Acyclovir Ointment. Aetna Better Health Virginia Medallion/FAMIS 3.0. Products Affected. acyclovir ointment 5 % external Details.

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1 Aetna Better Health Virginia Medallion/FAMIS 3.0 Acyclovir Ointment acyclovir ointment 5 % external Use of oral acyclovir in the previous 130 days 1

2 Adcirca tadalafil (pah) tablet 20 mg oral Use of sildenafil in previous 30 days 2

3 Albenza albendazole tablet 200 mg oral Use ivermectin or pyrantel in previous 3 days 3

4 Albuterol Nebulizers albuterol sulfate nebulization solution 0.63 mg/3ml inhalation albuterol sulfate nebulization solution 1.25 mg/3ml inhalation Use of albuterol nebulizers 0.083% in past 14 days 4

5 Auryxia AURYXIA TABLET 1 GM 210 MG(FE) ORAL Use of calcium acetate for at least 30 days in the previous 130 days 5

6 Avandia AVANDIA TABLET 2 MG ORAL AVANDIA TABLET 4 MG ORAL Use of metformin and pioglitazone for at least 90 days in the previous 130 days. 6

7 Azopt AZOPT SUSPENSION 1 % OPHTHALMIC Use of dorzolamide or dorzolamide/timolol in the previous 130 days 7

8 Celecoxib celecoxib capsule 100 mg oral celecoxib capsule 200 mg oral celecoxib capsule 400 mg oral celecoxib capsule 50 mg oral Use of at least 2 of the following agents in the previous 130 days: formulary NSAIDs. In addition, patients with a claim for a PPI, H2 Receptor Antagonist, prednisone, or warfarin in the previous 130 days are not subject to the step requirement. 8

9 Combigan COMBIGAN SOLUTION % OPHTHALMIC Use of 1 of the following for at least 15 days in the previous 130 days: Brimonidine Ophth Solution, Timolol Maleate Ophth Solution 9

10 DPP4 JANUMET TABLET MG ORAL JANUMET TABLET MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUVIA TABLET 100 MG ORAL JANUVIA TABLET 25 MG ORAL JANUVIA TABLET 50 MG ORAL JARDIANCE TABLET 10 MG ORAL JARDIANCE TABLET 25 MG ORAL Use of metformin or a formulary metformin containing product for at least 60 days in the previous 130 days. 10

11 Ezetimibe ezetimibe tablet 10 mg oral Use of at least 2 of the following: atorvastatin or simvastatin in the previous 130 days. 11

12 GLP1 Agonists TRULICITY SOLUTION PEN- INJECTOR 0.75 MG/0.5ML SUBCUTANEOUS TRULICITY SOLUTION PEN- INJECTOR 1.5 MG/0.5ML SUBCUTANEOUS Use of metformin for at least 90 days duration in the previous 130 days. 12

13 Isotretinoin Products myorisan capsule 10 mg oral myorisan capsule 20 mg oral myorisan capsule 30 mg oral myorisan capsule 40 mg oral zenatane capsule 10 mg oral zenatane capsule 20 mg oral zenatane capsule 30 mg oral zenatane capsule 40 mg oral Use of minocycline or doxycycline in the previous 130 days. 13

14 Levalbuterol HFA levalbuterol tartrate aerosol 45 mcg/act inhalation Use of Ventolin HFA in the previous 130 days 14

15 Lyrica LYRICA CAPSULE 100 MG ORAL LYRICA CAPSULE 150 MG ORAL LYRICA CAPSULE 200 MG ORAL LYRICA CAPSULE 225 MG ORAL LYRICA CAPSULE 25 MG ORAL LYRICA CAPSULE 300 MG ORAL LYRICA CAPSULE 50 MG ORAL LYRICA CAPSULE 75 MG ORAL LYRICA SOLUTION 20 MG/ML ORAL Use of duloxetine and gabapentin in the previous 130 days. Lyrica will be covered for the use of postherpetic neuralgia, spinal cord injury, or partial seizures. 15

16 Malathion malathion lotion 0.5 % external spinosad suspension 0.9 % external Use of permethrin or pyrethrin in the previous day 16

17 Naproxen Suspension naproxen suspension 125 mg/5ml oral Use of ibuprofen suspension for 15 days within the previous 130 days 17

18 Nasal Steroids flunisolide solution 25 mcg/act (0.025%) nasal fluticasone propionate suspension 50 mcg/act nasal mometasone furoate suspension 50 mcg/act Use of 2 of the following agents in the previous 130 days: Flonase OTC, Rhinocort OTC, or Nasacort OTC 18

19 Omega 3 Acid Ethyl Esters omega-3-acid ethyl esters capsule 1 gm oral Use of OTC Fish Oil for at least 60 days in the previous 130 days. 19

20 Ophthalmic antihistamines azelastine hcl solution 0.05 % ophthalmic epinastine hcl solution 0.05 % ophthalmic Use of ketotifen ophthalmic in the previous 90 days. 20

21 Paricalcitol paricalcitol capsule 1 mcg oral paricalcitol capsule 2 mcg oral paricalcitol capsule 4 mcg oral Use of calcitriol in the previous 130 days 21

22 Pen Needles BD AUTOSHIELD 29G X 5MM BD AUTOSHIELD 29G X 8MM BD AUTOSHIELD DUO 30G X 5 MM BD ECLIPSE SYRINGE 25G X 5/8" 1 ML BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.3 ML BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML BD INSULIN SYR ULTRAFINE II 31G X 5/16" 1 ML BD INSULIN SYRINGE 29G X 1/2" 1 ML BD INSULIN SYRINGE 30G X 1/2" 0.5 ML BD INSULIN SYRINGE 31G X 5/16" 0.3 ML BD INSULIN SYRINGE HALF-UNIT 31G X 5/16" 0.3 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.5 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 ML BD INSULIN SYRINGE ULTRAFINE 30G X 1/2" 0.3 ML BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.3 ML BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 ML BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 1 ML BD PEN NEEDLE MINI U/F 31G X 5 MM BD PEN NEEDLE NANO U/F 32G X 4 MM BD PEN NEEDLE SHORT U/F 31G X 8 MM BD PEN NEEDLE ULTRAFINE 29G X 12.7MM BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML BD SAFETY-LOK INSULIN SYRINGE 29G X 1/2" 1 ML BD ULTRA-FINE MICRO PEN NEEDLE 32G X 6 MM Requires use of a pen device 22

23 Ribasphere ribasphere capsule 200 mg oral ribasphere tablet 200 mg oral Paid claim for a direct-acting antiviral for Hepatitis C or Pegasys in the previous 5 days to assure that patients are taking ribavirin with other appropriate hepatitis C medications and not as monotherapy. 23

24 Rosuvastatin atorvastatin calcium tablet 10 mg oral atorvastatin calcium tablet 20 mg oral atorvastatin calcium tablet 40 mg oral atorvastatin calcium tablet 80 mg oral Use of atorvastatin for 60 days in the previous 130 days 24

25 Rozerem ROZEREM TABLET 8 MG ORAL Use of BOTH zolpidem and zaleplon in the previous 130 days 25

26 Savella SAVELLA TABLET 100 MG ORAL SAVELLA TABLET 12.5 MG ORAL SAVELLA TABLET 25 MG ORAL SAVELLA TABLET 50 MG ORAL SAVELLA TITRATION PACK 12.5 & 25 & 50 MG ORAL Use of duloxetine in the previous 130 days. 26

27 Sevelamer Carbonate sevelamer carbonate tablet 800 mg oral Use of calcium acetate or ferric citrate (Auryxia) for at least 30 days in the previous 130 days. 27

28 SGLT2 Inhibitors INVOKAMET TABLET MG ORAL INVOKAMET TABLET MG ORAL INVOKAMET TABLET MG ORAL INVOKAMET TABLET MG ORAL INVOKANA TABLET 100 MG ORAL INVOKANA TABLET 300 MG ORAL JARDIANCE TABLET 10 MG ORAL JARDIANCE TABLET 25 MG ORAL SYNJARDY TABLET MG ORAL SYNJARDY TABLET MG ORAL SYNJARDY TABLET MG ORAL SYNJARDY TABLET MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL Use of metformin for at least 90 days in the previous 130 days. 28

29 Simvastatin 80mg simvastatin tablet 80 mg oral Use of simvastatin 80 mg in the previous 180 days. 29

30 Stiolto Respimat STIOLTO RESPIMAT AEROSOL SOLUTION MCG/ACT INHALATION Use of ONE of the following in the previous 130 days: Incruse Ellipta or Anoro Ellipta 30

31 Timolol Gel timolol maleate gel forming solution 0.25 % ophthalmic timolol maleate gel forming solution 0.5 % ophthalmic Use of Timolol Solution for 15 days in the previous 130 days 31

32 Topical Calcineurin Inhibitors ELIDEL CREAM 1 % EXTERNAL tacrolimus ointment 0.03 % external tacrolimus ointment 0.1 % external Use of 2 different topical corticosteroids in the previous 130 days 32

33 Topical Retinoids adapalene cream 0.1 % external adapalene gel 0.1 % external tretinoin cream % external tretinoin cream 0.05 % external tretinoin cream 0.1 % external tretinoin gel 0.01 % external tretinoin gel % external Use of OTC Differin 0.1% Gel in the previous 130 days 33

34 Topical Steroids clobetasol propionate cream 0.05 % external clobetasol propionate gel 0.05 % external clobetasol propionate ointment 0.05 % external Use of 1 of the following for at least 10 days within the past 60 days: AUG Betamethasone Dip Gel 0.05%, AUG Betamethasone Dip Lotion 0.05%, AUG Betamethasone Dip Ointment 0.05%, Halobetasol 0.05% Cream, Halobetasol 0.05% Ointment 34

35 Uloric ULORIC TABLET 40 MG ORAL ULORIC TABLET 80 MG ORAL Use of allopurinol in the previous 130 days 35

36 Zafirlukast zafirlukast tablet 10 mg oral zafirlukast tablet 20 mg oral Use of montelukast in the previous 130 days 36

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