Covered and non-covered drugs

- -

Covered and

non-covered

drugs

Drugs not covered – and

their covered alternatives

2022 Advanced Control Plan - Aetna Federal

Employees Formulary Exclusions Drug List

834500 01 01 (1/22)

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Below is a list of medications that will not be covered without a

prior authorization for medical necessity. If you continue using

one of these drugs without prior approval, you may be required

to pay the full cost. Ask your doctor to choose one of the generic

or brand formulary options listed below.

Key

UPPERCASE Brand-name medicine

lowercase italics Generic medicine

Preferred Options For Excluded Medications

Excluded drug name(s) Preferred option(s)

ABILIFY aripiprazole, asenapine, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone,

ziprasidone, LATUDA, VRAYLAR

ABSORICA isotretinoin

ACANYA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

ACIPHEX, ACIPHEX

SPRINKLE

esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-

rel tablet, DEXILANT

ACTEMRA INTRAVENOUS REMICADE, SIMPONI ARIA

ACTICLATE doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

ACTOS pioglitazone

ACUVAIL bromfenac, diclofenac, ketorolac

acyclovir cream acyclovir (except acyclovir cream), valacyclovir

ADCIRCA sildenal, tadalal

ADDERALL dexmethylphenidate, dextroamphetamine, methylphenidate

ADZENYS ER, ADZENYS

XR-ODT

amphetamine-dextroamphetamine mixed salts ext-rel

†

, dexmethylphenidate ext-rel,

dextroamphetamine ext-rel, methylphenidate ext-rel

†

, MYDAYIS, VYVANSE

AIMOVIG AJOVY, EMGALITY

AKYNZEO aprepitant WITH granisetron, ondansetron or SANCUSO

ALDARA imiquimod

ALLISON MEDICAL

INSULIN SYRINGES



ALORA estradiol, DIVIGEL, EVAMIST

ALPROLIX Consult doctor

ALREX azelastine, bepotastine, cromolyn sodium, olopatadine

ALTOPREV atorvastatin, ezetimibe-simvastatin, uvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

ALVESCO 

AMITIZA lubiprostone, LINZESS, MOVANTIK, SYMPROIC

AMRIX carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

Health benefits and health insurance plans are offered, and/or underwritten by Aetna Health Inc., Aetna Health

Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna Health Insurance Company

and/or Aetna Life Insurance Company (Aetna). In Florida by Aetna Health Inc. and/or Aetna Life Insurance

Company. In Utah and Wyoming by Aetna Health of Utah Inc. and/or Aetna Life Insurance Company. In

Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial

responsibility for its own products.

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.



Excluded drug name(s) Preferred option(s)

ANDROGEL testosteronegel (except authorized generics for TESTIM and VOGELXO), testosteronesolution,

ANDRODERM, NATESTO

ANGELIQ estradiol-norethindrone, BIJUVA

APEXICON E desoximetasone (except desoximetasone ointment 0.05%), uocinonide (except uocinonide

cream 0.1%), BRYHALI

APIDRA FIASP, NOVOLOG

APOKYN INBRIJA, KYNMOBI

APTENSIO XR amphetamine-dextroamphetamine mixed salts ext-rel

†

, dexmethylphenidate ext-rel,

dextroamphetamine ext-rel, methylphenidate ext-rel

†

, MYDAYIS, VYVANSE

APTIOM carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin,

lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital,

phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide,

FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

APTIVUS Consult doctor

ARALAST NP PROLASTIN-C

ARTHROTEC celecoxib; diclofenacsodium, ibuprofen, meloxicam tablet or naproxen (except naproxen CR or

naproxen suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole

delayed-rel, pantoprazole delayed-rel tablet or DEXILANT

ASCENSIA KITS AND

STRIPS

ACCU-CHEK AVIVA PLUS STRIPS AND KITS







, ONETOUCH

ULTRA STRIPS AND KITS

, ONETOUCH VERIO STRIPS AND KITS

ASMANEX, ASMANEX HFA 

ASTAGRAF XL tacrolimus

ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan,

losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-

hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

ATIVAN alprazolam, clonazepam, diazepam, lorazepam, oxazepam

ATR ALIN adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

ATRIPLA efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir disoproxil

fumarate, BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ

ATROVENT HFA ipratropiuminhalationsolution, SPIRIVA, YUPELRI

AUVI-Q epinephrine auto-injector, EPIPEN, EPIPEN JR, SYMJEPI

AVONEX dimethyl fumarate delayed-rel, glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA,

KESIMPTA, MAYZENT, REBIF, TYSABRI, VUMERITY, ZEPOSIA

AVSOLA REMICADE, SIMPONI ARIA, STELARA INTRAVENOUS

AZASITE 

tobramycin

AZELEX adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

AZESCO

prenatal vitamins, CITRANATAL

AZOPT brinzolamide, dorzolamide

AZOR amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan

BALCOLTR A ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-

levonorgestrel, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,

LO LOESTRIN FE

BANZEL SUSPENSION clobazam, lamotrigine, runamide, topiramate, TROKENDI XR

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

BARACLUDE TABLET

Preferred option(s)

entecavir, lamivudine, tenofovirdisoproxilfumarate, 

BECONASEAQ azelastine-uticasone, unisolide, uticasone, mometasone

BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan,

losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-

hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

BENZACLIN adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

benzonatate (NDCs^

69336012615,

69499032915 only)

benzonatate (except NDCs^ 69336012615, 69499032915)

BEPREVE azelastine, bepotastine, cromolyn sodium, olopatadine

BERINERT icatibant, RUCONEST

BESIVANCE ciprooxacin, erythromycin, gentamicin, levooxacin, moxioxacin, ooxacin, sulfacetamide,

tobramycin

betamethasone

acetate-betamethasone

sodium phosphate (NDC^

71283062002 only),

BETAMETHASONE

ACETATE-

BETAMETHASONE

SODIUM PHOSPHATE

dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone

BETAPACE, BETAPACEAF sotalol

BETIMOL timolol maleate solution

BETOPTIC S timolol maleate solution

BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT

BEYA Z ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-

levonorgestrel, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,

LO LOESTRIN FE

bimatoprost solution 0.03% latanoprost, travoprost, ZIOPTAN

BREEZE 2 STRIPS AND

KITS

ACCU-CHEK AVIVA PLUS STRIPS AND KITS







, ONETOUCH

ULTRA STRIPS AND KITS

, ONETOUCH VERIO STRIPS AND KITS

BRIVIACT carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin,

lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital,

phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide,

OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

BROMSITE bromfenac, diclofenac, ketorolac

BROVANA PERFOROMIST

Bupap diclofenac sodium, ibuprofen, naproxen(except naproxen CR or naproxen suspension)

BUPHENYL sodium phenylbutyrate

bupropion ext-rel tablet

450 mg

bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg)

butalbital-acetaminophen

tablet 50-300 mg,

BUTALBITAL-

ACETAMINOPHEN (NDC^

69499034230 only)

diclofenac sodium, ibuprofen, naproxen(except naproxen CR or naproxen suspension)

butalbital-acetaminophen-

caffeinecapsule

diclofenac sodium, ibuprofen, naproxen(except naproxen CR or naproxen suspension)

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

BUTRANS

Preferred option(s)

buprenorphine transdermal, BELBUCA

BYDUREON BCISE OZEMPIC, RYBELSUS, TRULICITY, VICTOZA

BYETTA OZEMPIC, RYBELSUS, TRULICITY, VICTOZA

BYSTOLIC atenolol, carvedilol, carvedilolphosphateext-rel, metoprololsuccinateext-rel, metoprololtartrate,

nadolol, propranolol, propranololext-rel

CAFERGOT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY,



calcipotriene cream,

calcipotriene foam,

CALCIPOTRIENE FOAM

calcipotriene ointment, calcipotriene solution

calcipotriene-

betamethasone

calcipotriene ointment or calcipotriene solution WITH desoximetasone (except desoximetasone

ointment 0.05%), uocinonide (except uocinonide cream 0.1%) or BRYHALI; DUOBRII, ENSTILAR,

TACLONEX

calcitriol ointment calcipotriene ointment, calcipotriene solution

CAMBIA diclofenac sodium, ibuprofen, naproxen(except naproxen CR or naproxen suspension)

CANASA hydrocortisoneenema, mesalaminesuppository, mesalaminesuspension, CORTIFOAM

CAPEX ketoconazoleshampoo 2%, selenium sulde lotion 2.5%

CARAC uorouracilcream5%, uorouracilsolution, imiquimod

CARAFATE sucralfate tablet

CARBINOXAMINE TABLET

6 MG

levocetirizine

CARDIZEM, CARDIZEM CD,

CARDIZEM LA

diltiazemext-rel (except generics for CARDIZEM LA)

carisoprodol 250 mg carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

CARNITOR, CARNITOR SF levocarnitine

CELEBREX celecoxib, diclofenacsodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or

naproxen suspension)

CELLCEPT mycophenolate mofetil, mycophenolatesodium

chlordiazepoxide-clidinium

(NDCs^ 11534019701,

42494040901,

51293069601,

51293069610,

67877073101,

70700018501 only)"

dicyclomine

chlorzoxazone 375 mg,

chlorzoxazone 500 mg

(NDC^ 73007001303

only), chlorzoxazone 750

mg, CHLORZOXAZONE

250 MG

carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

CHORIONIC

GONADOTROPIN

OVIDREL

CIALIS sildenal, tadalal, vardenal

CILOXAN ciprooxacin, erythromycin, gentamicin, levooxacin, moxioxacin, ooxacin, sulfacetamide,

tobramycin

CIMZIA LYOPHILIZED

POWDER

REMICADE, SIMPONI ARIA, STELARA INTRAVENOUS

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

CIPRO HC

Preferred option(s)

ciprooxacin-dexamethasone, ooxacin otic

CIPRODEX ciprooxacin-dexamethasone, ooxacin otic

CLINDAGEL adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

clindamycin gel (NDC^

68682046275 only)

adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

clobetasol spray clobetasolfoam

CLOBEX SPRAY clobetasolfoam

clocortolone cream hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

COLAZAL balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine

ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, PENTASA

colchicine capsule colchicine tablet, MITIGARE

COLCRYS colchicine tablet, MITIGARE

COMBIPATCH CLIMARA PRO

COMPLERA efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir disoproxil

fumarate, BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ

CONSENSI amlodipine WITH celecoxib

CONTOURNEXTSTRIPS

AND KITS

CONTOUR

STRIPS AND KITS

ACCU-CHEK AVIVA PLUS STRIPS AND KITS







, ONETOUCH

ULTRA STRIPS AND KITS

, ONETOUCH VERIO STRIPS AND KITS

CONTRAVE QSYMIA

, SAXENDA



CORDRAN CREAM,

CORDRAN LOTION

desonide, hydrocortisone

CORDRAN OINTMENT hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

CORDRAN TAPE clobetasol cream, clobetasol foam, clobetasol gel, clobetasol lotion, clobetasol ointment,

halobetasol cream, halobetasol ointment

COREG CR atenolol, carvedilol, carvedilolphosphateext-rel, metoprololsuccinateext-rel, metoprololtartrate,

nadolol, propranolol, propranololext-rel

CoreMino doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

COSOPT PF dorzolamide-timolol

COZAAR candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

CRESEMBA itraconazole

CRESTOR atorvastatin, ezetimibe-simvastatin, uvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

CRINONE ENDOMETRIN

CUPRIMINE penicillamine

cyclobenzaprine ext-rel

capsule, cyclobenzaprine

tablet 7.5 mg

carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

CYCLOSET Consult doctor

CYMBALTA desvenlafaxineext-rel, duloxetine, venlafaxine, venlafaxineext-relcapsule

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.



Excluded drug name(s)

CYTOMEL

Preferred option(s)

levothyroxine, liothyronine

DARAPRIM pyrimethamine

DAYTRANA amphetamine-dextroamphetamine mixed salts ext-rel

†

, dexmethylphenidate ext-rel,

dextroamphetamine ext-rel, methylphenidate ext-rel

†

, MYDAYIS, VYVANSE

DELZICOL balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine

ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, PENTASA

DENAVIR acyclovir (except acyclovir cream), valacyclovir

DEPO-SUBQ PROVERA

104MG

medroxyprogesterone acetate 150 mg/mL

DESFERAL deferasirox, deferiprone, deferoxamine

desoximetasone ointment

0.05%

hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

DESVENLAFAXINE ER desvenlafaxineext-rel, duloxetine, venlafaxine, venlafaxineext-relcapsule

DETROL LA darifenacinext-rel, oxybutyninext-rel, solifenacin, tolterodine, tolterodineext-rel, trospium,

trospiumext-rel, MYRBETRIQ, TOVIAZ

dexchlorpheniramine clemastine 2.68 mg, cyproheptadine, levocetirizine

Dexifol folic acid,folic acid-vitamin B6-vitamin B12

DIASTAT diazepam rectal gel, NAYZILAM, VALTOCO

DIFFERIN LOTION adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

diflorasone cream,

diflorasone ointment

desoximetasone (except desoximetasone ointment 0.05%), uocinonide (except uocinonide

cream 0.1%), BRYHALI

dihydroergotamine spray eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY,



DILANTIN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin,

lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital,

phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide,

FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

diltiazem ext-rel (generics

for CARDIZEM LA only)

diltiazemext-rel (except generics for CARDIZEM LA)

DIOVAN, DIOVANHCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan,

losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-

hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

DORYX, DORYX MPC doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

doxepin cream desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA

doxycycline hyclate

delayed-rel tablet 50 mg,

100 mg, 200 mg

doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

doxycycline hyclate tablet

50 mg (NDC^

72143021160 only),

doxycycline hyclate

tablet 75 mg, doxycycline

hyclate tablet 150 mg

doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

doxycycline monohydrate

capsule 75 mg,

doxycycline monohydrate

capsule 150 mg

doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

doxycycline monohydrate

delayed-rel capsule

Preferred option(s)

ORACEA

DUAVEE estradiol-norethindrone, raloxifene, BIJUVA

DUEXIS ibuprofen AND famotidine

DULERA ADVAIR DISKUS, ADVAIR HFA

†



†

, SYMBICORT

DUTOPROL metoprololsuccinateext-rel WITH hydrochlorothiazide

DYRENIUM amiloride, triamterene

E.E.S. GRANULES erythromycins

ECOZA ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazole (except NDCs^

00168035830, 51672135902)

EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan,

losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-

hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

EDLUAR doxepin, ramelteon, temazepam, zolpidem, zolpidemext-rel

EFFEXOR XR desvenlafaxineext-rel, duloxetine, venlafaxine, venlafaxineext-relcapsule

ELELYSO CERDELGA, CEREZYME

ELESTRIN estradiol, DIVIGEL, EVAMIST

ELIDEL pimecrolimus, tacrolimus, EUCRISA

ELMIRON Consult doctor

EMEND aprepitant

ENLITE CONTINUOUS

GLUCOSE MONITORING

SYSTEM

DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

ENTYVIO (For Crohn’s

Disease Only)

REMICADE, STELARA INTRAVENOUS

ENVARSUS XR tacrolimus

EPIVIR HBV entecavir, lamivudine, tenofovirdisoproxilfumarate, 

EPOGEN ARANESP, RETACRIT

ergotamine-caffeine eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY,



ERTACZO ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazole (except NDCs^

00168035830, 51672135902)

ERYPED erythromycins

estradiol vaginal tablet estradiol vaginal cream, IMVEXXY, VAGIFEM

ESTRING estradiol vaginal cream, IMVEXXY, VAGIFEM

ESTROGEL estradiol, DIVIGEL, EVAMIST

EVEKEO dexmethylphenidate, dextroamphetamine, methylphenidate

EVERSENSE CONTINUOUS

GLUCOSE MONITORING

SYSTEM

DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan

EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide

EXJADE deferasirox, deferiprone, deferoxamine

EXTAVIA dimethyl fumarate delayed-rel, glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA,

KESIMPTA, MAYZENT, REBIF, TYSABRI, VUMERITY, ZEPOSIA

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

FABIOR

Preferred option(s)

adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

FANAPT aripiprazole, asenapine, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone,

ziprasidone, LATUDA, VRAYLAR

FEIBA NOVOSEVEN RT, SEVENFACT

FEMHRTLOWDOSE estradiol-norethindrone, BIJUVA

FEMRING estradiol, IMVEXXY, VAGIFEM

fenofibrate capsule 50 mg,

130 mg; fenofibrate tablet

40 mg, 120 mg

fenobrate (except fenobrate capsule 50 mg, 130 mg; fenobrate tablet 40 mg, 120 mg), fenobric

acid delayed-rel

FENOGLIDE TABLET 120

fenobrate (except fenobrate capsule 50 mg, 130 mg; fenobrate tablet 40 mg, 120 mg), fenobric

acid delayed-rel

fenoprofen, FENOPROFEN

CAPSULE

diclofenacsodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

FENTORA fentanyltransmucosal, SUBSYS

FERIVA 21/7 folic acid,folic acid-vitamin B6-vitamin B12

FERRIPROX deferasirox, deferiprone, deferoxamine

FETZIMA desvenlafaxineext-rel, duloxetine, venlafaxine, venlafaxineext-relcapsule

Fexmid carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

FINACEA GEL 

FIORICET CAPSULE diclofenac sodium, ibuprofen, naproxen(except naproxen CR or naproxen suspension)

FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL

FLECTOR diclofenac sodium, diclofenac sodium solution, ibuprofen, meloxicam tablet, naproxen (except

naproxen CR or naproxen suspension)

flucytosine capsule 500 mg uconazole

fluocinonide cream 0.1% clobetasol cream, halobetasol cream

FLUOROPLEX uorouracilcream5%, uorouracilsolution, imiquimod

fluorouracil cream 0.5% uorouracilcream5%, uorouracilsolution, imiquimod

fluoxetine tablet 60 mg,

FLUOXETINE60MG

citalopram, escitalopram, uoxetine (except uoxetine tablet 60 mg, uoxetine tablet [generics

for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline,

TRINTELLIX

fluoxetine tablet(generics

for SARAFEM only)

uoxetine (except uoxetine tablet 60 mg, uoxetine tablet [generics for SARAFEM]), paroxetine HCl

ext-rel (except NDC^ 60505367503), sertraline

flurandrenolide cream,

flurandrenolide lotion

desonide, hydrocortisone

flurandrenolide ointment hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

FML FORTE, FML

LIQUIFILM, FML S.O.P.

dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL

FOCALIN XR amphetamine-dextroamphetamine mixed salts ext-rel

†

, dexmethylphenidate ext-rel,

dextroamphetamine ext-rel, methylphenidate ext-rel

†

, MYDAYIS, VYVANSE

FOLIC-K folic acid,folic acid-vitamin B6-vitamin B12

FOLLISTIM AQ GONAL-F

†

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.



Excluded drug name(s)

FORTAMET

Preferred option(s)

metformin, metforminext-rel )

FORTESTA testosteronegel (except authorized generics for TESTIM and VOGELXO), testosteronesolution,

ANDRODERM, NATESTO

FOSRENOL calciumacetate, sevelamercarbonate, PHOSLYRA, VELPHORO

FRAGMIN enoxaparin

FREESTYLE LIBRE

CONTINUOUS GLUCOSE

MONITORING SYSTEM

DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

FREESTYLE STRIPS AND

KITS

ACCU-CHEK AVIVA PLUS STRIPS AND KITS







, ONETOUCH

ULTRA STRIPS AND KITS

, ONETOUCH VERIO STRIPS AND KITS

FULPHILA ZIEXTENZO

GELNIQUE darifenacinext-rel, oxybutyninext-rel, solifenacin, tolterodine, tolterodineext-rel, trospium,

trospiumext-rel, MYRBETRIQ, TOVIAZ

GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX

GENOTROPIN NORDITROPIN

GEODON CAPSULE aripiprazole, asenapine, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone,

ziprasidone, LATUDA, VRAYLAR

GEODON

INTRAMUSCULAR

haloperidol, ziprasidone

GLASSIA PROLASTIN-C

GLEEVEC imatinibmesylate, BOSULIF, SPRYCEL

GLUMETZA metformin, metforminext-rel 

GLYCOPYRROLATE TABLET

1.5 MG

dicyclomine

G OLY TE LY peg 3350-electrolytes, CLENPIQ

GRANIX NIVESTYM

GUARDIAN

CONNECT CONTINUOUS

GLUCOSE MONITORING

SYSTEM

DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

GUARDIAN REAL-TIME

CONTINUOUS GLUCOSE

MONITORING SYSTEM

DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

halcinonide cream desoximetasone (except desoximetasone ointment 0.05%), uocinonide (except uocinonide

cream 0.1%), BRYHALI

HALOG desoximetasone (except desoximetasone ointment 0.05%), uocinonide (except uocinonide

cream 0.1%), BRYHALI

HEPSERA entecavir, lamivudine, tenofovirdisoproxilfumarate,

HORIZANT gabapentin, GRALISE

HUMALOG FIASP, NOVOLOG

HUMALOG MIX 50/50 

HUMALOG MIX 75/25 

HUMATROPE NORDITROPIN

HUMULIN 70/30 

HUMULIN N NOVOLIN N

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

HUMULIN R

Preferred option(s)

NOVOLIN R

HYALGAN DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX

hydrocortisone butyrate

lipophilic cream 0.1%

hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

hydrocortisone butyrate

lotion

hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

HYSINGLA ER fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, 



HYZAAR candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide,

olmesartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide

icosapent ethyl omega-3 acid ethyl esters, VASCEPA

ILEVRO bromfenac, diclofenac, ketorolac

ILUMYA REMICADE

INCRUSE ELLIPTA SPIRIVA, YUPELRI

INDERAL LA, INDERAL XL atenolol, carvedilol, carvedilolphosphateext-rel, metoprololsuccinateext-rel, metoprololtartrate,

nadolol, propranolol, propranololext-rel

INDOCIN diclofenac sodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

indomethacin capsule 20

diclofenac sodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

INFLECTRA REMICADE, SIMPONI ARIA, STELARA INTRAVENOUS

INNOPRANXL atenolol, carvedilol, carvedilolphosphateext-rel, metoprololsuccinateext-rel, metoprololtartrate,

nadolol, propranolol, propranololext-rel

INTRAROSA estradiol vaginal cream, IMVEXXY, VAGIFEM

INTUNIV amphetamine-dextroamphetaminemixedsaltsext-rel

†

, atomoxetine, dexmethylphenidateext-rel,

dextroamphetamineext-rel, guanfacineext-rel, methylphenidateext-rel

†

, MYDAYIS, VYVANSE

INVELTYS dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL

INVIRASE atazanavir, lopinavir-ritonavir, EVOTAZ, PREZCOBIX, PREZISTA

INVOKAMET, INVOKAMET

SYNJARDY, SYNJARDY XR, XIGDUO XR

INVOKANA FARXIGA, JARDIANCE

ISORDIL isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate

isosorbide dinitrate 40 mg

tab

isosorbide dinitrate (except isosorbide dinitrate 40 mg), isosorbide mononitrate

ISTALOL timolol maleate solution

JADENU deferasirox, deferiprone, deferoxamine

JALY N dutasteride-tamsulosin; dutasteride or nasteride WITH alfuzosin ext-rel, doxazosin, silodosin,

tamsulosin or terazosin

JENTADUETO,

JENTADUETO XR

JANUMET, JANUMET XR

JUBLIA 

K APVAY amphetamine-dextroamphetaminemixedsaltsext-rel

†

, atomoxetine, dexmethylphenidateext-rel,

dextroamphetamineext-rel, guanfacineext-rel, methylphenidateext-rel

†

, MYDAYIS, VYVANSE

KAZANO 

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

KENALOG

Preferred option(s)

hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

KEPPRA, KEPPRA XR carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin,

lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital,

phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide,

FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

KERYDIN terbinane tablet

ketoconazole foam 2% ketoconazoleshampoo 2%, selenium sulde lotion 2.5%

Ketodan ketoconazoleshampoo 2%, selenium sulde lotion 2.5%

ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

KOMBI GLY Z E XR 

KUVAN sapropterin

LACRISERT XIIDRA

LACTULOSE PAK lactulose solution

LANOXIN TABLET (125MCG

and 250MCG only)

digoxin

lanthanum carbonate calciumacetate, sevelamercarbonate, PHOSLYRA, VELPHORO

LANTUS BASAGLAR, LEVEMIR

LASTACAFT azelastine, bepotastine, cromolyn sodium, olopatadine

LAZANDA fentanyltransmucosal, SUBSYS

LESCOL XL atorvastatin, ezetimibe-simvastatin, uvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

LETAIRIS ambrisentan, bosentan, OPSUMIT

levorphanol fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, 



LEXAPRO citalopram, escitalopram, uoxetine (except uoxetine tablet 60 mg, uoxetine tablet [generics

for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline,

TRINTELLIX

LEXIVA atazanavir, lopinavir-ritonavir, EVOTAZ, PREZCOBIX, PREZISTA

LIALDA balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine

ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, PENTASA

LIBRAX dicyclomine

LIDOCAINE-TETRACAINE

CREAM (NDC^

71800063115 only)

lidocaine-prilocaine

LILETTA KYLEENA, MIRENA, SKYLA

LIPITOR atorvastatin, ezetimibe-simvastatin, uvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

LITHOSTAT Consult doctor

LIVALO atorvastatin, ezetimibe-simvastatin, uvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Lorzone carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

LOTEMAX, LOTEMAX SM dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

luliconazole

Preferred option(s)

ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazole (except NDCs^

00168035830, 51672135902)

LUMIGAN latanoprost, travoprost, ZIOPTAN

LUNESTA doxepin, ramelteon, temazepam, zolpidem, zolpidemext-rel

LUPRON DEPOT ELIGARD, FIRMAGON, ORIAHNN, ORILISSA

LUPRON DEPOT-PED TRIPTODUR

LUXIQ hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

LUZU ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazole (except NDCs^

00168035830, 51672135902)

LYRICA duloxetine, pregabalin

MACRODANTIN nitrofurantoin (except NDCs^ 16571074024, 70408023932)

Matzim LA diltiazemext-rel (except generics for CARDIZEM LA)

MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI

MAXALT, MAXALT-MLT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, 

ZOMIG NASAL SPRAY

MAXIDEX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL

mefenamic acid (NDC^

69336012830 only)

diclofenacsodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

meloxicam capsule diclofenac sodium, ibuprofen, meloxicam tablet, naproxen (except naproxen CR or naproxen

suspension)

MENEST estradiol

MENOSTAR estradiol

meperidine hydromorphone, morphine, oxycodone, NUCYNTA

mesalamine delayed-rel

tablet 800 mg

balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine

ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, PENTASA

MESTINON pyridostigmine, pyridostigmineext-rel

metaxalone 400 mg tab carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

metformin ext-rel (generics

for FORTAMET and

GLUMETZA only)

metformin, metforminext-rel 

methocarbamol 500 mg

(NDC^ 69036091010

only), methocarbamol

750 mg (NDCs^

69036093090,

70868090190 only)

carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

METROGEL azelaicacidgel, metronidazole, 

MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO

†

, PROLIA

†

, TYMLOS

†

MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan,

losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-

hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

Migergot eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY,



MIGRANAL eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY,



Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

MILLIPRED

Preferred option(s)

dexamethasone, hydrocortisone, methylprednisolone, prednisolonesolution, prednisone

MINASTRIN 24 FE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-

levonorgestrel, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,

LO LOESTRIN FE

MINIVELLE estradiol, DIVIGEL, EVAMIST

minocycline ext-rel doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg



MINOLIRA doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

MIRVASO azelaicacidgel, metronidazole, 

Mondoxyne NL capsule 75

doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

MONOVISC DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX

MOVIPREP peg 3350-electrolytes, CLENPIQ

mupirocin cream gentamicin, mupirocin ointment

MYFORTIC mycophenolatemofetil, mycophenolatesodium

MYTESI diphenoxylate-atropine, loperamide

NAFTIN ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazole (except NDCs^

00168035830, 51672135902)

NAMENDA XR memantine

NAPRELAN diclofenacsodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

naproxen CR diclofenacsodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

naproxen suspension diclofenacsodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

naproxen-esomeprazole diclofenac sodium, ibuprofen, meloxicam tablet or naproxen (except naproxen CR or naproxen

suspension) WITH esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel,

pantoprazole delayed-rel tablet or DEXILANT

NASCOBAL cyanocobalamin inj

NATA ZIA 



LOESTRIN FE

NATURE-THROID levothyroxine, liothyronine

NEO-SYNALAR desonide or hydrocortisone WITH gentamicin

NESINA JANUVIA

NEULASTA ZIEXTENZO

NEULASTA ONPRO ZIEXTENZO

NEUPOGEN NIVESTYM

NEVANAC bromfenac, diclofenac, ketorolac

NEXIUM esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-

rel tablet, DEXILANT

niacin tablet 500 mg niacin ext-rel

Niacor niacin ext-rel

NILANDRON abiraterone, bicalutamide, ERLEADA, XTANDI, YONSA

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

 

Excluded drug name(s)

nitrofurantoin (NDC^

70408023932 only)

Preferred option(s)

nitrofurantoin (except NDCs^ 16571074024, 70408023932)

NITROMIST nitroglycerinlingualspray, nitroglycerinsublingual

Nolix desonide, hydrocortisone

NORGESIC FORTE carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

NORITATE azelaicacidgel, metronidazole,

NORPACE disopyramide

NORVASC amlodipine

NOURIANZ amantadine, entacapone, pramipexole, pramipexole ext-rel, rasagiline, ropinirole, ropinirole ext-rel,

selegiline, NEUPRO

NOVAREL OVIDREL

†

NOVO NORDISK NEEDLES

BD ULTRAFINE NEEDLES

NOXAFIL uconazole, itraconazole

NUTROPIN AQ NORDITROPIN

NUVARING ethinyl estradiol-etonogestrel, ANNOVERA

NUVESSA clindamycin, metronidazole

NUVIGIL armodanil, modanil, SUNOSI

OLEPTRO trazodone

OLUX-E clobetasolfoam

omeprazole-sodium

bicarbonate

esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-

rel tablet, DEXILANT

OMNARIS azelastine-uticasone, unisolide, uticasone, mometasone

OMNITROPE NORDITROPIN

ONFI clobazam, lamotrigine, runamide, topiramate, TROKENDI XR

O NG LY Z A JANUVIA

ORENCIA INTRAVENOUS REMICADE, SIMPONI ARIA

orphenadrine-aspirin-

caffeine

carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

Orphengesic Forte carisoprodol 350 mg, chlorzoxazone 500 mg (except NDC^ 73007001303),cyclobenzaprine

(except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, methocarbamol (except NDCs^

69036091010, 69036093090, 70868090190)

ORTHOVISC DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX

OSENI WITH pioglitazone

OSMOPREP peg 3350-electrolytes, CLENPIQ

OSPHENA estradiol

OTOVEL ciprooxacin-dexamethasone, ooxacin otic

OTREXUP RASUVO

OWEN MUMFORD

NEEDLES

BD ULTRAFINE NEEDLES

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

oxiconazole (NDCs^

00168035830,

51672135902 only)

Preferred option(s)

ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazole (except NDCs^

00168035830, 51672135902)

OXISTAT ciclopirox, clotrimazole, econazole, ketoconazole cream 2%, oxiconazole (except NDCs^



OXYCONTIN fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, 



oxymorphone ext-rel fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, 



OXYTROL darifenacinext-rel, oxybutyninext-rel, solifenacin, tolterodine, tolterodineext-rel, trospium,

trospiumext-rel, MYRBETRIQ, TOVIAZ

PANCREAZE CREON, VIOKACE, ZENPEP

pantoprazole delayed-rel

suspension

esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-

rel tablet, DEXILANT

paroxetine HCl ext-rel

(NDC* 60505367503

only)

citalopram, escitalopram, uoxetine (except uoxetine tablet 60 mg, uoxetine tablet [generics

for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC* 60505367503), sertraline,

TRINTELLIX

paroxetine mesylate

capsule 7.5 mg

paroxetine HCl

PAXIL, PAXIL CR citalopram, escitalopram, uoxetine (except uoxetine tablet 60 mg, uoxetine tablet [generics

for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline,

TRINTELLIX

PEGASYS Consult doctor

PENNSAID diclofenac sodium, diclofenac sodium solution, ibuprofen, meloxicam tablet, naproxen (except

naproxen CR or naproxen suspension)

PERCOCET hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA

PERRIGONEEDLES4 BD ULTRAFINE NEEDLES

PERTZYE CREON, VIOKACE, ZENPEP

PEXEVA citalopram, escitalopram, uoxetine (except uoxetine tablet 60 mg, uoxetine tablet [generics

for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline,

TRINTELLIX

PLAVIX clopidogrel, dipyridamoleext-rel-aspirin, prasugrel, BRILINTA

PLEGRIDY dimethyl fumarate delayed-rel, glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA,

KESIMPTA, MAYZENT, REBIF, TYSABRI, VUMERITY, ZEPOSIA

PLENVU peg 3350-electrolytes, CLENPIQ

posaconazole delayed-rel

tablet

uconazole, itraconazole

PRADAXA warfarin, ELIQUIS, XARELTO

PRECISION XTRA STRIPS

AND KITS

ACCU-CHEK AVIVA PLUS STRIPS AND KITS







, ONETOUCH

ULTRA STRIPS AND KITS

, ONETOUCH VERIO STRIPS AND KITS

PRED FORTE, PRED MILD dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL

PREFEST estradiol-norethindrone, BIJUVA

PREGNYL OVIDREL

†

PREMARIN estradiol

PREMARIN CREAM estradiol vaginal cream, IMVEXXY, VAGIFEM

PREMPHASE estradiol-norethindrone, BIJUVA

PREMPRO estradiol-norethindrone, BIJUVA

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.



Excluded drug name(s)

PRENATAL PLUS 6

Preferred option(s)

prenatal vitamins, CITRANATAL

PREVACID esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-

rel tablet, DEXILANT

PRILOSEC esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-

rel tablet, DEXILANT

PRISTIQ desvenlafaxineext-rel, duloxetine, venlafaxine, venlafaxineext-relcapsule

PROAIR HFA, PROAIR

RESPICLICK

albuterolsulfateCFC-freeaerosol, levalbuteroltartrateCFC-freeaerosol

PROCRIT ARANESP, RETACRIT

PROCTOCORT hydrocortisoneenema, mesalaminesuppository, mesalaminesuspension, CORTIFOAM

PROCYSBI CYSTAGON

PROGRAF tacrolimus

PROLENSA bromfenac, diclofenac, ketorolac

PROMETRIUM medroxyprogesterone; progesterone, micronized

PROTONIX esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-

rel tablet, DEXILANT

PROVENTIL HFA albuterolsulfateCFC-freeaerosol, levalbuteroltartrateCFC-freeaerosol

PROVIGIL armodanil, modanil, SUNOSI

PROZAC citalopram, escitalopram, uoxetine (except uoxetine tablet 60 mg, uoxetine tablet [generics

for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline,

TRINTELLIX

PSORCON desoximetasone (except desoximetasone ointment 0.05%), uocinonide (except uocinonide

cream 0.1%), BRYHALI

PULMICORT RESPULES budesonide inhalation suspension, 



QNASL azelastine-uticasone, unisolide, uticasone, mometasone

QTERN GLYXAMBI

QUARTETTE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-

levonorgestrel, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,

LO LOESTRIN FE

quazepam doxepin, ramelteon, temazepam, zolpidem, zolpidemext-rel

RAPAFLO alfuzosinext-rel, doxazosin, silodosin, tamsulosin, terazosin

RAPAMUNE everolimus, sirolimus

RAVICTI sodium phenylbutyrate

RAYOS dexamethasone, hydrocortisone, methylprednisolone, prednisolonesolution, prednisone

RELION INSULIN 

RELISTOR lubiprostone, MOVANTIK, SYMPROIC

REMODULIN treprostinil

RENFLEXIS REMICADE, SIMPONI ARIA, STELARA INTRAVENOUS

REPATHA PRALUENT

RESTASIS XIIDRA

REVATIO sildenal, tadalal

†

RHOFADE azelaicacidgel, metronidazole, 

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

RIOMET

Preferred option(s)

metformin, metforminext-rel

ROWASA mesalamine suspension

ROZEREM doxepin, ramelteon, temazepam, zolpidem, zolpidemext-rel

RyClora clemastine 2.68 mg, cyproheptadine, levocetirizine

RYTARY carbidopa-levodopa, carbidopa-levodopa ext-rel

SABRIL vigabatrin

SAIZEN NORDITROPIN

SANDOSTATIN L AR SOMATULINE DEPOT

SEASONIQUE ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-

levonorgestrel, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,

LO LOESTRIN FE

SEREVENT STRIVERDI RESPIMAT

SEROQUEL XR aripiprazole, asenapine, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone,

ziprasidone, LATUDA, VRAYLAR

SEYSARA doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

SFROWASA mesalamine suspension

SIGNIFOR LAR SOMATULINE DEPOT

SILENOR doxepin, ramelteon, temazepam, zolpidem, zolpidemext-rel

SINGULAIR montelukast, zarlukast

SITAVIG oral acyclovir, valacyclovir

SOLODYN doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

SOLOSEC clindamycin, metronidazole

SOMAVERT SOMATULINE DEPOT

SORILUX calcipotriene ointment, calcipotriene solution

SPORANOX CAPSULE itraconazole, terbinane tablet

SPORANOX SOLUTION uconazole

SPRIX diclofenacsodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

STAX YN sildenal, tadalal, vardenal

†

STENDRA sildenal, tadalal, vardenal

†

STRIBILD efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir disoproxil

fumarate, BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ

SUBOXONE buprenorphine-naloxone sublingual, ZUBSOLV

sucralfate suspension sucralfate tablet

sumatriptan-naproxen diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH

eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY or ZOMIG

NASAL SPRAY

SUPREP peg 3350-electrolytes, CLENPIQ

SYNDROS dronabinol

SYNVISC, SYNVISC-ONE DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX

SYPRINE trientine

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

 

Excluded drug name(s)

TARGADOX

Preferred option(s)

doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

TASIGNA imatinibmesylate, BOSULIF, SPRYCEL

tavaborole terbinane tablet

TAYTULLA ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-

levonorgestrel, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,

LO LOESTRIN FE

tavaborole terbinane tablet

TAZORAC adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON; calcipotriene ointment, calcipotriene solution

TECFIDERA dimethyl fumarate delayed-rel, glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA,

KESIMPTA, MAYZENT, REBIF, TYSABRI, VUMERITY, ZEPOSIA

TESTIM testosteronegel (except authorized generics for TESTIM and VOGELXO), testosteronesolution,

ANDRODERM, NATESTO

testosterone gel 1%

(authorized generics for

TESTIM and VOGELXO

only)

testosteronegel (except authorized generics for TESTIM and VOGELXO), testosteronesolution,

ANDRODERM, NATESTO

THEO-24 ipratropium inhalation solution, PERFOROMIST, SPIRIVA, STRIVERDI RESPIMAT, YUPELRI

THIOLA, THIOLA EC tiopronin

TIMOPTIC OCUDOSE timolol maleate solution

TIROSINT levothyroxine

TIVORBEX diclofenac sodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

TOBI, TOBI PODHALER tobramycininhalationsolution, BETHKIS

TOBRADEX neomycin-polymyxinB-bacitracin-hydrocortisone, neomycin-polymyxinB-dexamethasone,

tobramycin-dexamethasone

TOBRADEX ST neomycin-polymyxinB-bacitracin-hydrocortisone, neomycin-polymyxinB-dexamethasone,

tobramycin-dexamethasone

topiramate ext-rel capsule

(generics for QUDEXY XR

only)

carbamazepine, carbamazepine ext-rel, clobazam, divalproex sodium, divalproex sodium ext-rel,

gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine,



topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

TOPROL-XL atenolol, carvedilol, carvedilolphosphateext-rel, metoprololsuccinateext-rel, metoprololtartrate,

nadolol, propranolol, propranololext-rel

TRACLEER ambrisentan, bosentan, OPSUMIT

TRADJENTA JANUVIA

tramadol (NDC^

52817019610 only),

tramadol ext-rel capsule

tramadol (except NDC^ 52817019610), tramadol ext-rel tablet

TRANSDERM SCOP meclizine, scopolamine transdermal

TR AVATAN Z latanoprost, travoprost, ZIOPTAN

TRELSTAR MIXJECT ELIGARD, FIRMAGON

TREXIMET diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH

eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, UBRELVY or ZOMIG

NASAL SPRAY

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.



Excluded drug name(s)

triamcinolone aerosol 0.2%

Preferred option(s)

hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

triamcinolone ointment

0.05%

hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

Trianex hydrocortisone butyrate cream, hydrocortisone butyrate ointment, hydrocortisone butyrate

solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment (except

triamcinolone ointment 0.05%)

TRICOR fenobrate (except fenobrate capsule 50 mg, 130 mg; fenobrate tablet 40 mg, 120 mg), fenobric

acid delayed-rel

TRINAZ

prenatal vitamins, CITRANATAL

TRULANCE lubiprostone, LINZESS

TRUVADA abacavir-lamivudine, emtricitabine-tenofovir disoproxil fumarate, lamivudine-zidovudine, CIMDUO,

DESCOVY, TEMIXYS

TUDORZA SPIRIVA, YUPELRI

UCERIS FOAM hydrocortisoneenema, mesalaminesuppository, mesalaminesuspension, CORTIFOAM

UCERIS TABLET balsalazide, mesalamine delayed-rel (except mesalamine delayed-rel tablet 800 mg), mesalamine

ext-rel, sulfasalazine, sulfasalazine delayed-rel, ASACOL HD, PENTASA

UDENYCA ZIEXTENZO

ULORIC allopurinol

ULTIMED INSULIN

SYRINGES



ULTIMED NEEDLES

BD ULTRAFINE NEEDLES

ULTRAVATE clobetasol cream, clobetasol foam, clobetasol gel, clobetasol lotion, clobetasol ointment,

halobetasol cream, halobetasol ointment

UROXATRAL alfuzosinext-rel, doxazosin, silodosin, tamsulosin, terazosin

VALCYTE valganciclovir

VALTRE X acyclovir (except acyclovir cream, ointment), valacyclovir

VANOS clobetasol cream, halobetasol cream

VARUBI aprepitant

VECTICAL calcipotriene ointment, calcipotriene solution

VELTIN adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

venlafaxine ext-rel tablet

(except 225mg)

desvenlafaxineext-rel, duloxetine, venlafaxine, venlafaxineext-relcapsule

VENTOLINHFA albuterolsulfateCFC-freeaerosol, levalbuteroltartrateCFC-freeaerosol

VERDESO desonide, hydrocortisone

VEREGEN imiquimod, podolox

VESICARE darifenacinext-rel, oxybutyninext-rel, solifenacin, tolterodine, tolterodineext-rel, trospium,

trospiumext-rel, MYRBETRIQ, TOVIAZ

VIAGRA sildenal, tadalal, vardenal

†

VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4. 5, 6)

VIIBRYD citalopram, escitalopram, uoxetine (except uoxetine tablet 60 mg, uoxetine tablet [generics

for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline,

TRINTELLIX

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

VIMOVO

Preferred option(s)

naproxen AND esomeprazole

VIRACEPT atazanavir, lopinavir-ritonavir, EVOTAZ, PREZCOBIX, PREZISTA

VISCO-3 DUROLANE, EUFLEXXA, GELSYN-3, SUPARTZ FX

VITAFOL-ONE

prenatal vitamins, CITRANATAL

VIVELLE-DOT estradiol, DIVIGEL, EVAMIST

VIVLODEX diclofenac sodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

VOGELXO testosteronegel (except authorized generics for TESTIM and VOGELXO), testosteronesolution,

ANDRODERM, NATESTO

VUSION nystatin

WESTHROID levothyroxine, liothyronine

WP THYROID levothyroxine, liothyronine

XALKORI ALECENSA, ALUNBRIG, ZYKADIA

XANAX, XANAX XR alprazolam, clonazepam, diazepam, lorazepam, oxazepam

XENAZINE tetrabenazine, AUSTEDO

XENICAL QSYMIA

, SAXENDA



XERESE acyclovir (except acyclovir cream, ointment), valacyclovir

XIFAXAN200MG sulfamethoxazole-trimethoprim

XIMINO doxycycline hyclate capsule, doxycycline hyclate tablet (except doxycycline hyclate tablet 50 mg

[NDC^ 72143021160 only], 75 mg, 150 mg), minocycline, tetracycline

XOLEGEL ciclopirox, ketoconazole cream 2%

XOPENEXHFA albuterolsulfateCFC-freeaerosol, levalbuteroltartrateCFC-freeaerosol

YASMIN ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-

levonorgestrel, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,

LO LOESTRIN FE, NATAZIA

YAZ ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-

levonorgestrel, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate,

LO LOESTRIN FE

Yuvafem estradiol vaginal cream, IMVEXXY, VAGIFEM

ZALVIT 6 prenatal vitamins, CITRANATAL

ZARXIO NIVESTYM

ZEGERID esomeprazole delayed-rel, lansoprazole delayed-rel, omeprazole delayed-rel, pantoprazole delayed-

rel tablet, DEXILANT

ZELAPAR rasagiline, selegiline

ZEMAIRA PROLASTIN-C

ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

ZESTORETIC fosinopril-hydrochlorothiazide, lisinopril-hydrochlorothiazide, quinapril-hydrochlorothiazide

ZETIA ezetimibe

ZETONNA azelastine-uticasone, unisolide, uticasone, mometasone

ZIANA adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution,

clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin,

EPIDUO, ONEXTON

zileuton ext-rel montelukast, zarlukast

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Coverage may not apply in all plans. Refer to plan documents.

Excluded drug name(s)

ZIPSOR

Preferred option(s)

diclofenacsodium

ZIRGAN triuridine

ZOHYDROER fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, 



ZOLOFT citalopram, escitalopram, uoxetine (except uoxetine tablet 60 mg, uoxetine tablet [generics

for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel (except NDC^ 60505367503), sertraline,

TRINTELLIX

zolpidem sublingual doxepin, ramelteon, temazepam, zolpidem, zolpidem ext-rel

ZOLPIMIST doxepin, ramelteon, temazepam, zolpidem, zolpidem ext-rel

ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin,

lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital,

phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide,

FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT, XCOPRI

ZONTIVITY Consult doctor

ZORTRESS everolimus, sirolimus

ZORVOLEX diclofenacsodium, ibuprofen, meloxicam tablet, naproxen(except naproxen CR or naproxen

suspension)

ZOVIRAX 

ZUPLENZ GRANISETRON, ONDANSETRON, SANCUSO

ZYCLARA 

ZYDELIG COPIKTRA

ZYFLO/ZYFLO CR ZAFIRLUKAST, MONTELUKAST

ZYLET 



ZYMAXID CIPROFLOXACIN, ERYTHROMYCIN, GENTAMICIN, LEVOFLOXACIN, MOXIFLOXACIN, OFLOXACIN,

SULFACETAMIDE, TOBRAMYCIN

ZYTIGA abiraterone, bicalutamide, ERLEADA, XTANDI, YONSA

ZYVOX LINEZOLID

Table 1

Preferred Options For Indication Based Autoimmune Excluded Medications

Condition

Excluded Drug Name(s) Preferred Option(s)

ANKYLOSING

SPONDYLITIS

CIMZIA PREFILLED SYRINGE

SIMPONI

TA LTZ

COSENTYX

ENBREL

HUMIRA

CROHN'S DISEASE CIMZIA PREFILLED SYRINGE HUMIRA

STELARA SUBCUTANEOUS #

PSORIASIS CIMZIA PREFILLED SYRINGE

COSENTYX

ENBREL

HUMIRA

OTEZLA

SKYRIZI

STELARA SUBCUTANEOUS

TA LTZ

TREMFYA

PSORIATIC ARTHRITIS CIMZIA PREFILLED SYRINGE

ORENCIA CLICKJECT

ORENCIA SUBCUTANEOUS

SIMPONI

STELARA SUBCUTANEOUS

TALTZ

TREMFYA

XELJANZ

XELJANZ XR

COSENTYX

ENBREL

HUMIRA

OTEZLA

RHEUMATOID ARTHRITIS ACTEMRA ACTPEN

ACTEMRA SUBCUTANEOUS

CIMZIA PREFILLED SYRINGE

KINERET

SIMPONI

ENBREL

HUMIRA

KEVZARA

ORENCIA CLICKJECT

ORENCIA SUBCUTANEOUS

RINVOQ

XELJANZ

XELJANZ XR

ULCERATIVE COLITIS SIMPONI HUMIRA

STELARA SUBCUTANEOUS #

XELJANZ #

XELJANZ XR #

ALL OTHER CONDITIONS ACTEMRA ACTPEN

ACTEMRA SUBCUTANEOUS

KINERET

ORENCIA CLICKJECT

ORENCIA SUBCUTANEOUS

ENBREL

HUMIRA

# After failure of HUMIRA

The listed formulary options are subject to change.

Advanced Control Plan - Aetna Formulary Exclusions Drug List (1/2022)

Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify

the manufacturer, strength, dosage form, formulation and package size.

†

Listing does not include certain NDCs^.

* Th e preferred options in this list are a broad representation within therapeutic categories of available treatment

options and do not necessarily represent clinical equivalency.

For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or

sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3).

An ACCU-CHEK or ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those

individuals currently using a meter other than ACCU-CHEK or ONETOUCH. For more information on how to obtain a



An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an

excluded medication.

BD ULTRAFINE syringes and needles are the only preferred options.

ACCU-CHEK or ONETOUCH brand test strips are the only preferred optons.

Coverage may not apply in all plans. Refer to plan documents.



Certain drugs may not be covered by your particular pharmacy plan. Diabetic supplies may be covered under your

medical plan.

Information is subject to change.

To check coverage and copay information for a specific medicine, log into your member website. For questions, please

call the toll free number on the back of your member ID card.

Policy forms issued in Oklahoma include: AL OK HCOC, HC COC00010.

Policy forms issued in Missouri include: AL HGrpPol 01R5, HI HGrpAg 05, HO HGrpPol 04, HO GrpPolAmend-

ThirdPartyPay 01.

834500-01-01 (1/22)