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151 Farmington AvenueHartford, CT 06156March, 2015Upcoming changes to your prescription drugcoverageHere are important details about upcoming plan changes.The enclosed chart shows changes that start on July 1, 2015. We’re adding some brand-name andgeneric drugs to our pharmacy plan and specialty drug list and removing others. We’re changing yourplan’s precertification, quantity limits and step-therapy programs.If these updates affect the prescription drugs you take, the amount you pay for these drugs may alsochange. Talk to your doctor about your treatment options. In the end, you and your doctor make thedecisions about your drug therapy.Drug coverage reviewsSome drugs must meet certain coverage requirements. We review them to make sure they meetthese requirements.The following reviews and coverages may be part of your plan:PrecertificationWe have to approve some drugs before we can cover them.Quantity limitsSome drugs have quantity limits to make sure that you get a safeamount of your drug.Step therapyYour doctor may need to prescribe certain drugs first before we’llcover another drug.Check to see if you can lower your costsYou can find your pharmacy plan and specialty drug list at www.aetna.com/formulary. Use thelist to lower your out-of-pockets costs by choosing a preferred alternative drug to treat yourconditions. If your doctor agrees that a preferred alternative will work for you, ask to have yourprescription changed.Know what to expect when using brand-name drugsIf you choose a non-preferred brand, you can fill that prescription but you may pay more. Wecall drugs “preferred” because your copay may be lower than the copay for non-preferreddrugs. You typically pay lower out-of-pocket costs when you use preferred drugs.You and your doctor can decide if using the brand-name drug is best for you. If so, your doctorwill write “DAW” on your prescription. This stands for “dispense as written.” In this case, yourpharmacist will fill your prescription with the brand-name drug. You’ll pay the difference incost between the brand name and generic, plus your copay.We’re here to helpIf you have questions, visit your Aetna Navigator secure member website. Just visitwww.aetna.com. Or, call us at the toll-free number on your member ID card. 2015 Aetna Inc.05.32.657.1 (1/15)070115 FC subscriber AETET-0051-15
EnclosureThis document is available in other languages:Please note that if your prescription drug benefits plan changes, the information in this letter may no longer apply.A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor forcovered prescriptions except as required by law to be otherwise. Some drugs on the Aetna Pharmacy Plan and SpecialtyDrug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That meansit may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug.Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., 151Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products.Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitationsand conditions of coverage. Plan features and availability may vary by location and are subject to change.Aetna receives rebates from drug manufacturers that may be taken into account in determining the Aetna PharmacyPlan and Specialty Drug List. Rebates do not reduce the amount a member pays the pharmacy for coveredprescriptions. Information is subject to change. For more information about Aetna plans, refer to www.aetna.com.In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal EmployeeHealth Benefit Plan members) who are receiving coverage for medications that are added or removed from theAetna Pharmacy Plan and Specialty Drug List will continue to have those medications covered at the same benefitlevel until their plan’s renewal date. In Texas, precertification approval is known as “preservice utilization review.” Itis not "verification" as defined by Texas law.In accordance with state law, fully insured commercial California HMO members (except Federal Employee HealthBenefit Plan members) who are receiving coverage for medications that are to receive precertification or steptherapy reviews will continue to have those medications covered, for as long as the treating physician continuesprescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treatingthe enrollee's medical condition.In accordance with state law, fully insured commercial Connecticut PPO members (except Federal Employee HealthBenefit Plan members) who are receiving coverage for medications that are to receive precertification or steptherapy reviews will continue to have those medications covered for as long as the treating physician prescribesthem, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing inthis section shall preclude the prescribing provider from prescribing another drug covered by the plan that ismedically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drugsubstitutions.The drugs on the Aetna Pharmacy Plan and Specialty Drug List including formulary exclusions, precertification, quantitylimit and step-therapy reviews are subject to change. The quantity limits and step-therapy drug coverage reviewprograms are not available in all service areas. For example, step-therapy programs do not apply to fully insuredmembers in Indiana. Step therapy does not apply to fully insured members in New Jersey. However, these programsare available to self-funded plans.This material is for information only. It contains only a partial, general description of plan benefits or programs anddoes not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations andconditions of coverage. Plan features and availability may vary by location and are subject to change. Providers areindependent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna doesnot provide care or guarantee access to health services. For more information about Aetna plans, refer towww.aetna.com. 2015 Aetna Inc.05.32.657.1 (2/15)070115 FC subscriber AETET-0051-15
Aetna Commercial Formulary for Fully Insured MembersJuly 1, 2015 UpdatesKey:PA Prior Authorization only applies if your plan includes Precertification. If this is required,your doctor must contact us to request approval of coverage.* Generic drug is availableNPB Non-Preferred Brand-name drugNPL National Precertification List. This means prior authorization is required for all plans. Your doctor must contactus to request approval for coverage.PB Preferred Brand-name drugQL Quantity Limits only apply if your plan includes Precertification. If you go past the quantity,ST your doctor must contact us to request approval of coverage.Step Therapy only applies if your plan incudes Step Therapy. This means that you must try one or moreSDL prerequisite drug(s) before we cover a step-therapy drug.Specialty Drug List. This means the drug is on the Specialty Drug List. If your plan includes the Specialty Drug list,you may pay higher out of pocket costs and may be required to obtain these products at an AetnaSpecialty Pharmacy Network Provider like Aetna Specialty Pharmacy. Specialty products are not available atAetna Rx Home Delivery. For questions, call 1-866-237-3320.UPPERCASE Brand-name medication; lower case italics generic medicationCurrentTierTier as of7/1/15ACCOLATE33ACTONEL TAB 35MG23alendronateACTONEL TAB 150MG33alendronateACTONEL TAB 5/30MG23alendronatealendronate TAB 5/10/40MG(generic FOSAMAX)111111112233323311Drug Namealprazolam TAB(generic XANAX)alprazolam ER/XR TAB(generic XANAX)alprazolam ODT(generic XANAX)ATELVIAAZILECTBANZEL TABBONIVA TABcalcitonin(generic MIACALCIN)Formulary Alternative(s)Notesremoved QLadded STadded STadded QLadded STadded QLadded age limitationadded QLadded age limitationalendronateadded age limitationadded STadded QLadded QLremoved STadded QL
Aetna Commercial Formulary for Fully Insured MembersJuly 1, 2015 UpdatesDrug Namecarb/levo ENTACAP(generic STALEVO)CARBATROLcarbidopa(generic LODOSYN)CELEBREXcelecoxib(generic CELEBREX)CELLCEPT CAP, TAB SUSPCELONTINchlordiazepoxide(generic LIBRIUM)clopidogrel(generic PLAVIX)clorazepate dipot (genericTRANXENE)COLCRYScolesevelam(generic WELCHOL)DEPAKOTEDIASTATdiazepam GEL(generic DIASTAT)DILANTIN 30/50/100MGDILANTIN-125EFFIENTetidron disd(generic DIDRONEL)EVISTAflorometholone susp(generic FML LIQUIFORM)FML FORTE LIQUIFILM SUSPFML LIQUIFILM SUSPFORTICALFOSAMAX 5/10MG TABFUSILEVgabapentin SOL(generic NEURONTIN)CurrentTierTier as estyramine, colestipol333211332223BRILINTA, PB11Formulary Alternative(s)Notescarb/levo, entacaponearbidopa/levodopadiclofenac, naproxen,meloxicamdiclofenac, naproxen,meloxicammycophenolateadded STremoved PAadded STAdded to SDLadded age limitationadded QLadded age limitationadded QLremoved STadded QLadded QLadded PAremoved STremoved QLremoved QLremoved QLadded QLadded QLadded PAadded to NPLSDLadded QL
Aetna Commercial Formulary for Fully Insured MembersJuly 1, 2015 UpdatesDrug NameGABITRILibandronate TAB(generic BONIVA)CurrentTierTier as of7/1/153313Formulary Alternative(s)added QLremoved PAalendronateadded to NPLSDLILARISINDOCIN SUSKEPPRA TAB/SOLPB33PB23KEPPRA XR33LAMICTAL ODT KIT33lamotrigineLAMICTAL ODT TAB33lamotrigineLAMICTAL XR TABlamotrigine ER(generic LAMICTAL)lamotrigine orallydisintegrating tabletlevetiracetam ER(generic 3LOVAZAMAXIDEX SUSPmefenam acid(generic PONSTEL)MIACALCIN INJMIACALCIN SPRMIRAPEX333313332333MIRAPEX ER33MITIGARE e cap, tab, suspNEUPRONIASPANNIRAVAMnitroglycerin aer(generic NITROMIST)Notesremoved STadded QLremoved STadded STadded STadded QLadded QLadded STadded QLadded STadded QLadded QLremoved PAremoved STremoved STremoved QLdiclofenac, naproxen,meloxicampramipexoleniacin erisosorbide dinitrate,NITROLINGUAL*removed QLremoved PAadded QLremoved STadded QLremoved STadded QLadded to NPLSDLadded to SDLadded QLremoved STadded age limitation
Aetna Commercial Formulary for Fully Insured MembersJuly 1, 2015 UpdatesCurrentTierTier as of7/1/15Formulary Alternative(s)NotesNPBNPBHARVONI, SOVALDIadded to STSDLOMECLAMOXomega-3-acid(generic LOVAZA)23PREVPAC*11OMNARIS33OMNIPRED SUSPONFI TABoxazepam(generic SERAX)333311OXTELLAR XR33oxcarbazepinePENNSAID 2%PHENYTEK3332VOLTAREN GELPLAVIX33PONSTELPRED FORTE SUSPPRED MILD SUSPprednisolone acetate SUSP(generic PRED FORTE)PREDNISOLONE SODIUM UIP IQUE33SINGULAIRSKELIDTEGRETOL333332Drug NameOLYSIOrisedronate TAB 150MG(generic ACTONEL)risedronate TAB 5/30/35MG(generic ACTONEL)ropinirole ER(generic REQUIP XL)SABRILadded QLfluticasone, flunisolide ,NASONEXadded STremoved QLadded QLadded age limitationadded QLadded STadded STadded QLremoved STremoved QLremoved QLremoved QLPREVPAC*removed QLremoved QLremoved PAremoved STremoved STremoved STadded QLremoved STadded STadded QLadded QLadded QLremoved PAremoved STremoved STadded QL
Aetna Commercial Formulary for Fully Insured MembersJuly 1, 2015 UpdatesCurrentTierTier as cin er, fenofibrateVEXOL SUSPVIMOVOXANAX323333esomeprazole, naproxenXANAX XR33zafirlukast11NPB3NPB3ZORVOLEX33ZYFLOZYFLO CR3333Drug Nametiagabine(generic GABITRIL)TOPAMAXTOPAMAX SPRtopiramate cap(generic TOPAMAX)TRANXENE TULORICVALCYTE TAB, SOLvalganciclovir tab, solZAVESCAZELAPARFormulary Alternative(s)Notesadded QLremoved PAremoved STadded QLremoved STvalgancicloviradded QLadded age limitationadded to QLadded to SDLadded to SDLadded QLadded STremoved QLadded age limitationadded QLadded age limitationremoved QLadded to PAremoved from NPLSDLadded QLadded QLremoved PAremoved QLremoved QL
cost between the brand name and generic, plus your copay. We’re here to help . If you have questions, visit your Aetna Navigator secure member website. Just visit www.aetna.com. Or, call us at the
