Microsoft word - 2013 summary of changes final.doc

2013 Changes Aetna’s Preferred Drug, Precertification, Quantity Limit, Step-
Therapy and Specialty Care Rx Lists
Medications added to the Preferred Drug List
(* = may be added prior to 1/1/13)
BYDUREON
MICARDIS *10/1/2012
STRATTERA *9/1/2012
VIIBRYD KIT *8/1/12
DUTOPROL *8/1/12
MICARDIS HCT *10/1/2012
VIIBRYD *8/1/12
EFFIENT *9/1/2012
Medications removed from the Preferred Drug List1
(^ = generic equivalent available…….FE = formulary excluded in Closed Formulary plans NP = non-preferred in Open Formulary plans)
ADCIRCA FE, NP
Medications to be removed from the Formulary Exclusions List
(covered in Closed Formulary plans, non-preferred in Open Formulary plans)
(* = may be removed prior to 1/1/13)
BYDUREON
MICARDIS *10/1/2012
VIIBRYD *8/1/12
DUTOPROL*8/1/12
MICARDIS HCT *10/1/2012
VIIBRYD KIT *8/1/12
EFFIENT *9/1/2012
STRATTERA *9/1/2012
Medications added to the Precertification List 2,3,4
(* = prior-authorization is being added to include males)
ACTEMRA
Medications to be removed from the Precertification List (edit will no longer apply)
None
Medications added to the Quantity Limits List or changes to the Quantity Limit3,4
AVINZA
Medications to be removed from the Quantity Limit List (edit will no longer apply)
None
UPPER CASE = brand name medication lower case italics = generic medication
Medications added to the Step-Therapy List3,4
+ = Trial of a generic equivalent is required first ++ Step-therapy will not be implemented until sometime after generic equivalent becomes available
AVINZA
MAXALT ++
MAXALT MLT ++
KEPPRA +
KEPPRA XR +
New Benefit Exclusions
Bulk chemicals used for compounded medications:
Compound drug therapy using bulk chemicals will no longer be covered as of January 1, 2013 for fully insured business only. Self-funded plans
are currently exempt from this exclusion
EGRIFTA
Medications to be removed from the Step-Therapy List (edit will no longer apply)
(* = may be removed prior to 1/1/13)
ACTEMRA
BUTRANS*8/10/12
LIVALO *8/10/12
STRATTERA *9/1/2012
Additions to Aetna Specialty Care Rx list
# = limited distribution- not available at Aetna Specialty Pharmacy ## =now available at Aetna Specialty Pharmacy
EYLEA
2013 Precertification Safety Edits and National Precert List for Self Insured plans only
ABSTRAL
ACTIQ PR and QL = 120/30 days
DURAGESIC QL = 20/30 days
NUCYNTA QL = 180/30 days
ONSOLIS PR and QL = 4/day
QL = 28/30 days
OXYCONTIN QL = 120/30 days
PR and QL = 120/30 days
fentanyl patch QL = 20/30 days
FENTORA PR and
QL = 120/30 days
buprenorphine PR and QL
2 mg = 24/30 days,
8 mg = 8/30 days
QL = 2 bottles/30 days
BUTRANS PR and QL = 4/30 days
UPPER CASE = brand name medication lower case italics = generic medication
SUBUTEX PR and QL
2 mg = 24/30 days,
8 mg = 8/30 days
QL = 2 bottles/30 days
SUBOXONE PR and QL = 3/day
2013 Precertification Safety Edits and National Precert List for Fully Insured plans only
ABSTRAL
QL = 2 bottles/30 days
BUTRANS PR and QL = 4/30 days
QL = 120/30 days
CASODEX PR in females only
CELEBREX PR < 60 yrs old
NUCYNTA QL = 180/30 days
adapalene PR ≥ 36 yr old
alfuzosin PR in females only
ONSOLIS PR and QL = 4/day
PR  10 yr old
PR  8 yr old
QL = 28/30 days
DDAVP nasal PR  17 yr old
OXYCONTIN QL = 120/30 days
PR < 2 yr old
PR  17 yr old
DIFFERIN PR ≥ 36 yr old
DURAGESIC QL = 20/30 days
PR < 6 yr old
JALYN PR in females only
EPIDUO PR ≥ 36 yr old
PROSCAR PR in all females
and males < 50 yrs old
EXALGO QL
ATRALIN PR ≥ 36 yr old
8mg, 12mg = 2/day;
QUALAQUIN PR and
avita PR ≥ 36 yr old
16mg = 4/day
QL = 42/year
AVODART PR in females only
RAPAFLO PR in females only
PR and QL = 120/30 days
fentanyl patch QL = 20/30 days
FENTORA PR and
PR in females only
QL = 120/30 days
finasteride PR in al females
PR ≥ 36 yr old
and males < 50 yrs old
RETIN-A PR ≥ 36 yr old
PR  17 yr old
buprenorphine PR and QL
FLOMAX PR in females only
2 mg = 24/30 days,
8 mg = 8/30 days
UPPER CASE = brand name medication lower case italics = generic medication
PR in females only
VELTIN PR ≥ 36 yr old
QL = 2 bottles/30 days
tamsulosin PR in females only
TAZORAC PR ≥ 36 yr old
ZIANA PR ≥ 36 yr old
PR  17 yr old
SUBOXONE PR and QL = 3/day
tretinoin PR ≥ 36 yr old
SUBUTEX PR and QL
TRETIN-X PR ≥ 36 yr old
2 mg = 24/30 days,
8 mg = 8/30 days
1 In accordance with state law, full-risk members in Texas who are receiving coverage for medications that are removed from the Preferred Drug List during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. 2 The term precertification means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. 3 In accordance with state law, California HMO members who are receiving coverage for medications that are added to the Precertification or Step-Therapy lists will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee's medical condition. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. 4 Some programs, such precertification, quantity limits and step-therapy are not available in all service areas and are subject to change. For example, precertification and step therapy programs do not apply to fully insured members in Indiana. Step-therapy does not apply to fully insured members in New Jersey. However, these programs are available to self-insured plans. Please refer to your plan documents or call the Member Services number on your ID card. UPPER CASE = brand name medication lower case italics = generic medication

Source: http://www.aetna.com/faqs-health-insurance/documents/2013-Summary-Changes.pdf