2018 Aetna Premier Plus Plan - Lee County, Florida
Transcript of 2018 Aetna Premier Plus Plan - Lee County, Florida
2018 Aetna Premier Plus Plan
Absorica
Products Affected• ABSORICA
PA Criteria Criteria Details
Covered Uses Severe recalcitrant nodular or cystic acne
Exclusion Criteria
Required Medical Information
Member is enrolled in the FDA iPLEDGE program and, because of significant adverse reactions associated with its use, should be reserved for patients with multiple severe nodular acne who are unresponsive to conventional therapy, including topical acne products and systemic antibiotics
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 02/2017
Revision DatePrior Authorization: August 22, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
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Abstral
Products Affected• ABSTRAL
PA Criteria Criteria Details
Covered Uses Breakthrough cancer pain, General anesthesia
Exclusion Criteria
Required Medical Information
A documented diagnosis of cancer and concomitant use of long acting opioid therapy or member's resident state or contract state is California and the member is terminally ill
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
2018 Aetna Premier Plus Plan01/01/2018
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PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, member must meet the following requirements: A Documented diagnosis of cancer and prescription is written by an oncologist or pain specialist, or member is enrolled in a hospice program or meets hospice criteria, or member's resident state or contract state is California and the member is terminally ill, or the patient has signed opioid agreement in support of clinical guidelines by the American Pain Society and the American Academy of Pain Medicine, Healthcare Provider verbal confirmation that an agreement has been signed by the patient meets the criteria requirement.*Exceptions to requiring the signed opioid agreement for additional quantities are only for those patients that have a diagnosis of cancer or that are enrolled in a hospice program and documentation of one of the following: Member has current diagnosis of cancer(*see exception to opioid agreement above) as the primary cause of the pain and is currently on long-acting opioid and is being titrated on the long-acting opioid by physician, and member has tried and failed an adequate trial of two weeks of a single entity or combination pain medication containing an immediate release acting opioid (ex. oxycodone, morphine sulfate oral(Roxanol), oxymorphone(Opana), hydromorphone(Dilaudid), oxycodone/apap(Percocet))
QL Criteria 120 tablets Per 30 Days
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: April 25, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
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Acetaminophen-Codeine
Products Affected• acetaminophen-codeine
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
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QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
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Acetaminophen-Codeine #2
Products Affected• acetaminophen-codeine #2
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
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QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
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Acetaminophen-Codeine #3
Products Affected• acetaminophen-codeine #3
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
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QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
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Acetaminophen-Codeine #4
Products Affected• acetaminophen-codeine #4
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
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QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
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Actemra
Products Affected• ACTEMRA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Actemra.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
12
Actimmune
Products Affected• ACTIMMUNE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/actimmune.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
13
Actiq
Products Affected• ACTIQ
PA Criteria Criteria Details
Covered Uses Breakthrough cancer pain, General anesthesia
Exclusion Criteria
Required Medical Information
A documented diagnosis of cancer and concomitant use of long acting opioid therapy or member's resident state or contract state is California and the member is terminally ill
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
2018 Aetna Premier Plus Plan01/01/2018
14
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, member must meet the following requirements: A Documented diagnosis of cancer and prescription is written by an oncologist or pain specialist, or member is enrolled in a hospice program or meets hospice criteria, or member's resident state or contract state is California and the member is terminally ill, or the patient has signed opioid agreement in support of clinical guidelines by the American Pain Society and the American Academy of Pain Medicine, Healthcare Provider verbal confirmation that an agreement has been signed by the patient meets the criteria requirement.*Exceptions to requiring the signed opioid agreement for additional quantities are only for those patients that have a diagnosis of cancer or that are enrolled in a hospice program and documentation of one of the following: Member has current diagnosis of cancer(*see exception to opioid agreement above) as the primary cause of the pain and is currently on long-acting opioid and is being titrated on the long-acting opioid by physician, and member has tried and failed an adequate trial of two weeks of a single entity or combination pain medication containing an immediate release acting opioid (ex. oxycodone, morphine sulfate oral(Roxanol), oxymorphone(Opana), hydromorphone(Dilaudid), oxycodone/apap(Percocet))
QL Criteria 120 lozenges Per 30 Days
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: April 25, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
15
Adcirca
Products Affected• ADCIRCA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
16
Adderall
Products Affected• ADDERALL
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
17
Adderall XR
Products Affected• ADDERALL XR
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
18
Adempas
Products Affected• ADEMPAS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 3 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
19
Advate
Products Affected• ADVATE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
20
Adynovate
Products Affected• adynovate
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
21
Adzenys XR-ODT
Products Affected• ADZENYS XR-ODT
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
22
Afinitor
Products Affected• AFINITOR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
23
Afinitor Disperz
Products Affected• AFINITOR DISPERZ
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
24
Afstyla
Products Affected• AFSTYLA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
25
Aldurazyme
Products Affected• ALDURAZYME
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
26
Alecensa
Products Affected• ALECENSA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
27
Alphanate/VWF Complex/Human
Products Affected• ALPHANATE/VWF COMPLEX/HUMAN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
28
AlphaNine SD
Products Affected• ALPHANINE SD
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
29
Alprolix
Products Affected• ALPROLIX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
30
Alunbrig
Products Affected• ALUNBRIG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Alunbrig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
31
Amnesteem
Products Affected• AMNESTEEM
PA Criteria Criteria Details
Covered Uses Severe recalcitrant nodular or cystic acne
Exclusion Criteria
Required Medical Information
Member is enrolled in the FDA iPLEDGE program and, because of significant adverse reactions associated with its use, should be reserved for patients with multiple severe nodular acne who are unresponsive to conventional therapy, including topical acne products and systemic antibiotics
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 02/2017
Revision DatePrior Authorization: August 22, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
32
Amphetamine-Dextroamphet ER
Products Affected• amphetamine-dextroamphet er
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
33
Amphetamine-Dextroamphetamine
Products Affected• amphetamine-dextroamphetamine
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
34
Ampyra
Products Affected• AMPYRA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Ampyra.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
35
APAP-Caff-Dihydrocodeine
Products Affected• apap-caff-dihydrocodeine oral capsule• apap-caff-dihydrocodeine oral tablet 325-30-
16 mg
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
36
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
37
Aptensio XR
Products Affected• APTENSIO XR
QL Criteria 1 capsule Per 1 Day
Notes/References
Annual Review: 05/2017
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
38
Aralast NP
Products Affected• ARALAST NP
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Alpha-1 Antitrypsin Inhibitor Therapy.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
39
Aranesp (Albumin Free)
Products Affected• ARANESP (ALBUMIN FREE) INJECTION
SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 150 MCG/0.75ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML
• ARANESP (ALBUMIN FREE) INJECTION
SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Erythropoiesis_Stimulating_Agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
40
Arcalyst
Products Affected• ARCALYST
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Arcalyst.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
41
Arymo ER
Products Affected• ARYMO ER
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
42
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
43
Ascomp-Codeine
Products Affected• ASCOMP-CODEINE
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
44
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
45
Aspirin-Caff-Dihydrocodeine
Products Affected• aspirin-caff-dihydrocodeine
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
46
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
47
Atomoxetine HCl
Products Affected• atomoxetine hcl oral capsule 10 mg, 18 mg,
25 mg, 40 mg, 60 mg
QL Criteria 2 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
48
Atomoxetine HCl
Products Affected• atomoxetine hcl oral capsule 100 mg, 80 mg
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
49
Aubagio
Products Affected• AUBAGIO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Aubagio.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
50
Austedo
Products Affected• AUSTEDO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Austedo.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
51
AVINza
Products Affected• AVINZA ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 60 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
52
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
53
Avonex
Products Affected• AVONEX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
54
Avonex Pen
Products Affected• AVONEX PEN INTRAMUSCULAR
AUTO-INJECTOR KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
55
Avonex Prefilled
Products Affected• AVONEX PREFILLED
INTRAMUSCULAR PREFILLED SYRINGE KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
56
Bebulin
Products Affected• BEBULIN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
57
Bebulin VH
Products Affected• BEBULIN VH
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
58
Belbuca
Products Affected• BELBUCA
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
59
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
60
BeneFIX
Products Affected• BENEFIX INTRAVENOUS SOLUTION
RECONSTITUTED
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
61
Benlysta
Products Affected• BENLYSTA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/benlysta.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
62
Berinert
Products Affected• BERINERT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/hereditary_angioedema.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
63
Betaseron
Products Affected• BETASERON SUBCUTANEOUS KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 15 vials Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
64
Bexarotene
Products Affected• bexarotene
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Targretin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
65
Bivigam
Products Affected• BIVIGAM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
66
Bosulif
Products Affected• BOSULIF
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
67
Botox
Products Affected• BOTOX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/botulinum_toxin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
68
Bravelle
Products Affected• BRAVELLE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
69
Bunavail
Products Affected• BUNAVAIL BUCCAL FILM 2.1-0.3 MG
QL Criteria 6 films Per 1 Day
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
70
Bunavail
Products Affected• BUNAVAIL BUCCAL FILM 4.2-0.7 MG
QL Criteria 3 films Per 1 Day
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
71
Bunavail
Products Affected• BUNAVAIL BUCCAL FILM 6.3-1 MG
QL Criteria 2 films Per 1 Day
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
72
Buphenyl
Products Affected• BUPHENYL ORAL POWDER 3 GM/TSP • BUPHENYL ORAL TABLET
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
73
Buprenorphine
Products Affected• buprenorphine
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
74
QL Criteria 4 patches Per 28 Days
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
75
Buprenorphine HCl
Products Affected• buprenorphine hcl sublingual
QL Criteria 3 tablets Per 1 Day
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
76
Buprenorphine HCl-Naloxone HCl
Products Affected• buprenorphine hcl-naloxone hcl
QL Criteria 90 tablets Per 30 Days
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
77
Butalbital-APAP-Caff-Cod
Products Affected• butalbital-apap-caff-cod
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
78
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
79
Butalbital-ASA-Caff-Codeine
Products Affected• butalbital-asa-caff-codeine
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
80
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
81
Butorphanol Tartrate
Products Affected• butorphanol tartrate nasal
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
82
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
83
Butrans
Products Affected• BUTRANS
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
84
QL Criteria 4 patches Per 28 Days
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: October 04, 2017
2018 Aetna Premier Plus Plan01/01/2018
85
Cabometyx
Products Affected• CABOMETYX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
86
Capecitabine
Products Affected• capecitabine
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
87
Capital/Codeine
Products Affected• CAPITAL/CODEINE
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
88
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
89
Caprelsa
Products Affected• CAPRELSA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
90
Carbaglu
Products Affected• CARBAGLU
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
91
Carimune NF
Products Affected• CARIMUNE NF INTRAVENOUS
SOLUTION RECONSTITUTED 12 GM, 6 GM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
92
Cerdelga
Products Affected• CERDELGA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/gaucher_disease.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 caps Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
93
Cerezyme
Products Affected• CEREZYME
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/gaucher_disease.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
94
Cetrotide
Products Affected• CETROTIDE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
95
Cholbam
Products Affected• CHOLBAM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Cholbam.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
96
Chorionic Gonadotropin
Products Affected• chorionic gonadotropin intramuscular
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
97
Cimzia
Products Affected• CIMZIA SUBCUTANEOUS KIT 2 X 200
MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Cimzia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 kit Per 1 month
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
98
Cimzia Prefilled
Products Affected• CIMZIA PREFILLED
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Cimzia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 kit Per 1 month
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
99
Cimzia Starter Kit
Products Affected• CIMZIA STARTER KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Cimzia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 kit Per 1 year
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
100
Cinqair
Products Affected• CINQAIR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/RESP/Cinqair.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
101
Cinryze
Products Affected• CINRYZE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/hereditary_angioedema.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
102
Claravis
Products Affected• CLARAVIS
PA Criteria Criteria Details
Covered Uses Severe recalcitrant nodular or cystic acne
Exclusion Criteria
Required Medical Information
Member is enrolled in the FDA iPLEDGE program and, because of significant adverse reactions associated with its use, should be reserved for patients with multiple severe nodular acne who are unresponsive to conventional therapy, including topical acne products and systemic antibiotics
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 02/2017
Revision DatePrior Authorization: August 22, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
103
CloNIDine HCl ER
Products Affected• clonidine hcl er
QL Criteria 4 tablets Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
104
Coagadex
Products Affected• COAGADEX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
105
Codeine Sulfate
Products Affected• codeine sulfate oral tablet
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
106
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
107
Cometriq (100 mg Daily Dose)
Products Affected• COMETRIQ (100 MG DAILY DOSE)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
108
Cometriq (140 mg Daily Dose)
Products Affected• COMETRIQ (140 MG DAILY DOSE)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
109
Cometriq (60 mg Daily Dose)
Products Affected• COMETRIQ (60 MG DAILY DOSE)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
110
Concerta
Products Affected• CONCERTA ORAL TABLET EXTENDED
RELEASE 18 MG, 27 MG, 54 MG
QL Criteria 2 tablets Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
111
Concerta
Products Affected• CONCERTA ORAL TABLET EXTENDED
RELEASE 36 MG
QL Criteria 4 tablets Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
112
ConZip
Products Affected• CONZIP
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
113
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
114
Copaxone
Products Affected• COPAXONE SUBCUTANEOUS
SOLUTION PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/glatiramer.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
115
Corifact
Products Affected• CORIFACT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
116
Cosentyx
Products Affected• COSENTYX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Cosentyx.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
117
Cosentyx Sensoready Pen
Products Affected• COSENTYX SENSOREADY PEN
SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Cosentyx.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
118
Cotellic
Products Affected• COTELLIC
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
119
Cotempla XR-ODT
Products Affected• COTEMPLA XR-ODT
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
120
Cuprimine
Products Affected• CUPRIMINE ORAL CAPSULE 250 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
121
Cuvitru
Products Affected• CUVITRU
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
122
Cystadane
Products Affected• CYSTADANE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
123
Cystaran
Products Affected• CYSTARAN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/EYE/ophthalmic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
124
Daklinza
Products Affected• DAKLINZA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
125
Daytrana
Products Affected• DAYTRANA
QL Criteria 1 patch Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
126
Demerol
Products Affected• DEMEROL ORAL
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
127
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
128
Depen Titratabs
Products Affected• DEPEN TITRATABS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
129
Descovy
Products Affected• DESCOVY
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antiviral_hiv.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
130
Desoxyn
Products Affected• DESOXYN
QL Criteria 4 tablets Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
131
Dexedrine
Products Affected• DEXEDRINE ORAL CAPSULE
EXTENDED RELEASE 24 HOUR
QL Criteria 3 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
132
Dexedrine
Products Affected• DEXEDRINE ORAL TABLET
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
133
Dexmethylphenidate HCl
Products Affected• dexmethylphenidate hcl
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
134
Dexmethylphenidate HCl ER
Products Affected• dexmethylphenidate hcl er oral capsule
extended release 24 hour 10 mg, 20 mg, 30 mg
• dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 40 mg, 5 mg
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
135
Dextroamphetamine Sulfate
Products Affected• dextroamphetamine sulfate oral solution
QL Criteria 40 ML Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
136
Dextroamphetamine Sulfate
Products Affected• dextroamphetamine sulfate oral tablet
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
137
Dextroamphetamine Sulfate ER
Products Affected• dextroamphetamine sulfate er
QL Criteria 3 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
138
Dibenzyline
Products Affected• DIBENZYLINE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/antihypertensive_misc.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
139
Diclofenac Sodium
Products Affected• diclofenac sodium transdermal gel 1 %
QL Criteria 200 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
140
Diclofenac Sodium
Products Affected• diclofenac sodium transdermal gel 3 %
PA Criteria Criteria Details
Covered Uses Actinic keratoses (AK)
Exclusion Criteria
Documentation of any of the following patients/situations: use in treatment of postoperative pain after coronary artery bypass graft (CABG) surgery, any known hypersensitivity to diclofenac or any component of the formulation, any history of Asthma and aspirin triad, the planned area of application includes non-intact skin, or if the medication will be compounded with other products that would alter the total dose/dosage form being administered
Required Medical Information
Documentation that sun avoidance is indicated during therapy
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 100 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: September 29, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
141
Dilaudid
Products Affected• DILAUDID ORAL
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
142
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
143
Dolophine
Products Affected• DOLOPHINE
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
144
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
145
Doxepin HCl
Products Affected• doxepin hcl external
QL Criteria 45 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
146
Dupixent
Products Affected• DUPIXENT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Dupixent.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
147
Duragesic-100
Products Affected• DURAGESIC-100
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
148
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
149
Duragesic-12
Products Affected• DURAGESIC-12
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
150
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
151
Duragesic-25
Products Affected• DURAGESIC-25
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
152
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
153
Duragesic-50
Products Affected• DURAGESIC-50
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
154
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
155
Duragesic-75
Products Affected• DURAGESIC-75
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
156
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
157
Dyanavel XR
Products Affected• DYANAVEL XR
QL Criteria 240 ml Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
158
Dysport
Products Affected• DYSPORT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/botulinum_toxin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
159
Elaprase
Products Affected• ELAPRASE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
160
Elelyso
Products Affected• ELELYSO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/gaucher_disease.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
161
Eligard
Products Affected• ELIGARD
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
162
Ella
Products Affected• ELLA
QL Criteria 2 tablets Per 1 fill
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
163
Eloctate
Products Affected• ELOCTATE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
164
Embeda
Products Affected• EMBEDA
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
165
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
166
Emflaza
Products Affected• EMFLAZA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Emflaza.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
167
EMLA
Products Affected• EMLA
PA Criteria Criteria Details
Covered Uses
***AUTHORIZATION IS NOT REQUIRED FOR LESS THAN 50 GRAMS OF LIDOCAINE EVERY 30 DAYS*** For quantities over 50 grams every 30 days, there must be a documented temporary need for topical anesthetic in either of the following situations: Normal, intact skin for local analgesia, or Genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia
Exclusion Criteria
Documentation of any of the following: Planned area of application includes non-intact skin, Sensitivity to amide-type local anesthetics or any other component of the product, Planned use on large surface area of the body or for a period of time over 3 hours as this can lead to increased toxicity, the medication is being used in conjunction with a cosmetic procedure (i.e. hair removal), Use in situations where the drug may migrate into the middle ear, beyond the tympanic membrane, History of methemoglobinemia, or if the product will be compounded with other products that would alter the total dose/dosage form being administered
Required Medical Information
A documented need for topical anesthetic in either of the following situations: Normal, intact skin for local analgesia, or Genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 months
2018 Aetna Premier Plus Plan01/01/2018
168
PA Criteria Criteria Details
Other Criteria
*Topical lidocaine/prilocaine cream is used for temporary anesthesia. Prescription renewals for longer than 3 months require clinical documentation of medical necessity.Due to Safety Concerns higher quantities and prolonged use are not recommended. Renewal Duration: 3 months *Up to an additional 30 grams per 30 days. Higher additional quantities are not approvable.
Notes/References
Revision DatePrior Authorization: October 03, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
169
Enbrel
Products Affected• ENBREL SUBCUTANEOUS KIT• ENBREL SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 25 MG/0.5ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Enbrel.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 8 units Per 28 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
170
Enbrel
Products Affected• ENBREL SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 50 MG/ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Enbrel.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 units Per 28 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
171
Enbrel SureClick
Products Affected• ENBREL SURECLICK SUBCUTANEOUS
SOLUTION AUTO-INJECTOR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Enbrel.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 units Per 28 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
172
Endocet
Products Affected• ENDOCET ORAL TABLET 10-325 MG,
2.5-325 MG, 5-325 MG, 7.5-325 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
173
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
174
Entecavir
Products Affected• entecavir
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
175
Entyvio
Products Affected• ENTYVIO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Entyvio.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
176
Epclusa
Products Affected• EPCLUSA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
177
Epogen
Products Affected• EPOGEN INJECTION SOLUTION 10000
UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Erythropoiesis_Stimulating_Agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
178
Epoprostenol Sodium
Products Affected• epoprostenol sodium
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
179
Erivedge
Products Affected• ERIVEDGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
180
Esbriet
Products Affected• ESBRIET ORAL CAPSULE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Idiopathic_Pulmonary_Fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 9 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
181
Esbriet
Products Affected• ESBRIET ORAL TABLET
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Idiopathic_Pulmonary_Fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
182
Euflexxa
Products Affected• EUFLEXXA INTRA-ARTICULAR
SOLUTION PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
183
Evekeo
Products Affected• EVEKEO
QL Criteria 120 tablets Per 30 Days
Notes/References
Annual Review: 02/2017
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
184
Exalgo
Products Affected• EXALGO ORAL TABLET ER 24 HOUR
ABUSE-DETERRENT
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
185
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
186
Exjade
Products Affected• EXJADE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Anitdotes.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
187
Extavia
Products Affected• EXTAVIA SUBCUTANEOUS KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 15 vials Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
188
Eylea
Products Affected• EYLEA INTRAOCULAR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/EYE/ophthalmic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
189
Fabrazyme
Products Affected• FABRAZYME
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
190
Falmina
Products Affected• FALMINA
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
191
Farydak
Products Affected• FARYDAK
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 12 capsules Per 30 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
192
Faslodex
Products Affected• FASLODEX INTRAMUSCULAR
SOLUTION 250 MG/5ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
193
Feiba
Products Affected• FEIBA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
194
Feiba NF
Products Affected• FEIBA NF
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
195
Feiba VH Immuno
Products Affected• FEIBA VH IMMUNO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
196
FentaNYL
Products Affected• fentanyl
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
197
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
198
FentaNYL Citrate
Products Affected• fentanyl citrate buccal
PA Criteria Criteria Details
Covered Uses Breakthrough cancer pain, General anesthesia
Exclusion Criteria
Required Medical Information
A documented diagnosis of cancer and concomitant use of long acting opioid therapy or member's resident state or contract state is California and the member is terminally ill
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
2018 Aetna Premier Plus Plan01/01/2018
199
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, member must meet the following requirements: A Documented diagnosis of cancer and prescription is written by an oncologist or pain specialist, or member is enrolled in a hospice program or meets hospice criteria, or member's resident state or contract state is California and the member is terminally ill, or the patient has signed opioid agreement in support of clinical guidelines by the American Pain Society and the American Academy of Pain Medicine, Healthcare Provider verbal confirmation that an agreement has been signed by the patient meets the criteria requirement.*Exceptions to requiring the signed opioid agreement for additional quantities are only for those patients that have a diagnosis of cancer or that are enrolled in a hospice program and documentation of one of the following: Member has current diagnosis of cancer(*see exception to opioid agreement above) as the primary cause of the pain and is currently on long-acting opioid and is being titrated on the long-acting opioid by physician, and member has tried and failed an adequate trial of two weeks of a single entity or combination pain medication containing an immediate release acting opioid (ex. oxycodone, morphine sulfate oral(Roxanol), oxymorphone(Opana), hydromorphone(Dilaudid), oxycodone/apap(Percocet))
QL Criteria 120 lozenges Per 30 Days
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: April 25, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
200
Fentora
Products Affected• FENTORA BUCCAL TABLET 100 MCG,
200 MCG, 400 MCG, 600 MCG, 800 MCG
PA Criteria Criteria Details
Covered Uses Breakthrough cancer pain, General anesthesia
Exclusion Criteria
Required Medical Information
A documented diagnosis of cancer and concomitant use of long acting opioid therapy or member's resident state or contract state is California and the member is terminally ill
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
2018 Aetna Premier Plus Plan01/01/2018
201
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, member must meet the following requirements: A Documented diagnosis of cancer and prescription is written by an oncologist or pain specialist, or member is enrolled in a hospice program or meets hospice criteria, or member's resident state or contract state is California and the member is terminally ill, or the patient has signed opioid agreement in support of clinical guidelines by the American Pain Society and the American Academy of Pain Medicine, Healthcare Provider verbal confirmation that an agreement has been signed by the patient meets the criteria requirement.*Exceptions to requiring the signed opioid agreement for additional quantities are only for those patients that have a diagnosis of cancer or that are enrolled in a hospice program and documentation of one of the following: Member has current diagnosis of cancer(*see exception to opioid agreement above) as the primary cause of the pain and is currently on long-acting opioid and is being titrated on the long-acting opioid by physician, and member has tried and failed an adequate trial of two weeks of a single entity or combination pain medication containing an immediate release acting opioid (ex. oxycodone, morphine sulfate oral(Roxanol), oxymorphone(Opana), hydromorphone(Dilaudid), oxycodone/apap(Percocet))
QL Criteria 120 tablets Per 30 Days
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: April 25, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
202
Ferriprox
Products Affected• FERRIPROX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Anitdotes.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
203
Fioricet/Codeine
Products Affected• FIORICET/CODEINE ORAL CAPSULE
50-300-40-30 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
204
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
205
Fiorinal/Codeine #3
Products Affected• FIORINAL/CODEINE #3
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
206
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
207
Firazyr
Products Affected• FIRAZYR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/hereditary_angioedema.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
208
Firmagon
Products Affected• FIRMAGON
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
209
Flebogamma
Products Affected• FLEBOGAMMA INTRAVENOUS
SOLUTION 0.5 GM/10ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
210
Flebogamma DIF
Products Affected• FLEBOGAMMA DIF
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
211
Flolan
Products Affected• FLOLAN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
212
Focalin
Products Affected• FOCALIN
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
213
Focalin XR
Products Affected• FOCALIN XR
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
214
Follistim AQ
Products Affected• FOLLISTIM AQ
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
215
Fuzeon
Products Affected• FUZEON
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antiviral_hiv.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
216
Gammagard
Products Affected• GAMMAGARD
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
217
Gammagard S/D
Products Affected• GAMMAGARD S/D INTRAVENOUS
SOLUTION RECONSTITUTED 10 GM, 5 GM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
218
Gammaked
Products Affected• GAMMAKED
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
219
Gammaplex
Products Affected• GAMMAPLEX INTRAVENOUS
SOLUTION 10 GM/200ML, 2.5 GM/50ML, 20 GM/400ML, 5 GM/100ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
220
Gamunex-C
Products Affected• GAMUNEX-C
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
221
Ganirelix Acetate
Products Affected• ganirelix acetate
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
222
Gattex
Products Affected• GATTEX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gattex.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
223
Gel-One
Products Affected• GEL-ONE INTRA-ARTICULAR
PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
224
Gelsyn-3
Products Affected• GELSYN-3
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
225
Genotropin
Products Affected• GENOTROPIN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
226
Genotropin MiniQuick
Products Affected• GENOTROPIN MINIQUICK
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
227
Gildagia
Products Affected• GILDAGIA
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
228
Gildess FE 1.5/30
Products Affected• GILDESS FE 1.5/30
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
229
Gildess FE 1/20
Products Affected• GILDESS FE 1/20
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
230
Gilenya
Products Affected• GILENYA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Gilenya.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
231
Gilotrif
Products Affected• GILOTRIF
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
232
Glassia
Products Affected• GLASSIA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Alpha-1 Antitrypsin Inhibitor Therapy.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
233
Glatopa
Products Affected• GLATOPA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/glatiramer.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
234
Gleevec
Products Affected• GLEEVEC
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
235
Gonal-f
Products Affected• GONAL-F
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
236
Gonal-f RFF
Products Affected• GONAL-F RFF
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
237
Gonal-f RFF Pen
Products Affected• GONAL-F RFF PEN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
238
Gonal-f RFF Rediject
Products Affected• GONAL-F RFF REDIJECT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
239
Granix
Products Affected• GRANIX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/G-CSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
240
GuanFACINE HCl ER
Products Affected• guanfacine hcl er
QL Criteria 1 tablet Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
241
Haegarda
Products Affected• HAEGARDA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/hereditary_angioedema.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
242
Harvoni
Products Affected• HARVONI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
243
Helixate FS
Products Affected• HELIXATE FS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
244
Hemofil M
Products Affected• HEMOFIL M INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1501-2000 UNIT, 1700 UNIT, 220-400 UNIT, 250 UNIT, 401-800 UNIT, 500 UNIT, 801-1500 UNIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
245
Hetlioz
Products Affected• HETLIOZ
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/sedative-hypnotics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
246
Hizentra
Products Affected• HIZENTRA SUBCUTANEOUS
SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
247
HP Acthar
Products Affected• HP ACTHAR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/acthar.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
248
Humate-P
Products Affected• HUMATE-P INTRAVENOUS SOLUTION
RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
249
Humatrope
Products Affected• HUMATROPE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
250
Humira
Products Affected• HUMIRA SUBCUTANEOUS PREFILLED
SYRINGE KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Humira.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
251
Humira Pediatric Crohns Start
Products Affected• HUMIRA PEDIATRIC CROHNS START
SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Humira.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
252
Humira Pen
Products Affected• HUMIRA PEN SUBCUTANEOUS PEN-
INJECTOR KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Humira.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
253
Humira Pen-Crohns Starter
Products Affected• HUMIRA PEN-CROHNS STARTER
SUBCUTANEOUS PEN-INJECTOR KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Humira.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
254
Humira Pen-Psoriasis Starter
Products Affected• HUMIRA PEN-PSORIASIS STARTER
SUBCUTANEOUS PEN-INJECTOR KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Humira.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
255
Hyalgan
Products Affected• HYALGAN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
256
Hycamtin
Products Affected• HYCAMTIN ORAL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
257
Hycet
Products Affected• HYCET
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
258
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
259
Hydrocodone-Acetaminophen
Products Affected• hydrocodone-acetaminophen oral solution
10-325 mg/15ml, 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml
• hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
260
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
261
Hydrocodone-Ibuprofen
Products Affected• hydrocodone-ibuprofen
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
262
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
263
HYDROmorphone HCl
Products Affected• hydromorphone hcl oral • hydromorphone hcl rectal
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
264
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
265
HYDROmorphone HCl ER
Products Affected• hydromorphone hcl er
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
266
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
267
Hymovis
Products Affected• HYMOVIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
268
Hyqvia
Products Affected• HYQVIA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
269
Hysingla ER
Products Affected• HYSINGLA ER
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
270
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
271
Ibrance
Products Affected• IBRANCE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 21 capsules Per 28 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
272
Ibudone
Products Affected• IBUDONE
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
273
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
274
Iclusig
Products Affected• ICLUSIG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
275
Idelvion
Products Affected• IDELVION
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
276
IDHIFA
Products Affected• IDHIFA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Idhifa.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
277
Ilaris
Products Affected• ILARIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Ilaris.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
278
Ilaris (150mg Delivered)
Products Affected• ILARIS (150MG DELIVERED)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Ilaris.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
279
Imatinib Mesylate
Products Affected• imatinib mesylate
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
280
Imbruvica
Products Affected• IMBRUVICA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
281
Increlex
Products Affected• INCRELEX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Increlex.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
282
Infergen
Products Affected• INFERGEN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
283
Inflectra
Products Affected• INFLECTRA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Inflectra.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
284
Ingrezza
Products Affected• INGREZZA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Ingrezza.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
285
Inlyta
Products Affected• INLYTA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
286
Intron A
Products Affected• INTRON A
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
287
Intuniv
Products Affected• INTUNIV
QL Criteria 1 tablet Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
288
Iressa
Products Affected• IRESSA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Iressa.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
289
Ixinity
Products Affected• IXINITY
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
290
Jadenu
Products Affected• JADENU
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Anitdotes.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
291
Jadenu Sprinkle
Products Affected• JADENU SPRINKLE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Anitdotes.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
292
Jakafi
Products Affected• JAKAFI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
293
Jetrea
Products Affected• JETREA INTRAOCULAR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/EYE/ophthalmic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
294
Junel 1.5/30
Products Affected• JUNEL 1.5/30
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
295
Junel 1/20
Products Affected• JUNEL 1/20
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
296
Junel FE 1.5/30
Products Affected• JUNEL FE 1.5/30
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
297
Junel FE 1/20
Products Affected• JUNEL FE 1/20
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
298
Juxtapid
Products Affected• JUXTAPID ORAL CAPSULE 10 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Antilipidemic Agents_HOFH.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 28 capsules Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
299
Juxtapid
Products Affected• JUXTAPID ORAL CAPSULE 20 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Antilipidemic Agents_HOFH.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 84 capsules Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
300
Juxtapid
Products Affected• JUXTAPID ORAL CAPSULE 30 MG, 40
MG, 60 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Antilipidemic Agents_HOFH.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
301
Juxtapid
Products Affected• JUXTAPID ORAL CAPSULE 5 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Antilipidemic Agents_HOFH.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 14 capsules Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
302
Kadian
Products Affected• KADIAN ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG
• KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG, 40 MG, 70 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
303
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
304
Kalbitor
Products Affected• KALBITOR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/hereditary_angioedema.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
305
Kalydeco
Products Affected• KALYDECO ORAL PACKET
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/cystic_fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
306
Kalydeco
Products Affected• KALYDECO ORAL TABLET
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/cystic_fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
307
Kanuma
Products Affected• KANUMA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
308
Kapvay
Products Affected• KAPVAY ORAL
QL Criteria 2 EA Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
309
Kapvay
Products Affected• KAPVAY ORAL TABLET EXTENDED
RELEASE 12 HOUR
QL Criteria 4 tablets Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
310
Kariva
Products Affected• KARIVA
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
311
Kelnor 1/35
Products Affected• KELNOR 1/35
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
312
Keveyis
Products Affected• KEVEYIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/carbonic_anhydrase_inhibitor.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
313
Kevzara
Products Affected• KEVZARA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Kevzara.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
314
Kineret
Products Affected• KINERET SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Kineret.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
315
Kisqali 200 Dose
Products Affected• KISQALI 200 DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Kisqali.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
316
Kisqali 400 Dose
Products Affected• KISQALI 400 DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Kisqali.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
317
Kisqali 600 Dose
Products Affected• KISQALI 600 DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Kisqali.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
318
Kisqali Femara 200 Dose
Products Affected• KISQALI FEMARA 200 DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Kisqali.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
319
Kisqali Femara 400 Dose
Products Affected• KISQALI FEMARA 400 DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Kisqali.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
320
Kisqali Femara 600 Dose
Products Affected• KISQALI FEMARA 600 DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Kisqali.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
321
Koate
Products Affected• KOATE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
322
Koate-DVI
Products Affected• KOATE-DVI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
323
Kogenate FS
Products Affected• KOGENATE FS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
324
Kogenate FS Bio-Set
Products Affected• KOGENATE FS BIO-SET
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
325
Korlym
Products Affected• KORLYM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/antidiabetic agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
326
Kovaltry
Products Affected• KOVALTRY
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
327
Krystexxa
Products Affected• KRYSTEXXA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/gout.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
328
Kurvelo
Products Affected• KURVELO
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
329
Kuvan
Products Affected• KUVAN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
330
Kynamro
Products Affected• KYNAMRO SUBCUTANEOUS
SOLUTION PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Antilipidemic Agents_HOFH.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
331
Lazanda
Products Affected• LAZANDA
PA Criteria Criteria Details
Covered Uses Breakthrough cancer pain, General anesthesia
Exclusion Criteria
Required Medical Information
A documented diagnosis of cancer and concomitant use of long acting opioid therapy or member's resident state or contract state is California and the member is terminally ill
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
2018 Aetna Premier Plus Plan01/01/2018
332
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, member must meet the following requirements: A Documented diagnosis of cancer and prescription is written by an oncologist or pain specialist, or member is enrolled in a hospice program or meets hospice criteria, or member's resident state or contract state is California and the member is terminally ill, or the patient has signed opioid agreement in support of clinical guidelines by the American Pain Society and the American Academy of Pain Medicine, Healthcare Provider verbal confirmation that an agreement has been signed by the patient meets the criteria requirement.*Exceptions to requiring the signed opioid agreement for additional quantities are only for those patients that have a diagnosis of cancer or that are enrolled in a hospice program and documentation of one of the following: Member has current diagnosis of cancer(*see exception to opioid agreement above) as the primary cause of the pain and is currently on long-acting opioid and is being titrated on the long-acting opioid by physician, and member has tried and failed an adequate trial of two weeks of a single entity or combination pain medication containing an immediate release acting opioid (ex. oxycodone, morphine sulfate oral(Roxanol), oxymorphone(Opana), hydromorphone(Dilaudid), oxycodone/apap(Percocet))
QL Criteria 4 bottles Per 30 Days
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: April 25, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
333
Lazanda
Products Affected• LAZANDA
PA Criteria Criteria Details
Covered Uses Breakthrough cancer pain, General anesthesia
Exclusion Criteria
Required Medical Information
Documentation that member is terminally ill or has a documented diagnosis of cancer with concomitant use of around the clock long acting opioid therapy for cancer pain, requiring management of breakthrough pain and is intolerant of two (2) immediate-release opioids including morphine, hydrocodone, oxycodone, or hydromorphone.
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria Step therapy may apply
QL Criteria 4 bottles Per 30 Days
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: December 29, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
334
Leena
Products Affected• LEENA
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
335
Lemtrada
Products Affected• LEMTRADA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Lemtrada.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 5 vials Per 365 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
336
Lenvima 10 MG Daily Dose
Products Affected• LENVIMA 10 MG DAILY DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 day supply Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
337
Lenvima 14 MG Daily Dose
Products Affected• LENVIMA 14 MG DAILY DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 day supply Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
338
Lenvima 18 MG Daily Dose
Products Affected• LENVIMA 18 MG DAILY DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
339
Lenvima 20 MG Daily Dose
Products Affected• LENVIMA 20 MG DAILY DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 day supply Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
340
Lenvima 24 MG Daily Dose
Products Affected• LENVIMA 24 MG DAILY DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 day supply Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
341
Lenvima 8 MG Daily Dose
Products Affected• LENVIMA 8 MG DAILY DOSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
342
Lessina
Products Affected• LESSINA
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
343
Letairis
Products Affected• LETAIRIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
344
Leukine
Products Affected• LEUKINE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/G-CSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
345
Leuprolide Acetate
Products Affected• leuprolide acetate injection
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
346
Levonest
Products Affected• LEVONEST
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
347
Levonorgestrel-Ethinyl Estrad
Products Affected• levonorgestrel-ethinyl estrad oral tablet
0.15-30 mg-mcg
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
348
Levora 0.15/30 (28)
Products Affected• LEVORA 0.15/30 (28)
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
349
Levorphanol Tartrate
Products Affected• levorphanol tartrate oral
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
350
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
351
Lidocaine
Products Affected• lidocaine external ointment
PA Criteria Criteria Details
Covered Uses
***AUTHORIZATION IS NOT REQUIRED FOR LESS THAN 50 GRAMS OF LIDOCAINE EVERY 30 DAYS*** For quantities over 50 grams every 30 days, there must be a documented temporary need for anesthesia for any of the following: Accessible mucous membranes of the oropharynx, skin and mucous membranes or stomatitis, or pain associated with a minor burns, including sunburn, abrasions of the skin, and insect bites.
Exclusion Criteria
Documentation of any of the following: Planned area of application includes non-intact skin, sensitivity to amide-type local anesthetics or any other component of the product, planned use on large surface area of the body as this can lead to increased toxicity, planned area of application includes severely traumatized skin (e.g.,mucosal or skin abrasion, eczema, burns), the medication is being used in conjunction with a cosmetic procedure (i.e. hair removal), of if the product will be compounded with other products that would alter the total dose/dosage form being administered
Required Medical Information
A documented need for temporary anesthesia for any of the following: Accessible mucous membranes of the oropharynx, skin and mucous membranes or stomatitis, or pain associated with a minor burns, including sunburn, abrasions of the skin, and insect bites.
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 months
2018 Aetna Premier Plus Plan01/01/2018
352
PA Criteria Criteria Details
Other Criteria
*Topical lidocaine ointment is used for temporary anesthesia. Prescription renewals for longer than 3 months require clinical documentation of medical necessity. Due to Safety Concerns higher quantities and prolonged use are not recommended. Renewal Duration: 3 months *Approval can made up to an additional 50gms per 30 days. Higher additional quantities are not approvable *FOR ADULTS: A single application should not exceed 5 g of Lidocaine Ointment 5%, containing 250 mg of lidocaine base (equivalent chemically to approximately 300 mg of lidocaine hydrochloride). This is roughly equivalent to squeezing a six (6) inch length of ointment from the tube. In a 70 kg adult this dose equals 3.6 mg/kg (1.6 mg/lb) lidocaine base. No more than one-half tube, approximately 17-20 g of ointment or 850-1000 mg lidocaine base, should be administered in any one day. FOR CHILDREN: For children less than ten years who have a normal lean body mass and a normal lean body development, the maximum dose may be determined by the application of one of the standard pediatric drug formulas (e.g., Clark's rule). For example a child of five years weighing 50 lbs., the dose of lidocaine should not exceed 75-100 mg when calculated according to Clark's rule. In any case, the maximum amount of lidocaine administered should not exceed 4.5 mg/kg (2.0 mg/lb) of body weight ***Lidocaine toxicity resulting from transcutaneous absorption is theoretically possible. Signs and symptoms of systemic lidocaine toxicity include CNS excitation and/or depression, nervousness, confusion, dizziness, tinnitus, blurred or double vision, vomiting, twitching, tremors, seizures, unconsciousness, respiratory depression, bradycardia, hypotension, and cardiopulmonary arrest. If there is suspicion of lidocaine-related systemic toxicity, check lidocaine blood concentrations
QL Criteria 50 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: October 03, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
353
Lidocaine-Prilocaine
Products Affected• lidocaine-prilocaine external cream
PA Criteria Criteria Details
Covered Uses
***AUTHORIZATION IS NOT REQUIRED FOR LESS THAN 50 GRAMS OF LIDOCAINE EVERY 30 DAYS*** For quantities over 50 grams every 30 days, there must be a documented temporary need for topical anesthetic in either of the following situations: Normal, intact skin for local analgesia, or Genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia
Exclusion Criteria
Documentation of any of the following: Planned area of application includes non-intact skin, Sensitivity to amide-type local anesthetics or any other component of the product, Planned use on large surface area of the body or for a period of time over 3 hours as this can lead to increased toxicity, the medication is being used in conjunction with a cosmetic procedure (i.e. hair removal), Use in situations where the drug may migrate into the middle ear, beyond the tympanic membrane, History of methemoglobinemia, or if the product will be compounded with other products that would alter the total dose/dosage form being administered
Required Medical Information
A documented need for topical anesthetic in either of the following situations: Normal, intact skin for local analgesia, or Genital mucous membranes for superficial minor surgery and as pretreatment for infiltration anesthesia
Age Restrictions
Prescriber Restrictions
Coverage Duration
3 months
2018 Aetna Premier Plus Plan01/01/2018
354
PA Criteria Criteria Details
Other Criteria
*Topical lidocaine/prilocaine cream is used for temporary anesthesia. Prescription renewals for longer than 3 months require clinical documentation of medical necessity.Due to Safety Concerns higher quantities and prolonged use are not recommended. Renewal Duration: 3 months *Up to an additional 30 grams per 30 days. Higher additional quantities are not approvable.
QL Criteria 30 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: October 03, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
355
Lonsurf
Products Affected• LONSURF
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
356
Lorcet
Products Affected• LORCET
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
357
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
358
Lorcet HD
Products Affected• LORCET HD
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
359
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
360
Lorcet Plus
Products Affected• LORCET PLUS ORAL TABLET 7.5-325
MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
361
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
362
Lortab
Products Affected• LORTAB ORAL ELIXIR 10-300 MG/15ML• LORTAB ORAL TABLET 10-325 MG, 5-
325 MG, 7.5-325 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
363
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
364
Low-Ogestrel
Products Affected• LOW-OGESTREL
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
365
Lucentis
Products Affected• LUCENTIS INTRAOCULAR• LUCENTIS INTRAVITREAL SOLUTION
PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/EYE/ophthalmic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
366
Lumizyme
Products Affected• LUMIZYME
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
367
Lupaneta Pack
Products Affected• LUPANETA PACK
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
368
Lupron Depot (1-Month)
Products Affected• LUPRON DEPOT (1-MONTH)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
369
Lupron Depot (3-Month)
Products Affected• LUPRON DEPOT (3-MONTH)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
370
Lupron Depot (4-Month)
Products Affected• LUPRON DEPOT (4-MONTH)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
371
Lupron Depot (6-Month)
Products Affected• LUPRON DEPOT (6-MONTH)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
372
Lupron Depot-Ped (1-Month)
Products Affected• LUPRON DEPOT-PED (1-MONTH)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
373
Lupron Depot-Ped (3-Month)
Products Affected• LUPRON DEPOT-PED (3-MONTH)
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
374
Lutera
Products Affected• LUTERA
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
375
Lynparza
Products Affected• LYNPARZA ORAL CAPSULE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 day supply Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
376
Lynparza
Products Affected• LYNPARZA ORAL TABLET
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
377
Macugen
Products Affected• MACUGEN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/EYE/ophthalmic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
378
Makena
Products Affected• MAKENA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/hydroxyprogesterone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
379
Marlissa
Products Affected• marlissa
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
380
Mavyret
Products Affected• MAVYRET
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
381
Mekinist
Products Affected• MEKINIST
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
382
Menopur
Products Affected• MENOPUR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
383
Meperidine HCl
Products Affected• meperidine hcl oral
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
384
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
385
Metadate CD
Products Affected• METADATE CD
QL Criteria 1 capsule Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
386
Metadate ER
Products Affected• METADATE ER ORAL TABLET
EXTENDED RELEASE 20 MG
QL Criteria 3 tablets Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
387
Methadone HCl
Products Affected• methadone hcl oral
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
388
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
389
Methadone HCl Intensol
Products Affected• METHADONE HCL INTENSOL
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
390
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
391
Methadose
Products Affected• METHADOSE ORAL CONCENTRATE 10
MG/ML
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
392
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
393
Methadose Sugar-Free
Products Affected• METHADOSE SUGAR-FREE
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
394
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
395
Methamphetamine HCl
Products Affected• methamphetamine hcl
QL Criteria 4 tablets Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
396
Methylin
Products Affected• METHYLIN ORAL SOLUTION 10
MG/5ML
QL Criteria 30 ML Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
397
Methylin
Products Affected• METHYLIN ORAL SOLUTION 5
MG/5ML
QL Criteria 60 ML Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
398
Methylin
Products Affected• METHYLIN ORAL TABLET CHEWABLE
QL Criteria 3 tablets Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
399
Methylphenidate HCl
Products Affected• methylphenidate hcl oral solution 10 mg/5ml
QL Criteria 30 ML Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
400
Methylphenidate HCl
Products Affected• methylphenidate hcl oral solution 5 mg/5ml
QL Criteria 60 ML Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
401
Methylphenidate HCl
Products Affected• methylphenidate hcl oral tablet • methylphenidate hcl oral tablet chewable
QL Criteria 6 tablets Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
402
Methylphenidate HCl ER
Products Affected• methylphenidate hcl er oral tablet extended
release 10 mg
QL Criteria 3 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
403
Methylphenidate HCl ER
Products Affected• methylphenidate hcl er oral tablet extended
release 18 mg, 27 mg, 54 mg
QL Criteria 2 tablets Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
404
Methylphenidate HCl ER
Products Affected• methylphenidate hcl er oral tablet extended
release 20 mg
QL Criteria 3 tablets Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
405
Methylphenidate HCl ER
Products Affected• methylphenidate hcl er oral tablet extended
release 36 mg
QL Criteria 4 tablets Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
406
Methylphenidate HCl ER
Products Affected• methylphenidate hcl er oral tablet extended
release 24 hour 18 mg, 27 mg, 54 mg
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
407
Methylphenidate HCl ER
Products Affected• methylphenidate hcl er oral tablet extended
release 24 hour 36 mg
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
408
Methylphenidate HCl ER (CD)
Products Affected• methylphenidate hcl er (cd)
QL Criteria 1 capsule Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
409
Methylphenidate HCl ER (LA)
Products Affected• methylphenidate hcl er (la) oral capsule
extended release 24 hour 20 mg• methylphenidate hcl er (la) oral capsule
extended release 24 hour 40 mg
QL Criteria 1 capsule Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
410
Methylphenidate HCl ER (LA)
Products Affected• methylphenidate hcl er (la) oral capsule
extended release 24 hour 30 mg
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
411
Methylphenidate HCl ER (LA)
Products Affected• methylphenidate hcl er (la) oral capsule
extended release 24 hour 60 mg
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
412
Microgestin 1.5/30
Products Affected• MICROGESTIN 1.5/30
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
413
Microgestin 1/20
Products Affected• MICROGESTIN 1/20
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
414
Microgestin FE 1.5/30
Products Affected• MICROGESTIN FE 1.5/30
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
415
Microgestin FE 1/20
Products Affected• MICROGESTIN FE 1/20
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
416
Mircera
Products Affected• MIRCERA INJECTION SOLUTION
PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Erythropoiesis_Stimulating_Agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
417
Monoclate-P
Products Affected• MONOCLATE-P
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
418
Mononine
Products Affected• MONONINE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
419
Monovisc
Products Affected• MONOVISC
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
420
MorphaBond ER
Products Affected• MORPHABOND ER
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
421
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
422
Morphine Sulfate
Products Affected• morphine sulfate oral • morphine sulfate rectal
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
423
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
424
Morphine Sulfate (Concentrate)
Products Affected• morphine sulfate (concentrate) oral solution
100 mg/5ml, 20 mg/ml
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
425
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
426
Morphine Sulfate ER
Products Affected• morphine sulfate er oral capsule extended
release 24 hour• morphine sulfate er oral tablet extended
release
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
427
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
428
Morphine Sulfate ER Beads
Products Affected• morphine sulfate er beads
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
429
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
430
MS Contin
Products Affected• MS CONTIN ORAL TABLET EXTENDED
RELEASE
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
431
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
432
Myalept
Products Affected• MYALEPT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/myalept.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
433
Mydayis
Products Affected• MYDAYIS
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
434
Myorisan
Products Affected• MYORISAN
PA Criteria Criteria Details
Covered Uses Severe recalcitrant nodular or cystic acne
Exclusion Criteria
Required Medical Information
Member is enrolled in the FDA iPLEDGE program and, because of significant adverse reactions associated with its use, should be reserved for patients with multiple severe nodular acne who are unresponsive to conventional therapy, including topical acne products and systemic antibiotics
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: August 22, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
435
Myorisan
Products Affected• MYORISAN
PA Criteria Criteria Details
Covered Uses Severe recalcitrant nodular or cystic acne
Exclusion Criteria
Required Medical Information
Member is enrolled in the FDA iPLEDGE program and, because of significant adverse reactions associated with its use, should be reserved for patients with multiple severe nodular acne who are unresponsive to conventional therapy, including topical acne products and systemic antibiotics
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 02/2017
Revision DatePrior Authorization: August 22, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
436
Myozyme
Products Affected• MYOZYME
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
437
Naglazyme
Products Affected• NAGLAZYME
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
438
Natpara
Products Affected• NATPARA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
439
Necon 0.5/35 (28)
Products Affected• NECON 0.5/35 (28)
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
440
Necon 1/35 (28)
Products Affected• NECON 1/35 (28)
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
441
Necon 10/11 (28)
Products Affected• NECON 10/11 (28)
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
442
Nerlynx
Products Affected• NERLYNX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Nerlynx.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
443
Neulasta
Products Affected• NEULASTA SUBCUTANEOUS
SOLUTION PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/G-CSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
444
Neulasta Delivery Kit
Products Affected• NEULASTA DELIVERY KIT
SUBCUTANEOUS PREFILLED SYRINGE KIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/G-CSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
445
Neumega
Products Affected• NEUMEGA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Neumega.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
446
Neupogen
Products Affected• NEUPOGEN INJECTION SOLUTION 300
MCG/ML, 480 MCG/1.6ML• NEUPOGEN INJECTION SOLUTION
PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/G-CSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
447
NexAVAR
Products Affected• NEXAVAR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
448
Ninlaro
Products Affected• NINLARO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
449
Nityr
Products Affected• NITYR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
450
Norco
Products Affected• NORCO
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
451
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
452
Norditropin FlexPro
Products Affected• NORDITROPIN FLEXPRO
SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
453
Norditropin NordiFlex Pen
Products Affected• NORDITROPIN NORDIFLEX PEN
SUBCUTANEOUS SOLUTION 30 MG/3ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
454
Norgestrel-Ethinyl Estradiol
Products Affected• norgestrel-ethinyl estradiol
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
455
Northera
Products Affected• NORTHERA ORAL CAPSULE 100 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Northera.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 3 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
456
Northera
Products Affected• NORTHERA ORAL CAPSULE 200 MG,
300 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/Northera.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 6 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
457
Nortrel 0.5/35 (28)
Products Affected• NORTREL 0.5/35 (28)
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
458
Nortrel 1/35 (21)
Products Affected• NORTREL 1/35 (21)
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
459
Nortrel 1/35 (28)
Products Affected• NORTREL 1/35 (28)
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
460
Novarel
Products Affected• novarel intramuscular solution reconstituted
10000 unit
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
461
Novoeight
Products Affected• NOVOEIGHT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
462
NovoSeven RT
Products Affected• NOVOSEVEN RT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
463
Nplate
Products Affected• NPLATE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Neumega.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
464
Nucala
Products Affected• NUCALA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/RESP/Interleukin Antagonist.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
465
Nucynta
Products Affected• NUCYNTA
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
466
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
467
Nucynta ER
Products Affected• NUCYNTA ER
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
468
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
469
Nuplazid
Products Affected• NUPLAZID
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Nuplazid.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
470
Nutropin
Products Affected• NUTROPIN SUBCUTANEOUS
SOLUTION RECONSTITUTED 10 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
471
Nutropin AQ
Products Affected• NUTROPIN AQ
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
472
Nutropin AQ NuSpin 10
Products Affected• NUTROPIN AQ NUSPIN 10
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
473
Nutropin AQ NuSpin 20
Products Affected• NUTROPIN AQ NUSPIN 20
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
474
Nutropin AQ NuSpin 5
Products Affected• NUTROPIN AQ NUSPIN 5
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
475
Nutropin AQ Pen
Products Affected• NUTROPIN AQ PEN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
476
Nuwiq
Products Affected• NUWIQ INTRAVENOUS KIT 1000 UNIT,
2000 UNIT, 250 UNIT, 500 UNIT• NUWIQ INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
477
Ocaliva
Products Affected• OCALIVA ORAL TABLET 5 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/Primary_Biliary_Cholagitis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
478
Octagam
Products Affected• OCTAGAM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
479
Octreotide Acetate
Products Affected• octreotide acetate
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Sandostatin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
480
Odomzo
Products Affected• ODOMZO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Odomzo.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
481
Ofev
Products Affected• OFEV
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Idiopathic_Pulmonary_Fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
482
Olysio
Products Affected• OLYSIO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
483
Omnitrope
Products Affected• OMNITROPE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
484
Opana
Products Affected• OPANA ORAL
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
485
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
486
Opana ER
Products Affected• OPANA ER ORAL TABLET ER 12 HOUR
ABUSE-DETERRENT
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
487
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
488
Opsumit
Products Affected• OPSUMIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
489
Orencia
Products Affected• ORENCIA INTRAVENOUS• ORENCIA SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Orencia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
490
Orencia
Products Affected• ORENCIA SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 125 MG/ML
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Orencia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 syringes Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
491
Orencia ClickJect
Products Affected• ORENCIA CLICKJECT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Orencia.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
492
Orenitram
Products Affected• ORENITRAM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
493
Orfadin
Products Affected• ORFADIN ORAL CAPSULE 10 MG, 2
MG, 5 MG• ORFADIN ORAL SUSPENSION
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
494
Orkambi
Products Affected• ORKAMBI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/cystic_fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
495
Orsythia
Products Affected• ORSYTHIA
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
496
OrthoVisc
Products Affected• ORTHOVISC INTRA-ARTICULAR
SOLUTION PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
497
Otezla
Products Affected• OTEZLA ORAL TABLET• OTEZLA ORAL TABLET THERAPY
PACK
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Otezla.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
498
Ovidrel
Products Affected• OVIDREL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
499
Oxaydo
Products Affected• OXAYDO
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
500
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
501
OxyCODONE HCl
Products Affected• oxycodone hcl oral capsule• oxycodone hcl oral concentrate 100 mg/5ml• oxycodone hcl oral concentrate 20 mg/ml
• oxycodone hcl oral solution• oxycodone hcl oral tablet
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
502
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
503
OxyCODONE HCl ER
Products Affected• oxycodone hcl er oral tablet er 12 hour
abuse-deterrent
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
504
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
505
OxyCODONE HCl ER
Products Affected• oxycodone hcl er oral tablet er 12 hour
abuse-deterrent
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
506
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
507
Oxycodone-Acetaminophen
Products Affected• oxycodone-acetaminophen oral solution• oxycodone-acetaminophen oral tablet 10-325
mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
508
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
509
Oxycodone-Aspirin
Products Affected• oxycodone-aspirin oral tablet 4.8355-325 mg
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
510
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
511
Oxycodone-Ibuprofen
Products Affected• oxycodone-ibuprofen
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
512
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
513
OxyCONTIN
Products Affected• OXYCONTIN ORAL TABLET ER 12
HOUR ABUSE-DETERRENT
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
514
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
515
Oxymorphone HCl
Products Affected• oxymorphone hcl
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
516
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
517
OxyMORphone HCl ER
Products Affected• oxymorphone hcl er
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
518
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
519
Ozurdex
Products Affected• OZURDEX INTRAOCULAR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/EYE/ophthalmic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
520
Pegasys
Products Affected• PEGASYS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
521
Pegasys ProClick
Products Affected• PEGASYS PROCLICK
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
522
PegIntron
Products Affected• PEGINTRON
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
523
Peg-Intron
Products Affected• PEG-INTRON
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
524
Peg-Intron Redipen
Products Affected• PEG-INTRON REDIPEN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
525
Peg-Intron Redipen Pak 4
Products Affected• PEG-INTRON REDIPEN PAK 4
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
526
Pentazocine-Naloxone HCl
Products Affected• pentazocine-naloxone hcl
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
527
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
528
Percocet
Products Affected• PERCOCET ORAL TABLET 10-325 MG,
2.5-325 MG, 5-325 MG, 7.5-325 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
529
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
530
Phenoxybenzamine HCl
Products Affected• phenoxybenzamine hcl oral
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/antihypertensive_misc.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
531
Philith
Products Affected• PHILITH
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
532
Plegridy
Products Affected• PLEGRIDY
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 ML Per 28 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
533
Plegridy Starter Pack
Products Affected• PLEGRIDY STARTER PACK
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 ML Per 28 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
534
Pomalyst
Products Affected• POMALYST
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
535
Portia-28
Products Affected• PORTIA-28
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
536
Praluent
Products Affected• PRALUENT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/PCSK9.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
537
Pregnyl
Products Affected• pregnyl
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
538
Primlev
Products Affected• PRIMLEV
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
539
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
540
Privigen
Products Affected• PRIVIGEN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/ivig.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
541
ProCentra
Products Affected• PROCENTRA
QL Criteria 40 ML Per 1 Day
Notes/References
Annual Review: 10/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
542
Procrit
Products Affected• PROCRIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Erythropoiesis_Stimulating_Agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
543
Procysbi
Products Affected• PROCYSBI ORAL CAPSULE DELAYED
RELEASE 25 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
544
Procysbi
Products Affected• PROCYSBI ORAL CAPSULE DELAYED
RELEASE 75 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 25 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
545
Profilnine SD
Products Affected• PROFILNINE SD
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
546
Prolastin-C
Products Affected• PROLASTIN-C INTRAVENOUS
SOLUTION RECONSTITUTED 1000 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Alpha-1 Antitrypsin Inhibitor Therapy.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
547
Prolia
Products Affected• PROLIA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
548
Promacta
Products Affected• PROMACTA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Promacta.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
549
Prudoxin
Products Affected• PRUDOXIN
QL Criteria 45 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
550
Pulmozyme
Products Affected• PULMOZYME
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/cystic_fibrosis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
551
Purixan
Products Affected• PURIXAN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
552
QuilliChew ER
Products Affected• QUILLICHEW ER ORAL TABLET
CHEWABLE EXTENDED RELEASE 20 MG, 40 MG
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
553
QuilliChew ER
Products Affected• QUILLICHEW ER ORAL TABLET
CHEWABLE EXTENDED RELEASE 30 MG
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
554
Quillivant XR
Products Affected• QUILLIVANT XR
QL Criteria 12 ML Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
555
Ravicti
Products Affected• RAVICTI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
556
Rebif
Products Affected• REBIF SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
557
Rebif Rebidose
Products Affected• REBIF REBIDOSE SUBCUTANEOUS
SOLUTION AUTO-INJECTOR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
558
Rebif Rebidose Titration Pack
Products Affected• REBIF REBIDOSE TITRATION PACK
SUBCUTANEOUS SOLUTION AUTO-INJECTOR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
559
Rebif Titration Pack
Products Affected• REBIF TITRATION PACK
SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/MSinterferons.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
560
Reclipsen
Products Affected• RECLIPSEN
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
561
Recombinate
Products Affected• RECOMBINATE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
562
Remicade
Products Affected• REMICADE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Remicade.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
563
Remodulin
Products Affected• REMODULIN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
564
Renflexis
Products Affected• RENFLEXIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Renflexis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
565
Repatha
Products Affected• REPATHA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/PCSK9.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
566
Repatha Pushtronex System
Products Affected• REPATHA PUSHTRONEX SYSTEM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/PCSK9.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
567
Repatha SureClick
Products Affected• REPATHA SURECLICK
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/PCSK9.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
568
Reprexain
Products Affected• REPREXAIN ORAL TABLET 10-200 MG,
5-200 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
569
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
570
Repronex
Products Affected• REPRONEX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/infertility.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
571
Revatio
Products Affected• REVATIO INTRAVENOUS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
572
Revatio
Products Affected• REVATIO ORAL SUSPENSION
RECONSTITUTED
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 bottles Per 30 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
573
Revatio
Products Affected• REVATIO ORAL TABLET
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 3 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
574
Revlimid
Products Affected• REVLIMID
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
575
RiaSTAP
Products Affected• RIASTAP
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Riastap.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
576
Ritalin
Products Affected• RITALIN
QL Criteria 6 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
577
Ritalin LA
Products Affected• RITALIN LA ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 60 MG
QL Criteria 1 capsule Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
578
Ritalin LA
Products Affected• RITALIN LA ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 30 MG
QL Criteria 2 capsule Per 1 Day
Notes/References
Annual Review: 09/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
579
Rixubis
Products Affected• RIXUBIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
580
Rosuvastatin Calcium
Products Affected• rosuvastatin calcium
QL Criteria 1 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
581
Roxicet
Products Affected• ROXICET ORAL SOLUTION
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
582
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
583
Roxicodone
Products Affected• ROXICODONE ORAL TABLET
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
584
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
585
Rubraca
Products Affected• RUBRACA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Rubraca.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
586
Ruconest
Products Affected• RUCONEST
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/hereditary_angioedema.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
587
Rydapt
Products Affected• RYDAPT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Rydapt.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
588
Sabril
Products Affected• SABRIL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/anticonvulsants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
589
Saizen
Products Affected• SAIZEN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
590
Saizen Click.Easy
Products Affected• SAIZEN CLICK.EASY
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
591
Samsca
Products Affected• SAMSCA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/samsca.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
592
SandoSTATIN
Products Affected• SANDOSTATIN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Sandostatin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
593
SandoSTATIN LAR Depot
Products Affected• SANDOSTATIN LAR DEPOT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Sandostatin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
594
Serostim
Products Affected• SEROSTIM SUBCUTANEOUS
SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
595
Signifor
Products Affected• SIGNIFOR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Signifor.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 10 ampules Per 30 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
596
Signifor LAR
Products Affected• SIGNIFOR LAR INTRAMUSCULAR
SUSPENSION RECONSTITUTED
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Signifor.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 injection Per 28 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
597
Sildenafil Citrate
Products Affected• sildenafil citrate oral
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
598
Siliq
Products Affected• SILIQ
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Siliq.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
599
Simponi
Products Affected• SIMPONI SUBCUTANEOUS SOLUTION
AUTO-INJECTOR• SIMPONI SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Simponi.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 syringe Per 30 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
600
Simponi Aria
Products Affected• SIMPONI ARIA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Simponi_Aria.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
601
Sirturo
Products Affected• SIRTURO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antimycobacterial_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 68 tablets Per 30 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
602
Sodium Phenylbutyrate
Products Affected• sodium phenylbutyrate oral powder 3 gm/tsp
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
603
Solaraze
Products Affected• SOLARAZE
PA Criteria Criteria Details
Covered Uses Actinic keratoses (AK)
Exclusion Criteria
Documentation of any of the following patients/situations: use in treatment of postoperative pain after coronary artery bypass graft (CABG) surgery, any known hypersensitivity to diclofenac or any component of the formulation, any history of Asthma and aspirin triad, the planned area of application includes non-intact skin, or if the medication will be compounded with other products that would alter the total dose/dosage form being administered
Required Medical Information
Documentation that sun avoidance is indicated during therapy
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 100 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: September 29, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
604
Soliris
Products Affected• SOLIRIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/soliris.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
605
Somatuline Depot
Products Affected• SOMATULINE DEPOT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Sandostatin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
606
Somavert
Products Affected• SOMAVERT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
607
Sovaldi
Products Affected• SOVALDI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 tab Per 1 fill
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
608
Sprycel
Products Affected• SPRYCEL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
609
Sronyx
Products Affected• SRONYX
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
610
Stelara
Products Affected• STELARA INTRAVENOUS• STELARA SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Stelara.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
611
Stiolto Respimat
Products Affected• STIOLTO RESPIMAT
QL Criteria 1 inhaler Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
612
Stivarga
Products Affected• STIVARGA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 21 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
613
Strattera
Products Affected• STRATTERA ORAL CAPSULE 10 MG, 18
MG, 25 MG, 40 MG, 60 MG
QL Criteria 2 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
614
Strattera
Products Affected• STRATTERA ORAL CAPSULE 100 MG,
80 MG
QL Criteria 1 capsule Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
615
Strensiq
Products Affected• STRENSIQ
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
616
Suboxone
Products Affected• SUBOXONE SUBLINGUAL FILM 12-3
MG
QL Criteria 2 films Per 1 Day
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
617
Suboxone
Products Affected• SUBOXONE SUBLINGUAL FILM 2-0.5
MG, 4-1 MG, 8-2 MG
QL Criteria 90 films Per 30 Days
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
618
Suboxone
Products Affected• SUBOXONE SUBLINGUAL TABLET
SUBLINGUAL
QL Criteria 2 tablets Per 1 Day
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
619
Subsys
Products Affected• SUBSYS
PA Criteria Criteria Details
Covered Uses Breakthrough cancer pain, General anesthesia
Exclusion Criteria
Required Medical Information
A documented diagnosis of cancer and concomitant use of long acting opioid therapy or member's resident state or contract state is California and the member is terminally ill
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
2018 Aetna Premier Plus Plan01/01/2018
620
PA Criteria Criteria Details
Other Criteria
For coverage of additional quantities, member must meet the following requirements: A Documented diagnosis of cancer and prescription is written by an oncologist or pain specialist, or member is enrolled in a hospice program or meets hospice criteria, or member's resident state or contract state is California and the member is terminally ill, or the patient has signed opioid agreement in support of clinical guidelines by the American Pain Society and the American Academy of Pain Medicine, Healthcare Provider verbal confirmation that an agreement has been signed by the patient meets the criteria requirement.*Exceptions to requiring the signed opioid agreement for additional quantities are only for those patients that have a diagnosis of cancer or that are enrolled in a hospice program and documentation of one of the following: Member has current diagnosis of cancer(*see exception to opioid agreement above) as the primary cause of the pain and is currently on long-acting opioid and is being titrated on the long-acting opioid by physician, and member has tried and failed an adequate trial of two weeks of a single entity or combination pain medication containing an immediate release acting opioid (ex. oxycodone, morphine sulfate oral(Roxanol), oxymorphone(Opana), hydromorphone(Dilaudid), oxycodone/apap(Percocet))
QL Criteria 120 sprays Per 30 Days
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: April 25, 2016Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
621
Supartz
Products Affected• SUPARTZ INTRA-ARTICULAR
SOLUTION PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
622
Supprelin LA
Products Affected• SUPPRELIN LA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
623
Sutent
Products Affected• SUTENT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
624
Sylatron
Products Affected• SYLATRON SUBCUTANEOUS KIT 200
MCG, 300 MCG, 4 X 200 MCG, 4 X 300 MCG, 600 MCG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
625
Synagis
Products Affected• SYNAGIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Synagis.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
626
Synalgos-DC
Products Affected• SYNALGOS-DC
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
627
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
628
Synarel
Products Affected• SYNAREL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
629
Synvisc
Products Affected• SYNVISC INTRA-ARTICULAR
SOLUTION PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
630
Synvisc One
Products Affected• SYNVISC ONE INTRA-ARTICULAR
SOLUTION PREFILLED SYRINGE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/viscosupplements.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
631
Syprine
Products Affected• SYPRINE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
632
Tacrolimus
Products Affected• tacrolimus external
QL Criteria 60 GM Per 1 fill
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
633
Tafinlar
Products Affected• TAFINLAR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
634
Tagrisso
Products Affected• TAGRISSO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Tagrisso.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
635
Taltz
Products Affected• TALTZ
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Taltz.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
636
Tarceva
Products Affected• TARCEVA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
637
Targretin
Products Affected• TARGRETIN ORAL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Targretin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
638
Tasigna
Products Affected• TASIGNA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
639
Tecfidera
Products Affected• TECFIDERA ORAL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Tecfidera.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 starter pack Per 30 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
640
Tecfidera
Products Affected• TECFIDERA ORAL CAPSULE DELAYED
RELEASE 120 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Tecfidera.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 14 capsules Per 7 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
641
Tecfidera
Products Affected• TECFIDERA ORAL CAPSULE DELAYED
RELEASE 240 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Tecfidera.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
642
Technivie
Products Affected• TECHNIVIE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
643
Temodar
Products Affected• TEMODAR ORAL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
644
Temozolomide
Products Affected• temozolomide
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
645
Tetrabenazine
Products Affected• tetrabenazine
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/xenazine.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
646
Tev-Tropin
Products Affected• TEV-TROPIN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
647
Thalomid
Products Affected• THALOMID
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
648
Thiola
Products Affected• THIOLA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
649
Tilia Fe
Products Affected• TILIA FE
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
650
Tracleer
Products Affected• TRACLEER
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
651
TraMADol HCl
Products Affected• tramadol hcl oral
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
652
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
653
TraMADol HCl ER
Products Affected• tramadol hcl er
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
654
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
655
TraMADol HCl ER (Biphasic)
Products Affected• tramadol hcl er (biphasic)
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
656
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
657
Tramadol-Acetaminophen
Products Affected• tramadol-acetaminophen
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
658
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
659
Trelstar
Products Affected• TRELSTAR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
660
Trelstar Mixject
Products Affected• TRELSTAR MIXJECT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
661
Tremfya
Products Affected• TREMFYA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Tremfya.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
662
Tretten
Products Affected• TRETTEN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
663
Trezix
Products Affected• TREZIX ORAL CAPSULE 320.5-30-16 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
664
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
665
Tri-Legest Fe
Products Affected• TRI-LEGEST FE
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
666
Trivora (28)
Products Affected• TRIVORA (28)
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
667
Truvada
Products Affected• TRUVADA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antiviral_hiv.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
668
Tykerb
Products Affected• TYKERB
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
669
Tylenol with Codeine #3
Products Affected• TYLENOL WITH CODEINE #3
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
670
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
671
Tylenol with Codeine #4
Products Affected• TYLENOL WITH CODEINE #4
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
672
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
673
Tymlos
Products Affected• TYMLOS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 pen Per 1 month
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
674
Tysabri
Products Affected• TYSABRI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Tysabri.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
675
Tyvaso
Products Affected• TYVASO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
676
Tyvaso Refill
Products Affected• TYVASO REFILL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
677
Tyvaso Starter
Products Affected• TYVASO STARTER
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
678
Ultracet
Products Affected• ULTRACET
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
679
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
680
Ultram
Products Affected• ULTRAM
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
681
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
682
Ultram ER
Products Affected• ULTRAM ER ORAL TABLET
EXTENDED RELEASE 24 HOUR 100 MG, 300 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
2018 Aetna Premier Plus Plan01/01/2018
683
PA Criteria Criteria Details
Other Criteria
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
684
Uptravi
Products Affected• UPTRAVI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
685
Valchlor
Products Affected• VALCHLOR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
686
Valcyte
Products Affected• VALCYTE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antiviraloraltopical.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
687
ValGANciclovir HCl
Products Affected• valganciclovir hcl
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ID/antiviraloraltopical.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
688
Vantas
Products Affected• VANTAS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
689
Vecamyl
Products Affected• VECAMYL
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/antihypertensive_misc.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 10 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
690
Veletri
Products Affected• VELETRI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
691
Velivet
Products Affected• VELIVET
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
692
Veltassa
Products Affected• VELTASSA
PA Criteria Criteria Details
Covered Uses Treatment of hyperkalemia
Exclusion Criteria
Required Medical Information
Documentation that a member (at least 18 years of age) has a diagnosis of chronic kidney disease (CKD) and has hyperkalemia (serum potassium level of 5.1 to greater than 6.5 mEq/L), that the member is stable on an angiotensin converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), or an aldosterone antagonist (e.g. spironolactone, eplerenone)(if taking one of the medications), the patient has been counseled to take all other oral medications 3 hours before or 3 hours after Veltassa, Veltassa will not be used as an emergency treatment for life-threatening hyperkalemia, and the member is following a low potassium diet (less than or equal to 3 grams per day).
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
Reauthorization criteria: Use of Veltassa has been effective in treating hyperkalemia (e.g. current serum potassium level is lower than the pretreatment baseline serum potassium level), the member continues to require treatment for hyperkalemia, the member is stable on an angiotensin converting enzyme (ACE) inhibitor, angiotensin II receptor blocker (ARB), or an aldosterone antagonist (e.g. spironolactone, eplerenone)(if taking one of the medications) and the member continues to follow a low potassium diet (less than or equal to 3 grams per day).
Notes/References
2018 Aetna Premier Plus Plan01/01/2018
693
Revision DatePrior Authorization: August 24, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
694
Vemlidy
Products Affected• VEMLIDY
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/Vemlidy.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
695
Venclexta
Products Affected• VENCLEXTA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Venclexta.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
696
Venclexta Starting Pack
Products Affected• VENCLEXTA STARTING PACK
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Venclexta.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 1 pack Per 28 Days
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
697
Ventavis
Products Affected• VENTAVIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CV/pulmonaryhypertensionagents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
698
Verdrocet
Products Affected• VERDROCET
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
699
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
700
Vicodin
Products Affected• VICODIN ORAL TABLET 5-300 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
701
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
702
Vicodin ES
Products Affected• VICODIN ES ORAL TABLET 7.5-300 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
703
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
704
Vicodin HP
Products Affected• VICODIN HP ORAL TABLET 10-300 MG
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
705
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
706
Vicoprofen
Products Affected• VICOPROFEN
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
707
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
708
Victrelis
Products Affected• VICTRELIS
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 12 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
709
Viekira Pak
Products Affected• VIEKIRA PAK
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
710
Viekira XR
Products Affected• VIEKIRA XR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
711
Vimizim
Products Affected• VIMIZIM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/lysosomal_storage.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
712
Visudyne
Products Affected• VISUDYNE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/EYE/ophthalmic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
713
Voltaren
Products Affected• VOLTAREN TRANSDERMAL
QL Criteria 200 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
714
Vonvendi
Products Affected• VONVENDI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
715
Vosevi
Products Affected• VOSEVI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
716
Votrient
Products Affected• VOTRIENT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
717
Vpriv
Products Affected• VPRIV
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/gaucher_disease.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
718
Vyvanse
Products Affected• VYVANSE
QL Criteria 2 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
719
Vyvanse
Products Affected• VYVANSE
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
720
Wera
Products Affected• WERA
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
721
Wilate
Products Affected• WILATE INTRAVENOUS KIT• WILATE INTRAVENOUS SOLUTION
RECONSTITUTED 1000-1000 UNIT, 500-500 UNIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
722
Xalkori
Products Affected• XALKORI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
723
Xartemis XR
Products Affected• XARTEMIS XR
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
724
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
725
Xeljanz
Products Affected• XELJANZ
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Xeljanz_XeljanzXR.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
726
Xeljanz XR
Products Affected• XELJANZ XR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/Xeljanz_XeljanzXR.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
727
Xeloda
Products Affected• XELODA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
728
Xenazine
Products Affected• XENAZINE ORAL TABLET 12.5 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/xenazine.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
729
Xenazine
Products Affected• XENAZINE ORAL TABLET 25 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/xenazine.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 2 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
730
Xeomin
Products Affected• XEOMIN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/botulinum_toxin.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
731
Xermelo
Products Affected• XERMELO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Xermelo.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
732
Xgeva
Products Affected• XGEVA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MUSC/bone_disease_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
733
Xodol
Products Affected• XODOL
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
734
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
735
Xolair
Products Affected• XOLAIR
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/RESP/Xolair.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
736
Xtampza ER
Products Affected• XTAMPZA ER
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
737
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
738
Xtandi
Products Affected• XTANDI
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
739
Xuriden
Products Affected• XURIDEN
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/metabolic_agents.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
740
Xyntha
Products Affected• XYNTHA INTRAVENOUS KIT 1000
UNIT, 2000 UNIT, 250 UNIT, 500 UNIT
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
741
Xyntha Solofuse
Products Affected• XYNTHA SOLOFUSE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/bloodproducts_coagulants.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
742
Xyrem
Products Affected• XYREM
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/cataplexy-xyrem.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
743
Zamicet
Products Affected• ZAMICET
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
744
QL Criteria 90 MME Per 1 Day
Notes/References
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
745
Zarxio
Products Affected• ZARXIO
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/G-CSF.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
746
Zavesca
Products Affected• ZAVESCA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/gaucher_disease.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
747
Zejula
Products Affected• ZEJULA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Zejula.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
748
Zelboraf
Products Affected• ZELBORAF
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 8 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
749
Zemaira
Products Affected• ZEMAIRA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/Alpha-1 Antitrypsin Inhibitor Therapy.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
750
Zenatane
Products Affected• ZENATANE
PA Criteria Criteria Details
Covered Uses Severe recalcitrant nodular or cystic acne
Exclusion Criteria
Required Medical Information
Member is enrolled in the FDA iPLEDGE program and, because of significant adverse reactions associated with its use, should be reserved for patients with multiple severe nodular acne who are unresponsive to conventional therapy, including topical acne products and systemic antibiotics
Age Restrictions
Prescriber Restrictions
Coverage Duration
1 year
Other Criteria
QL Criteria 2 capsules Per 1 Day
Notes/References
Annual Review: 02/2016
Revision DatePrior Authorization: August 22, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
751
Zenchent
Products Affected• ZENCHENT
QL Criteria 1.5 tablet Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
752
Zenzedi
Products Affected• ZENZEDI
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
753
Zepatier
Products Affected• ZEPATIER
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/GI/hepatitis_c.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: August 02, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
754
Zinbryta
Products Affected• ZINBRYTA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/CNS/Zinbryta.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
755
Zohydro ER
Products Affected• ZOHYDRO ER
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
756
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 06/2016
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
757
Zohydro ER
Products Affected• ZOHYDRO ER
PA Criteria Criteria Details
Covered Uses All FDA approved indications
Exclusion Criteria
Required Medical Information
(1) A MEMBER WILL RECEIVE LIFETIME APPROVAL OF THE REQUESTED MEDICATION WHEN: Member is in hospice care, if terminally ill or has end-of-life care (other than hospice), or has an active oncology diagnosis (pain medication being used for pain for cancer patients) or palliative care. (2) FOR A DOCUMENTED DIAGNOSIS OF MODERATE TO SEVERE ACUTE PAIN (INCLUDING POST-SURGICAL PAIN), TRAUMATIC INJURY, OR FOR A CHILD ON AN OPIOID WEAN AT TIME OF HOSPITAL DISCHARGE: additional medication after initial coverage will be approved for up to 1 month. (3) FOR A DOCUMENTED DIAGNOSIS OF CHRONIC PAIN: which includes conditions of chronic pain not mentioned above, the prescriber must certify there is an active treatment plan that includes but is not limited to a specific treatment objective, the use of other pharmacological and non-pharmacological agents for pain relief as appropriate, that there has been an informed consent document signed and an addiction risk assessment performed, and that a written/signed agreement between prescriber and patient addressing issues of prescription management, diversion, and the use of other substances exists. When these criteria are met, the medication will be approved for an initial 3 months. Continuation requests may be approved for up to an additional 6 months.
Age Restrictions
Prescriber Restrictions
Coverage Duration
Length of Therapy; see required medical information
Other Criteria
2018 Aetna Premier Plus Plan01/01/2018
758
QL Criteria 90 MME Per 1 Day
Notes/References
Annual Review: 06/2017
Revision DatePrior Authorization: September 06, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
759
Zoladex
Products Affected• ZOLADEX
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/MISC/Gonadotropins.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
760
Zolinza
Products Affected• ZOLINZA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 30 days maximum Per 1 fill
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
761
Zomacton
Products Affected• ZOMACTON
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
762
Zonalon
Products Affected• ZONALON
QL Criteria 45 grams Per 30 Days
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
763
Zorbtive
Products Affected• ZORBTIVE
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ENDO/growthhormone.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
764
Zovia 1/35E (28)
Products Affected• ZOVIA 1/35E (28)
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
765
Zovia 1/50E (28)
Products Affected• ZOVIA 1/50E (28)
QL Criteria 1.5 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
766
Zubsolv
Products Affected• ZUBSOLV SUBLINGUAL TABLET
SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG
QL Criteria 90 tablets Per 30 Days
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
767
Zubsolv
Products Affected• ZUBSOLV SUBLINGUAL TABLET
SUBLINGUAL 11.4-2.9 MG
QL Criteria 1 tablet Per 1 Day
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
768
Zubsolv
Products Affected• ZUBSOLV SUBLINGUAL TABLET
SUBLINGUAL 2.9-0.71 MG
QL Criteria 3 tablets Per 1 Day
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
769
Zubsolv
Products Affected• ZUBSOLV SUBLINGUAL TABLET
SUBLINGUAL 8.6-2.1 MG
QL Criteria 2 tablets Per 1 Day
Notes/References
Annual Review: 04/2016
Revision DatePrior Authorization: August 25, 2015Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
770
Zydelig
Products Affected• ZYDELIG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
771
Zykadia
Products Affected• ZYKADIA
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
772
Zytiga
Products Affected• ZYTIGA ORAL TABLET 250 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
QL Criteria 4 tablets Per 1 Day
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
773
Zytiga
Products Affected• ZYTIGA ORAL TABLET 500 MG
PA Criteria Criteria Details
Covered Uses
Refer to the clinical policy bulletin for details: http://www.aetna.com/products/rxnonmedicare/data/2018/ANEOPL/Antineoplastics.html
Exclusion Criteria
Required Medical Information
Age Restrictions
Prescriber Restrictions
Coverage Duration
Refer to the clinical policy bulletin above for details.
Other Criteria
Notes/References
Revision DatePrior Authorization: September 26, 2017Step Therapy: August 25, 2015Quantity Limits: August 25, 2015
2018 Aetna Premier Plus Plan01/01/2018
774
IndexIndex
ABSORICA................................................1ABSTRAL..................................................2acetaminophen-codeine ................................ 4acetaminophen-codeine #2 ...........................6acetaminophen-codeine #3 ...........................8acetaminophen-codeine #4 ......................... 10ACTEMRA..............................................12ACTIMMUNE........................................ 13ACTIQ..................................................... 14ADCIRCA............................................... 16ADDERALL............................................17ADDERALL XR..................................... 18ADEMPAS...............................................19ADVATE................................................. 20adynovate .................................................. 21ADZENYS XR-ODT...............................22AFINITOR.............................................. 23AFINITOR DISPERZ.............................24AFSTYLA................................................25ALDURAZYME..................................... 26ALECENSA.............................................27ALPHANATE/VWF COMPLEX/HUMAN..............................28ALPHANINE SD.................................... 29ALPROLIX..............................................30ALUNBRIG............................................ 31AMNESTEEM.........................................32amphetamine-dextroamphet er ...................33amphetamine-dextroamphetamine ..............34AMPYRA................................................ 35apap-caff-dihydrocodeine oral capsule ........36apap-caff-dihydrocodeine oral tablet 325-30-16 mg ................................................... 36APTENSIO XR........................................38ARALAST NP......................................... 39ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 150 MCG/0.75ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML.............................................40
Index
ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML............................................ 40ARCALYST.............................................41ARYMO ER............................................ 42ASCOMP-CODEINE.............................. 44aspirin-caff-dihydrocodeine ........................46atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg, 60 mg ..................................48atomoxetine hcl oral capsule 100 mg, 80 mg .............................................................49AUBAGIO............................................... 50AUSTEDO...............................................51AVINZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 60 MG...........................................................52AVONEX.................................................54AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT.......................... 55AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT........................................ 56BEBULIN................................................ 57BEBULIN VH..........................................58BELBUCA............................................... 59BENEFIX INTRAVENOUS SOLUTION RECONSTITUTED........... 61BENLYSTA............................................. 62BERINERT..............................................63BETASERON SUBCUTANEOUS KIT. 64bexarotene .................................................65BIVIGAM................................................ 66BOSULIF.................................................67BOTOX.................................................... 68BRAVELLE............................................. 69BUNAVAIL BUCCAL FILM 2.1-0.3 MG...........................................................70
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Index
BUNAVAIL BUCCAL FILM 4.2-0.7 MG...........................................................71BUNAVAIL BUCCAL FILM 6.3-1 MG.72BUPHENYL ORAL POWDER 3 GM/TSP................................................... 73BUPHENYL ORAL TABLET................ 73buprenorphine ............................................74buprenorphine hcl sublingual ...................... 76buprenorphine hcl-naloxone hcl ..................77butalbital-apap-caff-cod .............................78butalbital-asa-caff-codeine .........................80butorphanol tartrate nasal ..........................82BUTRANS...............................................84CABOMETYX.........................................86capecitabine ...............................................87CAPITAL/CODEINE..............................88CAPRELSA............................................. 90CARBAGLU........................................... 91CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM................................................92CERDELGA............................................93CEREZYME............................................94CETROTIDE........................................... 95CHOLBAM..............................................96chorionic gonadotropin intramuscular ........ 97CIMZIA PREFILLED............................ 99CIMZIA STARTER KIT.......................100CIMZIA SUBCUTANEOUS KIT 2 X 200 MG.................................................... 98CINQAIR...............................................101CINRYZE.............................................. 102CLARAVIS............................................ 103clonidine hcl er .........................................104COAGADEX......................................... 105codeine sulfate oral tablet .........................106COMETRIQ (100 MG DAILY DOSE). 108COMETRIQ (140 MG DAILY DOSE). 109COMETRIQ (60 MG DAILY DOSE)... 110CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 54 MG............................................111
Index
CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG........... 112CONZIP................................................. 113COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 115CORIFACT............................................116COSENTYX...........................................117COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML....................... 118COTELLIC............................................ 119COTEMPLA XR-ODT.......................... 120CUPRIMINE ORAL CAPSULE 250 MG......................................................... 121CUVITRU..............................................122CYSTADANE........................................123CYSTARAN.......................................... 124DAKLINZA...........................................125DAYTRANA......................................... 126DEMEROL ORAL................................ 127DEPEN TITRATABS............................129DESCOVY............................................. 130DESOXYN.............................................131DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR...... 132DEXEDRINE ORAL TABLET............ 133dexmethylphenidate hcl ............................134dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg ........................................................... 135dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 40 mg, 5 mg ........................................................... 135dextroamphetamine sulfate er .................. 138dextroamphetamine sulfate oral solution .. 136dextroamphetamine sulfate oral tablet ......137DIBENZYLINE.....................................139diclofenac sodium transdermal gel 1 % ..... 140diclofenac sodium transdermal gel 3 % ..... 141DILAUDID ORAL................................142DOLOPHINE........................................ 144doxepin hcl external .................................146DUPIXENT........................................... 147
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Index
DURAGESIC-100..................................148DURAGESIC-12................................... 150DURAGESIC-25................................... 152DURAGESIC-50................................... 154DURAGESIC-75................................... 156DYANAVEL XR................................... 158DYSPORT............................................. 159ELAPRASE............................................160ELELYSO.............................................. 161ELIGARD..............................................162ELLA......................................................163ELOCTATE........................................... 164EMBEDA...............................................165EMFLAZA.............................................167EMLA.................................................... 168ENBREL SUBCUTANEOUS KIT....... 170ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML............................................. 170ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML..................................................171ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR............................................ 172ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG......................................................... 173entecavir .................................................. 175ENTYVIO.............................................. 176EPCLUSA.............................................. 177EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML...............................................178epoprostenol sodium .................................179ERIVEDGE........................................... 180ESBRIET ORAL CAPSULE................. 181ESBRIET ORAL TABLET....................182EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 183EVEKEO................................................184
Index
EXALGO ORAL TABLET ER 24 HOUR ABUSE-DETERRENT............. 185EXJADE.................................................187EXTAVIA SUBCUTANEOUS KIT......188EYLEA INTRAOCULAR.................... 189FABRAZYME.......................................190FALMINA............................................. 191FARYDAK............................................192FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML.....................193FEIBA.................................................... 194FEIBA NF..............................................195FEIBA VH IMMUNO........................... 196fentanyl ................................................... 197fentanyl citrate buccal ..............................199FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG................................................ 201FERRIPROX......................................... 203FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG................. 204FIORINAL/CODEINE #3.................... 206FIRAZYR.............................................. 208FIRMAGON..........................................209FLEBOGAMMA DIF........................... 211FLEBOGAMMA INTRAVENOUS SOLUTION 0.5 GM/10ML....................210FLOLAN................................................212FOCALIN.............................................. 213FOCALIN XR....................................... 214FOLLISTIM AQ.................................... 215FUZEON............................................... 216GAMMAGARD.................................... 217GAMMAGARD S/D INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM..............................................218GAMMAKED....................................... 219GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/200ML, 2.5 GM/50ML, 20 GM/400ML, 5 GM/100ML............................................ 220GAMUNEX-C....................................... 221ganirelix acetate ...................................... 222
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Index
GATTEX................................................223GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE....................... 224GELSYN-3.............................................225GENOTROPIN......................................226GENOTROPIN MINIQUICK.............. 227GILDAGIA............................................228GILDESS FE 1.5/30............................... 229GILDESS FE 1/20.................................. 230GILENYA..............................................231GILOTRIF.............................................232GLASSIA............................................... 233GLATOPA............................................. 234GLEEVEC..............................................235GONAL-F..............................................236GONAL-F RFF..................................... 237GONAL-F RFF PEN.............................238GONAL-F RFF REDIJECT................. 239GRANIX................................................240guanfacine hcl er ......................................241HAEGARDA.........................................242HARVONI............................................. 243HELIXATE FS...................................... 244HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1501-2000 UNIT, 1700 UNIT, 220-400 UNIT, 250 UNIT, 401-800 UNIT, 500 UNIT, 801-1500 UNIT.........245HETLIOZ...............................................246HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML..................... 247HP ACTHAR.........................................248HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT......................................................249HUMATROPE...................................... 250HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML............................................. 252
Index
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT............................253HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT.........................................................254HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT.........................................................255HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT............... 251HYALGAN............................................256HYCAMTIN ORAL..............................257HYCET.................................................. 258hydrocodone-acetaminophen oral solution10-325 mg/15ml, 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml ....................... 260hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg ............260hydrocodone-ibuprofen .............................262hydromorphone hcl er ...............................266hydromorphone hcl oral ........................... 264hydromorphone hcl rectal .........................264HYMOVIS............................................. 268HYQVIA................................................ 269HYSINGLA ER.....................................270IBRANCE.............................................. 272IBUDONE............................................. 273ICLUSIG................................................275IDELVION............................................ 276IDHIFA..................................................277ILARIS...................................................278ILARIS (150MG DELIVERED)........... 279imatinib mesylate .....................................280IMBRUVICA.........................................281INCRELEX............................................282INFERGEN........................................... 283INFLECTRA......................................... 284INGREZZA........................................... 285INLYTA.................................................286INTRON A............................................ 287INTUNIV...............................................288IRESSA.................................................. 289
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Index
IXINITY................................................ 290JADENU................................................291JADENU SPRINKLE........................... 292JAKAFI..................................................293JETREA INTRAOCULAR...................294JUNEL 1.5/30.........................................295JUNEL 1/20............................................296JUNEL FE 1.5/30................................... 297JUNEL FE 1/20......................................298JUXTAPID ORAL CAPSULE 10 MG. 299JUXTAPID ORAL CAPSULE 20 MG. 300JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG....................................... 301JUXTAPID ORAL CAPSULE 5 MG... 302KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG....................................... 303KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG, 40 MG, 70 MG...............................303KALBITOR........................................... 305KALYDECO ORAL PACKET............. 306KALYDECO ORAL TABLET..............307KANUMA............................................. 308KAPVAY ORAL................................... 309KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR...... 310KARIVA................................................ 311KELNOR 1/35........................................312KEVEYIS...............................................313KEVZARA.............................................314KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 315KISQALI 200 DOSE.............................. 316KISQALI 400 DOSE.............................. 317KISQALI 600 DOSE.............................. 318KISQALI FEMARA 200 DOSE............319KISQALI FEMARA 400 DOSE............320KISQALI FEMARA 600 DOSE............321KOATE.................................................. 322KOATE-DVI..........................................323KOGENATE FS.................................... 324
Index
KOGENATE FS BIO-SET.................... 325KORLYM.............................................. 326KOVALTRY..........................................327KRYSTEXXA........................................328KURVELO............................................ 329KUVAN................................................. 330KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 331LAZANDA............................................ 332LAZANDA............................................ 334LEENA...................................................335LEMTRADA......................................... 336LENVIMA 10 MG DAILY DOSE........ 337LENVIMA 14 MG DAILY DOSE........ 338LENVIMA 18 MG DAILY DOSE........ 339LENVIMA 20 MG DAILY DOSE........ 340LENVIMA 24 MG DAILY DOSE........ 341LENVIMA 8 MG DAILY DOSE.......... 342LESSINA............................................... 343LETAIRIS..............................................344LEUKINE..............................................345leuprolide acetate injection .......................346LEVONEST........................................... 347levonorgestrel-ethinyl estrad oral tablet0.15-30 mg-mcg ....................................... 348LEVORA 0.15/30 (28)............................ 349levorphanol tartrate oral .......................... 350lidocaine external ointment ...................... 352lidocaine-prilocaine external cream .......... 354LONSURF............................................. 356LORCET................................................ 357LORCET HD......................................... 359LORCET PLUS ORAL TABLET 7.5-325 MG...................................................361LORTAB ORAL ELIXIR 10-300 MG/15ML.............................................. 363LORTAB ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG...........................363LOW-OGESTREL................................. 365LUCENTIS INTRAOCULAR.............. 366LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE.. 366LUMIZYME..........................................367
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Index
LUPANETA PACK...............................368LUPRON DEPOT (1-MONTH)............369LUPRON DEPOT (3-MONTH)............370LUPRON DEPOT (4-MONTH)............371LUPRON DEPOT (6-MONTH)............372LUPRON DEPOT-PED (1-MONTH)...373LUPRON DEPOT-PED (3-MONTH)...374LUTERA................................................375LYNPARZA ORAL CAPSULE............376LYNPARZA ORAL TABLET.............. 377MACUGEN........................................... 378MAKENA..............................................379marlissa ................................................... 380MAVYRET............................................ 381MEKINIST............................................ 382MENOPUR............................................383meperidine hcl oral ...................................384METADATE CD................................... 386METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG........... 387METHADONE HCL INTENSOL........ 390methadone hcl oral ...................................388METHADOSE ORAL CONCENTRATE 10 MG/ML...............392METHADOSE SUGAR-FREE.............394methamphetamine hcl .............................. 396METHYLIN ORAL SOLUTION 10 MG/5ML................................................ 397METHYLIN ORAL SOLUTION 5 MG/5ML................................................ 398METHYLIN ORAL TABLET CHEWABLE..........................................399methylphenidate hcl er (cd) ..................... 409methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg ................ 410methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg ................ 411methylphenidate hcl er (la) oral capsule extended release 24 hour 40 mg ................ 410methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg ................ 412methylphenidate hcl er oral tablet extended release 10 mg ........................................... 403
Index
methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg .....................404methylphenidate hcl er oral tablet extended release 20 mg ........................................... 405methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg ........ 407methylphenidate hcl er oral tablet extended release 24 hour 36 mg ...............................408methylphenidate hcl er oral tablet extended release 36 mg ........................................... 406methylphenidate hcl oral solution 10 mg/5ml .................................................... 400methylphenidate hcl oral solution 5 mg/5ml................................................................ 401methylphenidate hcl oral tablet .................402methylphenidate hcl oral tablet chewable ..402MICROGESTIN 1.5/30..........................413MICROGESTIN 1/20............................ 414MICROGESTIN FE 1.5/30....................415MICROGESTIN FE 1/20.......................416MIRCERA INJECTION SOLUTION PREFILLED SYRINGE....................... 417MONOCLATE-P................................... 418MONONINE......................................... 419MONOVISC...........................................420MORPHABOND ER.............................421morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml .................425morphine sulfate er beads ......................... 429morphine sulfate er oral capsule extended release 24 hour .........................................427morphine sulfate er oral tablet extended release ..................................................... 427morphine sulfate oral ............................... 423morphine sulfate rectal .............................423MS CONTIN ORAL TABLET EXTENDED RELEASE....................... 431MYALEPT.............................................433MYDAYIS............................................. 434MYORISAN.......................................... 435MYORISAN.......................................... 436MYOZYME........................................... 437NAGLAZYME...................................... 438
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Index
NATPARA.............................................439NECON 0.5/35 (28)................................ 440NECON 1/35 (28)................................... 441NECON 10/11 (28)................................. 442NERLYNX............................................ 443NEULASTA DELIVERY KIT SUBCUTANEOUS PREFILLED SYRINGE KIT...................................... 445NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 444NEUMEGA........................................... 446NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML........... 447NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE....................... 447NEXAVAR............................................ 448NINLARO............................................. 449NITYR................................................... 450NORCO..................................................451NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML............................................. 453NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS SOLUTION 30 MG/3ML................................................ 454norgestrel-ethinyl estradiol .......................455NORTHERA ORAL CAPSULE 100 MG......................................................... 456NORTHERA ORAL CAPSULE 200 MG, 300 MG.......................................... 457NORTREL 0.5/35 (28)........................... 458NORTREL 1/35 (21).............................. 459NORTREL 1/35 (28).............................. 460novarel intramuscular solution reconstituted 10000 unit ........................... 461NOVOEIGHT........................................ 462NOVOSEVEN RT..................................463NPLATE................................................ 464NUCALA...............................................465NUCYNTA............................................466NUCYNTA ER......................................468NUPLAZID........................................... 470
Index
NUTROPIN AQ.................................... 472NUTROPIN AQ NUSPIN 10................473NUTROPIN AQ NUSPIN 20................474NUTROPIN AQ NUSPIN 5..................475NUTROPIN AQ PEN............................476NUTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG......................................................... 471NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT......................................................477NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT................. 477OCALIVA ORAL TABLET 5 MG........478OCTAGAM........................................... 479octreotide acetate .....................................480ODOMZO.............................................. 481OFEV..................................................... 482OLYSIO................................................. 483OMNITROPE........................................ 484OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT............. 487OPANA ORAL...................................... 485OPSUMIT.............................................. 489ORENCIA CLICKJECT....................... 492ORENCIA INTRAVENOUS................ 490ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML........................................... 491ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML................. 490ORENITRAM....................................... 493ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG..............................................494ORFADIN ORAL SUSPENSION........ 494ORKAMBI.............................................495ORSYTHIA........................................... 496ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 497OTEZLA ORAL TABLET.................... 498
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Index
OTEZLA ORAL TABLET THERAPY PACK..................................................... 498OVIDREL.............................................. 499OXAYDO...............................................500oxycodone hcl er oral tablet er 12 hour abuse-deterrent ........................................ 504oxycodone hcl er oral tablet er 12 hour abuse-deterrent ........................................ 506oxycodone hcl oral capsule .......................502oxycodone hcl oral concentrate 100 mg/5ml................................................................ 502oxycodone hcl oral concentrate 20 mg/ml . 502oxycodone hcl oral solution ...................... 502oxycodone hcl oral tablet ......................... 502oxycodone-acetaminophen oral solution ... 508oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg................................................................ 508oxycodone-aspirin oral tablet 4.8355-325 mg ........................................................... 510oxycodone-ibuprofen ................................512OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT............. 514oxymorphone hcl ......................................516oxymorphone hcl er ..................................518OZURDEX INTRAOCULAR.............. 520PEGASYS.............................................. 521PEGASYS PROCLICK......................... 522PEGINTRON........................................ 523PEG-INTRON....................................... 524PEG-INTRON REDIPEN.....................525PEG-INTRON REDIPEN PAK 4......... 526pentazocine-naloxone hcl ......................... 527PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG......................................................... 529phenoxybenzamine hcl oral ...................... 531PHILITH................................................532PLEGRIDY........................................... 533PLEGRIDY STARTER PACK.............534POMALYST.......................................... 535PORTIA-28............................................ 536PRALUENT.......................................... 537
Index
pregnyl .................................................... 538PRIMLEV.............................................. 539PRIVIGEN.............................................541PROCENTRA........................................542PROCRIT.............................................. 543PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG..............544PROCYSBI ORAL CAPSULE DELAYED RELEASE 75 MG..............545PROFILNINE SD..................................546PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG......................................................... 547PROLIA................................................. 548PROMACTA......................................... 549PRUDOXIN.......................................... 550PULMOZYME...................................... 551PURIXAN..............................................552QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 40 MG....................................... 553QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 30 MG.................................................... 554QUILLIVANT XR.................................555RAVICTI............................................... 556REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR........... 558REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR................................ 559REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE....................... 557REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE....................... 560RECLIPSEN.......................................... 561RECOMBINATE...................................562REMICADE.......................................... 563REMODULIN....................................... 564RENFLEXIS..........................................565REPATHA............................................. 566REPATHA PUSHTRONEX SYSTEM.567
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Index
REPATHA SURECLICK......................568REPREXAIN ORAL TABLET 10-200 MG, 5-200 MG....................................... 569REPRONEX.......................................... 571REVATIO INTRAVENOUS.................572REVATIO ORAL SUSPENSION RECONSTITUTED...............................573REVATIO ORAL TABLET.................. 574REVLIMID............................................575RIASTAP............................................... 576RITALIN............................................... 577RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 60 MG................. 578RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 30 MG......................................................... 579RIXUBIS................................................580rosuvastatin calcium .................................581ROXICET ORAL SOLUTION............. 582ROXICODONE ORAL TABLET......... 584RUBRACA............................................ 586RUCONEST.......................................... 587RYDAPT................................................588SABRIL..................................................589SAIZEN..................................................590SAIZEN CLICK.EASY......................... 591SAMSCA................................................592SANDOSTATIN....................................593SANDOSTATIN LAR DEPOT.............594SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG........................................... 595SIGNIFOR.............................................596SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED..... 597sildenafil citrate oral ................................ 598SILIQ......................................................599SIMPONI ARIA.................................... 601SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR........... 600SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 600
Index
SIRTURO.............................................. 602sodium phenylbutyrate oral powder 3 gm/tsp ......................................................603SOLARAZE........................................... 604SOLIRIS.................................................605SOMATULINE DEPOT........................606SOMAVERT.......................................... 607SOVALDI.............................................. 608SPRYCEL.............................................. 609SRONYX............................................... 610STELARA INTRAVENOUS................ 611STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE.. 611STIOLTO RESPIMAT.......................... 612STIVARGA............................................613STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG, 60 MG.... 614STRATTERA ORAL CAPSULE 100 MG, 80 MG............................................615STRENSIQ.............................................616SUBOXONE SUBLINGUAL FILM 12-3 MG...................................................... 617SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG.......................618SUBOXONE SUBLINGUAL TABLET SUBLINGUAL...................................... 619SUBSYS................................................. 620SUPARTZ INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 622SUPPRELIN LA....................................623SUTENT................................................ 624SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 4 X 200 MCG, 4 X 300 MCG, 600 MCG.............................. 625SYNAGIS...............................................626SYNALGOS-DC....................................627SYNAREL............................................. 629SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 630SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE.. 631SYPRINE...............................................632tacrolimus external .................................. 633
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783
Index
TAFINLAR........................................... 634TAGRISSO............................................ 635TALTZ................................................... 636TARCEVA............................................. 637TARGRETIN ORAL............................ 638TASIGNA.............................................. 639TECFIDERA ORAL............................. 640TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG............ 641TECFIDERA ORAL CAPSULE DELAYED RELEASE 240 MG............ 642TECHNIVIE.......................................... 643TEMODAR ORAL................................644temozolomide ...........................................645tetrabenazine ........................................... 646TEV-TROPIN........................................ 647THALOMID.......................................... 648THIOLA.................................................649TILIA FE............................................... 650TRACLEER...........................................651tramadol hcl er .........................................654tramadol hcl er (biphasic) ........................656tramadol hcl oral ..................................... 652tramadol-acetaminophen ..........................658TRELSTAR........................................... 660TRELSTAR MIXJECT......................... 661TREMFYA............................................ 662TRETTEN..............................................663TREZIX ORAL CAPSULE 320.5-30-16 MG......................................................... 664TRI-LEGEST FE................................... 666TRIVORA (28).......................................667TRUVADA............................................ 668TYKERB................................................669TYLENOL WITH CODEINE #3..........670TYLENOL WITH CODEINE #4..........672TYMLOS............................................... 674TYSABRI...............................................675TYVASO................................................ 676TYVASO REFILL................................. 677TYVASO STARTER............................. 678ULTRACET...........................................679ULTRAM.............................................. 681
Index
ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 300 MG.......................................... 683UPTRAVI.............................................. 685VALCHLOR.......................................... 686VALCYTE............................................. 687valganciclovir hcl ..................................... 688VANTAS................................................689VECAMYL............................................ 690VELETRI............................................... 691VELIVET............................................... 692VELTASSA............................................ 693VEMLIDY............................................. 695VENCLEXTA........................................696VENCLEXTA STARTING PACK....... 697VENTAVIS............................................ 698VERDROCET........................................699VICODIN ES ORAL TABLET 7.5-300 MG......................................................... 703VICODIN HP ORAL TABLET 10-300 MG......................................................... 705VICODIN ORAL TABLET 5-300 MG..701VICOPROFEN...................................... 707VICTRELIS........................................... 709VIEKIRA PAK...................................... 710VIEKIRA XR........................................ 711VIMIZIM............................................... 712VISUDYNE........................................... 713VOLTAREN TRANSDERMAL...........714VONVENDI...........................................715VOSEVI..................................................716VOTRIENT............................................717VPRIV.................................................... 718VYVANSE............................................. 719VYVANSE............................................. 720WERA.................................................... 721WILATE INTRAVENOUS KIT........... 722WILATE INTRAVENOUS SOLUTION RECONSTITUTED 1000-1000 UNIT, 500-500 UNIT.........................................722XALKORI............................................. 723XARTEMIS XR.....................................724XELJANZ.............................................. 726
2018 Aetna Premier Plus Plan01/01/2018
784
Index
XELJANZ XR....................................... 727XELODA............................................... 728XENAZINE ORAL TABLET 12.5 MG 729XENAZINE ORAL TABLET 25 MG... 730XEOMIN................................................731XERMELO............................................ 732XGEVA..................................................733XODOL..................................................734XOLAIR.................................................736XTAMPZA ER...................................... 737XTANDI................................................ 739XURIDEN............................................. 740XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT......................................................741XYNTHA SOLOFUSE..........................742XYREM................................................. 743ZAMICET..............................................744ZARXIO.................................................746ZAVESCA..............................................747ZEJULA.................................................748ZELBORAF...........................................749ZEMAIRA............................................. 750ZENATANE.......................................... 751ZENCHENT.......................................... 752ZENZEDI.............................................. 753ZEPATIER.............................................754ZINBRYTA........................................... 755ZOHYDRO ER......................................756ZOHYDRO ER......................................758ZOLADEX.............................................760ZOLINZA.............................................. 761ZOMACTON......................................... 762ZONALON............................................ 763ZORBTIVE............................................ 764ZOVIA 1/35E (28)...................................765ZOVIA 1/50E (28)...................................766ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG......................................................... 767ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG................. 768
Index
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 2.9-0.71 MG................. 769ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6-2.1 MG...................770ZYDELIG.............................................. 771ZYKADIA............................................. 772ZYTIGA ORAL TABLET 250 MG.......773ZYTIGA ORAL TABLET 500 MG.......774
2018 Aetna Premier Plus Plan01/01/2018
785