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.

Pharmacy PA Worksheet

Prescribing Opioids NJ




June 2020


  • Acne Medication Lotion (Benzoyl Peroxide) 10%
  • Alahist-D Tab 17.5-10mg
  • Atovaquone-Proguanil Tabs 62.5-25mg, 250mg-100mg (Quantity Level Limit)
  • Benzoyl Peroxide Gel 2.5%
  • Claravis Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)
  • Dovato Tab 50-300mg (Quantity Level Limit)
  • Gvoke Hypopen Inj (Quantity Level Limit)
  • Isotretinoin Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)
  • Jock Itch/Athlete’s Foot Spray (Tolnaftate) Aerosol Powder 1% (Quantity Level Limit)
  • Primaquine Tab 26.3mg (Quantity Level Limit)

Other Updates:

  • Clotrimazole Solution 1% (Removed Step Therapy)

May 2020


  • Dexamethasone Concentrate 1mg/ml
  • Dexamethasone Vials 20mg/5ml, 120mg/30ml, 10mg/ml
  • Solu-Cortef PF Vial 100mg, 250mg, 500mg, 1000mg
  • Pyrimethamine Tab 25mg (Generic) (Prior Authorization Required)


  • Daraprim Tab (Brand)

April 2020


  • Aripiprazole Tab 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Generic) (Age Limit, Quantity Level Limit) 
  • Omeprazole Tab Delayed Release Disintegrating 20 Mg (OTC) (Quantity Level Limit)
  • Orkambi Packet 100-125mg, 200-125mg (Prior Authorization Required)
  • Orkambi Tab 100-125mg, 200-125mg (Prior Authorization Required)
  • Tramadol Hcl Tab 100mg (Quantity Level Limit)


  • Diphenhydramine Hcl Liquid 6.25mg/ml
  • Polyethylene Glycol 3350 Oral Packet
  • Psyllium Powder Packet 100%
  • Sennosides Tab 17.2mg
  • Sodium Bicarbonate Powder

Other Updates:

  • Chloroquine Tabs 250mg, 500mg (Prior Authorization Required, Quantity Level Limit)
  • Hydroxychloroquine Tab 200mg (Prior Authorization Required, Quantity Level Limit)
  • Kaletra Tabs (Quantity Level Limit)
  • Lopinavir-Ritonavir Solution 400-100mg/5ml (Quantity Level Limit)

March 2020


  • Mesalamine Caps ER 0.375mg (Generic)
  • Nicotine Polacrilex Gum 2mg, 4mg (Age Limit)
  • OneTouch Verio Flex Kit (Quantity Level Limit)
  • Penicillamine Tab 250mg (Prior Authorization Required, Quantity Level Limit)      


  • Ambi 60pse/400gfn Tab
  • Apriso Caps ER 0.375gm (Brand)
  • Artificial Tears Solution 1% Ophthalmic
  • Diflunisal Powder
  • Fluoritab Solution 0.275 (0.125 F) Mg/Drop
  • Hydrocodone-Acetaminophen Solution 10-325 Mg/15ml
  • PR Natal 430 Pak
  • PR Natal 400, 430 Pak Ec
  • Prevident Solution Rinse
  • Regenecare Ha Gel 2%
  • Robitussin Syrup 7.5 Mg/5ml
  • Sodium Chloride Solution 0.9% Injection

February 2020


  • Bimatoprost Solution 0.03% (Step Therapy)
  • Ethinyl Estradiol – Etonogestrel Ring 0.015/0.12mg (Quantity Level Limit)
  • Travoprost Ophthalmic Solution


  • Alprazolam Concentrate 1mg/ml Solution
  • Chlorothiazide Tabs 250mg, 500mg
  • Demeclocycline Tabs 150mg, 300mg
  • Doxycycline Monohydrate Tab 150mg
  • First-Vanco Solution 25mg/ml, 50mg/ml
  • Methyclothiazide Tabs 5mg
  • Mirena
  • Nausea Liquid Relief (fructose-dextrose-phosphoric acid)
  • Nizatidine Solution 15mg/ml
  • Nuvaring (Brand)
  • Rabeprazole EC Caps 20mg
  • Ranitidine Caps 150mg, 300mg
  • Skyla
  • Travatan Z Ophthalmic Solution (Brand)

Other Updates:

  • Atropine Sulfate Ophthalmic Ointment 1% (Quantity Level Limit)
  • Atropine Sulfate Ophthalmic Solution 1% (Quantity Level Limit)
  • Buspirone Tabs 5mg, 7.5mg, 10mg 15mg (Age Limit)
  • Combigan Solution 0.2%/0.5% (Quantity Level Limit)
  • Diazepam Concentrate Solution 5mg/ml (Quantity Level Limit)
  • Diazepam Oral Solution (Quantity Level Limit)
  • Diazepam Tabs 2mg, 5mg, 10mg (Quantity Level Limit)
  • Divalproex Er Tabs 250mg, 500mg (Prior Authorization Required)
  • Dorzolamide Hcl-Timolol Maleate Ophthalmic Solution 22.3-6.8mg/ml (Step Therapy, Quantity Level Limit)
  • Doxycycline Monohydrate Suspension 25mg/ml (Age Limit)
  • Granisetron Tab 1mg (Step Therapy)
  • Hydroxyzine Hcl Syrup 10mg/5ml (Quantity Level Limit)
  • Hydroxyzine Hcl Tab 50mg (Quantity Level Limit)
  • Hydroxyzine Pamoate Caps 25mg, 50mg, 100mg (Quantity Level Limit)
  • Ibrandronate Inj 3mg/3ml (Quantity Level Limit)
  • Levofloxacin Solution 0.5% (Quantity Level Limit)
  • Lorazepam Conc 2mg/ml (Age Limit, Quantity Level Limit)
  • Memantine Hcl Tabs 5mg, 10mg (Quantity Level Limit)
  • Methazolamide Tabs 25mg, 50mg (Step Therapy)
  • Tazarotene Cream 0.1% (Step Therapy)
  • Timolol Gel Ophthalmic Solution 0.25%, 0.5% (Quantity Level Limit)
  • Trifluridine Ophthalmic Solution 1% (Quantity Level Limit)

January 2020


  • Ventolin HFA Inhaler (Brand)

December 2019


  • Bunavail Buccal Film 2.1-0.3mg, 4.2-0.7mg, 6.3-1mg (Brand) (Step Therapy Required, Quantity Level Limit)
  • Buprenorphine-Naloxone Film 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Generic) (Step Therapy Required, Quantity Level Limit)
  • Suboxone Film 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Brand) (Step Therapy Required, Quantity Level Limit)
  • Zubsolv Sublingual Tablets 0.7-0.18mg, 1.4-0.36mg, 2.9-0.71mg, 5.7-1.4mg, 8.6-2.1mg, 11.4-2.9mg (Brand) (Step Therapy Required, Quantity Level Limit)


  • PreNata Chewable Tab 29-1mg

November 2019


  • Aminocaproic Acid 0.25gm/ml Solution


  • Amicar 0.25gm/ml Solution (Brand)

October 2019


  • Nicadan Tab
  • Strovite Forte Tab

September 2019


  • Alinia Sus 100/5ml
  • Alinia Tabs 500mg
  • Ambrisentan Tabs 5mg, 10mg (Prior Authorization Required, Quantity Level Limit)
  • Bosentan Tabs 62.5mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Estradiol Bi-Weekly patches 0.025mg, 0.0375mg, 0.05mg, 0.075mg, 0.1mg (Quantity Level Limit)
  • Febuxostat Tabs 40mg, 80mg (Step Therapy Required)
  • First-Omperazole Sus 2mg/ml
  • Ramelteon Tab 8mg (Step Therapy Required, Quantity Level Limit)
  • Ribavirin Caps 200mg (Step Therapy Required)
  • Ribavirin Tabs 200mg (Step Therapy Required)
  • Sodium Chloride Neb 3%
  • Sucraid Sol 8500/ml


  • Letairis Tabs 5mg, 10mg (Brand)
  • Rozerem Tab 8mg (Brand)
  • Tracleer Tabs 62.5mg, 125mg (Brand)
  • Uloric Tabs 40mg, 80mg (Brand)

August 2019


  • Butenafine Hcl Cream 1%
  • Emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg (Prior Authorization Required, Quantity Level Limit)
  • Lidocaine patch 4% (Quantity Level Limit)
  • Pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml (Prior Authorization Required, Quantity Level Limit)


  • Butalbital-acetaminophen-caffeine cap 50-325-40 mg
  • Ciclopirox Gel 0.77%
  • Clotrimazole with Betamethasone Lotion 1-0.05%
  • Colestipol hcl granule packets 5 gm
  • Colestipol hcl granules 5 gm
  • Entecavir oral soln 0.05 mg/ml
  • Epinastine hcl ophth soln 0.05%
  • Erythromycin ethylsuccinate for susp 200 mg/5ml, 400 mg/5ml
  • Esterified estrogens tab 0.3mg, 0.625mg, 1.25mg, 2.5mg
  • Estradiol tab 1 mg(15)/estrad-norgestimate tab 1-0.09mg(15)
  • Etodolac tab er 24hr 400 mg,500 mg, 600 mg
  • Fluphenazine hcl elixir 2.5 mg/5ml
  • Fluphenazine hcl inj 2.5 mg/ml
  • Lindane shampoo 1%
  • Moexipril hcl tab 7.5mg, 15mg
  • Olopatadine HCl Ophth Solution 0.2%
  • Quinidine gluconate tab cr 324 mg

Other Updates:

  • Calcipotriene cream 0.005% (Added Prior Authorization, Changed Quantity Level Limit)
  • Calcipotriene soln 0.005% (50 mcg/ml) (Added Prior Authorization, Changed Quantity Level Limit)
  • Darunavir ethanolate tab 75mg, 150mg, 600mg, 800mg (BASE EQUIV) (Added Prior Authorization, Quantity Level Limit)
  • Delavirdine mesylate tab 200mg (Added Prior Authorization, Quantity Level Limit)
  • Didanosine delayed release capsule 125 mg (Changed Quantity Level Limit)
  • Elvitegrav-cobic-emtricitab-tenofovdf tab 150-150-200-300 mg (Added Prior Authorization Required, Changed Quantity Level Limit)
  • Etravirine tab 25mg, 100mg, 200mg (Added Prior Authorization, Quantity Level Limit)
  • Fosamprenavir calcium susp 50 mg/ml (BASE EQUIV) (Added Prior Authorization, Quantity Level Limit)
  • Fosamprenavir calcium tab 700 mg (BASE EQUIV) (Added Prior Authorization, Quantity Level Limit)
  • Indinavir sulfate cap 200mg, 400mg (Added Prior Authorization, Quantity Level Limit)
  • Lamivudine oral soln 10 mg/ml (Changed Quantity Level Limit)
  • Lidocaine cream 4% (Changed Quantity Level Limit)
  • Lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Added Prior Authorization, Quantity Level Limit)
  • Lopinavir-ritonavir tab 100-25 mg, 200-50 mg (Added Prior Authorization, Quantity Level Limit)
  • Nelfinavir mesylate tab 250mg, 625mg (added prior authorization, quantity level limit)
  • Nevirapine tab er 24hr 100 mg (changed quantity level limit)
  • Olanzapine orally disintegrating tab 5mg, 10mg, 15mg, 20mg (age limit)
  • Olanzapine tab 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg (age limit)
  • Quetiapine fumarate tab 25mg, 50mg, 100mg, 200mg, 300mg, 400mg (age limit)
  • Risperidone orally disintegrating tab 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg (age limit)
  • Risperidone soln 1 mg/ml (age limit)
  • Risperidone tab 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg (age limit)
  • Sertraline hcl oral concentrate for solution 20 mg/ml (Age Limit)
  • Tenofovir disoproxil fumarate oral powder 40 mg/gm (Added Prior Authorization Required, Changed Quantity Level Limit)
  • Thyroid tab 180mg (3 grain), 240mg (4 grain), 300mg (5 grain) (Changed Quantity Level Limit)

July 2019


  • Erlotinib Tab 150mg (Prior Authorization Required)
  • Kevzara Injection 150mg, 200mg (Prior Authorization Required, Quantity Level Limit)
  • Mesalamine DR Cap 400mg (Quantity Level Limit)


  • Tarceva Tab 150mg (brand)

June 2019


  • Docosanol Cream 10% (Quantity Level Limit)
  • Melatonin Tabs 1mg, 3mg, 5mg


  • Abreva Cream 10% (brand)

May 2019


  • Erythromycin Ethylsuccinate Suspension 400mg/5ml
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)
  • Sirolimus Solution 1mg/ml


  • Eryped Suspension (brand) 400mg/5ml
  • Rapamune Solution (brand) 1mg/ml

April 2019


  • Sublocade Injection
  • Vivitrol Injection (Quantity Level Limit)


  • Suboxone Films

Other Updates:

  • Buprenorphine Tabs (Removed Prior Authorization Required, Changed Quantity Level Limit)
  • Buprenorphine-Naloxone Tabs (Removed Prior Authorization Required, Changed Quantity Level Limit)

March 2019


  • Admelog Vial 300 units/3ml
  • Albuterol HFA Inhaler 90mcg –Generic Ventolin HFA (Quantity Level Limit)
  • Mesalamine Suppository 1000mg
  • Toremifene Tab 60mg


  • Canasa Suppository 1000mg
  • Fareston Tab 60mg
  • Norethindrone Acet-Ethinyl Estradiol-FE Tab 1mg-20mcg

Other Updates:

  • Butalbital Containing Products (Quantity Level Limit)
  • Smoking Cessation Products (Quantity Level Limit)

February 2019


  • Arnuity Ellipta Inhaler
  • Calcipotriene Ointment 0.005% (Quantity Level Limit)
  • Flebogamma IV Solution 5gm/50ml, 10gm/100ml, 20gm/200ml (Prior Authorization Required)
  • Immune Globulin IV Solution 1gm/10ml, 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml, 30gm/300ml, 40gm/400ml (Prior Authorization Required)
  • Leuprolide Acetate Kit 1mg/0.2ml (Prior Authorization Required)
  • Ozempic Injection (Step Therapy, Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-0.8mg (Quantity Level Limit)
  • Prenatal Vitamin with ferrous Fumarate-Folic Acid Tab 28-0.8mg (Quantity Level Limit)
  • Prenatal Vitamin with Minerals-Ferrous Fumarate-Folic Acid-DHA Pack 28-0.8-200mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 20-20-1.25mg (Quantity Level Limit)
  • Segluromet Tabs (Step Therapy, Quantity Level Limit)
  • Steglatro Tabs (Step Therapy, Quantity Level Limit)
  • Victoza Injection (Step Therapy, Quantity Level Limit)


  • Alprazolam Orally Disintegrating Tabs
  • Calcitriol Ointment
  • Cleocin Vaginal Ovule 100mg
  • Clorazepate Tabs
  • Condylox Gel 0.5%
  • Cortifoam Rectal Aerosol
  • Dihydroergotamine Products
  • Dulera Inhaler
  • Elidel Cream 1%
  • Ergotamine Products
  • Ergotamine/Caffeine Products
  • Flovent Diskus Inhalers
  • Histrelin Acetate Implant Kit 50mg
  • Humalog Vials/Pens
  • Humalog Vials/Pens
  • Invokamet Tabs
  • Invokana Tabs
  • Levonorgestrel/Ethinyl Estradiol Tab 0.1-0.02mg (84) & 0.01mg (7)
  • Lidocaine-Hydrocortisone Kit 20x7gm
  • Lidocaine-Hydrocortisone Kit 3-1%
  • Lo Loestrin FE Tabs
  • Meprobamate Tabs
  • Miconazole-3 Vaginal Suppository 200mg
  • Neonatal Plus Tab
  • Nitro-Bid Packets 2%
  • Novolog Vials/Pens
  • Penicillamine Cap 250mg
  • Plan B Tabs (Brand Only)
  • Prenatal Vitamin with Ferrous Fumarate-L Methylfolate-Folic Acid Tab 27-0.6-0.4mg
  • Prenatal Vitamin with Ferrous-Fumarate-Folic Acid Tab 65-1mg
  • Prenatal Vitamin with Iron Carbonyl-Folic Acid Tab 50-1.25mg
  • Prenatal Vitamin with Iron Carbonyl-Iron Aspart Glyc-Folic Acid-Omega 3 Cap 27-1mg
  • Prenatal Vitamin with Iron Polysaccharide Complex-Folic Acid Chewable Tab 29-1mg
  • Prenatal Vitamin with Minerals-Ferrous Fumarate-Folic Acid-DHA Pack 65-1mg & 250mg
  • Prenatal Vitamin with Minerals-Iron Polysaccharide Complex-Folic Acid-DHA Pack 29-1 & 250mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-DSS-Folic Acid-DHA Cap 27-1.25-300mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-DSS-Folic Acid-DHA Cap 27-1.25-300mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-L Methylfolate-Folic Acid-DHA Cap 27-0.6-0.4-300mg
  • Prenatal Vitamin without Vit A with Iron Carbonyl-Ferrous Gluconate-DSS-Folic Acid-DHA Pack 27-1mg & 250mg
  • Prenatal Vitamin without Vit A with Iron Carbonyl-Ferrous Gluconate-Docusate-Folic Acid Tab 27-1mg
  • Prenatal Vitamin without Vit A with Iron Carbonyl-Ferrous Gluconate-DSS-Folic Acid-DHA Pack 35-1mg & 300mg
  • Pulmicort Flexhalers
  • Qvar Inhaler
  • Relenza Diskhaler
  • Synjardy Tabs
  • Terconazole Vaginal Suppository 80mg
  • Thalomid Caps
  • Trelstar Mix Injection 3.75mg, 11.25mg, 22.5mg
  • Tricare Tab
  • Trulicity Injection

Other Updates:

  • Abilify Maintena Injections (Quantity Level Limit)
  • Acyclovir Suspension 200mg/5ml (Age Limit)
  • Alprazolam SR Tabs (Age Limit)
  • Alprazolam Tabs (Quantity Level Limit)
  • Aristada Injections (Quantity Level Limit)
  • Breo Ellipta Inhalers (Age Limit)
  • Calcipotriene Cream 0.005% (Quantity Level Limit)
  • Calcipotriene Solution 0.005% (Quantity Level Limit)
  • Carafate Suspension 1gm/10ml (Age Limit)
  • Chlordiazepoxide Caps (Quantity Level Limit)
  • Chlorpromazine Tabs (Quantity Level Limit)
  • Citalopram Solution 10mg/5ml (Age Limit)
  • Clozapine Tabs (Quantity Level Limit)
  • Codeine Containing Products (Age Limit)
  • Dicyclomine Solution 10mg/ml (Age Limit)
  • Escitalopram Solution 5mg/5ml (Age Limit)
  • Famotidine Suspension 40mg/5ml (Age Limit)
  • Flovent HFA Inhalers (Age Limit)
  • Fluphenazine Concentrate 5mg/ml (Quantity Level Limit)
  • Fluphenazine Decanoate Injection 25mg/ml (Quantity Level Limit)
  • Fluphenazine Elixir 2.5mg/5ml (Quantity Level Limit)
  • Fluphenazine Tabs (Quantity Level Limit)
  • Fluphenazine Vial 2.5mg/ml (Quantity Level Limit)
  • Haloperidol Concentrate 2mg/ml (Quantity Level Limit)
  • Haloperidol Decanoate Injections (Quantity Level Limit)
  • Haloperidol Lactate Injection 5mg/ml (Quantity Level Limit)
  • Haloperidol Tabs (Quantity Level Limit)
  • Hydrocodone Containing Products (Age Limit)
  • Hydroxyzine HCL Tabs (Quantity Level Limit)
  • Invega Sustena Injections (Quantity Level Limit)
  • Invega Trinza Injections (Quantity Level Limit)
  • Jardiance Tabs (Remove Step Therapy, Add Prior Authorization Required)
  • Lansoprazole Suspension 3mg/ml (Age Limit)
  • Lithium Carbonate Caps (Quantity Level Limit)
  • Lithium Carbonate ER Tabs 300mg, 450mg (Quantity Level Limit)
  • Lithium Carbonate Tab 300mg (Quantity Level Limit)
  • Lithium Solution 8meq/5ml (Quantity Level Limit)
  • Lorazepam Tabs (Quantity Level Limit)
  • Loxapine Caps (Quantity Level Limit)
  • Nitrofurantoin Suspension 25mg/5ml (Age Limit)
  • Nortriptyline Solution 10mg/5ml (Age Limit)
  • Olanzapine Tabs (Quantity Level Limit)
  • Omeprazole Suspension 2mg/ml (Age Limit)
  • Oseltamivir Cap 30mg (Quantity Level Limit, Age Limit)
  • Oseltamivir Caps 45mg, 75mg (Quantity Level Limit)
  • Oseltamivir Suspension 6mg/ml (Quantity Level Limit, Age Limit)
  • Oxazepam Caps (Quantity Level Limit)
  • Perphenazine Tabs (Quantity Level Limit)
  • Prednisone Solution 5mg/5ml (Age Limit)
  • Prochlorperazine Suppository 25mg (Quantity Level Limit)
  • Prochlorperazine Tabs (Quantity Level Limit)
  • Quetiapine Tabs (Quantity Level Limit)
  • Risperdal Consta Injections (Quantity Level Limit)
  • Risperidone Orally Disintegrating Tabs (Quantity Level Limit)
  • Risperidone Solution 1mg/ml (Quantity Level Limit)
  • Risperidone Tabs 3mg, 4mg (Quantity Level Limit)
  • Thioridazine Tabs (Quantity Level Limit)
  • Thiothixene Caps (Quantity Level Limit)
  • Tramadol Containing Products (Age Limit)
  • Trifluoperazine Tabs (Quantity Level Limit)
  • Ziprasidone Caps (Quantity Level Limit)

January 2019

No Changes

December 2018


  • Itraconazole Solution 10mg/ml
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)


  • Gleostine Caps 10mg, 40mg, 100mg
  • Sporanox Solution 10mg/ml
  • Trixaicin Cream 0.025%

November 2018


  • Albendazole Tab 200mg (Step Therapy Required)


  • Albenza Tab 200mg

October 2018


  • Loratadine Chewable Tab 5mg (Quantity Level Limit)
  • Prasugrel Tabs (Quantity Level Limit)
  • Retacrit Injection (Prior Authorization Required)
  • Tadalafil Tab 20mg (Step Therapy, Quantity Level Limit)
  • Tazarotene Cream 0.1% (Quantity Level Limit)
  • Tymlos Pen (Prior Authorization Required, Quantity Level Limit)
  • Valganciclovir Tab 450mg (Quantity Level Limit)


  • Adcirca Tab 20mg

Other Updates:

  • Ondansetron Tabs 4mg, 8mg (Quantity Level Limit)

September 2018


  • Humira Pen Kit CD/UC/HS Starter Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen PS/UV Starter Kit 80mg/0.8ml and 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Saline Nasal Spray 0.65%
  • Symtuza Tab (Prior Authorization Required, Quantity Level Limit)


  • Biotuss Liquid
  • BP Wash Liquid 2.5%
  • Brompheniramine Chewable Tab 12mg
  • Chlorhexidine Gluconate Solution 20%
  • Ergocal Cap 2500 Units
  • Fluoridex Daily Concentrate
  • Fluoroplex Cream 1%
  • Flura-Drops
  • Homatropine Ophthalmic Solution 5%
  • Mynatal Cap
  • Mynate 90 Plus Tab
  • Nature-Throid Tabs
  • Pseudoephedrine-Brompheniramine-Dextromethorphan Syrup 30-3-15mg/5ml
  • Pseudoephedrine-Dextromethorphan-Guaifenesin Syrup 30-15-150mg/5ml
  • Sodium Fluoride Tab 0.5mg, 1mg
  • Sodium Sulfate Wash Liquid 10%
  • Trimipramine Maleate Powder

August 2018


  • Diclofenac Gel 1% (Quantity Level Limit)
  • Omega 3 Ethyl Esters Caps (Quantity Level Limit, Step Therapy)
  • Sevelamer Tab 800mg (Quantity Level Limit, Step Therapy)
  • Tolterodine ER Caps 2mg, 4mg (Quantity Level Limit, Step Therapy)
  • Vemlidy Tab 25mg (Quantity Level Limit)
  • Verzenio Tabs 50mg, 100mg, 150mg, 200mg (Prior Authorization Required, Quantity Level Limit)


  • Amlodipine-Valsartan-Hydrochlorothiazide Tabs
  • Betaxolol Tabs
  • Calcitriol Solution
  • Captopril Tabs
  • Captopril-Hydrochlorothiazide Tabs
  • Chlorpropramide Tabs
  • Climara Pro Patch
  • Desipramine Tabs
  • Diltiazem CD Caps 360mg
  • Femring
  • Fenofibrate Tab 48mg, 145mg
  • Fenofibric DR Caps
  • Fenoprofen Tabs 600mg
  • Marplan Tab 10mg
  • Meclofenamate Caps
  • Nadolol Tabs
  • Nisoldipine ER Tabs
  • Ondansetron Solution
  • Oxaprozin Tabs 600mg
  • Pindolol Tabs
  • Pioglitazone-Glimepiride
  • Pioglitazone-Metformin
  • Potassium/Sodium Citrates & Citric Acid Solution
  • Premaring Vaginal Cream
  • Premphase Tabs
  • Prempro Tabs
  • Protriptyline Tabs
  • Tolazamide Tabs
  • Tolbutamide Tab 500mg
  • Tranylcypromine Tab 10mg
  • Verapamil Extended Release 24 hour Cap 100mg, 200mg, 300mg

Other Updates:

  • ADHD Stimulants (Prior Authorization Required)
  • Amlodipine Tabs 2.5mg, 5mg (Quantity Level Limit)
  • Baraclude Solution (Quantity Level Limit)
  • Benzonatate Caps 100mg, 200mg (Age Limit, Quantity Level Limit)
  • Clonidine Patch 0.1mg, 0.2mg, 0.3mg (Step Therapy)
  • Diltiazem CD Cap 180mg (Quantity Level Limit)
  • Diltiazem ER Beads Cap 180mg (Quantity Level Limit)
  • Diltiazem ER Cap 180mg (Quantity Level Limit)
  • Estradiol Vaginal Cream (Prior Authorization Required)
  • Estring Vaginal Ring (Quantity Level Limit)
  • Flunisolide Nasal Solution (Quantity Level Limit)
  • Gabapentin (Cumulative Quantity Level Limit)
  • Griseofulvin Suspension (Step Therapy)
  • Griseofulvin Tabs (Step Therapy)
  • Hydrocodone-Homatropine Syrup (Age Limit, Quantity Level Limit)
  • Hydrocodone-Homatropine Tab (Age Limit, Quantity Level Limit)
  • Lidocaine 5% Ointment (Prior Authorization Required)
  • Lisinopril Tabs 2.5mg, 5mg, 10mg, 20mg, 30mg (Quantity Level Limit)
  • Mometasone Furoate Nasal Suspension (Quantity Level Limit)
  • Narcan Nasal Spray (Changed Quantity Level Limit)
  • Propranolol ER Cap 80mg (Quantity Level Limit)
  • Telmisartan Tabs 20mg, 40mg, 80mg (Added Quantity Level Limit)
  • Tenofovir Tab 300mg (Quantity Level Limit)
  • Tolterodine IR Tabs 1mg, 2mg (Step Therapy)
  • Trospium ER Tab (Step Therapy)
  • Trospium IR Tab (Step Therapy)
  • Vemlidy Tab 25mg (Quantity Level Limit)
  • Verapamil ER Tab 120mg (Quantity Level Limit)

July 2018


  • Baclofen Tab 5mg (Quantity Level Limit)
  • Diphenhydramine Liquid 6.25mg/ml
  • Norvir Powder Packet 100mg (Prior Authorization Required)
  • Pediatric Multiple Vitamins with Iron Drops 11mg/ml
  • Phytonadione Tab 5mg
  • Pradaxa Cap 110mg (Prior Authorization Required)
  • Zenpep Cap 15,000 Units
  • Zenpep Cap 3000 Units


  • Mephyton Tab 5mg

Other Updates:

  • Eliquis Tab 2.5mg, 5mg (Removed Prior Authorization, Added Quantity Level Limit)
  • Tobacco Cessation Products (Removed Prior Authorization)
  • Xarelto Tab 10mg, 15mg, 20mg (Removed Prior Authorization, Added Quantity Level Limit)

June 2018


  • Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8ml and 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Pen-Injector Kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 10mg/0.1ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 20mg/0.2ml (Prior Authorization Required, Quantity Level Limit)
  • Humira Prefilled Syringe Kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
  • Lansoprazole ODT (Prior Authorization Required)
  • Praziquantel Tab 600mg (Prior Authorization Required)
  • Symfi Tab (Prior Authorization Required, Quantity Level Limit)
  • Tasigna Cap 50mg (Prior Authorization Required, Quantity Level Limit)
  • Zenpep Cap 10,000 Units


  • Biltricide Tab 600mg
  • Prevacid ODT

May 2018


  • Colchicine Cap 0.6mg
  • Firvanq Sol 25mg/Ml
  • Firvanq Sol 50mg/Ml
  • Flovent HFA 110mcg
  • Flovent HFA 220mcg
  • Flovent HFA 44mcg
  • Imbruvica   Cap 70mg
  • Jardiance Tablet
  • Symfi Lo Tablet
  • Synjardy Tablet
  • Synjardy XR 10mg/1000mg
  • Synjardy XR 12.5mg/1000mg
  • Synjardy XR 25mg/1000mg
  • Synjardy XR 5mg/1000mg

Other Updates:

  • Naproxen 125/5ml susp (Changed Quantity Level Limit)
  • Rosuvastatin Tab (Added Quantity Level Limit) 

April 2018


  • Biktarvy 50-200-25mg Tablet
  • Zenpep Cap 5000 Units
  • Zenpep Cap 25000 Units  

March 2018


  • Abilifiy Maintena Injection
  • Abilifiy Maintena Injection
  • Aristada
  • Invega Sustenna Injection 117mg
  • Invega Sustenna Injection 156mg
  • Invega Sustenna Injection 234mg
  • Invega Sustenna Injection 39mg
  • Invega Sustenna Injection 78mg
  • Invega Trinza Injection 273mg
  • Invega Trinza Injection 410mg
  • Invega Trinza Injection 546mg
  • Invega Trinza Injection 819mg
  • Risperdal Consta Injection

February 2018


  • Efavirenz
  • Janumet 50-1000 MG, 50-500 MG
  • Janumet XR ER 24HR 50-1000 MG, ER 24HR 50-500 MG, ER 24HR 100-1000 MG
  • Januvia 100 MG, 25 MG ,50 M
  • Juluca TAB 50-25MG
  • QVAR Redihaler AER 80MCG
  • QVAR Redihaler AER 40MCG
  • Sprycel tablets, all strengths
  • Tenofovir


  • Albuterol Tablets
  • Amcinonide Cre 0.1%
  • Amcinonide Lot 0.1%
  • Betoptic-S susp 0.25%
  • Brimonidine 0.15% ophth soln
  • Cefaclor ER tablets 500mg
  • Cefixime Suspension, all strengths
  • Cephalexin tablets, all strengths
  • Ciloxan Ointment 0.3%
  • Ciprofloxacin ER tablets, all strengths
  • Clobetasol Aer .05%Foam
  • Clobetasol Aer Emul.05%
  • Clobetasol Lot 0.05%
  • Clobetasol Sha 0.05%
  • Desonide Cre 0.05%
  • Desonide Lot 0.05%
  • Desonide Oin 0.05%
  • Desoximetasone Cre 0.05% And 0.25%
  • Desoximetasone Gel 0.05%
  • Desoximetasone Oin 0.25%
  • Diflorasone Cre 0.05%
  • Diflorasone Oin 0.05%
  • Fluocin Body Oil 0.01%
  • Fluocin Sclp Oil 0.01%
  • Fluocinonide Cre 0.1%
  • FML Forte 0.25%
  • Fondaparinux, all strengths
  • Fragmin, all strengths
  • Gatifloxacin Solution 0.5%
  • Hc Valerate Cre 0.2%
  • Hc Valerate Oin 0.2%
  • Hydrocort Sol But 0.1%
  • Jentadueto -2.5-1000 MG , 2.5-850 MG, 2.5-500 MG
  • Jentadueto XR-2.5-1000 MG ,5-1000 MG
  • Modafinil tablets-100 MG, 200 MG
  • Morphine ER Capsule, all strengths
  • Moxifloxacin Solution 0.5%
  • Neomycin/Polymixin/HC Susp
  • Ofloxacin tablets, all strengths
  • Oxycodone 5mg Capsule
  • Oxycodone concentrated solution (20mg/mL)            
  • Oxymorphone IR tablets, all strengths
  • Pen needles- BD brand covered
  • Pred Mild 0.12%
  • Prednicarbat Cre 0.1%
  • Reyataz
  • Suprax chew tablets, all strengths
  • Terbutaline Tablets
  • Tobradex Ointment 0.3-0.1%
  • Tobramycin/dexamethasone Suspension 0.3-0.1%
  • Tobrex Ointment 0.3%
  • Tradjenta 5mg
  • Trianex Oin 0.05%
  • Triderm Cre 0.1% (NDC Level)
  • Viread

January 2018


  • Abilify Maintenna
  • Armodafinil
  • Avonex
  • BD Pen Needles
  • Carbamide peroxide
  • Carboxymethylcellulose Sodium
  • Eliquis
  • Invega Sustenna
  • Invega Trinza
  • Opsumit
  • Oseltamivir phosphate
  • Risperdal Consta
  • Zenpep Capsules


  • Tamiflu

December 2017


  • Abacavir solution
  • Electrolyte solution
  • Enbrel Mini
  • Fluticasone/salmeterol aerosol powder
  • Glatiramer
  • Mavyret


  • Copaxone
  • Zepatier
  • Ziagen solution

November 2017


  • Fosamprenavir Tablet 700mg

September 2017


  • Mesalamine Tab 1.2gm
  • Moxifloxacin Sol 0.5% ophthalmic drops


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.

Dual eligible members: Over-The-Counter (OTC) Wrap Formulary for Dual Eligible Members

*Dual-eligible beneficiaries are enrolled in Medicare and Medicaid (Aetna Better Health of New Jersey).

Guidelines (effective 04.01.2020) for pharmacy prior authorization for:

Botulinum Toxins (effective 04.01.2020)

Colony Stimulating Factors (effective 04.01.2020)

COVID-19 (effective 03.01.2020)

Cytokines and CAM Antagonists (effective 06.03.2019)

Fabry Disease Products (effective 01.01.2020)

Growth Hormone (effective 04.01.2020)

Hepatitis C

Immune Globulins (effective 04.01.2020)

Injectable Osteoporosis Agents (effective 04.01.2020)

Lambert-Eaton Myasthenic Syndrome (LEMS) (effective 01.01.2020)

Multiple Sclerosis (effective 04.01.2020)

Opioids (effective 04.01.2020)

Stensiq (effective 01.01.2020)


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

Opioids  Updated 04.01.2020

Universal Pharmacy Prior Authorization Fax Form                                                              


Afinitor-Afinitor Disperz                                                                                                            

Antidepressants non-formulary                                                                  

Atypical Antipsychotics Oral  Updated 04.01.2020

Atypical Antipsychotics Long-Acting Injectable  New 04.01.2020                           

Botulinum Toxins   Updated 04.01.2020                                         

Brand name drug                                                                 

Calcitonin Gene-Related Peptide Receptor Antagonists (Aimovig, Ajovy, Emgality)   Updated 04.01.2020                                                                                             


Central Nervous System Stimulants

Colony Stimulating Factors   Updated 04.01.2020                                         

Cystic Fibrosis  New 04.01.2020

Cytokine and CAM Antagonists                                                                                                                                                             

Dalfampridine (Ampyra)  Updated 04.01.2020


Dose Optimization                                          

DPP-4 Inhibitors                                           

Dupixent    Updated 04.01.2020                                                                                                                                                        

Erythropoiesis Stimulating Agents  New 04.01.2020                                                                                    

Gonadotropin Releasing Hormone Analogs New 04.01.2020

Growth Hormone    Updated 04.01.2020                                        


Hepatitis C     

Hereditary Angioedema                                               

HIV Duplicative Use, Inappropriate Interaction, Unboosted Updated 04.23.2020                                                                                                                                          

Hyaluronic Acid Derivatives   Updated 04.01.2020  

Hyperlipidemia Medications  (Omega-3 Carboxylic Acid)     

Idiopathic Pulmonary Fibrosis                                                                                                  



Injectable Osteoporosis New 04.01.2020



Interleukin-5 Antagonists                                                            

IPF Agents                                  

Janus Associated Kinase Inhibitors (Jakafi)  Updated 04.01.2020                                                                                                                                                                                                                                                                                               

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591


Group: RX8829

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.