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Plan for your best health
2018 Aetna Pharmacy Drug Guide Aetna Value Plus Plan
aetna.com 05.02.354.1 L (9/18)
How to use this guide
Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.
Your plan includes
• Brand and generic drugs that are hand-picked for their quality and effectiveness
• Aetna Specialty Pharmacy® fills specialty drug prescriptions (ones that are injected, infused or taken by mouth) — and provides services that include personal support, helpful resources and training, and free secure home delivery
• Aetna Rx Home Delivery® pharmacy that delivers maintenance drugs to your home or wherever you choose (for drugs that are taken regularly to treat conditions like arthritis, diabetes or asthma)
What you can expect to pay
With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the drug’s/medicine’s price.
Each drug is grouped as a generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non-preferred drug. Generic drugs are less expensive than brands.
Specialty prescription drugs typically include higher-cost drugs that require special handling, special storage or monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.
You’re covered for all types of medicine — some more expensive, and some less.
• Preferred generic: the lowest cost
• Preferred brand: a slightly higher cost
• Non-preferred brand and generic: a higher cost
• Preferred Specialty: lower cost for specialty drugs
• Non-preferred specialty: higher cost for non-preferred specialty drugs
Your pharmacy plan may not have all the coverage levels listed above so check your plan documents to see how much you will pay.
For your exact coverage and cost, and to learn more about your plan
Visit the website that’s on your member ID card. Then log in to your account, where you can:
• Find out the coverage and estimate of cost for specific drugs
• View your deductibles and plan limits
• Order medications
• Check your pharmacy order status
• Get a member ID card
• View your claims, Explanation of Benefits and more
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Pharmacy Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefits portion of your health plan and has no financial responsibility therefor. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment.
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Have more questions about your pharmacy benefits?
We’re here to help. There are several ways you can learn more about your benefits:
• Check your Plan Design and Benefits Summary in your enrollment kit.
• Call the toll-free number on your member ID card.
• Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on your member ID card to search for the “Pharmacy FAQ.”
Aetna Specialty Pharmacy
Aetna Specialty Pharmacy® medicine and support services is our in-house specialty pharmacy that can fill your prescriptions for specialty drugs. These are the types of drugs that may be injected, infused or taken by mouth. They often need special storage and handling. And they need to be delivered quickly. A nurse or pharmacist may monitor you during your treatment, if needed. With Aetna Specialty Pharmacy, you can get this medicine sent right to your mailbox.
How to get started with Aetna Specialty Pharmacy
Ordering your prescription through Aetna Specialty Pharmacy is easy. And we typically offer a 30-day medicine supply.
• To transfer your prescription, just call us toll-free at 1-866-353-1892.
• For a new prescription, your doctor can send it to us in one of four ways:
1. Electronically: Through e-prescribe
2. Fax: 1-866-FAX-ASRX (1-866-329-2779)
3. Mail: Aetna Specialty Pharmacy 503 Sunport Lane Orlando, FL 32809
4. Phone: 1-866-782-ASRX (1-866-782-2779), option 2
If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that’s on your member ID card, to search for the “Patient Profile Form.”
Aetna Rx Home Delivery
You can have maintenance drugs sent right to your home or anywhere else you choose with Aetna Rx Home Delivery® pharmacy. These are drugs that are taken regularly for chronic conditions like arthritis, diabetes or asthma. Depending on your plan, you can get up to a 90-day supply of medicine for less cost. It’s fast and convenient, and standard shipping is always free.
Get started right away
You can submit your order using one of these options:
1. Online — Visit your secure member website and sign in to your account. There you can add or remove your prescriptions.
2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. If you need the help of a telephone device for the deaf, call 1-877-833-2779.
3. Mail — Get a new prescription from your doctor. Then mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form.
Your doctor can submit your order using one of these options:
1. Online — They can submit your prescriptions using the e-prescribe services on our provider website.
2. Fax — They can fax your prescription to 1-877-270-3317. Make sure they include your member ID number, date of birth and mailing address on the fax cover sheet. Only a doctor may fax a prescription.
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Frequently asked questions
How can I save on prescriptions?
Here are some tips to pay less out of pocket for your prescription drugs:
• Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary).
• Ask your doctor to consider prescribing generic drugs instead of brand-name drugs.
• Check to see if your plan includes our home delivery pharmacy service. Depending upon your plan, our home delivery service may save you money. For more information, visit the website on your member ID card and log in to your account.
• Remind your doctor to check your plan to make sure you get maximum coverage.
What are generic drugs?
Generic drugs are proven to be just as safe and effective as brand-name drugs. They contain the same active ingredients in the same amounts as the brand-name drugs and work the same way. So they have the same risks and benefits as brand-name drugs. However, they typically cost less.
When appropriate, your doctor may decide to prescribe a generic drug or allow the pharmacist to substitute a generic drug.
What is precertification?
Precertification is one way that we can help you and your doctor find safe, appropriate drugs and keep costs down. Precertification means that you or your doctor need to get approval from the plan before certain drugs will be covered. Generally, precertification applies to drugs that:
• Are often taken in the wrong way
• Should only be used for certain conditions
• Often cost more than other drugs that are proven to be just as effective
Keep in mind that your doctor must contact us to request approval of coverage for these drugs.
What is step therapy?
Some drugs require step therapy. This means that you must try one or more prerequisite drug(s) before a step therapy drug is covered.
The prerequisite drugs are equally effective, have U.S. Food and Drug Administration (FDA) approval and may cost less. They treat the same condition as the step therapy drug.
If you don’t try the appropriate alternative drug first, you may need to pay full cost for the brand-name version.
What are quantity limits?
Quantity limits help your doctor and pharmacist make sure that you use your drug correctly and safely. We use medical guidelines and FDA-approved recommendations from drug makers to set these coverage limits. The quantity limit program includes:
• Dose efficiency edits — Limits prescription coverage to one dose per day for drugs that have approval for once-daily dosing
• Maximum daily dose — If a prescription is lower than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy
• Quantity limits over time — Limits prescription coverage to a specific number of units over a specific amount of time
What if I need a drug that requires an exception to the precertification, step therapy or quantity limits requirements? Or what if I need a drug that’s not covered under my plan?
In certain cases, you or your prescriber can request a medical exception to the precertification, step therapy or quantity limits requirements. And also for a drug that’s not covered in your plan. If you ask for your request to be expedited, a coverage determination will be made within 24 hours of receiving it.
We’ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design.
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How can your provider request a medical exception?
• Submit their request through our secure provider website on NaviNet®.
• Call the Aetna Pharmacy Precertification Unit at 1-855-240-0535.
• Fax the completed request form to 1-877-269-9916.
• Mail the completed request form to: Aetna Pharmacy Management 1300 East Campbell Road Richardson, TX 75081
How is the formulary (drug list) developed?
Our Pharmacy and Therapeutics Committee meets regularly to review new drugs and new information about current drugs. We review them for their safety, effectiveness and current use in therapy.
This committee includes licensed pharmacists and doctors. They are currently in practice or are Aetna employees.
Once we complete our clinical review, we also consider overall value before adding or removing a drug from the formulary. We may recommend moving a drug to a different coverage level. Or that it be placed on our Formulary Exclusions List and no longer be covered.
Can the formulary change during the year?
The formulary can change throughout the year. Some reasons why they can change include:
• New drugs are approved.
• Existing drugs are removed from the market.
• Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs are not generally covered in a formulary.
• Brand-name drugs lose patent protection and generic versions become available. When this happens, the brand-name drug is likely to be covered at a higher cost. And the generic versions cost less. See the “What are generic drugs?” section above for more information.
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Commercial 1557 Nondiscrimination Notice
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.
Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at:
U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).
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Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.
Please note that if your prescription drug benefits plan changes, the information here may no longer apply. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Preferred Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Pharmacy Drug (formulary) Guide. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. The drugs on the Pharmacy Drug (formulary) Guide, Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and drug coverage review programs are not available in all service areas. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug (formulary) Guide, Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law, fully insured Commercial California health maintenance organization (HMO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered for as long as the treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change.
aetna.com ©2018 Aetna Inc. 05.02.354.1 L (9/18)
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
Table of Contents
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................17*AGENTS FOR NARCOTIC WITHDRAWAL***.................................................................................18*AMEBICIDES*........................................................................................................................................18*AMINO ACIDS***..................................................................................................................................18*AMINOGLYCOSIDES*..........................................................................................................................18*ANALGESICS - ANTI-INFLAMMATORY*........................................................................................ 19*ANALGESICS - NONNARCOTIC*.......................................................................................................22*ANALGESICS - OPIOID*.......................................................................................................................22*ANDROGENS-ANABOLIC*................................................................................................................. 26*ANORECTAL AGENTS*....................................................................................................................... 27*ANTHELMINTICS*............................................................................................................................... 28*ANTIANGINAL AGENTS*................................................................................................................... 28*ANTIANXIETY AGENTS*....................................................................................................................28*ANTIARRHYTHMICS*.........................................................................................................................29*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*.............................................................. 30*ANTICOAGULANTS*........................................................................................................................... 32*ANTICONVULSANTS*......................................................................................................................... 33*ANTIDEMENTIA AGENT COMBINATIONS***............................................................................... 36*ANTIDEPRESSANTS*........................................................................................................................... 36*ANTIDIABETICS*..................................................................................................................................38*ANTIDIARRHEALS*.............................................................................................................................42*ANTIDOTES AND SPECIFIC ANTAGONISTS*.................................................................................42*ANTIDOTES*..........................................................................................................................................43*ANTIEMETICS*..................................................................................................................................... 43*ANTIFUNGALS*....................................................................................................................................44*ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***...........................................45*ANTIHISTAMINES*.............................................................................................................................. 45*ANTIHYPERLIPIDEMICS*.................................................................................................................. 46*ANTIHYPERTENSIVES*.......................................................................................................................48*ANTI-INFECTIVE AGENTS - MISC.*..................................................................................................51*ANTIMALARIALS*............................................................................................................................... 52*ANTIMYASTHENIC AGENTS*........................................................................................................... 53*ANTIMYASTHENIC/CHOLINERGIC AGENTS*.............................................................................. 53*ANTIMYCOBACTERIAL AGENTS*................................................................................................... 53*ANTINEOPLASTIC - BCL-2 INHIBITORS***.....................................................................................53*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................. 54*ANTIPARKINSON AGENTS*.............................................................................................................. 58*ANTIPSYCHOTICS/ANTIMANIC AGENTS*..................................................................................... 59*ANTIRETROVIRALS ADJUVANTS***...............................................................................................61*ANTIVIRALS*........................................................................................................................................ 61*ASSORTED CLASSES*.......................................................................................................................... 64*ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES***............................................................66*BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB***............................. 66*BETA BLOCKERS*................................................................................................................................ 66*BILE ACID SYNTHESIS DISORDER AGENTS***............................................................................ 67*BIOLOGICALS MISC*........................................................................................................................... 67*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***................................67
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*CALCIUM CHANNEL BLOCKERS*................................................................................................... 67*CARDIOTONICS*.................................................................................................................................. 69*CARDIOVASCULAR AGENTS - MISC.*.............................................................................................69*CEPHALOSPORINS*............................................................................................................................. 70*CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS***.................................................72*CONTRACEPTIVES*............................................................................................................................. 72*CORTICOSTEROIDS*........................................................................................................................... 77*COUGH/COLD/ALLERGY*..................................................................................................................78*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***.............................................................. 79*CYSTIC FIBROSIS AGENT - COMBINATIONS***............................................................................79*DERMATOLOGICALS*........................................................................................................................ 79*DIAGNOSTIC PRODUCTS*................................................................................................................. 90*DIGESTIVE AIDS*................................................................................................................................. 94*DIRECT-ACTING P2Y12 INHIBITORS***..........................................................................................94*DIURETICS*........................................................................................................................................... 94*ENDOCRINE AND METABOLIC AGENTS - MISC.*........................................................................95*ESTROGENS*......................................................................................................................................... 98*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***..............................99*FARNESOID X RECEPTOR (FXR) AGONISTS***............................................................................ 99*FLUOROQUINOLONES*......................................................................................................................99*GASTROINTESTINAL AGENTS - MISC.*........................................................................................ 100*GENITOURINARY AGENTS - MISCELLANEOUS*....................................................................... 102*GOUT AGENTS*.................................................................................................................................. 102*HEMATOLOGICAL AGENTS - MISC.*.............................................................................................103*HEMATOPOIETIC AGENTS*.............................................................................................................105*HEMOSTATICS*...................................................................................................................................109*HEPATITIS C AGENT - COMBINATIONS***.................................................................................. 109*HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS**.................................................109*HYPNOTICS*........................................................................................................................................109*HYPOPHOSPHATASIA (HPP) AGENTS***...................................................................................... 110*IBS AGENT - MU-OPIOID RECEPTOR AGONISTS***................................................................... 110*INSULIN-INCRETIN MIMETIC COMBINATIONS***................................................................... 110*INTEGRIN RECEPTOR ANTAGONISTS***.................................................................................... 110*INTERLEUKIN ANTAGONISTS***.................................................................................................. 110*INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)***.................................................................... 110*INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)***.................................................................... 110*ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS***.......................................................111*ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS***.......................................................111*LAXATIVES*........................................................................................................................................ 111*LEPTIN ANALOGUES***................................................................................................................... 111*LHRH/GNRH AGONIST ANALOG COMBINATIONS***.............................................................. 111*LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG***............................112*LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS***.................................................. 112*MACROLIDES*.................................................................................................................................... 112*MEDICAL DEVICES*.......................................................................................................................... 112*MIGRAINE PRODUCTS*....................................................................................................................115*MINERALS & ELECTROLYTES*.......................................................................................................116*MONOBACTAMS***........................................................................................................................... 117*MOUTH/THROAT/DENTAL AGENTS*............................................................................................117*MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS***............................................................ 118
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*MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID***.......................... 118*MULTIVITAMINS*..............................................................................................................................118*MUSCULOSKELETAL THERAPY AGENTS*.................................................................................. 119*NASAL AGENTS - SYSTEMIC AND TOPICAL*.............................................................................. 120*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***.............................121*NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS***.......................................121*NEUROMUSCULAR AGENTS*.........................................................................................................121*OPHTHALMIC AGENTS*................................................................................................................... 122*OPHTHALMIC RHO KINASE INHIBITORS***...............................................................................126*OREXIN RECEPTOR ANTAGONISTS***.........................................................................................126*OTIC AGENTS*.................................................................................................................................... 126*OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***............................................................. 127*OXYTOCICS*........................................................................................................................................127*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***............................................................. 127*PASSIVE IMMUNIZING AGENTS*...................................................................................................127*PCSK9 INHIBITORS***....................................................................................................................... 128*PEDIATRIC MULTIPLE VITAMINS W/FLUORIDE-IRON-ZINC***............................................128*PENICILLINS*......................................................................................................................................129*PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS***................................................... 129*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***.....................................................129*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***.........................................................................129*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS**......................................................130*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS***.....................................................130*POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS***................................130*POTASSIUM REMOVING AGENTS***.............................................................................................130*PROGESTINS*...................................................................................................................................... 130*PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS***.......................................... 131*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*..........................................131*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***....................................................133*PULMONARY FIBROSIS AGENTS***..............................................................................................133*PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST***........................133*RESPIRATORY AGENTS - MISC.*.................................................................................................... 134*SEROTONIN MODULATORS***.......................................................................................................134*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***......................................................134*SINUS NODE INHIBITORS**.............................................................................................................134*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***..................... 134*SPLEEN TYROSINE KINASE (SYK) INHIBITORS***.................................................................... 135*SULFONAMIDES*............................................................................................................................... 135*TETRACYCLINES*..............................................................................................................................135*THYROID AGENTS*........................................................................................................................... 136*TRYPTOPHAN HYDROXYLASE INHIBITORS***......................................................................... 136*ULCER DRUGS*.................................................................................................................................. 136*URINARY ANTI-INFECTIVES*.........................................................................................................139*URINARY ANTISPASMODICS*........................................................................................................ 139*VAGINAL PRODUCTS*...................................................................................................................... 140*VASOPRESSORS*.................................................................................................................................141*VITAMINS*........................................................................................................................................... 141
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2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
lowercase italics = Generic drugsUPPERCASE = Brand name drugs
Drug StatusCE = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations may apply.NC = Not CoveredNP = Non-Preferred Brand and GenericNPS = Non-Preferred SpecialtyPB = Preferred BrandPG = Preferred GenericPSP = Preferred Specialty
Drug Details# = Brand-name drug expected to become available generically in the near future. After the generic drug becomes available, the brand-name drug may be covered at a higher non-preferred copay and/or added to the Formulary Exclusion List. The brand-name drug may also be subject to precertification and/or step-therapy.AL = Age LimitLGC = Lowest Generic CopayMPG = PG tier applies to members residing in Massachusetts.MST = Step Therapy does not apply to members residing in Massachusetts.N1 = Refer to member plan documents for erectile dysfuncition use/coveragePA = Prior Authorization QL = Quantity LimitSelect OTC = Select OTC Program if your pharmacy plan includes this program you may have coverage for products noted with a doctors prescription. Please see your plan benefit information for specific coverage details.SP = You may pay higher out of pocket costs and may be required to get these products at an Aetna Specialty Pharmacy network provider, like Aetna Specialty Pharmacy. Specialty products are
limited to a 30 day supply.ST = Step Therapy
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201816
Drug Name Drug Status Drug Details
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*
ADDERALL NP ST; QL
ADDERALL XR NP ST; QL
ADZENYS ER NP PA; ST; QL
ADZENYS XR-ODT NP PA; ST; QL
amphetamine-dextroamphet er PG QL
amphetamine-dextroamphetamine PG QL
APTENSIO XR NP PA; ST; #; QL
armodafinil PG PA; QL
atomoxetine hcl PG QL
clonidine hcl er PG PA; QL
CONCERTA NP ST; QL
COTEMPLA XR-ODT NP PA; ST; QL
DAYTRANA NP PA; ST; #; QL
DESOXYN NP PA; ST; QL
DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR
NP ST; QL
dexmethylphenidate hcl PG QL
dexmethylphenidate hcl er PG QL
dextroamphetamine sulfate er PG QL
dextroamphetamine sulfate oral solution PG PA; QL
dextroamphetamine sulfate oral tablet PG QL
DIDREX NP
DYANAVEL XR NP PA; ST; QL
EVEKEO NP PA; ST; QL
FOCALIN NP ST; QL
FOCALIN XR NP ST; QL
guanfacine hcl er NP PA; QL
INTUNIV NP PA; ST; QL
KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR
NP PA; ST; QL
METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG
PG QL
methamphetamine hcl PG PA; QL
METHYLIN ORAL SOLUTION NP ST; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201817
Drug Name Drug Status Drug Details
methylphenidate hcl er PG QL
methylphenidate hcl er (cd) PG QL
methylphenidate hcl er (la) PG QL
methylphenidate hcl oral solution 10 mg/5ml PG QL
methylphenidate hcl oral solution 5 mg/5ml NP QL
methylphenidate hcl oral tablet PG QL
methylphenidate hcl oral tablet chewable NP QL
modafinil PG PA; QL
MYDAYIS NP PA; ST; QL
NUVIGIL NP PA; QL
PROCENTRA NP PA; ST; QL
PROVIGIL NP PA; QL
QUILLICHEW ER NP PA; ST; QL
QUILLIVANT XR NP PA; ST; #; QL
RELEXXII PG QL
RITALIN NP ST; QL
RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG
NP ST; QL
STRATTERA NP ST; QL
VYVANSE PB QL
ZENZEDI ORAL TABLET 10 MG, 5 MG PG QL
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
NC
*AGENTS FOR NARCOTIC WITHDRAWAL***
LUCEMYRA NP QL
*AMEBICIDES*
SOLOSEC NC
*AMINO ACIDS***
ENDARI NP PA; ST; QL
*AMINOGLYCOSIDES*
BETHKIS NPS SP; QL
gentamicin sulfate injection NC
neomycin sulfate oral PG
paromomycin sulfate oral PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201818
Drug Name Drug Status Drug Details
streptomycin sulfate intramuscular NC
TOBI NPS SP; QL
TOBI PODHALER PSP SP; QL
tobramycin inhalation PSP SP; QL
tobramycin sulfate injection solution 10 mg/ml, 2 gm/50ml
NC
tobramycin sulfate injection solution reconstituted
NC
*ANALGESICS - ANTI-INFLAMMATORY*
ACTEMRA INTRAVENOUS NPS PA; ST; SP
ACTEMRA SUBCUTANEOUS NPS PA; ST; SP; QL
ANAPROX DS NP
ARAVA NP QL
ARCALYST NPS PA; SP
ARTHROTEC ORAL TABLET DELAYED RELEASE
NP
CELEBREX NP QL
celecoxib oral NP QL
DAYPRO NP
diclofenac potassium PG
diclofenac sodium er PG
diclofenac sodium oral tablet delayed release 25 mg, 50 mg
PG
diclofenac sodium oral tablet delayed release 75 mg
PG LGC
diclofenac-misoprostol oral tablet delayed release
PG
DUEXIS NC
EC-NAPROSYN NP
ENBREL MINI PSP PA; ST; SP; QL
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PSP PA; ST; SP; QL
ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR
PSP PA; ST; SP; QL
etodolac er PG
etodolac oral PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201819
Drug Name Drug Status Drug Details
FELDENE NP
fenoprofen calcium oral PG
flurbiprofen oral PG
HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
NPS PA; ST; SP; QL
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT
NPS PA; ST; SP; QL
HUMIRA PEN-CD/UC/HS STARTER NPS PA; ST; SP; QL
HUMIRA PEN-PS/UV STARTER NPS PA; ST; SP; QL
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT
NPS PA; ST; SP; QL
IBUPROFEN COMFORT PAC NC
ibuprofen oral tablet 400 mg, 600 mg, 800 mg PG LGC
IC 400 NC
IC 800 NC
ILARIS SUBCUTANEOUS SOLUTION NPS PA; SP
INDOCIN ORAL NP
INDOCIN RECTAL NP
indomethacin er PG
indomethacin oral PG QL
ketoprofen er PG
ketorolac tromethamine oral PG QL
KEVZARA NPS PA; ST; SP; QL
KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
NPS PA; ST; SP; QL
leflunomide oral PG QL
LODINE NP
meclofenamate sodium oral PG
mefenamic acid oral NP QL
meloxicam oral tablet PG LGC
MOBIC ORAL TABLET NP
nabumetone oral PG
NALFON ORAL CAPSULE 400 MG NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201820
Drug Name Drug Status Drug Details
NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG, 750 MG
NC
NAPROSYN ORAL TABLET 250 MG, 500 MG
NP
NAPROXEN COMFORT PAC NC
naproxen dr PG
naproxen oral suspension PG
naproxen oral tablet PG LGC
naproxen sodium er NC
naproxen sodium oral tablet 275 mg, 550 mg PG
OLUMIANT NPS PA; ST; SP; QL
ORENCIA CLICKJECT NPS PA; ST; SP; QL
ORENCIA INTRAVENOUS NPS PA; ST; SP
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
NPS PA; ST; SP; QL
OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML
NPS ST; SP
OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 12.5 MG/0.4ML
NPS ST
oxaprozin PG
piroxicam oral PG
PONSTEL NP QL
RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML
NPS ST; SP
RIDAURA NP
SIMPONI ARIA PSP PA; ST; SP; QL
SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR
PSP PA; ST; SP; QL
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PSP PA; ST; SP; QL
SPRIX NC #
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201821
Drug Name Drug Status Drug Details
sulindac oral PG
TIVORBEX NC
tolmetin sodium PG
VIMOVO NC
VIVLODEX NC
XELJANZ PSP PA; ST; SP; QL
XELJANZ XR PSP PA; ST; SP; QL
ZIPSOR NC
ZORVOLEX NC
*ANALGESICS - NONNARCOTIC*
ALLZITAL NC
BUPAP ORAL TABLET 50-300 MG NC
butalbital-acetaminophen oral capsule NC
butalbital-acetaminophen oral tablet 50-300 mg NC
butalbital-acetaminophen oral tablet 50-325 mg PG
butalbital-apap-caffeine oral capsule PG
butalbital-apap-caffeine oral tablet 50-325-40 mg
PG
butalbital-asa-caffeine PG
choline-mag trisalicylate PG
diflunisal oral PG
eq aspirin low dose oral tablet chewable CE
eq aspirin low dose oral tablet delayed release CE
ESGIC ORAL CAPSULE PG
FIORICET ORAL CAPSULE NP
FIORINAL NP
PRIALT NPS SP
salsalate oral PG
VANATOL LQ NC
ZEBUTAL ORAL CAPSULE 50-325-40 MG PG
*ANALGESICS - OPIOID*
ABSTRAL NP PA; ST; #; QL
acetaminophen-codeine PG PA; QL
acetaminophen-codeine #2 PG PA; QL
acetaminophen-codeine #3 PG PA; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201822
Drug Name Drug Status Drug Details
acetaminophen-codeine #4 PG PA; QL
ACTIQ NP PA; ST; QL
apap-caff-dihydrocodeine oral capsule NP PA; QL
apap-caff-dihydrocodeine oral tablet 325-30-16 mg
NC
ARYMO ER NP PA; ST; MPG; QL
ASCOMP-CODEINE PG PA; QL
BELBUCA NP PA; QL
BUNAVAIL NP ST; MST; QL
buprenorphine PG PA; QL
buprenorphine hcl sublingual PG QL
buprenorphine hcl-naloxone hcl sublingual tablet sublingual
PG QL
butalbital-apap-caff-cod PG PA; QL
butalbital-asa-caff-codeine PG PA; QL
butorphanol tartrate nasal NP PA; QL
BUTRANS NP PA; QL
codeine sulfate oral tablet PG PA; QL
CONZIP NC
DILAUDID ORAL NP PA; QL
DOLOPHINE NP PA; QL
DURAGESIC-100 NP PA; ST; QL
DURAGESIC-12 NP PA; ST; QL
DURAGESIC-25 NP PA; ST; QL
DURAGESIC-50 NP PA; ST; QL
DURAGESIC-75 NP PA; ST; QL
EMBEDA PB PA; MPG; QL
ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG
PG PA; QL
EXALGO ORAL TABLET ER 24 HOUR ABUSE-DETERRENT
NP PA; ST; QL
fentanyl PG PA; QL
fentanyl citrate buccal NP PA; ST; QL
FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG
NP PA; ST; #; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201823
Drug Name Drug Status Drug Details
FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG
NP PA; QL
FIORINAL/CODEINE #3 NP PA; QL
hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml
NP PA; QL
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
PG PA; QL
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg
PG PA; QL
hydromorphone hcl er NP PA; QL
hydromorphone hcl oral PG PA; QL
hydromorphone hcl rectal PG PA; QL
HYSINGLA ER PB PA; #; QL
IBUDONE ORAL TABLET 10-200 MG NP PA; QL
ibudone oral tablet 5-200 mg PG PA; QL
KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG
NP PA; ST; QL
LAZANDA NC
levorphanol tartrate oral NP PA; QL
LORCET PG PA; QL
LORCET HD PG PA; QL
LORCET PLUS ORAL TABLET 7.5-325 MG PG PA; QL
LORTAB ORAL ELIXIR 10-300 MG/15ML NP PA; QL
meperidine hcl oral PG PA; QL
METHADONE HCL INTENSOL NP PA; QL
methadone hcl oral concentrate NP PA; QL
methadone hcl oral solution PG PA; QL
methadone hcl oral tablet PG PA; QL
METHADOSE ORAL CONCENTRATE 10 MG/ML
NP PA; QL
METHADOSE SUGAR-FREE NP PA; QL
MORPHABOND ER NP PA; ST; MPG; QL
morphine sulfate (concentrate) oral solution 100 mg/5ml
PG PA; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201824
Drug Name Drug Status Drug Details
morphine sulfate er beads PG PA; QL
morphine sulfate er oral capsule extended release 24 hour
PG PA; QL
morphine sulfate er oral tablet extended release PG PA; QL
morphine sulfate oral PG PA; QL
morphine sulfate rectal PG PA; QL
MS CONTIN ORAL TABLET EXTENDED RELEASE
NP PA; ST; QL
nalbuphine hcl injection NC
nalocet NC
NORCO NP PA; QL
NUCYNTA NP PA; ST; QL
NUCYNTA ER NP PA; ST; QL
OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT
NP PA; ST; QL
OPANA ORAL NP PA; QL
OXAYDO PB PA; MPG; QL
oxycodone hcl er oral tablet er 12 hour abuse-deterrent
PG PA; QL
oxycodone hcl oral capsule PG PA; QL
oxycodone hcl oral concentrate 100 mg/5ml PG PA; QL
oxycodone hcl oral solution PG PA; QL
oxycodone hcl oral tablet PG PA; QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
PG PA; QL
oxycodone-aspirin oral tablet 4.8355-325 mg PG PA; QL
oxycodone-ibuprofen PG PA; QL
OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT
PB PA; QL
oxymorphone hcl PG PA; QL
oxymorphone hcl er PG PA; QL
pentazocine-naloxone hcl NP PA; QL
PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG
NP PA; QL
PRIMLEV NC
ROXICODONE ORAL TABLET NP PA; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201825
Drug Name Drug Status Drug Details
SUBOXONE SUBLINGUAL FILM NP #; QL
SUBSYS NC
tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg
PG PA; QL
tramadol hcl er oral capsule extended release 24 hour
NC
tramadol hcl er oral tablet extended release 24 hour
PG PA; QL
tramadol hcl oral PG PA; QL
tramadol-acetaminophen PG PA; QL
TREZIX ORAL CAPSULE 320.5-30-16 MG NP PA; QL
TYLENOL WITH CODEINE #3 NP PA; QL
TYLENOL WITH CODEINE #4 NP PA; QL
ULTRACET NP PA; QL
ULTRAM NP PA; QL
VERDROCET PG PA; QL
vicodin es oral tablet 7.5-300 mg PG PA; QL
vicodin hp oral tablet 10-300 mg PG PA; QL
vicodin oral tablet 5-300 mg PG PA; QL
XODOL ORAL TABLET 5-300 MG, 7.5-300 MG
NP PA; QL
XTAMPZA ER NP PA; ST; QL
ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT
NP PA; ST; QL
ZUBSOLV NP ST; MST; QL
*ANDROGENS-ANABOLIC*
ANADROL-50 NP
ANDRODERM TRANSDERMAL PATCH 24 HOUR
NC
ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)
PB PA; #; QL
ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)
PB PA; #; QL
ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%), 50 MG/5GM (1%)
NC
danazol oral PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201826
Drug Name Drug Status Drug Details
DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION
NP
FORTESTA NC
methitest NP
methyltestosterone oral PG
NATESTO NC
OXANDRIN ORAL TABLET 10 MG NP
STRIANT NC
TESTIM NC
testosterone cypionate intramuscular solution200 mg/ml
PG
testosterone enanthate intramuscular solution PG
testosterone transdermal gel 10 mg/act (2%) PG QL
testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)
PG PA; QL
testosterone transdermal solution NP PA; ST; QL
VOGELXO PUMP NC
VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%)
NC
*ANORECTAL AGENTS*
ANA-LEX NC
ANALPRAM-HC RECTAL CREAM NP
ANALPRAM-HC RECTAL LOTION 2.5-1 %
NP
anucort-hc NC
ANUSOL-HC RECTAL CREAM NP
ANUSOL-HC RECTAL SUPPOSITORY NC
CORTIFOAM NC
hydrocortisone ace-pramoxine rectal cream 2.5-1 %
NC
hydrocortisone acetate rectal NC
hydrocortisone rectal cream 2.5 % PG
lidocaine-hydrocortisone ace rectal NC
PROCTOCORT NC
PROCTOFOAM HC NC
PROCTO-PAK PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201827
Drug Name Drug Status Drug Details
PROCTOZONE-HC RECTAL PG
RECTIV NP QL
UCERIS RECTAL NP PA; #; QL
*ANTHELMINTICS*
ALBENZA NP QL
benznidazole NP PA; QL
BILTRICIDE NP
EMVERM NP QL
ivermectin oral PG
praziquantel oral PG
STROMECTOL NP
*ANTIANGINAL AGENTS*
DILATRATE-SR NP
GONITRO NP
ISORDIL TITRADOSE NP
isosorbide dinitrate er PG
isosorbide dinitrate oral PG
isosorbide mononitrate PG
isosorbide mononitrate er PG
MINITRAN PG
NITRO-BID NP
NITRO-DUR NP
nitroglycerin er oral capsule extended release 9 mg
PG
nitroglycerin sublingual PG
nitroglycerin transdermal patch 24 hour PG
nitroglycerin translingual solution PG
NITROLINGUAL NP
NITROMIST NP
NITROSTAT NP ST
NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 9 MG
PG
RANEXA PB #; QL
*ANTIANXIETY AGENTS*
alprazolam er PG QL; AL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201828
Drug Name Drug Status Drug Details
ALPRAZOLAM INTENSOL NP
alprazolam oral PG AL
alprazolam xr PG QL; AL
ATIVAN ORAL NC
buspirone hcl oral tablet 10 mg, 5 mg PG LGC
buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg PG
chlordiazepoxide hcl PG AL
clorazepate dipotassium PG AL
DIAZEPAM INTENSOL PG
diazepam oral concentrate PG
diazepam oral solution 5 mg/5ml PG
diazepam oral tablet PG
hydroxyzine hcl oral syrup PG
hydroxyzine hcl oral tablet PG
hydroxyzine pamoate oral PG
lorazepam oral PG
meprobamate PG
oxazepam PG AL
TRANXENE-T ORAL TABLET 7.5 MG NP AL
VALIUM NP
VISTARIL NP
XANAX NC AL
XANAX XR NC AL
*ANTIARRHYTHMICS*
amiodarone hcl oral PG
disopyramide phosphate oral PG
dofetilide PG
flecainide acetate PG
mexiletine hcl oral PG
MULTAQ NP QL
NORPACE NP
NORPACE CR NP
propafenone hcl PG
propafenone hcl er PG SP; QL
quinidine gluconate er PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201829
Drug Name Drug Status Drug Details
quinidine sulfate oral PG
RYTHMOL SR NP QL
TIKOSYN NP
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*
ACCOLATE NP QL
ADVAIR DISKUS NP #; QL
ADVAIR HFA NP QL
AIRDUO RESPICLICK 113/14 NP PA; ST; QL
AIRDUO RESPICLICK 232/14 NP PA; ST; QL
AIRDUO RESPICLICK 55/14 NP PA; ST; QL
albuterol sulfate er PG
albuterol sulfate inhalation PG
albuterol sulfate oral PG
ALVESCO NP PA; ST; QL
ANORO ELLIPTA PB QL
ARCAPTA NEOHALER NP PA; ST; QL
ARMONAIR RESPICLICK 113 NP PA; ST; QL
ARMONAIR RESPICLICK 232 NP PA; ST; QL
ARMONAIR RESPICLICK 55 NP PA; ST; QL
ARNUITY ELLIPTA NP QL
ASMANEX 120 METERED DOSES PB #; QL
ASMANEX 14 METERED DOSES PB #; QL
ASMANEX 30 METERED DOSES PB #; QL
ASMANEX 60 METERED DOSES PB #; QL
ASMANEX 7 METERED DOSES PB #; QL
ASMANEX HFA PB QL
ATROVENT HFA NP QL
BEVESPI AEROSPHERE NP PA; ST; QL
BREO ELLIPTA PB QL
BROVANA NP PA; ST; QL
budesonide inhalation PG PA; QL; AL
COMBIVENT RESPIMAT PB QL
cromolyn sodium inhalation PG
DALIRESP NP PA; ST; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201830
Drug Name Drug Status Drug Details
DULERA PB QL
ELIXOPHYLLIN NP
FLOVENT DISKUS NP #; QL
FLOVENT HFA NP QL
fluticasone-salmeterol PG QL
INCRUSE ELLIPTA PB QL
ipratropium bromide inhalation PG
ipratropium-albuterol PG
levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml
PG
LONHALA MAGNAIR REFILL KIT NP PA; ST; QL
LONHALA MAGNAIR STARTER KIT NP PA; ST; QL
metaproterenol sulfate oral PG
montelukast sodium oral PG QL
PERFOROMIST NP PA; ST; QL
PROAIR HFA PB #
PROAIR RESPICLICK PB
PROVENTIL HFA NP ST; #
PULMICORT NP PA; QL; AL
PULMICORT FLEXHALER NP PA; ST; QL
QVAR REDIHALER PB QL
SEEBRI NEOHALER NP PA; ST; QL
SEREVENT DISKUS PB QL
SINGULAIR NP QL
SPIRIVA HANDIHALER PB QL
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT
PB QL
STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT
PB QL
STRIVERDI RESPIMAT NP PA; ST; QL
SYMBICORT PB QL
terbutaline sulfate oral PG
THEO-24 PB
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201831
Drug Name Drug Status Drug Details
THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG
PG
theophylline PG
theophylline er PG
TRELEGY ELLIPTA PB QL
TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED
NP PA; ST; QL
UTIBRON NEOHALER NP PA; ST; QL
VENTOLIN HFA PB
XOLAIR PSP PA; ST; SP
XOPENEX NP
XOPENEX CONCENTRATE NP
XOPENEX HFA NP ST; QL
zafirlukast PG QL
zileuton er NP QL
ZYFLO NP QL
ZYFLO CR NP QL
*ANTICOAGULANTS*
ARIXTRA NP QL
BEVYXXA NP PA; ST; QL
COUMADIN ORAL NP
ELIQUIS PB QL
ELIQUIS STARTER PACK PB QL
enoxaparin sodium PG QL
fondaparinux sodium NP QL
FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML
NP QL
heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml
PG
heparin sodium (porcine) pf PG
IPRIVASK NP QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201832
Drug Name Drug Status Drug Details
JANTOVEN PG
LOVENOX NP QL
PRADAXA NP ST; QL
SAVAYSA NP ST; QL
warfarin sodium oral PG LGC
XARELTO PB QL
XARELTO STARTER PACK PB QL
*ANTICONVULSANTS*
APTIOM NP QL
BANZEL ORAL TABLET NP QL
BRIVIACT ORAL NP PA; QL
carbamazepine er PG
carbamazepine oral PG
CARBATROL PB
CELONTIN PB
clonazepam oral PG
DEPAKENE ORAL CAPSULE NP
DEPAKENE ORAL SOLUTION NP
DEPAKOTE NP
DEPAKOTE ER NP
DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE
NP
DIASTAT ACUDIAL PB QL
DIASTAT PEDIATRIC PB QL
diazepam rectal PG QL
DILANTIN PB
DILANTIN INFATABS PB
divalproex sodium er oral tablet extended release 24 hour
PG
divalproex sodium oral capsule delayed release sprinkle
PG
divalproex sodium oral tablet delayed release PG
EPITOL PG
ethosuximide oral PG
felbamate PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201833
Drug Name Drug Status Drug Details
FELBATOL NP
FYCOMPA ORAL SUSPENSION NP
FYCOMPA ORAL TABLET NP QL
gabapentin oral capsule PG QL
gabapentin oral solution 250 mg/5ml PG
gabapentin oral tablet PG QL
GABITRIL NP QL
KEPPRA ORAL NP
KEPPRA XR NP QL
KLONOPIN NP
LAMICTAL ODT ORAL KIT NP
LAMICTAL ODT ORAL TABLET DISPERSIBLE
NP QL
LAMICTAL ORAL TABLET NP
LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG
NP
LAMICTAL STARTER NP
LAMICTAL XR ORAL KIT NP
LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR
NP QL
lamotrigine er PG QL
lamotrigine oral tablet PG
lamotrigine oral tablet chewable PG
lamotrigine oral tablet dispersible NP QL
lamotrigine starter kit-blue PG
lamotrigine starter kit-green PG
lamotrigine starter kit-orange PG
levetiracetam er PG QL
levetiracetam oral PG
LYRICA PB #
MYSOLINE NP
NEURONTIN ORAL CAPSULE NP QL
NEURONTIN ORAL SOLUTION NP
NEURONTIN ORAL TABLET NP QL
ONFI ORAL SUSPENSION NP #
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201834
Drug Name Drug Status Drug Details
ONFI ORAL TABLET 10 MG, 20 MG NP #; QL
oxcarbazepine PG
OXTELLAR XR NP QL
PEGANONE NP
PHENYTEK PB
PHENYTOIN INFATABS PG
phenytoin oral suspension 125 mg/5ml PG
phenytoin oral tablet chewable PG
phenytoin sodium extended PG
primidone oral PG
QUDEXY XR NP QL
SABRIL ORAL PACKET NPS PA; SP; QL
SABRIL ORAL TABLET NPS PA; #; SP; QL
SPRITAM NP ST; QL
TEGRETOL ORAL SUSPENSION PB
TEGRETOL ORAL TABLET PB
TEGRETOL-XR PB
tiagabine hcl PG QL
TOPAMAX NP
TOPAMAX SPRINKLE NP QL
topiramate oral capsule sprinkle PG QL
topiramate oral tablet PG
TRILEPTAL NP
TROKENDI XR NP #; QL
valproate sodium oral solution PG
valproic acid oral capsule PG
valproic acid oral solution PG
vigabatrin PSP PA; SP; QL
VIGADRONE PSP PA; SP; QL
VIMPAT ORAL NP #; QL
ZARONTIN NP
ZONEGRAN NP
zonisamide oral PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201835
Drug Name Drug Status Drug Details
*ANTIDEMENTIA AGENT COMBINATIONS***
NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK
PB PA; AL
NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG
PB PA; AL
*ANTIDEPRESSANTS*
amitriptyline hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg, 75 mg
PG LGC
amitriptyline hcl oral tablet 150 mg PG
amoxapine PG
ANAFRANIL NP
APLENZIN NC
bupropion hcl er (sr) PG QL
bupropion hcl er (xl) PG QL
bupropion hcl oral PG QL
CELEXA ORAL TABLET NP QL
citalopram hydrobromide oral solution PG
citalopram hydrobromide oral tablet PG LGC; QL
clomipramine hcl oral PG
CYMBALTA NP QL
desipramine hcl oral PG
desvenlafaxine er NP QL
desvenlafaxine succinate er NP PA; ST; QL
doxepin hcl oral PG
duloxetine hcl oral PG QL
EFFEXOR XR NP QL
EMSAM NP #; QL
escitalopram oxalate oral solution PG
escitalopram oxalate oral tablet PG QL
FETZIMA NP PA; ST; QL
FETZIMA TITRATION NP PA; ST; QL
fluoxetine hcl oral capsule PG LGC; QL
fluoxetine hcl oral capsule delayed release PG QL
fluoxetine hcl oral solution PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201836
Drug Name Drug Status Drug Details
fluoxetine hcl oral tablet 10 mg, 20 mg PG QL
fluoxetine hcl oral tablet 60 mg NP QL
fluvoxamine maleate PG QL
fluvoxamine maleate er PG QL
FORFIVO XL NC #
imipramine hcl oral PG
imipramine pamoate NP
KHEDEZLA NP PA; ST; QL
LEXAPRO ORAL TABLET NP QL
maprotiline hcl PG QL
MARPLAN NP
mirtazapine oral PG QL
NARDIL NP
nefazodone hcl NP
NORPRAMIN ORAL TABLET 10 MG, 25 MG
NP
nortriptyline hcl oral capsule 10 mg, 25 mg PG LGC
nortriptyline hcl oral capsule 50 mg, 75 mg PG
nortriptyline hcl oral solution PG
PAMELOR ORAL CAPSULE NP
PARNATE NP
paroxetine hcl er PG QL
paroxetine hcl oral tablet PG LGC; QL
PAXIL NP QL
PAXIL CR NP QL
PEXEVA NC
phenelzine sulfate oral PG
PRISTIQ NP PA; ST; QL
protriptyline hcl PG
PROZAC ORAL CAPSULE NP QL
REMERON ORAL TABLET 15 MG, 30 MG NP QL
REMERON SOLTAB NP QL
sertraline hcl oral concentrate PG
sertraline hcl oral tablet PG LGC; QL
SURMONTIL NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201837
Drug Name Drug Status Drug Details
TOFRANIL NP
tranylcypromine sulfate PG
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg PG LGC
trazodone hcl oral tablet 300 mg PG
trimipramine maleate oral NP
TRINTELLIX NP PA; ST; QL
venlafaxine hcl PG QL
venlafaxine hcl er oral capsule extended release 24 hour
PG QL
venlafaxine hcl er oral tablet extended release 24 hour
NP QL
VIIBRYD ORAL TABLET NP QL
VIIBRYD STARTER PACK NP
WELLBUTRIN SR NP QL
WELLBUTRIN XL NC
ZOLOFT ORAL CONCENTRATE NP
ZOLOFT ORAL TABLET NP QL
*ANTIDIABETICS*
acarbose PG
ACTOPLUS MET NP QL
ACTOPLUS MET XR NP QL
ACTOS NP QL
ADLYXIN NC
ADLYXIN STARTER PACK NC
ADMELOG NC
ADMELOG SOLOSTAR NC
AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 (90) & 8 (90) UNIT, 4 UNIT, 8 UNIT
NP PA
alogliptin benzoate PG QL
alogliptin-metformin hcl PG QL
alogliptin-pioglitazone PG QL
AMARYL NP
APIDRA NC
APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR
NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201838
Drug Name Drug Status Drug Details
AVANDIA ORAL TABLET 2 MG, 4 MG NP QL
BASAGLAR KWIKPEN PB
BYDUREON BCISE NC
BYDUREON SUBCUTANEOUS PEN-INJECTOR
NC
BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER
NC
BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR
NC #
BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR
NC #
chlorpropamide PG
CYCLOSET NP QL
DUETACT NP QL
FARXIGA NP QL
FIASP NC
FIASP FLEXTOUCH NC
FORTAMET NC
glimepiride PG LGC
glipizide er oral tablet extended release 24 hour10 mg, 5 mg
PG LGC
glipizide er oral tablet extended release 24 hour2.5 mg
PG
glipizide oral PG LGC
glipizide xl PG
glipizide-metformin hcl PG
GLUCAGEN HYPOKIT PB QL
GLUCAGON EMERGENCY PB QL
GLUCOPHAGE NP
GLUCOPHAGE XR NP
GLUCOTROL NP
GLUCOTROL XL NP
GLUCOVANCE ORAL TABLET 5-500 MG NP
GLUMETZA NC
glyburide micronized oral tablet 1.5 mg PG
glyburide micronized oral tablet 3 mg, 6 mg PG LGC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201839
Drug Name Drug Status Drug Details
glyburide oral tablet 1.25 mg PG
glyburide oral tablet 2.5 mg, 5 mg PG LGC
glyburide-metformin PG
GLYNASE NP
GLYSET NP
HUMALOG PB
HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML
PB
HUMALOG MIX 50/50 PB
HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
PB
HUMALOG MIX 75/25 PB
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
PB
HUMULIN 70/30 PB
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
PB
HUMULIN N PB
HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
PB
HUMULIN R PB
HUMULIN R U-500 (CONCENTRATED) PB
HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR
PB
INVOKANA PB QL
JANUMET PB QL
JANUMET XR PB QL
JANUVIA PB QL
JARDIANCE PB QL
JENTADUETO PB QL
JENTADUETO XR PB QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201840
Drug Name Drug Status Drug Details
KAZANO NC
KOMBIGLYZE XR NC
KORLYM NPS PA; SP; QL
LANTUS NC
LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR
NC
LEVEMIR PB
LEVEMIR FLEXTOUCH PB
metformin hcl er (mod) NC
metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg
NC
metformin hcl er oral tablet extended release 24 hour 500 mg
PG LGC
metformin hcl er oral tablet extended release 24 hour 750 mg
PG
metformin hcl oral tablet PG LGC
miglitol PG
nateglinide NP
NESINA NC
NOVOLIN 70/30 NC
NOVOLIN 70/30 RELION NC
NOVOLIN N NC
NOVOLIN N RELION NC
NOVOLIN R NC
NOVOLIN R RELION NC
NOVOLOG NC
NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR
NC
NOVOLOG MIX 70/30 NC
NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR
NC
NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE
NC
ONGLYZA NC
OSENI NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201841
Drug Name Drug Status Drug Details
OZEMPIC NC
pioglitazone hcl PG QL
pioglitazone hcl-glimepiride PG QL
pioglitazone hcl-metformin hcl PG QL
PRANDIN ORAL TABLET 1 MG, 2 MG NP
PRECOSE NP
PROGLYCEM NP
repaglinide NP
repaglinide-metformin hcl NP QL
RIOMET NP
STARLIX NP
STEGLATRO NC
SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR
NP PA; #; QL
SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR
NP PA; #
tolazamide PG
tolbutamide NP
TOUJEO MAX SOLOSTAR NC
TOUJEO SOLOSTAR NC
TRADJENTA PB QL
TRESIBA FLEXTOUCH PB
TRULICITY PB PA; ST; QL
VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR
PB PA; ST; QL
*ANTIDIARRHEALS*
diphenatol PG
diphenoxylate-atropine PG
LOMOTIL ORAL TABLET NP
MOTOFEN NP
MYTESI NP PA; ST; QL
opium NP
*ANTIDOTES AND SPECIFIC ANTAGONISTS*
deferoxamine mesylate PSP SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201842
Drug Name Drug Status Drug Details
DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG
NPS SP
VISTOGARD PSP SP; QL
*ANTIDOTES*
CHEMET NP
deferoxamine mesylate PSP SP
DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG
NPS SP
EVZIO INJECTION SOLUTION AUTO-INJECTOR 2 MG/0.4ML
NC
EXJADE NPS PA; #; SP
FERRIPROX ORAL SOLUTION NPS PA
FERRIPROX ORAL TABLET NPS PA; SP
JADENU NPS PA; #; SP
JADENU SPRINKLE NPS PA; SP
naltrexone hcl oral PG
NARCAN PB #; QL
RADIOGARDASE NP
VISTOGARD PSP SP; QL
VIVITROL NP
*ANTIEMETICS*
AKYNZEO ORAL NP PA; ST; QL
ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML
NC #
ANZEMET ORAL NP QL
aprepitant PG QL
BONJESTA NP PA; ST; QL
CESAMET NP QL
DICLEGIS NP PA; QL
dronabinol NP PA; QL
EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG
NP QL
EMEND ORAL SUSPENSION RECONSTITUTED
PB
granisetron hcl oral NP
MARINOL NP PA; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201843
Drug Name Drug Status Drug Details
ondansetron PG
ondansetron hcl oral PG
SANCUSO NP QL
scopolamine PG
SYNDROS NP PA; QL
TIGAN INTRAMUSCULAR NC
TIGAN ORAL NP
TRANSDERM-SCOP (1.5 MG) NP
trimethobenzamide hcl oral PG
VARUBI ORAL NP QL
ZOFRAN ODT NP
ZOFRAN ORAL NP
ZUPLENZ NC
*ANTIFUNGALS*
ANCOBON NP
CRESEMBA ORAL NP
DIFLUCAN NP
fluconazole oral suspension reconstituted PG AL
fluconazole oral tablet PG
flucytosine oral NP
griseofulvin microsize oral PG
griseofulvin ultramicrosize PG
itraconazole oral PG QL
ketoconazole oral PG QL
LAMISIL ORAL TABLET NP
NOXAFIL ORAL SUSPENSION NP
NOXAFIL ORAL TABLET DELAYED RELEASE
NP QL
nystatin oral tablet PG
SPORANOX ORAL CAPSULE NP QL
SPORANOX ORAL SOLUTION NP
SPORANOX PULSEPAK NP QL
terbinafine hcl oral PG
VFEND NP
voriconazole oral tablet PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201844
Drug Name Drug Status Drug Details
*ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***
HEMLIBRA NPS PA; SP
*ANTIHISTAMINES*
ALAVERT ORAL TABLET DISPERSIBLE PG Select OTC
ALLEGRA ALLERGY PG Select OTC; QL
ALLEGRA ALLERGY CHILDRENS ORAL SUSPENSION
PG Select OTC
ALLEGRA ALLERGY CHILDRENS ORAL TABLET DISPERSIBLE
PG Select OTC
allergy relief oral tablet dispersible PG Select OTC
carbinoxamine maleate oral tablet 4 mg PG
carbinoxamine maleate oral tablet 6 mg NC
cetirizine hcl oral tablet PG Select OTC
cetirizine hcl oral tablet chewable PG Select OTC
childrens loratadine PG Select OTC
CLARINEX ORAL SYRUP NP
CLARINEX ORAL TABLET NP QL
CLARITIN PG Select OTC
CLARITIN REDITABS PG Select OTC
cyproheptadine hcl oral PG
desloratadine oral tablet NP QL
desloratadine oral tablet dispersible 2.5 mg NP QL
desloratadine oral tablet dispersible 5 mg NP
fexofenadine hcl childrens PG Select OTC
fexofenadine hcl oral tablet 180 mg, 60 mg PG Select OTC
KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE
NP
levocetirizine dihydrochloride oral NC
loratadine childrens oral solution PG Select OTC
loratadine childrens oral syrup PG Select OTC
loratadine oral capsule PG Select OTC
loratadine oral solution PG Select OTC
loratadine oral tablet PG Select OTC
loratadine oral tablet chewable PG Select OTC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201845
Drug Name Drug Status Drug Details
PHENADOZ RECTAL SUPPOSITORY 12.5 MG
PG
promethazine hcl oral solution PG AL
promethazine hcl oral syrup PG AL
promethazine hcl oral tablet PG
promethazine hcl rectal PG AL
PROMETHEGAN RECTAL SUPPOSITORY 25 MG, 50 MG
PG
RYVENT NC
TRIAMINIC ALLERCHEWS PG Select OTC
XYZAL ALLERGY 24HR PG Select OTC
XYZAL ALLERGY 24HR CHILDRENS PG Select OTC
ZYRTEC ALLERGY ORAL CAPSULE PG Select OTC
ZYRTEC ALLERGY ORAL TABLET PG Select OTC
*ANTIHYPERLIPIDEMICS*
ALTOPREV NP #; QL
ANTARA ORAL CAPSULE 30 MG, 90 MG NP #; QL
atorvastatin calcium oral tablet 10 mg CE QL
atorvastatin calcium oral tablet 20 mg, 40 mg, 80 mg
PG QL
cholestyramine light PG
cholestyramine oral PG
colesevelam hcl PG
COLESTID NP
COLESTID FLAVORED NP
colestipol hcl PG
CRESTOR NP ST; QL
ezetimibe PG QL
ezetimibe-simvastatin PG QL
fenofibrate micronized oral capsule 130 mg, 43 mg
NP QL
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
PG QL
fenofibrate oral capsule 150 mg, 50 mg NP QL
fenofibrate oral tablet 120 mg, 40 mg NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201846
Drug Name Drug Status Drug Details
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg
PG QL
fenofibric acid PG QL
FENOGLIDE NC
FIBRICOR NP QL
flolipid NC
fluvastatin sodium PG QL
fluvastatin sodium er NP QL
gemfibrozil oral PG LGC
JUXTAPID NPS PA; ST; SP; QL
KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
NPS PA; ST; SP; QL
LESCOL ORAL CAPSULE 20 MG NP QL
LESCOL XL NP QL
LIPITOR NP QL
LIPOFEN NP QL
LIVALO NP ST; QL
LOPID NP
lovastatin PG LGC; QL
LOVAZA NP QL
MEVACOR ORAL TABLET 40 MG NP QL
niacin er (antihyperlipidemic) PG
NIACOR NP
NIASPAN NP
omega-3-acid ethyl esters PG QL
PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG
NP QL
pravastatin sodium PG QL
PREVALITE PG
QUESTRAN NP
QUESTRAN LIGHT ORAL POWDER NP
rosuvastatin calcium PG QL
simvastatin oral tablet 10 mg, 5 mg CE LGC; QL
simvastatin oral tablet 20 mg, 40 mg, 80 mg PG LGC; QL
TRICOR NP QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201847
Drug Name Drug Status Drug Details
TRIGLIDE ORAL TABLET 160 MG NP QL
TRILIPIX NP QL
VASCEPA PB QL
VYTORIN NP ST; QL
WELCHOL NP #
ZETIA NP ST; QL
ZOCOR NP QL
ZYPITAMAG NC
*ANTIHYPERTENSIVES*
ACCUPRIL NP
ACCURETIC NP
ALTACE ORAL CAPSULE NP
amlodipine besy-benazepril hcl PG
amlodipine besylate-valsartan PG QL
amlodipine-olmesartan NP QL
amlodipine-valsartan-hctz PG QL
ATACAND NP QL
ATACAND HCT NP QL
atenolol-chlorthalidone PG
AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG
NP QL
AVAPRO NP QL
AZOR NP ST; QL
benazepril hcl oral PG LGC
benazepril-hydrochlorothiazide PG
BENICAR NP ST; QL
BENICAR HCT NP ST; QL
bisoprolol-hydrochlorothiazide PG LGC
candesartan cilexetil PG QL
candesartan cilexetil-hctz PG QL
captopril oral PG
captopril-hydrochlorothiazide PG
CARDURA NP
CATAPRES NP
CATAPRES-TTS-1 NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201848
Drug Name Drug Status Drug Details
CATAPRES-TTS-2 NP
CATAPRES-TTS-3 NP
clonidine hcl oral PG LGC
clonidine hcl transdermal NP
CORZIDE NP
COZAAR ORAL TABLET 100 MG NP
COZAAR ORAL TABLET 25 MG, 50 MG NP QL
DEMSER NPS ST; SP
DIBENZYLINE NPS ST; QL
DIOVAN NP QL
DIOVAN HCT NP QL
doxazosin mesylate oral PG
DUTOPROL NC
EDARBI NP ST; QL
EDARBYCLOR NP ST; QL
enalapril maleate oral PG LGC
enalapril-hydrochlorothiazide PG LGC
EPANED ORAL SOLUTION NP PA; #; QL
eplerenone NP
eprosartan mesylate NP QL
EXFORGE NP QL
EXFORGE HCT NP QL
fosinopril sodium PG
fosinopril sodium-hctz PG
guanfacine hcl oral PG
hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg PG
hydralazine hcl oral tablet 25 mg PG LGC
HYZAAR NP
INSPRA NP
irbesartan PG QL
irbesartan-hydrochlorothiazide PG QL
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg PG LGC
lisinopril oral tablet 30 mg, 40 mg PG
lisinopril-hydrochlorothiazide PG LGC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201849
Drug Name Drug Status Drug Details
LOPRESSOR HCT ORAL TABLET 50-25 MG
NP
losartan potassium oral tablet 100 mg PG LGC
losartan potassium oral tablet 25 mg, 50 mg PG LGC; QL
losartan potassium-hctz PG LGC
LOTENSIN ORAL TABLET 20 MG, 40 MG NP
LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG
NP
MAVIK ORAL TABLET 4 MG NP
methyldopa oral PG
methyldopa-hydrochlorothiazide PG
metoprolol-hctz er NC
metoprolol-hydrochlorothiazide PG
MICARDIS NP QL
MICARDIS HCT NP QL
MINIPRESS NP
minoxidil oral PG
moexipril hcl PG
moexipril-hydrochlorothiazide PG
nadolol-bendroflumethiazide NP
olmesartan medoxomil oral PG QL
olmesartan medoxomil-hctz PG QL
olmesartan-amlodipine-hctz NP QL
perindopril erbumine NP
phenoxybenzamine hcl oral PSP QL
prazosin hcl oral PG
PRESTALIA NP #
PRINIVIL NP
propranolol-hctz PG
QBRELIS NP PA
quinapril hcl PG
quinapril-hydrochlorothiazide PG
ramipril PG
TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2-240 MG, 4-240 MG
NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201850
Drug Name Drug Status Drug Details
TEKTURNA NP ST; #; QL
TEKTURNA HCT NP ST; QL
telmisartan PG QL
telmisartan-amlodipine NP ST; QL
telmisartan-hctz PG QL
TENORETIC 100 NP
TENORETIC 50 NP
terazosin hcl oral PG LGC
trandolapril PG
trandolapril-verapamil hcl er PG
TRIBENZOR NP ST; QL
TWYNSTA NP ST; QL
valsartan PG QL
valsartan-hydrochlorothiazide PG QL
VASERETIC NP
VASOTEC NC
VECAMYL NPS PA; ST; SP; QL
ZESTORETIC NP
ZESTRIL NP
ZIAC NP
*ANTI-INFECTIVE AGENTS - MISC.*
ALINIA NP #; QL
atovaquone oral PG
BACTRIM NP
BACTRIM DS NP
CLEOCIN ORAL NP
CLEOCIN PHOSPHATE INJECTION NC
CLEOCIN PHOSPHATE INTRAVENOUS SOLUTION 600 MG/4ML, 900 MG/6ML
NC
clindamycin hcl oral PG
clindamycin phosphate injection solution 9 gm/60ml, 9000 mg/60ml
NC
clindamycin phosphate intravenous solution 900 mg/6ml
NC
COLY-MYCIN M NPS SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201851
Drug Name Drug Status Drug Details
dapsone oral PG
FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML
NP
FLAGYL NP
IMPAVIDO NP PA; QL
linezolid oral PG QL
MEPRON NP
metronidazole oral PG
NEBUPENT PB
SIVEXTRO ORAL NP QL
sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml
PG LGC
sulfamethoxazole-trimethoprim oral tablet PG LGC
TINDAMAX ORAL TABLET 500 MG NP
tinidazole oral NP
trimethoprim oral PG
trimpex NP
VANCOCIN HCL NP
vancomycin hcl oral NP
XIFAXAN ORAL TABLET 200 MG NP QL
XIFAXAN ORAL TABLET 550 MG PB PA; QL
ZYVOX ORAL SUSPENSION RECONSTITUTED
PB QL
ZYVOX ORAL TABLET NP QL
*ANTIMALARIALS*
atovaquone-proguanil hcl NP
chloroquine phosphate oral PG
COARTEM NP
DARAPRIM PB
hydroxychloroquine sulfate oral PG
MALARONE NP
mefloquine hcl NP
PLAQUENIL NP
primaquine phosphate oral PG
QUALAQUIN NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201852
Drug Name Drug Status Drug Details
quinine sulfate oral NP
*ANTIMYASTHENIC AGENTS*
guanidine hcl oral PG
MESTINON NP
pyridostigmine bromide er PG
pyridostigmine bromide oral PG
*ANTIMYASTHENIC/CHOLINERGIC AGENTS*
guanidine hcl oral PG
MESTINON NP
pyridostigmine bromide er PG
pyridostigmine bromide oral PG
*ANTIMYCOBACTERIAL AGENTS*
CAPASTAT SULFATE NC
cycloserine oral NP
ethambutol hcl oral PG
isoniazid oral PG
MYAMBUTOL ORAL TABLET 400 MG NP
MYCOBUTIN NP
PASER NP
PRIFTIN NP
pyrazinamide oral PG
rifabutin PG
RIFADIN ORAL NP
RIFAMATE NP
rifampin oral PG
RIFATER NP
SIRTURO NPS PA; SP; QL
TRECATOR NP
*ANTINEOPLASTIC - BCL-2 INHIBITORS***
VENCLEXTA NPS PA; SP; QL
VENCLEXTA STARTING PACK NPS PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201853
Drug Name Drug Status Drug Details
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*
ACTIMMUNE NPS PA; SP
AFINITOR NPS PA; SP; QL
AFINITOR DISPERZ NPS PA; SP; QL
ALECENSA NPS PA; SP; QL
ALFERON N NPS SP
ALKERAN INTRAVENOUS NC
ALKERAN ORAL NP ST
ALUNBRIG NPS PA; SP; QL
anastrozole oral PG
ARIMIDEX NP
AROMASIN NP
ARRANON NC #
ARZERRA NC
bexarotene PSP PA; SP
bicalutamide PG QL
BOSULIF NPS PA; ST; SP; QL
BRAFTOVI NPS PA; SP; QL
BUSULFEX NC
CABOMETYX PSP PA; SP; QL
CALQUENCE NPS PA; SP; QL
CAMPTOSAR NC
capecitabine PG PA; SP
CAPRELSA NPS PA; SP; QL
CASODEX NP QL
COMETRIQ (100 MG DAILY DOSE) NPS PA; SP; QL
COMETRIQ (140 MG DAILY DOSE) NPS PA; SP; QL
COMETRIQ (60 MG DAILY DOSE) NPS PA; SP; QL
COTELLIC NPS PA; SP; QL
cyclophosphamide injection NC
cyclophosphamide oral capsule PG
ELIGARD NPS PA; SP
EMCYT PB
ERIVEDGE NPS PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201854
Drug Name Drug Status Drug Details
ERLEADA NPS PA; SP; QL
ETHYOL NC
etoposide intravenous solution 100 mg/5ml, 500 mg/25ml
NC
etoposide oral PG
exemestane PG
FARESTON PB
FARYDAK NPS PA; SP; QL
FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML
NPS PA; #; SP
FEMARA NP
FIRMAGON NPS PA; SP
flutamide PG
GILOTRIF NPS PA; SP; QL
GLEEVEC NC SP
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG
NP PA
HEXALEN PB
HYCAMTIN ORAL NPS PA; SP
HYDREA NP
hydroxyurea oral PG
ICLUSIG NPS PA; SP; QL
imatinib mesylate PG PA; SP; QL
IMBRUVICA ORAL CAPSULE 70 MG NPS PA; SP; QL
IMBRUVICA ORAL TABLET NPS PA; SP; QL
INLYTA NPS PA; SP; QL
INTRON A NPS PA; SP
IRESSA NPS PA; QL
irinotecan hcl NC
JAKAFI ORAL TABLET 10 MG NPS PA; SP
JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG
NPS PA; SP; QL
JEVTANA NC
KISQALI FEMARA 200 DOSE NPS PA; SP; QL
KISQALI FEMARA 400 DOSE NPS PA; SP; QL
KISQALI FEMARA 600 DOSE NPS PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201855
Drug Name Drug Status Drug Details
LENVIMA 10 MG DAILY DOSE NPS PA; SP; QL
LENVIMA 14 MG DAILY DOSE NPS PA; SP; QL
LENVIMA 18 MG DAILY DOSE NPS PA; SP; QL
LENVIMA 20 MG DAILY DOSE NPS PA; SP; QL
LENVIMA 24 MG DAILY DOSE NPS PA; SP; QL
LENVIMA 8 MG DAILY DOSE NPS PA; SP; QL
letrozole oral PG
leucovorin calcium oral PG
LEUKERAN PB
leuprolide acetate injection PG PA; SP
LONSURF NPS PA; QL
LUPRON DEPOT (1-MONTH) NPS PA; #; SP
LUPRON DEPOT (3-MONTH) NPS PA; #; SP
LUPRON DEPOT (4-MONTH) NPS PA; #; SP
LUPRON DEPOT (6-MONTH) NPS PA; #; SP
LYSODREN PB
MATULANE PB
megestrol acetate oral tablet PG
MEKINIST NPS PA; SP; QL
MEKTOVI NPS PA; SP; QL
melphalan PG
melphalan hcl NC
mercaptopurine oral PG
methotrexate oral PG
methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml, 50 mg/2ml
PG
MYLERAN PB
NERLYNX NPS PA; SP; QL
NEXAVAR NPS PA; SP; QL
NILANDRON PB
nilutamide PG
NINLARO NPS PA; QL
ODOMZO NPS PA; QL
POMALYST NPS PA; SP; QL
PURIXAN NPS PA; ST; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201856
Drug Name Drug Status Drug Details
RYDAPT NPS PA; SP; QL
SOLTAMOX NP #
SPRYCEL NPS PA; ST; SP; QL
STIVARGA NPS PA; SP; QL
SUTENT PSP PA; SP; QL
SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG
NPS PA; SP
SYNRIBO NC
TABLOID PB
TAFINLAR NPS PA; SP; QL
TAGRISSO NPS PA; SP; QL
tamoxifen citrate oral CE
TARCEVA PSP PA; #; SP; QL
TARGRETIN ORAL NPS PA; SP
TASIGNA NPS PA; ST; SP; QL
TEMODAR ORAL NC
temozolomide PG PA; SP
toposar intravenous solution 100 mg/5ml NC
TORISEL NC #
TRELSTAR MIXJECT NPS PA; #; SP
tretinoin oral PG SP
TYKERB NPS PA; SP
VANTAS NPS PA; SP
VELCADE INJECTION NC #
VORAXAZE NC
VOTRIENT NPS PA; SP; QL
XALKORI NPS PA; SP; QL
XATMEP NP PA
XELODA NC
XTANDI NPS PA; ST; SP; QL
YERVOY NC
YONSA NPS PA; ST; SP; QL
ZANOSAR NC
ZELBORAF NPS PA; SP; QL
ZOLADEX NPS PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201857
Drug Name Drug Status Drug Details
ZOLINZA NPS PA; SP; QL
ZYKADIA NPS PA; SP
ZYTIGA PSP PA; #; SP; QL
*ANTIPARKINSON AGENTS*
amantadine hcl oral PG
AZILECT NP QL
benztropine mesylate oral PG LGC
bromocriptine mesylate oral PG
carbidopa oral PG
carbidopa-levodopa PG
carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg
PG
carbidopa-levodopa-entacapone NP
COMTAN NP
DUOPA ENTERAL NPS PA; ST
ELDEPRYL NP
entacapone PG
GOCOVRI NC
LODOSYN NP
MIRAPEX NP
MIRAPEX ER NP QL
NEUPRO NP #; QL
OSMOLEX ER NC
PARLODEL ORAL CAPSULE NP
pramipexole dihydrochloride PG
pramipexole dihydrochloride er NP QL
rasagiline mesylate oral PG QL
REQUIP NP
REQUIP XL NP QL
ropinirole hcl PG
ropinirole hcl er NP QL
RYTARY NP #
selegiline hcl oral PG
SINEMET NP
SINEMET CR NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201858
Drug Name Drug Status Drug Details
STALEVO 100 NP
STALEVO 125 NP
STALEVO 150 NP
STALEVO 200 NP
STALEVO 50 NP
STALEVO 75 NP
TASMAR ORAL TABLET 100 MG NP
tolcapone NP
trihexyphenidyl hcl oral elixir PG
trihexyphenidyl hcl oral tablet 2 mg PG LGC
trihexyphenidyl hcl oral tablet 5 mg PG
XADAGO NP PA; ST; QL
ZELAPAR NC
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*
ABILIFY ORAL TABLET NP PA; ST; QL
aripiprazole PG QL
chlorpromazine hcl oral PG
clozapine PG QL
CLOZARIL NP PA; ST; QL
COMPRO PG
EQUETRO NP
FANAPT NP ST; QL
FANAPT TITRATION PACK NP ST
FAZACLO NP PA; ST; QL
fluphenazine hcl oral PG
GEODON ORAL NP PA; ST; QL
haloperidol lactate oral PG
haloperidol oral PG
INVEGA NP PA; ST; QL
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 80 MG
PB ST; #; QL
LATUDA ORAL TABLET 60 MG PB ST; #
lithium PG
lithium carbonate er PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201859
Drug Name Drug Status Drug Details
lithium carbonate oral PG
LITHOBID NP
loxapine succinate oral PG
NUPLAZID NPS PA; SP; QL
olanzapine oral PG QL
paliperidone er NP QL
perphenazine oral PG
prochlorperazine PG
prochlorperazine maleate oral PG
quetiapine fumarate PG QL
quetiapine fumarate er NP QL
REXULTI NP PA; ST; QL
RISPERDAL ORAL SOLUTION NP PA; ST
RISPERDAL ORAL TABLET NP PA; ST; QL
RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG
PG QL
risperidone oral solution PG
risperidone oral tablet PG QL
risperidone oral tablet dispersible 0.25 mg PG
risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
PG QL
SAPHRIS NP PA; ST; QL
SEROQUEL NP PA; ST; QL
SEROQUEL XR NP PA; ST; QL
thioridazine hcl oral PG
thiothixene oral PG
trifluoperazine hcl oral PG
VERSACLOZ NP PA; ST
VRAYLAR ORAL CAPSULE NP PA; ST; QL
VRAYLAR ORAL CAPSULE THERAPY PACK
NP PA; ST
ziprasidone hcl PG QL
ZYPREXA ORAL NP PA; ST; QL
ZYPREXA ZYDIS NP PA; ST; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201860
Drug Name Drug Status Drug Details
*ANTIRETROVIRALS ADJUVANTS***
TYBOST NP QL
*ANTIVIRALS*
abacavir sulfate PG
abacavir sulfate-lamivudine PG
abacavir-lamivudine-zidovudine PG
acyclovir oral capsule PG LGC
acyclovir oral suspension PG
acyclovir oral tablet 400 mg PG LGC
acyclovir oral tablet 800 mg PG
adefovir dipivoxil PG SP; QL
APTIVUS PB
atazanavir sulfate PG QL
ATRIPLA PB QL
BARACLUDE ORAL SOLUTION NPS SP
BARACLUDE ORAL TABLET NPS SP; QL
BIKTARVY NP PA
cidofovir intravenous PG SP
CIMDUO NP QL
COMBIVIR NP
COMPLERA PB QL
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
NP
CYTOVENE NPS SP
DAKLINZA NPS PA; ST; SP; QL
DESCOVY NP QL
didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg
PG
EDURANT NP QL
efavirenz PG
EMTRIVA ORAL CAPSULE PB QL
EMTRIVA ORAL SOLUTION PB
entecavir PG SP; QL
EPIVIR NP
EPIVIR HBV ORAL SOLUTION NP #
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201861
Drug Name Drug Status Drug Details
EPIVIR HBV ORAL TABLET NP
EPZICOM NP
EVOTAZ NP
famciclovir oral PG QL
FLUMADINE NP
fosamprenavir calcium PG
FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED
NPS PA; #; SP
ganciclovir sodium intravenous solution reconstituted
PG SP
GENVOYA NP PA; QL
HEPSERA NPS SP; QL
INTELENCE NP QL
INVIRASE NP
ISENTRESS HD PB QL
ISENTRESS ORAL PACKET PB
ISENTRESS ORAL TABLET PB QL
ISENTRESS ORAL TABLET CHEWABLE PB QL
JULUCA NP ST; QL
KALETRA ORAL SOLUTION NP
KALETRA ORAL TABLET PB #
lamivudine PG
lamivudine-zidovudine PG
LEXIVA PB #
lopinavir-ritonavir PG
MODERIBA 1200 DOSE PACK NPS SP
MODERIBA 800 DOSE PACK NPS SP
moderiba oral tablet 200 mg PG SP
nevirapine er PG QL
nevirapine oral tablet PG
NORVIR ORAL CAPSULE PB #
NORVIR ORAL PACKET PB
NORVIR ORAL SOLUTION PB #
NORVIR ORAL TABLET NP #
ODEFSEY NP QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201862
Drug Name Drug Status Drug Details
oseltamivir phosphate oral PG QL
PEGASYS PROCLICK NPS PA; SP
PEGASYS SUBCUTANEOUS SOLUTION NPS PA; SP
PREVYMIS ORAL NPS PA; SP; QL
PREZCOBIX PB
PREZISTA ORAL SUSPENSION PB QL
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
PB QL
REBETOL NPS SP
RELENZA DISKHALER NP QL
RESCRIPTOR NP
RETROVIR INTRAVENOUS NC
RETROVIR ORAL CAPSULE NP
RETROVIR ORAL SYRUP NP
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
NP QL
REYATAZ ORAL PACKET PB #
ribasphere PG SP
ribasphere ribapak oral tablet 400 mg, 600 mg PG SP
ribavirin oral capsule PG SP
ribavirin oral tablet 200 mg PG SP
rimantadine hcl PG
ritonavir PG
SELZENTRY ORAL SOLUTION NP QL
SELZENTRY ORAL TABLET 150 MG, 25 MG, 75 MG
NP QL
SELZENTRY ORAL TABLET 300 MG NP
SITAVIG NC
SOVALDI PSP PA; SP; QL
stavudine oral capsule PG
STRIBILD NP PA; QL
SUSTIVA NP
SYMFI NP
SYMFI LO NP
TAMIFLU ORAL CAPSULE NP QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201863
Drug Name Drug Status Drug Details
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML
NP QL
tenofovir disoproxil fumarate PG QL
TIVICAY PB QL
TRIUMEQ PB QL
TRIZIVIR NP
TRUVADA PB
valacyclovir hcl oral PG
VALCYTE NPS PA; SP; QL
valganciclovir hcl PG PA; SP; QL
VALTREX NP ST
VEMLIDY NPS PA; ST; SP; QL
VIDEX PB
VIDEX EC NP
VIRACEPT ORAL TABLET NP
VIRAMUNE NP
VIRAMUNE XR NP QL
VIREAD ORAL POWDER PB #
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
PB #; QL
VIREAD ORAL TABLET 300 MG NP QL
ZERIT NP
ZIAGEN NP
zidovudine PG
ZOVIRAX ORAL NP
*ASSORTED CLASSES*
ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG
NPS #; SP; QL
ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG
NPS #; SP
ATGAM NPS SP
azathioprine oral PG
BENLYSTA INTRAVENOUS NPS PA; ST; SP
BENLYSTA SUBCUTANEOUS NPS PA; ST; SP; QL
CELLCEPT NPS SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201864
Drug Name Drug Status Drug Details
CUPRIMINE ORAL CAPSULE 250 MG NPS PA; ST; #
cyclosporine intravenous PG SP
cyclosporine modified PG
cyclosporine oral capsule PG
DEPEN TITRATABS PSP PA
ENVARSUS XR NPS
gengraf oral capsule 100 mg, 25 mg PG
gengraf oral solution PG
HYLAFEM NC
IMURAN NP
KIONEX ORAL SUSPENSION PG
morcin NC
mycophenolate mofetil PG SP
mycophenolate sodium PG SP
MYFORTIC NPS SP
NEORAL NPS SP
NULOJIX NPS SP
PROGRAF NPS SP
RAPAMUNE NPS SP
REVLIMID NPS PA; SP; QL
SANDIMMUNE NPS SP
SIMULECT NPS SP
sirolimus oral PG SP
sodium polystyrene sulfonate oral PG
SPS PG
SYPRINE NPS PA; #
tacrolimus oral PG SP
THALOMID NPS PA; #; SP
THYMOGLOBULIN NPS SP
TRAUMEEL EXTERNAL OINTMENT NC
trientine hcl PSP PA; SP
VELTASSA NP PA; QL
XIAFLEX PSP SP
ZORTRESS NPS #; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201865
Drug Name Drug Status Drug Details
*ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES***
DUPIXENT NPS PA; SP; QL
*BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB***
BYVALSON NP PA; ST; QL
*BETA BLOCKERS*
acebutolol hcl oral PG
atenolol oral PG LGC
BETAPACE AF NP
BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG
NP
betaxolol hcl oral NP
bisoprolol fumarate PG
BYSTOLIC NP PA; ST; QL
carvedilol PG LGC
carvedilol phosphate er NP QL
COREG NP
COREG CR NP QL
CORGARD NP
HEMANGEOL NP PA
INDERAL LA NC
INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 80 MG
NP QL
INNOPRAN XL NP QL
KAPSPARGO SPRINKLE NP
labetalol hcl oral PG
metoprolol succinate er PG QL
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
PG LGC
metoprolol tartrate oral tablet 37.5 mg, 75 mg PG
nadolol oral tablet 20 mg, 40 mg, 80 mg PG
pindolol PG
propranolol hcl er PG
propranolol hcl oral solution PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201866
Drug Name Drug Status Drug Details
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg
PG LGC
propranolol hcl oral tablet 60 mg PG
sotalol hcl (af) oral tablet 120 mg PG LGC
sotalol hcl (af) oral tablet 160 mg, 80 mg PG
sotalol hcl oral tablet 120 mg, 80 mg PG LGC
sotalol hcl oral tablet 160 mg, 240 mg PG
SOTYLIZE NP
TENORMIN NP
timolol maleate oral PG
TOPROL XL NP QL
*BILE ACID SYNTHESIS DISORDER AGENTS***
CHOLBAM NPS PA
*BIOLOGICALS MISC*
ADAGEN NPS SP
mixed vespid venom protein injection solution reconstituted
NC
VENOMIL MIXED VESPID VENOM NC
*CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG***
AIMOVIG NP PA; ST; QL
AIMOVIG 140 DOSE NP PA; ST; QL
*CALCIUM CHANNEL BLOCKERS*
ADALAT CC NP QL
AFEDITAB CR PG QL
amlodipine besylate oral PG LGC
CALAN ORAL TABLET 120 MG, 80 MG NP
CALAN SR NP
CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG
NC
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG
NP QL
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 420 MG
NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201867
Drug Name Drug Status Drug Details
CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG
NP
CARTIA XT PG QL
diltiazem cd PG QL
diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg
PG QL
diltiazem hcl er coated beads oral capsule extended release 24 hour
PG QL
diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg
NP QL
diltiazem hcl er coated beads oral tablet extended release 24 hour 420 mg
NP
diltiazem hcl er oral capsule extended release 12 hour
PG
diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg
PG
diltiazem hcl er oral capsule extended release 24 hour 240 mg
PG QL
diltiazem hcl oral PG LGC
dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg
PG
dilt-xr oral capsule extended release 24 hour 240 mg
PG QL
felodipine er PG QL
isradipine PG
MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG
NP QL
MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 420 MG
NP
nicardipine hcl oral PG
NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG
PG QL
nifedipine er PG QL
nifedipine er osmotic release PG QL
nifedipine oral PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201868
Drug Name Drug Status Drug Details
nimodipine oral PG
nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
PG QL
nisoldipine er oral tablet extended release 24 hour 25.5 mg
PG
NORVASC NP
NYMALIZE ORAL SOLUTION 60 MG/20ML
NP QL
PROCARDIA NP
PROCARDIA XL NP QL
SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG, 34 MG, 8.5 MG
NP QL
TAZTIA XT PG QL
TIAZAC NP QL
verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg
PG QL
verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg
PG
verapamil hcl er oral tablet extended release 120 mg
PG LGC
verapamil hcl er oral tablet extended release 180 mg, 240 mg
PG
verapamil hcl oral PG LGC
VERELAN NP
VERELAN PM NP QL
*CARDIOTONICS*
DIGITEK PG
DIGOX PG
digoxin oral PG
LANOXIN ORAL NP
*CARDIOVASCULAR AGENTS - MISC.*
ADCIRCA NPS PA; ST; #; SP; QL
ADEMPAS NPS PA; ST; SP; QL
amlodipine-atorvastatin NC
BIDIL NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201869
Drug Name Drug Status Drug Details
CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG
NC
CIALIS ORAL TABLET 2.5 MG, 5 MG PB PA; N1; #; QL
epoprostenol sodium PG PA; SP
FLOLAN NPS PA; SP
LETAIRIS PSP PA; #; SP
OPSUMIT PSP PA; SP; QL
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG
NPS PA; ST; SP
ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG
NPS PA; SP
REMODULIN NPS PA; #; SP
REVATIO INTRAVENOUS NPS PA; ST; SP
REVATIO ORAL SUSPENSION RECONSTITUTED
NPS PA; ST; #; SP
REVATIO ORAL TABLET NPS PA; ST; SP; QL
sildenafil citrate oral tablet 20 mg PG PA; SP; QL
TRACLEER ORAL TABLET PSP PA; #; SP
TRACLEER ORAL TABLET SOLUBLE PSP PA; SP
TYVASO NPS PA; ST; SP; QL
TYVASO REFILL NPS PA; ST; SP; QL
TYVASO STARTER NPS PA; ST; SP; QL
VELETRI NPS PA; SP
VENTAVIS NPS PA; SP
*CEPHALOSPORINS*
cefaclor PG
cefaclor er PG
cefadroxil PG
cefazolin sodium injection NC
cefazolin sodium intravenous solution reconstituted
NC
cefdinir PG
cefditoren pivoxil NP
cefepime hcl NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201870
Drug Name Drug Status Drug Details
cefepime-dextrose NC
cefixime NP
cefotaxime sodium injection solution reconstituted 1 gm, 500 mg
NC
cefotetan disodium NC
cefoxitin sodium NC
cefoxitin sodium-dextrose NC
cefpodoxime proxetil PG
cefprozil PG
ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm
NC
ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg
NC
ceftriaxone sodium intravenous NC
cefuroxime axetil oral tablet PG
cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg
NC
cefuroxime sodium intravenous solution reconstituted 1.5 gm
NC
cephalexin oral capsule 250 mg, 500 mg PG LGC
cephalexin oral capsule 750 mg PG
cephalexin oral suspension reconstituted PG
cephalexin oral tablet PG
DAXBIA NC
KEFLEX NP
MAXIPIME INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM
NC
MAXIPIME INTRAVENOUS NC
ROCEPHIN INJECTION SOLUTION RECONSTITUTED 1 GM
NC
SPECTRACEF ORAL TABLET 400 MG NP
SUPRAX ORAL CAPSULE NP #
SUPRAX ORAL SUSPENSION RECONSTITUTED
NP
SUPRAX ORAL TABLET CHEWABLE NP #
tazicef injection NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201871
Drug Name Drug Status Drug Details
tazicef intravenous solution reconstituted NC
TEFLARO NC
*CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS***
TRULANCE PB QL
*CONTRACEPTIVES*
ALTAVERA CE
alyacen 1/35 CE
alyacen 7/7/7 CE
AMETHIA CE
AMETHIA LO CE
APRI CE
ARANELLE PG
AVIANE CE
AZURETTE PG
BALCOLTRA NP
BALZIVA PG
BEYAZ NP
briellyn CE
CAMRESE CE
CAMRESE LO CE
CAZIANT CE
CHATEAL CE
CRYSELLE-28 PG
CYCLAFEM 1/35 PG
DASETTA 1/35 PG
DASETTA 7/7/7 PG
DAYSEE CE
DELYLA CE
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML
NP
desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg
CE
drospirenone-ethinyl estradiol oral tablet 3-0.02 mg
PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201872
Drug Name Drug Status Drug Details
drospirenone-ethinyl estradiol oral tablet 3-0.03 mg
CE
ELINEST CE
ELLA CE #
EMOQUETTE CE
ENPRESSE-28 PG
ENSKYCE ORAL TABLET 0.15-30 MG-MCG
CE
ERRIN PG
ESTARYLLA PG
ESTROSTEP FE NP
FALMINA CE
FAYOSIM CE
GENERESS FE NP
GIANVI PG
GILDESS FE 1.5/30 PG
GILDESS FE 1/20 PG
HEATHER CE
INTROVALE CE
ISIBLOOM CE
JENCYCLA PG
JOLESSA CE
JOLIVETTE PG
JUNEL 1.5/30 PG
JUNEL 1/20 PG
JUNEL FE 1.5/30 PG
JUNEL FE 1/20 PG
KARIVA PG
KELNOR 1/35 CE
KURVELO PG
KYLEENA CE
LARIN 1.5/30 CE
LARIN 1/20 CE
LARIN FE 1.5/30 CE
LARIN FE 1/20 CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201873
Drug Name Drug Status Drug Details
LEENA CE
LESSINA CE
LEVONEST CE
levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 mg
CE
levonorgestrel oral tablet 1.5 mg CE
levonorgestrel-ethinyl estrad CE
LEVORA 0.15/30 (28) PG
LO LOESTRIN FE NP
LOESTRIN 1.5/30 (21) NP
LOESTRIN 1/20 (21) NP
LORYNA PG
LOSEASONIQUE NP
LOW-OGESTREL PG
LUTERA CE
LYZA PG
marlissa CE
medroxyprogesterone acetate intramuscular suspension
CE
MIBELAS 24 FE CE
MICROGESTIN 1.5/30 PG
MICROGESTIN 1/20 PG
MICROGESTIN FE 1.5/30 PG
MICROGESTIN FE 1/20 PG
MINASTRIN 24 FE NP
MIRCETTE NP
MIRENA (52 MG) CE #
MONO-LINYAH PG
MONONESSA PG
NATAZIA NP
NECON 0.5/35 (28) PG
NECON 1/35 (28) CE
NEXPLANON CE
NEXT CHOICE ONE DOSE CE
NIKKI PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201874
Drug Name Drug Status Drug Details
NORA-BE PG
norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg
CE
norethin ace-eth estrad-fe oral tablet chewable CE
norethindrone oral CE
norethin-eth estradiol-fe oral tablet chewable0.8-25 mg-mcg
CE
norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg
CE
norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-35 mcg
CE
NORTREL 0.5/35 (28) PG
NORTREL 1/35 (21) PG
NORTREL 1/35 (28) PG
NORTREL 7/7/7 PG
NUVARING CE #
OCELLA PG
OGESTREL PG
OPTION 2 CE
ORSYTHIA CE
ORTHO MICRONOR NP
ORTHO TRI-CYCLEN (28) NP
ORTHO TRI-CYCLEN LO NP
ORTHO-CYCLEN (28) NP
ORTHO-NOVUM 1/35 (28) NP
ORTHO-NOVUM 7/7/7 (28) NP
PARAGARD INTRAUTERINE COPPER NP
PHILITH PG
PIMTREA CE
PIRMELLA 1/35 CE
PLAN B ONE-STEP PG
PORTIA-28 PG
PREVIFEM PG
QUARTETTE NP
QUASENSE CE
RAJANI CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201875
Drug Name Drug Status Drug Details
RECLIPSEN PG
RIVELSA CE
SAFYRAL NP #
SEASONIQUE NP
SKYLA CE
SPRINTEC 28 PG
SRONYX CE
SYEDA PG
TAKE ACTION CE
TAYTULLA NP
TILIA FE CE
TRI FEMYNOR CE
TRI-ESTARYLLA PG
TRI-LEGEST FE PG
TRI-LINYAH PG
TRI-MILI CE
TRINESSA (28) PG
TRI-NORINYL (28) NP
TRI-PREVIFEM PG
TRI-SPRINTEC PG
TRIVORA (28) PG
TULANA CE
TYDEMY CE
VELIVET PG
VESTURA PG
VYFEMLA CE
WERA CE
WYMZYA FE CE
XULANE CE
YASMIN 28 NP
YAZ NP
ZARAH PG
ZENCHENT PG
ZOVIA 1/35E (28) PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201876
Drug Name Drug Status Drug Details
*CORTICOSTEROIDS*
budesonide er oral tablet extended release 24 hour
PG QL
budesonide oral PG
CORTEF NP
cortisone acetate oral PG
DEXAMETHASONE INTENSOL NP
dexamethasone oral elixir PG
dexamethasone oral solution PG
dexamethasone oral tablet PG
EMFLAZA NC
ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES
NP
fludrocortisone acetate oral PG
hydrocortisone oral PG
MEDROL NP
methylprednisolone oral PG
MILLIPRED NP
ORAPRED ODT NP
prednisolone oral solution PG
prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml
NP
prednisolone sodium phosphate oral solution 25 mg/5ml, 6.7 (5 base) mg/5ml
PG
prednisolone sodium phosphate oral tablet dispersible
NP
PREDNISONE INTENSOL NP
prednisone oral solution PG
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg
PG LGC
prednisone oral tablet 50 mg PG
prednisone oral tablet therapy pack PG
RAYOS NC
TAPERDEX 12-DAY NC
TAPERDEX 6-DAY NC
UCERIS ORAL NP ST; #; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201877
Drug Name Drug Status Drug Details
VERIPRED 20 NP
*COUGH/COLD/ALLERGY*
acetylcysteine inhalation PG
ALAVERT ALLERGY/SINUS PG Select OTC
ALLEGRA-D ALLERGY & CONGESTION PG Select OTC
benzonatate PG
cetirizine-pseudoephedrine er PG Select OTC
CLARINEX-D 12 HOUR NP QL
CLARITIN-D 12 HOUR PG Select OTC
CLARITIN-D 24 HOUR PG Select OTC
fexofenadine-pseudoephed er oral tablet extended release 24 hour
PG Select OTC
guaifenesin ac NC
guaifenesin-codeine oral syrup NC
hydrocod polst-cpm polst er oral suspension extended release
NP QL
hydrocodone-homatropine PG
loratadine-d 12hr PG Select OTC
loratadine-d 24hr PG Select OTC
NEBUSAL INHALATION NEBULIZATION SOLUTION 3 %
PG
promethazine vc PG
promethazine vc/codeine PG
promethazine-dm PG
pseudoeph-chlorphen-hydrocod NP
SEMPREX-D NP
sodium chloride inhalation nebulization solution10 %, 3 %
PG
SSKI PB
TESSALON PERLES NP
TUSNEL C NC
TUSSICAPS NP QL
TUSSIONEX PENNKINETIC ER ORAL SUSPENSION EXTENDED RELEASE
NP QL
ZYRTEC-D ALLERGY & CONGESTION PG Select OTC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201878
Drug Name Drug Status Drug Details
*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***
IBRANCE NPS PA; SP; QL
KISQALI 200 DOSE NPS PA; SP; QL
KISQALI 400 DOSE NPS PA; SP; QL
KISQALI 600 DOSE NPS PA; SP; QL
VERZENIO NPS PA; SP; QL
*CYSTIC FIBROSIS AGENT - COMBINATIONS***
ORKAMBI ORAL TABLET NPS PA; QL
SYMDEKO NPS PA; SP; QL
*DERMATOLOGICALS*
ABREVA PG Select OTC
ABSORICA NC
ACANYA NC #
acitretin PG QL
acyclovir external NP
ACZONE NP ST; QL
adapalene external cream NP PA; AL
adapalene external gel 0.1 % NC
adapalene external gel 0.3 % NP PA; AL
adapalene external lotion NP PA; AL
adapalene-benzoyl peroxide PG PA; AL
AKTIPAK NP
ALA-QUIN NC
alclometasone dipropionate PG
ALCORTIN A NC
ALDARA NP QL
ALTABAX NP
amcinonide NP
AMELUZ NP
AMNESTEEM NP PA; QL
APEXICON E NP
ASTERO NC
ATRALIN NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201879
Drug Name Drug Status Drug Details
AVAR CLEANSER NC
AVAR LS CLEANSER NC
avar-e emollient NC
avar-e green NC
AVAR-E LS NC
avita PG PA; AL
AZELEX NP
BACTROBAN EXTERNAL CREAM NP QL
bensal hp NC
BENZACLIN NC
BENZACLIN WITH PUMP NC
BENZAMYCIN NP
benzoyl peroxide-erythromycin PG
betamethasone dipropionate aug external cream PG
betamethasone dipropionate aug external gel PG QL
betamethasone dipropionate aug external lotion PG QL
betamethasone dipropionate aug external ointment
PG QL
betamethasone valerate external NP
bp 10-1 NC
calcipotriene external cream NP ST
calcipotriene external ointment NP ST
calcipotriene external solution NP
calcipotriene-betameth diprop NC
calcitrene NP ST
calcitriol external NP
CAPEX NC
CARAC NC
CEM-UREA NC
CENTANY NP QL
CICLODAN EXTERNAL SOLUTION PG
CICLODAN SOLUTION NC
ciclopirox external gel NP
ciclopirox external shampoo NP
ciclopirox external solution PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201880
Drug Name Drug Status Drug Details
ciclopirox olamine external cream PG
ciclopirox treatment NC
claravis NP PA; QL
CLEOCIN-T NP
CLINDACIN ETZ EXTERNAL KIT NC
CLINDACIN PAC NC
CLINDAGEL NP
clindamycin phos-benzoyl perox NC
clindamycin phosphate external NP
clindamycin-tretinoin NP PA; AL
clobetasol propionate e NP QL
clobetasol propionate emulsion NP QL
clobetasol propionate external NP QL
CLOBEX NP QL
CLOBEX SPRAY NP QL
clocortolone pivalate NP
clodan external shampoo NP QL
CLODERM NP
CLODERM PUMP NP
clotrimazole-betamethasone external cream PG
coal tar external solution PG
CONDYLOX EXTERNAL GEL NP
CORDRAN EXTERNAL CREAM NP QL
CORDRAN EXTERNAL LOTION NP QL
CORDRAN EXTERNAL OINTMENT NP QL
CORDRAN EXTERNAL TAPE NP #; QL
CORTISPORIN EXTERNAL OINTMENT PB
COSENTYX NPS PA; ST; SP
COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML
NPS PA; ST; SP
CROTAN PG
CUTIVATE EXTERNAL LOTION NP
dapsone external PG QL
DENAVIR NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201881
Drug Name Drug Status Drug Details
DERMA-SMOOTHE/FS BODY PB
DERMA-SMOOTHE/FS SCALP PB
DESONATE NP #
desonide external NP
DESOWEN EXTERNAL CREAM NP
DESOWEN EXTERNAL LOTION NP
desoximetasone external cream NP
desoximetasone external gel NP
desoximetasone external liquid NC
desoximetasone external ointment NP
diclofenac sodium transdermal gel 1 % PG QL
diclofenac sodium transdermal gel 3 % NC
diclofenac sodium transdermal solution NC
DICLOFEX DC NC
DIFFERIN EXTERNAL CREAM NP PA; AL
DIFFERIN EXTERNAL GEL 0.1 % PG PA; Select OTC; AL
DIFFERIN EXTERNAL GEL 0.3 % NP PA; ST; AL
DIFFERIN EXTERNAL LOTION NP PA; ST; AL
diflorasone diacetate external NP
DIPROLENE NP QL
DIPROLENE AF NP
DOVONEX EXTERNAL CREAM NP ST
doxepin hcl external NP QL
doxycycline NC
DUAC NC
econazole nitrate external NP QL
ECOZA NC
EFUDEX EXTERNAL CREAM NC
ELIDEL NP PA; ST; #
ELIMITE NP
ELOCON EXTERNAL CREAM NP
ELOCON EXTERNAL OINTMENT NP
ENSTILAR NP QL
EPIDUO PB PA; AL
EPIDUO FORTE PB PA; #; AL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201882
Drug Name Drug Status Drug Details
ERTACZO NC
ery PG
erythromycin external pad PG
erythromycin external solution PG
EURAX NP
EVOCLIN NP
EXELDERM NC
EXTINA NC
FABIOR NP PA; ST; AL
FINACEA EXTERNAL FOAM NP
FINACEA EXTERNAL GEL NP #
FLECTOR NC #
fluocinolone acetonide body PG
fluocinolone acetonide external cream NP
fluocinolone acetonide external ointment NP
fluocinolone acetonide scalp PG
fluocinonide external cream NP ST; QL
fluocinonide external gel NP QL
fluocinonide external ointment NP QL
fluocinonide external solution PG QL
FLUOROPLEX NC
fluorouracil external cream 0.5 % NC
fluorouracil external cream 5 % PG
fluorouracil external solution PG
flurandrenolide NP QL
fluticasone propionate external cream NP
fluticasone propionate external lotion NP
fluticasone propionate external ointment PG
gentamicin sulfate external PG
GORDONS UREA EXTERNAL OINTMENT 22 %
NC
halobetasol propionate NP QL
HALOG NP
hydrocortisone ace-pramoxine external cream2.5-1 %
NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201883
Drug Name Drug Status Drug Details
hydrocortisone acetate NC
hydrocortisone butyr lipo base PG
hydrocortisone butyrate external cream PG
hydrocortisone butyrate external lotion NP
hydrocortisone butyrate external ointment PG
hydrocortisone butyrate external solution PG
hydrocortisone external cream 2.5 % PG
hydrocortisone external lotion 2.5 % PG
hydrocortisone external ointment 2.5 % PG
hydrocortisone valerate PG
imiquimod external PG QL
IMPOYZ NC
JUBLIA NP PA; ST
KENALOG EXTERNAL NP
KERALYT EXTERNAL GEL 6 % NP
ketoconazole external foam NC
KLARON NP
KLOFENSAID II NC
lactic acid external lotion NP
LDO PLUS NC
LEVULAN KERASTICK NP QL
lidocaine external ointment NP PA; QL
lidocaine external patch 5 % NP PA; ST; QL
lidocaine hcl external solution PG
lidocaine pak NP PA; QL
lidocaine-prilocaine external cream PG PA; QL
lidocaine-tetracaine PG QL
LIDODERM NP PA; ST; QL
lindane external shampoo PB
LOCOID EXTERNAL CREAM NP
LOCOID EXTERNAL LOTION NC #
LOCOID LIPOCREAM NP
LOPROX EXTERNAL KIT 0.77 % NC
LOPROX EXTERNAL SHAMPOO NP
LOTRISONE EXTERNAL CREAM NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201884
Drug Name Drug Status Drug Details
luliconazole NC
LUXIQ NP
LUZU NC
malathion external PG
methoxsalen rapid PG
METROCREAM NP
METROGEL EXTERNAL GEL NP
METROLOTION NP
metronidazole external cream PG
metronidazole external gel 0.75 % PG
metronidazole external gel 1 % NP
metronidazole external lotion PG
MICORT-HC NC
MIRVASO NC
mometasone furoate external cream NP
mometasone furoate external ointment NP
mometasone furoate external solution PG
mupirocin calcium PG QL
mupirocin external PG QL
myorisan oral capsule 10 mg, 20 mg, 40 mg NP PA; QL
MYORISAN ORAL CAPSULE 30 MG NP PA; QL
naftifine hcl external cream 1 % NP
naftifine hcl external cream 2 % NC
NAFTIN EXTERNAL CREAM 2 % NC
NAFTIN EXTERNAL GEL 1 % NC
NAFTIN EXTERNAL GEL 2 % NC #
napro external NC
NATROBA NP
NEO-SYNALAR EXTERNAL CREAM NP
NEUAC EXTERNAL GEL NC
NOLIX EXTERNAL LOTION NP QL
NORITATE NP
NUCORT NC
nystatin external cream PG
nystatin external ointment PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201885
Drug Name Drug Status Drug Details
nystatin-triamcinolone PG
OLUX NP QL
OLUX-E NP QL
ONEXTON NC #
ORACEA NC
OVACE WASH NP
OVIDE NP
oxiconazole nitrate NC
OXISTAT NC
OXSORALEN ULTRA NP
PANDEL NP
PANRETIN PB
PENLAC NP PA; ST
PENNSAID TRANSDERMAL SOLUTION 2 %
NC
permethrin external cream PG
PICATO PB QL
PLEXION NC
PLEXION CLEANSER EXTERNAL LIQUID
NC
PLEXION CLEANSING CLOTH EXTERNAL PAD
NC
podocon NP
podofilox external PG
PRAMOSONE EXTERNAL CREAM 1-1 % NP
PRAMOSONE EXTERNAL LOTION NP
prednicarbate NP
PROTOPIC NP PA; ST
PRUDOXIN NP QL
psorcon NP
REGRANEX NP PA; QL
RETIN-A NP PA; ST; AL
RETIN-A MICRO NP PA; ST; AL
RETIN-A MICRO PUMP NP PA; ST; AL
RHOFADE NP QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201886
Drug Name Drug Status Drug Details
ROSADAN EXTERNAL CREAM PG
ROSADAN EXTERNAL GEL NP
ROSADAN EXTERNAL KIT NC
ROSANIL CLEANSER NC
rynoderm NC
SALEX EXTERNAL SHAMPOO NP
salicylic acid external cream NP
salicylic acid external gel NP
salicylic acid external liquid NP
salicylic acid external lotion NP
salicylic acid external shampoo NP
SANTYL NP QL
seb-prev wash NP
selenium sulfide external lotion PG
selenium sulfide external shampoo 2.25 % NC
SELRX NC
SELSUN BLUE MEDICATED NC
SERNIVO NP
SILIQ NPS PA; ST; SP; QL
SILVADENE NP
silver nitrate external NP
silver sulfadiazine external PG
sodium sulfacetamide external shampoo NP
SOOLANTRA NP ST
SORIATANE ORAL CAPSULE 10 MG, 25 MG
NP QL
SORILUX NC
spinosad PG
sss 10-5 NC
STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PSP PA; ST; SP; QL
sulfacetamide sodium external gel NP
sulfacetamide sodium external liquid NP
sulfacetamide sodium-sulfur external cream NC
sulfacetamide sodium-sulfur external emulsion NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201887
Drug Name Drug Status Drug Details
sulfacetamide sodium-sulfur external liquid 10-2 %, 9.8-4.8 %
NC
sulfacetamide sodium-sulfur external lotion NC
sulfacetamide sodium-sulfur external pad 10-4 % NC
sulfacetamide sodium-sulfur external suspension NC
sulfacetamide sod-sulfur wash external kit NC
sulfacetamide-sulfur in urea external emulsion PG
sulfacleanse 8/4 NC
SULFAMYLON NP
SUMADAN NC
SUMADAN XLT NC
SUMAXIN NC
SUMAXIN CP NC
SUMAXIN TS NC
SYNALAR NP
SYNALAR (CREAM) NC
SYNALAR (OINTMENT) NC
SYNALAR TS NC
SYNERA NP QL
TACLONEX EXTERNAL OINTMENT NC
TACLONEX EXTERNAL SUSPENSION NP QL
tacrolimus external NP PA; ST
TALTZ NPS PA; ST; SP
TARGRETIN EXTERNAL PSP SP
tazarotene external PG PA; AL
TAZORAC NP PA; ST; AL
TEMOVATE EXTERNAL CREAM NP QL
TEMOVATE EXTERNAL OINTMENT NP QL
TOLAK NC #
TOPICORT EXTERNAL CREAM NP
TOPICORT EXTERNAL GEL NP
TOPICORT EXTERNAL OINTMENT NP
TOPICORT SPRAY NC
TREMFYA PSP PA; ST; SP; QL
tretinoin external cream PG PA; AL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201888
Drug Name Drug Status Drug Details
tretinoin external gel 0.01 %, 0.025 % PG PA; AL
tretinoin external gel 0.05 % NP PA
tretinoin microsphere PG PA; AL
tretinoin microsphere pump PG PA; AL
triamcinolone acetonide external aerosol solution
PG
triamcinolone acetonide external cream PG LGC
triamcinolone acetonide external ointment PG LGC
TRIDERM EXTERNAL CREAM PG
TRIDESILON NP
ULESFIA NP QL
ULTRAVATE NP QL
ULTRAVATE X (CREAM) NC
ULTRAVATE X (OINTMENT) NC
UTOPIC NC
VALCHLOR NPS PA; SP; QL
VANOS NC
VANOXIDE-HC NP
VECTICAL NP
VELTIN NP PA; ST; AL
VENIPUNCTURE CPI NC
VERDESO NC
VEREGEN NP
VOLTAREN TRANSDERMAL PB QL
XELITRAL NC
XERESE NP
XOLEGEL NC
zenatane oral capsule 10 mg, 20 mg, 40 mg NP PA; QL
ZENATANE ORAL CAPSULE 30 MG NP PA; QL
ZIANA NP PA; ST; AL
ZONALON NP QL
ZOVIRAX EXTERNAL CREAM NP
ZOVIRAX EXTERNAL OINTMENT NC
ZYCLARA NC #
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201889
Drug Name Drug Status Drug Details
ZYCLARA PUMP EXTERNAL CREAM 2.5 %
NC
ZYCLARA PUMP EXTERNAL CREAM 3.75 %
NC #
*DIAGNOSTIC PRODUCTS*
ACCU-CHEK AVIVA PLUS IN VITRO NC
ACCU-CHEK COMPACT PLUS NC
ACCU-CHEK SMARTVIEW NC
ACCUTREND GLUCOSE NC
ADVANCE INTUITION TEST NC
ADVANCE MICRO-DRAW TEST NC
ADVOCATE REDI-CODE IN VITRO NC
ADVOCATE REDI-CODE+ TEST NC
ADVOCATE TEST NC
AGAMATRIX AMP TEST NC
AGAMATRIX JAZZ TEST NC
AGAMATRIX KEYNOTE TEST NC
AGAMATRIX PRESTO TEST NC
ASSURE 3 TEST NC
ASSURE 4 TEST NC
ASSURE II NC
ASSURE II CHECK NC
ASSURE PLATINUM NC
ASSURE PRISM MULTI TEST NC
ASSURE PRO TEST NC
BAYER BREEZE 2 TEST NC
BAYER CONTOUR TEST NC
BIOSCANNER GLUCOSE TEST NC
blood glucose test NC
CARESENS N GLUCOSE TEST NC
CLEVER CHEK AUTO-CODE TEST NC
CLEVER CHEK AUTO-CODE VOICE IN VITRO
NC
CLEVER CHEK TEST NC
CLEVER CHOICE AUTO-CODE TEST NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201890
Drug Name Drug Status Drug Details
CLEVER CHOICE MICRO TEST NC
COOL BLOOD GLUCOSE TEST STRIPS NC
CVS ADVANCED GLUCOSE TEST NC
diatrue plus test NC
DUO-CARE TEST NC
easy plus blood glucose test NC
EASY STEP TEST NC
easy talk blood glucose test NC
EASY TOUCH TEST NC
easy trak blood glucose test NC
EASYGLUCO IN VITRO NC
EASYGLUCO PLUS IN VITRO NC
EASYMAX 15 TEST NC
EASYMAX TEST NC
easyplus blood glucose test NC
EASYPRO BLOOD GLUCOSE TEST NC
EASYPRO PLUS IN VITRO NC
element compact test NC
ELEMENT TEST NC
EMBRACE BLOOD GLUCOSE TEST NC
EMBRACE EVO BLOOD GLUCOSE TEST NC
EMBRACE PRO GLUCOSE TEST NC
EVENCARE BLOOD GLUCOSE TEST NC
EVENCARE G2 TEST NC
EVENCARE G3 TEST NC
EVENCARE MINI GLUCOSE TEST NC
EVOLUTION AUTOCODE IN VITRO NC
EZ SMART BLOOD GLUCOSE TEST NC
EZ SMART PLUS GLUCOSE TEST NC
FIFTY50 GLUCOSE TEST 2.0 NC
FORA D15G BLOOD GLUCOSE TEST NC
FORA D20 BLOOD GLUCOSE TEST NC
FORA D40/G31 BLOOD GLUCOSE NC
FORA G20 BLOOD GLUCOSE TEST NC
FORA G30/PREM V10 GLUCOSE TEST NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201891
Drug Name Drug Status Drug Details
FORA GD20 TEST NC
FORA GD50 BLOOD GLUCOSE TEST NC
FORA TN'G/TN'G VOICE NC
FORA V10 BLOOD GLUCOSE TEST NC
FORA V12 BLOOD GLUCOSE TEST NC
FORA V20 BLOOD GLUCOSE TEST NC
FORA V30A BLOOD GLUCOSE TEST NC
FORACARE GD40 TEST NC
FORACARE PREMIUM V10 TEST NC
FORACARE TEST N GO TEST NC
FORTISCARE TEST NC
FREESTYLE INSULINX TEST PB QL
FREESTYLE LITE TEST PB QL
FREESTYLE PRECISION NEO TEST PB QL
FREESTYLE TEST PB QL
ge100 blood glucose test NC
GENSTRIP 50 NC
ght test NC
GLUCO PERFECT 3 TEST NC
GLUCOCARD 01 SENSOR PLUS NC
GLUCOCARD EXPRESSION TEST NC
GLUCOCARD SHINE TEST NC
GLUCOCARD VITAL TEST NC
GLUCOCARD X-SENSOR NC
GLUCOCOM TEST NC
GLUCONAVII BLOOD GLUCOSE TEST NC
IN TOUCH BLOOD GLUCOSE TEST NC
INFINITY BLOOD GLUCOSE TEST NC
kroger blood glucose test NC
kroger test NC
LIBERTY NEXT GENERATION TEST NC
liberty test NC
meijer blood glucose test NC
MEIJER TRUETEST TEST NC
MEIJER TRUETRACK TEST NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201892
Drug Name Drug Status Drug Details
MICRODOT TEST NC
MYGLUCOHEALTH TEST NC
NEUTEK 2TEK TEST NC
NOVA MAX GLUCOSE TEST NC
ON CALL EXPRESS BLOOD GLUCOSE NC
ON CALL PLUS BLOOD GLUCOSE NC
ON CALL VIVID BLOOD GLUCOSE NC
ONETOUCH ULTRA BLUE PB QL
ONETOUCH VERIO IN VITRO STRIP PB QL
POCKETCHEM EZ TEST NC
PRECISION PCX PB QL
PRECISION PCX PLUS TEST PB QL
PRECISION POINT OF CARE TEST PB QL
PRECISION QID TEST PB QL
PRECISION SOF-TACT TEST PB QL
PRECISION XTRA BLOOD GLUCOSE PB QL
PRODIGY NO CODING BLOOD GLUC NC
PTS PANELS GLUCOSE TEST NC
RA TRUETEST TEST NC
SMART SENSE VALUE TEST NC
SMARTEST BLOOD GLUCOSE TEST NC
SOLUS V2 TEST NC
SUPREME TEST NC
SURE EDGE TEST NC
SURECHEK BLOOD GLUCOSE TEST NC
SURE-TEST EASYPLUS MINI TEST NC
TELCARE BLOOD GLUCOSE TEST NC
THYROGEN PSP SP
TRUE METRIX BLOOD GLUCOSE TEST NC
TRUETEST TEST NC
TRUETRACK TEST NC
ULTIMA TEST NC
ULTRATRAK PRO TEST NC
ULTRATRAK ULTIMATE TEST NC
UNISTRIP1 GENERIC NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201893
Drug Name Drug Status Drug Details
VICTORY AGM-4000 TEST NC
VOCAL POINT BLOOD GLUCOSE TEST NC
*DIGESTIVE AIDS*
CREON PB
PANCREAZE NP ST
PERTZYE NP ST
SUCRAID NPS SP
VIOKACE NP ST
ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT
PB
*DIRECT-ACTING P2Y12 INHIBITORS***
BRILINTA PB QL
*DIURETICS*
acetazolamide er NC
acetazolamide oral PG
ALDACTAZIDE NP
ALDACTONE NP
amiloride hcl oral PG
amiloride-hydrochlorothiazide PG LGC
bumetanide oral PG
CAROSPIR NC
chlorothiazide oral PG
chlorthalidone oral tablet 25 mg, 50 mg PG
DEMADEX ORAL TABLET 10 MG, 20 MG NP
DIURIL NP
DYAZIDE NP
DYRENIUM NP
EDECRIN NP
ethacrynic acid oral NP
furosemide oral tablet PG LGC
hydrochlorothiazide oral capsule PG LGC
hydrochlorothiazide oral tablet 12.5 mg PG
hydrochlorothiazide oral tablet 25 mg, 50 mg PG LGC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201894
Drug Name Drug Status Drug Details
indapamide oral PG
KEVEYIS NPS PA; QL
LASIX NP
MAXZIDE NP
MAXZIDE-25 NP
methazolamide oral PG
methyclothiazide oral NP
metolazone PG
MICROZIDE NP
spironolactone oral tablet 100 mg, 50 mg PG
spironolactone oral tablet 25 mg PG LGC
spironolactone-hctz PG
torsemide oral PG
triamterene-hctz oral capsule 37.5-25 mg PG LGC
triamterene-hctz oral tablet PG LGC
*ENDOCRINE AND METABOLIC AGENTS - MISC.*
ACTONEL ORAL TABLET 150 MG, 30 MG, 35 MG, 5 MG
NP ST; QL
ALDURAZYME NPS PA; SP
alendronate sodium oral solution PG
alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg
PG QL
alendronate sodium oral tablet 70 mg PG LGC; QL
AMMONUL NPS SP
ATELVIA NP QL
BINOSTO NC
BONIVA INTRAVENOUS NPS SP
BONIVA ORAL TABLET 150 MG NP ST; QL
BUPHENYL ORAL POWDER 3 GM/TSP NPS PA; SP
BUPHENYL ORAL TABLET NPS PA; SP; QL
cabergoline PG
calcitonin (salmon) PG QL
calcitriol oral capsule PG
CARBAGLU NPS PA; #; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201895
Drug Name Drug Status Drug Details
CARNITOR ORAL SOLUTION NP
CARNITOR SF NP
CYSTADANE NPS PA; SP
DDAVP INJECTION SOLUTION 4 MCG/ML
NC
DDAVP NASAL NP
DDAVP ORAL NP
DDAVP RHINAL TUBE NP
desmopressin ace spray refrig PG
desmopressin acetate injection NC
desmopressin acetate oral PG
desmopressin acetate spray PG
doxercalciferol intravenous NC
doxercalciferol oral PG QL
ELAPRASE PSP PA; SP
etidronate disodium NP
EVISTA NP
FABRAZYME NPS PA; SP
FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML
NPS PA; ST; SP
FOSAMAX ORAL TABLET 70 MG NP QL
FOSAMAX PLUS D NP QL
GENOTROPIN NPS PA; ST; SP
GENOTROPIN MINIQUICK NPS PA; ST; SP
HECTOROL INTRAVENOUS NC
HP ACTHAR NPS PA; SP
HUMATROPE NPS PA; ST; SP
ibandronate sodium intravenous solution 3 mg/3ml
PG SP
ibandronate sodium oral NP ST; QL
INCRELEX PSP PA; SP
JYNARQUE PSP PA; SP
KUVAN NPS PA; SP
levocarnitine oral solution PG
LUMIZYME NPS PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201896
Drug Name Drug Status Drug Details
LUPRON DEPOT-PED (1-MONTH) NPS PA; #; SP
LUPRON DEPOT-PED (3-MONTH) NPS PA; #; SP
MIACALCIN NASAL NP ST; QL
NAGLAZYME NPS PA; SP
NATPARA NPS PA; QL
NITYR NPS PA; SP
NOCTIVA PB QL; AL
NORDITROPIN FLEXPRO NPS PA; ST; SP
NUTROPIN AQ NUSPIN 10 NPS PA; ST; SP
NUTROPIN AQ NUSPIN 20 NPS PA; ST; SP
NUTROPIN AQ NUSPIN 5 NPS PA; ST; SP
octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml
PG PA; SP
OMNITROPE PSP PA; SP
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG
NPS PA; SP
ORFADIN ORAL CAPSULE 20 MG NPS PA
ORFADIN ORAL SUSPENSION NPS PA; SP
ORILISSA NPS PA; SP; QL
OSPHENA NP QL
PALYNZIQ NPS PA; ST; SP; QL
pamidronate disodium PG SP
paricalcitol intravenous NC
paricalcitol oral PG QL
PROLIA NPS PA; ST; SP
raloxifene hcl PG
RAVICTI NPS PA; ST; SP; QL
RAYALDEE NP PA; ST; QL
RECLAST NPS SP
risedronate sodium oral tablet 150 mg NP ST; QL
risedronate sodium oral tablet 30 mg, 35 mg, 5 mg
NP QL
risedronate sodium oral tablet delayed release NP QL
ROCALTROL NP
SAIZEN NPS PA; ST; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201897
Drug Name Drug Status Drug Details
SAMSCA PSP PA; #; SP; QL
SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 MCG/ML, 500 MCG/ML
NPS PA; SP
SANDOSTATIN LAR DEPOT NPS PA; #; SP
SENSIPAR NP PA; #; QL
SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG
NPS PA; SP
SIGNIFOR NPS PA; SP; QL
sod benz-sod phenylacet PG
sodium phenylbutyrate oral powder 3 gm/tsp PSP PA; SP
sodium phenylbutyrate oral tablet PSP PA; SP; QL
SOMATULINE DEPOT NPS PA; SP
SOMAVERT NPS PA; #; SP
STIMATE NP PA
SUPPRELIN LA PSP PA; SP
SYNAREL NPS PA; SP
TRIPTODUR NPS PA; SP
TYMLOS PSP PA; ST; SP; QL
XGEVA NPS PA; ST; SP
ZEMPLAR INTRAVENOUS NC
ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG
NP ST; QL
zoledronic acid intravenous concentrate PG SP
zoledronic acid intravenous solution PG SP
ZOMACTON NPS PA; ST; SP
ZOMETA NPS SP
ZORBTIVE NPS PA; SP
*ESTROGENS*
ACTIVELLA NP QL
ALORA NP QL
AMABELZ PG QL
ANGELIQ NP
CLIMARA NP QL
CLIMARA PRO NP #; QL
COMBIPATCH NP QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201898
Drug Name Drug Status Drug Details
DIVIGEL NP
ELESTRIN NP QL
ESTRACE ORAL NP
estradiol oral PG LGC
estradiol transdermal PG QL
estradiol valerate intramuscular oil 20 mg/ml PG
estradiol-norethindrone acet PG QL
ESTROGEL NP QL
EVAMIST NP QL
FEMHRT LOW DOSE NP
FYAVOLV PG
jevantique lo PG
JINTELI PG
MENEST ORAL TABLET 0.3 MG, 0.625 MG
PB
MENEST ORAL TABLET 1.25 MG NP
MENOSTAR NP #; QL
MIMVEY PG QL
MIMVEY LO PG QL
MINIVELLE NP #; QL
norethindrone-eth estradiol PG
PREFEST NP QL
PREMARIN ORAL PB
PREMPHASE PB
PREMPRO PB
VIVELLE-DOT NP QL
*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***
DUAVEE PB QL
*FARNESOID X RECEPTOR (FXR) AGONISTS***
OCALIVA ORAL TABLET 5 MG NPS PA; ST; SP; QL
*FLUOROQUINOLONES*
AVELOX ORAL NP
BAXDELA ORAL NP PA; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/201899
Drug Name Drug Status Drug Details
CIPRO ORAL SUSPENSION RECONSTITUTED
NP
CIPRO ORAL TABLET 250 MG, 500 MG NP
CIPRO XR NP
ciprofloxacin hcl oral tablet 100 mg, 750 mg PG
ciprofloxacin hcl oral tablet 250 mg, 500 mg PG LGC
ciprofloxacin oral suspension reconstituted 500 mg/5ml (10%)
PG
ciprofloxacin-ciproflox hcl er PG
LEVAQUIN ORAL TABLET NP
levofloxacin oral PG
moxifloxacin hcl oral PG
ofloxacin oral tablet 300 mg PG QL
ofloxacin oral tablet 400 mg PG
*GASTROINTESTINAL AGENTS - MISC.*
ACTIGALL NP
alosetron hcl PG PA; ST
AMITIZA NP ST; QL
APRISO NP #; QL
ASACOL HD NP ST; QL
AZULFIDINE NP QL
AZULFIDINE EN-TABS NP QL
balsalazide disodium PG QL
CANASA PB #; QL
CHENODAL NP PA
CIMZIA PREFILLED NPS PA; ST; SP; QL
CIMZIA STARTER KIT NPS PA; ST; SP; QL
CIMZIA SUBCUTANEOUS KIT 2 X 200 MG
NPS PA; ST; SP; QL
COLAZAL NP ST; QL
DELZICOL PB #; QL
DIPENTUM NP ST; QL
enulose PG LGC
FOSRENOL ORAL PACKET NP
FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG
NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018100
Drug Name Drug Status Drug Details
GATTEX NPS PA; SP; QL
INFLECTRA PSP PA; ST; SP
lactulose encephalopathy PG LGC
lanthanum carbonate NP
LIALDA PB QL
LINZESS PB QL
LOTRONEX NP PA; ST
mesalamine oral PG QL
mesalamine rectal PG
metoclopramide hcl oral solution 5 mg/5ml PG LGC
metoclopramide hcl oral tablet 10 mg PG LGC
metoclopramide hcl oral tablet 5 mg PG
metoclopramide hcl oral tablet dispersible PG
MOVANTIK PB QL
PENTASA PB QL
PHOSLO NP
REGLAN ORAL NP
RELISTOR ORAL NP PA; #; QL
RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 MG/0.4ML
NP PA; QL
REMICADE PSP PA; ST; SP
RENAGEL ORAL TABLET 800 MG NP #
RENFLEXIS PSP PA; ST; SP
RENVELA PB
sevelamer carbonate PG
SFROWASA NP
sulfasalazine oral PG QL
SULFAZINE PG QL
SYMPROIC NP PA; ST; QL
URSO 250 NP
URSO FORTE NP
ursodiol oral capsule PG
ursodiol oral tablet NP
VELPHORO NP #
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018101
Drug Name Drug Status Drug Details
*GENITOURINARY AGENTS - MISCELLANEOUS*
acetic acid irrigation PG
alfuzosin hcl er PG QL
AVODART NP QL
CARDURA XL NP QL
CYSTAGON NP PA
cytra-2 NC
CYTRA-3 PG
cytra-k PG
dutasteride oral PG QL
dutasteride-tamsulosin hcl PG
ELMIRON PB QL
finasteride oral tablet 5 mg PG PA
FLOMAX NP
JALYN NP
PHENAZO ORAL TABLET 200 MG PG
phenazopyridine hcl oral tablet 100 mg, 200 mg PG
potassium citrate er PG
PROCYSBI NPS PA; ST; SP; QL
PROSCAR NP PA
PYRIDIUM ORAL TABLET 100 MG NP
RAPAFLO PB #
SHOHLS MODIFIED NC
sod citrate-citric acid NC
tamsulosin hcl PG LGC
THIOLA NPS PA; ST
tricitrates PG
UROCIT-K 10 NP
UROCIT-K 15 NP
UROCIT-K 5 NP
UROXATRAL NP QL
*GOUT AGENTS*
allopurinol oral PG LGC
colchicine oral PG QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018102
Drug Name Drug Status Drug Details
colchicine-probenecid PG
COLCRYS NC
DUZALLO NP PA; ST; QL
KRYSTEXXA NPS PA; ST; SP
MITIGARE NP QL
probenecid oral PG
ULORIC NP QL
ZURAMPIC NP PA; ST; QL
ZYLOPRIM NP
*HEMATOLOGICAL AGENTS - MISC.*
ADVATE PSP PA; SP
adynovate intravenous solution reconstituted1000 unit, 2000 unit, 250 unit, 500 unit
NPS PA
adynovate intravenous solution reconstituted1500 unit, 3000 unit, 750 unit
NPS PA; SP
AFSTYLA NPS PA; SP
AGGRENOX NP
AGRYLIN NP
ALPHANATE/VWF COMPLEX/HUMAN NPS PA; SP
ALPHANINE SD NPS PA; SP
ALPROLIX NPS PA; SP
anagrelide hcl PG
aspirin-dipyridamole er PG
BEBULIN NPS PA; SP
BENEFIX INTRAVENOUS KIT PSP PA; SP
BERINERT NPS PA; ST; SP
BRILINTA PB QL
cilostazol PG
CINRYZE NPS PA; ST; SP; QL
clopidogrel bisulfate oral PG QL
COAGADEX NPS PA
CORIFACT NPS PA; SP
dipyridamole oral PG
DURLAZA NP
EFFIENT NP PA; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018103
Drug Name Drug Status Drug Details
ELOCTATE NPS PA; SP
FEIBA PSP PA; SP
FIBRYGA PSP PA; SP
FIRAZYR NPS PA; ST; #; SP; QL
HAEGARDA PSP PA; ST; SP; QL
HELIXATE FS NPS PA; SP
HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT
NPS PA; SP
HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 500-1200 UNIT
NPS PA; SP
IDELVION NPS PA; SP
IXINITY NPS PA; SP
KALBITOR NPS PA; ST; SP
KCENTRA NPS PA
KOATE NPS PA; SP
KOATE-DVI NPS PA; SP
KOGENATE FS NPS PA; SP
KOGENATE FS BIO-SET INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 3000 UNIT
NPS PA; SP
KOVALTRY NPS PA; SP
MONOCLATE-P INTRAVENOUS KIT 1000 UNIT, 1500 UNIT
PSP PA; SP
MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT
PSP PA; SP
NOVOEIGHT NPS PA; SP
NOVOSEVEN RT PSP PA; SP
NUWIQ NPS PA; SP
pentoxifylline er PG
PLAVIX NP QL
prasugrel hcl NP PA; QL
PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT
NPS PA; SP
PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1500 UNIT
NPS PA
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018104
Drug Name Drug Status Drug Details
PROFILNINE SD NPS PA; SP
REBINYN NPS PA; SP
RECOMBINATE NPS PA; SP
RIASTAP PSP PA; SP
RIXUBIS NPS PA; SP
RUCONEST NPS PA; SP
TRETTEN NPS PA; SP
VONVENDI NPS PA
WILATE INTRAVENOUS KIT NPS PA; SP
XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT
NPS PA; SP
XYNTHA SOLOFUSE NPS PA; SP
YOSPRALA NC
*HEMATOPOIETIC AGENTS*
ABANEU-SL NC
active fe NC
AIRAVITE NC
ANIMI-3 NC
ANIMI-3/VITAMIN D NC
ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML
PSP PA; SP
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
PSP PA; SP
av-vite fb NC
b-6 folic acid NC
BIFERARX NC
bp vit 3 NC
CENFOL NC
CENTRATEX NC
CERDELGA PSP PA; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018105
Drug Name Drug Status Drug Details
CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT
PSP PA; SP
CIFEREX NC
CORVITA 150 NC
CORVITE 150 ORAL TABLET 150-1.25 MG NC
cyanocobalamin injection PG
DIVISTA NC
DOPTELET ORAL TABLET 20 MG NPS PA; SP; QL
durachol NC
ELELYSO NPS PA; SP
EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
NPS PA; SP
fabb NC
fa-vitamin b-6-vitamin b-12 NC
FERIVA 21/7 NC
ferocon NC
ferotrinsic NC
ferraplus 90 NC
FERRLECIT NPS SP
FERROCITE PLUS ORAL TABLET NC
FERRO-PLEX HEMATINIC NC
FERROTRIN NC
folbee NC
FOLGARD RX NC
folic acid oral capsule 20 mg PG
folic acid oral tablet 1 mg CE LGC
folic acid oral tablet 400 mcg PG
FOLIVANE-F NC
FOLIVANE-PLUS NC
folplex 2.2 NC
foltrin NC
FULPHILA PSP PA; SP
FUSION PLUS NC
gnp folic acid PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018106
Drug Name Drug Status Drug Details
GRANIX NPS PA; ST; SP
hematinic plus vit/minerals NC
hematinic/folic acid NC
HEMATOGEN FA NC
HEMATOGEN FORTE NC
hemetab NC
HEMOCYTE PLUS NC
HEMOCYTE-F ORAL TABLET NC
hemocyte-plus oral tablet 106-1 mg NC
hm folic acid PG
INTEGRA F NC
INTEGRA PLUS NC
IROSPAN 24/6 NC
IS 24/6 NC
kp folic acid oral tablet 800 mcg CE
K-TAN PLUS NC
LEUKINE INTRAVENOUS NPS PA; SP
MAXFE ORAL TABLET NC
miglustat PSP PA; SP; QL
MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML
NPS PA
MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML, 30 MCG/0.3ML
NPS PA; SP
MOZOBIL NC
MULTIGEN NC
MULTIGEN FOLIC NC
MULTIGEN PLUS NC
na ferric gluc cplx in sucrose PSP
NASCOBAL NC
NEPHRON FA NC
NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PSP PA
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018107
Drug Name Drug Status Drug Details
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML
NPS PA; ST; SP
NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE
NPS PA; ST
neurin-sl NC
NPLATE NPS PA; SP
NUFOL NC
ortho d NC
PROCRIT PSP PA; SP
PROFERRIN-FORTE NC
PROMACTA NPS PA; SP; QL
PROTECTIRON NC
purefe plus NC
purevit dualfe plus NC
px folic acid PG
ra folic acid oral tablet 400 mcg PG
RETACRIT PSP PA; SP
revesta NC
se-tan plus NC
SIKLOS NP PA
sm folic acid PG
TANDEM F NC
TANDEM PLUS NC
taron forte NC
tl gard rx NC
tl icon NC
TRICON NC
trigels-f forte NC
VENOFER NPS SP
VIRT-GARD NC
VPRIV PSP PA; SP
ZARXIO PSP PA
zavara NC
ZAVESCA NPS PA; #; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018108
Drug Name Drug Status Drug Details
*HEMOSTATICS*
AMICAR ORAL SOLUTION NP
AMICAR ORAL TABLET PB
LYSTEDA NP QL
tranexamic acid oral NP QL
*HEPATITIS C AGENT - COMBINATIONS***
EPCLUSA PSP PA; SP; QL
HARVONI PSP PA; SP
MAVYRET NPS PA; ST; SP; QL
TECHNIVIE NPS PA; ST; QL
VIEKIRA PAK NPS PA; ST; SP
VIEKIRA XR NPS PA; ST; QL
VOSEVI PSP PA; SP; QL
ZEPATIER PSP PA; SP; QL
*HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS**
XURIDEN PSP PA; SP; QL
*HYPNOTICS*
AMBIEN NP QL; AL
AMBIEN CR NP QL; AL
BUTISOL SODIUM ORAL TABLET 30 MG NP
DORAL NP
EDLUAR NC AL
estazolam PG AL
eszopiclone PG QL; AL
flurazepam hcl oral capsule 15 mg PG
flurazepam hcl oral capsule 30 mg PG AL
HALCION NP AL
HETLIOZ NPS PA; SP
INTERMEZZO NC AL
LUNESTA NP QL; AL
phenobarbital oral PG
quazepam NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018109
Drug Name Drug Status Drug Details
RESTORIL ORAL CAPSULE 15 MG, 30 MG
NP AL
RESTORIL ORAL CAPSULE 22.5 MG, 7.5 MG
NP QL; AL
ROZEREM NP ST; #; QL; AL
SILENOR NC AL
SONATA NP QL
temazepam oral capsule 15 mg, 30 mg PG AL
temazepam oral capsule 22.5 mg, 7.5 mg NP QL; AL
triazolam PG AL
zolpidem tartrate er NP QL; AL
zolpidem tartrate oral PG QL; AL
zolpidem tartrate sublingual NC
ZOLPIMIST NC #
*HYPOPHOSPHATASIA (HPP) AGENTS***
STRENSIQ NPS PA; SP
*IBS AGENT - MU-OPIOID RECEPTOR AGONISTS***
VIBERZI PB PA; QL
*INSULIN-INCRETIN MIMETIC COMBINATIONS***
SOLIQUA PB ST; QL
XULTOPHY PB ST; QL
*INTEGRIN RECEPTOR ANTAGONISTS***
ENTYVIO PSP PA; ST; SP
*INTERLEUKIN ANTAGONISTS***
STELARA INTRAVENOUS PSP PA; ST; SP
*INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)***
NUCALA NPS PA; SP; QL
*INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)***
CINQAIR NPS PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018110
Drug Name Drug Status Drug Details
*ISOCITRATE DEHYDROGENASE-1 (IDH1) INHIBITORS***
TIBSOVO NPS PA; SP; QL
*ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS***
IDHIFA NPS PA; SP; QL
*LAXATIVES*
CLENPIQ CE
COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 240 GM
NP QL
gavilax oral packet CE
GAVILYTE-H CE
GOLYTELY NP
KRISTALOSE NP QL
lactulose oral solution 10 gm/15ml PG LGC
lactulose oral solution 20 gm/30ml PG
MIRALAX CE
MOVIPREP CE #
NULYTELY WITH FLAVOR PACKS NP
OSMOPREP CE #
peg 3350 CE
peg 3350/electrolytes CE
peg 3350-kcl-na bicarb-nacl CE
peg-3350/electrolytes CE
PEG-PREP CE
polyethylene glycol 3350 oral CE
PREPOPIK CE #
SUPREP BOWEL PREP KIT CE
TRILYTE CE
*LEPTIN ANALOGUES***
MYALEPT PSP PA; SP; QL
*LHRH/GNRH AGONIST ANALOG COMBINATIONS***
LUPANETA PACK NPS PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018111
Drug Name Drug Status Drug Details
*LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG***
XIIDRA PB
*LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS***
KANUMA PSP PA; SP
*MACROLIDES*
azithromycin oral packet PG
azithromycin oral suspension reconstituted PG
azithromycin oral tablet 250 mg, 500 mg, 600 mg
PG
BIAXIN ORAL TABLET 500 MG NP
clarithromycin er PG
clarithromycin oral PG
DIFICID NP QL
E.E.S. 400 ORAL TABLET NP
E.E.S. GRANULES NP
ERYPED 200 NP
ERYPED 400 NP
ERY-TAB NP
ERYTHROCIN STEARATE ORAL TABLET 250 MG
NP
erythromycin base oral tablet PG
erythromycin ethylsuccinate oral tablet PG
erythromycin stearate oral tablet 250 mg PG
ZITHROMAX ORAL NP
ZITHROMAX TRI-PAK NP
ZITHROMAX Z-PAK NP
*MEDICAL DEVICES*
ACCU-CHEK FASTCLIX LANCETS NP
ACCU-CHEK MULTICLIX LANCETS NP
ACCU-CHEK SOFT TOUCH LANCETS NP
ACCU-CHEK SOFTCLIX LANCETS NP
ACTIVE 1ST BLOOD LANCETS 30G NP
ASSURE LANCETS NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018112
Drug Name Drug Status Drug Details
BAYER MICROLET LANCETS NP
BD AUTOSHIELD 29G X 5MM , 29G X 8MM
PB
BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML, U-100 1 ML
PB
BD INSULIN SYRINGE HALF-UNIT PB
BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML
PB
BD INSULIN SYRINGE U-500 PB
BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
PB
BD LANCET ULTRAFINE 30G NP
BD LANCET ULTRAFINE 33G NP
BD MICROTAINER LANCETS NP
BD PEN PB
BD PEN MINI PB
BD PEN NEEDLE MINI U/F PB
BD PEN NEEDLE NANO U/F PB
BD PEN NEEDLE SHORT U/F PB
BD PEN NEEDLE ULTRAFINE PB
BD SAFETYGLIDE INSULIN SYRINGE 29G X 1/2" 0.5 ML, 30G X 5/16" 0.5 ML
PB
BD SAFETY-LOK INSULIN SYRINGE PB
bullseye mini safety lancets NP
BULLSEYE SAFETY LANCETS NP
COAGUCHEK LANCETS NP
comfort assured lancets 28g NP
comfort assured lancets 33g NP
EASY TOUCH LANCETS 21G NP
EASY TOUCH LANCETS 23G NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018113
Drug Name Drug Status Drug Details
EASY TOUCH LANCETS 26G NP
EASY TOUCH LANCETS 26G/TWIST NP
EASY TOUCH LANCETS 28G NP
EASY TOUCH LANCETS 28G/TWIST NP
EASY TOUCH LANCETS 30G NP
EASY TOUCH LANCETS 30G/TWIST NP
EASY TOUCH LANCETS 32G NP
EASY TOUCH LANCETS 32G/TWIST NP
EASY TOUCH LANCETS 33G/TWIST NP
EASY TOUCH LANCING DEVICE NP
EASY TOUCH SAFETY LANCETS 21G NP
EASY TOUCH SAFETY LANCETS 23G NP
EASY TOUCH SAFETY LANCETS 26G NP
EASY TOUCH SAFETY LANCETS 28G NP
EASY TWIST & CAP LANCETS NP
FC2 FEMALE CONDOM CE
FEMCAP CE
FINGERSTIX LANCETS NP
FREESTYLE LANCETS NP
FREESTYLE UNISTICK II LANCETS NP
insulin syringe PG
insulin syringe/needle PG
insulin syringe-needle u-100 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml
PG
lancets PG
lancets super thin 28g NP
LANCETS ULTRA THIN NP
lancets ultra thin 30g NP
LIFESCAN UNISTIK 2 NP
LIFESCAN UNISTIK II LANCETS NP
lite touch lancets NP
LITETOUCH LANCETS NP
MICROLET LANCETS NP
MICROTAINER SAFETY FLOW LANCET NP
ONETOUCH CLUB LANCETS FINE PT NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018114
Drug Name Drug Status Drug Details
ONETOUCH COMBO PACK NP
ONETOUCH DELICA LANCETS 33G NP
ONETOUCH DELICA LANCETS FINE NP
ONETOUCH DELICA LANCING DEV NP
ONETOUCH FINEPOINT LANCETS NP
ONETOUCH ULTRASOFT LANCETS NP
pen needles PG
pen needles 1/2" PG
pen needles 3/16" PG
pen needles 5/16" PG
SAFETY LET LANCETS NP
SAFETY-GLIDE SYRINGE PB
sapscare twist top lancets NP
SIMPLE DIAGNOSTICS LANCING DEV NP
super thin lancets NP
TRUEPLUS LANCETS 26G NP
TRUEPLUS LANCETS 30G NP
TRUEPLUS SAFETY LANCETS 28G NP
VANISHPOINT INSULIN SYRINGE 30G X 3/16" 0.5 ML, 30G X 3/16" 1 ML
NP
WIDE-SEAL DIAPHRAGM 60 CE
WIDE-SEAL DIAPHRAGM 65 CE
WIDE-SEAL DIAPHRAGM 70 CE
WIDE-SEAL DIAPHRAGM 75 CE
WIDE-SEAL DIAPHRAGM 80 CE
WIDE-SEAL DIAPHRAGM 85 CE
WIDE-SEAL DIAPHRAGM 90 CE
WIDE-SEAL DIAPHRAGM 95 CE
*MIGRAINE PRODUCTS*
almotriptan malate NP QL
AMERGE NP QL
CAFERGOT PB
CAMBIA NC
D.H.E. 45 NP
dihydroergotamine mesylate injection NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018115
Drug Name Drug Status Drug Details
dihydroergotamine mesylate nasal NP ST; QL
eletriptan hydrobromide NP QL
ERGOMAR NP
FROVA NP QL
frovatriptan succinate NP QL
IMITREX NP QL
IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE
NP QL
IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR
NP QL
MAXALT ORAL TABLET 10 MG NP QL
MAXALT-MLT NP QL
MIGRANAL NC
naratriptan hcl PG QL
ONZETRA XSAIL NP ST; QL
RELPAX NP QL
rizatriptan benzoate PG QL
sumatriptan nasal PG QL
sumatriptan succinate oral PG QL
sumatriptan succinate refill subcutaneous solution cartridge
PG QL
sumatriptan succinate subcutaneous solution 6 mg/0.5ml
PG QL
sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml
PG QL
sumatriptan-naproxen sodium NC
TREXIMET NC #
ZEMBRACE SYMTOUCH NP ST; QL
zolmitriptan oral PG QL
ZOMIG NP QL
ZOMIG ZMT NP QL
*MINERALS & ELECTROLYTES*
FLUORABON CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018116
Drug Name Drug Status Drug Details
FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP
CE
GALZIN NP
KLOR-CON 10 PG
KLOR-CON ORAL PACKET 20 MEQ NP QL
K-PHOS-NEUTRAL NP
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
NP
potassium chloride crys er oral tablet extended release 10 meq
PG LGC
potassium chloride er oral capsule extended release 10 meq
PG LGC
potassium chloride er oral capsule extended release 8 meq
PG
potassium chloride er oral tablet extended release 10 meq, 20 meq
PG
potassium chloride er oral tablet extended release 8 meq
PG LGC
potassium chloride oral packet NP QL
potassium chloride oral solution 20 meq/15ml (10%)
PG
potassium chloride oral solution 40 meq/15ml (20%)
NP
sodium fluoride oral solution CE
sodium fluoride oral tablet PG
sodium fluoride oral tablet chewable PG
*MONOBACTAMS***
AZACTAM NC
aztreonam NC
CAYSTON NPS SP; QL
*MOUTH/THROAT/DENTAL AGENTS*
cevimeline hcl PG QL
chlorhexidine gluconate mouth/throat PG
clotrimazole mouth/throat PG
DEBACTEROL NP
EVOXAC PG QL
GELCLAIR NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018117
Drug Name Drug Status Drug Details
lidocaine viscous PG
NEUTRASAL NC
nystatin mouth/throat PG
ORAVIG NP QL
paroex PG
periogard PG
SALAGEN NP
triamcinolone acetonide mouth/throat PG
*MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS***
VIMIZIM PSP PA; SP
*MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID***
QUFLORA FE NP
*MULTIVITAMINS*
CITRANATAL 90 DHA ORAL 90-1 & 300 MG
NP
CITRANATAL B-CALM NP
CITRANATAL DHA NP
CITRANATAL HARMONY ORAL CAPSULE 27-1-260 MG
NP
CITRANATAL MEDLEY NP
CITRANATAL RX NP
MYNATAL ADVANCE PG
MYNATAL ORAL TABLET PG
mynatal plus PG
mynatal-z PG
NEEVO DHA ORAL CAPSULE 27-1.13 MG NP
NESTABS NP
NICOMIDE ORAL TABLET 750-27-2-0.5 MG
NP
OB COMPLETE GOLD NP
O-CAL PRENATAL NP
OCUVEL ORAL CAPSULE 0.5 MG NP
POLY-VI-FLOR FS ORAL STRIP 1 MG CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018118
Drug Name Drug Status Drug Details
POLY-VI-FLOR ORAL TABLET CHEWABLE
PB
PREFERAOB ONE NP
PRENATABS RX NP
PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG
NP QL
QUFLORA FE PEDIATRIC NP
QUFLORA PEDIATRIC NP
SYNAGEX NC
SYNATEK NC
TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG
NP
TRINATE PG
TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML
PB
TRI-VI-FLOR ORAL SUSPENSION 0.5 MG/ML
NP
VINATE DHA RF NP
VITAFOL FE+ NP
VITAFOL GUMMIES NP
VITAPEARL NP
VITATRUE NP
VIVA DHA NP
*MUSCULOSKELETAL THERAPY AGENTS*
AMRIX NC #
baclofen oral tablet 10 mg PG LGC
baclofen oral tablet 20 mg, 5 mg PG
carisoprodol oral tablet 250 mg NC
carisoprodol oral tablet 350 mg PG
carisoprodol-aspirin NP
carisoprodol-aspirin-codeine NP
chlorzoxazone oral tablet 250 mg NC
chlorzoxazone oral tablet 500 mg PG
cyclobenzaprine hcl oral tablet 10 mg, 5 mg PG LGC
cyclobenzaprine hcl oral tablet 7.5 mg PG
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018119
Drug Name Drug Status Drug Details
DANTRIUM ORAL CAPSULE 25 MG, 50 MG
NP
dantrolene sodium oral PG
DUROLANE INTRA-ARTICULAR NPS PA; ST; SP
EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE
PSP PA; SP
GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE
NPS PA; ST; SP
GELSYN-3 NPS PA; ST
HYALGAN NPS PA; ST; SP
HYMOVIS NPS PA; ST; SP
LORZONE NC
metaxalone NP
methocarbamol oral PG
MONOVISC PSP PA; SP
orphenadrine citrate er PG
ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE
PSP PA; SP
ROBAXIN ORAL NP
SKELAXIN NP
SOMA NC
SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE
NPS PA; ST; SP
SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE
NPS PA; ST; SP
TIZANIDINE COMFORT PAC NC
tizanidine hcl oral capsule NC
tizanidine hcl oral tablet PG
ZANAFLEX NC
*NASAL AGENTS - SYSTEMIC AND TOPICAL*
ADRENALIN NASAL PB
ASTEPRO NASAL SOLUTION 0.15 % NP
azelastine hcl nasal solution 0.1 % PG
azelastine hcl nasal solution 0.15 % NP
BACTROBAN NASAL PB SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018120
Drug Name Drug Status Drug Details
BECONASE AQ NP ST
budesonide nasal NP Select OTC
DYMISTA NC
FLONASE NC
FLONASE ALLERGY RELIEF PG Select OTC
flunisolide nasal solution 25 mcg/act (0.025%) PG
fluticasone propionate nasal PG Select OTC
ipratropium bromide nasal PG QL
mometasone furoate nasal PG
NASACORT ALLERGY 24HR PG Select OTC; QL
NASACORT ALLERGY 24HR CHILDREN PG Select OTC; QL
nasal allergy 24 hour PG Select OTC; QL
NASONEX NP ST
olopatadine hcl nasal NP
OMNARIS NP ST; #
PATANASE NP
QNASL NP ST
QNASL CHILDRENS NP ST
RHINOCORT ALLERGY PG Select OTC
triamcinolone acetonide nasal aerosol PG Select OTC; QL
XHANCE NC
ZETONNA NP ST
*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***
ENTRESTO PB PA; QL
*NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS***
NORTHERA NPS PA; ST; SP; QL
*NEUROMUSCULAR AGENTS*
BOTOX PSP PA; ST; SP
DYSPORT NPS PA; SP
RILUTEK NP PA
riluzole PG PA
XEOMIN NPS PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018121
Drug Name Drug Status Drug Details
*OPHTHALMIC AGENTS*
ACULAR NP
ACULAR LS NP
ACUVAIL NP
AKTEN NC
ALAWAY PG Select OTC
ALAWAY CHILDRENS ALLERGY PG Select OTC
allergy eye drops PG Select OTC
ALOCRIL NP
ALOMIDE NP
ALPHAGAN P NP
ALREX PB
altafluor NP
apraclonidine hcl PG
atropine sulfate ophthalmic PG
AZASITE NP #
azelastine hcl ophthalmic PG
AZOPT PB
bacitracin ophthalmic PG
bacitracin-polymyxin b ophthalmic ointment500-10000 unit/gm
PG
BEPREVE NP #
BESIVANCE NP
BETAGAN NP
betaxolol hcl ophthalmic PG
BETIMOL NP
BETOPTIC-S NP
bimatoprost ophthalmic NP PA; ST
bio glo NP
BLEPH-10 NP
BLEPHAMIDE NP
BLEPHAMIDE S.O.P. NP
brimonidine tartrate ophthalmic solution 0.15 % NP
brimonidine tartrate ophthalmic solution 0.2 % PG
bromfenac sodium (once-daily) NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018122
Drug Name Drug Status Drug Details
BROMSITE NP
carteolol hcl PG
CILOXAN NP
CLARITIN EYE PG Select OTC
COMBIGAN PB
COSOPT NP
COSOPT PF NP #
cromolyn sodium ophthalmic PG
CYCLOGYL NP
CYCLOMYDRIL NP
cyclopentolate hcl ophthalmic PG
CYSTARAN NPS PA; SP; QL
dexamethasone sodium phosphate ophthalmic PG
diclofenac sodium ophthalmic PG
dorzolamide hcl ophthalmic PG
dorzolamide hcl-timolol mal PG
DUREZOL PB #
ELESTAT NP
EMADINE NP
epinastine hcl PG
erythromycin ophthalmic PG
eye itch relief PG Select OTC
EYLEA INTRAVITREAL NPS PA; SP
FLAREX NP
flucaine NC
fluorescein-benoxinate NP
fluor-i-strips a.t. NP
fluorometholone ophthalmic PG
flurbiprofen sodium PG
FML PB
FML FORTE NP
FML LIQUIFILM NP
FUL-GLO OPHTHALMIC STRIP 0.6 MG NP
ful-glo ophthalmic strip 1 mg NP
gatifloxacin ophthalmic NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018123
Drug Name Drug Status Drug Details
gentamicin sulfate ophthalmic solution PG
ILEVRO NP
IOPIDINE NP
ISOPTO CARPINE NP
ISTALOL NP
JETREA INTRAVITREAL SOLUTION 0.375 MG/0.3ML
NPS PA; SP
ketorolac tromethamine ophthalmic NP
ketotifen fumarate ophthalmic PG Select OTC
LACRISERT NP
LASTACAFT NP
latanoprost ophthalmic PG
levobunolol hcl ophthalmic solution 0.5 % PG
levofloxacin ophthalmic PG
LOTEMAX OPHTHALMIC GEL PB #
LOTEMAX OPHTHALMIC OINTMENT PB
LOTEMAX OPHTHALMIC SUSPENSION PB
LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE
NPS PA; SP
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
NP PA; ST
MACUGEN NPS PA; SP
MAXIDEX NP
MAXITROL NP
metipranolol PG
MOXEZA NP #
moxifloxacin hcl ophthalmic PG
MYDRIACYL NP
NATACYN NP
neomycin-polymyxin-dexameth ophthalmic ointment
PG
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
PG
NEOSPORIN NP
NEVANAC NP
OCUFLOX NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018124
Drug Name Drug Status Drug Details
ofloxacin ophthalmic PG
olopatadine hcl ophthalmic PG
OMNIPRED NP
PATADAY NP
PATANOL NP
PAZEO NP
PHOSPHOLINE IODIDE PB
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %
PG
polymyxin b-trimethoprim PG
POLYTRIM NP
PRED FORTE NP
PRED MILD NP
PRED-G NP
PRED-G S.O.P. NP
prednisolone acetate ophthalmic PG
prednisolone sodium phosphate ophthalmic PG
PROLENSA NP
proparacaine-fluorescein NC
RESTASIS PB #
RESTASIS MULTIDOSE PB #
SIMBRINZA NP
sulfacetamide sodium ophthalmic PG
sulfacetamide-prednisolone ophthalmic solution PG
sulfacetamide-prednisolone ophthalmic suspension
PB
timolol maleate ophthalmic gel forming solution PG
timolol maleate ophthalmic solution 0.25 %, 0.5 %
PG
timolol maleate ophthalmic solution 0.5 % (daily)
NP
TIMOPTIC NP
TIMOPTIC OCUDOSE NP
TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.5 %
NP
TOBRADEX NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018125
Drug Name Drug Status Drug Details
TOBRADEX ST NP
TOBREX NP
TRAVATAN Z PB #
trifluridine ophthalmic PG
tropicamide ophthalmic NP
TRUSOPT NP
VIGAMOX NP
VIROPTIC NP
VISUDYNE NPS PA; #; SP
VYZULTA NP PA; ST
XALATAN NP PA; ST
ZADITOR PG Select OTC
ZIOPTAN NP PA; ST
ZIRGAN NP #
ZYLET NP
ZYMAXID NP
*OPHTHALMIC RHO KINASE INHIBITORS***
RHOPRESSA NP ST
*OREXIN RECEPTOR ANTAGONISTS***
BELSOMRA NP ST; QL; AL
*OTIC AGENTS*
ACETASOL HC PG
acetic acid otic PG
CETRAXAL NP
CIPRO HC NP #
CIPRODEX PB #
ciprofloxacin hcl otic NP
COLY-MYCIN S NP
CORTANE-B AQUEOUS NC
CORTANE-B OTIC NC
cortic-nd NC
cyotic NC
DERMOTIC NP
exotic-hc NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018126
Drug Name Drug Status Drug Details
FLOXIN OTIC NP
fluocinolone acetonide otic NP
hydrocortisone-acetic acid PG
neomycin-polymyxin-hc otic solution 1 % PG
neomycin-polymyxin-hc otic suspension PG
ofloxacin otic PG
OTICIN HC NR NC
OTIPRIO NP
otomax-hc NC
OTOVEL NP
*OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***
KERYDIN NP PA; ST
*OXYTOCICS*
CERVIDIL NP
METHERGINE ORAL PG QL
PREPIDIL NP
*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***
HYQVIA NPS PA; ST; SP
*PASSIVE IMMUNIZING AGENTS*
BIVIGAM NPS PA; ST; SP
CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM
NPS PA; ST; SP
CUVITRU NPS PA; ST
CYTOGAM PSP SP
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML
PSP PA; SP
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML
PSP PA
GAMASTAN S/D INTRAMUSCULAR INJECTABLE
NPS SP
GAMMAGARD NPS PA; ST; SP
GAMMAGARD S/D LESS IGA NPS PA; ST; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018127
Drug Name Drug Status Drug Details
GAMMAKED NPS PA; ST; SP
GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/200ML, 20 GM/400ML, 5 GM/100ML
PSP PA; SP
GAMUNEX-C PSP PA; SP
HEPAGAM B PSP
HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML
PSP PA; SP
HYPERHEP B S/D NPS SP
HYPERRAB NPS SP
HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE
NPS SP
HYPERTET S/D PSP SP
MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE
NPS SP
NABI-HB NPS SP
OCTAGAM PSP PA; SP
PRIVIGEN NPS PA; ST; SP
RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE
NPS SP
RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE
PSP SP
SYNAGIS PSP PA; SP
WINRHO SDF NPS SP
*PCSK9 INHIBITORS***
PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR
PSP PA; ST; QL
REPATHA PSP PA; ST; QL
REPATHA PUSHTRONEX SYSTEM PSP PA; ST; QL
REPATHA SURECLICK PSP PA; ST; QL
*PEDIATRIC MULTIPLE VITAMINS W/FLUORIDE-IRON-ZINC***
TEXAVITE LQ CE
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018128
Drug Name Drug Status Drug Details
*PENICILLINS*
amoxicillin oral capsule PG LGC
amoxicillin oral suspension reconstituted PG LGC
amoxicillin oral tablet PG
amoxicillin oral tablet chewable 125 mg, 250 mg PG
amoxicillin-pot clavulanate er PG
amoxicillin-pot clavulanate oral PG
ampicillin oral capsule 500 mg PG
AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML
PB
AUGMENTIN ORAL SUSPENSION RECONSTITUTED 250-62.5 MG/5ML
NP
AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG
NP
AUGMENTIN XR NP
dicloxacillin sodium PG
MOXATAG NP
penicillin v potassium oral solution reconstituted125 mg/5ml
PG LGC
penicillin v potassium oral solution reconstituted250 mg/5ml
PG
penicillin v potassium oral tablet 250 mg PG LGC
penicillin v potassium oral tablet 500 mg PG
piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm
NC
ZOSYN INTRAVENOUS SOLUTION RECONSTITUTED
NC
*PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS***
ZYDELIG NPS PA; SP; QL
*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL***
EUCRISA NC
*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***
OTEZLA ORAL TABLET PSP PA; ST; SP; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018129
Drug Name Drug Status Drug Details
OTEZLA ORAL TABLET THERAPY PACK
PSP PA; ST; SP; QL
*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS**
LYNPARZA NPS PA; SP; QL
RUBRACA ORAL TABLET 200 MG, 300 MG
NPS PA; QL
RUBRACA ORAL TABLET 250 MG NPS PA; SP; QL
ZEJULA NPS PA; SP; QL
*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS***
LYNPARZA NPS PA; SP; QL
RUBRACA ORAL TABLET 200 MG, 300 MG
NPS PA; QL
RUBRACA ORAL TABLET 250 MG NPS PA; SP; QL
ZEJULA NPS PA; SP; QL
*POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS***
GRALISE NP ST; QL
GRALISE STARTER NP ST; QL
LYRICA CR PB QL
*POTASSIUM REMOVING AGENTS***
KIONEX ORAL SUSPENSION PG
sodium polystyrene sulfonate oral PG
SPS PG
VELTASSA NP PA; QL
*PROGESTINS*
AYGESTIN NP
hydroxyprogesterone caproate intramuscular oil PSP PA; SP
MAKENA INTRAMUSCULAR NC #
MAKENA SUBCUTANEOUS NPS PA; SP; QL
medroxyprogesterone acetate oral PG LGC
MEGACE ES NP
megestrol acetate oral suspension 625 mg/5ml NP
PROMETRIUM NP QL
PROVERA NP
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Drug Name Drug Status Drug Details
*PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS***
ZONTIVITY NP PA; QL
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*
acamprosate calcium NP QL
AMPYRA NPS PA; #; SP; QL
ANTABUSE NP
ARICEPT ORAL TABLET 10 MG, 23 MG, 5 MG
NP PA; AL
AUBAGIO PSP PA; SP; QL
AUSTEDO NPS PA; ST; SP; QL
AVONEX PSP PA; SP; QL
AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT
PSP PA; SP; QL
AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT
PSP PA; SP; QL
BETASERON SUBCUTANEOUS KIT PSP PA; SP; QL
BRISDELLE NP PA; ST; QL
bupropion hcl er (smoking det) CE QL
CHANTIX CE QL
CHANTIX CONTINUING MONTH PAK CE QL
CHANTIX STARTING MONTH PAK CE
chlordiazepoxide-amitriptyline NP
COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML
NC SP
COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML
PSP PA; SP
disulfiram oral PG
donepezil hcl oral tablet 10 mg, 5 mg PG PA; AL
donepezil hcl oral tablet 23 mg NP PA; AL
donepezil hcl oral tablet dispersible PG PA; AL
ergoloid mesylates oral NP
EXELON TRANSDERMAL NP PA
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018131
Drug Name Drug Status Drug Details
EXTAVIA SUBCUTANEOUS KIT NPS PA; ST; SP; QL
fluoxetine hcl (pmdd) PG
galantamine hydrobromide NP PA; AL
galantamine hydrobromide er NP PA; AL
GILENYA ORAL CAPSULE 0.25 MG PSP PA; SP; QL
GILENYA ORAL CAPSULE 0.5 MG PSP PA; #; SP; QL
GRALISE NP ST; QL
GRALISE STARTER NP ST; QL
HORIZANT ORAL TABLET EXTENDED RELEASE
NP PA; ST; QL
INGREZZA NPS PA; SP; QL
LEMTRADA PSP PA; SP; QL
LYRICA CR PB QL
memantine hcl er PG PA; AL
memantine hcl oral tablet PG PA; AL
NAMENDA ORAL TABLET NP PA
NAMENDA TITRATION PAK NP PA
NAMENDA XR PB PA; #; AL
NAMENDA XR TITRATION PACK PB PA; #; AL
nicotine CE QL
nicotine polacrilex mouth/throat CE QL
NICOTROL CE QL
NICOTROL NS CE QL
NUEDEXTA PB QL
olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-25 mg, 6-50 mg
NP QL
olanzapine-fluoxetine hcl oral capsule 3-25 mg NP
ORAP NP
paroxetine mesylate NP PA; QL
perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-25 mg
PG
pimozide NP
PLEGRIDY PSP PA; SP; QL
PLEGRIDY STARTER PACK PSP PA; SP; QL
RAZADYNE ER NP AL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
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Drug Name Drug Status Drug Details
RAZADYNE ORAL TABLET NP PA; AL
REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR
PSP PA; SP; QL
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR
PSP PA; SP; QL
REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PSP PA; SP; QL
REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PSP PA; SP; QL
rivastigmine NP PA
rivastigmine tartrate NP PA
SARAFEM ORAL TABLET 10 MG, 20 MG PG
SAVELLA NP ST; QL
SAVELLA TITRATION PACK NP ST; QL
SYMBYAX ORAL CAPSULE 12-25 MG, 12-50 MG, 6-25 MG, 6-50 MG
NP QL
SYMBYAX ORAL CAPSULE 3-25 MG NP
TECFIDERA PSP PA; SP; QL
tetrabenazine PSP PA; QL
TYSABRI NPS PA; ST; SP
XENAZINE NPS PA; ST; SP; QL
XYREM NPS PA; SP
ZYBAN NP QL
*PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS***
OFEV NPS PA; SP; QL
*PULMONARY FIBROSIS AGENTS***
ESBRIET NPS PA; SP; QL
*PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST***
UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 400 MCG, 600 MCG, 800 MCG
NPS PA; SP; QL
UPTRAVI ORAL TABLET 200 MCG NPS PA; SP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
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Drug Name Drug Status Drug Details
UPTRAVI ORAL TABLET THERAPY PACK
NPS PA; SP
*RESPIRATORY AGENTS - MISC.*
ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG
NPS PA; SP
GLASSIA NPS PA; SP
KALYDECO NPS PA; SP; QL
PROLASTIN-C INTRAVENOUS SOLUTION
NPS PA; SP
PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG
NPS PA; SP
PULMOZYME PSP PA; SP; QL
ZEMAIRA NPS PA; SP
*SEROTONIN MODULATORS***
nefazodone hcl NP
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg PG LGC
trazodone hcl oral tablet 300 mg PG
TRINTELLIX NP PA; ST; QL
VIIBRYD ORAL TABLET NP QL
VIIBRYD STARTER PACK NP
*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***
GLYXAMBI PB QL
QTERN NC
STEGLUJAN NC
*SINUS NODE INHIBITORS**
CORLANOR NP PA; ST; QL
*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***
INVOKAMET PB QL
INVOKAMET XR PB QL
SEGLUROMET NC
SYNJARDY PB QL
SYNJARDY XR PB QL
XIGDUO XR NP QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
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Drug Name Drug Status Drug Details
*SPLEEN TYROSINE KINASE (SYK) INHIBITORS***
TAVALISSE NPS PA; SP; QL
*SULFONAMIDES*
sulfadiazine oral NP
*TETRACYCLINES*
ACTICLATE NC
avidoxy NC
AVIDOXY DK NC
COREMINO NC
demeclocycline hcl oral NP
DORYX MPC NC
DORYX ORAL TABLET DELAYED RELEASE 200 MG, 50 MG
NC
doxycycline hyclate oral capsule PG
doxycycline hyclate oral tablet 100 mg, 50 mg PG
doxycycline hyclate oral tablet 150 mg, 75 mg NC
doxycycline hyclate oral tablet 20 mg NP
doxycycline hyclate oral tablet delayed release NC
doxycycline monohydrate oral capsule 100 mg, 50 mg
PG
doxycycline monohydrate oral capsule 150 mg, 75 mg
NC
doxycycline monohydrate oral suspension reconstituted
PG
doxycycline monohydrate oral tablet NC
MINOCIN ORAL CAPSULE 100 MG, 50 MG
NP
minocycline hcl er NC
minocycline hcl oral capsule PG
minocycline hcl oral tablet NC
MORGIDOX COMBINATION NC
MORGIDOX ORAL CAPSULE 100 MG PG
SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG
NC #
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018135
Drug Name Drug Status Drug Details
TARGADOX NC
tetracycline hcl oral PG
VIBRAMYCIN NP
XIMINO NC
*THYROID AGENTS*
ARMOUR THYROID ORAL TABLET 120 MG
PG
ARMOUR THYROID ORAL TABLET 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG
NP
CYTOMEL NP
levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
PG LGC
levothyroxine sodium oral tablet 300 mcg PG
LEVOXYL PG
liothyronine sodium oral PG
methimazole oral PG
NATURE-THROID NP
np thyroid oral tablet 30 mg, 60 mg, 90 mg PG
propylthiouracil oral PG
SYNTHROID NP
TAPAZOLE NP
TIROSINT NP
UNITHROID PG
UNITHROID DIRECT PG
WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 MG, 97.5 MG
NP
WP THYROID ORAL TABLET 113.75 MG, 130 MG, 32.5 MG, 65 MG
NP
*TRYPTOPHAN HYDROXYLASE INHIBITORS***
XERMELO NPS PA; SP; QL
*ULCER DRUGS*
acid reducer maximum strength oral tablet 150 mg
NC
acid reducer oral tablet 150 mg NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018136
Drug Name Drug Status Drug Details
ACIPHEX NP PA; ST; QL
ACIPHEX SPRINKLE NP PA; ST; #; QL
amoxicill-clarithro-lansopraz PG
BENTYL ORAL CAPSULE NP
CARAFATE NP
chlordiazepoxide-clidinium NC
cimetidine hcl oral PG
cimetidine oral tablet 200 mg NC
cimetidine oral tablet 300 mg, 400 mg, 800 mg PG
CUVPOSA NP
CYTOTEC NP
DEXILANT NC
dicyclomine hcl oral capsule PG LGC
dicyclomine hcl oral tablet PG LGC
esomeprazole magnesium oral capsule delayed release 20 mg
PG Select OTC; QL
esomeprazole magnesium oral capsule delayed release 40 mg
PG QL
esomeprazole strontium oral capsule delayed release 49.3 mg
NC
famotidine oral tablet 10 mg PG
famotidine oral tablet 40 mg PG LGC
FIRST-LANSOPRAZOLE NC
FIRST-OMEPRAZOLE NC
glycopyrrolate oral tablet 1 mg, 2 mg NP
heartburn relief 150 max st NC
hyoscyamine sulfate NC
lansoprazole oral capsule delayed release 15 mg PG Select OTC; QL
lansoprazole oral capsule delayed release 30 mg PG QL
lansoprazole oral tablet dispersible NP QL
LIBRAX NC
misoprostol oral PG
NEXIUM 24HR PG Select OTC; QL
NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG
NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018137
Drug Name Drug Status Drug Details
NEXIUM ORAL CAPSULE DELAYED RELEASE 40 MG
NP QL
NEXIUM ORAL PACKET NP #; QL
nizatidine PG
OMECLAMOX-PAK NP
omeprazole magnesium PG Select OTC
omeprazole oral capsule delayed release 10 mg, 40 mg
PG
omeprazole oral tablet delayed release PG Select OTC
OMEPRAZOLE+SYRSPEND SF ALKA NC
omeprazole-sodium bicarbonate oral capsule 20-1100 mg
PG Select OTC; QL
omeprazole-sodium bicarbonate oral capsule 40-1100 mg
NC
omeprazole-sodium bicarbonate oral packet NC
pantoprazole sodium oral PG
PEPCID ORAL SUSPENSION RECONSTITUTED
NP
PEPCID ORAL TABLET 40 MG NP
PREVACID 24HR PG Select OTC; QL
PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG
NC
PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG
NP QL
PREVACID SOLUTAB NP PA; ST; QL; AL
PREVPAC NP
PRILOSEC ORAL PACKET NC
PRILOSEC OTC PG Select OTC
propantheline bromide NC
propantheline bromide oral PG
PROTONIX ORAL NP
PYLERA NP #
rabeprazole sodium PG QL
ranitidine hcl oral capsule PG
ranitidine hcl oral tablet 300 mg PG LGC
ROBINUL ORAL NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018138
Drug Name Drug Status Drug Details
ROBINUL-FORTE NP
sucralfate oral PG
SYMAX DUOTAB NC
ZANTAC ORAL TABLET 300 MG NP
ZEGERID NC
ZEGERID OTC PG Select OTC; QL
*URINARY ANTI-INFECTIVES*
FURADANTIN NP
HIPREX NP
hyophen NC
MACROBID NP
MACRODANTIN NP
methenamine hippurate PG
methenamine mandelate oral PG
MONUROL NP
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
PG
nitrofurantoin monohyd macro PG
nitrofurantoin oral suspension PG
phosphasal NC
urelle NC
uretron d/s NC
uribel NC
URIMAR-T NC
urin ds NC
uro-mp NC
ustell NC
utira-c NC
utrona-c NC
*URINARY ANTISPASMODICS*
bethanechol chloride oral PG
darifenacin hydrobromide er NP QL
DETROL NP ST
DETROL LA NP ST; QL
DITROPAN XL NP ST; QL
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018139
Drug Name Drug Status Drug Details
ENABLEX NP ST; QL
flavoxate hcl PG
GELNIQUE TRANSDERMAL GEL 10 % NP ST
MYRBETRIQ PB ST; QL
oxybutynin chloride er PG QL
oxybutynin chloride oral syrup PG
oxybutynin chloride oral tablet PG LGC; QL
OXYTROL NC #
OXYTROL FOR WOMEN PG #; Select OTC; QL
tolterodine tartrate PG
tolterodine tartrate er NP QL
TOVIAZ NP ST; QL
trospium chloride PG QL
trospium chloride er PG QL
URECHOLINE NP
VESICARE NP ST; #; QL
*VAGINAL PRODUCTS*
AVC VAGINAL NP
CLEOCIN VAGINAL NP
clindamycin phosphate vaginal PG
CLINDESSE NP
CRINONE VAGINAL GEL 4 % NP
ESTRACE VAGINAL NP
estradiol vaginal cream PG
estradiol vaginal tablet NP
ESTRING NP
FEM PH NP
FEMRING NP #; QL
GYNAZOLE-1 NP
IMVEXXY MAINTENANCE PACK NP ST
IMVEXXY STARTER PACK NP ST
INTRAROSA NP QL
METROGEL-VAGINAL NP
metronidazole vaginal PG
miconazole 3 vaginal suppository NP
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018140
Drug Name Drug Status Drug Details
NUVESSA NP
PREMARIN VAGINAL PB
RELAGARD NP
TERAZOL 7 NP
terconazole PG
TODAY SPONGE CE
VAGIFEM VAGINAL TABLET 10 MCG NP
VANDAZOLE PG
VCF VAGINAL CONTRACEPTIVE VAGINAL FILM
CE
VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM
CE
YUVAFEM NP
*VASOPRESSORS*
ADYPHREN NP QL
ADYPHREN AMP II NP QL
ADYPHREN II NP QL
AUVI-Q INJECTION SOLUTION AUTO-INJECTOR
NC
epinephrine injection solution auto-injector PG QL
EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR
PB #; QL
EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR
PB #; QL
EPISNAP NP QL
midodrine hcl PG SP
*VITAMINS*
BPROTECTED PEDIA D-VITE CE
CALCIDOL NC
CALCIFEROL NC
cvs d3 oral capsule 2000 unit, 5000 unit NC
cvs d3 oral capsule 400 unit CE
d 10000 NC
d 2000 NC
d 400 oral tablet CE
d 5000 NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018141
Drug Name Drug Status Drug Details
d-2000 maximum strength NC
d2000 ultra strength NC
D3 DOTS NC
d3 maximum strength NC
d3 super strength NC
d3-1000 oral tablet CE
d-3-5 NC
D3-50 NC
d-5000 NC
DDROPS ORAL LIQUID 2000 UNT/0.03ML, 2000 UT/0.028ML
NC
DECARA ORAL CAPSULE 25000 UNIT, 50000 UNIT
NC
DIALYVITE VITAMIN D 5000 NC
DIALYVITE VITAMIN D3 MAX NC
DRISDOL ORAL CAPSULE NP
D-VI-SOL CE
eql vitamin d3 oral capsule 2000 unit, 5000 unit NC
ergocal NP
ergocalciferol oral capsule PG
ergocalciferol oral solution NC
gnp vitamin d maximum strength NC
gnp vitamin d oral tablet chewable CE
gnp vitamin d super strength NC
hm vitamin d3 NC
MAXIMUM D3 NC
MEPHYTON PB QL
nat-rul vitamin d oral tablet 2000 unit, 5000 unit NC
natural vitamin d-3 NC
OPTIMAL D3 M NC
OPTIMAL-D NC
OPURITY VITAMIN D NC
pa vitamin d-3 oral capsule NC
phytonadione oral PG QL
ra vitamin d-3 oral capsule NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018142
Drug Name Drug Status Drug Details
REPLESTA NC
REPLESTA CHILDRENS NC
REPLESTA NX NC
sm vitamin d3 oral capsule 2000 unit, 4000 unit NC
super daily d3 oral liquid 2000 ut/0.028ml NC
THERA-D 2000 NC
THERA-D 4000 NC
THERA-D RAPID REPLETION NC
vitamin d (ergocalciferol) oral capsule 50000 unit
PG
vitamin d oral capsule 2000 unit NC
vitamin d oral tablet 2000 unit NC
vitamin d2 oral tablet 2000 unit NC
vitamin d3 maximum strength NC
vitamin d-3 oral capsule CE
vitamin d3 oral capsule 10000 unit, 2000 unit, 5000 unit, 50000 unit
NC
vitamin d3 oral liquid 5000 unit/ml NC
vitamin d3 oral tablet 10000 unit, 2000 unit, 3000 unit, 5000 unit, 50000 unit
NC
vitamin d3 oral tablet chewable 2000 unit, 5000 unit
NC
vitamin d3 super strength oral tablet NC
2018 Aetna Pharmacy Drug Guide - Aetna Value Plus Plan
The formulary is updated the first week of each month.
09/01/2018143
Index
abacavir sulfate ........................ 61abacavir sulfate-lamivudine ...... 61abacavir-lamivudine-zidovudine 61ABANEU-SL........................ 105ABILIFY................................ 59ABREVA................................ 79ABSORICA............................ 79ABSTRAL.............................. 22acamprosate calcium .............. 131ACANYA............................... 79acarbose ...................................38ACCOLATE........................... 30ACCU-CHEK AVIVA PLUS.90ACCU-CHEK COMPACT PLUS...................................... 90ACCU-CHEK FASTCLIX LANCETS............................ 112ACCU-CHEK MULTICLIX LANCETS............................ 112ACCU-CHEK SMARTVIEW........................ 90ACCU-CHEK SOFT TOUCH LANCETS............. 112ACCU-CHEK SOFTCLIX LANCETS............................ 112ACCUPRIL............................ 48ACCURETIC......................... 48ACCUTREND GLUCOSE....90acebutolol hcl ........................... 66acetaminophen-codeine .............22acetaminophen-codeine #2 ........22acetaminophen-codeine #3 ........22acetaminophen-codeine #4 ........23ACETASOL HC................... 126acetazolamide .......................... 94acetazolamide er ...................... 94acetic acid .......................102, 126acetylcysteine ...........................78acid reducer ............................136acid reducer maximum strength...............................................136ACIPHEX.............................137ACIPHEX SPRINKLE........ 137acitretin ................................... 79ACTEMRA............................ 19ACTICLATE........................ 135ACTIGALL.......................... 100ACTIMMUNE....................... 54ACTIQ.................................... 23
ACTIVE 1ST BLOOD LANCETS 30G.....................112active fe ..................................105ACTIVELLA.......................... 98ACTONEL............................. 95ACTOPLUS MET.................. 38ACTOPLUS MET XR............38ACTOS................................... 38ACULAR..............................122ACULAR LS........................ 122ACUVAIL............................ 122acyclovir .............................61, 79ACZONE................................79ADAGEN............................... 67ADALAT CC......................... 67adapalene .................................79adapalene-benzoyl peroxide ......79ADCIRCA..............................69ADDERALL.......................... 17ADDERALL XR....................17adefovir dipivoxil ......................61ADEMPAS............................. 69ADLYXIN..............................38ADLYXIN STARTER PACK..................................... 38ADMELOG............................38ADMELOG SOLOSTAR.......38ADRENALIN...................... 120ADVAIR DISKUS................. 30ADVAIR HFA....................... 30ADVANCE INTUITION TEST.......................................90ADVANCE MICRO-DRAW TEST.......................................90ADVATE.............................. 103ADVOCATE REDI-CODE... 90ADVOCATE REDI-CODE+ TEST.......................................90ADVOCATE TEST................ 90adynovate ...............................103ADYPHREN........................ 141ADYPHREN AMP II...........141ADYPHREN II.................... 141ADZENYS ER....................... 17ADZENYS XR-ODT............. 17AFEDITAB CR......................67AFINITOR.............................54AFINITOR DISPERZ........... 54AFREZZA..............................38
AFSTYLA............................ 103AGAMATRIX AMP TEST... 90AGAMATRIX JAZZ TEST...90AGAMATRIX KEYNOTE TEST.......................................90AGAMATRIX PRESTO TEST.......................................90AGGRENOX....................... 103AGRYLIN............................103AIMOVIG.............................. 67AIMOVIG 140 DOSE.............67AIRAVITE........................... 105AIRDUO RESPICLICK 113/14...................................... 30AIRDUO RESPICLICK 232/14...................................... 30AIRDUO RESPICLICK 55/14........................................30AKTEN.................................122AKTIPAK.............................. 79AKYNZEO.............................43ALA-QUIN............................ 79ALAVERT..............................45ALAVERT ALLERGY/SINUS.................78ALAWAY.............................122ALAWAY CHILDRENS ALLERGY........................... 122ALBENZA..............................28albuterol sulfate ....................... 30albuterol sulfate er ................... 30alclometasone dipropionate .......79ALCORTIN A........................79ALDACTAZIDE....................94ALDACTONE........................94ALDARA............................... 79ALDURAZYME....................95ALECENSA........................... 54alendronate sodium ...................95ALFERON N......................... 54alfuzosin hcl er ....................... 102ALINIA.................................. 51ALKERAN.............................54ALLEGRA ALLERGY......... 45ALLEGRA ALLERGY CHILDRENS......................... 45ALLEGRA-D ALLERGY & CONGESTION...................... 78allergy eye drops .................... 122
144
allergy relief .............................45allopurinol ..............................102ALLZITAL.............................22almotriptan malate ................. 115ALOCRIL.............................122alogliptin benzoate ................... 38alogliptin-metformin hcl ........... 38alogliptin-pioglitazone .............. 38ALOMIDE............................122ALORA.................................. 98alosetron hcl ...........................100ALOXI....................................43ALPHAGAN P.....................122ALPHANATE/VWF COMPLEX/HUMAN...........103ALPHANINE SD................. 103alprazolam ............................... 29alprazolam er ........................... 28ALPRAZOLAM INTENSOL 29alprazolam xr ...........................29ALPROLIX.......................... 103ALREX.................................122ALTABAX............................. 79ALTACE................................ 48altafluor ................................. 122ALTAVERA...........................72ALTOPREV........................... 46ALUNBRIG........................... 54ALVESCO.............................. 30alyacen 1/35 ............................. 72alyacen 7/7/7 ............................ 72AMABELZ............................. 98amantadine hcl ......................... 58AMARYL...............................38AMBIEN.............................. 109AMBIEN CR........................ 109amcinonide ...............................79AMELUZ............................... 79AMERGE............................. 115AMETHIA............................. 72AMETHIA LO....................... 72AMICAR.............................. 109amiloride hcl ............................ 94amiloride-hydrochlorothiazide .. 94amiodarone hcl .........................29AMITIZA............................. 100amitriptyline hcl ....................... 36amlodipine besy-benazepril hcl ..48amlodipine besylate .................. 67amlodipine besylate-valsartan ...48
amlodipine-atorvastatin ............ 69amlodipine-olmesartan ............. 48amlodipine-valsartan-hctz .........48AMMONUL...........................95AMNESTEEM....................... 79amoxapine ............................... 36amoxicill-clarithro-lansopraz ..137amoxicillin ............................. 129amoxicillin-pot clavulanate ..... 129amoxicillin-pot clavulanate er . 129amphetamine-dextroamphet er . 17amphetamine-dextroamphetamine ..................17ampicillin ............................... 129AMPYRA............................. 131AMRIX.................................119ANADROL-50....................... 26ANAFRANIL........................ 36anagrelide hcl ......................... 103ANA-LEX.............................. 27ANALPRAM-HC...................27ANAPROX DS.......................19anastrozole ...............................54ANCOBON............................ 44ANDRODERM......................26ANDROGEL..........................26ANDROGEL PUMP..............26ANGELIQ.............................. 98ANIMI-3...............................105ANIMI-3/VITAMIN D........ 105ANORO ELLIPTA.................30ANTABUSE......................... 131ANTARA............................... 46anucort-hc ................................27ANUSOL-HC......................... 27ANZEMET.............................43apap-caff-dihydrocodeine ......... 23APEXICON E........................ 79APIDRA................................. 38APIDRA SOLOSTAR............38APLENZIN............................ 36apraclonidine hcl .................... 122aprepitant ................................ 43APRI.......................................72APRISO................................ 100APTENSIO XR...................... 17APTIOM.................................33APTIVUS................................61ARALAST NP......................134ARANELLE...........................72
ARANESP (ALBUMIN FREE)...................................105ARAVA.................................. 19ARCALYST........................... 19ARCAPTA NEOHALER.......30ARICEPT............................. 131ARIMIDEX............................54aripiprazole ..............................59ARIXTRA.............................. 32armodafinil .............................. 17ARMONAIR RESPICLICK 113...........................................30ARMONAIR RESPICLICK 232...........................................30ARMONAIR RESPICLICK 55.............................................30ARMOUR THYROID.........136ARNUITY ELLIPTA............ 30AROMASIN...........................54ARRANON............................54ARTHROTEC........................19ARYMO ER........................... 23ARZERRA............................. 54ASACOL HD........................100ASCOMP-CODEINE.............23ASMANEX 120 METERED DOSES....................................30ASMANEX 14 METERED DOSES....................................30ASMANEX 30 METERED DOSES....................................30ASMANEX 60 METERED DOSES....................................30ASMANEX 7 METERED DOSES....................................30ASMANEX HFA................... 30aspirin-dipyridamole er ...........103ASSURE 3 TEST....................90ASSURE 4 TEST....................90ASSURE II............................. 90ASSURE II CHECK.............. 90ASSURE LANCETS............ 112ASSURE PLATINUM...........90ASSURE PRISM MULTI TEST.......................................90ASSURE PRO TEST..............90ASTAGRAF XL.....................64ASTEPRO.............................120ASTERO.................................79ATACAND............................ 48
145
ATACAND HCT................... 48atazanavir sulfate ..................... 61ATELVIA............................... 95atenolol .................................... 66atenolol-chlorthalidone ............. 48ATGAM................................. 64ATIVAN................................. 29atomoxetine hcl ........................17atorvastatin calcium ................. 46atovaquone ...............................51atovaquone-proguanil hcl ..........52ATRALIN.............................. 79ATRIPLA............................... 61atropine sulfate .......................122ATROVENT HFA................. 30AUBAGIO............................131AUGMENTIN..................... 129AUGMENTIN XR...............129AUSTEDO............................131AUVI-Q................................ 141AVALIDE.............................. 48AVANDIA..............................39AVAPRO................................ 48AVAR CLEANSER............... 80AVAR LS CLEANSER..........80avar-e emollient ........................80avar-e green ............................. 80AVAR-E LS............................80AVC VAGINAL................... 140AVELOX................................ 99AVIANE................................. 72avidoxy .................................. 135AVIDOXY DK.....................135avita .........................................80AVODART...........................102AVONEX..............................131AVONEX PEN..................... 131AVONEX PREFILLED.......131av-vite fb ................................ 105AYGESTIN.......................... 130AZACTAM...........................117AZASITE..............................122azathioprine ............................. 64azelastine hcl .................. 120, 122AZELEX.................................80AZILECT............................... 58azithromycin .......................... 112AZOPT..................................122AZOR..................................... 48aztreonam .............................. 117
AZULFIDINE......................100AZULFIDINE EN-TABS.... 100AZURETTE........................... 72b-6 folic acid ...........................105bacitracin ............................... 122bacitracin-polymyxin b ........... 122baclofen ..................................119BACTRIM..............................51BACTRIM DS........................51BACTROBAN........................80BACTROBAN NASAL........120BALCOLTRA........................ 72balsalazide disodium ...............100BALZIVA............................... 72BANZEL................................ 33BARACLUDE........................61BASAGLAR KWIKPEN....... 39BAXDELA............................. 99BAYER BREEZE 2 TEST......90BAYER CONTOUR TEST....90BAYER MICROLET LANCETS............................ 113BD AUTOSHIELD.............. 113BD INSULIN SYRINGE.....113BD INSULIN SYRINGE HALF-UNIT........................ 113BD INSULIN SYRINGE MICROFINE........................113BD INSULIN SYRINGE U-500.........................................113BD INSULIN SYRINGE ULTRAFINE....................... 113BD LANCET ULTRAFINE 30G........................................113BD LANCET ULTRAFINE 33G........................................113BD MICROTAINER LANCETS............................ 113BD PEN................................ 113BD PEN MINI......................113BD PEN NEEDLE MINI U/F........................................113BD PEN NEEDLE NANO U/F........................................113BD PEN NEEDLE SHORT U/F........................................113BD PEN NEEDLE ULTRAFINE....................... 113BD SAFETYGLIDE INSULIN SYRINGE........... 113
BD SAFETY-LOK INSULIN SYRINGE........... 113BEBULIN............................. 103BECONASE AQ................... 121BELBUCA..............................23BELSOMRA.........................126benazepril hcl ........................... 48benazepril-hydrochlorothiazide . 48BENEFIX............................. 103BENICAR.............................. 48BENICAR HCT..................... 48BENLYSTA............................64bensal hp .................................. 80BENTYL...............................137BENZACLIN......................... 80BENZACLIN WITH PUMP..80BENZAMYCIN..................... 80benznidazole .............................28benzonatate ..............................78benzoyl peroxide-erythromycin .80benztropine mesylate ................ 58BEPREVE.............................122BERINERT.......................... 103BESIVANCE........................ 122BETAGAN........................... 122betamethasone dipropionate aug ...........................................80betamethasone valerate ............ 80BETAPACE............................66BETAPACE AF......................66BETASERON.......................131betaxolol hcl ..................... 66, 122bethanechol chloride ............... 139BETHKIS............................... 18BETIMOL.............................122BETOPTIC-S........................ 122BEVESPI AEROSPHERE..... 30BEVYXXA............................. 32bexarotene ............................... 54BEYAZ................................... 72BIAXIN................................ 112bicalutamide .............................54BIDIL..................................... 69BIFERARX.......................... 105BIKTARVY............................61BILTRICIDE..........................28bimatoprost ............................ 122BINOSTO............................... 95bio glo .................................... 122
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BIOSCANNER GLUCOSE TEST.......................................90bisoprolol fumarate .................. 66bisoprolol-hydrochlorothiazide ..48BIVIGAM.............................127BLEPH-10.............................122BLEPHAMIDE.................... 122BLEPHAMIDE S.O.P.......... 122blood glucose test ..................... 90BONIVA................................. 95BONJESTA............................ 43BOSULIF............................... 54BOTOX.................................121bp 10-1 .....................................80bp vit 3 ................................... 105BPROTECTED PEDIA D-VITE..................................... 141BRAFTOVI............................ 54BREO ELLIPTA.................... 30briellyn .....................................72BRILINTA......................94, 103brimonidine tartrate ................122BRISDELLE.........................131BRIVIACT............................. 33bromfenac sodium (once-daily)...............................................122bromocriptine mesylate ............ 58BROMSITE.......................... 123BROVANA.............................30budesonide .................. 30, 77, 121budesonide er ............................77bullseye mini safety lancets ..... 113BULLSEYE SAFETY LANCETS............................ 113bumetanide ...............................94BUNAVAIL........................... 23BUPAP................................... 22BUPHENYL...........................95buprenorphine .......................... 23buprenorphine hcl ..................... 23buprenorphine hcl-naloxone hcl .23bupropion hcl ........................... 36bupropion hcl er (smoking det)...............................................131bupropion hcl er (sr) ................ 36bupropion hcl er (xl) ................36buspirone hcl ............................ 29BUSULFEX........................... 54butalbital-acetaminophen ......... 22butalbital-apap-caff-cod ........... 23
butalbital-apap-caffeine ............22butalbital-asa-caff-codeine ....... 23butalbital-asa-caffeine .............. 22BUTISOL SODIUM.............109butorphanol tartrate ................. 23BUTRANS............................. 23BYDUREON..........................39BYDUREON BCISE..............39BYETTA 10 MCG PEN......... 39BYETTA 5 MCG PEN........... 39BYSTOLIC............................. 66BYVALSON........................... 66cabergoline ...............................95CABOMETYX....................... 54CADUET................................70CAFERGOT.........................115CALAN.................................. 67CALAN SR.............................67CALCIDOL.......................... 141CALCIFEROL..................... 141calcipotriene .............................80calcipotriene-betameth diprop ...80calcitonin (salmon) .................. 95calcitrene ................................. 80calcitriol ............................. 80, 95CALQUENCE........................54CAMBIA.............................. 115CAMPTOSAR........................54CAMRESE............................. 72CAMRESE LO....................... 72CANASA.............................. 100candesartan cilexetil .................48candesartan cilexetil-hctz ......... 48CAPASTAT SULFATE......... 53capecitabine ............................. 54CAPEX................................... 80CAPRELSA............................54captopril ...................................48captopril-hydrochlorothiazide ... 48CARAC.................................. 80CARAFATE......................... 137CARBAGLU.......................... 95carbamazepine ......................... 33carbamazepine er ..................... 33CARBATROL........................ 33carbidopa ................................. 58carbidopa-levodopa .................. 58carbidopa-levodopa er .............. 58carbidopa-levodopa-entacapone 58carbinoxamine maleate .............45
CARDIZEM...........................68CARDIZEM CD.................... 67CARDIZEM LA.....................67CARDURA............................ 48CARDURA XL.................... 102CARESENS N GLUCOSE TEST.......................................90CARIMUNE NF.................. 127carisoprodol ........................... 119carisoprodol-aspirin ................119carisoprodol-aspirin-codeine ... 119CARNITOR........................... 96CARNITOR SF......................96CAROSPIR............................ 94carteolol hcl ............................123CARTIA XT...........................68carvedilol ................................. 66carvedilol phosphate er ............. 66CASODEX............................. 54CATAPRES............................48CATAPRES-TTS-1.................48CATAPRES-TTS-2.................49CATAPRES-TTS-3.................49CAYSTON............................117CAZIANT.............................. 72cefaclor .................................... 70cefaclor er ................................ 70cefadroxil .................................70cefazolin sodium .......................70cefdinir .....................................70cefditoren pivoxil ......................70cefepime hcl ............................. 70cefepime-dextrose .....................71cefixime ................................... 71cefotaxime sodium ....................71cefotetan disodium ....................71cefoxitin sodium ....................... 71cefoxitin sodium-dextrose .........71cefpodoxime proxetil ................ 71cefprozil ................................... 71ceftazidime ...............................71ceftriaxone sodium ................... 71cefuroxime axetil ..................... 71cefuroxime sodium ................... 71CELEBREX............................19celecoxib .................................. 19CELEXA................................ 36CELLCEPT............................ 64CELONTIN............................33CEM-UREA........................... 80
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CENFOL.............................. 105CENTANY.............................80CENTRATEX...................... 105cephalexin ................................ 71CERDELGA.........................105CEREZYME.........................106CERVIDIL........................... 127CESAMET..............................43cetirizine hcl .............................45cetirizine-pseudoephedrine er .... 78CETRAXAL......................... 126cevimeline hcl ......................... 117CHANTIX............................ 131CHANTIX CONTINUING MONTH PAK...................... 131CHANTIX STARTING MONTH PAK...................... 131CHATEAL............................. 72CHEMET............................... 43CHENODAL........................ 100childrens loratadine .................. 45chlordiazepoxide hcl ................. 29chlordiazepoxide-amitriptyline131chlordiazepoxide-clidinium ..... 137chlorhexidine gluconate .......... 117chloroquine phosphate .............. 52chlorothiazide ...........................94chlorpromazine hcl ................... 59chlorpropamide ........................ 39chlorthalidone .......................... 94chlorzoxazone ........................ 119CHOLBAM............................ 67cholestyramine ......................... 46cholestyramine light ................. 46choline-mag trisalicylate ...........22CIALIS................................... 70CICLODAN........................... 80CICLODAN SOLUTION...... 80ciclopirox ................................. 80ciclopirox olamine .................... 81ciclopirox treatment ................. 81cidofovir ...................................61CIFEREX............................. 106cilostazol ................................ 103CILOXAN............................ 123CIMDUO................................61cimetidine ...............................137cimetidine hcl ......................... 137CIMZIA................................100CIMZIA PREFILLED......... 100
CIMZIA STARTER KIT..... 100CINQAIR............................. 110CINRYZE.............................103CIPRO.................................. 100CIPRO HC............................126CIPRO XR............................100CIPRODEX.......................... 126ciprofloxacin .......................... 100ciprofloxacin hcl ............. 100, 126ciprofloxacin-ciproflox hcl er ..100citalopram hydrobromide ..........36CITRANATAL 90 DHA...... 118CITRANATAL B-CALM.... 118CITRANATAL DHA...........118CITRANATAL HARMONY...............................................118CITRANATAL MEDLEY...118CITRANATAL RX..............118claravis .................................... 81CLARINEX............................45CLARINEX-D 12 HOUR...... 78clarithromycin ........................ 112clarithromycin er .................... 112CLARITIN............................. 45CLARITIN EYE...................123CLARITIN REDITABS.........45CLARITIN-D 12 HOUR........78CLARITIN-D 24 HOUR........78CLENPIQ............................. 111CLEOCIN....................... 51, 140CLEOCIN PHOSPHATE.......51CLEOCIN-T........................... 81CLEVER CHEK AUTO-CODE TEST...........................90CLEVER CHEK AUTO-CODE VOICE........................ 90CLEVER CHEK TEST.......... 90CLEVER CHOICE AUTO-CODE TEST...........................90CLEVER CHOICE MICRO TEST.......................................91CLIMARA............................. 98CLIMARA PRO.....................98CLINDACIN ETZ................. 81CLINDACIN PAC................. 81CLINDAGEL.........................81clindamycin hcl .........................51clindamycin phos-benzoyl perox ....................................... 81clindamycin phosphate .51, 81, 140
clindamycin-tretinoin ................81CLINDESSE.........................140clobetasol propionate ................81clobetasol propionate e ............. 81clobetasol propionate emulsion . 81CLOBEX................................ 81CLOBEX SPRAY...................81clocortolone pivalate .................81clodan ...................................... 81CLODERM............................ 81CLODERM PUMP................ 81clomipramine hcl ...................... 36clonazepam .............................. 33clonidine hcl ............................. 49clonidine hcl er ......................... 17clopidogrel bisulfate ................103clorazepate dipotassium ............29clotrimazole ........................... 117clotrimazole-betamethasone ..... 81clozapine .................................. 59CLOZARIL............................ 59COAGADEX........................103COAGUCHEK LANCETS..113coal tar .................................... 81COARTEM............................ 52codeine sulfate ..........................23COLAZAL............................100colchicine ............................... 102colchicine-probenecid ..............103COLCRYS............................ 103colesevelam hcl .........................46COLESTID.............................46COLESTID FLAVORED...... 46colestipol hcl ............................ 46COLY-MYCIN M.................. 51COLY-MYCIN S..................126COLYTE WITH FLAVOR PACKS..................................111COMBIGAN........................ 123COMBIPATCH...................... 98COMBIVENT RESPIMAT....30COMBIVIR............................ 61COMETRIQ (100 MG DAILY DOSE)....................... 54COMETRIQ (140 MG DAILY DOSE)....................... 54COMETRIQ (60 MG DAILY DOSE).....................................54comfort assured lancets 28g .... 113comfort assured lancets 33g .... 113
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COMPLERA.......................... 61COMPRO............................... 59COMTAN...............................58CONCERTA.......................... 17CONDYLOX..........................81CONZIP..................................23COOL BLOOD GLUCOSE TEST STRIPS.........................91COPAXONE.........................131CORDRAN............................ 81COREG.................................. 66COREG CR............................ 66COREMINO.........................135CORGARD............................ 66CORIFACT.......................... 103CORLANOR........................ 134CORTANE-B........................126CORTANE-B AQUEOUS... 126CORTEF................................ 77cortic-nd .................................126CORTIFOAM........................ 27cortisone acetate ...................... 77CORTISPORIN......................81CORVITA 150...................... 106CORVITE 150.......................106CORZIDE.............................. 49COSENTYX........................... 81COSENTYX SENSOREADY PEN............. 81COSOPT............................... 123COSOPT PF..........................123COTELLIC.............................54COTEMPLA XR-ODT.......... 17COUMADIN..........................32COZAAR................................49CREON.................................. 94CRESEMBA...........................44CRESTOR.............................. 46CRINONE............................ 140CRIXIVAN............................ 61cromolyn sodium ...............30, 123CROTAN................................81CRYSELLE-28....................... 72CUPRIMINE......................... 65CUTIVATE............................ 81CUVITRU............................ 127CUVPOSA............................ 137CVS ADVANCED GLUCOSE TEST................... 91cvs d3 ..................................... 141
cyanocobalamin ......................106CYCLAFEM 1/35...................72cyclobenzaprine hcl .................119CYCLOGYL.........................123CYCLOMYDRIL.................123cyclopentolate hcl ................... 123cyclophosphamide .................... 54cycloserine ............................... 53CYCLOSET............................39cyclosporine ............................. 65cyclosporine modified ............... 65CYMBALTA.......................... 36cyotic ..................................... 126cyproheptadine hcl ....................45CYSTADANE........................ 96CYSTAGON.........................102CYSTARAN.........................123CYTOGAM.......................... 127CYTOMEL........................... 136CYTOTEC............................ 137CYTOVENE...........................61cytra-2 ................................... 102CYTRA-3..............................102cytra-k ................................... 102d 10000 .................................. 141d 2000 .................................... 141d 400 ...................................... 141d 5000 .................................... 141D.H.E. 45.............................. 115d-2000 maximum strength ...... 142d2000 ultra strength ................142D3 DOTS.............................. 142d3 maximum strength ............. 142d3 super strength .................... 142d3-1000 .................................. 142d-3-5 ...................................... 142D3-50.....................................142d-5000 ....................................142DAKLINZA........................... 61DALIRESP.............................30danazol .................................... 26DANTRIUM........................ 120dantrolene sodium ...................120dapsone .............................. 52, 81DARAPRIM.......................... 52darifenacin hydrobromide er ... 139DASETTA 1/35.......................72DASETTA 7/7/7......................72DAXBIA.................................71DAYPRO................................19
DAYSEE.................................72DAYTRANA......................... 17DDAVP.................................. 96DDAVP RHINAL TUBE...... 96DDROPS.............................. 142DEBACTEROL....................117DECARA..............................142deferoxamine mesylate ....... 42, 43DELYLA................................ 72DELZICOL...........................100DEMADEX............................94demeclocycline hcl .................. 135DEMSER................................49DENAVIR..............................81DEPAKENE...........................33DEPAKOTE...........................33DEPAKOTE ER.....................33DEPAKOTE SPRINKLES.... 33DEPEN TITRATABS............ 65DEPO-PROVERA..................72DEPO-TESTOSTERONE...... 27DERMA-SMOOTHE/FS BODY..................................... 82DERMA-SMOOTHE/FS SCALP.................................... 82DERMOTIC......................... 126DESCOVY..............................61DESFERAL............................43desipramine hcl .........................36desloratadine ............................45desmopressin ace spray refrig ... 96desmopressin acetate ................ 96desmopressin acetate spray .......96desogestrel-ethinyl estradiol ......72DESONATE........................... 82desonide ................................... 82DESOWEN.............................82desoximetasone ........................ 82DESOXYN............................. 17desvenlafaxine er ......................36desvenlafaxine succinate er .......36DETROL.............................. 139DETROL LA........................ 139dexamethasone .........................77DEXAMETHASONE INTENSOL............................ 77dexamethasone sodium phosphate ............................... 123DEXEDRINE.........................17DEXILANT..........................137
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dexmethylphenidate hcl ............ 17dexmethylphenidate hcl er ........ 17dextroamphetamine sulfate .......17dextroamphetamine sulfate er ...17DIALYVITE VITAMIN D 5000....................................... 142DIALYVITE VITAMIN D3 MAX..................................... 142DIASTAT ACUDIAL............33DIASTAT PEDIATRIC.........33diatrue plus test ........................ 91diazepam ............................ 29, 33DIAZEPAM INTENSOL.......29DIBENZYLINE..................... 49DICLEGIS..............................43diclofenac potassium .................19diclofenac sodium ........ 19, 82, 123diclofenac sodium er ................. 19diclofenac-misoprostol ..............19DICLOFEX DC..................... 82dicloxacillin sodium ................ 129dicyclomine hcl .......................137didanosine ................................ 61DIDREX.................................17DIFFERIN............................. 82DIFICID...............................112diflorasone diacetate .................82DIFLUCAN........................... 44diflunisal .................................. 22DIGITEK............................... 69DIGOX................................... 69digoxin .....................................69dihydroergotamine mesylate....................................... 115, 116DILANTIN............................ 33DILANTIN INFATABS........ 33DILATRATE-SR................... 28DILAUDID............................23diltiazem cd ..............................68diltiazem hcl .............................68diltiazem hcl er .........................68diltiazem hcl er beads ............... 68diltiazem hcl er coated beads .... 68dilt-xr ...................................... 68DIOVAN................................ 49DIOVAN HCT....................... 49DIPENTUM......................... 100diphenatol ................................ 42diphenoxylate-atropine .............42DIPROLENE......................... 82
DIPROLENE AF................... 82dipyridamole .......................... 103disopyramide phosphate ............29disulfiram ...............................131DITROPAN XL................... 139DIURIL.................................. 94divalproex sodium .................... 33divalproex sodium er ................ 33DIVIGEL................................99DIVISTA.............................. 106dofetilide .................................. 29DOLOPHINE.........................23donepezil hcl ...........................131DOPTELET.......................... 106DORAL................................ 109DORYX................................ 135DORYX MPC...................... 135dorzolamide hcl ...................... 123dorzolamide hcl-timolol mal ....123DOVONEX............................ 82doxazosin mesylate ...................49doxepin hcl ......................... 36, 82doxercalciferol ......................... 96doxycycline .............................. 82doxycycline hyclate ................ 135doxycycline monohydrate ....... 135DRISDOL.............................142dronabinol ................................43drospirenone-ethinyl estradiol...........................................72, 73DUAC.....................................82DUAVEE................................99DUETACT............................. 39DUEXIS................................. 19DULERA................................31duloxetine hcl ........................... 36DUO-CARE TEST.................91DUOPA.................................. 58DUPIXENT............................66durachol ................................. 106DURAGESIC-100.................. 23DURAGESIC-12....................23DURAGESIC-25....................23DURAGESIC-50....................23DURAGESIC-75....................23DUREZOL........................... 123DURLAZA...........................103DUROLANE........................120dutasteride ............................. 102dutasteride-tamsulosin hcl .......102
DUTOPROL.......................... 49DUZALLO........................... 103D-VI-SOL............................. 142DYANAVEL XR................... 17DYAZIDE.............................. 94DYMISTA............................ 121DYRENIUM..........................94DYSPORT............................ 121E.E.S. 400.............................. 112E.E.S. GRANULES..............112easy plus blood glucose test .......91EASY STEP TEST..................91easy talk blood glucose test .......91EASY TOUCH LANCETS 21G........................................113EASY TOUCH LANCETS 23G........................................113EASY TOUCH LANCETS 26G........................................114EASY TOUCH LANCETS 26G/TWIST...........................114EASY TOUCH LANCETS 28G........................................114EASY TOUCH LANCETS 28G/TWIST...........................114EASY TOUCH LANCETS 30G........................................114EASY TOUCH LANCETS 30G/TWIST...........................114EASY TOUCH LANCETS 32G........................................114EASY TOUCH LANCETS 32G/TWIST...........................114EASY TOUCH LANCETS 33G/TWIST...........................114EASY TOUCH LANCING DEVICE................................114EASY TOUCH SAFETY LANCETS 21G.....................114EASY TOUCH SAFETY LANCETS 23G.....................114EASY TOUCH SAFETY LANCETS 26G.....................114EASY TOUCH SAFETY LANCETS 28G.....................114EASY TOUCH TEST.............91easy trak blood glucose test ...... 91EASY TWIST & CAP LANCETS............................ 114EASYGLUCO........................ 91
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EASYGLUCO PLUS............. 91EASYMAX 15 TEST..............91EASYMAX TEST.................. 91easyplus blood glucose test ........91EASYPRO BLOOD GLUCOSE TEST................... 91EASYPRO PLUS................... 91EC-NAPROSYN.................... 19econazole nitrate ...................... 82ECOZA................................... 82EDARBI................................. 49EDARBYCLOR.....................49EDECRIN.............................. 94EDLUAR..............................109EDURANT............................ 61efavirenz .................................. 61EFFEXOR XR....................... 36EFFIENT..............................103EFUDEX................................82ELAPRASE............................ 96ELDEPRYL........................... 58ELELYSO.............................106element compact test ................ 91ELEMENT TEST...................91ELESTAT............................. 123ELESTRIN............................. 99eletriptan hydrobromide ..........116ELIDEL..................................82ELIGARD.............................. 54ELIMITE................................82ELINEST................................73ELIQUIS.................................32ELIQUIS STARTER PACK.. 32ELIXOPHYLLIN...................31ELLA...................................... 73ELMIRON............................102ELOCON................................82ELOCTATE..........................104EMADINE........................... 123EMBEDA............................... 23EMBRACE BLOOD GLUCOSE TEST................... 91EMBRACE EVO BLOOD GLUCOSE TEST................... 91EMBRACE PRO GLUCOSE TEST.......................................91EMCYT.................................. 54EMEND..................................43EMFLAZA............................. 77EMOQUETTE........................73
EMSAM..................................36EMTRIVA..............................61EMVERM.............................. 28ENABLEX............................140enalapril maleate ......................49enalapril-hydrochlorothiazide ... 49ENBREL................................ 19ENBREL MINI...................... 19ENBREL SURECLICK......... 19ENDARI.................................18ENDOCET............................. 23enoxaparin sodium ................... 32ENPRESSE-28........................73ENSKYCE..............................73ENSTILAR.............................82entacapone ............................... 58entecavir .................................. 61ENTOCORT EC.....................77ENTRESTO..........................121ENTYVIO.............................110enulose ................................... 100ENVARSUS XR.....................65EPANED................................ 49EPCLUSA.............................109EPIDUO................................. 82EPIDUO FORTE................... 82epinastine hcl ..........................123epinephrine .............................141EPIPEN 2-PAK.................... 141EPIPEN JR 2-PAK............... 141EPISNAP.............................. 141EPITOL.................................. 33EPIVIR................................... 61EPIVIR HBV.................... 61, 62eplerenone ................................ 49EPOGEN.............................. 106epoprostenol sodium ................. 70eprosartan mesylate ..................49EPZICOM.............................. 62eq aspirin low dose ....................22eql vitamin d3 ......................... 142EQUETRO............................. 59ergocal ................................... 142ergocalciferol ......................... 142ergoloid mesylates .................. 131ERGOMAR..........................116ERIVEDGE............................54ERLEADA............................. 55ERRIN....................................73ERTACZO..............................83
ery ........................................... 83ERYPED 200........................ 112ERYPED 400........................ 112ERY-TAB............................. 112ERYTHROCIN STEARATE...............................................112erythromycin .................... 83, 123erythromycin base .................. 112erythromycin ethylsuccinate ....112erythromycin stearate .............112ESBRIET.............................. 133escitalopram oxalate ................ 36ESGIC.....................................22esomeprazole magnesium ........137esomeprazole strontium .......... 137ESTARYLLA......................... 73estazolam ............................... 109ESTRACE....................... 99, 140estradiol ............................99, 140estradiol valerate ......................99estradiol-norethindrone acet ..... 99ESTRING............................. 140ESTROGEL............................99ESTROSTEP FE.....................73eszopiclone ............................. 109ethacrynic acid ......................... 94ethambutol hcl ..........................53ethosuximide ............................ 33ETHYOL................................ 55etidronate disodium .................. 96etodolac ................................... 19etodolac er ............................... 19etoposide .................................. 55EUCRISA............................. 129EUFLEXXA......................... 120EURAX.................................. 83EVAMIST...............................99EVEKEO................................ 17EVENCARE BLOOD GLUCOSE TEST................... 91EVENCARE G2 TEST...........91EVENCARE G3 TEST...........91EVENCARE MINI GLUCOSE TEST................... 91EVISTA.................................. 96EVOCLIN...............................83EVOLUTION AUTOCODE..91EVOTAZ................................ 62EVOXAC.............................. 117EVZIO.................................... 43
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EXALGO................................23EXELDERM.......................... 83EXELON.............................. 131exemestane ...............................55EXFORGE............................. 49EXFORGE HCT.................... 49EXJADE................................. 43exotic-hc ................................ 126EXTAVIA.............................132EXTINA................................. 83eye itch relief ..........................123EYLEA................................. 123EZ SMART BLOOD GLUCOSE TEST................... 91EZ SMART PLUS GLUCOSE TEST................... 91ezetimibe ..................................46ezetimibe-simvastatin ............... 46fabb ........................................106FABIOR................................. 83FABRAZYME....................... 96FALMINA............................. 73famciclovir ............................... 62famotidine .............................. 137FANAPT................................ 59FANAPT TITRATION PACK..................................... 59FARESTON........................... 55FARXIGA..............................39FARYDAK............................ 55FASLODEX........................... 55fa-vitamin b-6-vitamin b-12 .....106FAYOSIM.............................. 73FAZACLO..............................59FC2 FEMALE CONDOM... 114FEIBA...................................104felbamate ................................. 33FELBATOL............................34FELDENE..............................20felodipine er ............................. 68FEM PH................................140FEMARA............................... 55FEMCAP.............................. 114FEMHRT LOW DOSE.......... 99FEMRING........................... 140fenofibrate ..........................46, 47fenofibrate micronized ..............46fenofibric acid .......................... 47FENOGLIDE......................... 47fenoprofen calcium ................... 20
fentanyl ....................................23fentanyl citrate .........................23FENTORA............................. 23FERIVA 21/7........................ 106ferocon ................................... 106ferotrinsic ...............................106ferraplus 90 ............................ 106FERRIPROX......................... 43FERRLECIT........................ 106FERROCITE PLUS............. 106FERRO-PLEX HEMATINIC....................... 106FERROTRIN....................... 106FETZIMA.............................. 36FETZIMA TITRATION........36fexofenadine hcl ....................... 45fexofenadine hcl childrens .........45fexofenadine-pseudoephed er .... 78FIASP..................................... 39FIASP FLEXTOUCH............ 39FIBRICOR............................. 47FIBRYGA............................ 104FIFTY50 GLUCOSE TEST 2.0............................................91FINACEA.............................. 83finasteride .............................. 102FINGERSTIX LANCETS... 114FIORICET..............................22FIORICET/CODEINE...........24FIORINAL.............................22FIORINAL/CODEINE #3.....24FIRAZYR.............................104FIRMAGON.......................... 55FIRST-LANSOPRAZOLE...137FIRST-OMEPRAZOLE.......137FIRVANQ.............................. 52FLAGYL................................ 52FLAREX.............................. 123flavoxate hcl ...........................140FLEBOGAMMA DIF..........127flecainide acetate ......................29FLECTOR.............................. 83FLOLAN................................ 70flolipid ..................................... 47FLOMAX............................. 102FLONASE............................ 121FLONASE ALLERGY RELIEF................................ 121FLOVENT DISKUS.............. 31FLOVENT HFA.....................31
FLOXIN OTIC..................... 127flucaine .................................. 123fluconazole ...............................44flucytosine ................................44fludrocortisone acetate ............. 77FLUMADINE........................62flunisolide ...............................121fluocinolone acetonide .......83, 127fluocinolone acetonide body ...... 83fluocinolone acetonide scalp ......83fluocinonide ..............................83FLUORABON......................116fluorescein-benoxinate ............ 123fluor-i-strips a.t. ..................... 123fluorometholone ..................... 123FLUOROPLEX......................83fluorouracil .............................. 83fluoxetine hcl ...................... 36, 37fluoxetine hcl (pmdd) .............132fluphenazine hcl ........................59FLURA-DROPS.................. 117flurandrenolide ......................... 83flurazepam hcl ........................109flurbiprofen .............................. 20flurbiprofen sodium .................123flutamide ..................................55fluticasone propionate ....... 83, 121fluticasone-salmeterol ...............31fluvastatin sodium .................... 47fluvastatin sodium er ................ 47fluvoxamine maleate .................37fluvoxamine maleate er .............37FML......................................123FML FORTE........................123FML LIQUIFILM................123FOCALIN.............................. 17FOCALIN XR........................17folbee ..................................... 106FOLGARD RX.................... 106folic acid ................................ 106FOLIVANE-F...................... 106FOLIVANE-PLUS............... 106folplex 2.2 .............................. 106foltrin .....................................106fondaparinux sodium ................ 32FORA D15G BLOOD GLUCOSE TEST................... 91FORA D20 BLOOD GLUCOSE TEST................... 91
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FORA D40/G31 BLOOD GLUCOSE..............................91FORA G20 BLOOD GLUCOSE TEST................... 91FORA G30/PREM V10 GLUCOSE TEST................... 91FORA GD20 TEST................ 92FORA GD50 BLOOD GLUCOSE TEST................... 92FORA TN'G/TN'G VOICE....92FORA V10 BLOOD GLUCOSE TEST................... 92FORA V12 BLOOD GLUCOSE TEST................... 92FORA V20 BLOOD GLUCOSE TEST................... 92FORA V30A BLOOD GLUCOSE TEST................... 92FORACARE GD40 TEST..... 92FORACARE PREMIUM V10 TEST................................92FORACARE TEST N GO TEST.......................................92FORFIVO XL........................ 37FORTAMET.......................... 39FORTEO................................ 96FORTESTA............................27FORTISCARE TEST............. 92FOSAMAX.............................96FOSAMAX PLUS D.............. 96fosamprenavir calcium ..............62fosinopril sodium ...................... 49fosinopril sodium-hctz ...............49FOSRENOL......................... 100FRAGMIN.............................32FREESTYLE INSULINX TEST.......................................92FREESTYLE LANCETS..... 114FREESTYLE LITE TEST......92FREESTYLE PRECISION NEO TEST..............................92FREESTYLE TEST............... 92FREESTYLE UNISTICK II LANCETS............................ 114FROVA.................................116frovatriptan succinate ............. 116FUL-GLO.............................123ful-glo .................................... 123FULPHILA.......................... 106FURADANTIN................... 139
furosemide ................................94FUSION PLUS.....................106FUZEON................................62FYAVOLV............................. 99FYCOMPA.............................34gabapentin ............................... 34GABITRIL............................. 34galantamine hydrobromide ..... 132galantamine hydrobromide er ..132GALZIN............................... 117GAMASTAN S/D.................127GAMMAGARD...................127GAMMAGARD S/D LESS IGA....................................... 127GAMMAKED......................128GAMMAPLEX.................... 128GAMUNEX-C......................128ganciclovir sodium ....................62gatifloxacin ............................ 123GATTEX.............................. 101gavilax ................................... 111GAVILYTE-H......................111ge100 blood glucose test ........... 92GELCLAIR.......................... 117GELNIQUE..........................140GEL-ONE.............................120GELSYN-3........................... 120gemfibrozil ............................... 47GENERESS FE...................... 73gengraf .....................................65GENOTROPIN...................... 96GENOTROPIN MINIQUICK..........................96GENSTRIP 50........................ 92gentamicin sulfate ....... 18, 83, 124GENVOYA............................ 62GEODON............................... 59ght test .....................................92GIANVI..................................73GILDESS FE 1.5/30................73GILDESS FE 1/20.................. 73GILENYA............................ 132GILOTRIF............................. 55GLASSIA..............................134GLEEVEC.............................. 55GLEOSTINE.......................... 55glimepiride ............................... 39glipizide ................................... 39glipizide er ............................... 39glipizide xl ............................... 39
glipizide-metformin hcl ............. 39GLUCAGEN HYPOKIT.......39GLUCAGON EMERGENCY.......................39GLUCO PERFECT 3 TEST...92GLUCOCARD 01 SENSOR PLUS...................................... 92GLUCOCARD EXPRESSION TEST..............92GLUCOCARD SHINE TEST.......................................92GLUCOCARD VITAL TEST.......................................92GLUCOCARD X-SENSOR...92GLUCOCOM TEST...............92GLUCONAVII BLOOD GLUCOSE TEST................... 92GLUCOPHAGE.....................39GLUCOPHAGE XR.............. 39GLUCOTROL........................39GLUCOTROL XL................. 39GLUCOVANCE.....................39GLUMETZA..........................39glyburide .................................. 40glyburide micronized ................ 39glyburide-metformin .................40glycopyrrolate ........................ 137GLYNASE............................. 40GLYSET.................................40GLYXAMBI.........................134gnp folic acid .......................... 106gnp vitamin d ..........................142gnp vitamin d maximum strength ..................................142gnp vitamin d super strength ... 142GOCOVRI..............................58GOLYTELY......................... 111GONITRO..............................28GORDONS UREA................ 83GRALISE......................130, 132GRALISE STARTER...130, 132granisetron hcl ......................... 43GRANIX.............................. 107griseofulvin microsize ............... 44griseofulvin ultramicrosize ........44guaifenesin ac ...........................78guaifenesin-codeine .................. 78guanfacine hcl .......................... 49guanfacine hcl er ...................... 17guanidine hcl ............................ 53
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GYNAZOLE-1..................... 140HAEGARDA....................... 104HALCION............................ 109halobetasol propionate ..............83HALOG.................................. 83haloperidol ............................... 59haloperidol lactate ....................59HARVONI............................109heartburn relief 150 max st ..... 137HEATHER............................. 73HECTOROL...........................96HELIXATE FS..................... 104HEMANGEOL...................... 66hematinic plus vit/minerals ......107hematinic/folic acid .................107HEMATOGEN FA.............. 107HEMATOGEN FORTE.......107hemetab ..................................107HEMLIBRA........................... 45HEMOCYTE PLUS............. 107HEMOCYTE-F.................... 107hemocyte-plus .........................107HEMOFIL M....................... 104HEPAGAM B.......................128heparin sodium (porcine) ......... 32heparin sodium (porcine) pf ..... 32HEPSERA.............................. 62HETLIOZ............................. 109HEXALEN............................. 55HIPREX................................139HIZENTRA..........................128hm folic acid ...........................107hm vitamin d3 .........................142HORIZANT......................... 132HP ACTHAR......................... 96HUMALOG........................... 40HUMALOG KWIKPEN....... 40HUMALOG MIX 50/50......... 40HUMALOG MIX 50/50 KWIKPEN............................. 40HUMALOG MIX 75/25......... 40HUMALOG MIX 75/25 KWIKPEN............................. 40HUMATE-P......................... 104HUMATROPE.......................96HUMIRA............................... 20HUMIRA PEDIATRIC CROHNS START.................. 20HUMIRA PEN.......................20
HUMIRA PEN-CD/UC/HS STARTER.............................. 20HUMIRA PEN-PS/UV STARTER.............................. 20HUMULIN 70/30................... 40HUMULIN 70/30 KWIKPEN............................. 40HUMULIN N.........................40HUMULIN N KWIKPEN.....40HUMULIN R.........................40HUMULIN R U-500 (CONCENTRATED)............. 40HUMULIN R U-500 KWIKPEN............................. 40HYALGAN.......................... 120HYCAMTIN.......................... 55hydralazine hcl ......................... 49HYDREA............................... 55hydrochlorothiazide ..................94hydrocod polst-cpm polst er ...... 78hydrocodone-acetaminophen .....24hydrocodone-homatropine ........ 78hydrocodone-ibuprofen ............. 24hydrocortisone .............. 27, 77, 84hydrocortisone ace-pramoxine...........................................27, 83hydrocortisone acetate ........ 27, 84hydrocortisone butyr lipo base .. 84hydrocortisone butyrate ............84hydrocortisone valerate ............ 84hydrocortisone-acetic acid ...... 127hydromorphone hcl ...................24hydromorphone hcl er ............... 24hydroxychloroquine sulfate .......52hydroxyprogesterone caproate 130hydroxyurea .............................55hydroxyzine hcl ........................ 29hydroxyzine pamoate ............... 29HYLAFEM............................ 65HYMOVIS............................120hyophen ..................................139hyoscyamine sulfate ................137HYPERHEP B S/D...............128HYPERRAB.........................128HYPERRHO S/D................. 128HYPERTET S/D...................128HYQVIA...............................127HYSINGLA ER..................... 24HYZAAR............................... 49ibandronate sodium .................. 96
IBRANCE.............................. 79IBUDONE..............................24ibudone .................................... 24ibuprofen ..................................20IBUPROFEN COMFORT PAC........................................ 20IC 400......................................20IC 800......................................20ICLUSIG................................ 55IDELVION........................... 104IDHIFA................................ 111ILARIS................................... 20ILEVRO................................124imatinib mesylate ..................... 55IMBRUVICA......................... 55imipramine hcl ..........................37imipramine pamoate ................. 37imiquimod ................................ 84IMITREX............................. 116IMITREX STATDOSE REFILL................................ 116IMITREX STATDOSE SYSTEM...............................116IMPAVIDO............................ 52IMPOYZ.................................84IMURAN............................... 65IMVEXXY MAINTENANCE PACK.....140IMVEXXY STARTER PACK....................................140IN TOUCH BLOOD GLUCOSE TEST................... 92INCRELEX............................ 96INCRUSE ELLIPTA............. 31indapamide ...............................95INDERAL LA........................66INDERAL XL........................66INDOCIN...............................20indomethacin ............................20indomethacin er ........................20INFINITY BLOOD GLUCOSE TEST................... 92INFLECTRA........................101INGREZZA..........................132INLYTA................................. 55INNOPRAN XL.....................66INSPRA..................................49insulin syringe ........................ 114insulin syringe/needle ..............114insulin syringe-needle u-100 .... 114
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INTEGRA F.........................107INTEGRA PLUS..................107INTELENCE..........................62INTERMEZZO.................... 109INTRAROSA....................... 140INTRON A.............................55INTROVALE......................... 73INTUNIV............................... 17INVEGA.................................59INVIRASE............................. 62INVOKAMET...................... 134INVOKAMET XR............... 134INVOKANA.......................... 40IOPIDINE............................ 124ipratropium bromide ......... 31, 121ipratropium-albuterol ............... 31IPRIVASK..............................32irbesartan .................................49irbesartan-hydrochlorothiazide . 49IRESSA...................................55irinotecan hcl ............................55IROSPAN 24/6......................107IS 24/6................................... 107ISENTRESS........................... 62ISENTRESS HD.................... 62ISIBLOOM............................. 73isoniazid ...................................53ISOPTO CARPINE.............. 124ISORDIL TITRADOSE.........28isosorbide dinitrate ................... 28isosorbide dinitrate er ............... 28isosorbide mononitrate ............. 28isosorbide mononitrate er ..........28isradipine ................................. 68ISTALOL..............................124itraconazole ............................. 44ivermectin ................................ 28IXINITY...............................104JADENU................................ 43JADENU SPRINKLE............43JAKAFI.................................. 55JALYN..................................102JANTOVEN........................... 33JANUMET............................. 40JANUMET XR...................... 40JANUVIA...............................40JARDIANCE......................... 40JENCYCLA............................73JENTADUETO...................... 40JENTADUETO XR............... 40
JETREA................................124jevantique lo ............................. 99JEVTANA.............................. 55JINTELI................................. 99JOLESSA................................73JOLIVETTE........................... 73JUBLIA.................................. 84JULUCA.................................62JUNEL 1.5/30......................... 73JUNEL 1/20............................ 73JUNEL FE 1.5/30................... 73JUNEL FE 1/20...................... 73JUXTAPID.............................47JYNARQUE...........................96KADIAN................................ 24KALBITOR.......................... 104KALETRA............................. 62KALYDECO........................ 134KANUMA............................112KAPSPARGO SPRINKLE....66KAPVAY................................17KARBINAL ER..................... 45KARIVA.................................73KAZANO............................... 41KCENTRA........................... 104KEFLEX................................ 71KELNOR 1/35........................ 73KENALOG............................ 84KEPPRA.................................34KEPPRA XR.......................... 34KERALYT............................. 84KERYDIN............................127ketoconazole .......................44, 84ketoprofen er ............................20ketorolac tromethamine .... 20, 124ketotifen fumarate .................. 124KEVEYIS............................... 95KEVZARA............................. 20KHEDEZLA.......................... 37KINERET.............................. 20KIONEX......................... 65, 130KISQALI 200 DOSE.............. 79KISQALI 400 DOSE.............. 79KISQALI 600 DOSE.............. 79KISQALI FEMARA 200 DOSE......................................55KISQALI FEMARA 400 DOSE......................................55KISQALI FEMARA 600 DOSE......................................55
KLARON............................... 84KLOFENSAID II...................84KLONOPIN........................... 34KLOR-CON......................... 117KLOR-CON 10.....................117KOATE.................................104KOATE-DVI........................ 104KOGENATE FS...................104KOGENATE FS BIO-SET...104KOMBIGLYZE XR...............41KORLYM...............................41KOVALTRY........................ 104kp folic acid ............................107K-PHOS-NEUTRAL............117KRISTALOSE......................111kroger blood glucose test .......... 92kroger test ................................92KRYSTEXXA...................... 103K-TAB.................................. 117K-TAN PLUS....................... 107KURVELO.............................73KUVAN..................................96KYLEENA............................. 73KYNAMRO........................... 47labetalol hcl ..............................66LACRISERT........................ 124lactic acid .................................84lactulose ................................. 111lactulose encephalopathy ........ 101LAMICTAL........................... 34LAMICTAL ODT.................. 34LAMICTAL STARTER.........34LAMICTAL XR.....................34LAMISIL................................44lamivudine ................................62lamivudine-zidovudine .............. 62lamotrigine ...............................34lamotrigine er ...........................34lamotrigine starter kit-blue ....... 34lamotrigine starter kit-green ..... 34lamotrigine starter kit-orange ...34lancets ....................................114lancets super thin 28g ............. 114LANCETS ULTRA THIN... 114lancets ultra thin 30g .............. 114LANOXIN..............................69lansoprazole ........................... 137lanthanum carbonate .............. 101LANTUS................................ 41LANTUS SOLOSTAR........... 41
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LARIN 1.5/30......................... 73LARIN 1/20............................ 73LARIN FE 1.5/30................... 73LARIN FE 1/20...................... 73LASIX.....................................95LASTACAFT....................... 124latanoprost ............................. 124LATUDA................................59LAZANDA.............................24LDO PLUS............................. 84LEENA................................... 74leflunomide ...............................20LEMTRADA........................132LENVIMA 10 MG DAILY DOSE......................................56LENVIMA 14 MG DAILY DOSE......................................56LENVIMA 18 MG DAILY DOSE......................................56LENVIMA 20 MG DAILY DOSE......................................56LENVIMA 24 MG DAILY DOSE......................................56LENVIMA 8 MG DAILY DOSE......................................56LESCOL................................. 47LESCOL XL........................... 47LESSINA................................74LETAIRIS.............................. 70letrozole ................................... 56leucovorin calcium ....................56LEUKERAN.......................... 56LEUKINE............................ 107leuprolide acetate ..................... 56levalbuterol hcl ......................... 31LEVAQUIN..........................100LEVEMIR.............................. 41LEVEMIR FLEXTOUCH..... 41levetiracetam ............................34levetiracetam er ........................34levobunolol hcl ........................124levocarnitine .............................96levocetirizine dihydrochloride ... 45levofloxacin .................... 100, 124LEVONEST............................74levonorgest-eth estrad 91-day ... 74levonorgestrel ...........................74levonorgestrel-ethinyl estrad ..... 74LEVORA 0.15/30 (28).............74levorphanol tartrate ..................24
levothyroxine sodium ..............136LEVOXYL............................136LEVULAN KERASTICK......84LEXAPRO..............................37LEXIVA..................................62LIALDA............................... 101LIBERTY NEXT GENERATION TEST........... 92liberty test ................................92LIBRAX............................... 137lidocaine ...................................84lidocaine hcl ............................. 84lidocaine pak ............................ 84lidocaine viscous ..................... 118lidocaine-hydrocortisone ace .....27lidocaine-prilocaine .................. 84lidocaine-tetracaine .................. 84LIDODERM.......................... 84LIFESCAN UNISTIK 2.......114LIFESCAN UNISTIK II LANCETS............................ 114lindane ..................................... 84linezolid ................................... 52LINZESS.............................. 101liothyronine sodium ................ 136LIPITOR.................................47LIPOFEN............................... 47lisinopril ...................................49lisinopril-hydrochlorothiazide ... 49lite touch lancets .....................114LITETOUCH LANCETS.....114lithium ..................................... 59lithium carbonate ..................... 60lithium carbonate er ................. 59LITHOBID............................. 60LIVALO..................................47LO LOESTRIN FE.................74LOCOID................................. 84LOCOID LIPOCREAM.........84LODINE................................. 20LODOSYN............................. 58LOESTRIN 1.5/30 (21)........... 74LOESTRIN 1/20 (21).............. 74LOMOTIL.............................. 42LONHALA MAGNAIR REFILL KIT.......................... 31LONHALA MAGNAIR STARTER KIT...................... 31LONSURF............................. 56LOPID.................................... 47
lopinavir-ritonavir .................... 62LOPRESSOR HCT.................50LOPROX................................ 84loratadine .................................45loratadine childrens .................. 45loratadine-d 12hr ......................78loratadine-d 24hr ......................78lorazepam ................................ 29LORCET................................ 24LORCET HD......................... 24LORCET PLUS......................24LORTAB................................ 24LORYNA............................... 74LORZONE........................... 120losartan potassium ....................50losartan potassium-hctz ............ 50LOSEASONIQUE..................74LOTEMAX...........................124LOTENSIN............................ 50LOTREL.................................50LOTRISONE..........................84LOTRONEX.........................101lovastatin ................................. 47LOVAZA................................ 47LOVENOX............................. 33LOW-OGESTREL................. 74loxapine succinate .................... 60LUCEMYRA......................... 18LUCENTIS...........................124luliconazole .............................. 85LUMIGAN...........................124LUMIZYME.......................... 96LUNESTA............................ 109LUPANETA PACK............. 111LUPRON DEPOT (1-MONTH)................................ 56LUPRON DEPOT (3-MONTH)................................ 56LUPRON DEPOT (4-MONTH)................................ 56LUPRON DEPOT (6-MONTH)................................ 56LUPRON DEPOT-PED (1-MONTH)................................ 97LUPRON DEPOT-PED (3-MONTH)................................ 97LUTERA................................ 74LUXIQ....................................85LUZU..................................... 85LYNPARZA.........................130
156
LYRICA................................. 34LYRICA CR................. 130, 132LYSODREN...........................56LYSTEDA............................ 109LYZA......................................74MACROBID.........................139MACRODANTIN................139MACUGEN..........................124MAKENA............................ 130MALARONE......................... 52malathion .................................85maprotiline hcl ......................... 37MARINOL............................. 43marlissa ................................... 74MARPLAN............................ 37MATULANE......................... 56MATZIM LA......................... 68MAVIK...................................50MAVYRET...........................109MAXALT............................. 116MAXALT-MLT................... 116MAXFE................................ 107MAXIDEX........................... 124MAXIMUM D3................... 142MAXIPIME............................71MAXITROL......................... 124MAXZIDE............................. 95MAXZIDE-25.........................95meclofenamate sodium ............. 20MEDROL...............................77medroxyprogesterone acetate......................................... 74, 130mefenamic acid .........................20mefloquine hcl .......................... 52MEGACE ES........................130megestrol acetate .............. 56, 130meijer blood glucose test ...........92MEIJER TRUETEST TEST.. 92MEIJER TRUETRACK TEST.......................................92MEKINIST.............................56MEKTOVI..............................56meloxicam ................................20melphalan .................................56melphalan hcl ........................... 56memantine hcl ........................ 132memantine hcl er .................... 132MENEST................................ 99MENOSTAR.......................... 99meperidine hcl .......................... 24
MEPHYTON........................142meprobamate ........................... 29MEPRON............................... 52mercaptopurine ........................ 56mesalamine ............................ 101MESTINON........................... 53METADATE ER....................17metaproterenol sulfate ..............31metaxalone .............................120metformin hcl ........................... 41metformin hcl er ....................... 41metformin hcl er (mod) ............41metformin hcl er (osm) ............ 41methadone hcl .......................... 24METHADONE HCL INTENSOL............................ 24METHADOSE....................... 24METHADOSE SUGAR-FREE...................................... 24methamphetamine hcl ...............17methazolamide ......................... 95methenamine hippurate ...........139methenamine mandelate ..........139METHERGINE................... 127methimazole ........................... 136methitest .................................. 27methocarbamol .......................120methotrexate ............................56methotrexate sodium (pf) ........ 56methoxsalen rapid .................... 85methyclothiazide ...................... 95methyldopa .............................. 50methyldopa-hydrochlorothiazide ..................50METHYLIN...........................17methylphenidate hcl ..................18methylphenidate hcl er ..............18methylphenidate hcl er (cd) ......18methylphenidate hcl er (la) ...... 18methylprednisolone ...................77methyltestosterone ................... 27metipranolol ........................... 124metoclopramide hcl .................101metolazone ...............................95metoprolol succinate er .............66metoprolol tartrate ................... 66metoprolol-hctz er .................... 50metoprolol-hydrochlorothiazide 50METROCREAM................... 85METROGEL.......................... 85
METROGEL-VAGINAL.....140METROLOTION...................85metronidazole ..............52, 85, 140MEVACOR............................ 47mexiletine hcl ........................... 29MIACALCIN......................... 97MIBELAS 24 FE.................... 74MICARDIS............................ 50MICARDIS HCT................... 50miconazole 3 ...........................140MICORT-HC......................... 85MICRHOGAM ULTRA-FILTERED PLUS................ 128MICRODOT TEST................ 93MICROGESTIN 1.5/30.......... 74MICROGESTIN 1/20.............74MICROGESTIN FE 1.5/30.... 74MICROGESTIN FE 1/20....... 74MICROLET LANCETS.......114MICROTAINER SAFETY FLOW LANCET.................. 114MICROZIDE......................... 95midodrine hcl ..........................141miglitol .................................... 41miglustat ................................ 107MIGRANAL........................ 116MILLIPRED.......................... 77MIMVEY................................99MIMVEY LO......................... 99MINASTRIN 24 FE............... 74MINIPRESS........................... 50MINITRAN........................... 28MINIVELLE.......................... 99MINOCIN............................ 135minocycline hcl .......................135minocycline hcl er ................... 135minoxidil ..................................50MIRALAX........................... 111MIRAPEX..............................58MIRAPEX ER........................58MIRCERA............................107MIRCETTE............................74MIRENA (52 MG)................. 74mirtazapine .............................. 37MIRVASO..............................85misoprostol .............................137MITIGARE.......................... 103mixed vespid venom protein ...... 67MOBIC................................... 20modafinil ..................................18
157
moderiba .................................. 62MODERIBA 1200 DOSE PACK..................................... 62MODERIBA 800 DOSE PACK..................................... 62moexipril hcl ............................ 50moexipril-hydrochlorothiazide .. 50mometasone furoate ..........85, 121MONOCLATE-P..................104MONO-LINYAH................... 74MONONESSA....................... 74MONONINE........................ 104MONOVISC......................... 120montelukast sodium ..................31MONUROL..........................139morcin ......................................65MORGIDOX........................135MORPHABOND ER............. 24morphine sulfate .......................25morphine sulfate (concentrate) .24morphine sulfate er ...................25morphine sulfate er beads ......... 25MOTOFEN............................ 42MOVANTIK........................ 101MOVIPREP.......................... 111MOXATAG..........................129MOXEZA............................. 124moxifloxacin hcl ............. 100, 124MOZOBIL............................ 107MS CONTIN.......................... 25MULTAQ...............................29MULTIGEN.........................107MULTIGEN FOLIC............ 107MULTIGEN PLUS.............. 107mupirocin ................................. 85mupirocin calcium .................... 85MYALEPT........................... 111MYAMBUTOL...................... 53MYCOBUTIN........................53mycophenolate mofetil ..............65mycophenolate sodium ..............65MYDAYIS..............................18MYDRIACYL......................124MYFORTIC........................... 65MYGLUCOHEALTH TEST. 93MYLERAN............................ 56MYNATAL.......................... 118MYNATAL ADVANCE......118mynatal plus ...........................118mynatal-z ............................... 118
myorisan .................................. 85MYORISAN...........................85MYRBETRIQ.......................140MYSOLINE........................... 34MYTESI................................. 42na ferric gluc cplx in sucrose ... 107NABI-HB..............................128nabumetone ..............................20nadolol ..................................... 66nadolol-bendroflumethiazide .....50naftifine hcl .............................. 85NAFTIN................................. 85NAGLAZYME.......................97nalbuphine hcl .......................... 25NALFON................................20nalocet ..................................... 25naltrexone hcl ...........................43NAMENDA......................... 132NAMENDA TITRATION PAK...................................... 132NAMENDA XR...................132NAMENDA XR TITRATION PACK.............132NAMZARIC.......................... 36NAPRELAN.......................... 21napro ....................................... 85NAPROSYN.......................... 21naproxen ..................................21NAPROXEN COMFORT PAC........................................ 21naproxen dr ..............................21naproxen sodium ...................... 21naproxen sodium er .................. 21naratriptan hcl ........................116NARCAN............................... 43NARDIL.................................37NASACORT ALLERGY 24HR.....................................121NASACORT ALLERGY 24HR CHILDREN...............121nasal allergy 24 hour .............. 121NASCOBAL......................... 107NASONEX........................... 121NATACYN...........................124NATAZIA.............................. 74nateglinide ................................41NATESTO.............................. 27NATPARA............................. 97NATROBA.............................85nat-rul vitamin d .....................142
natural vitamin d-3 ................. 142NATURE-THROID.............136NEBUPENT........................... 52NEBUSAL..............................78NECON 0.5/35 (28).................74NECON 1/35 (28)....................74NEEVO DHA....................... 118nefazodone hcl .................. 37, 134neomycin sulfate .......................18neomycin-polymyxin-dexameth...............................................124neomycin-polymyxin-hc ..........127NEORAL................................65NEOSPORIN........................124NEO-SYNALAR....................85NEPHRON FA.....................107NERLYNX.............................56NESINA................................. 41NESTABS............................. 118NEUAC.................................. 85NEULASTA......................... 107NEUPOGEN........................ 108NEUPRO................................58neurin-sl ................................. 108NEURONTIN........................ 34NEUTEK 2TEK TEST...........93NEUTRASAL...................... 118NEVANAC...........................124nevirapine .................................62nevirapine er .............................62NEXAVAR.............................56NEXIUM...................... 137, 138NEXIUM 24HR................... 137NEXPLANON....................... 74NEXT CHOICE ONE DOSE.74niacin er (antihyperlipidemic) .. 47NIACOR.................................47NIASPAN...............................47nicardipine hcl .......................... 68NICOMIDE..........................118nicotine .................................. 132nicotine polacrilex .................. 132NICOTROL..........................132NICOTROL NS....................132NIFEDICAL XL.................... 68nifedipine ................................. 68nifedipine er ............................. 68nifedipine er osmotic release ..... 68NIKKI.................................... 74NILANDRON........................56
158
nilutamide ................................ 56nimodipine ................................69NINLARO..............................56nisoldipine er ............................ 69NITRO-BID........................... 28NITRO-DUR......................... 28nitrofurantoin .........................139nitrofurantoin macrocrystal .... 139nitrofurantoin monohyd macro139nitroglycerin .............................28nitroglycerin er .........................28NITROLINGUAL................. 28NITROMIST.......................... 28NITROSTAT..........................28NITRO-TIME........................ 28NITYR....................................97nizatidine ................................138NOCTIVA.............................. 97NOLIX....................................85NORA-BE.............................. 75NORCO.................................. 25NORDITROPIN FLEXPRO. 97norethin ace-eth estrad-fe ......... 75norethindrone ........................... 75norethindrone-eth estradiol ....... 99norethin-eth estradiol-fe ........... 75norgestimate-eth estradiol ........ 75norgestim-eth estrad triphasic ...75NORITATE............................85NORPACE............................. 29NORPACE CR.......................29NORPRAMIN....................... 37NORTHERA........................ 121NORTREL 0.5/35 (28)............75NORTREL 1/35 (21)...............75NORTREL 1/35 (28)...............75NORTREL 7/7/7.....................75nortriptyline hcl ........................37NORVASC............................. 69NORVIR.................................62NOVA MAX GLUCOSE TEST.......................................93NOVOEIGHT.......................104NOVOLIN 70/30.....................41NOVOLIN 70/30 RELION.....41NOVOLIN N.......................... 41NOVOLIN N RELION.......... 41NOVOLIN R.......................... 41NOVOLIN R RELION.......... 41NOVOLOG............................ 41
NOVOLOG FLEXPEN..........41NOVOLOG MIX 70/30.......... 41NOVOLOG MIX 70/30 FLEXPEN.............................. 41NOVOLOG PENFILL........... 41NOVOSEVEN RT................ 104NOXAFIL.............................. 44np thyroid ...............................136NPLATE...............................108NUCALA............................. 110NUCORT............................... 85NUCYNTA............................ 25NUCYNTA ER...................... 25NUEDEXTA........................ 132NUFOL.................................108NULOJIX............................... 65NULYTELY WITH FLAVOR PACKS.................111NUPLAZID............................60NUTROPIN AQ NUSPIN 10 97NUTROPIN AQ NUSPIN 20 97NUTROPIN AQ NUSPIN 5.. 97NUVARING.......................... 75NUVESSA............................ 141NUVIGIL............................... 18NUWIQ................................ 104NYMALIZE........................... 69nystatin .......................44, 85, 118nystatin-triamcinolone ..............86OB COMPLETE GOLD.......118O-CAL PRENATAL............ 118OCALIVA.............................. 99OCELLA................................ 75OCTAGAM.......................... 128octreotide acetate ..................... 97OCUFLOX........................... 124OCUVEL.............................. 118ODEFSEY.............................. 62ODOMZO...............................56OFEV.................................... 133ofloxacin ................. 100, 125, 127OGESTREL............................75olanzapine ................................60olanzapine-fluoxetine hcl ........ 132olmesartan medoxomil ............. 50olmesartan medoxomil-hctz ...... 50olmesartan-amlodipine-hctz ......50olopatadine hcl ................121, 125OLUMIANT.......................... 21OLUX..................................... 86
OLUX-E................................. 86OMECLAMOX-PAK...........138omega-3-acid ethyl esters ..........47omeprazole .............................138omeprazole magnesium ...........138OMEPRAZOLE+SYRSPEND SF ALKA..........................138omeprazole-sodium bicarbonate ............................ 138OMNARIS............................121OMNIPRED.........................125OMNITROPE........................ 97ON CALL EXPRESS BLOOD GLUCOSE............... 93ON CALL PLUS BLOOD GLUCOSE..............................93ON CALL VIVID BLOOD GLUCOSE..............................93ondansetron ..............................44ondansetron hcl ........................ 44ONETOUCH CLUB LANCETS FINE PT............ 114ONETOUCH COMBO PACK....................................115ONETOUCH DELICA LANCETS 33G.....................115ONETOUCH DELICA LANCETS FINE.................. 115ONETOUCH DELICA LANCING DEV...................115ONETOUCH FINEPOINT LANCETS............................ 115ONETOUCH ULTRA BLUE......................................93ONETOUCH ULTRASOFT LANCETS............................ 115ONETOUCH VERIO.............93ONEXTON.............................86ONFI.................................34, 35ONGLYZA.............................41ONZETRA XSAIL...............116OPANA.................................. 25OPANA ER............................ 25opium .......................................42OPSUMIT...............................70OPTIMAL D3 M.................. 142OPTIMAL-D........................ 142OPTION 2...............................75OPURITY VITAMIN D...... 142ORACEA................................86
159
ORAP....................................132ORAPRED ODT....................77ORAVIG...............................118ORENCIA.............................. 21ORENCIA CLICKJECT........21ORENITRAM........................70ORFADIN..............................97ORILISSA.............................. 97ORKAMBI............................. 79orphenadrine citrate er ............120ORSYTHIA............................75ortho d ................................... 108ORTHO MICRONOR........... 75ORTHO TRI-CYCLEN (28).. 75ORTHO TRI-CYCLEN LO... 75ORTHO-CYCLEN (28)..........75ORTHO-NOVUM 1/35 (28)... 75ORTHO-NOVUM 7/7/7 (28).. 75ORTHOVISC........................120oseltamivir phosphate ............... 63OSENI.................................... 41OSMOLEX ER.......................58OSMOPREP......................... 111OSPHENA..............................97OTEZLA....................... 129, 130OTICIN HC NR................... 127OTIPRIO.............................. 127otomax-hc .............................. 127OTOVEL...............................127OTREXUP............................. 21OVACE WASH...................... 86OVIDE....................................86OXANDRIN.......................... 27oxaprozin .................................21OXAYDO............................... 25oxazepam .................................29oxcarbazepine .......................... 35oxiconazole nitrate ................... 86OXISTAT............................... 86OXSORALEN ULTRA......... 86OXTELLAR XR.................... 35oxybutynin chloride ................ 140oxybutynin chloride er ............ 140oxycodone hcl .......................... 25oxycodone hcl er .......................25oxycodone-acetaminophen ........25oxycodone-aspirin .................... 25oxycodone-ibuprofen ................ 25OXYCONTIN........................ 25oxymorphone hcl ...................... 25
oxymorphone hcl er .................. 25OXYTROL........................... 140OXYTROL FOR WOMEN..140OZEMPIC.............................. 42pa vitamin d-3 .........................142paliperidone er ..........................60PALYNZIQ............................ 97PAMELOR.............................37pamidronate disodium .............. 97PANCREAZE........................ 94PANDEL................................ 86PANRETIN............................86pantoprazole sodium ...............138PARAGARD INTRAUTERINE COPPER..75paricalcitol ............................... 97PARLODEL........................... 58PARNATE............................. 37paroex ....................................118paromomycin sulfate ................ 18paroxetine hcl ...........................37paroxetine hcl er .......................37paroxetine mesylate ................132PASER....................................53PATADAY........................... 125PATANASE..........................121PATANOL............................125PAXIL.................................... 37PAXIL CR.............................. 37PAZEO..................................125peg 3350 .................................111peg 3350/electrolytes .............. 111peg 3350-kcl-na bicarb-nacl .... 111peg-3350/electrolytes .............. 111PEGANONE.......................... 35PEGASYS...............................63PEGASYS PROCLICK..........63PEG-PREP............................111pen needles ............................. 115pen needles 1/2" ...................... 115pen needles 3/16" .................... 115pen needles 5/16" .................... 115penicillin v potassium ..............129PENLAC.................................86PENNSAID............................ 86PENTASA............................ 101pentazocine-naloxone hcl ..........25pentoxifylline er ..................... 104PEPCID................................ 138PERCOCET............................25
PERFOROMIST.................... 31perindopril erbumine .................50periogard ................................118permethrin ................................86perphenazine ............................ 60perphenazine-amitriptyline ..... 132PERTZYE.............................. 94PEXEVA.................................37PHENADOZ.......................... 46PHENAZO........................... 102phenazopyridine hcl ................ 102phenelzine sulfate ..................... 37phenobarbital ......................... 109phenoxybenzamine hcl ..............50PHENYTEK...........................35phenytoin ................................. 35PHENYTOIN INFATABS.... 35phenytoin sodium extended ....... 35PHILITH................................ 75PHOSLO...............................101phosphasal ..............................139PHOSPHOLINE IODIDE....125phytonadione ..........................142PICATO..................................86pilocarpine hcl ........................ 125pimozide .................................132PIMTREA.............................. 75pindolol .................................... 66pioglitazone hcl ........................ 42pioglitazone hcl-glimepiride ...... 42pioglitazone hcl-metformin hcl ..42piperacillin sod-tazobactam so 129PIRMELLA 1/35.................... 75piroxicam .................................21PLAN B ONE-STEP...............75PLAQUENIL......................... 52PLAVIX................................104PLEGRIDY.......................... 132PLEGRIDY STARTER PACK....................................132PLEXION...............................86PLEXION CLEANSER......... 86PLEXION CLEANSING CLOTH...................................86POCKETCHEM EZ TEST.....93podocon ....................................86podofilox ..................................86polyethylene glycol 3350 .........111polymyxin b-trimethoprim ...... 125POLYTRIM..........................125
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POLY-VI-FLOR...................119POLY-VI-FLOR FS............. 118POMALYST...........................56PONSTEL...............................21PORTIA-28.............................75potassium chloride .................. 117potassium chloride crys er .......117potassium chloride er .............. 117potassium citrate er ................ 102PRADAXA.............................33PRALUENT......................... 128pramipexole dihydrochloride .....58pramipexole dihydrochloride er .58PRAMOSONE....................... 86PRANDIN..............................42prasugrel hcl ...........................104PRAVACHOL........................47pravastatin sodium ................... 47praziquantel ............................. 28prazosin hcl .............................. 50PRECISION PCX...................93PRECISION PCX PLUS TEST.......................................93PRECISION POINT OF CARE TEST........................... 93PRECISION QID TEST.........93PRECISION SOF-TACT TEST.......................................93PRECISION XTRA BLOOD GLUCOSE..............................93PRECOSE...............................42PRED FORTE......................125PRED MILD........................ 125PRED-G................................125PRED-G S.O.P..................... 125prednicarbate ........................... 86prednisolone ............................. 77prednisolone acetate ............... 125prednisolone sodium phosphate......................................... 77, 125prednisone ................................77PREDNISONE INTENSOL.. 77PREFERAOB ONE..............119PREFEST............................... 99PREMARIN................... 99, 141PREMPHASE........................ 99PREMPRO............................. 99PRENATABS RX.................119PRENATE MINI..................119PREPIDIL............................ 127
PREPOPIK........................... 111PRESTALIA...........................50PREVACID.......................... 138PREVACID 24HR................138PREVACID SOLUTAB....... 138PREVALITE.......................... 47PREVIFEM............................ 75PREVPAC............................ 138PREVYMIS............................ 63PREZCOBIX.......................... 63PREZISTA............................. 63PRIALT.................................. 22PRIFTIN................................ 53PRILOSEC........................... 138PRILOSEC OTC...................138primaquine phosphate ...............52primidone ................................. 35PRIMLEV.............................. 25PRINIVIL...............................50PRISTIQ................................. 37PRIVIGEN........................... 128PROAIR HFA........................31PROAIR RESPICLICK......... 31probenecid ..............................103PROCARDIA.........................69PROCARDIA XL.................. 69PROCENTRA........................ 18prochlorperazine .......................60prochlorperazine maleate ..........60PROCRIT............................. 108PROCTOCORT......................27PROCTOFOAM HC..............27PROCTO-PAK....................... 27PROCTOZONE-HC...............28PROCYSBI........................... 102PRODIGY NO CODING BLOOD GLUC...................... 93PROFERRIN-FORTE......... 108PROFILNINE...................... 104PROFILNINE SD................ 105PROGLYCEM....................... 42PROGRAF............................. 65PROLASTIN-C.................... 134PROLENSA..........................125PROLIA..................................97PROMACTA........................ 108promethazine hcl ...................... 46promethazine vc ....................... 78promethazine vc/codeine ........... 78promethazine-dm ......................78
PROMETHEGAN................. 46PROMETRIUM...................130propafenone hcl ........................ 29propafenone hcl er .................... 29propantheline bromide ............ 138proparacaine-fluorescein .........125propranolol hcl ................... 66, 67propranolol hcl er ..................... 66propranolol-hctz .......................50propylthiouracil ......................136PROSCAR............................ 102PROTECTIRON.................. 108PROTONIX..........................138PROTOPIC.............................86protriptyline hcl ........................37PROVENTIL HFA.................31PROVERA............................130PROVIGIL............................. 18PROZAC................................ 37PRUDOXIN...........................86pseudoeph-chlorphen-hydrocod . 78psorcon .................................... 86PTS PANELS GLUCOSE TEST.......................................93PULMICORT.........................31PULMICORT FLEXHALER........................ 31PULMOZYME.....................134purefe plus ..............................108purevit dualfe plus .................. 108PURIXAN.............................. 56px folic acid ............................108PYLERA...............................138pyrazinamide ............................53PYRIDIUM..........................102pyridostigmine bromide ............ 53pyridostigmine bromide er ........ 53QBRELIS................................50QNASL................................. 121QNASL CHILDRENS......... 121QTERN.................................134QUALAQUIN........................52QUARTETTE........................ 75QUASENSE........................... 75quazepam ............................... 109QUDEXY XR.........................35QUESTRAN...........................47QUESTRAN LIGHT............. 47quetiapine fumarate ..................60quetiapine fumarate er ..............60
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QUFLORA FE..................... 118QUFLORA FE PEDIATRIC...............................................119QUFLORA PEDIATRIC.....119QUILLICHEW ER.................18QUILLIVANT XR................. 18quinapril hcl ............................. 50quinapril-hydrochlorothiazide ... 50quinidine gluconate er ...............29quinidine sulfate ....................... 30quinine sulfate .......................... 53QVAR REDIHALER.............31ra folic acid ............................ 108RA TRUETEST TEST........... 93ra vitamin d-3 ......................... 142rabeprazole sodium .................138RADIOGARDASE................ 43RAJANI..................................75raloxifene hcl ........................... 97ramipril ....................................50RANEXA............................... 28ranitidine hcl .......................... 138RAPAFLO............................102RAPAMUNE......................... 65rasagiline mesylate ................... 58RASUVO................................ 21RAVICTI................................97RAYALDEE.......................... 97RAYOS...................................77RAZADYNE........................ 133RAZADYNE ER..................132REBETOL.............................. 63REBIF...................................133REBIF REBIDOSE.............. 133REBIF REBIDOSE TITRATION PACK.............133REBIF TITRATION PACK 133REBINYN............................ 105RECLAST.............................. 97RECLIPSEN...........................76RECOMBINATE................. 105RECTIV..................................28REGLAN..............................101REGRANEX..........................86RELAGARD........................ 141RELENZA DISKHALER......63RELEXXII............................. 18RELISTOR........................... 101RELPAX...............................116REMERON............................ 37
REMERON SOLTAB............ 37REMICADE......................... 101REMODULIN....................... 70RENAGEL........................... 101RENFLEXIS........................ 101RENVELA............................101repaglinide ............................... 42repaglinide-metformin hcl .........42REPATHA............................128REPATHA PUSHTRONEX SYSTEM...............................128REPATHA SURECLICK.... 128REPLESTA...........................143REPLESTA CHILDRENS...143REPLESTA NX....................143REQUIP................................. 58REQUIP XL........................... 58RESCRIPTOR........................63RESTASIS............................ 125RESTASIS MULTIDOSE....125RESTORIL........................... 110RETACRIT.......................... 108RETIN-A................................86RETIN-A MICRO..................86RETIN-A MICRO PUMP......86RETROVIR............................63REVATIO...............................70revesta ....................................108REVLIMID............................ 65REXULTI...............................60REYATAZ............................. 63RHINOCORT ALLERGY.. 121RHOFADE.............................86RHOGAM ULTRA-FILTERED PLUS................ 128RHOPHYLAC......................128RHOPRESSA....................... 126RIASTAP..............................105ribasphere ................................ 63ribasphere ribapak ....................63ribavirin ................................... 63RIDAURA............................. 21rifabutin ................................... 53RIFADIN............................... 53RIFAMATE........................... 53rifampin ................................... 53RIFATER...............................53RILUTEK.............................121riluzole ................................... 121rimantadine hcl ........................ 63
RIOMET.................................42risedronate sodium ................... 97RISPERDAL.......................... 60risperidone ............................... 60RISPERIDONE M-TAB........ 60RITALIN................................18RITALIN LA......................... 18ritonavir ................................... 63rivastigmine ............................133rivastigmine tartrate ............... 133RIVELSA............................... 76RIXUBIS.............................. 105rizatriptan benzoate ................116ROBAXIN............................ 120ROBINUL............................ 138ROBINUL-FORTE.............. 139ROCALTROL........................ 97ROCEPHIN............................71ropinirole hcl ............................ 58ropinirole hcl er ........................ 58ROSADAN.............................87ROSANIL CLEANSER......... 87rosuvastatin calcium ................. 47ROXICODONE..................... 25ROZEREM...........................110RUBRACA...........................130RUCONEST......................... 105RYDAPT................................ 57rynoderm ..................................87RYTARY................................58RYTHMOL SR...................... 30RYVENT................................46SABRIL.................................. 35SAFETY LET LANCETS.... 115SAFETY-GLIDE SYRINGE...............................................115SAFYRAL..............................76SAIZEN.................................. 97SALAGEN............................118SALEX....................................87salicylic acid .............................87salsalate ................................... 22SAMSCA................................ 98SANCUSO..............................44SANDIMMUNE.................... 65SANDOSTATIN.................... 98SANDOSTATIN LAR DEPOT................................... 98SANTYL.................................87SAPHRIS................................60
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sapscare twist top lancets ........115SARAFEM........................... 133SAVAYSA.............................. 33SAVELLA.............................133SAVELLA TITRATION PACK....................................133scopolamine ............................. 44SEASONIQUE....................... 76seb-prev wash ........................... 87SEEBRI NEOHALER............31SEGLUROMET................... 134selegiline hcl .............................58selenium sulfide ........................ 87SELRX....................................87SELSUN BLUE MEDICATED........................ 87SELZENTRY......................... 63SEMPREX-D......................... 78SENSIPAR............................. 98SEREVENT DISKUS............ 31SERNIVO...............................87SEROQUEL........................... 60SEROQUEL XR.....................60SEROSTIM............................ 98sertraline hcl ............................ 37se-tan plus .............................. 108sevelamer carbonate ............... 101SFROWASA.........................101SHOHLS MODIFIED..........102SIGNIFOR............................. 98SIKLOS.................................108sildenafil citrate ........................70SILENOR............................. 110SILIQ...................................... 87SILVADENE..........................87silver nitrate ............................. 87silver sulfadiazine ..................... 87SIMBRINZA........................ 125SIMPLE DIAGNOSTICS LANCING DEV...................115SIMPONI................................21SIMPONI ARIA.....................21SIMULECT............................ 65simvastatin ...............................47SINEMET...............................58SINEMET CR........................ 58SINGULAIR.......................... 31sirolimus .................................. 65SIRTURO...............................53SITAVIG................................ 63
SIVEXTRO.............................52SKELAXIN.......................... 120SKYLA................................... 76sm folic acid ........................... 108sm vitamin d3 ......................... 143SMART SENSE VALUE TEST.......................................93SMARTEST BLOOD GLUCOSE TEST................... 93sod benz-sod phenylacet ............98sod citrate-citric acid .............. 102sodium chloride ........................ 78sodium fluoride .......................117sodium phenylbutyrate ..............98sodium polystyrene sulfonate......................................... 65, 130sodium sulfacetamide ................87SOLIQUA.............................110SOLODYN........................... 135SOLOSEC...............................18SOLTAMOX.......................... 57SOLUS V2 TEST.................... 93SOMA................................... 120SOMATULINE DEPOT........ 98SOMAVERT.......................... 98SONATA.............................. 110SOOLANTRA........................ 87SORIATANE......................... 87SORILUX...............................87sotalol hcl .................................67sotalol hcl (af) ......................... 67SOTYLIZE............................. 67SOVALDI...............................63SPECTRACEF....................... 71spinosad ................................... 87SPIRIVA HANDIHALER.....31SPIRIVA RESPIMAT............31spironolactone .......................... 95spironolactone-hctz .................. 95SPORANOX...........................44SPORANOX PULSEPAK..... 44SPRINTEC 28........................ 76SPRITAM...............................35SPRIX.....................................21SPRYCEL...............................57SPS.................................. 65, 130SRONYX................................76SSKI........................................78sss 10-5 .................................... 87STALEVO 100........................ 59
STALEVO 125........................ 59STALEVO 150........................ 59STALEVO 200........................ 59STALEVO 50..........................59STALEVO 75..........................59STARLIX............................... 42stavudine .................................. 63STEGLATRO.........................42STEGLUJAN....................... 134STELARA.......................87, 110STIMATE...............................98STIOLTO RESPIMAT...........31STIVARGA............................ 57STRATTERA......................... 18STRENSIQ........................... 110streptomycin sulfate ................. 19STRIANT............................... 27STRIBILD.............................. 63STRIVERDI RESPIMAT...... 31STROMECTOL..................... 28SUBOXONE...........................26SUBSYS..................................26SUCRAID.............................. 94sucralfate ............................... 139SULAR................................... 69sulfacetamide sodium ........ 87, 125sulfacetamide sodium-sulfur 87, 88sulfacetamide sod-sulfur wash ...88sulfacetamide-prednisolone ..... 125sulfacetamide-sulfur in urea ......88sulfacleanse 8/4 ........................ 88sulfadiazine ............................ 135sulfamethoxazole-trimethoprim 52SULFAMYLON.....................88sulfasalazine ...........................101SULFAZINE........................ 101sulindac ....................................22SUMADAN............................88SUMADAN XLT................... 88sumatriptan ............................ 116sumatriptan succinate ............. 116sumatriptan succinate refill .....116sumatriptan-naproxen sodium .116SUMAXIN............................. 88SUMAXIN CP........................88SUMAXIN TS........................88super daily d3 ......................... 143super thin lancets ....................115SUPPRELIN LA.................... 98SUPRAX................................ 71
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SUPREME TEST................... 93SUPREP BOWEL PREP KIT...............................................111SURE EDGE TEST................93SURECHEK BLOOD GLUCOSE TEST................... 93SURE-TEST EASYPLUS MINI TEST............................ 93SURMONTIL........................ 37SUSTIVA................................63SUTENT.................................57SYEDA................................... 76SYLATRON...........................57SYMAX DUOTAB...............139SYMBICORT......................... 31SYMBYAX...........................133SYMDEKO............................ 79SYMFI....................................63SYMFI LO..............................63SYMLINPEN 120...................42SYMLINPEN 60.................... 42SYMPROIC..........................101SYNAGEX........................... 119SYNAGIS............................. 128SYNALAR............................. 88SYNALAR (CREAM)........... 88SYNALAR (OINTMENT).....88SYNALAR TS........................88SYNAREL..............................98SYNATEK............................119SYNDROS..............................44SYNERA................................ 88SYNJARDY......................... 134SYNJARDY XR...................134SYNRIBO...............................57SYNTHROID.......................136SYNVISC..............................120SYNVISC ONE.................... 120SYPRINE............................... 65TABLOID...............................57TACLONEX...........................88tacrolimus ...........................65, 88TAFINLAR............................57TAGRISSO.............................57TAKE ACTION..................... 76TALTZ....................................88TAMIFLU........................ 63, 64tamoxifen citrate ......................57tamsulosin hcl .........................102TANDEM F......................... 108
TANDEM PLUS.................. 108TAPAZOLE..........................136TAPERDEX 12-DAY............ 77TAPERDEX 6-DAY.............. 77TARCEVA............................. 57TARGADOX........................136TARGRETIN................... 57, 88TARKA.................................. 50taron forte ..............................108TASIGNA...............................57TASMAR................................59TAVALISSE......................... 135TAYTULLA...........................76tazarotene ................................ 88tazicef ................................ 71, 72TAZORAC............................. 88TAZTIA XT........................... 69TECFIDERA........................133TECHNIVIE.........................109TEFLARO..............................72TEGRETOL........................... 35TEGRETOL-XR.................... 35TEKTURNA.......................... 51TEKTURNA HCT................. 51TELCARE BLOOD GLUCOSE TEST................... 93telmisartan ...............................51telmisartan-amlodipine ............. 51telmisartan-hctz ....................... 51temazepam ............................. 110TEMODAR............................ 57TEMOVATE.......................... 88temozolomide ........................... 57tenofovir disoproxil fumarate ....64TENORETIC 100................... 51TENORETIC 50..................... 51TENORMIN.......................... 67TERAZOL 7......................... 141terazosin hcl ............................. 51terbinafine hcl .......................... 44terbutaline sulfate .....................31terconazole .............................141TESSALON PERLES.............78TESTIM..................................27testosterone ..............................27testosterone cypionate .............. 27testosterone enanthate .............. 27tetrabenazine ..........................133tetracycline hcl ....................... 136TEXAVITE LQ.....................128
THALOMID.......................... 65THEO-24................................ 31THEOCHRON....................... 32theophylline ..............................32theophylline er ..........................32THERA-D 2000.................... 143THERA-D 4000.................... 143THERA-D RAPID REPLETION........................ 143THIOLA............................... 102thioridazine hcl .........................60thiothixene ............................... 60THYMOGLOBULIN.............65THYROGEN..........................93tiagabine hcl .............................35TIAZAC..................................69TIBSOVO..............................111TIGAN................................... 44TIKOSYN...............................30TILIA FE................................76timolol maleate ................. 67, 125TIMOPTIC........................... 125TIMOPTIC OCUDOSE....... 125TIMOPTIC-XE.....................125TINDAMAX.......................... 52tinidazole ................................. 52TIROSINT............................136TIVICAY................................64TIVORBEX............................ 22TIZANIDINE COMFORT PAC.......................................120tizanidine hcl .......................... 120tl gard rx ................................108tl icon .....................................108TOBI....................................... 19TOBI PODHALER................ 19TOBRADEX.........................125TOBRADEX ST................... 126tobramycin ...............................19tobramycin sulfate ....................19TOBREX.............................. 126TODAY SPONGE................141TOFRANIL............................38TOLAK...................................88tolazamide ................................42tolbutamide .............................. 42tolcapone ..................................59tolmetin sodium ........................22tolterodine tartrate ................. 140tolterodine tartrate er ............. 140
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TOPAMAX............................ 35TOPAMAX SPRINKLE........ 35TOPICORT............................ 88TOPICORT SPRAY...............88topiramate ............................... 35toposar .....................................57TOPROL XL.......................... 67TORISEL................................57torsemide ................................. 95TOUJEO MAX SOLOSTAR. 42TOUJEO SOLOSTAR............42TOVIAZ................................140TRACLEER........................... 70TRADJENTA.........................42tramadol hcl ............................. 26tramadol hcl er ......................... 26tramadol hcl er (biphasic) ........ 26tramadol-acetaminophen .......... 26trandolapril .............................. 51trandolapril-verapamil hcl er .... 51tranexamic acid ......................109TRANSDERM-SCOP (1.5 MG)........................................ 44TRANXENE-T.......................29tranylcypromine sulfate ............ 38TRAUMEEL.......................... 65TRAVATAN Z..................... 126trazodone hcl .................... 38, 134TRECATOR...........................53TRELEGY ELLIPTA............ 32TRELSTAR MIXJECT..........57TREMFYA.............................88TRESIBA FLEXTOUCH...... 42tretinoin ........................ 57, 88, 89tretinoin microsphere ................89tretinoin microsphere pump ...... 89TRETTEN............................ 105TREXIMET..........................116TREZIX..................................26TRI FEMYNOR.................... 76triamcinolone acetonide..................................89, 118, 121TRIAMINIC ALLERCHEWS..................... 46triamterene-hctz ....................... 95triazolam ................................110TRIBENZOR......................... 51TRICARE PRENATAL DHA ONE............................ 119tricitrates ............................... 102
TRICON............................... 108TRICOR................................. 47TRIDERM............................. 89TRIDESILON........................ 89trientine hcl .............................. 65TRI-ESTARYLLA................. 76trifluoperazine hcl .................... 60trifluridine ..............................126trigels-f forte .......................... 108TRIGLIDE............................. 48trihexyphenidyl hcl ................... 59TRI-LEGEST FE................... 76TRILEPTAL...........................35TRI-LINYAH.........................76TRILIPIX............................... 48TRILYTE............................. 111trimethobenzamide hcl ..............44trimethoprim ............................ 52TRI-MILI............................... 76trimipramine maleate ............... 38trimpex .................................... 52TRINATE.............................119TRINESSA (28)...................... 76TRI-NORINYL (28)...............76TRINTELLIX.................38, 134TRI-PREVIFEM.................... 76TRIPTODUR......................... 98TRI-SPRINTEC..................... 76TRIUMEQ............................. 64TRI-VI-FLOR...................... 119TRIVORA (28)....................... 76TRIZIVIR...............................64TROKENDI XR.................... 35tropicamide ............................ 126trospium chloride ....................140trospium chloride er ................140TRUE METRIX BLOOD GLUCOSE TEST................... 93TRUEPLUS LANCETS 26G115TRUEPLUS LANCETS 30G115TRUEPLUS SAFETY LANCETS 28G.....................115TRUETEST TEST..................93TRUETRACK TEST............. 93TRULANCE.......................... 72TRULICITY...........................42TRUSOPT............................ 126TRUVADA............................ 64TUDORZA PRESSAIR......... 32TULANA................................76
TUSNEL C............................. 78TUSSICAPS........................... 78TUSSIONEX PENNKINETIC ER...............78TWYNSTA.............................51TYBOST................................. 61TYDEMY...............................76TYKERB................................ 57TYLENOL WITH CODEINE #3......................... 26TYLENOL WITH CODEINE #4......................... 26TYMLOS................................98TYSABRI............................. 133TYVASO.................................70TYVASO REFILL................. 70TYVASO STARTER..............70UCERIS............................ 28, 77ULESFIA............................... 89ULORIC............................... 103ULTIMA TEST...................... 93ULTRACET........................... 26ULTRAM...............................26ULTRATRAK PRO TEST.... 93ULTRATRAK ULTIMATE TEST.......................................93ULTRAVATE........................ 89ULTRAVATE X (CREAM)...89ULTRAVATE X (OINTMENT)........................ 89UNISTRIP1 GENERIC......... 93UNITHROID....................... 136UNITHROID DIRECT....... 136UPTRAVI..................... 133, 134URECHOLINE.................... 140urelle ......................................139uretron d/s ..............................139uribel ......................................139URIMAR-T.......................... 139urin ds .................................... 139UROCIT-K 10...................... 102UROCIT-K 15...................... 102UROCIT-K 5........................ 102uro-mp ................................... 139UROXATRAL..................... 102URSO 250............................. 101URSO FORTE......................101ursodiol .................................. 101ustell ...................................... 139UTIBRON NEOHALER....... 32
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utira-c .................................... 139UTOPIC..................................89utrona-c ................................. 139VAGIFEM............................141valacyclovir hcl .........................64VALCHLOR.......................... 89VALCYTE..............................64valganciclovir hcl ......................64VALIUM................................ 29valproate sodium ...................... 35valproic acid .............................35valsartan .................................. 51valsartan-hydrochlorothiazide ...51VALTREX..............................64VANATOL LQ.......................22VANCOCIN HCL.................. 52vancomycin hcl .........................52VANDAZOLE......................141VANISHPOINT INSULIN SYRINGE.............................115VANOS...................................89VANOXIDE-HC.................... 89VANTAS................................ 57VARUBI................................. 44VASCEPA.............................. 48VASERETIC.......................... 51VASOTEC.............................. 51VCF VAGINAL CONTRACEPTIVE............. 141VECAMYL.............................51VECTICAL.............................89VELCADE..............................57VELETRI............................... 70VELIVET................................76VELPHORO......................... 101VELTASSA..................... 65, 130VELTIN..................................89VEMLIDY..............................64VENCLEXTA........................ 53VENCLEXTA STARTING PACK..................................... 53VENIPUNCTURE CPI..........89venlafaxine hcl ......................... 38venlafaxine hcl er ..................... 38VENOFER............................108VENOMIL MIXED VESPID VENOM..................................67VENTAVIS.............................70VENTOLIN HFA...................32verapamil hcl ............................69
verapamil hcl er ........................69VERDESO..............................89VERDROCET........................ 26VEREGEN............................. 89VERELAN............................. 69VERELAN PM.......................69VERIPRED 20........................78VERSACLOZ......................... 60VERZENIO............................ 79VESICARE........................... 140VESTURA..............................76VFEND...................................44VIBERZI...............................110VIBRAMYCIN.....................136vicodin ..................................... 26vicodin es ................................. 26vicodin hp .................................26VICTORY AGM-4000 TEST. 94VICTOZA...............................42VIDEX....................................64VIDEX EC..............................64VIEKIRA PAK.....................109VIEKIRA XR....................... 109vigabatrin .................................35VIGADRONE........................ 35VIGAMOX........................... 126VIIBRYD........................ 38, 134VIIBRYD STARTER PACK......................................... 38, 134VIMIZIM..............................118VIMOVO................................ 22VIMPAT................................. 35VINATE DHA RF............... 119VIOKACE.............................. 94VIRACEPT.............................64VIRAMUNE.......................... 64VIRAMUNE XR....................64VIREAD................................. 64VIROPTIC............................126VIRT-GARD........................ 108VISTARIL.............................. 29VISTOGARD......................... 43VISUDYNE..........................126VITAFOL FE+.....................119VITAFOL GUMMIES......... 119vitamin d ................................ 143vitamin d (ergocalciferol) .......143vitamin d2 .............................. 143vitamin d3 .............................. 143vitamin d-3 ............................. 143
vitamin d3 maximum strength .143vitamin d3 super strength ........ 143VITAPEARL........................ 119VITATRUE.......................... 119VIVA DHA........................... 119VIVELLE-DOT...................... 99VIVITROL............................. 43VIVLODEX............................22VOCAL POINT BLOOD GLUCOSE TEST................... 94VOGELXO............................. 27VOGELXO PUMP................. 27VOLTAREN...........................89VONVENDI......................... 105VORAXAZE.......................... 57voriconazole ............................. 44VOSEVI................................ 109VOTRIENT............................ 57VPRIV...................................108VRAYLAR.............................60VYFEMLA.............................76VYTORIN.............................. 48VYVANSE..............................18VYZULTA............................126warfarin sodium ....................... 33WELCHOL.............................48WELLBUTRIN SR................ 38WELLBUTRIN XL................38WERA.................................... 76WESTHROID.......................136WIDE-SEAL DIAPHRAGM 60...........................................115WIDE-SEAL DIAPHRAGM 65...........................................115WIDE-SEAL DIAPHRAGM 70...........................................115WIDE-SEAL DIAPHRAGM 75...........................................115WIDE-SEAL DIAPHRAGM 80...........................................115WIDE-SEAL DIAPHRAGM 85...........................................115WIDE-SEAL DIAPHRAGM 90...........................................115WIDE-SEAL DIAPHRAGM 95...........................................115WILATE............................... 105WINRHO SDF..................... 128WP THYROID..................... 136WYMZYA FE........................ 76
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XADAGO...............................59XALATAN........................... 126XALKORI..............................57XANAX..................................29XANAX XR........................... 29XARELTO............................. 33XARELTO STARTER PACK..................................... 33XATMEP................................57XELITRAL............................ 89XELJANZ.............................. 22XELJANZ XR........................22XELODA................................57XENAZINE..........................133XEOMIN.............................. 121XERESE................................. 89XERMELO...........................136XGEVA.................................. 98XHANCE............................. 121XIAFLEX...............................65XIFAXAN..............................52XIGDUO XR........................134XIIDRA................................ 112XIMINO............................... 136XODOL.................................. 26XOLAIR................................. 32XOLEGEL..............................89XOPENEX............................. 32XOPENEX CONCENTRATE.................. 32XOPENEX HFA.................... 32XTAMPZA ER.......................26XTANDI.................................57XULANE................................76XULTOPHY.........................110XURIDEN............................109XYNTHA............................. 105XYNTHA SOLOFUSE........ 105XYREM................................133XYZAL ALLERGY 24HR.... 46XYZAL ALLERGY 24HR CHILDRENS......................... 46YASMIN 28............................76YAZ........................................ 76YERVOY................................57YONSA...................................57YOSPRALA......................... 105YUVAFEM.......................... 141ZADITOR............................ 126zafirlukast ................................32
ZANAFLEX......................... 120ZANOSAR............................. 57ZANTAC.............................. 139ZARAH.................................. 76ZARONTIN........................... 35ZARXIO............................... 108zavara .................................... 108ZAVESCA............................ 108ZEBUTAL.............................. 22ZEGERID.............................139ZEGERID OTC....................139ZEJULA............................... 130ZELAPAR.............................. 59ZELBORAF........................... 57ZEMAIRA............................134ZEMBRACE SYMTOUCH. 116ZEMPLAR............................. 98zenatane ...................................89ZENATANE...........................89ZENCHENT...........................76ZENPEP................................. 94ZENZEDI...............................18ZEPATIER........................... 109ZERIT.....................................64ZESTORETIC........................ 51ZESTRIL................................ 51ZETIA.....................................48ZETONNA........................... 121ZIAC.......................................51ZIAGEN................................. 64ZIANA....................................89zidovudine ................................ 64zileuton er ................................ 32ZIOPTAN............................. 126ziprasidone hcl ..........................60ZIPSOR.................................. 22ZIRGAN...............................126ZITHROMAX...................... 112ZITHROMAX TRI-PAK..... 112ZITHROMAX Z-PAK......... 112ZOCOR...................................48ZOFRAN................................44ZOFRAN ODT...................... 44ZOHYDRO ER...................... 26ZOLADEX............................. 57zoledronic acid ......................... 98ZOLINZA...............................58zolmitriptan ............................116ZOLOFT.................................38zolpidem tartrate .................... 110
zolpidem tartrate er ................ 110ZOLPIMIST......................... 110ZOMACTON......................... 98ZOMETA............................... 98ZOMIG................................. 116ZOMIG ZMT....................... 116ZONALON.............................89ZONEGRAN..........................35zonisamide ............................... 35ZONTIVITY.........................131ZORBTIVE.............................98ZORTRESS............................ 65ZORVOLEX...........................22ZOSYN................................. 129ZOVIA 1/35E (28)................... 76ZOVIRAX.........................64, 89ZUBSOLV.............................. 26ZUPLENZ.............................. 44ZURAMPIC......................... 103ZYBAN.................................133ZYCLARA............................. 89ZYCLARA PUMP................. 90ZYDELIG.............................129ZYFLO................................... 32ZYFLO CR.............................32ZYKADIA..............................58ZYLET..................................126ZYLOPRIM..........................103ZYMAXID........................... 126ZYPITAMAG........................ 48ZYPREXA..............................60ZYPREXA ZYDIS................. 60ZYRTEC ALLERGY.............46ZYRTEC-D ALLERGY & CONGESTION...................... 78ZYTIGA................................. 58ZYVOX...................................52
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