYSINGLA ER (NDC^ 69036091010 only) SANDOSTATIN LAR1
methocarbamol 750 mg OSENI
INCRUSE ELLIPTA OSMOPREP SCARSILK PAD
(NDCs^ 69036093090,
INDERAL LA OSPHENA SEROQUEL XR
70868090190 only)
INDERAL XL OTREXUP1 SIGNIFOR LAR1
MIACALCIN INJECTION
INDOCIN MIACALCIN NASAL SPRAY OWEN MUMFORD NEEDLES6 SIL-K PAD
indomethacin capsule 20 mg Migergot oxiconazole SILIVEX
Inflammacin (NDCs^ 00168035830, SILTREX
MILLIPRED
INNOPRAN XL 51672135902 only) SIMPONI1
MINASTRIN 24 FE
INTERMEZZO OXYCONTIN SINGULAIR
MINIVELLE
INTRAROSA oxymorphone ext-rel SOMAVERT1
MINOCIN
INTUNIV minocycline ext-rel OXYTROL SORILUX
INVEGA SUSTENNA MIRVASO PAXIL SPRIX
INVOKAMET Mondoxyne NL capsule 75 mg PAXIL CR STENDRA
INVOKAMET XR MONOVISC1 PEGASYS1 STRIBILD1
INVOKANA MOVIPREP PENNSAID SUBOXONE
isosorbide dinitrate 40 mg MultiPro PERCOCET sucralfate suspension
JALYN mupirocin cream PERRIGO NEEDLES6 sumatriptan-naproxen
JENTADUETO MYFORTIC1 PEXEVA SUPREP
JENTADUETO XR MYTESI PLAVIX SYNERDERM
KAMDOY NAPRELAN PLEGRIDY1 SYNVISC1
KAZANO naproxen-esomeprazole POLYTOZA SYNVISC-ONE1
ketoconazole foam 2% naproxen CR posaconazole TALIVA
Ketodan naproxen suspension delayed-rel tablet TARGADOX
ketoprofen capsule 25 mg NATAZIA PRADAXA TASIGNA1
ketoprofen ext-rel capsule NATESTO PRED FORTE TAYTULLA
KINERET1 NESINA PREGNYL1 TAZORAC
KOMBIGLYZE XR NEULASTA1 PREMARIN TECFIDERA1
KYPROLIS1 NEULASTA ONPRO1 PREMARIN CREAM TESTIM
LACRISERT NEUPOGEN1 PREVACID testosterone gel 1%
LACTULOSE PAK NEXIUM PREVIDENT (authorized generics for
LANOXIN TABLET (125 MCG niacin tablet 500 mg PRIMLEV TESTIM and VOGELXO only)
AND 250 MCG ONLY) Niacor TIMOPTIC OCUDOSE
PRISTIQ
lanthanum carbonate NICADAN
PROAIR HFA TIROSINT
LANTUS NICAPRIN
PROAIR RESPICLICK TOBI1
LAZANDA NICAZEL
PROCRIT1 TOBI PODHALER1
LESCOL XL NICAZEL FORTE
PROCYSBI1 TOPROL-XL
LETAIRIS1 NICOMIDE TRACLEER1
PRODIGEN
levorphanol NILANDRON
PROGRAF1 TRADJENTA
LEXAPRO NORGESIC FORTE tramadol
PROLENSA
LIALDA NORITATE (NDC^ 52817019610 only)
PROTONIX
LIDOCAINE-TETRACAINE NORVASC TRANSDERM SCOP
PROVAD
CREAM (NDC^ NOVACORT TREXIMET
PROVENTIL HFA
71800063115 only) NOVAREL1 triamcinolone
PROZAC
LIDOTREX NOVO NORDISK NEEDLES6 acetonide aerosol 0.2%
NuDiclo SoluPak PSORCON
LILETTA1 TRICOR
NuDiclo TabPak QNASL TRIVIDIA INSULIN SYRINGES6
LIPITOR
NUTROPIN AQ1 QSYMIA TronVite
LIVALO
Lorid NUVARING QTERN TRULANCE
Lorzone NUVIGIL quazepam TUDORZA
LOTEMAX OLEPTRO RAPAFLO UDENYCA1
OLUX-E RAPAMUNE1 ULTIMED INSULIN SYRINGES6
LOTEMAX SM
omeprazole-sodium RAVICTI1 ULTIMED NEEDLES6
LUNESTA
bicarbonate RAYOS UROXATRAL
LUPRON DEPOT1
OMNARIS RECEDO VALCYTE
MACRODANTIN
Matzim LA OMNITROPE1 REPATHA1 VALTREX
MAVYRET1 OMNIVEX REVATIO1 Vanatol LQ
mefenamic acid ONFI RHEUMATE Vanatol S
(NDC^ 69336012830 only) ONGLYZA RIBOZEL Vanoxide-HC
MENEST ORENCIA INTRAVENOUS1 RIMSO-50 VASCULERA
metaxalone 400 mg orphenadrine-aspirin-caffeine RIOMET VECTICAL
Aetna Standard Plan Formulary Exclusions Drug List (01/2021)List of Formulary Drug Removals VELTIN XENAZINE1 ZIANA venlafaxine ext-rel tablet XOLEGEL ZIRGAN (except 225 mg) XOPENEX HFA ZOHYDRO ER VENTOLIN HFA Xvite ZOLPIMIST VEREGEN XYZBAC ZONEGRAN VIAGRA YAZ ZONTIVITY VIEKIRA PAK1 ZALVIT ZORTRESS1 VIIBRYD ZARXIO1 ZORVOLEX VISCO-31 ZEGERID ZUPLENZ Vitasure ZELAC ZYDELIG1 VIVELLE-DOT ZEMAIRA1 ZYLET VOGELXO ZEPATIER1 ZYTIGA1 XANAX ZETIA ZYVIT XANAX XR ZETONNA Aetna Standard Plan Formulary Exclusions Drug List (01/2021)
*
This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one
condition.
†
Listing does not include certain NDCs^.
^
Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify
the manufacturer, strength, dosage form, formulation and package size.
1
An exception process may exist for specific clinical or regulatory circumstances that may require coverage of a
non-covered medication. If your doctor believes you have a specific clinical need for a non-covered product, he
or she should fax an exception request to: 1-888-487-9257.
2
For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or
sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).
3
If approved for coverage and prescribed for primary prevention of cardiovascular disease, may be covered without
cost sharing through an exceptions process.
4
Rebranded or private label formulations are not covered (i.e., RELION).
5
Long Acting Insulins - First Generation.
6
BD ULTRAFINE syringes and needles are the only preferred options.
7
ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals
A
currently using a meter other than ONETOUCH. For more information on how to obtain a blood glucose meter,
call: 1-877-418-4746.
8
ONETOUCH brand test strips are the only preferred options.
This is not a complete list of medications covered or excluded under your plan. We only list the most common ones.
Certain drugs may not be covered by your particular pharmacy plan. Diabetic supplies may be covered under your
medical plan.
Information is believed to be accurate as of the production date; however, it is subject to change.
To check coverage and copay information for a specific medicine, log into your member website. For questions, please
call the toll free number on the back of your member ID card.
©2020 Aetna Inc.
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