2008 Aetna Preferred Drug Guide
Four-Tier Copay/Open Formulary Plan
Includes generic
and brand-name
medications on
Aetna’s Preferred
Drug List
05.05.315.1 (9/07) ©2007 Aetna Inc.
Questions?
Call the toll-free Member Services number listed on your Member ID card.
Member Services representatives are available to take your call
Monday – Friday, 9:00 am – 5:00 pm.*
Visit www.aetna.com for the most up-to-date information.
TDD for hearing or speech impaired please call 1-800-628-3323.
*Depending on your geographic location, some Member Services call centers may offer extended
hours for your convenience.
Dear Member:
To help you know which medications are covered by your plan, we are pleased
to provide you with a copy of our 2008 Preferred Drug Guide. The drugs on the
Preferred Drug List were selected based on their effectiveness, quality, safety, cost
and other factors.
This book provides helpful information on the Aetna Preferred Drug List and your
pharmacy benefit plan. You may want to take this guide with you when you see your
doctor, to talk about what is covered under your pharmacy benefit plan.
Many commonly prescribed medications are listed in this book. Please remember
that this is not a complete list of medications covered under your plan. Because
there are thousands of medications included in your pharmacy benefit plan, we only
list the most commonly prescribed ones.
In accordance with state law, California HMO 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. Nothing in this
material 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 material be construed to prohibit generic
drug substitutions.
For members in Texas, additions to the 2008 Preferred Drug list will be effective no later than January 1,
2008. In accordance with state law, full-risk members in Texas who receive coverage for medications that
are removed from the Preferred Drug list during the plan year will continue to have those medications
covered at the same benefit level until their plan renewal date.
Step-therapy, precertification and quantity limits do not apply in all service areas. For example, step-therapy
does not apply to fully insured members in New Jersey and Indiana. Please refer to your plan documents
or call the Member Service number on your ID card for further information.
Table of Contents
What Pharmacy Benefits Plan Do I Have? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
What is the Preferred Drug List? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Who Reviews Medications for the Preferred Drug List? . . . . . . . . . . . . . . . . . . . . . . 3
How is the Preferred Drug List Developed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Why is the Preferred Drug List Subject to Change? . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Why Do Some Medications Require Prior Authorization or Precertification? . . . . . 4
Why Do Some Medications Have Quantity Limits? . . . . . . . . . . . . . . . . . . . . . . . . . . 5
What is Step-Therapy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
What is Therapeutic Duplication?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
What are Generic Medications? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How Can I Save Money on Prescriptions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
What is Aetna Rx Home Delivery? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
How Do I Contact Aetna Rx Home Delivery? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
What is Aetna Specialty Pharmacy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Preferred Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Antineoplastic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Blood Products - Modifiers - Volume Expanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Central Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Dermatological Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Endocrine System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Gastrointestinal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Genitourinary System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Immunological Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Infections and Infestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Ophthalmic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Otic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Respiratory Tract Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Precertification List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Quantity Limit List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Step-Therapy List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
www.aetna.com/formulary 1
What Pharmacy Benefits Your plan may have a “mandatory
Plan Do I Have? generic cost-sharing requirement,” which
means that if you receive a brand-name
You are enrolled in a four-tier/ medication when a generic is available,
open formulary plan.*
you pay the difference in cost between
Open formulary means your pharmacy
the brand-name and generic medication,
benefit covers medications that are on
the Preferred Drug List (also known as in addition to your copay. For a
a formulary), as well as many that are summary of your pharmacy benefits
not. Your plan may not cover certain plan, including copay amounts, please
medications, even though some are log in to Aetna NavigatorTM, your secure
listed, such as contraceptives, infertility member website, at www.aetna.com or
medications, erectile dysfunction
medications and diabetic supplies. Please call the Member Services number on
see your plan documents for a complete your ID card.
description of your pharmacy benefit,
or call the Member Services number What is the Preferred
on your ID card.
Drug List?
Four-tier means there are four copay
The Preferred Drug List is a list of
tiers or levels for covered prescription
medications. medications selected by Aetna in
consultation with a team of health-care
Copay Tier** Type of Drug providers. Aetna will generally cover the
Tier 1 Covered preferred
generic medications drugs listed in our Preferred Drug List
(not self-injectable).*** as long as the drug is medically necessary
Tier 2 Covered preferred and plan rules are followed. For more
brand-name medications
(not self-injectable). information on the Preferred Drug List,
Tier 3 Covered non-preferred please review your plan documents or
generic and brand-name
medications call the Member Services number listed
(not self-injectable). on your ID card. Drugs that appear on
Tier 4 Preferred and non-preferred Aetna’s Preferred Drug List have been
self-injectable drugs covered
by prescription benefits. chosen on the basis of sound medical
If covered, insulin is data, safety and cost.
available at the applicable
Tier 1, Tier 2 or Tier 3 Copay.
* Your enrollment in an Aetna four-tier/open formulary plan was based on information available at
the time of this mailing. If your pharmacy benefits plan changes, the copays and coverage of
certain medications detailed in this booklet may no longer apply.
** If your plan has a deductible or copay levels based on a percentage of Aetna’s negotiated charge
with the participating pharmacy, rebates that Aetna receives from drug manufacturers do not reduce
the amount you pay to the pharmacy for an individual prescription drug. Also, in some cases, if you
need to pay a percentage of the cost of a drug or an amount to meet a deductible, your costs may
be higher for a preferred drug than they would be for a non-preferred drug.
*** If you are enrolled in a PPO plan, all covered generic medications available at the lowest copay (tier
one), regardless of whether they are preferred. In most HMO plans, non-preferred generic
medications are available at the highest copay (tier three). Refer to your plan documents, visit Aetna
Navigator or call Member Services for information about your benefits plan.
2 www.aetna.com/formulary
I Both brand-name and generic List. Although the committee includes
medications are on Aetna’s Preferred staff from Aetna, most of the members are
Drug List. practicing doctors or pharmacists who are
I All medications on the Preferred Drug chosen to represent various clinical
list have been approved by the Food and specialties. All committee members must
Drug Administration (FDA). disclose any factors that may create a real
I The Preferred Drug List is updated
or apparent conflict of interest or financial
stake related to any of the manufacturers
on an ongoing basis and is subject
whose products are being reviewed.
to change.
I
The P&T’s clinical determinations are
Many medications on the Preferred
based on the strength of scientific
Drug List are subject to manufacturer
evidence from a number of sources
rebate arrangements between Aetna and
including but not limited to: DrugPoints,
the manufacturer of those medications.
American Hospital Formulary Service
Please visit the Aetna website at Drug Information (AHFS-DI), DrugDex,
www.aetna.com/formulary for a more Medline and other databases, including
complete and current listing of relevant findings of federal government
medications that may be covered by your agencies, the pharmaceutical
plan. It is important to note that you and manufacturers, medical professional
your physician are responsible for making associations, national commissions and
the final decision on your drug therapy. peer-reviewed journals.
For a complete description of your
The P&T Committee meets regularly to
pharmacy benefit, see your plan
evaluate new drug indications and new
documents or call the Member Services
clinical information on existing preferred
number on your ID card for further
drugs to verify that they continue to meet
information.
the criteria for safety, effectiveness, current
use in therapy and overall value. Once the
Who Reviews Medications P&T completes its clinical review, Aetna
for the Preferred Drug List? conducts additional reviews of
Aetna’s Pharmaceutical and Therapeutics medications based on P&T’s clinical
(P&T) Committee reviews available determinations and information regarding
clinical literature for medications that overall value (including cost and
have been approved by the FDA. manufacturer rebate arrangements) and
other factors before a decision on
How is the Preferred Preferred Drug List status is made.
Drug List Developed?
Our P&T Committee reviews drugs for
possible inclusion on our Preferred Drug
www.aetna.com/formulary 3
Why is the Preferred Drug Why Do Some Medications
List Subject to Change? Require Prior Authorization
We often review our Preferred Drug List or Precertification?
to make sure it meets the criteria for Precertification encourages the
safety, effectiveness and overall value. appropriate and cost-effective use of
The list is subject to change. Medications medications by allowing coverage only
may be covered at a higher copayment when certain conditions are met.
or removed from the Preferred Drug List Reasons for precertification include:
at any time.
I Age or gender of the member if outside
I As brand-name medications lose their
of recommended dosing guidelines
patents and generic versions become
I Preventing duplicate therapies and
available, the brand-name medication
I To help health-care providers check
may be covered at a higher copayment.
Medications likely to become available that a medication is being used based
generically in 2008 are identified in on generally accepted medical criteria.
this booklet with a # symbol. The precertification program is based
I The Preferred Drug List may change
upon current medical findings, FDA-
because the FDA approves many new approved manufacturer labeling
medications throughout the year. Open information and cost and manufacturer
formulary plans generally cover new rebate arrangements.
FDA-approved medications before they I If your plan includes our
have completed Aetna’s new drug review precertification program, your doctor
process. Depending on their plan, some must request approval from Aetna for
members may pay a higher copayment. coverage of the medication. If we
The medication also may be subject to approve the request, we will notify
precertification or step-therapy your doctor. The medication will then
requirements. be covered at the applicable copay
I The Preferred Drug List also may
under your plan. You will also be
change if a medication is withdrawn notified of approvals where the state
from the market or becomes available requires notification of members. If the
without a prescription. When an over- request is denied, you and your doctor
the-counter (OTC) equivalent becomes will be notified.
available, the prescription medication I Some medications in this guide may
may no longer be covered under many require prior authorization before they
of Aetna’s pharmacy benefits. will be covered under your pharmacy
benefits. For information on whether
precertification applies to your plan,
please refer to your plan documents or
4 www.aetna.com/formulary
call the Member Services number on excess of the quantity listed, the
your ID card. Refer to pages 33-34 for prescribing physician must request a
further details on which medications medical exception. Refer to pages 35-41
require precertification. for further details on which medications
I The list of medications requiring have quantity limits. The list of
precertification is subject to medications with quantity limits is
change. Refer to our website at subject to change. Refer to our website
www.aetna.com/formulary or call at www.aetna.com/formulary or call the
the Member Services number on Member Services number on your ID
your ID card for the most up-to- card for the most up-to-date information.
date information.
What is Step-Therapy?
Why Do Some Medications Step-therapy means you must first
Have Quantity Limits? try one or more “prerequisite”
Quantity limits are included as part of medications before we cover the
our precertification program. They are step-therapy medication.
designed to help promote safe,
Step-therapy is based upon current
appropriate and efficient medication use.
medical findings, FDA-approved
Quantity limits are based on generally manufacturer labeling information
accepted pharmaceutical guidelines, and cost and manufacturer rebate
efficient dosing regimens and dosing arrangements.
recommendations. Three types of I Prerequisite medications and their
quantity limits are in place: corresponding step-therapy medications
I Dose Efficiency Edits – Limits coverage are FDA-approved and are used to treat
of prescriptions to one dose per day the same conditions.
for drugs that are approved for once- I If it is medically necessary, you can
daily dosing. obtain coverage for a step-therapy
I Maximum Daily Dose – Informational medication without trying a
message is sent to the pharmacy if prerequisite medication first. In this
prescription lies outside recommended case, your doctor must request
minimum and maximum doses. coverage for a step-therapy medication
I Quantity Limits Over Time – Limits
as a medical exception. If the request
coverage of prescriptions to a specific is approved, we will notify your doctor.
number of units over a defined amount The medication will then be covered
of time. at the applicable copay under your
plan. You will also be notified of
Quantity limit medications may be approvals where states require it. If the
covered up to the quantity indicated. In request is denied, we will notify you
order to receive coverage for amounts in and your doctor.
www.aetna.com/formulary 5
I For information on whether step- necessary, or whether one of the
therapy applies to your plan, please medications should be discontinued.
refer to your plan documents or
Medications subject to the therapeutic
call the Member Services number
duplication program include:
on your ID card.
I Selective Serotonin Reuptake Inhibitors
I Refer to page 42-46 for further
(SSRI) used to treat depression
details on which medications require
I Proton Pump Inhibitors used
step-therapy.
to treat ulcers
The list of medications requiring step-
I “Triptan” drugs used to treat
therapy is subject to change. Refer to our
website at www.aetna.com/formulary or migraine headaches
call the Member Services number on your I Inhaled steroids for the treatment
ID card for the most up-to-date of asthma
information. I “Statin” medications used to
treat high cholesterol
What is Therapeutic
Duplication? What are Generic
Therapeutic Duplication is when two Medications?
drugs from the same therapeutic category Generic drugs are identical to brand-
are used at the same time by the same name drugs in dosage, strength, route
person. Rarely are two drugs from the of administration, performance
same category necessary to treat a medical characteristics and intended use.
condition. Sometimes therapeutic Although generic drugs are chemically
duplication results when two physicians the same as their branded counterparts,
are prescribing medications for the same they are typically sold at substantial
person or when a physician changes from discounts from the branded price.
one medication to another within the Generic medications have been approved
same therapeutic class, but does not by the FDA. They contain the same
discontinue the first medication. In either active ingredients in the same amounts
situation, the person may end up taking as the brand-name products, although
two drugs with similar actions generics may be a different color, shape
unnecessarily, potentially leading to or size than brand-name products.
serious side effects.
Your pharmacist generally can substitute
If a therapeutic duplication is identified a generic medication for a brand-name
by our claims system, your pharmacist medication when filling your prescription
may ask you and/or your physician about when the generic is rated by the FDA
the medications you are supposed to be as equivalent and where substitution is
taking. He or she can then help permitted by law and by your doctor.
determine if both medications are
6 www.aetna.com/formulary
How Can I Save Money How Do I Contact Aetna
on Prescriptions? Rx Home Delivery?
Ask your doctor to consider prescribing Aetna Rx Home Delivery has two
medications on the Preferred Drug List pharmacy locations – Florida and
whenever appropriate. Medications on Missouri. Not sure which pharmacy you
the Preferred Drug List generally cost you should use? Contact Member Services at
less money with a lower copayment. the toll-free phone number on your ID
card. If you know which one serves your
In many plans, covered generic
pharmacy plan, contact that facility as
medications on the Preferred Drug
shown below:
List are available at the lowest copay.
Florida Mail-order Pharmacy
Ask your doctor or pharmacist
Aetna Rx Home Delivery
whether generic medications are
P.O. Box 829518
appropriate for you.
Pembroke Pines, FL
33082-9913
What is Aetna Rx Home
Delivery? 1-800-227-5720
Aetna Rx Home Delivery® is our www.Aetna.com/AetnaRxHomeDelivery
mail-order prescription service. Aetna
Hours: Monday – Friday,
Rx Home Delivery is an ideal way to
7:00 am – 11:00 pm EST
obtain your medications that are taken
Saturday, 8:00 am – 9:30 pm EST
regularly to treat a chronic condition
Sunday, 8:00 am – 6:00 pm EST
such as arthritis, diabetes or heart disease.
These medications are delivered right
Missouri Mail-order Pharmacy
to your door.
Aetna Rx Home Delivery
P.O. Box 417019
Kansas City, MO 64179-9892
1-866-612-3862
www.AetnaRxHomeDelivery.com
Hours: Monday – Friday,
7:00 am – 11:00 pm EST
Saturday, 7:00 am – 9:30 pm EST
Sunday, 8:00 am – 5:30 pm EST
www.aetna.com/formulary 7
What is Aetna
Specialty Pharmacy? THERAPEUTIC CLASS LIST KEY
Aetna Specialty Pharmacy® is available UPPERCASE – Brand-name medication
to fill your specialty injectable lower case italics – Generic medication
medication needs. Some injectable PR – Precertification required under
medications, as well as other disease- most plans
specific drugs, require special handling, ST – Step-therapy applies under
storage or shipping. These drugs are most plans
often referred to as specialty medications QL – Quantity limit applies under
and are often used to treat certain most plans
conditions such as hemophilia, hepatitis PMED – Preferred injectable medication
and multiple sclerosis. that may be covered under the
medical benefit
Aetna Specialty Pharmacy provides MED – Injectable medication that may be
convenient mail-order services for covered under the medical benefit
specialty medications that are not always # – Brand-name medication expected to
available at retail pharmacies. Aetna become available generically in the
Specialty Pharmacy also offers near future. After the generic
medication becomes available, the
educational and clinical support services brand-name medication may be
to help members manage their covered at a higher copayment.
medications and health condition. The brand-name medication may
also be subject to precertification
Depending on your benefits plan, you and/or step-therapy.
may have a copay for specialty injectable
medications. Please refer to your plan
documents or contact Member Services
at the number on your ID card for
further information. For more
information on Aetna Specialty
Pharmacy, call toll free at
1-866-782-ASRX (2779) or visit
www.AetnaSpecialtyRx.com.
8 www.aetna.com/formulary
4-Tier Member Guide
Copay Tier
Copay Tier
Quantity
Quantity
Therapy
Therapy
Precert
Precert
Limits
Limits
Step-
Step-
LABEL NAME LABEL NAME
Antineoplastic Agents Antineoplastic Enzyme Inhibitors
GLEEVEC 2
Adrenal Steroid Inhibitors
IRESSA 3
CYTADREN 3
NEXAVAR 2
Alkylating Agents SPRYCEL 3
ALKERAN 2 SUTENT 2
CEENU 2 TARCEVA 2
cyclophosphamide 1 Antineoplastics - Miscellaneous
CYTOXAN 3 ACTIMMUNE 4
HEXALEN 2 ALFERON N 4
LEUKERAN 2 HYDREA 3
MYLERAN 2 hydroxyurea 1
TEMODAR 2 INTRON-A 4
Antimetabolites MATULANE 2
MYLOCEL 3
mercaptopurine 1
PHOTOFRIN MED
methotrexate 1
PROLEUKIN MED
PURINETHOL 3
ROFERON-A 4
TABLOID 2
TARGRETIN 4
TREXALL 3 THERACYS MED
XELODA 2 TICE BCG MED
Antineoplastic - Hormonal Agents tretinoin 10 mg 1
ARIMIDEX 2 TYKERB 3
AROMASIN 2 UVADEX MED
CASODEX # 2 VESANOID 4
DEPO-PROVERA 3 ZOLINZA 3
EMCYT 2 Chemotherapy Rescue/Antidote Agents
EULEXIN 3 leucovorin calcium 1
FARESTON 3 MESNEX 3
FASLODEX MED Immunomodulators
FEMARA 2 REVLIMID 3
flutamide 1 THALOMID 3
leuprolide 4
Mitotic Inhibitors
LUPRON 4
etoposide 1
LUPRON DEPOT PMED VEPESID 3
LYSODREN 3
MEGACE 3 Blood Products- Modifiers-
MEGACE ES 3
Volume Expanders
megestrol 1 Anticoagulants - Coumarin
NILANDRON 2 COUMADIN 3
NOLVADEX 3 warfarin 1
tamoxifen 1 Anticoagulants - Heparins
TESLAC 3 ARIXTRA 4
ZOLADEX MED FRAGMIN 4
www.aetna.com/formulary 9
4-Tier Member Guide
Copay Tier
Copay Tier
Quantity
Quantity
Therapy
Therapy
Precert
Precert
Limits
Limits
Step-
Step-
LABEL NAME LABEL NAME
Anticoagulants - Heparins (continued) Platelet Aggregation Inhibitors
heparin sodium PMED AGGRENOX 2
INNOHEP 4 AGRYLIN 3
LOVENOX 4 anagrelide 1
Antiinhibitor Coagulant Complex cilostazol 1
dipyridamole 1
FEIBA 4
PERSANTINE 3
Blood Clotting Factor VIIa PLAVIX # 2
NOVOSEVEN 4 PLETAL 3
Blood Clotting Factor VIII Human TICLID 3
ALPHANATE 4 ticlopidine 1
HEMOFIL M 4 Cardiovascular System
HUMATE-P 4
Alpha-Beta Blockers
KOATE-DVI 4
COREG # 2
MONARC-M 4 (See page 42 for
MONOCLATE-P 4 step-therapy note)
Blood Clotting Factor VIII Recombinant COREG CR 2
ADVATE 4 labetalol 1
HELIXATE FS 4 TRANDATE 3
KOGENATE FS 4 Anaphylaxis Therapy Agents
RECOMBINATE 4 EPIPEN 2
REFACTO 4 TWINJECT 3
EPIPEN-JR 2
Blood Clotting Factor IX
Non-Recombinant Angiotensin Converting Enzyme (ACE)
ALPHANINE SD 4 Inhibitors and Combinations
MONONINE 4 ACCUPRIL 3
PROFILNINE 4 ACCURETIC 3
ACEON # 3
Blood Clotting Factor IX Complex
ALTACE # 2
BEBULIN 4
benazepril 1
PROPLEX 4 benazepril/
Blood Clotting Factor IX Recombinant hydrochlorothiazide 1
BENEFIX 4 CAPOTEN 3
CAPOZIDE 3
Gaucher Disease
captopril 1
CEREDASE MED captopril/
CEREZYME MED hydrochlorothiazide 1
ZAVESCA 3 enalapril 1
Hematopoietic Growth Factors enalapril/
hydrochlorothiazide 1
ARANESP PMED
fosinopril 1
EPOGEN MED
fosinopril/
PROCRIT PMED hydrochlorothiazide 1
LEUKINE MED lisinopril 1
NEULASTA PMED lisinopril/
NEUPOGEN MED hydrochlorothiazide 1
10 www.aetna.com/formulary
Copay Tier
Copay Tier
Quantity
Quantity
Therapy
Therapy
Precert
Precert
Limits
Limits
Step-
Step-
LABEL NAME LABEL NAME
Angiotensin Converting Enzyme (ACE) Antiadrenergic Antihypertensives
Inhibitors and Combinations (continued) (continued)
moexipril 1 guanfacine 1
moexipril/ HYTRIN 3
hydrochlorothiazide 1 methyldopa 1
LOTENSIN 3 MINIPRESS 3
LOTENSIN HCT 3 prazosin 1
MAVIK 3 reserpine 1
MONOPRIL 3 TENEX 3
MONOPRIL HCT 3 terazosin 1
PRINIVIL 3
Antianginals - Nitrates
PRINZIDE 3
amyl nitrite 1
quinapril 1
DILATRATE SR 3
quinaretic 1
IMDUR 3
trandolapril 1
ISMO 3
UNIRETIC 3
ISORDIL 3
UNIVASC 3
isosorbide dinitrate 1
VASERETIC 3
isosorbide mononitrate 1
VASOTEC 3
MONOKET 3
ZESTORETIC 3
NITROBID 3
ZESTRIL 3 NITRO-DUR 3
Angiotensin II Receptor nitroglycerin 1
Antagonists and Combinations nitroglycerin CR 1
ATACAND 3 nitroglycerin SL 1
ATACAND HCT 3 NITROLINGUAL 3
AVAPRO 3 NITROSTAT 2
AVALIDE 3 nitro-transderm 1
BENICAR 3
Antianginals - Other
BENICAR HCT 3
RANEXA 3
COZAAR 2
DIOVAN 2 Antiarrhythmics Type I-A
DIOVAN HCT 2 disopyramide 1
HYZAAR 2 NORPACE 3
MICARDIS 3 procainamide 1
MICARDIS HCT 3 procainamide ER 1
TEVETEN 3 PROCANBID 3
TEVETEN HCT 3 PRONESTYL 3
PRONESTYL SR 3
Antiadrenergic Antihypertensives quinidine gluconate 1
CARDURA 3 quinidine sulfate 1
CARDURA XL 3
CATAPRES 3 Antiarrhythmics Type I-B
CATAPRES-TTS 3 mexiletine 1
clonidine 1 Antiarrhythmics Type I-C
doxazosin 1 flecainide 1
guanabenz 1 propafenone 1
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Antiarrhythmics Type I-C (continued) Antihyperlipidemics - Intestinal
RYTHMOL 3 Cholesterol Absorption Inhibitors
RYTHMOL SR 3 ZETIA 2
TAMBOCOR 3 Antihyperlipidemics - Miscellaneous
Antiarrhythmics Type III LIPEX 3
amiodarone 1 LOVAZA 3
CORDARONE 3 Antihyperlipidemics -
PACERONE 3 Nicotinic Acid Derivatives
TIKOSYN 3 NIASPAN 2
Antihyperlipidemics - Bile Sequestrants Beta Blockers Cardioselective
cholestyramine 1 and Combinations
COLESTID 3 acebutolol 1
colestipol 1 atenolol 1
prevalite 1 atenolol/chlorthalidone 1
QUESTRAN 3 betaxolol 1
WELCHOL 2 bisoprolol fumarate 1
bisoprolol/
Antihyperlipidemics - hydrochlorothiazide 1
Fibric Acid Derivatives KERLONE 3
ANTARA 2 LOPRESS HCT 3
gemfibrozil 1 LOPRESSOR 3
fenofibrate 1 metoprolol 1
LOFIBRA 3 metoprolol succinate SR 3
LOPID 3 SECTRAL 3
TRICOR # 2 TENORMIN 3
TRIGLIDE 3 TENORETIC 3
Antihyperlipidemics - TOPROL XL 3
HMG CoA Reductase Inhibitors ZEBETA 3
ADVICOR 2 ZIAC 3
ALTOPREV 3 Beta Blockers Non-Selective
CADUET 3 and Combinations
CRESTOR 5 mg 2 BETAPACE 3
CRESTOR BETAPACE AF 3
(all other strengths) 2 CARTROL 3
LESCOL 2 CORGARD 3
LESCOL XL 2 CORZIDE 3
LIPITOR 3 INDERAL 3
lovastatin 1 INDERAL LA 3
MEVACOR 3 INDERIDE 3
PRAVACHOL 3 INNOPRAN XL 3
pravastatin 1 LEVATOL 3
simvastatin 1 metoprolol/
VYTORIN 10 mg / 10 mg 2 hydrochlorothiazide 1
VYTORIN nadolol 1
(all other strengths) 2 pindolol 1
ZOCOR 3 propranolol 1
12 www.aetna.com/formulary
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Beta Blockers Non-Selective Calcium Blockers (continued)
and Combinations (continued) TIAZAC 3
propranolol SR 1 verapamil 1
propranolol/ verapamil CR/ER/SR 1
hydrochlorothiazide 1
VERELAN 3
sorine 1
VERELAN PM 3
sotalol AF 1
sotalol hcl 1 Cardiac Glycosides
TIMOLIDE 3 digitek 1
timolol maleate 1 digoxin 1
LANOXICAPS 3
Calcium Blockers
LANOXIN 3
ADALAT CC 3
afeditab 1 Cardiovascular Combinations -
amlodipine 1 Miscellaneous
CALAN 3 amlodipine/benazepril 1
CALAN SR 3 BIDIL 3
CARDENE 3 CLORPRES 3
CARDENE SR 3 hydralazine/
CARDIZEM 3 hydrochlorothiazide 1
LEXXEL 3
CARDIZEM CD 3
CARDIZEM LA 2 LOTREL 3
cartia XT 1 methyldopa/
hydrochlorothiazide 1
COVERA HS 3
rauwolfia/
DILACOR XR 3
bendroflumethiazide 1
diltia XT 1 TARKA 3
diltiazem 1
diltiazem CD/ER/CR/XT 1 Direct Renin Inhibitor
diltiazem extended TEKTURNA 3
release beads SR 1 Diuretics - Carbonic
DYNACIRC CR 3 Anhydrase Inhibitors
felodipine 1 acetazolamide 1
ISOPTIN SR 3 DIAMOX 3
isradipine 1 methazolamide 1
nicardipine 1
Diuretics - Loop
nifediac CC 1
nifedical XL 1 bumetanide 1
nifedipine 1 BUMEX 3
nifedipine CR/ER/SR 1 DEMADEX 3
nimodipine 1 EDECRIN 3
NIMOTOP 3 furosemide 1
NORVASC 3 LASIX 3
PLENDIL 3 torsemide 1
PROCARDIA 3 Diuretics - Potassium Sparing
PROCARDIA XL 3 and Combinations
SULAR 3 ALDACTAZIDE 3
taztia XT 1 ALDACTONE 3
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Diuretics - Potassium Sparing Vasodilators
and Combinations (continued) hydralazine 1
amiloride 1 isoxsuprine 1
amiloride/ minoxidil 1
hydrochlorothiazide 1 papaverine ER 1
DYAZIDE 3 VASODILAN 3
DYRENIUM 3
Central Nervous System
MAXZIDE 3
ALS Agents
spironolactone 1
RILUTEK 3
spironolactone/
hydrochlorothiazide 1 Alzheimer’s Disease - Antidementia
triamterene/ ARICEPT # 3
hydrochlorothiazide 1 ARICEPT ODT 3
Diuretics - Selective Aldosterone COGNEX 3
Receptor Antagonists (SARAs) EXELON 2
INSPRA 3 NAMENDA 2
RAZADYNE # 3
Diuretics - Thiazide and Thiazide-Like RAZADYNE ER 3
chlorothiazide 1
Antianxiety - Benzodiazepines
chlorthalidone 1
alprazolam 1
DIURIL 3
alprazolam ER 1
hydrochlorothiazide 1 chlordiazepoxide 1
indapamide 1 clorazepate 1
methychlothiazide 1 diazepam 1
metolazone 1 lorazepam 1
MICROZIDE 3 NIRAVAM 3
NATURETIN 3 oxazepam 1
THALITONE 3 XANAX XR 3
ZAROXOLYN 3 Antianxiety - Miscellaneous
Erectile Dysfunction buspirone 1
CAVERJECT 3 hydroxyzine hcl 1
EDEX 3 hydroxyzine pamoate 1
meprobamate 1
MUSE 3
papaverine inj. 1 Anticonvulsants - Benzodiazepines
clonazepam 1
Pheochromocytoma Agents
clonazepam orally
DEMSER 3 disintegrating tab 1
DIBENZYLINE 2 DIASTAT 3
phentolamine 4 KLONOPIN 3
Pulmonary Hypertension Agents KLONOPIN WAFER 3
LETAIRIS 3 Anticonvulsants - Carbamates
REVATIO 2 FELBATOL 3
TRACLEER 2 Anticonvulsants - GABA Modulators
VENTAVIS 2 GABITRIL 3
14 www.aetna.com/formulary
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Anticonvulsants - Hydantoins Antidepressants - Miscellaneous
phenytoin extended 1 (continued)
phenytoin sodium 1 maprotiline 1
Anticonvulsants - Miscellaneous WELLBUTRIN 3
WELLBUTRIN SR 3
carbamazepine 1
gabapentin 1 WELLBUTRIN XL # 2
GABARONE 3 Antidepressants - Modified Cyclics
KEPPRA 2 DESYREL 3
LAMICTAL 2 nefazodone 3
lamotrigine chew 1 trazodone 1
LYRICA 3
Antidepressants - Serotonin-
NEURONTIN 3
Norepinephrine Reuptake Inhibitors
primidone 1
CYMBALTA 2
TEGRETOL 3
EFFEXOR 3
TEGRETOL XR 3
EFFEXOR XR 2
TOPAMAX # 3
TRILEPTAL 2 venlafaxine 1
ZONEGRAN 3 Antidepressants - Selective
zonisamide 1 Serotonin Reuptake Inhibitors
Anticonvulsants - Succinimides CELEXA 3
CELONTIN 3 citalopram 1
ethosuximide 1 fluoxetine 1
ZARONTIN 3 fluvoxamine 1
LEXAPRO 3
Anticonvulsants - Valproic Acid
paroxetine 1
DEPAKOTE # 2
PAXIL 3
DEPAKOTE ER # 2
PAXIL CR 3
DEPAKOTE SPRINKLE # 2
PEXEVA 3
Antidepressants - Alpha-2 PROZAC 3
Receptor Antagonists
PROZAC WEEKLY 3
mirtazapine 1
RAPIFLUX 3
mirtazapine ODT 1
sertraline 1
REMERON 3
ZOLOFT 3
REMERON SOLUTAB 3
Antidepressants - MAO Inhibitors Antidepressants - Tricyclic Agents
EMSAM 3 amitriptyline 1
MARPLAN 3 amoxapine 1
NARDIL 3 clomipramine 1
PARNATE 3 desipramine 1
tranylcypromine sulfate 1 doxepin hcl 1
imipramine hcl 1
Antidepressants - Miscellaneous
nortriptyline 1
budeprion 1
vanatrip 1
budeprion XL 1
bupropion 1 Antiparkinsonian Adjuvants
bupropion SR 1 LODOSYN 3
www.aetna.com/formulary 15
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Antiparkinsonian Anticholinergic Antipsychotics - Combinations
AKINETON 3 chlordiazepoxide/
benztropine 1 amitriptyline 1
COGENTIN 3 perphenazine/
amitriptyline 1
KEMADRIN 3
trihexyphenidyl 1 SYMBYAX 3
Antiparkinsonian COMT Inhibitors Antipsychotics - First Generation
COMTAN 2 chlorpromazine 1
TASMAR 3 compro 1
fluphenazine 1
Antiparkinsonian Dopaminergic
haloperidol 1
amantadine 1
loxapine 1
APOKYN 3
perphenazine 1
atamet 1
prochlorperazine 1
bromocriptine 1
thioridazine 1
carbidopa/levodopa 1
thiothixene 1
carbidopa/levodopa SR 1
MIRAPEX # 2 trifluoperazine 1
NEUPRO 3 Antipsychotics - Miscellaneous
PARCOPA 3 EQUETRO 3
PARLODEL 3 Chemical Dependency
REQUIP # 2
ANTABUSE 3
SINEMET 3
CAMPRAL 3
SINEMET CR 3
naltrexone 1
STALEVO 3
SYMMETREL 3 Lithium
Antiparkinsonian Monoamine lithium carbonate 1
Oxidase Inhibitor lithium carbonate CR 1
AZILECT 3 lithium citrate 1
ELDEPRYL 3 LITHOBID 3
selegiline 1 Migraine Products
Antipsychotics - Atypical AMERGE 2
ABILIFY 3 AXERT 3
ABILIFY DISC 3 FROVA 3
clozapine 1 IMITREX inj. # 2
CLOZARIL 3 IMITREX tab/spray # 2
FAZACLO 3 MAXALT 2
GEODON # 3 MAXALT MLT 2
INVEGA 3 MIGRANAL 3
RISPERDAL # 2 RELPAX 3
(See page 43 for ZOMIG 3
step-therapy note)
ZOMIG ZMT 3
RISPERDAL CONSTA MED
RISPERDAL M 2 Multiple Sclerosis Agents
SEROQUEL 2 AVONEX 4
SEROQUEL XR 2 BETASERON 4
ZYPREXA # 2 COPAXONE 4
ZYPREXA ZYDIS 2 REBIF 4
16 www.aetna.com/formulary
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Narcotic Agonists Narcotic Combinations (continued)
ACTIQ 3 hydrocodone/
AVINZA 3 acetaminophen 1
codeine phosphate 1 hydrocodone/ibuprofen 1
codeine sulfate 1 LIQUICET 3
DARVON-N 3 LORCET 3
DEMEROL 3 LORCET PLUS 3
DILAUDID 3 LORTAB 3
DURAGESIC 3 LYNOX 3
fentanyl transmucosal
MAGNACET 3
lozenge 1
fentanyl transdermal 1 MAXIDONE 3
FENTORA 3 meperidine/promethazine 1
hydromorphone 1 meprozine 1
KADIAN 2 NORCO 3
levorphanol 1 oxycodone/acetaminophen 1
meperidine 1 oxycodone/aspirin 1
methadone 1 pentazocine/
methadose 1 acetaminophen 1
morphine sulfate 1 PERCOCET 3
morphine sulfate CR 1 PERCODAN 3
MS CONTIN 3 phrenilin/caffeine/
OPANA 3 codeine 1
OPANA ER 2 propoxyphene/
ORAMORPH SR 3 acetaminophen 1
oxycodone 1 propoxyphene-N/
OXYCONTIN CR # 2 acetaminophen 1
oxyfast 1 REPREXAIN 3
OXYIR 3 ROXICET 3
propoxyphene 1 STAGESIC 1
tramadol hcl 1 STAFLEX 3
ULTRAM 3 SYNALGOS DC 3
ULTRAM ER 3 TALACEN 3
Narcotic Combinations tramadol/acetaminophen 1
acetaminophen/codeine 1 TRYCET 3
ALCET 3 TYLENOL/CODEINE 3
aspirin/codeine 1 TYLOX 3
butalbital/acetaminophen/ ULTRACET 3
caffeine/codeine 1
VICODIN 3
butalbital/aspirin/
caffeine/codeine 1 VICODIN ES 3
CAPITAL/CODEINE 3 vicodin HP 1
COMBUNOX 3 VICOPROFEN 3
DARVOCET-N 3 VOPAC 3
FIORICET/CODEINE 3 XODOL 3
FIORINAL/CODEINE 3 ZYDONE 3
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Narcotic Partial Agonists Stimulants - Methylphenidate
butorphanol 1 CONCERTA # 3
pentazocine/naloxone 1 DAYTRANA 2
SUBOXONE 3 dexmethylphenidate 1
SUBUTEX 3 FOCALIN 3
TALWIN NX 3 FOCALIN XR 3
Premenstrual Dysphoric Disorder METADATE CD # 2
SARAFEM 3 METADATE ER 3
Psychotherapeutic and methylin 1
Neurological Agents METHYLIN chew/soln 3
ergoloid mesylate 1 methylin ER 1
ORAP 3 methylphenidate 1
PROVIGIL 3 methylphenidate ER 1
STRATTERA 3 methylphenidate SR 1
XYREM 3 RITALIN 3
Sedative/Hypnotics - Barbiturate RITALIN LA 3
BUTISOL SODIUM 3 RITALIN SR 3
MEBARAL 3 Dermatological Agents
mephobarbital 1
phenobarbital 1 Acne Products
SECONAL 3 ACCUTANE 3
AKNE-MYCIN 3
Sedative/Hypnotics - Nonbarbiturates
amnesteem 1
AMBIEN 3
AVAR 3
AMBIEN CR 2
AVAR GREEN 3
chloral hydrate 1
DORAL 3 AVITA 1
estazolam 1 AZELEX 3
flurazepam 1 BENZACLIN 2
LUNESTA 3 BENZAMYCIN 3
midazolam 1 BENZIQ 3
ROZEREM 3 BENZIQ LS 3
SONATA # 3 BENZIQ wash 3
temazepam 1 benzoyl peroxide 1
triazolam 1 benzoyl peroxide/
zolpidem 1 urea cream 1
Stimulants - Amphetamines BINORA 3
CLARIFOAM EF 3
ADDERALL 3
ADDERALL XR # 2 claravis 1
amphetamine/ clindamax 1
dextroamphetamine 1 clindamycin 1
DESOXYN 3 DIFFERIN gel/cream 2
DEXEDRINE 3 DUAC 2
dextroamphetamine 1 erythromycin 1
dextroamphetamine CR 1 erythromycin/benzoyl
dextrostat 3 peroxide 1
VYVANSE 2 EVOCLIN 3
18 www.aetna.com/formulary
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Acne Products (continued) Antifungals - Topical (continued)
INOVA 3 hydrocortisone/iodoquinol 1
isotretinoin 1 ketoconazole 1
KLARON 3 LOPROX
LAVOCLEN 3 cream/lotion/suspension 3
METROCREAM 3 LOPROX gel/shampoo # 2
METROGEL 1% only 2 LOTRISONE 3
METROLOTION 3 NAFTIN 3
metronidazole 1 nystatin 1
NEOBENZ MICRO 3
nystatin/triamcinolone 1
NORITATE 3
OXISTAT 3
NUOX 3
PENLAC # 3
PLEXION cloth 3
VUSION 3
PLEXION emulsion 3
PLEXION SCT 3 Antineoplastics and
PLEXION TS 3 Keratolytics - Topical
RETIN-A 3 CARAC 3
RETIN-A MICRO 2 EFUDEX 3
ROSAC 3 FLUOROPLEX 3
ROSULA 3 fluorouracil 1
ROZEX 3 LEVULAN KERA 3
sodium sulfacetamide/sulfur 1
PANRETIN 2
sotret 1
SOLARAZE 3
SULFACET-R 3
TARGRETIN 2
sulfatol 1
SULFOXYL 3 Antipruritics and Topical Anesthetics
tretinoin 1 cocaine hcl 1
TRIAZ 3 lidocaine 1
Z-CLINZ 3 lidocaine/prilocaine 1
ZIANA 2 LIDODERM 2
ZODERM 3 prudoxin 1
Antibiotics - Topical SYNERA 3
ALTABAX 3 ZONALON 3
BACTROBAN 3
Antipsoriatics
CENTANY 3
8-MOP 3
gentamicin 1
AMEVIVE 4
mupirocin 1
anthralin 1
Antifungals - Topical
DOVONEX # 3
ciclopirox 1
DRITHO-SCALP 3
clotrimazole/
betamethasone 1 OXSORALEN-UL 3
econazole 1 PSORIATEC 3
ERTACZO 3 RAPTIVA 4
EXELDERM 3 SORIATANE 2
hydrocortisone/clioquinol 1 TAZORAC 2
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Antiseborrheic Products Corticosteroids - Topical (continued)
CAPITROL TACLONEX 3
lotion/shampoo/spray 3 triamcinolone 1
OVACE 3 ULTRAVATE 3
ROSULA NS 3 VANOS 2
SEBIZON 3 VERDESO 3
selenium sulfide 1
sulfacetamide sodium 1
Immunomodulating Agents - Topical
ALDARA 2
Antiviral - Topical ELIDEL 2
DENAVIR 3 PROTOPIC 2
ZOVIRAX 3
Rosacea Agents
Corticosteroids - Topical FINACEA 3
alclometasone 1 ORACEA 3
amcinonide 1
augmented betamethasone Scabicides & Pediculicides
dipropionate 1 EURAX 3
betamethasone valerate 1 lindane 1
clobetasol 1 permethrin 1
clobevate 1 sulfurated lime solution 1
CLOBEX
lotion/shampoo/spray 2 Endocrine System
CLODERM 3 Antidiabetics -
CORDRAN 3 Alpha-Glucosidase Inhibitors
DERMATOP 3 GLYSET 3
DESONATE 3 PRECOSE 3
desonide 1 Antidiabetics - Biguanides
desoximetasone 1 and Combinations
diflorasone 1 FORTAMET 3
DIPROLENE AF 3 glipizide/metformin 1
ELOCON 3 GLUCOPHAGE 3
fluocinolone acetonide 1 GLUCOPHAGE XR 3
fluocinonide 1 GLUCOVANCE 3
fluticasone 1 glyburide/metformin 1
HALOG 3 METAGLIP 3
hydrocortisone 1 metformin 1
hydrocortisone butyrate 1 metformin ER 1
hydrocortisone valerate 1 RIOMET 3
hydrocortisone/pramoxine 1
lacticare/hydrocortisone 1 Antidiabetics - DPP-IV
Inhibitors and Combinations
lidocaine/hydrocortisone 1
JANUVIA 2
LUXIQ 2
JANUMET 2
mometasone 1
NUZON 3 Antidiabetics - Insulin
OLUX 2 APIDRA 3
OLUX-E 2 BYETTA 2
prednicarbate 1 EXUBERA 3
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Antidiabetics - Insulin (continued) Contraceptives - Oral (continued)
HUMALOG products 2 BREVICON 3
HUMULIN products 2 cesia 1
LANTUS 2 cryselle 1
LEVEMIR 2 CYCLESSA 3
NOVOLIN products 3 DEMULEN 1/35 3
NOVOLOG products 2 DEMULEN 1/50 3
RELION products 3 DESOGEN 3
SYMLIN 2 enpresse 1
Antidiabetics - Meglitinides ESTROSTEP FE 3
FEMCON 3
STARLIX 2
jolessa 1
PRANDIN 2
junel 1.5/30 1
Antidiabetics - Sulfonylureas junel 1/20 1
AMARYL 3 junel FE 1.5/30 1
chlorpropamide 1 junel FE 1/20 1
glimepiride 1 kariva 1
glipizide 1 kelnor 1
glipizide ER 1 leena 1
glipizide XL 1 lessina 1
glyburide 1 LEVLEN 3
glyburide micronized 1 LEVLITE 3
glycron 1 levora 1
tolazamide 1 LO/OVRAL 3
tolbutamide 1 LOESTRIN 1.5/30 3
Antidiabetics - Thiazolidinediones LOESTRIN 1/20 3
(TZDs) and Combinations LOESTRIN FE 3
ACTOS 2 LOESTRIN FE 1.5/30 3
ACTOPLUS MET 2 LOESTRIN-24 3
AVANDAMET 2 low-ogestrel 1
AVANDARYL 2 lutera 1
AVANDIA 2 LYBREL 3
DUETACT 2 microgestin 1.5/30 1
Antidiuretic Agents microgestin 1/20 1
microgestin FE 1.5/30 1
DDAVP 3
microgestin FE1/20 1
desmopressin 1
MIRCETTE 3
STIMATE 3
MODICON 0.5/35 3
Contraceptives - Injectable Progestins mononessa 1
medroxyprogesterone 1 necon 0.5/35 1
DEPO-PROVERA 3 necon 1/35 1
Contraceptives - Oral necon 1/50 1
ALESSE 3 necon 10/11 1
apri 1 necon 7/7/7 1
aranelle 1 NORDETTE 3
aviane 1 NORINYL 1+35 3
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Contraceptives - Oral (continued) Contraceptives - Transdermal
NORINYL 1+50 3 ORTHO EVRA 3
nortrel 0.5/35 1 Contraceptives - Vaginal
nortrel 1/35 1 NUVARING 3
nortrel 7/7/7 1
Diabetic Supplies
ogestrel 1
alcohol swabs NC
ORTHO TRI-CYCLEN 3
BD insulin syringes 2
ORTHO TRI-CYCLEN LO 3
FREESTYLE
ORTHO-CEPT 3
glucose test strips 2
ORTHO-CYCLEN 3
FREESTYLE LITE
ORTHO-NOVUM 1/35 3 glucose test strips 2
ORTHO-NOVUM 1/50 3 gauze pad NC
ORTHO-NOVUM 10/11 3 glucose test strips
ORTHO-NOVUM 7/7/7 3 (all other brands) 3
OVCON 50 3 insulin syringes
(all syringes other
OVCON-35 3
then BD brand) 3
portia 1
ONE TOUCH BASIC/
previfem 1 PROFILE/ONE TOUCH II
quasense 1 glucose test strips 2
reclipsen 1 ONE TOUCH FAST TAKE
SEASONALE 3 glucose test strips 2
SEASONIQUE 2 ONE TOUCH SURE STEP
glucose test strips 2
solia 1
ONE TOUCH ULTRA
sprintec 1 glucose test strips 2
sronyx 1 PRECISION Q-I-D
TRI-LEVLEN 3 glucose test strips 2
trinessa 1 PRECISION SOF-TACT
TRI-NORINYL 3 glucose test strips 2
TRIPHASIL 3 PRECISION XTRA
glucose test strips 2
tri-previfem 1
PRECISION XTRA
tri-sprintec 1 ketone test strips 2
trivora 1
Fertility Agents
velivet 1
BRAVELLE 4
YAZ 3
CETROTIDE 4
YASMIN 3
chorionic gonadotropin 4
zovia 1/35E 1
FOLLISTIM 4
zovia 1/50E 1
FOLLISTIM AQ 4
Contraceptives - Oral Progestins GANIRELIX 4
camila 1 GONAL-F 4
errin 1 LUVERIS 4
jolivette 1 MENOPUR 4
nora-be 1 NOVAREL 4
NOR-QD 3 OVIDREL 4
ORTHO MICRONOR 3 REPRONEX 4
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Glucose Elevating Agents Hormone Replacement - Estrogens
GLUCAGON 3 (continued)
PROGLYCEM 2 MENOSTAR 3
Growth Hormone Agents OGEN 3
ortho-est 1
GENOTROPIN 4
PREMARIN 3
GEREF 4
VIVELLE 3
HUMATROPE 4
NORDITROPIN 4 VIVELLE-DOT 3
NUTROPIN 4 Hormone Replacement -
NUTROPIN AQ 4 Estrogen Combinations
OMNITROPE 4 ACTIVELLA # 3
PROTROPIN 4 ANGELIQ 3
SAIZEN 4 CLIMARA PRO 3
SEROSTIM 4 COMBIPATCH 3
SOMAVERT 4 ESTRATEST 3
TEV-TROPIN 4 ESTRATEST HS 3
Growth Factors, Insulin-like FEMHRT 3
INCRELEX 4 FEMHRT LOW DOSE 3
IPLEX 4 FEMTRACE 3
PREFEST 3
Hormone Replacement - Androgens
PREMPHASE 3
ANDRODERM 2
PREMPRO 3
ANDROGEL 2
syntest D.S. 1
danazol 1
syntest H.S. 1
FIRST-TESTOSTERONE 3
STRIANT 3 Hormone Replacement - Progestins
TESTIM 3 medroxyprogesterone
testosterone inj. PMED acetate 1
norethindrone acetate 1
Hormone Replacement - Estrogens
PROMETRIUM 2
ALORA 3
CENESTIN 2 Metabolic Modifiers
CLIMARA 3 ADAGEN MED
DIVIGEL 2 ALDURAZYME 3
ELESTRIN 3 BUPHENYL 3
ENJUVIA 2 CARNITOR 3
ESCLIM 3 CYSTADANE 3
ESTRACE 3 ELAPRASE MED
ESTRADERM 3 FABRAZYME 3
estradiol tab 1 HECTOROL 3
estradiol patch 1 MYOZYME 3
ESTRASORB 2 NAGLAZYME MED
ESTROGEL 3 ORFADIN 2
estropipate 1 SENSIPAR 3
gynodiol 1 SUCRAID 3
MENEST 2 ZEMPLAR 2
www.aetna.com/formulary 23
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LABEL NAME LABEL NAME
Steroids - Glucocorticosteroids Acid Supressants -
CELESTONE 3 Proton Pump Inhibitors (continued)
cortisone AC 1 PRILOSEC 3
dexamethasone 1 PROTONIX # 3
ENTOCORT EC 3 ZEGERID 3
hydrocortisone 1 Antiemetics - 5-HT3
methylprednisolone 1 Receptor Antagonists
ORAPRED 3 ANZEMET 3
prednisolone 1 KYTRIL # 3
prednisone 1 ondansetron 1
Steroids - Mineralocorticoids ZOFRAN 3
fludrocort 1 ZOFRAN ODT 3
Thyroid Hormones Antiemetics - Anticholinergic
ARMOUR THYROID 3 maldemar 1
BIO-THROID 3 TRANSDERM-SCOP 3
levothroid 1 trimethobenzamide 1
levothyroxine 1 Antiemetics - Miscellaneous
levoxyl 1 CESAMET 3
SYNTHROID 3 EMEND 2
THYROLAR 3 tebamide 1
unithroid 1
Anti-Ulcer Drugs
Thyroid - Antithyroid Agents misoprostol 1
methimazole 1 sucralfate 1
propylthiouracil 1
Bowel Evacuants
TAPAZOLE 3
COLYTE 3
Gastrointestinal System GOLYTELY 3
Acid Supressants - H-2 Antagonists HALFLYTELY 3
AXID 3 NULYTELY 3
cimetidine 1 OSMOPREP 3
famotidine 1 peg 3350 1
nizatidine 1 polyethylene glycol 1
PEPCID 3 trilyte 1
PEPCID RPD 3 VISICOL 3
ranitidine 1 Chronic Constipation Agent
TAGAMET 3 AMITIZA 3
ZANTAC (all other forms) 3
Gallstone Solubilizing Agents
ZANTAC syrup 2
URSO 250 2
Acid Supressants - URSO FORTE 2
Proton Pump Inhibitors
ursodiol 1
ACIPHEX 3
NEXIUM 2
GI Antiallergy Agents
omeprazole 1 GASTROCROM 3
PREVACID # 2 GI Stimulants
PREVACID SOLUTAB 2 metoclopramide hcl 1
24 www.aetna.com/formulary
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LABEL NAME LABEL NAME
H. pylori Agents Genitourinary System
HELIDAC 3
Cystinosis Agents
PREVPAC 2
CYSTAGON 3
PYLERA 3
Interstitial Cystitis Agents
Inflammatory Bowel Agents
ELMIRON 3
ASACOL 2
RIMSO 3
AZULFIDINE 3
AZULFIDINE ENTABS 3 Phosphate Binders
CANASA 2 FOSRENOL 2
COLAZAL # 2 PHOSLO 2
DIPENTUM 3 RENAGEL 2
LIALDA 2 Prostatic Hypertrophy Agents
mesalamine 1 AVODART 3
PENTASA 3 finasteride 1
ROWASA (enema only) 2 FLOMAX 2
sulfasalazine 1 PROSCAR 3
sulfasalazine ER 1 UROXATRAL 2
sulfazine 1
Urinary Antispasmodics
sulfazine EC 1
bethanechol 1
Irritable Bowel Syndrome (IBS) Agents DETROL 3
LOTRONEX 3 DETROL LA 3
Laxatives DITROPAN 3
glycolax 1 DITROPAN XL 3
KRISTALOSE 3 ENABLEX 2
lactulose 1 flavoxate 1
hyoscyamine 1
Pancreatic Enzymes
oxybutynin 1
CREON 2
oxybutynin SR 1
DIGEX 3
OXYTROL 2
KU-ZYME 3
SANCTURA 3
KU-ZYME-HP 3 URECHOLINE 3
LIPRAM 3 URISPAS 3
LIPRAM CR 3 VESICARE 2
LIPRAM PN 3
PALCAPS 3 Urinary Anti-infectives
and Combinations
pancreatin 1
MACROBID 3
pancrelipase 1
methenamine hippurate 1
PANOCAPS 3
methenamine mandelate 1
ULTRACAPS 3
MONUROL 3
ULTRASE 2
nitrofurantoin 1
ULTRASE MT 2
nitrofurantoin monohydrate
VIOKASE 2 macrocrystal 1
Rectal Steroids UREX 3
colocort 1 URELLE 3
CORTIFOAM 3 UTA 3
www.aetna.com/formulary 25
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Vaginal Anti-infectives Infections and Infestations
CLEOCIN VAGINAL 3 Antibacterials - Aminoglycosides
clindamax 1 neomycin 1
CLINDESSE 3 paromomycin 1
GYNAZOLE-1 3 TOBI 3
METROGEL VAGINAL 3
Antibacterials - Ampicillins
nystatin vaginal 1 and Combinations
TERAZOL 3 amoxicillin 1
terconazole 1 amoxicillin/K clavulanate 1
tioconazole 1 AMOXIL 3
vandazole 1 ampicillin 1
zazole 1 AUGMENTIN 3
Vaginal Estrogens AUGMENTIN ES 3
AUGMENTIN XR 3
ESTRACE VAGINAL 3
DISPERMOX 3
ESTRING 3
principen 1
FEMRING 2
trimox 1
PREMARIN VAGINAL 3
VAGIFEM 3 Antibacterials - Cephalosporins,
1st Generation
Vaginal Progestins cefadroxil 1
CRINONE 3 cephalexin 1
PROCHIEVE 3 DURICEF 3
PROGESTERONE PANIXINE 3
VAGINAL 3
Antibacterials - Cephalosporins,
Immunological Agents 2nd Generation
cefaclor 1
Immunosuppressive Agents
cefaclor ER 1
ATGAM MED cefprozil 1
AZASAN 3 CEFTIN 3
azathioprine 1 cefuroxime 1
CELLCEPT 2 CEFZIL 3
cyclosporine 1 RANICLOR 3
cyclosporine modified 1 Antibacterials - Cephalosporins,
gengraf 1 3rd Generation
IMURAN 3 CEDAX 3
MYFORTIC 3 cefdinir 1
NEORAL 3 cefpodoxime 1
ORTHOCLONE MED OMNICEF 2
PROGRAF 2 SPECTRACEF 3
RAPAMUNE 3 SUPRAX 3
SANDIMMUNE 3 VANTIN 3
SIMULECT MED Antibacterials - Fluoroquinolones
THYMOGLOBULIN MED AVELOX 2
ZENAPAX MED AVELOX ABC 2
26 www.aetna.com/formulary
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Antibacterials - Fluoroquinolones Antibacterials - Sulfonamides
(continued) sulfadiazine 1
CIPRO 3 sulfisoxazole 1
CIPRO XR 3
ciprofloxacin 1 Antibacterials - Tetracyclines
ciprofloxacin ER 1 ADOXA 3
FACTIVE 3 ALODOX 3
LEVAQUIN 3 DECLOMYCIN 3
NOROXIN 3 demeclocycline hcl 1
ofloxacin 1 DORYX 3
PROQUIN XR 3 doxy-caps 1
TEQUIN # 3 doxycycline hyclate 1
Antibacterials - Ketolides doxycycline monohydrate 1
KETEK 3 DYNACIN 3
Antibacterials - Macrolides MINOCIN 3
minocycline 1
azithromycin 1
BIAXIN 3 MONODOX 3
BIAXIN XL 3 myrac 1
clarithromycin 1 PERIOSTAT 3
clarithromycin SR 1 SOLODYN 3
DYNABAC 3 SUMYCIN 3
e.e.s. 1 tetracycline 1
erythrocin 1 VIBRAMYCIN 3
erythromycin 1 VIBRATAB 3
erythromycin delayed
release particles 1 Antifungals
erythromycin ANCOBON 3
ethylsuccinate 1 BIO-STATIN 3
PCE 3 DIFLUCAN
ZITHROMAX 3 (all other strengths) 3
ZMAX 3 DIFLUCAN 150mg 3
Antibacterials - Miscellaneous fluconazole
(all other strengths) 1
clindamycin 1
metronidazole 1 fluconazole 150mg 1
metronidazole SR 1 GRIFULVIN V 3
NEBUPENT 2 GRIS-PEG 3
TINDAMAX 3 itraconazole 1
trimethoprim 1 ketoconazole 1
XIFAXAN 3 LAMISIL 3
ZYVOX 2 NOXAFIL 3
Antibacterials - Penicillins nystatin 1
dicloxacillin sodium 1 SPORANOX caps 3
GEOCILLIN 3 SPORANOX kit/soln 3
penicillin VK 1 terbinafine 1
veetids 1 VFEND 3
www.aetna.com/formulary 27
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LABEL NAME LABEL NAME
Antimalarials and Combinations Antiretrovirals - Nucleoside (NRTI) and
ARALEN 3 Nucleotide (NtRTI) Analogs (continued)
chloroquine 1 TRIZIVIR 3
DARAPRIM 3 TRUVADA 2
FANSIDAR 3 VIDEX 2
hydroxychloroquine sulfate 1 VIDEX EC 3
LARIAM 3 VIREAD 2
MALARONE 3 ZERIT # 2
mefloquine 1 ZIAGEN # 2
primaquine 1 zidovudine 1
quinerva 1 Antiretrovirals - Protease Inhibitors
quinine sulfate 1 AGENERASE 3
Antimycobacterial Agents APTIVUS 3
dapsone 1 CRIXIVAN 2
ethambutol 1 INVIRASE 2
isonarif 1 KALETRA 2
isoniazid 1 LEXIVA 2
MYAMBUTOL 2 NORVIR 2
pyrazinamide 1 PREZISTA 3
RIFAMATE 3 REYATAZ 2
rifampin 1 VIRACEPT 2
RIFATER 3 Antivirals -CMV Agents
Antiprotozoal Agents ganciclovir 1
ALINIA 3 VALCYTE 2
MEPRON 2 Antivirals -Hepatitis Agents
Antiretrovirals - Fusion Inhibitors BARACLUDE 3
FUZEON 4 COPEGUS 3
Antiretrovirals - NNRTI Combination EPIVIR HBV 2
HEPSERA 2
ATRIPLA 3
INFERGEN 4
Antiretrovirals - Non-Nucleoside PEGASYS 4
Reverse Transcriptase Inhibitors (NNRTIs)
PEG-INTRON 4
RESCRIPTOR 3
REBETOL 3
SUSTIVA 2
ribasphere 1
VIRAMUNE 2
ribavirin 1
Antiretrovirals - Nucleoside (NRTI) and TYZEKA 3
Nucleotide (NtRTI) Analogs
Antivirals -Herpes Agents
COMBIVIR 2
acyclovir 1
didanosine delayed release 1
FAMVIR 3
EMTRIVA 2
VALTREX 2
EPIVIR 2
ZOVIRAX 3
EPZICOM 3
RETROVIR caps/tabs 3 Antivirals - Influenza Agents
RETROVIR inj. MED FLUMADINE 3
RETROVIR syrup 3 RELENZA 3
28 www.aetna.com/formulary
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LABEL NAME LABEL NAME
Antivirals - Influenza Agents (continued) Muscle Relaxants and Combinations
rimantadine 1 (continued)
TAMIFLU 3 carisoprodol/aspirin 1
Antivirals -Respiratory carisoprodol/aspirin/codeine 1
Syncytial Virus (RSV) Agents chlorzoxazone 1
VIRAZOLE 3 cyclobenzaprine hcl 1
DANTRIUM 3
Musculoskeletal System FEXMID 3
Antimyasthenic Agents methocarbamol 1
MESTINON 2 orphenadrine cpd 1
MESTINON TIMESPAN 2 orphenadrine ER 1
pyridostigmine 1 orphenadrine/aspirin/
caffeine 1
Antirheumatic Agents
orphengesic 1
ARAVA 3
orphengesic forte 1
leflunomide 1
SKELAXIN # 2
RHEUMATREX 3
tizanidine 1
RIDAURA 3
ZANAFLEX 3
Calcium Regulators
NSAIDs
ACTONEL 2
ARTHROTEC 3
ACTONEL with CALCIUM 2
CELEBREX 3
AREDIA MED
DAYPRO 3
BONIVA 3
diclofenac 1
DIDRONEL 3
diclofenac potassium 1
FORTEO 4
diclofenac sodium XR 3
fortical 1
FOSAMAX # 2 etodolac 1
(See page 44 for etodolac ER 3
step-therapy note) fenoprofen 1
FOSAMAX PLUS D # 2 flurbiprofen 1
(See page 44 for ibuprofen 1
step-therapy note)
indomethacin 1
MIACALCIN inj. 3
indomethacin ER 1
MIACALCIN NASAL 3
ketoprofen 1
pamidronate 1
ketoprofen ER 3
RECLAST MED
ketorolac 1
SKELID 3
ZOMETA MED meclofenamate sodium 1
mefenamic acid 1
Immunomodulators meloxicam 1
ENBREL 4 MOBIC 3
HUMIRA 4 nabumetone 3
KINERET 4 NAPRELAN 3
ORENCIA MED naproxen 1
REMICADE PMED oxaprozin 3
RITUXAN MED piroxicam 1
Muscle Relaxants and Combinations PONSTEL 3
baclofen 1 PREVACID NAPRAPAC 3
carisoprodol 1 sulindac 1
www.aetna.com/formulary 29
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LABEL NAME LABEL NAME
NSAIDs (continued) Glaucoma - Prostaglandins
tolmetin sodium 3 LUMIGAN 2
VOLTAREN 3 TRAVATAN 2
VOLTAREN XR 3 TRAVATAN Z 2
XALATAN 3
Selective Estrogen Receptor
Modulator (SERM) Ophthalmic Antihistamines and NSAIDs
EVISTA 2 ACULAR 3
ACULAR LS 3
Ophthalmic Agents ACULAR PF 3
Glaucoma - Adrenergic Agents ALAMAST 3
ALPHAGAN P 2 ALOCRIL # 3
brimonidine 1 ALOMIDE 3
cromolyn sodium ophth 1
dipivefrin 1
ELESTAT 3
IOPIDINE 3
EMADINE 3
PROPINE 3
flurbiprofen 1
Glaucoma -Beta-blockers NEVANAC 3
betaxolol 1 OPTIVAR 2
BETIMOL 3 PATADAY 2
BETOPTIC-S 3 PATANOL # 2
carteolol 1 VOLTAREN 2
ISTALOL 3 XIBROM 3
levobunolol 1 Ophthalmic Anti-infectives
metipranolol 3 AZASITE 3
OPTIPRANOLOL 3 bacitracin 1
timolol 1 bacitracin/neomycin/
polymyxin 1
timolol maleate ophth 1
bacitracin/polymyxin 1
Glaucoma - Carbonic ciprofloxacin 1
Anhydrase Inhibitors erythromycin 1
AZOPT 2 gentamicin 1
COSOPT # 2 neomycin/polymyxin/
TRUSOPT # 2 gramicidin 1
ofloxacin 1
Glaucoma - Miotics polymyxin B/trimethoprim 1
carboptic 1 QUIXIN 3
ISO CARBACHOL 3 sulfacetamide sodium 1
ISOPTO CARPINE 3 tobramycin 1
PHOSPHOLINE 3 trifluridine 1
pilocar 1 triple antibiotic 1
pilocarpine 1 VIGAMOX 2
PILOPINE HS 3 ZYMAR 3
piloptic 1 Ophthalmic Immunomodulators
REV-EYES 3 RESTASIS 3
30 www.aetna.com/formulary
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Ophthalmic Steroidal Respiratory Tract Agents
Anti-inflammatory Drugs
Antiasthmatics - Anticholinergics
ak-pred 1
ALREX 2 ATROVENT HFA 3
bacitracin/polymyxin/ ipratropium inhaler 1
neomycin/hydrocortisone 1 SPIRIVA 2
BLEPHAMIDE S.O.P. 3 Antiasthmatic - Monocolonal Antibodies
dexacidin 1 XOLAIR MED
dexamethasone phosphate 1
dexamethasone/
Anti-Inflammatory Agents (nebulizer)
neomycin/polymyxin 1 cromolyn sodium nebulizer 1
dexasol 1 INTAL inhaler 3
dexasporin 1 INTAL nebulizer 3
fluorometholone 1 TILADE 3
fluor-op 1 Bronchodilators - Sympathomimetics
FML FORTE 3
ACCUNEB 3
FML LIQUIFILM 3
ADVAIR DISKUS # 2
FML S.O.P. 3
ADVAIR HFA 2
HMS 3
albuterol 1
LOTEMAX 2
albuterol/ipratropium 1
neomycin/polymyxin/
hydrocortisone 1 ALUPENT 3
poly-dex 1 BROVANA 3
POLY-PRED 3 COMBIVENT 2
PRED-G 3 DUONEB 2
PRED-G S.O.P 3 FORADIL 2
prednisolone 1 MAXAIR AUTOHALER 2
sulfacetamide sodium/ metaproterenol nebulizer 3
prednisolone 1 metaproterenol tab/syrup 3
TOBRADEX 3 micronefrin 1
VEXOL 3 PROAIR 2
ZYLET 3 PROVENTIL HFA # 2
Otic Agents SEREVENT DISKUS # 2
SYMBICORT 2
Otic Anti-infectives
terbutaline 1
FLOXIN OTIC 2
VENTOLIN HFA 3
Otic Combinations VOSPIRE ER 3
antipyrine/benzocaine 1 XOPENEX 3
CIPRO HC 3 XOPENEX HFA 3
CIPRODEX 2
COLY-MYCIN-S 3
Bronchodilators - Xanthines
cortomycin 1 aminophylline 1
neomycin/polymyxin/ BRONCAP 3
hydrocortisone 1 THEO-24 3
ZINOTIC 3 theocap 1
www.aetna.com/formulary 31
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LABEL NAME LABEL NAME
Bronchodilators - Xanthines (continued) Non-Sedating Antihistamines
theochron 1 and Combinations
theophylline ER 1 ALLEGRA 3
UNIPHYL 3 ALLEGRA-D 3
CLARINEX 3
Inhaled Corticosteroids
CLARINEX-D 3
AEROBID 3
CLARINEX REDITABS 3
AEROBID-M 3
fexofenadine 3
ASMANEX 2
XYZAL 3
AZMACORT 3
ZYRTEC 3
FLOVENT HFA # 2
ZYRTEC-D 3
FLOVENT DISKUS # 2
PULMICORT RESPULES 2
Upper Respiratory -
Cough/Cold/Allergy Combinations
PULMICORT FLEXHALER 3
SEMPREX-D 3
QVAR 3
TUSSIONEX 2
Leukotriene Modulators
ACCOLATE 3
SINGULAIR 2
ZYFLO 3
Mouth and Throat Products
EVOXAC 2
pilocarpine 1
SALAGEN 3
Nasal Antiallergy
ASTELIN NASAL 2
Nasal Anti-infectives
BACTROBAN NASAL 3
Nasal Anticholinergics
ATROVENT NASAL 3
ipratropium nasal 1
Nasal Steroids
BECONASE AQ 3
FLONASE 3
flunisolide 1
fluticasone propionate
nasal 1
NASACORT AQ 3
NASAREL 3
NASONEX 2
RHINOCORT AQ 3
VERAMYST 3
32 www.aetna.com/formulary
Precertification List
THERAPEUTIC CLASS PRECERTIFICATION DRUG(S)
Acid Supressants - ACIPHEX PREVACID PROTONIX
Proton Pump Inhibitors NEXIUM PRILOSEC ZEGERID
omeprazole
Acne Products ACCUTANE RETIN-A PR > 36 yr old
amnesteem sotret
AVITA PR > 36 yr old tretinoin PR > 36 yr old
claravis TRETIN-X cream kit PR > 36 yr old
isotretinoin ZIANA PR > 36 yr old
RETIN-A MICRO gel PR > 36 yr old
ALS Agents RILUTEK
Antibacterials - Fluoroquinolones AVELOX ciprofloxacin ER NOROXIN
PR 40 mg,
simvastatin > 40 mg,
CRESTOR, VYTORIN
LIPITOR > 40 mg CRESTOR > 10 mg and
VYTORIN > 10/10 mg
Antipsychotics - Atypical INVEGA RISPERDAL #
RISPERDAL # RISPERDAL M risperidone
(step-edit will not be
implemented until sometime
after generic becomes available)
Antirheumatic Agents ARAVA leflunomide
Beta-Blockers TOPROL XL metoprolol succinate SR
Cardioselective
Bronchodilators - BROVANA FORADIL or SEREVENT
Sympathomimetics FORADIL SEREVENT Any one of:
ASMANEX, FLOVENT HFA,
PULMICORT
XOPENEX solution albuterol nebules or concentrate
and concentrate
Calcium Blockers ADALAT PROCARDIA nifedipine
ADALAT CC PROCARDIA XL nifedical XL, nifedipine CR/ER
CALAN verapamil
CALAN SR ISOPTIN SR verapamil extended release
COVERA HS VERELAN SR
CARDENE nicardipine
CARDIZEM diltiazem
CARDIZEM CD Any one of:
DILACOR XR cartia XT, diltia XT,
diltiazem CD/CR/ER/XT
NORVASC amlodipine
TIAZAC diltiazem extended release beads SR
or taztia XT
www.aetna.com/formulary 43
Step-Therapy List
REQUIRED PREREQUISITE
THERAPEUTIC CLASS STEP-THERAPY DRUG DRUG(S)
Calcium Regulators BONIVA alendronate, alendronate plus D,
FOSAMAX #, or FOSAMAX PLUS D #
and ACTONEL or
ACTONEL with CALCIUM
FOSAMAX # alendronate
(step-edit will not be
implemented until sometime
after generic becomes available)
FOSAMAX PLUS D # alendronate or alendronate plus D
(step-edit will not be
implemented until sometime
after generic alendronate plus D
becomes available)
Cardiovascular Combinations LOTREL amlodipine/benazepril
- Miscellaneous
Corticosteroids-Topical TACLONEX TAZORAC and betamethasone
Diabetic Supplies All preferred blood glucose Any preferred blood glucose
test strips other than those test strip: FAST TAKE,
made by Abbott Diabetes FREESTYLE, FREESTYLE LITE,
Care or Lifescan ONE TOUCH BASIC/PROFILE,
ONE TOUCH ULTRA,
PRECISION Q-I-D,
PRECISION SOF-TACT,
PRECISION XTRA, SURESTEP
Direct Renin Inhibitor TEKTURNA Any one of:
amlodipine/benazepril,
benazepril,
benazepril/hydrochlorothiazide,
captopril,
captopril/hydrochlorothiazide,
enalapril,
enalapril/hydrochlorothiazide,
fosinopril,
fosinopril/hydrochlorothiazide,
lisinopril,
lisinopril/hydrochlorothiazide,
moexipril,
moexipril/hydrochlorothiazide,
quinapril,
quinaretic, trandolapril, ALTACE
and one of: COZAAR, DIOVAN,
DIOVAN HCT, HYZAAR
Hormone Replacement - FIRST-TESTOSTERONE ANDRODERM or ANDROGEL
Androgens TESTIM STRIANT
Immunomodulating Agents - ELIDEL PROTOPIC Any topical corticosteroid
Topical
44 www.aetna.com/formulary
REQUIRED PREREQUISITE
THERAPEUTIC CLASS STEP-THERAPY DRUG DRUG(S)
Narcotic Agonists ALCET PERCOCET oxycodone/acetaminophen
and Combinations MAGNACET TYLOX
LYNOX ROXICET
CAPITAL/CODEINE codeine/acetaminophen
TYLENOL #3
VOPAC
COMBUNOX Any oxycodone combinations
DARVOCET-N propoxyphene-N/acetaminophen
DURAGESIC fentanyl patches
FENTORA fentanyl transmucosal lozenge
FIORICET/CODEINE butalbital/acetaminophen/
caffeine/codeine
FIORINAL/CODEINE butalbital/aspirin/caffeine/codeine
LIQUICET NORCO hydrocodone/acetaminophen
LORCET VICODIN
LORCET PLUS VICODIN ES
LORTAB XODOL
MAXIDONE ZYDONE
PERCODAN oxycodone/aspirin
TALACEN pentazocine/acetaminophen
ULTRAM ULTRAM ER tramadol
VICOPROFEN REPREXAIN hydrocodone/ibuprofen
Nasal Steroids NASACORT AQ VERAMYST fluticasone and NASONEX
RHINOCORT AQ
Non-Sedating ALLEGRA fexofenadine fluticasone and NASONEX or
Antihistamines ALLEGRA-D SEMPREX-D ASTELIN
and Combinations CLARINEX XYZAL
CLARINEX ZYRTEC
REDITABS ZYRTEC-D
CLARINEX-D
NSAIDs MOBIC meloxicam
NAPRELAN Use of two (2) preferred
generic nsaids
Psychotherapeutic and STRATTERA Any one of:
Neurological Agents dexmethylphenidate,
methylphenidate,
methylphenidate SR,
amphetamine/dextroamphetamine,
ADDERALL XR, METADATE CD #,
VYVANSE
Sedative/Hypnotics - AMBIEN ROZEREM zolpidem
Nonbarbiturates AMBIEN CR SONATA
LUNESTA
Stimulants - Amphetamines DESOXYN Any one of:
methylphenidate,
methylphenidate SR,
amphetamine/dextroamphetamine,
ADDERALL XR, METADATE CD #,
VYVANSE
www.aetna.com/formulary 45
Step-Therapy List
REQUIRED PREREQUISITE
THERAPEUTIC CLASS STEP-THERAPY DRUG DRUG(S)
Stimulants - CONCERTA RITALIN Any one of:
Methylphenidate FOCALIN RITALIN LA amphetamine/dextroamphetamine,
FOCALIN XR RITALIN SR dexmethylphenidate,
METADATE ER methylphenidate,
METHYLIN chew/soln methylphenidate SR,
ADDERALL XR,
METADATE CD #, VYVANSE
Urinary Antispasmodics DETROL DITROPAN XL Any one of:
DETROL LA SANCTURA oxybutynin, ENABLEX, VESICARE,
OXYTROL
46 www.aetna.com/formulary
Index
# alendronate plus D. . . . . . . . . 44 aranelle . . . . . . . . . . . . . . . . . 21
8-MOP . . . . . . . . . . . . . . . . . . 19 ALESSE . . . . . . . . . . . . . . . . . 21 ARANESP . . . . . . . . . . . . . 10, 34
ALFERON N . . . . . . . . . . . . . . . 9 ARAVA. . . . . . . . . . . . . . . 29, 43
A ALINIA . . . . . . . . . . . . . . . . . 28 AREDIA . . . . . . . . . . . . . . . . . 29
ABILIFY . . . . . . . . . . . . . . 16, 37 ALKERAN . . . . . . . . . . . . . . . . . 9 ARICEPT . . . . . . . . . . . . . . . . 14
ABILIFY DISC . . . . . . . . . . . . . 16 ALLEGRA . . . . . . . 32, 34, 40, 45
ARICEPT ODT . . . . . . . . . . . . . 14
ACCOLATE . . . . . . . . . . . 32, 39 ALLEGRA-D . . . . . 32, 34, 40, 45
ALOCRIL . . . . . . . . . . . . . . . . 30 ARIMIDEX . . . . . . . . . . . . . . . . 9
ACCUNEB . . . . . . . . . . . . . . . 31
ALODOX . . . . . . . . . . . . . 27, 33 ARIXTRA . . . . . . . . . . . . . . . . . 9
ACCUPRIL . . . . . . . . . 10, 35, 42
ALOMIDE . . . . . . . . . . . . . . . . 30 ARMOUR THYROID . . . . . . . . 24
ACCURETIC . . . . . . . . . . 10, 42
ACCUTANE . . . . . 18, 33, 35, 42 ALORA. . . . . . . . . . . . . . . 23, 39 AROMASIN . . . . . . . . . . . . . . . 9
acebutolol . . . . . . . . . . . . . . . 12 ALPHAGAN P . . . . . . . . . . . . 30 ARTHROTEC. . . . . . . . . . . . . . 29
ACEON . . . . . . . . . . . . . . 10, 35 ALPHANATE . . . . . . . . . . . 10, 33 ASACOL . . . . . . . . . . . . . 25, 39
acetaminophen/codeine . . . . . 17 ALPHANINE SD . . . . . . . . 10, 33 ASMANEX . . . . . . . . . . . . 32, 43
acetazolamide . . . . . . . . . . . . 13 alprazolam . . . . . . . . . . . . . . . 14 aspirin/codeine. . . . . . . . . . . . 17
ACIPHEX . . . . . . . 24, 33, 35, 42 alprazolam ER . . . . . . . . . . . . 14 ASTELIN . . . . . . . . . . . . . . . . . 45
ALREX . . . . . . . . . . . . . . . . . . 31 ASTELIN NASAL . . . . . . . . . . . 32
ACTIMMUNE . . . . . . . . . . . . . . 9
ALTABAX . . . . . . . . . . . . . . . . 19
ACTIQ . . . . . . . . . . . . 17, 34, 40 ATACAND . . . . . . . . . 11, 35, 42
ALTACE . . . . . . . . . . . 10, 35, 44
ACTIVELLA. . . . . . . . . . . . . . . 23 ALTOPREV . . . . . . . . . 12, 37, 43 ATACAND HCT . . . . . 11, 35, 42
ACTONEL. . . . . . . . . . 29, 38, 44 ALUPENT . . . . . . . . . . . . . . . 31 atamet . . . . . . . . . . . . . . . . . . 16
ACTONEL with amantadine . . . . . . . . . . . . . . 16 atenolol . . . . . . . . . . . . . . . . . 12
CALCIUM . . . . . . . 29, 38, 44 AMARYL . . . . . . . . . . . . . . . . 21 atenolol/chlorthalidone . . . . . 12
ACTOPLUS MET . . . . . . . . . . . 21 AMBIEN . . . . . . . . . . . 18, 41, 45 ATGAM . . . . . . . . . . . . . . . . . 26
ACTOS. . . . . . . . . . . . . . . . . . 21 AMBIEN CR . . . . . . . . 18, 41, 45 ATRIPLA . . . . . . . . . . . . . . . . . 28
ACULAR . . . . . . . . . . . . . . . . 30 amcinonide . . . . . . . . . . . . . . 20 ATROVENT HFA . . . . . . . . . . . 31
ACULAR LS . . . . . . . . . . . . . . 30 AMERGE . . . . . . . . . . . . . 16, 39 ATROVENT NASAL . . . . . . . . . 32
ACULAR PF . . . . . . . . . . . . . . 30 AMEVIVE . . . . . . . . . . . . . . . . 19 augmented betamethasone
acyclovir. . . . . . . . . . . . . . . . . 28 amiloride . . . . . . . . . . . . . . . . 14 dipropionate . . . . . . . . . . . . 20
ADAGEN . . . . . . . . . . . . . . . . 23 amiloride/ AUGMENTIN . . . . . . . . . . . . . 26
ADALAT . . . . . . . . . . . . . . . . . 43 hydrochlorothiazide . . . . . . 14
ADALAT CC . . . . . . . . 13, 38, 43 aminophylline . . . . . . . . . . . . 31 AUGMENTIN ES . . . . . . . . . . . 26
ADDERALL . . . . . . . . . . . 18, 41 amiodarone . . . . . . . . . . . . . . 12 AUGMENTIN XR. . . . . . . . . . . 26
ADDERALL XR . . . 18, 41, 45, 46 AMITIZA . . . . . . . . . . . . . 24, 34 AVALIDE . . . . . . . . . . 11, 35, 42
ADOXA . . . . . . . . . . . . . . 27, 33 amitriptyline. . . . . . . . . . . . . . 15 AVANDAMET . . . . . . . . . . . . . 21
ADVAIR DISKUS . . . . . . . . . . . 31 amlodipine . . . . . 13, 38, 42, 43 AVANDARYL . . . . . . . . . . . . . 21
ADVAIR HFA . . . . . . . . . . . . . 31 amlodipine/benazepril . . . 13, 44 AVANDIA . . . . . . . . . . . . . . . . 21
ADVATE . . . . . . . . . . . . . . 10, 33 amnesteem . . . . . . . . 18, 33, 35 AVAPRO . . . . . . . . . . 11, 35, 42
ADVICOR . . . . . . . . . . . . . 12, 37 amoxapine . . . . . . . . . . . . . . . 15 AVAR . . . . . . . . . . . . . . . . . . . 18
AEROBID . . . . . . . . . . . . . . . . 32 amoxicillin . . . . . . . . . . . . . . . 26 AVAR GREEN . . . . . . . . . . . . . 18
AEROBID-M . . . . . . . . . . . . . . 32 amoxicillin/K clavulanate . . . . 26 AVELOX . . . . . . . . . . . . . 26, 33
afeditab . . . . . . . . . . . . . . 13, 38 AMOXIL . . . . . . . . . . . . . . . . 26 AVELOX ABC . . . . . . . . . 26, 33
AGENERASE. . . . . . . . . . . . . . 28 amphetamine/dextro-
amphetamine . . 18, 41, 45, 46 aviane . . . . . . . . . . . . . . . . . . 21
AGGRENOX . . . . . . . . . . . . . . 10 AVINZA . . . . . . . . . . . . . . . . . 17
AGRYLIN . . . . . . . . . . . . . . . . 10 ampicillin . . . . . . . . . . . . . . . . 26
amyl nitrite . . . . . . . . . . . . . . 11 AVITA. . . . . . . . . . . . . . . . 18, 33
AKINETON . . . . . . . . . . . . . . 16 AVODART . . . . . . . . . . . . 25, 34
anagrelide . . . . . . . . . . . . . . . 10
AKNE-MYCIN . . . . . . . . . . . . 18 AVONEX . . . . . . . . . . . . . . . . 16
ANCOBON . . . . . . . . . . . . . . . 27
ak-pred . . . . . . . . . . . . . . . . . 31 ANDRODERM . . . . . . . . . 23, 44 AXERT . . . . . . . . . . . . . . . 16, 39
ALAMAST . . . . . . . . . . . . . . . 30 ANDROGEL . . . . . . . . . . . 23, 44 AXID . . . . . . . . . . . . . . . . . . . 24
albuterol . . . . . . . . . . . . . . . . 31 ANGELIQ . . . . . . . . . . . . . . . . 23 AZASAN . . . . . . . . . . . . . . . . 26
albuterol nebules . . . . . . . . . . 43 ANTABUSE . . . . . . . . . . . . . . . 16
albuterol/ipratropium . . . . . . . 31 AZASITE . . . . . . . . . . . . . . . . . 30
ANTARA . . . . . . . . . . . . . . . . 12 azathioprine. . . . . . . . . . . . . . 26
ALCET . . . . . . . . . . . . . . . 17, 45 anthralin . . . . . . . . . . . . . . . . 19
alclometasone . . . . . . . . . . . . 20 AZELEX . . . . . . . . . . . . . . . . . 18
antipyrine/benzocaine . . . . . . 31
alcohol swabs . . . . . . . . . . . . 22 AZILECT . . . . . . . . . . . . . . . . . 16
ANZEMET . . . . . . . . . 24, 37, 43
ALDACTAZIDE . . . . . . . . . . . . 13 APIDRA . . . . . . . . . . . . . . . . . 20 azithromycin . . . . . . . . . . . . . 27
ALDACTONE . . . . . . . . . . . . . 13 APOKYN . . . . . . . . . . . . . . . . 16 AZMACORT . . . . . . . . . . . . . . 32
ALDARA . . . . . . . . . . . . . . . . 20 apri . . . . . . . . . . . . . . . . . . . . 21 AZOPT . . . . . . . . . . . . . . . . . . 30
ALDURAZYME . . . . . . . . . . . . 23 APTIVUS. . . . . . . . . . . . . . . . . 28 AZULFIDINE . . . . . . . . . . . 25, 39
alendronate . . . . . . . . . . . . . . 44 ARALEN . . . . . . . . . . . . . 28, 33 AZULFIDINE ENTABS . . . . 25, 39
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Index
B bumetanide . . . . . . . . . . . . . . 13 cefadroxil . . . . . . . . . . . . . . . . 26
bacitracin . . . . . . . . . . . . . . . . 30 BUMEX . . . . . . . . . . . . . . . . . 13 cefdinir . . . . . . . . . . . . . . . . . 26
bacitracin/neomycin/ BUPHENYL . . . . . . . . . . . . . . . 23 cefpodoxime . . . . . . . . . . . . . 26
polymyxin . . . . . . . . . . . . . . 30 bupropion . . . . . . . . . 15, 36, 42 cefprozil. . . . . . . . . . . . . . . . . 26
bacitracin/polymyxin. . . . . . . . 30 bupropion ER/SR . . . . . . . . . . 36 CEFTIN . . . . . . . . . . . . . . . . . 26
bacitracin/polymyxin/ bupropion SR. . . . . . . . . . 15, 42 cefuroxime. . . . . . . . . . . . . . . 26
neomycin/hydrocortisone . . 31 buspirone. . . . . . . . . . . . . . . . 14 CEFZIL . . . . . . . . . . . . . . . . . . 26
baclofen. . . . . . . . . . . . . . . . . 29 butalbital/acetaminophen/ CELEBREX . . . . . . . . . 29, 34, 40
BACTROBAN . . . . . . . . . . . . . 19 caffeine/codeine . . . . . . 17, 45 CELESTONE . . . . . . . . . . . . . . 24
BACTROBAN NASAL . . . . . . . 32 butalbital/aspirin/caffeine/ CELEXA . . . . . . . . . . 15, 36, 42
BARACLUDE . . . . . . . . . . 28, 38 codeine. . . . . . . . . . . . . 17, 45 CELLCEPT . . . . . . . . . . . . . . . 26
BD insulin syringes . . . . . . . . . 22 BUTISOL SODIUM . . . . . . . . . 18 CELONTIN . . . . . . . . . . . . . . . 15
BEBULIN. . . . . . . . . . . . . . . . . 10 butorphanol. . . . . . . . . . . . . . 18 CENESTIN . . . . . . . . . . . . . . . 23
BEBULIN VH . . . . . . . . . . . . . . 33 butorphanol nasal . . . . . . . . . 40 CENTANY. . . . . . . . . . . . . . . . 19
BECONASE AQ . . . . . . . . . . . 32 BYETTA . . . . . . . . . . . . . . 20, 37 cephalexin . . . . . . . . . . . . . . . 26
benazepril . . . . . . . . . 10, 35, 44 C CEREDASE . . . . . . . . . . . . . . 10
benazepril/ CEREZYME . . . . . . . . . . . . . . 10
CADUET . . . . . . . . . . 12, 37, 43
hydrochlorothiazide . . . 10, 44 CESAMET . . . . . . . . . . . . 24, 37
CALAN . . . . . . . . . . . . . . 13, 43
BENEFIX . . . . . . . . . . . . . . 10, 33 CALAN SR . . . . . . . . 13, 38, 43 cesia . . . . . . . . . . . . . . . . . . . 21
BENICAR . . . . . . . . . . . . . 11, 35 camila . . . . . . . . . . . . . . . . . . 22 CETROTIDE . . . . . . . . . . . . . . 22
BENICAR HCT . . . . . . . . . 11, 35 CAMPRAL . . . . . . . . . . . . . . . 16 chloral hydrate . . . . . . . . . . . . 18
BENZACLIN . . . . . . . . . . . . . . 18 CANASA . . . . . . . . . . . . . 25, 39 chlordiazepoxide . . . . . . . . . . 14
BENZAMYCIN . . . . . . . . . . . . 18 CAPITAL/CODEINE . . . . . . 17, 45 chlordiazepoxide/
BENZIQ . . . . . . . . . . . . . . . . . 18 CAPITROL amitriptyline . . . . . . . . . . . . 16
BENZIQ LS . . . . . . . . . . . . . . . 18 lotion/shampoo/spray . . . . . 20 chloroquine . . . . . . . . . . . 28, 33
BENZIQ wash . . . . . . . . . . . . . 18 CAPOTEN . . . . . . . . . . . . 10, 35 chlorothiazide . . . . . . . . . . . . 14
benzoyl peroxide . . . . . . . . . . 18 CAPOZIDE . . . . . . . . . . . . . . . 10 chlorpromazine . . . . . . . . . . . 16
benzoyl peroxide/urea cream . 18 captopril . . . . . . . . . . 10, 35, 44 chlorpropamide . . . . . . . . . . . 21
benztropine . . . . . . . . . . . . . . 16 captopril/ chlorthalidone . . . . . . . . . . . . 14
betamethasone . . . . . . . . . . . 44 hydrochlorothiazide . . . 10, 44 chlorzoxazone . . . . . . . . . . . . 29
betamethasone valerate . . . . . 20 CARAC . . . . . . . . . . . . . . . . . 19 cholestyramine. . . . . . . . . . . . 12
BETAPACE . . . . . . . . . . . . . . . 12 carbamazepine. . . . . . . . . . . . 15 chorionic gonadotropin . . . . . 22
BETAPACE AF. . . . . . . . . . . . . 12 carbidopa/levodopa . . . . . . . . 16 ciclopirox . . . . . . . . . . . . . . . . 19
BETASERON . . . . . . . . . . . . . . 16 carbidopa/levodopa SR. . . . . . 16 cilostazol . . . . . . . . . . . . . . . . 10
betaxolol . . . . . . . . . . . . . 12, 30 carboptic . . . . . . . . . . . . . . . . 30 cimetidine . . . . . . . . . . . . . . . 24
bethanechol. . . . . . . . . . . . . . 25 CARDENE . . . . . . . . . . . . 13, 43 CIPRO . . . . . . . . . . . . . . . 27, 33
BETIMOL . . . . . . . . . . . . . . . . 30 CARDENE SR . . . . . . . . . . . . . 13 CIPRO HC . . . . . . . . . . . . . . . 31
BETOPTIC-S . . . . . . . . . . . . . . 30 CARDIZEM . . . . . . . . . . . 13, 43 CIPRO XR . . . . . . . . . . . . . . . . 33
BIAXIN . . . . . . . . . . . . . . . . . 27 CARDIZEM CD . . . . . . 13, 38, 43 CIPRO XR . . . . . . . . . . . . . . . . 27
BIAXIN XL . . . . . . . . . . . . . . . 27 CARDIZEM LA . . . . . . . . . 13, 38 CIPRODEX . . . . . . . . . . . . . . . 31
BIDIL . . . . . . . . . . . . . . . . . . . 13 CARDURA . . . . . . . . . . . . . . . 11 ciprofloxacin . . . . . . . 27, 30, 33
BINORA . . . . . . . . . . . . . . . . . 18 CARDURA XL . . . . . . . . . . . . . 11 ciprofloxacin ER . . . . . . . . 27, 33
BIO-STATIN . . . . . . . . . . . . . . 27 carisoprodol . . . . . . . . . . . . . . 29 citalopram . . . . . . . . . 15, 36, 42
BIO-THROID . . . . . . . . . . . . . . 24 carisoprodol/aspirin . . . . . . . . 29 claravis . . . . . . . . 18, 33, 35, 42
bisoprolol fumarate . . . . . . . . 12 carisoprodol/aspirin/codeine . . 29 CLARIFOAM EF . . . . . . . . . . . 18
bisoprolol/ CARNITOR . . . . . . . . . . . . . . . 23 CLARINEX . . . . . . . 32, 34, 40, 45
hydrochlorothiazide . . . . . . 12 carteolol. . . . . . . . . . . . . . . . . 30 CLARINEX REDITABS . 32, 34, 40, 45
BLEPHAMIDE S.O.P. . . . . . . . . 31 cartia XT . . . . . . . . . . 13, 38, 43 CLARINEX-D . . . . 32, 34, 40, 45
BONIVA . . . . . . . . . . . 29, 38, 44 CARTROL . . . . . . . . . . . . . . . . 12 clarithromycin . . . . . . . . . . . . 27
BRAVELLE. . . . . . . . . . . . . . . . 22 carvedilol . . . . . . . . . . . . . . . . 42 clarithromycin SR . . . . . . . . . . 27
BREVICON . . . . . . . . . . . . . . 21 CASODEX . . . . . . . . . . . . . 9, 33 CLEERAVUE-M kit . . . . . . . . . 33
brimonidine . . . . . . . . . . . . . . 30 CATAPRES . . . . . . . . . . . . . . . 11 CLEOCIN VAGINAL . . . . . . . . 26
bromocriptine . . . . . . . . . . . . 16 CATAPRES-TTS . . . . . . . . . . . . 11 CLIMARA . . . . . . . . . . . . . 23, 39
BRONCAP . . . . . . . . . . . . . . . 31 CAVERJECT . . . . . . . . . . . . . . 14 CLIMARA PRO WEEKLY . . 23, 39
BROVANA . . . . . . . . . . . . 31, 43 CEDAX. . . . . . . . . . . . . . . . . . 26 clindamax . . . . . . . . . . . . 18, 26
budeprion . . . . . . . . . 15, 36, 42 CEENU . . . . . . . . . . . . . . . . . . . 9 clindamycin . . . . . . . . . . . 18, 27
budeprion ER/SR . . . . . . . . . . 36 cefaclor . . . . . . . . . . . . . . . . . 26 CLINDESSE . . . . . . . . . . . . . . . 26
budeprion XL . . . . . . . 15, 36, 42 cefaclor ER . . . . . . . . . . . . . . . 26 clobetasol . . . . . . . . . . . . . . . 20
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clobevate . . . . . . . . . . . . . . . . 20 cyclophosphamide . . . . . . . . . . 9 DIBENZYLINE . . . . . . . . . . . . . 14
CLOBEX cyclosporine . . . . . . . . . . . . . . 26 diclofenac . . . . . . . . . . . . . . . 29
lotion/shampoo/spray . . . . . 20 cyclosporine modified . . . . . . 26 diclofenac potassium . . . . . . . 29
CLODERM . . . . . . . . . . . . . . . 20 CYMBALTA . . . . . . . . 15, 36, 42 diclofenac sodium XR. . . . . . . 29
clomipramine . . . . . . . . . . . . . 15 CYSTADANE . . . . . . . . . . . . . 23 dicloxacillin sodium . . . . . . . . 27
clonazepam . . . . . . . . . . . . . . 14 CYSTAGON . . . . . . . . . . . . . . 25 didanosine delayed release. . . 28
clonazepam orally CYTADREN . . . . . . . . . . . . . . . 9 DIDRONEL . . . . . . . . . . . . . . . 29
disintegrating tab . . . . . . . . 14 CYTOXAN . . . . . . . . . . . . . . . . 9 DIFFERIN gel/cream . . . . . . . . 18
clonidine . . . . . . . . . . . . . . . . 11 diflorasone. . . . . . . . . . . . . . . 20
D
clorazepate . . . . . . . . . . . . . . 14 DIFLUCAN . . . . . . . . 27, 33, 37
danazol . . . . . . . . . . . . . . . . . 23 DIGEX . . . . . . . . . . . . . . . . . . 25
CLORPRES . . . . . . . . . . . . . . . 13 DANTRIUM . . . . . . . . . . . . . . 29
clotrimazole/betamethasone . 19 digitek . . . . . . . . . . . . . . . . . . 13
dapsone. . . . . . . . . . . . . . . . . 28 digoxin. . . . . . . . . . . . . . . . . . 13
clozapine . . . . . . . . . . . . . 16, 37 DARAPRIM . . . . . . . . . . . 28, 33
CLOZARIL . . . . . . . . . . . . 16, 37 DILACOR XR . . . . . . . 13, 38, 43
DARVOCET-N . . . . . . . . . 17, 45 DILATRATE SR . . . . . . . . . . . . 11
cocaine hcl. . . . . . . . . . . . . . . 19 DARVON-N . . . . . . . . . . . . . . 17 DILAUDID . . . . . . . . . . . . . . . 17
codeine phosphate . . . . . . . . 17 DAYPRO . . . . . . . . . . . . . . . . 29 diltia XT . . . . . . . . . . . 13, 38, 43
codeine sulfate . . . . . . . . . . . 17 DAYTRANA . . . . . . . . . . . 18, 41 diltiazem . . . . . . . . . . . . . 13, 43
codeine/acetaminophen . . . . . 45 DDAVP. . . . . . . . . . . . . . . 21, 42 diltiazem
COGENTIN . . . . . . . . . . . . . . . 16 DECLOMYCIN . . . . . . . . . 27, 33 CD/ER/CR/XT. . . . . . 13, 38, 43
COGNEX . . . . . . . . . . . . . . . . 14 DEMADEX . . . . . . . . . . . . . . . 13 diltiazem extended
COLAZAL . . . . . . . . . . . . . 25, 39 demeclocycline . . . . . . . . . . . 33 release beads SR. . . 13, 38, 43
COLESTID . . . . . . . . . . . . . . . 12 demeclocycline hcl . . . . . . . . . 27 DIOVAN . . . . . . . 11, 35, 42, 44
colestipol . . . . . . . . . . . . . . . . 12 DEMEROL . . . . . . . . . . . . . . . 17 DIOVAN HCT . . . 11, 35, 42, 44
colocort . . . . . . . . . . . . . . . . . 25 DEMSER . . . . . . . . . . . . . . . . 14 DIPENTUM . . . . . . . . . . . 25, 39
COLY-MYCIN-S. . . . . . . . . . . . 31 DEMULEN 1/35 . . . . . . . . . . . 21 dipivefrin . . . . . . . . . . . . . . . . 30
COLYTE . . . . . . . . . . . . . . . . . 24 DEMULEN 1/50 . . . . . . . . . . . 21 DIPROLENE AF . . . . . . . . . . . . 20
COMBIPATCH . . . . . . . . . 23, 39 DENAVIR . . . . . . . . . . . . . . . . 20 dipyridamole . . . . . . . . . . . . . 10
COMBIVENT. . . . . . . . . . . . . . 31 DEPAKOTE . . . . . . . . . . . . . . . 15 disopyramide . . . . . . . . . . . . . 11
COMBIVIR . . . . . . . . . . . . . . . 28 DEPAKOTE ER . . . . . . . . . . . . 15 DISPERMOX . . . . . . . . . . . . . . 26
COMBUNOX . . . . . . . 17, 40, 45 DEPAKOTE SPRINKLE . . . . . . . 15 DITROPAN . . . . . . . . . . . . . . . 25
compro . . . . . . . . . . . . . . . . . 16 DEPO-PROVERA . . . . . . . . . 9, 21 DITROPAN XL. . . . . . . . . . 25, 46
COMTAN . . . . . . . . . . . . . . . 16 DERMATOP . . . . . . . . . . . . . . 20 DIURIL . . . . . . . . . . . . . . . . . . 14
CONCERTA . . . . . . . . 18, 41, 46 desipramine . . . . . . . . . . . . . . 15 DIVIGEL . . . . . . . . . . . . . . . . . 23
COPAXONE . . . . . . . . . . . . . . 16 desmopressin . . . . . . . . . . 21, 42 DORAL. . . . . . . . . . . . . . . . . . 18
COPEGUS . . . . . . . . . . . . . . . 28 DESOGEN . . . . . . . . . . . . . . . 21 DORYX . . . . . . . . . . . . . . 27, 33
CORDARONE . . . . . . . . . . . . . 12 DESONATE . . . . . . . . . . . . . . . 20 DOVONEX . . . . . . . . . . . . . . . 19
CORDRAN . . . . . . . . . . . . . . . 20 desonide . . . . . . . . . . . . . . . . 20 doxazosin. . . . . . . . . . . . . . . . 11
COREG . . . . . . . . . . . . . . 10, 42 desoximetasone . . . . . . . . . . . 20 doxepin hcl . . . . . . . . . . . . . . 15
DESOXYN . . . . . . . . . 18, 41, 45 doxy-caps. . . . . . . . . . . . . . . . 27
COREG CR . . . . . . . . . . . . . . . 10
DESYREL . . . . . . . . . . . . . 15, 42 doxycycline . . . . . . . . . . . . . . 33
CORGARD . . . . . . . . . . . . . . . 12
DETROL . . . . . . . . . . . . . 25, 46 doxycycline hyclate . . . . . . . . 27
CORTIFOAM . . . . . . . . . . . . . 25
DETROL LA . . . . . . . . . . . 25, 46 doxycycline monohydrate. . . . 27
cortisone AC . . . . . . . . . . . . . 24 dexacidin . . . . . . . . . . . . . . . . 31
cortomycin. . . . . . . . . . . . . . . 31 DRITHO-SCALP. . . . . . . . . . . . 19
dexamethasone . . . . . . . . . . . 24 DUAC . . . . . . . . . . . . . . . . . . 18
CORZIDE . . . . . . . . . . . . . . . . 12 dexamethasone phosphate . . 31
COSOPT . . . . . . . . . . . . . . . . 30 DUETACT . . . . . . . . . . . . . . . . 21
dexamethasone/ DUONEB . . . . . . . . . . . . . . . . 31
COUMADIN . . . . . . . . . . . . . . 9 neomycin/polymyxin . . . . . . 31
COVERA HS . . . . . . . 13, 38, 43 DURAGESIC . . . . . . . . 17, 40, 45
dexasol . . . . . . . . . . . . . . . . . 31 DURICEF . . . . . . . . . . . . . . . . 26
COZAAR . . . . . . . 11, 35, 42, 44 dexasporin . . . . . . . . . . . . . . . 31
CREON . . . . . . . . . . . . . . . . . 25 DYAZIDE . . . . . . . . . . . . . . . . 14
DEXEDRINE . . . . . . . . . . . 18, 41 DYNABAC . . . . . . . . . . . . . . . 27
CRESTOR . . . . . . . . . . 12, 37, 43 DEXEDRINE CR. . . . . . . . . . . . 41 DYNACIN. . . . . . . . . . . . . 27, 33
CRINONE . . . . . . . . . . . . . . . . 26 dexmethylphenidate . 18, 41, 45, 46 DYNACIRC CR . . . . . . . . . . . . 13
CRIXIVAN . . . . . . . . . . . . . . . 28 dextroamphetamine. . . . . 18, 41 DYRENIUM . . . . . . . . . . . . . . 14
cromolyn sodium nebulizer . . 31 dextroamphetamine CR . . 18, 41
cromolyn sodium ophth . . . . . 30 dextrostat . . . . . . . . . . . . 18, 41 E
cryselle. . . . . . . . . . . . . . . . . . 21 DIAMOX . . . . . . . . . . . . . . . . 13 e.e.s. . . . . . . . . . . . . . . . . . . . 27
CYCLESSA . . . . . . . . . . . . . . . 21 DIASTAT . . . . . . . . . . . . . . . . . 14 econazole . . . . . . . . . . . . . . . 19
cyclobenzaprine hcl . . . . . . . . 29 diazepam . . . . . . . . . . . . . . . . 14 EDECRIN . . . . . . . . . . . . . . . . 13
www.aetna.com/formulary 49
Index
EDEX . . . . . . . . . . . . . . . . . . 14 etodolac ER . . . . . . . . . . . . . . 29 fluor-op . . . . . . . . . . . . . . . . . 31
EFFEXOR . . . . . . . . . . 15, 36, 42 etoposide. . . . . . . . . . . . . . . . . 9 FLUOROPLEX . . . . . . . . . . . . 19
EFFEXOR XR. . . . . . . . 15, 36, 42 EULEXIN. . . . . . . . . . . . . . . . . . 9 fluorouracil . . . . . . . . . . . . . . 19
EFUDEX . . . . . . . . . . . . . . . . 19 EURAX . . . . . . . . . . . . . . . . . . 20 fluoxetine . . . . . . . . . 15, 36, 42
ELAPRASE . . . . . . . . . . . . 23, 34 EVISTA . . . . . . . . . . . . . . . . . 30 fluphenazine . . . . . . . . . . . . . 16
ELDEPRYL . . . . . . . . . . . . . . . 16 EVOCLIN . . . . . . . . . . . . . . . . 18 flurazepam. . . . . . . . . . . . . . . 18
ELESTAT . . . . . . . . . . . . . . . . . 30 EVOXAC . . . . . . . . . . . . . . . . 32 flurbiprofen . . . . . . . . . . . 29, 30
ELESTRIN . . . . . . . . . . . . . . . . 23 EXELDERM . . . . . . . . . . . . . . 19 flutamide . . . . . . . . . . . . . . . . . 9
ELIDEL . . . . . . . . . . . . . . . 20, 44 EXELON . . . . . . . . . . . . . . . . 14 fluticasone . . . . . . . . . . . . 20, 45
ELMIRON . . . . . . . . . . . . . . . . 25 EXUBERA . . . . . . . 20, 33, 37, 42 fluticasone propionate
ELOCON . . . . . . . . . . . . . . . . 20 nasal. . . . . . . . . . . . . . . . . . 32
F
EMADINE . . . . . . . . . . . . . . . . 30 fluvoxamine . . . . . . . . 15, 36, 42
FABRAZYME. . . . . . . . . . . . . . 23 FML FORTE . . . . . . . . . . . . . . 31
EMCYT . . . . . . . . . . . . . . . . . . 9
FACTIVE . . . . . . . . . . . . . . 27, 33 FML LIQUIFILM . . . . . . . . . . . . 31
EMEND . . . . . . . . . . . . . . 24, 37
famotidine . . . . . . . . . . . . . . . 24 FML S.O.P. . . . . . . . . . . . . . . . 31
EMSAM . . . . . . . . . . . . . . 15, 36
FAMVIR . . . . . . . . . . . . . . . . . 28 FOCALIN . . . . . . . . . . 18, 41, 46
EMTRIVA . . . . . . . . . . . . . . . . 28
FANSIDAR . . . . . . . . . . . . 28, 33 FOCALIN XR . . . . . . . 18, 41, 46
ENABLEX . . . . . . . . . . . . . 25, 46
FARESTON . . . . . . . . . . . . . . . 9 FOLLISTIM . . . . . . . . . . . . . . . 22
enalapril. . . . . . . . . . . 10, 35, 44
FASLODEX . . . . . . . . . . . . . . . 9 FOLLISTIM AQ . . . . . . . . . . . . 22
enalapril/ FAST TAKE glucose test strips . . 44
hydrochlorothiazide . . . 10, 44 FORADIL . . . . . . . . . . . . . 31, 43
FAZACLO . . . . . . . . . . . . . 16, 37 FORTAMET . . . . . . . . . . . . . . 20
ENBREL . . . . . . . . . . . . . . . . . 29 FEIBA . . . . . . . . . . . . . . . . . . . 10
ENJUVIA. . . . . . . . . . . . . . . . . 23 FORTEO . . . . . . . . . . . . . . . . 29
FELBATOL . . . . . . . . . . . . . . . 14 fortical . . . . . . . . . . . . . . . . . . 29
enpresse . . . . . . . . . . . . . . . . 21 felodipine . . . . . . . . . . . . 13, 38
ENTOCORT EC . . . . . . . . . . . . 24 FOSAMAX . . . . . . . . . 29, 39, 44
FEMARA . . . . . . . . . . . . . . . . . 9 FOSAMAX PLUS D . . 29, 39, 44
EPIPEN . . . . . . . . . . . . . . . . . 10 FEMCON . . . . . . . . . . . . . . . . 21
EPIPEN-JR . . . . . . . . . . . . . . . . 10 fosinopril . . . . . . . . . . 10, 35, 44
FEMHRT . . . . . . . . . . . . . . . . . 23 fosinopril/
EPIVIR . . . . . . . . . . . . . . . . . . 28 FEMHRT LOW DOSE. . . . . . . . 23
EPIVIR HBV . . . . . . . . . . . . . . 28 hydrochlorothiazide . . . 10, 44
FEMRING . . . . . . . . . . . . . . . . 26 FOSRENOL . . . . . . . . . . . . . . . 25
EPOGEN. . . . . . . . . . . . . . 10, 34 FEMTRACE. . . . . . . . . . . . . . . 23
EPZICOM . . . . . . . . . . . . . . . . 28 FRAGMIN. . . . . . . . . . . . . . . . . 9
fenofibrate. . . . . . . . . . . . . . . 12 FREESTYLE
EQUETRO. . . . . . . . . . . . . . . . 16 fenoprofen. . . . . . . . . . . . . . . 29
ergoloid mesylate. . . . . . . . . . 18 glucose test strips . . . . . 22, 44
fentanyl patches . . . . . . . 40, 45 FREESTYLE LITE
errin. . . . . . . . . . . . . . . . . . . . 22 fentanyl transdermal . . . . . . . 17
ERTACZO . . . . . . . . . . . . . . . . 19 glucose test strips . . . . . 22, 44
fentanyl transmucosal lozenge FROVA . . . . . . . . . . . . . . . 16, 39
erythrocin . . . . . . . . . . . . . . . 27 . . . . . . . . . . . . 17, 34, 45, 40
erythromycin . . . . . . . 18, 27, 30 furosemide. . . . . . . . . . . . . . . 13
FENTORA . . . . . . . 17, 34, 40, 45 FUZEON . . . . . . . . . . . . . . . . 28
erythromycin delayed FEXMID . . . . . . . . . . . . . . . . . 29
release particles . . . . . . . . . 27 fexofenadine . . . . 32, 34, 40, 45 G
erythromycin ethylsuccinate . . 27 FINACEA . . . . . . . . . . . . . . . . 20 gabapentin . . . . . . . . 15, 36, 42
erythromycin/benzoyl finasteride . . . . . . . . . . . . 25, 34 GABARONE . . . . . . . . 15, 36, 42
peroxide . . . . . . . . . . . . . . . 18 FIORICET/CODEINE. . . . . . 17, 45 GABITRIL . . . . . . . . . . . . . . . . 14
ESCLIM . . . . . . . . . . . . . . 23, 39 FIORINAL/CODEINE . . . . . 17, 45 ganciclovir . . . . . . . . . . . . . . . 28
estazolam . . . . . . . . . . . . . . . 18 FIRST-TESTOSTERONE . . . . 23, 44 GANIRELIX . . . . . . . . . . . . . . . 22
ESTRACE . . . . . . . . . . . . . . . . 23 flavoxate . . . . . . . . . . . . . . . . 25 GASTROCROM . . . . . . . . . . . 24
ESTRACE VAGINAL . . . . . . . . 26 flecainide . . . . . . . . . . . . . . . . 11 gauze pad . . . . . . . . . . . . . . . 22
ESTRADERM . . . . . . . . . . 23, 39 FLOMAX . . . . . . . . . . . . . 25, 34 gemfibrozil. . . . . . . . . . . . . . . 12
estradiol patch . . . . . . . . 23, 39 FLONASE . . . . . . . . . . . . . . . . 32 gengraf . . . . . . . . . . . . . . . . . 26
estradiol tab. . . . . . . . . . . . . . 23 FLOVENT DISKUS . . . . . . . . . 32 GENOTROPIN . . . . . . . . . 23, 34
ESTRASORB . . . . . . . . . . . . . . 23 FLOVENT HFA . . . . . . . . . 32, 43 gentamicin. . . . . . . . . . . . 19, 30
ESTRATEST . . . . . . . . . . . . . . . 23 FLOXIN. . . . . . . . . . . . . . . . . . 33 GEOCILLIN . . . . . . . . . . . . . . . 27
ESTRATEST HS . . . . . . . . . . . . 23 FLOXIN OTIC . . . . . . . . . . . . . 31 GEODON . . . . . . . . . . . . . 16, 37
ESTRING. . . . . . . . . . . . . . . . . 26 fluconazole . . . . . . . . 27, 33, 37 GEREF . . . . . . . . . . . . . . . 23, 34
ESTROGEL . . . . . . . . . . . . . . . 23 fludrocort. . . . . . . . . . . . . . . . 24 GLEEVEC . . . . . . . . . . . . . . . . . 9
estropipate. . . . . . . . . . . . . . . 23 FLUMADINE . . . . . . . . . . . . . . 28 glimepiride. . . . . . . . . . . . . . . 21
ESTROSTEP FE . . . . . . . . . . . . 21 flunisolide . . . . . . . . . . . . . . . 32 glipizide . . . . . . . . . . . . . . . . . 21
ethambutol . . . . . . . . . . . . . . 28 fluocinolone acetonide. . . . . . 20 glipizide ER . . . . . . . . . . . . . . 21
ethosuximide . . . . . . . . . . . . . 15 fluocinonide. . . . . . . . . . . . . . 20 glipizide XL . . . . . . . . . . . . . . 21
etodolac. . . . . . . . . . . . . . . . . 29 fluorometholone . . . . . . . . . . 31 glipizide/metformin . . . . . . . . 20
50 www.aetna.com/formulary
GLUCAGON . . . . . . . . . . . . . 23 hydroxyzine hcl . . . . . . . . . . . 14 K
GLUCOPHAGE . . . . . . . . . . . 20 hydroxyzine pamoate . . . . . . . 14 KADIAN . . . . . . . . . . . . . . . . 17
GLUCOPHAGE XR . . . . . . . . . 20 hyoscyamine . . . . . . . . . . . . . 25 KALETRA . . . . . . . . . . . . . . . . 28
glucose test strips . . . . . . . . . 22 HYTRIN . . . . . . . . . . . . . . . . . 11 kariva. . . . . . . . . . . . . . . . . . . 21
GLUCOVANCE . . . . . . . . . . . . 20 HYZAAR . . . . . . . 11, 35, 42, 44 kelnor . . . . . . . . . . . . . . . . . . 21
glyburide . . . . . . . . . . . . . . . . 21 I KEMADRIN . . . . . . . . . . . . . . 16
glyburide micronized . . . . . . . 21 KEPPRA . . . . . . . . . . . . . . . . . 15
ibuprofen. . . . . . . . . . . . . . . . 29
glyburide/metformin . . . . . . . 20 KERLONE . . . . . . . . . . . . . . . . 12
IMDUR . . . . . . . . . . . . . . . . . . 11
glycolax . . . . . . . . . . . . . . . . . 25 KETEK . . . . . . . . . . . . . . . . . . 27
imipramine hcl . . . . . . . . . . . . 15
glycron. . . . . . . . . . . . . . . . . . 21 ketoconazole . . . . . . . . . . 19, 27
IMITREX . . . . . . . . . . . . . . 16, 39
GLYSET . . . . . . . . . . . . . . . . . 20 ketoprofen. . . . . . . . . . . . . . . 29
IMURAN . . . . . . . . . . . . . . . . 26
GOLYTELY . . . . . . . . . . . . . . . 24 ketoprofen ER . . . . . . . . . . . . 29
INCRELEX. . . . . . . . . . . . . 23, 34
GONAL-F . . . . . . . . . . . . . . . . 22 ketorolac . . . . . . . . . . . . . 29, 40
indapamide . . . . . . . . . . . . . . 14
granisetron . . . . . . . . . . . . . . 43 KINERET . . . . . . . . . . . . . . . . . 29
INDERAL . . . . . . . . . . . . . . . . 12
GRIFULVIN V . . . . . . . . . . . . . 27 KLARON . . . . . . . . . . . . . . . . 19
INDERAL LA . . . . . . . . . . . . . 12
GRIS-PEG . . . . . . . . . . . . . . . 27 KLONOPIN . . . . . . . . . . . . . . . 14
INDERIDE . . . . . . . . . . . . . . . 12 KLONOPIN WAFER . . . . . . . . . 14
guanabenz. . . . . . . . . . . . . . . 11
indomethacin. . . . . . . . . . . . . 29 KOATE-DVI. . . . . . . . . . . . 10, 33
guanfacine. . . . . . . . . . . . . . . 11
indomethacin ER . . . . . . . . . . 29 KOATE-HP . . . . . . . . . . . . . . . 33
GYNAZOLE-1 . . . . . . . . . . . . 26 INFERGEN . . . . . . . . . . . . 28, 33
gynodiol. . . . . . . . . . . . . . . . . 23 KOGENATE . . . . . . . . . . . . . . 33
INNOHEP . . . . . . . . . . . . . . . . 10 KOGENATE FS . . . . . . . . . 10, 33
H INNOPRAN XL . . . . . . . . . . . . 12 KONYNE 80 . . . . . . . . . . . . . . 33
HALFLYTELY . . . . . . . . . . . . . 24 INOVA . . . . . . . . . . . . . . . . . . 19 KRISTALOSE . . . . . . . . . . . . . . 25
HALOG . . . . . . . . . . . . . . . . . 20 INSPRA . . . . . . . . . . . . . . . . . 14 KU-ZYME . . . . . . . . . . . . . . . . 25
haloperidol. . . . . . . . . . . . . . . 16 insulin syringes . . . . . . . . . . . 22 KU-ZYME-HP . . . . . . . . . . . . 25
HECTOROL . . . . . . . . . . . . . . 23 INTAL . . . . . . . . . . . . . . . . . . . 31 KYTRIL . . . . . . . . . . . 24, 37, 43
HELIDAC . . . . . . . . . . . . . 25, 39 INTRON-A . . . . . . . . . . . . . . . . 9
HELIXATE . . . . . . . . . . . . . . . . 33 INVEGA . . . . . . . . . . . 16, 37, 43 L
HELIXATE FS. . . . . . . . . . . 10, 33 INVIRASE . . . . . . . . . . . . . . . 28 labetalol. . . . . . . . . . . . . . . . . 10
HEMOFIL M . . . . . . . . . . . 10, 33 IOPIDINE . . . . . . . . . . . . . . . . 30 lacticare/hydrocortisone . . . . . 20
heparin sodium . . . . . . . . . . . 10 IPLEX . . . . . . . . . . . . . . . . 23, 34 lactulose . . . . . . . . . . . . . . . . 25
HEPSERA . . . . . . . . . . . . . . . . 28 ipratropium inhaler . . . . . . . . 31 LAMICTAL . . . . . . . . . . . . . . . 15
HEXALEN . . . . . . . . . . . . . . . . . 9 ipratropium nasal . . . . . . . . . . 32 LAMISIL . . . . . . . . . . . . . . 27, 33
IRESSA . . . . . . . . . . . . . . . . . . 9 lamotrigine chew . . . . . . . . . . 15
HMS . . . . . . . . . . . . . . . . . . . 31
ISMO . . . . . . . . . . . . . . . . . . 11 LANOXICAPS . . . . . . . . . . . . . 13
HUMALOG products . . . . 21, 42
ISO CARBACHOL . . . . . . . . . . 30 LANOXIN . . . . . . . . . . . . . . . . 13
HUMATE-P . . . . . . . . . . . . 10, 33
isonarif. . . . . . . . . . . . . . . . . . 28 LANTUS . . . . . . . . . . . . . . . . 21
HUMATROPE . . . . . . . . . . 23, 34
isoniazid. . . . . . . . . . . . . . . . . 28 LARIAM . . . . . . . . . . . . . 28, 33
HUMIRA . . . . . . . . . . . . . . . . 29
ISOPTIN SR . . . . . . . . 13, 38, 43 LASIX . . . . . . . . . . . . . . . . . . . 13
HUMULIN products . . . . . 21, 42 LAVOCLEN . . . . . . . . . . . . . . . 19
HYATE:C . . . . . . . . . . . . . . . . 33 ISOPTO CARPINE . . . . . . . . . . 30
ISORDIL . . . . . . . . . . . . . . . . . 11 leena . . . . . . . . . . . . . . . . . . . 21
hydralazine . . . . . . . . . . . . . . 14 leflunomide . . . . . . . . . . . 29, 43
isosorbide dinitrate . . . . . . . . 11
hydralazine/ LESCOL . . . . . . . . . . . . . . 12, 37
isosorbide mononitrate . . . . . 11
hydrochlorothiazide . . . . . . 13 LESCOL XL . . . . . . . . . . . . 12, 37
isotretinoin . . . . . 19, 33, 35, 42
HYDREA . . . . . . . . . . . . . . . . . 9 lessina . . . . . . . . . . . . . . . . . . 21
isoxsuprine. . . . . . . . . . . . . . . 14
hydrochlorothiazide . . . . . . . . 14 LETAIRIS . . . . . . . . . . . . . . . . . 14
isradipine . . . . . . . . . . . . . . . . 13
hydrocodone/ leucovorin calcium . . . . . . . . . . 9
ISTALOL . . . . . . . . . . . . . . . . . 30
acetaminophen. . . . . . . 17, 45 LEUKERAN . . . . . . . . . . . . . . . 9
itraconazole . . . . . . . . . . . 27, 33
hydrocodone/ibuprofen . . 17, 45 LEUKINE. . . . . . . . . . . . . . . . . 10
IV IMMUNE GLOBULIN (IVIG) 34
hydrocortisone . . . . . . . . . 20, 24 leuprolide. . . . . . . . . . . . . . . . . 9
hydrocortisone butyrate . . . . . 20 J LEVAQUIN . . . . . . . . . . . . 27, 33
hydrocortisone valerate . . . . . 20 JANUMET. . . . . . . . . . . . . . . . 20 LEVATOL . . . . . . . . . . . . . . . . 12
hydrocortisone/clioquinol . . . . 19 JANUVIA . . . . . . . . . . . . . . . . 20 LEVEMIR . . . . . . . . . . . . . . . . 21
hydrocortisone/iodoquinol . . . 19 jolessa . . . . . . . . . . . . . . . . . . 21 LEVLEN . . . . . . . . . . . . . . . . . 21
hydrocortisone/pramoxine . . . 20 jolivette . . . . . . . . . . . . . . . . . 22 LEVLITE . . . . . . . . . . . . . . . . . 21
hydromorphone . . . . . . . . . . . 17 junel 1.5/30 . . . . . . . . . . . . . . 21 levobunolol . . . . . . . . . . . . . . 30
hydroxychloroquine . . . . . . . . 33 junel 1/20 . . . . . . . . . . . . . . . 21 levora. . . . . . . . . . . . . . . . . . . 21
hydroxychloroquine sulfate . . 28 junel FE 1.5/30. . . . . . . . . . . . 21 levorphanol . . . . . . . . . . . . . . 17
hydroxyurea . . . . . . . . . . . . . . . 9 junel FE 1/20 . . . . . . . . . . . . . 21 levothroid . . . . . . . . . . . . . . . 24
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Index
levothyroxine . . . . . . . . . . . . . 24 lutera . . . . . . . . . . . . . . . . . . . 21 methocarbamol . . . . . . . . . . . 29
levoxyl . . . . . . . . . . . . . . . . . . 24 LUVERIS . . . . . . . . . . . . . . . . . 22 methotrexate . . . . . . . . . . . . . . 9
LEVULAN KERA . . . . . . . . . . . 19 LUXIQ . . . . . . . . . . . . . . . . . . 20 methychlothiazide . . . . . . . . . 14
LEXAPRO . . . . . . . . . . 15, 36, 42 LYBREL . . . . . . . . . . . . . . . . . . 21 methyldopa . . . . . . . . . . . . . . 11
LEXIVA . . . . . . . . . . . . . . . . . 28 LYNOX . . . . . . . . . . . . . . . 17, 45 methyldopa/
LEXXEL . . . . . . . . . . . . . . . . . 13 LYRICA. . . . . . . . . . . . 15, 36, 42 hydrochlorothiazide . . . . . . 13
LIALDA . . . . . . . . . . . . . . 25, 39 LYSODREN . . . . . . . . . . . . . . . 9 methylin . . . . . . . . . . . . . 18, 41
lidocaine . . . . . . . . . . . . . . . . 19 M METHYLIN chewable
lidocaine/hydrocortisone . . . . 20 and solution . . . . . . 18, 41, 46
MACROBID . . . . . . . . . . . . . . 25
lidocaine/prilocaine . . . . . . . . 19 methylin ER . . . . . . . . . . . 18, 41
MAGNACET. . . . . . . . . . . 17, 45
LIDODERM . . . . . . . . . . . . . . 19 methylphenidate . 18, 41, 45, 46
MALARONE . . . . . . . . . . 28, 33
lindane. . . . . . . . . . . . . . . . . . 20 methylphenidate CR/ER/SR
maldemar . . . . . . . . . . . . . . . 24
LIPEX . . . . . . . . . . . . . . . . . . . 12 . . . . . . . . . . . . 18, 41, 45, 46
maprotiline . . . . . . . . . . . 15, 36
LIPITOR . . . . . . . . . . . 12, 37, 43 methylprednisolone . . . . . . . . 24
MARPLAN . . . . . . . . . . . . . . . 15
LIPRAM . . . . . . . . . . . . . . . . . 25 metipranolol . . . . . . . . . . . . . 30
MATULANE . . . . . . . . . . . . . . . 9
LIPRAM CR . . . . . . . . . . . . . . 25 metoclopramide hcl . . . . . . . . 24
MAVIK . . . . . . . . . . . . . . . 11, 35
LIPRAM PN. . . . . . . . . . . . . . . 25 metolazone . . . . . . . . . . . . . . 14
MAXAIR AUTOHALER . . . . . . 31
LIQUICET . . . . . . . . . . . . . 17, 45 metoprolol . . . . . . . . . . . . . . . 12
MAXALT . . . . . . . . . . . . . 16, 40
lisinopril . . . . . . . . . . . 10, 35, 44 MAXALT MLT . . . . . . . . . 16, 40 metoprolol succinate SR. . 12, 43
lisinopril/ MAXIDONE . . . . . . . . . . . 17, 45 metoprolol/
hydrochlorothiazide . . . 10, 44 MAXZIDE . . . . . . . . . . . . . . . . 14 hydrochlorothiazide . . . . . . 12
lithium carbonate. . . . . . . . . . 16 MEBARAL . . . . . . . . . . . . . . . 18 METROCREAM. . . . . . . . . . . . 19
lithium carbonate CR . . . . . . . 16 meclofenamate sodium . . . . . 29 METROGEL 1% only . . . . . . . 19
lithium citrate . . . . . . . . . . . . 16 medroxyprogesterone . . . . . . 21 METROGEL VAGINAL . . . . . . . 26
LITHOBID . . . . . . . . . . . . . . . 16 medroxyprogesterone METROLOTION. . . . . . . . . . . . 19
LO/OVRAL . . . . . . . . . . . . . . . 21 acetate . . . . . . . . . . . . . . . . 23 metronidazole . . . . . . . . . 19, 27
LODOSYN . . . . . . . . . . . . . . . 15 mefenamic acid . . . . . . . . . . . 29 metronidazole SR . . . . . . . . . . 27
LOESTRIN 1.5/30 . . . . . . . . . . 21 mefloquine . . . . . . . . . . . 28, 33 MEVACOR . . . . . . . . . 12, 37, 43
LOESTRIN 1/20 . . . . . . . . . . . 21 MEGACE . . . . . . . . . . . . . . . . . 9 mexiletine . . . . . . . . . . . . . . . 11
LOESTRIN FE . . . . . . . . . . . . . 21 MEGACE ES . . . . . . . . . . . . . . . 9 MIACALCIN inj. . . . . . . . . . . . 29
LOESTRIN FE 1.5/30 . . . . . . . . 21 megestrol. . . . . . . . . . . . . . . . . 9 MIACALCIN NASAL . . . . . . . . 29
LOESTRIN-24 . . . . . . . . . . . . . 21 meloxicam . . . . . . . . . . . . 29, 45 MICARDIS . . . . . . . . . . . . 11, 35
LOFIBRA. . . . . . . . . . . . . . . . . 12 MENEST . . . . . . . . . . . . . . . . 23 MICARDIS HCT . . . . . . . . 11, 35
LOPID. . . . . . . . . . . . . . . . . . . 12 MENOPUR . . . . . . . . . . . . . . . 22
LOPRESS HCT. . . . . . . . . . . . . 12 microgestin 1.5/30 . . . . . . . . . 21
MENOSTAR . . . . . . . . . . . 23, 39 microgestin 1/20 . . . . . . . . . . 21
LOPRESSOR . . . . . . . . . . . . . . 12 meperidine. . . . . . . . . . . . . . . 17
LOPROX microgestin FE 1.5/30 . . . . . . 21
meperidine/promethazine . . . 17 microgestin FE1/20 . . . . . . . . 21
cream/lotion/suspension . . . 19 mephobarbital . . . . . . . . . . . . 18
LOPROX gel/shampoo . . . . . . 19 micronefrin . . . . . . . . . . . . . . 31
meprobamate . . . . . . . . . . . . 14
lorazepam . . . . . . . . . . . . . . . 14 MICROZIDE . . . . . . . . . . . . . . 14
MEPRON . . . . . . . . . . . . . . . . 28
LORCET . . . . . . . . . . . . . 17, 45 midazolam . . . . . . . . . . . . . . . 18
meprozine . . . . . . . . . . . . . . . 17
LORCET PLUS. . . . . . . . . . 17, 45 MIGRANAL . . . . . . . . . . . 16, 40
mercaptopurine . . . . . . . . . . . . 9
LORTAB . . . . . . . . . . . . . . 17, 45 MIINOCIN PAK kit . . . . . . . . . 33
mesalamine . . . . . . . . . . . . . . 25
LOTEMAX . . . . . . . . . . . . . . . 31 MESNEX . . . . . . . . . . . . . . . . . 9 MINIPRESS . . . . . . . . . . . . . . . 11
LOTENSIN . . . . . . . . . . . . 11, 35 MESTINON . . . . . . . . . . . . . . 29 MINOCIN . . . . . . . . . . . . . 27, 33
LOTENSIN HCT . . . . . . . . . . . . 11 MESTINON TIMESPAN . . . . . . 29 minocycline . . . . . . . . . . . 27, 33
LOTREL . . . . . . . . . . . . . . 13, 44 METADATE CD . . 18, 41, 45, 46 minoxidil . . . . . . . . . . . . . . . . 14
LOTRISONE . . . . . . . . . . . . . . 19 METADATE ER . . . . . 18, 41, 46 MIRAPEX . . . . . . . . . . . . . . . . 16
LOTRONEX . . . . . . . . . . . 25, 34 METAGLIP . . . . . . . . . . . . . . . 20 MIRCETTE . . . . . . . . . . . . . . . 21
lovastatin . . . . . . . . . . 12, 37, 43 metaproterenol . . . . . . . . . . . 31 mirtazapine . . . . . . . . 15, 36, 42
LOVAZA . . . . . . . . . . . . . . . . . 12 metformin . . . . . . . . . . . . . . . 20 mirtazapine ODT . . . . . . . 15, 36
LOVENOX . . . . . . . . . . . . . . . 10 metformin ER. . . . . . . . . . . . . 20 misoprostol . . . . . . . . . . . . . . 24
low-ogestrel. . . . . . . . . . . . . . 21 methadone . . . . . . . . . . . . . . 17 MOBIC. . . . . . . . . . . . . . . 29, 45
loxapine . . . . . . . . . . . . . . . . . 16 methadose. . . . . . . . . . . . . . . 17 MODICON 0.5/35 . . . . . . . . . 21
LUMIGAN . . . . . . . . . . . . . . . 30 methazolamide . . . . . . . . . . . 13 moexipril . . . . . . . . . . 11, 35, 44
LUNESTA . . . . . . . . . . 18, 41, 45 methenamine hippurate. . . . . 25 moexipril/
LUPRON . . . . . . . . . . . . . . . . . 9 methenamine mandelate . . . . 25 hydrochlorothiazide . . . 11, 44
LUPRON DEPOT . . . . . . . . . . . . 9 methimazole . . . . . . . . . . . . . 24 mometasone . . . . . . . . . . . . . 20
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MONARC-M . . . . . . . . . . 10, 33 nifediac CC . . . . . . . . . . . 13, 38 OLUX-E . . . . . . . . . . . . . . . . . 20
MONOCLATE-P . . . . . . . . 10, 33 nifedical XL . . . . . . . . 13, 38, 43 omeprazole . . . . . . . . 24, 33, 35
MONODOX . . . . . . . . . . . 27, 33 nifedipine . . . . . . . . . . . . 13, 43 OMNICEF . . . . . . . . . . . . . . . . 26
MONOKET . . . . . . . . . . . . . . . 11 nifedipine CR/ER/SR . . 38, 13, 43 OMNITROPE. . . . . . . . . . . 23, 34
mononessa . . . . . . . . . . . . . . 21 NILANDRON. . . . . . . . . . . . . . . 9 ondansetron . . . . . . . 24, 37, 43
MONONINE . . . . . . . . . . . 10, 33 nimodipine. . . . . . . . . . . . . . . 13 ONE TOUCH BASIC/
MONOPRIL . . . . . . . . . . . 11, 35 NIMOTOP. . . . . . . . . . . . . . . . 13 PROFILE/ONE TOUCH II
MONOPRIL HCT . . . . . . . . . . . 11 NIRAVAM. . . . . . . . . . . . . . . . 14 glucose test strips . . . . . 22, 44
MONUROL . . . . . . . . . . . . . . . 25 nitrates . . . . . . . . . . . . . . . . . 42 ONE TOUCH FAST TAKE
morphine sulfate . . . . . . . . . . 17 NITROBID . . . . . . . . . . . . . . . 11 glucose test strips . . . . . . . . 22
morphine sulfate CR . . . . . . . 17 NITRO-DUR . . . . . . . . . . . . . . 11 ONE TOUCH SURE STEP
MS CONTIN . . . . . . . . . . . . . . 17 nitrofurantoin . . . . . . . . . . . . 25 glucose test strips . . . . . . . . 22
mupirocin . . . . . . . . . . . . . . . 19 nitrofurantoin monohydrate ONE TOUCH ULTRA
MUSE. . . . . . . . . . . . . . . . . . . 14 macrocrystal . . . . . . . . . . . . 25 glucose test strips . . . . . 22, 44
MYAMBUTOL. . . . . . . . . . . . . 28 nitroglycerin. . . . . . . . . . . . . . 11 OPANA . . . . . . . . . . . . . . . . . 17
MYFORTIC . . . . . . . . . . . . . . 26 nitroglycerin CR . . . . . . . . . . . 11 OPANA ER . . . . . . . . . . . . . . . 17
MYLERAN . . . . . . . . . . . . . . . . 9 nitroglycerin SL . . . . . . . . . . . 11 OPTIPRANOLOL . . . . . . . . . . . 30
MYLOCEL . . . . . . . . . . . . . . . . 9 NITROLINGUAL . . . . . . . . . . . 11 OPTIVAR . . . . . . . . . . . . . . . . 30
MYOZYME. . . . . . . . . . . . . . . 23 NITROSTAT . . . . . . . . . . . . . . . 11 ORACEA . . . . . . . 20, 33, 34, 41
myrac . . . . . . . . . . . . . . . 27, 33 nitro-transderm . . . . . . . . . . . 11 ORAMORPH SR . . . . . . . . . . . 17
nizatidine . . . . . . . . . . . . . . . . 24 ORAP . . . . . . . . . . . . . . . . . . 18
N NOLVADEX . . . . . . . . . . . . . . . 9 ORAPRED. . . . . . . . . . . . . . . . 24
nabumetone . . . . . . . . . . . . . 29 nora-be . . . . . . . . . . . . . . . . . 22 ORENCIA . . . . . . . . . . . . . . . . 29
nadolol . . . . . . . . . . . . . . . . . 12 NORCO . . . . . . . . . . . . . . 17, 45 ORFADIN . . . . . . . . . . . . . 23, 34
NAFTIN . . . . . . . . . . . . . . . . . 19 NORDETTE . . . . . . . . . . . . . . . 21 orphenadrine cpd . . . . . . . . . 29
NAGLAZYME . . . . . . . . . . . . . 23 NORDITROPIN . . . . . . . . . 23, 34 orphenadrine ER . . . . . . . . . . 29
naltrexone . . . . . . . . . . . . . . . 16 norethindrone acetate . . . . . . 23 orphenadrine/aspirin/caffeine . 29
NAMENDA. . . . . . . . . . . . . . . 14 NORINYL 1+35. . . . . . . . . . . . 21 orphengesic . . . . . . . . . . . . . . 29
NAPRELAN . . . . . . . . . . . 29, 45 NORINYL 1+50. . . . . . . . . . . . 22 orphengesic forte. . . . . . . . . . 29
naproxen . . . . . . . . . . . . . . . . 29 NORITATE . . . . . . . . . . . . . . . 19 ORTHO EVRA. . . . . . . . . . . . . 22
NARDIL . . . . . . . . . . . . . . . . . 15 NOROXIN. . . . . . . . . . . . . 27, 33 ORTHO MICRONOR . . . . . . . . 22
NASACORT AQ . . . . . . . . 32, 45 NORPACE. . . . . . . . . . . . . . . . 11 ORTHO TRI-CYCLEN . . . . . . . 22
NASAREL . . . . . . . . . . . . . . . . 32 NOR-QD . . . . . . . . . . . . . . . . 22 ORTHO TRI-CYCLEN LO . . . . . 22
NASONEX . . . . . . . . . . . . 32, 45 nortrel 0.5/35 . . . . . . . . . . . . 22 ORTHO-CEPT . . . . . . . . . . . . 22
NATURETIN . . . . . . . . . . . . . . 14 nortrel 1/35 . . . . . . . . . . . . . 22 ORTHOCLONE . . . . . . . . . . . . 26
NEBUPENT . . . . . . . . . . . . . . 27 nortrel 7/7/7 . . . . . . . . . . . . . 22 ORTHO-CYCLEN . . . . . . . . . . 22
necon 0.5/35 . . . . . . . . . . . . . 21 nortriptyline . . . . . . . . . . . . . . 15 ortho-est . . . . . . . . . . . . . . . . 23
necon 1/35 . . . . . . . . . . . . . . 21 NORVASC . . . . . . . . . 13, 38, 43 ORTHO-NOVUM 1/35 . . . . . . 22
necon 1/50 . . . . . . . . . . . . . . 21 NORVIR . . . . . . . . . . . . . . . . . 28
ORTHO-NOVUM 1/50 . . . . . . 22
necon 10/11 . . . . . . . . . . . . . 21 NOVAREL . . . . . . . . . . . . . . . . 22
ORTHO-NOVUM 10/11 . . . . . 22
necon 7/7/7 . . . . . . . . . . . . . . 21 NOVOLIN products. . . . . . 21, 42
ORTHO-NOVUM 7/7/7 . . . . . . 22
nefazodone . . . . . . . . . . . 15, 42 NOVOLOG products. . . . . 21, 42
OSMOPREP . . . . . . . . . . . . . . 24
NEOBENZ MICRO . . . . . . . . . . 19 NOVOSEVEN . . . . . . . . . . 10, 33
OVACE. . . . . . . . . . . . . . . . . . 20
neomycin . . . . . . . . . . . . . . . . 26 NOXAFIL . . . . . . . . . . . . . 27, 33
OVCON 50 . . . . . . . . . . . . . . 22
neomycin/polymyxin/ NULYTELY . . . . . . . . . . . . . . . 24
OVCON-35 . . . . . . . . . . . . . . 22
gramicidin. . . . . . . . . . . . . . 30 NUOX . . . . . . . . . . . . . . . . . . 19
OVIDREL . . . . . . . . . . . . . . . . 22
NUTROPIN . . . . . . . . . . . 23, 34
neomycin/polymyxin/ oxaprozin. . . . . . . . . . . . . . . . 29
NUTROPIN AQ . . . . . . . . 23, 34
hydrocortisone . . . . . . . . . . 31 oxazepam . . . . . . . . . . . . . . . 14
NUVARING . . . . . . . . . . . . . . 22
NEORAL . . . . . . . . . . . . . . . . 26 OXISTAT . . . . . . . . . . . . . . . . . 19
NUZON . . . . . . . . . . . . . . . . . 20
NEULASTA . . . . . . . . . . . . . . . 10 OXSORALEN-UL . . . . . . . . . . . 19
nystatin . . . . . . . . . . . . . . 19, 27
NEUPOGEN . . . . . . . . . . . . . . 10 oxybutynin . . . . . . . . . . . . 25, 46
nystatin vaginal . . . . . . . . . . . 26
NEUPRO. . . . . . . . . . . . . . 16, 37 oxybutynin SR . . . . . . . . . . . . 25
nystatin/triamcinolone . . . . . . 19
NEURONTIN . . . . . . . . 15, 36, 42 oxycodone . . . . . . . . . . . . . . . 17
NEVANAC . . . . . . . . . . . . . . . 30 O oxycodone/
NEXAVAR. . . . . . . . . . . . . . . . . 9 ofloxacin . . . . . . . . . . 27, 30, 33 acetaminophen. . . . . . . 17, 45
NEXIUM . . . . . . . 24, 33, 35, 42 OGEN . . . . . . . . . . . . . . . . . . 23 oxycodone/aspirin . . . . . . 17, 45
NIASPAN . . . . . . . . . . . . . . . . 12 ogestrel . . . . . . . . . . . . . . . . . 22 OXYCONTIN CR. . . . . . . . 17, 40
nicardipine . . . . . . . . . . . . 13, 43 OLUX . . . . . . . . . . . . . . . . . . 20 oxyfast . . . . . . . . . . . . . . . . . . 17
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Index
OXYIR . . . . . . . . . . . . . . . . . . 17 PLENDIL . . . . . . . . . . . . . . 13, 38 PROFILNINE SD. . . . . . . . . . . . 33
OXYTROL. . . . . . . . . . . . . 25, 46 PLETAL . . . . . . . . . . . . . . . . . 10 PROGESTERONE VAGINAL . . . 26
PLEXION cloth . . . . . . . . . . . . 19 PROGLYCEM . . . . . . . . . . . . . 23
P
PLEXION emulsion . . . . . . . . . 19 PROGRAF. . . . . . . . . . . . . . . . 26
PACERONE . . . . . . . . . . . . . . 12 PLEXION SCT . . . . . . . . . . . . . 19 PROLEUKIN . . . . . . . . . . . . . . . 9
PALCAPS . . . . . . . . . . . . . . . . 25 PLEXION TS . . . . . . . . . . . . . . 19 PROMETRIUM . . . . . . . . . . . . 23
pamidronate . . . . . . . . . . . . . 29 poly-dex. . . . . . . . . . . . . . . . . 31 PRONESTYL . . . . . . . . . . . . . . 11
pancreatin . . . . . . . . . . . . . . . 25 polyethylene glycol . . . . . . . . 24 PRONESTYL SR . . . . . . . . . . . . 11
pancrelipase. . . . . . . . . . . . . . 25 propafenone . . . . . . . . . . . . . 11
polymyxin B/trimethoprim . . . 30
PANIXINE . . . . . . . . . . . . . . . 26 PROPINE. . . . . . . . . . . . . . . . . 30
POLY-PRED . . . . . . . . . . . . . . . 31
PANOCAPS . . . . . . . . . . . . . . 25 PROPLEX . . . . . . . . . . . . . . . . 10
PONSTEL . . . . . . . . . . . . . . . . 29
PANRETIN . . . . . . . . . . . . . . . 19 PROPLEX T . . . . . . . . . . . . . . . 33
portia. . . . . . . . . . . . . . . . . . . 22
papaverine ER . . . . . . . . . . . . 14
PRANDIN . . . . . . . . . . . . . . . . 21 propoxyphene . . . . . . . . . . . . 17
papaverine inj. . . . . . . . . . . . . 14
PRAVACHOL . . . . . . . 12, 37, 43 propoxyphene/
PARCOPA . . . . . . . . . . . . . . . . 16
pravastatin. . . . . . . . . 12, 37, 43 acetaminophen. . . . . . . . . . 17
PARLODEL . . . . . . . . . . . . . . . 16
prazosin . . . . . . . . . . . . . . . . . 11 propoxyphene-N/
PARNATE . . . . . . . . . . . . . . . . 15
PRECISION Q-I-D acetaminophen. . . . . . . 17, 45
paromomycin. . . . . . . . . . . . . 26
glucose test strips . . . . . 22, 44 propranolol . . . . . . . . . . . . . . 12
paroxetine . . . . . . . . . 15, 36, 42
PRECISION SOF-TACT propranolol SR . . . . . . . . . . . . 13
PATADAY . . . . . . . . . . . . . . . . 30
glucose test strips . . . . . 22, 44 propranolol/
PATANOL . . . . . . . . . . . . . . . 30
PRECISION XTRA hydrochlorothiazide . . . . . . 13
PAXIL . . . . . . . . . . . . . 15, 36, 42
glucose test strips . . . . . 22, 44 propylthiouracil . . . . . . . . . . . 24
PAXIL CR . . . . . . . . . . . . . 15, 42
PRECISION XTRA PROQUIN XR . . . . . . . . . . 27, 33
PCE . . . . . . . . . . . . . . . . . . . . 27
ketone test strips . . . . . . . . 22 PROSCAR. . . . . . . . . . . . . 25, 34
peg 3350 . . . . . . . . . . . . . . . . 24
PRECOSE . . . . . . . . . . . . . . . . 20 PROTONIX . . . . . . 24, 33, 35, 42
PEGASYS . . . . . . . . . . . . . 28, 33
PRED-G . . . . . . . . . . . . . . . . . 31 PROTOPIC . . . . . . . . . . . . 20, 44
PEG-INTRON . . . . . . . . . . 28, 33
PRED-G S.O.P. . . . . . . . . . . . . 31 PROTROPIN . . . . . . . . . . . 23, 34
penicillin VK . . . . . . . . . . . . . . 27
prednicarbate. . . . . . . . . . . . . 20 PROVENTIL HFA . . . . . . . . . . . 31
PENLAC . . . . . . . . . . . . . . 19, 33
prednisolone . . . . . . . . . . 24, 31 PROVIGIL . . . . . . . . . 18, 34, 40
PENTASA . . . . . . . . . . . . . 25, 39
prednisone. . . . . . . . . . . . . . . 24 PROZAC . . . . . . . . . . 15, 36, 42
pentazocine/
PREFEST . . . . . . . . . . . . . . . . . 23 PROZAC WEEKLY . . . . . . . 15, 42
acetaminophen. . . . . . . 17, 45
pentazocine/naloxone . . . . . . 18 PREMARIN . . . . . . . . . . . . . . 23 prudoxin . . . . . . . . . . . . . . . . 19
PEPCID . . . . . . . . . . . . . . . . . 24 PREMARIN VAGINAL . . . . . . . 26 PSORIATEC. . . . . . . . . . . . . . . 19
PEPCID RPD . . . . . . . . . . . . . 24 PREMPHASE. . . . . . . . . . . . . . 23 PULMICORT . . . . . . . . . . . . . . 43
PERCOCET . . . . . . . . . . . 17, 45 PREMPRO. . . . . . . . . . . . . . . . 23 PULMICORT FLEXHALER. . . . . 32
PERCODAN . . . . . . . . . . . 17, 45 PREVACID . . . . . . 24, 33, 35, 42 PULMICORT RESPULES . . . . . . 32
PERIOSTAT . . . . . . . . . . . . 27, 33 PREVACID NAPRAPAC . . . 29, 34 PURINETHOL . . . . . . . . . . . . . . 9
permethrin. . . . . . . . . . . . . . . 20 PREVACID SOLUTAB. . . . . 24, 35 PYLERA . . . . . . . . . . . . . . 25, 39
perphenazine . . . . . . . . . . . . . 16 prevalite. . . . . . . . . . . . . . . . . 12 pyrazinamide . . . . . . . . . . . . . 28
perphenazine/amitriptyline . . . 16 previfem . . . . . . . . . . . . . . . . 22 pyridostigmine . . . . . . . . . . . . 29
PERSANTINE . . . . . . . . . . . . . 10 PREVPAC . . . . . . . . . . . . . 25, 39 Q
PEXEVA . . . . . . . . . . 15, 36, 42 PREZISTA . . . . . . . . . . . . . . . . 28 quasense . . . . . . . . . . . . . . . . 22
phenobarbital . . . . . . . . . . . . 18 PRILOSEC . . . . . . 24, 33, 35, 42 QUESTRAN. . . . . . . . . . . . . . . 12
phentolamine. . . . . . . . . . . . . 14 primaquine . . . . . . . . . . . . . . 28 quinapril . . . . . . . 11, 35, 42, 44
phenytoin extended . . . . . . . . 15 primidone . . . . . . . . . . . . . . . 15 quinaretic . . . . . . . . . 11, 42, 44
phenytoin sodium . . . . . . . . . 15 principen . . . . . . . . . . . . . . . . 26 quinerva. . . . . . . . . . . . . . . . . 28
PHOSLO . . . . . . . . . . . . . . . . . 25 PRINIVIL . . . . . . . . . . . . . 11, 35 quinidine gluconate . . . . . . . . 11
PHOSPHOLINE . . . . . . . . . . . . 30 PRINZIDE . . . . . . . . . . . . . . . . 11 quinidine sulfate . . . . . . . . . . 11
PHOTOFRIN . . . . . . . . . . . . . . . 9 PROAIR . . . . . . . . . . . . . . . . . 31 quinine sulfate . . . . . . . . . . . . 28
phrenilin/caffeine/codeine . . . 17 procainamide . . . . . . . . . . . . . 11 QUIXIN . . . . . . . . . . . . . . . . . 30
pilocar . . . . . . . . . . . . . . . . . . 30 procainamide ER . . . . . . . . . . 11 QVAR. . . . . . . . . . . . . . . . . . . 32
pilocarpine . . . . . . . . . . . . 30, 32 PROCANBID . . . . . . . . . . . . . . 11
PILOPINE HS . . . . . . . . . . . . . . 30 PROCARDIA . . . . . . . . . . . 13, 43 R
piloptic. . . . . . . . . . . . . . . . . . 30 PROCARDIA XL . . . . . 13, 38, 43 RANEXA . . . . . . . . . . 11, 35, 42
pindolol . . . . . . . . . . . . . . . . . 12 PROCHIEVE . . . . . . . . . . . . . . 26 RANICLOR . . . . . . . . . . . . . . 26
piroxicam . . . . . . . . . . . . . . . . 29 prochlorperazine . . . . . . . . . . 16 ranitidine . . . . . . . . . . . . . . . . 24
PLAQUENIL . . . . . . . . . . . . . . 33 PROCRIT . . . . . . . . . . . . . 10, 34 RAPAMUNE . . . . . . . . . . . . . . 26
PLAVIX . . . . . . . . . . . . . . . . . 10 PROFILNINE . . . . . . . . . . . 10, 33 RAPIFLUX . . . . . . . . . 15, 36, 42
54 www.aetna.com/formulary
RAPTIVA. . . . . . . . . . . . . . . . . 19 ROZEX . . . . . . . . . . . . . . . . . . 19 STRIANT. . . . . . . . . . . . . . 23, 44
rauwolfia/ RYTHMOL . . . . . . . . . . . . . . . 12 SUBOXONE . . . . . . . . . . . . . . 18
bendroflumethiazide. . . . . . 13 RYTHMOL SR . . . . . . . . . . . . 12 SUBUTEX . . . . . . . . . . . . . . . . 18
RAZADYNE . . . . . . . . . . . . . . 14 SUCRAID . . . . . . . . . . . . . . . . 23
S
RAZADYNE ER . . . . . . . . . . . . 14 sucralfate . . . . . . . . . . . . . . . . 24
REBETOL . . . . . . . . . . . . . . . . 28 SAIZEN . . . . . . . . . . . . . . 23, 34 SULAR . . . . . . . . . . . . . . . 13, 38
REBIF . . . . . . . . . . . . . . . . . . . 16 SALAGEN. . . . . . . . . . . . . . . . 32 sulfacetamide sodium . . . 20, 30
SANCTURA . . . . . . . . . . . 25, 46 sulfacetamide
RECLAST . . . . . . . . . . . . . . . . 29
SANDIMMUNE . . . . . . . . . . . 26 sodium/prednisolone. . . . . . 31
reclipsen . . . . . . . . . . . . . . . . 22
SARAFEM . . . . . . . . . . . . 18, 40 SULFACET-R . . . . . . . . . . . . . 19
RECOMBINATE. . . . . . . . . 10, 33
SEASONALE . . . . . . . . . . . . . . 22 sulfadiazine . . . . . . . . . . . . . . 27
REFACTO . . . . . . . . . . . . . 10, 33
SEASONIQUE . . . . . . . . . . . . . 22 sulfasalazine . . . . . . . . . . 25, 39
RELENZA . . . . . . . . . . . . . 28, 38
SEBIZON. . . . . . . . . . . . . . . . . 20 sulfasalazine ER . . . . . . . . 25, 39
RELION products . . . . . . . 21, 42
SECONAL. . . . . . . . . . . . . . . . 18 sulfatol. . . . . . . . . . . . . . . . . . 19
RELPAX . . . . . . . . . . . . . . 16, 40
SECTRAL . . . . . . . . . . . . . . . . 12 sulfazine . . . . . . . . . . . . . 25, 39
REMERON . . . . . . . . . 15, 36, 42
selegiline . . . . . . . . . . . . . . . . 16 sulfazine EC . . . . . . . . . . . 25, 39
REMERON SOLUTAB . 15, 36, 42
selenium sulfide . . . . . . . . . . . 20 sulfisoxazole. . . . . . . . . . . . . . 27
REMICADE . . . . . . . . . . . . . . . 29
SEMPREX-D . . . . . 32, 34, 40, 45 SULFOXYL . . . . . . . . . . . . . . . 19
RENAGEL . . . . . . . . . . . . . . . . 25 SENSIPAR . . . . . . . . . . . . . . . 23
REPREXAIN . . . . . . . . . . . 17, 45 sulfurated lime solution . . . . . 20
SEREVENT . . . . . . . . . . . . . . . 43 sulindac . . . . . . . . . . . . . . . . . 29
REPRONEX . . . . . . . . . . . . . . . 22 SEREVENT DISKUS . . . . . . . . . 31
REQUIP . . . . . . . . . . . . . . . . . 16 SUMYCIN . . . . . . . . . . . . 27, 33
SEROQUEL . . . . . . . . . . . 16, 38 SUPRAX . . . . . . . . . . . . . . . . 26
RESCRIPTOR . . . . . . . . . . . . . 28 SEROQUEL XR . . . . . . . . . 16, 38
reserpine . . . . . . . . . . . . . . . . 11 SURESTEP. . . . . . . . . . . . . . . . 44
SEROSTIM . . . . . . . . . . . . 23, 34 SUSTIVA. . . . . . . . . . . . . . . . . 28
RESTASIS . . . . . . . . . . . . . . . . 30 sertraline . . . . . . . 15, 36, 42, 42
RETIN-A . . . . . . . . . . . . . . 19, 33 SUTENT . . . . . . . . . . . . . . . . . . 9
SIMULECT . . . . . . . . . . . . . . . 26 SYMBICORT . . . . . . . . . . . . . . 31
RETIN-A MICRO . . . . . . . . 19, 33 simvastatin. . . . . . . . . 12, 37, 43
RETROVIR . . . . . . . . . . . . . . . 28 SYMBYAX . . . . . . . . . . . . 16, 38
SINEMET . . . . . . . . . . . . . . . . 16 SYMLIN . . . . . . . . . . . . . . . . . 21
REVATIO. . . . . . . . . . . . . . 14, 34 SINEMET CR . . . . . . . . . . . . . 16
REV-EYES . . . . . . . . . . . . . . . 30 SYMMETREL . . . . . . . . . . . . . 16
SINGULAIR . . . . . . . . . . . . 32, 39 SYNAGIS . . . . . . . . . . . . . . . . 34
REVLIMID . . . . . . . . . . . . . . . . . 9 SKELAXIN . . . . . . . . . . . . . . . 29
REYATAZ . . . . . . . . . . . . . . . . 28 SYNALGOS DC . . . . . . . . . . . 17
SKELID . . . . . . . . . . . . . . . . . 29 SYNERA . . . . . . . . . . . . . . . . . 19
RHEUMATREX . . . . . . . . . . . . 29 sodium sulfacetamide/sulfur. . 19
RHINOCORT AQ. . . . . . . . 32, 45 syntest D.S. . . . . . . . . . . . . . . 23
SOLARAZE . . . . . . . . . . . . . . . 19 syntest H.S. . . . . . . . . . . . . . . 23
ribasphere . . . . . . . . . . . . . . . 28 solia . . . . . . . . . . . . . . . . . . . . 22
ribavirin . . . . . . . . . . . . . . . . . 28 SYNTHROID . . . . . . . . . . . . . . 24
SOLODYN . . . . . . . . . . . . 27, 33
RIDAURA . . . . . . . . . . . . . . . . 29 SOMAVERT . . . . . . . . . . . 23, 34 T
RIFAMATE . . . . . . . . . . . . . . . 28 SONATA. . . . . . . . . . . 18, 41, 45 TABLOID . . . . . . . . . . . . . . . . . 9
rifampin . . . . . . . . . . . . . . . . . 28 SORIATANE . . . . . . . . . . . . . . 19 TACLONEX. . . . . . . . . . . . 20, 44
RIFATER . . . . . . . . . . . . . . . . . 28 sorine. . . . . . . . . . . . . . . . . . . 13 TAGAMET . . . . . . . . . . . . . . . 24
RILUTEK . . . . . . . . . . . . . . 14, 33 sotalol AF. . . . . . . . . . . . . . . . 13 TALACEN . . . . . . . . . . . . . 17, 45
rimantadine . . . . . . . . . . . . . . 29 sotalol hcl . . . . . . . . . . . . . . . 13 TALWIN NX . . . . . . . . . . . . . . 18
RIMSO . . . . . . . . . . . . . . . . . . 25 sotret. . . . . . . . . . 19, 33, 35, 42 TAMBOCOR . . . . . . . . . . . . . 12
RIOMET . . . . . . . . . . . . . . . . . 20 SPECTRACEF . . . . . . . . . . . . . 26 TAMIFLU . . . . . . . . . . . . . 29, 38
RISPERDAL . . . . . . . . 16, 38, 43 SPIRIVA . . . . . . . . . . . . . . . . . 31 tamoxifen . . . . . . . . . . . . . . . . 9
RISPERDAL CONSTA . . . . . . . . 16 spironolactone . . . . . . . . . . . . 14 TAPAZOLE . . . . . . . . . . . . . . . 24
RISPERDAL M. . . . . . . 16, 38, 43 spironolactone/ TARCEVA . . . . . . . . . . . . . . . . . 9
risperidone. . . . . . . . . . . . . . . 43 hydrochlorothiazide . . . . . . 14 TARGRETIN . . . . . . . . . . . . 9, 19
RITALIN . . . . . . . . . . . 18, 41, 46 SPORANOX . . . . . . . . . . . 27, 33 TARKA . . . . . . . . . . . . . . . . . . 13
RITALIN LA . . . . . . . . 18, 41, 46 sprintec . . . . . . . . . . . . . . . . . 22 TASMAR . . . . . . . . . . . . . . . . 16
RITALIN SR . . . . . . . . 18, 41, 46 SPRYCEL . . . . . . . . . . . . . . . . . 9 TAZORAC. . . . . . . . . . . . . 19, 44
RITUXAN . . . . . . . . . . . . . . . . 29 sronyx . . . . . . . . . . . . . . . . . . 22 taztia XT . . . . . . . . . . 13, 38, 43
ROFERON-A . . . . . . . . . . . . . . . 9 STADOL NS . . . . . . . . . . . . . . 40 tebamide . . . . . . . . . . . . . . . . 24
ROSAC. . . . . . . . . . . . . . . . . . 19 STAFLEX. . . . . . . . . . . . . . . . . 17 TEGRETOL . . . . . . . . . . . . . . . 15
ROSULA . . . . . . . . . . . . . . . . 19 STAGESIC. . . . . . . . . . . . . . . . 17 TEGRETOL XR . . . . . . . . . . . . 15
ROSULA NS . . . . . . . . . . . . . . 20 STALEVO . . . . . . . . . . . . . . . . 16 TEKTURNA. . . . . . . . . 13, 39, 44
ROWASA (enema only) . . . . . 25 STARLIX . . . . . . . . . . . . . . . . . 21 temazepam . . . . . . . . . . . . . . 18
ROXICET . . . . . . . . . . . . . 17, 45 STIMATE . . . . . . . . . . . . . . . . 21 TEMODAR . . . . . . . . . . . . . . . . 9
ROZEREM . . . . . . . . . 18, 41, 45 STRATTERA . . . . . . . . 18, 40, 45 TENEX . . . . . . . . . . . . . . . . . . 11
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Index
TENORETIC . . . . . . . . . . . . . . 12 trazodone . . . . . . . . . . . . 15, 42 UTA . . . . . . . . . . . . . . . . . . . . 25
TENORMIN . . . . . . . . . . . . . . 12 tretinoin. . . . . . . . . . . . 9, 19, 33 UVADEX . . . . . . . . . . . . . . . . . 9
TEQUIN . . . . . . . . . . . . . . 27, 33 TRETIN-X cream kit . . . . . . . . 33
TERAZOL . . . . . . . . . . . . . . . . 26 TREXALL . . . . . . . . . . . . . . . . . 9
V
terazosin . . . . . . . . . . . . . . . . 11 triamcinolone. . . . . . . . . . . . . 20 VAGIFEM . . . . . . . . . . . . . . . . 26
terbinafine . . . . . . . . . . . . 27, 33 triamterene/ VALCYTE . . . . . . . . . . . . . . . . 28
terbutaline . . . . . . . . . . . . . . . 31 hydrochlorothiazide . . . . . . 14 VALTREX . . . . . . . . . . . . . . . . 28
terconazole . . . . . . . . . . . . . . 26 TRIAZ . . . . . . . . . . . . . . . . . . . 19 vanatrip . . . . . . . . . . . . . . . . . 15
TESLAC . . . . . . . . . . . . . . . . . . 9 triazolam . . . . . . . . . . . . . . . . 18 vandazole . . . . . . . . . . . . . . . 26
TESTIM . . . . . . . . . . . . . . 23, 44 TRICOR . . . . . . . . . . . . . . . . . 12 VANOS. . . . . . . . . . . . . . . . . . 20
testosterone inj. . . . . . . . . . . . 23 trifluoperazine . . . . . . . . . . . . 16 VANTIN . . . . . . . . . . . . . . . . . 26
tetracycline . . . . . . . . . . . 27, 33 trifluridine . . . . . . . . . . . . . . . 30 VASERETIC . . . . . . . . . . . . . . . 11
TEVETEN . . . . . . . . . . . . . 11, 35 TRIGLIDE . . . . . . . . . . . . . . . . 12 VASODILAN . . . . . . . . . . . . . . 14
TEVETEN HCT . . . . . . . . . . . . 11 trihexyphenidyl. . . . . . . . . . . . 16 VASOTEC . . . . . . . . . . . . . 11, 35
TEV-TROPIN . . . . . . . . . . 23, 34 TRILEPTAL . . . . . . . . . . . . . . . 15 veetids . . . . . . . . . . . . . . . . . . 27
THALITONE . . . . . . . . . . . . . . 14 TRI-LEVLEN . . . . . . . . . . . . . . 22 velivet . . . . . . . . . . . . . . . . . . 22
THALOMID . . . . . . . . . . . . . . . 9 trilyte . . . . . . . . . . . . . . . . . . . 24 venlafaxine . . . . . . . . 15, 36, 42
THEO-24 . . . . . . . . . . . . . . . . 31 trimethobenzamide . . . . . . . . 24 VENTAVIS. . . . . . . . . . . . . . . . 14
theocap . . . . . . . . . . . . . . . . . 31 trimethoprim . . . . . . . . . . . . . 27 VENTOLIN HFA . . . . . . . . . . . . 31
theochron . . . . . . . . . . . . . . . 32 trimox . . . . . . . . . . . . . . . . . . 26 VEPESID . . . . . . . . . . . . . . . . . . 9
theophylline ER . . . . . . . . . . . 32 trinessa . . . . . . . . . . . . . . . . . 22 VERAMYST . . . . . . . . . . . 32, 45
THERACYS . . . . . . . . . . . . . . . 9 TRI-NORINYL . . . . . . . . . . . . . 22 verapamil . . . . . . . . . . . . . 13, 43
thioridazine . . . . . . . . . . . . . . 16 TRIPHASIL . . . . . . . . . . . . . . . 22 verapamil CR/ER/SR . . . . . 13, 38
thiothixene. . . . . . . . . . . . . . . 16 triple antibiotic. . . . . . . . . . . . 30 verapamil extended release . . 43
THYMOGLOBULIN . . . . . . . . . 26 tri-previfem . . . . . . . . . . . . . . 22
VERDESO . . . . . . . . . . . . . . . . 20
THYROLAR . . . . . . . . . . . . . . 24 tri-sprintec . . . . . . . . . . . . . . . 22
VERELAN . . . . . . . . . . . . . . . . 13
TIAZAC . . . . . . . . . . . 13, 38, 43 trivora . . . . . . . . . . . . . . . . . . 22
VERELAN PM . . . . . . . . . 13, 38
TICE BCG . . . . . . . . . . . . . . . . 9 TRIZIVIR . . . . . . . . . . . . . . . . 28
TRUSOPT . . . . . . . . . . . . . . . . 30 VERELAN SR. . . . . . . . . . . 38, 43
TICLID . . . . . . . . . . . . . . . . . . 10 VESANOID . . . . . . . . . . . . . . . 9
ticlopidine . . . . . . . . . . . . . . . 10 TRUVADA . . . . . . . . . . . . . . . 28
TRYCET . . . . . . . . . . . . . . . . . 17 VESICARE . . . . . . . . . . . . 25, 46
TIKOSYN . . . . . . . . . . . . . . . . 12 VEXOL . . . . . . . . . . . . . . . . . . 31
TILADE . . . . . . . . . . . . . . . . . 31 TUSSIONEX . . . . . . . . . . . . . . 32
TWINJECT . . . . . . . . . . . . . . . 10 VFEND . . . . . . . . . . . . . . . 27, 33
TIMOLIDE . . . . . . . . . . . . . . . 13 VIBRAMYCIN . . . . . . . . . . 27, 33
timolol . . . . . . . . . . . . . . . . . . 30 TYKERB . . . . . . . . . . . . . . . . . . 9
TYLENOL #3. . . . . . . . . . . . . . 45 VIBRATAB. . . . . . . . . . . . . 27, 33
timolol maleate . . . . . . . . . . . 13
TYLENOL/CODEINE. . . . . . . . . 17 VICODIN . . . . . . . . . . . . . 17, 45
timolol maleate ophth . . . . . . 30
TYLOX . . . . . . . . . . . . . . . 17, 45 VICODIN ES . . . . . . . . . . 17, 45
TINDAMAX . . . . . . . . . . . . . . 27
TYZEKA . . . . . . . . . . . . . . 28, 38 vicodin HP . . . . . . . . . . . . . . . 17
tioconazole . . . . . . . . . . . . . . 26
VICOPROFEN . . . . . . . . . 17, 45
tizanidine . . . . . . . . . . . . . . . . 29 U VIDEX . . . . . . . . . . . . . . . . . . 28
TOBI. . . . . . . . . . . . . . . . . . . . 26 ULTRACAPS . . . . . . . . . . . . . . 25 VIDEX EC . . . . . . . . . . . . . . . 28
TOBRADEX . . . . . . . . . . . . . . 31 ULTRACET . . . . . . . . . . . . . . . 17
tobramycin. . . . . . . . . . . . . . . 30 VIGAMOX . . . . . . . . . . . . . . . 30
ULTRAM . . . . . . . . . . . . . 17, 45
tolazamide . . . . . . . . . . . . . . . 21 VIOKASE . . . . . . . . . . . . . . . . 25
ULTRAM ER . . . . . . . . . . . . . . 17
tolbutamide . . . . . . . . . . . . . . 21 VIRACEPT . . . . . . . . . . . . . . . 28
ULTRASE . . . . . . . . . . . . . . . . 25
tolmetin sodium. . . . . . . . . . . 30 VIRAMUNE . . . . . . . . . . . . . . 28
ULTRASE MT . . . . . . . . . . . . . 25
TOPAMAX . . . . . . . . . . . . . . . 15 VIRAZOLE . . . . . . . . . . . . . . . 29
ULTRAVATE . . . . . . . . . . . . . . 20
TOPROL XL . . . . . . . . . . . 12, 43 UNIPHYL . . . . . . . . . . . . . . . . 32 VIREAD . . . . . . . . . . . . . . . . . 28
TORADOL . . . . . . . . . . . . . . . 40 UNIRETIC . . . . . . . . . . . . . . . 11 VISICOL . . . . . . . . . . . . . . . . . 24
torsemide. . . . . . . . . . . . . . . . 13 unithroid . . . . . . . . . . . . . . . . 24 VIVELLE . . . . . . . . . . . . . . 23, 39
TRACLEER . . . . . . . . . . . . . . . 14 UNIVASC . . . . . . . . . . . . . 11, 35 VIVELLE-DOT . . . . . . . . . . 23, 39
tramadol . . . . . . . . . . . . . 17, 45 URECHOLINE . . . . . . . . . . . . 25 VIVOTIF BERNIA EC . . . . . . . . 34
tramadol/acetaminophen . . . . 17 URELLE . . . . . . . . . . . . . . . . . 25 VOLTAREN . . . . . . . . . . . . . . 30
TRANDATE . . . . . . . . . . . . . . 10 UREX . . . . . . . . . . . . . . . . . . 25 VOLTAREN XR . . . . . . . . . . . . 30
trandolapril . . . . . . . . 11, 35, 44 URISPAS . . . . . . . . . . . . . . . . . 25 VOPAC. . . . . . . . . . . . . . . 17, 45
TRANSDERM-SCOP . . . . . . . . 24 UROXATRAL. . . . . . . . . . . 25, 34 VOSPIRE ER . . . . . . . . . . . . . . 31
tranylcypromine sulfate . . . . . 15 URSO 250 . . . . . . . . . . . . . . . 24 VUSION . . . . . . . . . . . . . . . . . 19
TRAVATAN . . . . . . . . . . . . . . 30 URSO FORTE . . . . . . . . . . . . . 24 VYTORIN . . . . . . . . . 12, 37, 43
TRAVATAN Z . . . . . . . . . . . . . 30 ursodiol . . . . . . . . . . . . . . . . . 24 VYVANSE. . . . . . . 18, 41, 45, 46
56 www.aetna.com/formulary
W ZOMIG ZMT. . . . . . . . . . . 16, 40
warfarin . . . . . . . . . . . . . . . . . . 9 ZONALON . . . . . . . . . . . . . . . 19
WELCHOL . . . . . . . . . . . . . . . 12 ZONEGRAN . . . . . . . . . . . . . . 15
WELLBUTRIN . . . . . . . 15, 36, 42 zonisamide. . . . . . . . . . . . . . . 15
WELLBUTRIN SR . . . . . 15, 36, 42 zovia 1/35E . . . . . . . . . . . . . . 22
WELLBUTRIN XL . . . . . 15, 36, 42 zovia 1/50E . . . . . . . . . . . . . . 22
ZOVIRAX . . . . . . . . . . . . . 20, 28
X ZYDONE . . . . . . . . . . . . . 17, 45
XALATAN . . . . . . . . . . . . . . . . 30 ZYFLO . . . . . . . . . . . . . . . 32, 39
XANAX XR . . . . . . . . . . . . . . . 14 ZYLET. . . . . . . . . . . . . . . . . . . 31
XELODA . . . . . . . . . . . . . . . . . 9 ZYMAR . . . . . . . . . . . . . . . . . 30
XIBROM . . . . . . . . . . . . . . . . . 30 ZYPREXA . . . . . . . . . . . . . 16, 38
XIFAXAN . . . . . . . . . . 27, 33, 35 ZYPREXA ZYDIS . . . . . . . . 16, 38
XODOL . . . . . . . . . . . . . . 17, 45 ZYRTEC . . . . . . . . 32, 34, 40, 45
XOLAIR . . . . . . . . . . . . . . . . . 31 ZYRTEC-D . . . . . . 32, 34, 40, 45
XOPENEX . . . . . . . . . . . . . . . . 31 ZYVOX. . . . . . . . . . . . . . . 27, 33
XOPENEX HFA . . . . . . . . . . . . 31
XOPENEX solution
and concentrate . . . . . . . . . 43
XYREM . . . . . . . . . . . . . . 18, 34
XYZAL . . . . . . . . . 32, 34, 40, 45
Y
YASMIN . . . . . . . . . . . . . . . . 22
YAZ . . . . . . . . . . . . . . . . . . . . 22
Z
ZANAFLEX . . . . . . . . . . . . . . . 29
ZANTAC. . . . . . . . . . . . . . . . . 24
ZARONTIN . . . . . . . . . . . . . . 15
ZAROXOLYN . . . . . . . . . . . . . 14
ZAVESCA . . . . . . . . . . . . . 10, 34
zazole . . . . . . . . . . . . . . . . . . 26
Z-CLINZ . . . . . . . . . . . . . . . . . 19
ZEBETA . . . . . . . . . . . . . . . . . 12
ZEGERID . . . . . . . 24, 33, 35, 42
ZEMPLAR . . . . . . . . . . . . . . . . 23
ZENAPAX . . . . . . . . . . . . . . . . 26
ZERIT . . . . . . . . . . . . . . . . . . . 28
ZESTORETIC . . . . . . . . . . . . . 11
ZESTRIL . . . . . . . . . . . . . . 11, 35
ZETIA . . . . . . . . . . . . . . . . 12, 37
ZIAC . . . . . . . . . . . . . . . . . . . 12
ZIAGEN . . . . . . . . . . . . . . . . . 28
ZIANA . . . . . . . . . . . . . . . 19, 33
zidovudine . . . . . . . . . . . . . . . 28
ZINOTIC . . . . . . . . . . . . . . . . . 31
ZITHROMAX. . . . . . . . . . . . . . 27
ZMAX . . . . . . . . . . . . . . . . . . 27
ZOCOR . . . . . . . . . . . 12, 37, 43
ZODERM . . . . . . . . . . . . . . . . 19
ZOFRAN. . . . . . . . . . . 24, 37, 43
ZOFRAN ODT . . . . . . . 24, 37, 43
ZOLADEX . . . . . . . . . . . . . . . . . 9
ZOLINZA . . . . . . . . . . . . . . . . . 9
ZOLOFT . . . . . . . . . . . 15, 36, 42
zolpidem . . . . . . . . . . 18, 41, 45
ZOMETA . . . . . . . . . . . . . . . . 29
ZOMIG. . . . . . . . . . . . . . . 16, 40
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Notes
58 www.aetna.com/formulary
Notes
www.aetna.com/formulary 59
Notes
60 www.aetna.com/formulary
“Aetna” is the brand name used for products and services provided by one or more of the Aetna group
of subsidiary companies. Those companies include: Aetna Health Inc., Aetna Health of California Inc.,
Aetna Health of the Carolinas Inc., Aetna Health of Illinois Inc., Aetna Health of Washington Inc., Aetna
Health Insurance Company of New York, Corporate Health Insurance Company and/or Aetna Life
Insurance Company.
This material is for informational purposes only and contains only a partial, general description of plan
benefits or programs and does not constitute a contract. Consult the plan documents (Schedule of
Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group Insurance Certificate,
Booklet, Booklet Certificate, Group Policy) to determine governing contractual provisions, including
procedures, exclusions and limitations relating to the plan.
Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. The
availability of a plan or program may vary by geographic service area. Some benefits are subject to
limitations or visit maximums. With the exception of Aetna Rx Home Delivery, all participating physicians,
hospitals and other health care providers are independent contractors in private practice and are neither
employees nor agents of Aetna. Aetna Rx Home Delivery and Aetna Specialty Pharmacy refer to Aetna Rx
Home Delivery, LLC, and Aetna Specialty Pharmacy, LLC, respectively. Aetna Rx Home Delivery and Aetna
Specialty Pharmacy are subsidiaries of Aetna Inc., and are licensed pharmacies that operate through mail-
order. The availability of any particular provider cannot be guaranteed, and provider network composition
is subject to change. Notice of the change shall be provided in accordance with applicable state law.
The term precertification means the utilization review process to determine whether the requested service,
procedure, prescription drug or medical device meets the company's clinical criteria for coverage. It does
not mean precertification as defined by Texas law, as a reliable representation of payment of care or
services to fully-insured HMO and PPO members.
In accordance with state law, California HMO 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. Nothing in this
material 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 material be construed to prohibit generic
drug substitutions.
Aetna has established a policy to allow exceptions or overrides to certain refill-too-soon limitations.
Requests for such exceptions or overrides will be evaluated on a case-by-case basis. While this material is
believed to be accurate as of the print date, it is subject to change.
www.aetna.com/formulary 61
2008
05.05.315.1 (9/07) ©2007 Aetna Inc.