Pharmacy

Formulary drug list

The Formulary is a list of drugs chosen by Aetna Better Health of New Jersey and a team of doctors and pharmacists. Drugs on this list are generally covered under the plan as long as they are medically necessary. Members must fill their prescriptions at an Aetna Better Health of New Jersey network pharmacy, and follow other plan rules.

Please review the Formulary for any restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health of New Jersey patient.

You can download the Formulary or you can also use the searchable formulary. You can also view a list of this month's formulary updates.

September 2017

Additions

  • MESALAMINE TAB 1.2GM
  • MOXIFLOXACIN SOL 0.5% ophthalmic   drops

August 2017

Additions

  • ISENTRESS HD TAB 600MG    
  • OLOPATADINE HCL 0.2% OPTHALMIC SOLUTION
  • ERGOCAL     CAP 2500UNIT  
  • MELPHALAN   TAB 2MG
  • OLOPATADINE 0.1% Ophthalmic Solution
  • Ribasphere 200mg tablets
  • Ribasphere 200mg capsules
  • Spinosad Susp 0.9%
  • Corlanor
  • Pulmozyme
  • Kitabis, 300/5ml, Neb
  • Basaglar
  • Letairis tablet
  • Tracleer tablets, all strengths
  • Epoprostenol Sodium powder for injection

Deletions

  • Cetirizine HCl Chew Tab 5 MG
  • Cetirizine HCl Chew Tab 10 MG
  • Potassium Chloride Oral Soln 10%
  • Potassium Chloride Oral Soln 20%
  • Potassium Chloride Packet 20 mEq
  • Potassium Chloride Packet 25 mEq
  • Ribavirin Cap 200 MG
  • Ribavirin Tab 200 MG
  • Ribavirin Tab 400 MG
  • Ribavirin Tab 600 MG
  • Ribavirin Pack
  • Chlorpromazine HCl Tab 10 MG
  • Chlorpromazine HCl Tab 25 MG
  • Chlorpromazine HCl Tab 50 MG
  • Chlorpromazine HCl Tab 100 MG
  • Chlorpromazine HCl Tab 200 MG
  • Fluphenazine HCl Tab 1 MG
  • Fluphenazine HCl Tab 2.5 MG
  • Fluphenazine HCl Tab 5 MG
  • Fluphenazine HCl Tab 10 MG
  • Benzyl Alcohol Lotion 5% (Ulefsia)
  • Econazole Nitrate Cream 1%
  • Acyclovir Ointment 5%
  • Azelastine HCl Nasal Spray 0.15%
  • Doxycycline Hyclate   DR tablets
  • Doxycycline Mono 75mg Capsules
  • E.E.S 400mg
  • ERY-TAB TAB - all strengths
  • ERYTHROCIN TAB 250MG
  • ERYTHROMYCIN BASE TABLETS
  • Erythromycin w/ Delayed Release Cap
  • Fluoxetine 10mg tablet
  • Niacin ER tablet
  • Nitroglycerin Solution (Pump/Spray)
  • Tetracycline capsules, all strengths
  • Metronidazole 1% gel
  • Lantus Vials
  • Insulin Glargine Pens
  • Levemir 100 U/ml vial
  • Levemir 100 U/ml Flextouch Pen
  • Alcohol pad/swabs- only certain NDCs not all

July 2017

Additions

  • Atomoxetine (all strengths)

Deletions

  • Strattera (all strengths)
  • Somatropin for Subcutane
  • Somatropin for inj 10 mg

JUNE 2017

No Changes

MAY 2017

Additions

  • Hydroxyprogesterone: Generic 17-HP
  • Methylphenidate LA 60mg  : Generic Ritalin LA 60mg
  • OTC Differin
  • OTC Calcium Acetate

APRIL 2017

Additions

  • Ivermectin, Pin-X and Reeses (pyrantel pamoate)-
  • Selzentry 25mg and 75mg tablets-
  • Linzess 72 mcg capsule-
  • Levalbuterol Tartrate Inhal Aerosol –with ST

MARCH 2017

Additions

  • GUANFACINE   TAB 1MG-QLL
  • GUANFACINE   TAB 1MG-QLL
  • DEXTROAMPHETAMINE TAB 5MG-QLL
  • DEXTROAMPHETAMINE TAB 10MG-QLL
  • DEXTROAMPHETAMINE CAP 5MG ER-QLL
  • DEXTROAMPHETAMINE CAP 10MG ER-QLL
  • DEXTROAMPHETAMINE CAP 15MG ER-QLL
  • METHYLPHENIDATE TAB 10MG ER-QLL
  • METHYLPHENIDATE TAB 20MG ER-QLL
  • METHYLPHENIDATE CAP 20MG ER-QLL
  • METHYLPHENIDATE CAP 30MG ER-QLL
  • METHYLPHENIDATE CAP 40MG ER-QLL
  • TRIUMEQ-PA
  • LOPINIVIR/RITONIVIR SOLUTION-PA
  • EZITIMIBE-ST
  • EPINEPHRINE

Changes

  • AMPHETAMINE/DEXTROAMPHETAMINE TAB 5MG-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE TAB 7.5MG-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE TAB 10MG-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE TAB 12.5MG-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE TAB 15MG-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE TAB 20MG-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE TAB 30MG-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE CAP 5MG ER-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE CAP 10MG ER-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE CAP 15MG ER-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE CAP 20MG ER-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE CAP 25MG ER-QLL
  • AMPHETAMINE/DEXTROAMPHETAMINE CAP 30MG ER-QLL
  • GUANFACINE   TAB 1MG ER-QLL
  • GUANFACINE   TAB 2MG ER-QLL
  • GUANFACINE   TAB 3MG ER-QLL
  • GUANFACINE   TAB 4MG ER-QLL
  • STRATTERA 10MG-QLL
  • STRATTERA 18MG-QLL
  • STRATTERA 25MG-QLL
  • STRATTERA 40MG-QLL
  • STRATTERA 60MG-QLL
  • STRATTERA 80MG-QLL
  • STRATTERA 100MG-QLL
  • DEXMETHYLPHENIDATE TAB 2.5MG-QLL
  • DEXMETHYLPHENIDATE TAB 5MG-QLL
  • DEXMETHYLPHENIDATE TAB 10MG-QLL
  • METHYLPHENIDATE CAP 10MG-QLL
  • METHYLPHENIDATE CAP 20MG-QLL
  • METHYLPHENIDATE CAP 30MG-QLL
  • METHYLPHENIDATE CAP 40MG-QLL
  • METHYLPHENIDATE CAP 50MG-QLL
  • METHYLPHENIDATE CAP 60MG-QLL
  • METHYLPHENIDATE TAB 5MG-QLL
  • METHYLPHENIDATE TAB 10MG-QLL
  • METHYLPHENIDATE TAB 20MG-QLL
  • METHYLPHENIDATE TAB 18MG ER-QLL
  • METHYLPHENIDATE TAB 27MG ER-QLL
  • METHYLPHENIDATE TAB 36MG ER-QLL
  • METHYLPHENIDATE TAB 54MG ER-QLL
  • METHYLPHENIDATE SOL 5MG/5ML-QLL
  • METHYLPHENIDATE SOL 10MG/5ML-QLL
  • MODAFINIL TAB 100MG-QLL
  • MODAFINIL TAB 200 MG-QLL

FEBRUARY 2017

Additions

  • Savella
  • Chlorzoxazone
  • Orphenadrine
  • Imbruvica
  • Gilenya
  • Tecfidera
  • Auryxia
  • Apriso
  • Viokace
  • Zarxio
  • Olopatadine 0.1% soln
  • Mesalamine 800mg DR
  • Zepatier
  • Epogen

Deletions

  • Lidocaine 3% lotion
  • Doxycycline hyclate IR
  • Doxycycline Monohydrate 150mg Capsule
  • Minocycline tablets
  • Nystatin/Triamcinolone combination cream/ointment
  • Cipro HC
  • Ciprodex
  • Naproxen Sodium 550mg
  • Fluoxetine 20mg and 60mg Tablets
  • Venlafaxine ER tablet
  • Buspirone 30mg
  • Mupirocin cream

Weight loss products will no longer be covered

  • Diltiazem ER/LA Tablets
  • Clomipramine
  • Imipramine CAPS*
  • Trazodone 300mg tab
  • Metaxalone 400mg and 800mg*
  • Carisoprodol 250mg
  • Tizanidine
  • Clindamycin Aerosol
  • Clindamycin/Benzoyl Peroxide combo
  • Erythromycin/Benzoyl Peroxide combo*
  • Sulfacetamide/Sulfur*
  • Claravis
  • TRETINOIN EM CRE 0.05%*
  • SALICYLIC AC GEL 6% *
  • BP WASH LIQ 7%*
  • BPO CREAMY KIT 4% WASH*
  • BPO GEL 4*
  • Copaxone 20mg*
  • Farxiga*
  • Renvela/Renagel*
  • Delzicol
  • Dipentum
  • Pentasa
  • Amitiza
  • Pancreaze
  • Advair *
  • Symbicort*
  • Spiriva
  • Tudorza*

JANUARY 2017

Additions

  • Stribild
  • Truvada
  • Isentress

Changes

Prior Authorizations to provide a diagnosis will NOW be required for all FIRST fill HIV medications.

DECEMBER 2016

Additions

  • NILUTAMIDE TAB 150MG
  • NITROGLYCERN SUB 0.3MG
  • NITROGLYCERN SUB 0.4MG
  • NITROGLYCERI SUB 0.6MG
  • ERYTHROM ETH SUS 200/5ML
  • Deletions
  • NILANDRON TAB 150MG
  • NITROSTAT SUB 0.3MG
  • NITROSTAT SUB 0.4MG
  • NITROSTAT SUB 0.6MG
  • E.E.S. GRAN SUS 200/5ML
  • ERYPED SUS 200/5ML

October 2016

Additions

  • Carbamazepine ER tablets, OLL
  • Rosuvastatin calcium- PA, QLL
  • Entresto- PA, QLL
  • Anoro Elipta-     QLL,
  • Stiolto- ST, QLL
  • Linzess- Step QLL
  • Movantik- PA; QLL
  • Rabeprazole- QLL 
  • Omeprazole QLL
  • Lansoprazole QLL 
  • Genvoya- QLL
  • Tivicay- QLL
  • Descovy- QLL
  • Cabometyx- PA; QLL
  • Ciprofloxacin Otic-
  • Prevacid Solu-tabs –PA,GF current utilizers
  • Pantoprazol-remove st  will GF current utilizers

Deletions

  • Crestor

September 2016

Additions

  • Nicotrol Spray with PA
  • Add PA to Chantix with GF current utilizers
  • Add PA to Nicotrol Inhaler with GF current utilizersAugust 2016

Changes

  • Avandia modify ST to require BOTH metformin and ploglitazone and GF all current utilizers
  • Multaq- PA requirements modified 

August 2016

Additions

  • Alogliptin(Nessina) with QLL of #30/30 days
  • Alogliptin/metformin(Kazano) with QLL of #30/30
  • Alogliptin/pioglitazone(Oseni) with QLL of #30/30
  • Flonase (allergy and Children’s Allergy) with a QLL #1/30 days
  • Rhinocort (allergy and Children’s Allergy)with a QLL #1/30 days
  • Nasacort (allergy and Children’s)with a QLL #1/30days
  • flunisolide RX with ST through 2 OTC products
  • fluticasone RX with ST through 2 OTC products
  • rosuvastatin

July 2016

Additions

  • Testosterone Cyprinate for injection with PA
  • Testosterone ethinate for injection with PA
  • Zepatier with PA
  • Carbamazepine ER tablets , 100mg with age limits of 6 years and older
  • Humalog Pens with age limit to process for School age children
  • Novolog Pens with age limit to process for School age children
  • Minocycline IR capsules
  • Paricalcitrol with Step Therapy via Calcitriol
  • Rozerem with Step Therapy via zolipem and zaleplon
  • Azopt with Step Therapy via dorzolamide
  • Acyclovir  Ointment with ADD Step Therapy  via acyclovir oral
  • Lantus Pens
  • Levemir Pens
  • Methotrexate 25mg/ml
  • Suprax 200mg chewable tablets
  • Cefixime 100mg/5ml and 200mg/5ml suspension
  • Abreva
  • Naratriptan
  • Lamotrigine IR
  • Lamotrigine ER
  • Calcipotriene Cream

 Deletions

  • Januvia with NO Grandfathering
  • Janumet with NO Grandfathering
  • Janumet XR with NO Grandfathering
  • Patanol with Grandfathering
  • generic Patanol ( olopatadine) with Grandfathering
  • Byetta with NO Grandfathering
  • Harvoni
  • Sovaldi
  • Sensipar with Grandfathering current utilizers
  • Temazepam, 7.5mg and 22.5mg with Grandfathering current utilizers
  • Minocycline ER tablets with Grandfathering current utilizers
  • Paroxetine ER with Grandfathering current utilizers
  • Nevanac with Grandfathering current utilizers
  • Azasan with Grandfathering current utilizers
  • Lumigam  0.01% ophthalmic with Grandfathering current utilizers
  • Bimaroprost 0.03% ophthalmic with Grandfathering current utilizers
  • Calcipotriene Oint with Grandfathering current utilizers

Changes

  • Adding Step Therapy to Azelastine with Grandfathering current utilizers
  • Adding Step Therapy through Metformin to Tanzeum
  • Adding Age Limits to Tramadol ( not to process without a PA < 16 y/o with no Gf)
  • Adding Quantity Limits for Gabapentin 800mg  except  for certain disease states
  • Increasing Quantity Limits on Chambers and Spacers to 2/per year
  • Adding Quantity Limits to Nexavar
  • Adding Quantity Limits to Viread

May 2016

Additions

  • Naratriptan with QLL
  • Abreva OTC ointment
  • IV Pamidronate
  • IV Ibandronate
  • Tanzeum with Step TX
  • Thalidomide with PA
  • Revlimid with PA
  • Sutent with PA and QLL
  • Votrient with PA and QLL
  • Tykerb with PA and QLL
  • Entecavir with QLL
  • Lamivudine HBV (100mg tablets and solution) with QLL
  • Testosterone ethinate for injection with PA
  • Testosterone topical* (Androgel and Testim) with PA
  • Capecitabine with PA and QLL
  • imatinib  tablets with PA and QLL

April 2016

Additions

  • Page 43                Olopatadine (generic Patanol)

Changes

  • Page 35                Fragmin change QLL to reflect 42 syringes for 21 days
  • Page 35                Enoxaparin change QLL to reflect 42 syringes for 21 days
  • Page 35                ondaparinux change QLL to reflect 42 syringes for 21 days

Removals

  • Page 29                Norditropin
  • Page 29                Norditropin Nordiflex
  • Page 29                Armour Thyroid with GF
  • Page  37               Generess FE  with GF
  • Page  20               Lanoxin tablets with GF
  • Page 19                Methylin tablets with GF
  • Page 35                Nephrocaps with GF
  • Page  6                 Suprax suspension

March 2016

Additions

  • Page 6        Harvoni with PA
  • Page 6        Sovaldi with PA
  • Page 22      Candesartan
  • Page 22      Candesartan/HCTZ
  • Page 22      Irbesartan/HCTZ
  • Page 22      Losartan/HCTZ
  • Page 22      Valsartan/HCTZ
  • Page 12      Imatinib tablets (generic Gleevec)

Removals

  • Page 12      Brand Gleevec

February 2016

Additions

  • Page 44 adding Flovent Diskus

January 2016 (effective 1/4/16)

Additions

  • Page 32. Glatiramer Acetate (Glatropa) – Adding with PA
  • Page 28. Tradjenta- Adding with ST
  • Page 28. Jentadueto- Adding with ST
  • Page 32. Aubagio- Adding with PA
  • Page 28. Invokana- Adding with ST
  • Page 28. Invokamet- Adding with ST
  • Page 28. Farxiga-Adding with ST
  • Page 28. Trulicity-Adding with ST
  • Page 29. Omnitrope Vials –Adding with PA
  • Page 48. Hyalgan-Adding with PA
  • Page 48. Modafanil –Adding with PA with QL #30/30
  • Page 48. Gel-One-Adding with PA
  • Page 46. Tolterodine IR (Detrol IR)- Adding with ST
  • Fondaparainux (Arixtra)- Adding with PA (21 day supply available without authorization)
  • Octreotide (Sandostatin)- Adding with PA
  • Tasgina-Adding with PA
  • Page 25. Topical Tacrolimus-Adding with ST
  • Page 35. Amicar
  • Rectiv
  • Page 43. Epinastine-Adding with ST

PA/Step Therapy Changes (effective 1/4/16)

  • Page 44 Budesonide Respules (Pulmicort Respules)-Adding Age edit Page 30. Pantoprazole (Protonix) – Adding Step Therapy
  • Page 44 EpiPen , EpiPen Jr.- Adding Step Therapy

Deletions (effective 1/4/16)

  • Page 29 Nutropin
  • Page   7 Macrodantin 25mg
  • Page 35 Aminocaproic Acid
  • Page 30 RX Lansoprazole
  • Page 30 RX Omeprazole
  • Page 32 Avonex
  • Page 32 Betaseron

 October 2015

  • P. 44    Remove Adrenaclick
  • P. 44    Add Epinephrine 0.3mg/0.3ml and 0.15mg/0.15ml pens
  • P. 11    Add Prior Authorization to Daraprim

September 2015

  • P. 45      Add Incruse to Formulary
  • P. 44      Add Arcapta to Formulary
  • P.44       Add Striverdi Respimat to Formulary
  • P.24       Add Crestor to Formulary
  • P.45       Add Adrenclick generic to Formulary
  • P.30       Add  OTC Esomeprazole (generic OTC Nexium) to Formulary with QLL of 60/30 days
  • P.30       Add OTC Lansoprazole ( generic OTC Prevacid) to Formulary with QLL of 60/30 days
  • P.12       Add Bexarotene Tablets (generic Targretin) to Formulary
  • P.12       Remove Targretin Tablets from Formulary
  • P.13       Add PA to Morphine Sulfate ER- adding smart edit to bypass PA process for diagnosis of Cancer and Sickle Cell
  • P.13       Add PA to Oxymorphone ER
  • P.13       Add PA  to  Fentanyl Patches- adding smart edit to bypass PA process for diagnosis of Cancer and Sickle Cell
  • P.13       Add STEP to Oxycontin with smart edit to bypass Pa process for diagnosis for Cancer and Sickle Cell

 August 2015

  • P.19: Add PA for all members <6 y/o and > 18Y/o
    • amphetamine/dextroamphetamine (Adderall,Adderall XR)
    • dextroamphetamine
    • dexmethylphenidate (Focalin)
    • guanfacine ER tablets (Intuniv)
    • METHYLIN CHEWABLE
    • methylphenidate, er tabs, solution (Ritalin, Methylin)
    • methylphenidate er, sr (Ritalin LA, SR)
    • methylphenidate er 18 mg, 27 mg, 36mg, & 54mg)
    • methylphenidate hcl (Ritalin)
    • methylphenidate CD (METADATE CD)
    • STRATTERA  
  • P.9 : Atovaquone (Mepron) removed PA and changed to STEP requiring generic Bactrim with in the last 130 days unless contraindicated
  • P.12: Added PA to Nexavar
  • P.11: Added PA to Gleevec
  • P.12: Added PA to Tarceva 
  • P.35: Added  to Formulary without a PA for first 45 days of therapy                        
    • Eliquis
    • Pradaxa
    • Xarelto

July 2015

  • P.12: Remove Teslac Tablets
  • P.15: Remove Mephobarbital
  • P.45: Remove OTC Sudagest cold and allergy tablets
  • P.45: Remove OTC q tap cold and allergy elixir
  • P.42: Remove Dipiverfrin HCL
  • P.39: Remove Natalcare glosstabs
  • P.32: Remove Viokase 8,16
  • P.41: Remove Femhrt
  • P.41 Add norethindrone/ethinyl estradiol (generic Femhrt)

June 2015

  • P.13: Add Terbinafine to formulary with QL 84 tablets /year

May 2015

  • P. 6 : Add QL Lidocaine Patches of 3 patches /day
  • P.13: Add Oxymorphone ER to formulary with STEP and QL 60 tablets /30 days
  • P.13: Add Oxymophone  IR   to formulary with STEP
  • P.17: Add QL of Ondansetron 4mg and 8mg tablets  to 21 tablets/ 30 days
  • P.17: Add QL of Ondansetron Solution to 50ml/30 days
  • P.46: Add QL of Glucose Test Strips to 150 strips/ 30 days

April 2015

  • P. 44:  Add Spiriva Respimat to formulary with STEP and QL 1 box/30 days
  • P. 22:  Remove STEP for valsartan and valsartan HCT
  • P. 22:  Add amlodipine/valsartan (generic Exforge) to formulary with QL 30/30 days
  • P. 22: Add amlodipine/valsartan/HCTZ (generic Exforge HCT) to formulary with QL 30/30 days

If your members take medicine for an ongoing health condition, they can have their medicines mailed to their home. Aetna Better Health of New Jersey works with a company called CVS Caremark to provide this service, at no cost to our members.

If they choose this option, their medicine comes right to their door. Here are some other features of home delivery:

  • Pharmacists check each order for safety.
  • Members can order refills by mail, by phone, online, or they can sign up for automatic refills.
  • Members can talk with pharmacists by phone at any time 24 hours a day, 7 days a week.

Members can sign up for this service in one of three ways. They can:

  • Call CVS Caremark toll free at 1-855-271-6603 Monday to Friday between 8 a.m. and 8 p.m., Eastern Time. CVS representatives will help your member sign up for home delivery. As their provider, CVS will call you to get the prescription.
  • Go to CVS Caremark member sign in. Then, log in and sign up for ReadyFill. Again, CVS Caremark will contact you, the provider, to get a prescription.
  • Request a prescription from you for a 90 day supply with up to one year of refills. The member will then complete the mail- order services form and mail it to CVS Caremark along with the prescription.

CVS Caremark Mail Order Service Form English / Spanish 

Aetna Better Health of New Jersey also covers certain over-the-counter drugs if they are on our list. Some of these may have rules about whether they will be covered. If the rules for that drug are met, we will cover the drug. Like other drugs, over-the-counter drugs must have a prescription for them to be covered at no cost to our members.

To quickly find a prior authorization form, click CTRL F on your keyboard and type in the form name.                                                                        

Acamprosate                                                   

Actemra                                                           

Actimmune                                                                                                               

Afinitor                                                           

Ampyra                                                           

Anticoagulant injectable agents                      

Antidepressants non-formulary                       

Aranesp                                                           

ARBs non-formulary       

Atypical Antipsychotics                               

Atypical Antipsychotics long acting injections         

Botulinum Toxins                                            

Brand name drug                                            

Buprenorphine, Naloxone                               

Cabometyx                                                      

Cambia                                                            

Capecitabine                                                    

Caprelsa                                                           

Celecoxib                                                        

Chantix                                                            

Cialis                                                               

Cimizia  

CNS Stimulants

CNS Stimulants Non-Formulary                                                          

Colony Stimulating Factors                            

Cometriq                             

Corlanor                            

Cosentyx                                                         

Crestor                                                             

Daliresp                                                           

Daraprim                                                         

Diabetic Strips and Machines                         

Direct Renin Inhibitors                                   

Dose Optimization                                          

DPP-4 Inhibitors                                             

Duavee                                                            

Egrifta                                                             

Eligard-Trelstar-Vantas                                   

Enbrel                                                              

Entresto                                                           

Entyvio                                                            

Epogen-Procrit                                                

Esbriet                                                             

Esbriet-Ofef                                                    

Forteo                                                              

GLP-1 Agonists                                              

Growth Hormone                                            

Hemophilia                                                      

Hepatitis C                                                      

Hetlioz

HIV Duplicative Use

HIV Inappropriate-Interaction                                                            

Humira     

HP Acthar                                                       

Hyaluronic Acid                                              

Hyaluronic Acid Derivatives                          

IL-5 Antagonists                                             

Ilaris                                                                

Imatinib                                                                                                   

Increlex   

Inhaled Antibiotics for CF                                                        

Inlyta                                                               

Insulin pens                                                     

Intravaginal Progesterone Products                

Intron A Alferon N                                         

Jakafi                                                               

Juxtapid-Kynamro                                          

Kalydeco                                                         

Kineret                                                            

Leukine                                                           

Leuprolide Acetate                                         

Lidocaine Patch                                              

Lupron Depot                                                  

Lyrica                                                              

CVS Caremark Specialty Pharmacy is a pharmacy that offers medications for a variety of conditions, such as cancer, hemophilia, immune deficiency, multiple sclerosis and rheumatoid arthritis. These specialty medications are not often available at local pharmacies. Specialty medications require service authorization before they can be filled and delivered. Providers can call 1-855-232-3596 to request prior authorization, or complete the applicable prior authorization form and fax to 1-855-296-0323.

Specialty medications can be delivered to the provider’s office, member’s home, or other location as requested.

The step therapy program requires certain first-line drugs, such as generic drugs or formulary brand drugs, to be prescribed prior to approval of specific, second-line drugs. Drugs with step therapy guidelines are identified on the formulary as “STEP.”

Certain drugs on the formulary have quantity limits and are identified on the formulary with the letters “QLL” The QLLs are established based on FDA-approved dosing levels and nationally established, recognized guidelines pertaining to the treatment and management of the condition being treated.

To request an override for the step therapy and/or quantity limit, please fax the correct pharmacy Prior Authorization request form to 1-855-296-0323. You can include any supporting medical records that will assist with the review of the request.