Acyclovir Ointment. Aetna Better Health Kentucky. Products Affected. acyclovir ointment 5 % external Details. Criteria

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1 Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health Kentucky Use of oral acyclovir or Abreva in the previous 130 days 1

2 Adcirca ADCIRCA TABLET 20 MG ORAL Use of sildenafil in previous 30 days 2

3 Albenza ALBENZA TABLET 200 MG ORAL Requires use of pyrantel or ivermectin for at least 3 days. When ST therapy requirements are not met, the criteria in the PA guideline must be met for approval. 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 the previous 14 days. Patients 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 Azopt AZOPT SUSPENSION 1 % OPHTHALMIC Use of dorzolamide or dorzolamide/timolol in the previous 130 days 6

7 Celecoxib celecoxib capsule 100 mg oral celecoxib capsule 200 mg oral celecoxib capsule 400 mg oral celecoxib capsule 50 mg oral Requires use of 3 different NSAIDs. When ST therapy requirements are not met, the criteria in the PA guideline must be met for approval. 7

8 Clonidine Patch clonidine hcl patch weekly 0.1 mg/24hr transdermal clonidine hcl patch weekly 0.2 mg/24hr transdermal clonidine hcl patch weekly 0.3 mg/24hr Use of clonidine tablets for at least 30 days within the past 130 days. 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 Diabetes INVOKAMET TABLET MG ORAL INVOKAMET TABLET MG ORAL INVOKAMET TABLET MG ORAL INVOKAMET TABLET MG ORAL INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL INVOKANA TABLET 100 MG ORAL INVOKANA TABLET 300 MG ORAL TANZEUM PEN-INJECTOR 30 MG SUBCUTANEOUS TANZEUM PEN-INJECTOR 50 MG SUBCUTANEOUS TRULICITY SOLUTION PEN- INJECTOR 0.75 MG/0.5ML SUBCUTANEOUS TRULICITY SOLUTION PEN- INJECTOR 1.5 MG/0.5ML SUBCUTANEOUS Use of a formulary metformin containing product for at least 90 days in the previous 130 days 10

11 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 Use of metformin or combination metformin products for at least 60 days in the previous 130 days 11

12 Ezetimibe ezetimibe tablet 10 mg oral Use of BOTH simvastatin and atorvastatin in the previous 130 days 12

13 Fentanyl Lozenge fentanyl citrate lozenge on a handle 1200 mcg buccal fentanyl citrate lozenge on a handle 1600 mcg buccal fentanyl citrate lozenge on a handle 200 mcg buccal fentanyl citrate lozenge on a handle 400 mcg buccal fentanyl citrate lozenge on a handle 600 mcg buccal fentanyl citrate lozenge on a handle 800 mcg buccal Use of 2 of the following; hydromorphone, morphine sulfate IR, oxycodone IR for at least 30 days each in the previous 180 days 13

14 Griseofulvin griseofulvin microsize suspension 125 mg/5ml oral griseofulvin microsize tablet 500 mg oral griseofulvin ultramicrosize tablet 125 mg oral griseofulvin ultramicrosize tablet 250 mg oral Use of any one: terbinafine tablets, ketoconazole tablets, fluconazole tablets/suspension, itraconazole capsules/solution for at least 7 days within the last 60 days. 14

15 Isotretinoin 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 doxycycline or minocycline for at least 30 days in the previous 130 days 15

16 Levalbuterol HFA levalbuterol tartrate aerosol 45 mcg/act inhalation Use of Ventolin HFA 16

17 Lice/Scabicides malathion lotion 0.5 % external spinosad suspension 0.9 % external Use of permethrin or pyrethrin in the previous day 17

18 Naproxen Suspension naproxen suspension 125 mg/5ml oral Use of ibuprofen suspension for 15 days within the previous 130 days 18

19 Nasal Steroids mometasone furoate suspension 50 mcg/act nasal Use of 2 of the following agents in the previous 130 days: Flonase OTC, Rhinocort OTC, or Nasacort OTC 19

20 Olopatadine Ophthalmic Solution olopatadine hcl solution 0.1 % ophthalmic olopatadine hcl solution 0.2 % ophthalmic Use of ketotifen ophthalmic solution in the previous 15 days 20

21 Omega 3 omega-3-acid ethyl esters capsule 1 gm oral Use of OTC Fish Oil for at least 60 days in the previous 130 days. 21

22 Ophthalmic antihistamines azelastine hcl solution 0.05 % ophthalmic Use of ketotifen ophthalmic in the previous 130 days 22

23 Paricalcitol paricalcitol capsule 1 mcg oral paricalcitol capsule 2 mcg oral paricalcitol capsule 4 mcg oral Use of calcitriol in the previous 130 days 23

24 Ribasphere REBETOL SOLUTION 40 MG/ML ORAL 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. 24

25 Rosiglitazone AVANDIA TABLET 2 MG ORAL AVANDIA TABLET 4 MG ORAL Use of both metformin and pioglitazone in the previous 130 days 25

26 Rosuvastatin rosuvastatin calcium tablet 10 mg oral rosuvastatin calcium tablet 20 mg oral rosuvastatin calcium tablet 40 mg oral rosuvastatin calcium tablet 5 mg oral Use of atorvastatin for 60 days in the previous 130 days 26

27 Rozerem ROZEREM TABLET 8 MG ORAL Use of zolpidem AND zaleplon in the previous 130 days 27

28 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 for at least 60 days in the previous 130 days 28

29 Sevelamer sevelamer carbonate tablet 800 mg oral Use of calcium acetate or ferric citrate (Auryxia) for at least 30 days in the previous 130 days. 29

30 SGLT2 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 or combination metformin products for at least 60 days in the previous 130 days 30

31 Stiolto STIOLTO RESPIMAT AEROSOL SOLUTION MCG/ACT INHALATION Use of ONE of the following: Incruse Ellipta or Anoro Ellipta in the previous 130 days 31

32 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 32

33 Tolterodine ER tolterodine tartrate er capsule extended release 24 hour 2 mg oral tolterodine tartrate er capsule extended release 24 hour 4 mg oral Use of oxybutynin, tolterodine IR, trospium IR, or trospium ER for at least 30 days in the previous 130 days. 33

34 Tolterodine IR tolterodine tartrate tablet 1 mg oral tolterodine tartrate tablet 2 mg oral Use of any one of the following: Oxybutynin IR/ER, Tolterodine ER, Trospium IR/ER for at least 30 days within the previous 130 days. 34

35 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 35

36 Topical Retinoids adapalene cream 0.1 % external adapalene gel 0.1 % external avita cream % external avita gel % 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 for at least 30 days in the previous 130 days 36

37 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 37

38 Trospium ER trospium chloride er capsule extended release 24 hour 60 mg oral Use of any one of the following: Oxybutynin IR/ER, Trospium IR, Tolterodine IR/ER for at least 30 days within the previous 130 days. 38

39 Trospium IR trospium chloride tablet 20 mg oral Use of any one of the following: Oxybutynin IR/ER, Trospium ER, Tolterodine IR/ER for at least 30 days within the previous 130 days. 39

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

41 Zafirlukast zafirlukast tablet 10 mg oral zafirlukast tablet 20 mg oral Use of montelukast for at least 30 days in the previous 130 days 41

42 42

Acyclovir Ointment. Aetna Better Health New Jersey. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health New Jersey. Products Affected. acyclovir ointment 5 % external Details. Criteria Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health New Jersey Use of oral acyclovir or Abreva in the previous 130 days 1 Adcirca tadalafil (pah) tablet 20 mg oral Use of sildenafil

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