Aetna Better Health® of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207 1-866-316-3784
AETNA BETTER HEALTH® June 2016 Formulary Change(s) The following medications will be added to the Aetna Better Health of MI formulary effective June 1, 2016: ABREVA CRE 10% ACIDOPHILUS POW LACTOBAC ACITRETIN CAP 10MG ACITRETIN CAP 17.5MG ACITRETIN CAP 25MG ACTIVE FE TAB 75-1.25 ADEFOV DIPIV TAB 10MG ADEMPAS TAB 0.5MG ADEMPAS TAB 0.5MG ADEMPAS TAB 1MG ADEMPAS TAB 1MG ADEMPAS TAB 1.5MG ADEMPAS TAB 1.5MG ADEMPAS TAB 2MG ADEMPAS TAB 2MG ADEMPAS TAB 2.5MG ADEMPAS TAB 2.5MG ADVANCED BOX AM/PM CALCIUM TAB FORMULA AEROSPAN AER 80MCG AFINITOR DIS TAB 2MG AFINITOR DIS TAB 3MG AFINITOR DIS TAB 5MG AIRAVITE TAB ALBA-LYBE NR LIQ ALKA-SELTZER TAB GOLD ALKA SELTZER TAB HEARTBRN ALLERGY EYE DRO ALLERGY RELF TAB 25MG ALLERGY RELF TAB 25MG ALUM HYDROX SUS 320/5ML AMPYRA TAB 10MG ANECREAM CRE 4% ANTACID MULT CHW SYMPTOM ANTACID ULTR CHW 1000-200 APETIGEN ELX APETIGEN-PLS SOL APETIGEN TAB PLUS APIDRA VIA U-100 APIDRA 5'S PEN SOLOSTAR APRACLONIDIN SOL 0.5% OP
APRISO CAP 0.375GM AQUA-E LIQ ARANESP FREE SYN 10MCG ARKALIOX CAP 200MG ATOVAQUONE SUS 750MG/5 AURYXIA TAB 210MG AV-VITE FB TAB 2.5-25-2 VITAMIN B CAP COMPLEX BD MAGNI- MIS GUIDE B-100 COMPLX TAB B-100 TAB TR BALANCE B-50 TAB B-COMPLEX TAB B-COMPLEX INJ 100 B-COMPLEX/C TAB B-COMPLEX-C CAP B-COMPLEX/ SUB B-12 B-COMPLEX TAB C/FA/BIO BEE ZEE TAB BEELITH TAB BENEFIBER PAK BENEFIBER POW DRINK MX BEROCCA TAB BEXAROTENE CAP 75MG BIFERA TAB 28MG BIFERARX TAB BIOTIN CAP 1MG BIOTIN TAB 300MCG BIOTIN TAB 800MCG BIOTIN TAB 5MG BIOTIN TAB 10MG BIOVOL SYP BLEPHAMIDE SUS -10 OP BLEPHAMIDE OIN OP BONE DENSITY TAB BONE ESSENTI CAP BP VIT 3 CAP BP VIT 3 CAP PLUS BREWERS YEAS TAB 500MG BUDESONIDE CAP 3MG/24HR CAFFEINE POW ANHYDROU CAFFEINE POW CITRATED CAL/MAG TAB CHEW
CALCET PETIT TAB 200250 CALCI-CHEW CHW 1250MG CALCI-MAX CAP CALCI-MIX CAP 1250MG CALCIONATE SYP 1.8GM/5 CALCIPOTRIEN CRE 0.005% CAL-CITRATE TAB PLUS D CALCIUM CARB CHW 500MG+D3 CALCIUM &MAG TAB CALCIUM + D CHW CALCIUM 1000 TAB + D CALCIUM 500 TAB CALCIUM ACET TAB 667MG CALCIUM CARB TAB 648MG CALCIUM CARB CHW 260MG CALCIUM CARB POW CALCIUM CARB POW 800/2GM CALCIUM CL INJ 10% CALCIUM GRA CITRATE CAL CIT MAL/ TAB VITAMIND CA CITRATE TAB PLUS CALCIUM CIT/ TAB VIT D CALC CITRATE TAB +D CA GLUCONATE TAB 50MG CALCIUM GLUC INJ 10% CALCIUM CHW GUMMIES CA LACTATE TAB 100MG CALCIUM LACT TAB 648MG CALCIUM TAB MAGNESIU CALCIUM SOFT CHW CHOCOLAT CALCIUM/C/D CHW 500MG CALC/MAGNES TAB 500250 CAL/MAG/VITD TAB CA/MG/ZN TAB
CALCIUM/VITD CAP 600400 CALC/VIT D3 CHW 200200 CALCIUM+D3 TAB GRAD REL CALMAG THINS TAB 200-50MG CAL-QUICK LIQ 500-400 CALTRATE 600 CHW 600-400 CALTRATE + D TAB 300800 CALTRATE 600 CHW 600-800 CARBINOXAMIN SOL 4MG/5ML CARBINOXAMIN SOL 4MG/5ML CARDIOTEK-RX TAB CAYSTON INH 75MG CENTRATEX CAP CENTRUM POW DRINK CEO-TWO SUP CEREFOLIN TAB CEREFOLN NAC TAB CHELATED CA TAB 200MG CHELATED MG TAB 100MG CIPROFLOXACN SUS 250MG/5 CIPROFLOXACN SUS 500MG/5 CITRACAL+D3 CHW 250500 CLR SOLUBLE POW FIBER COLOX CAP COLYTE/FLAVR SOL PACKS COMPLETE DRO PEDIATRI CORAL CALCIU CAP 1000MG CORAL CALCIU CAP CORAL CAP CALCIUM CORAL CALCIU CAP PLUS CORVITA TAB CORVITA 150 TAB COVARYX TAB 1.25/2.5 COVARYX HS TAB
Aetna Better Health® of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207 1-866-316-3784 Formulary Additions Continued
CROMOLYN SOD SPR 5.2/ACT CVS BIOTIN CAP 10000MCG CVS CALCIUM CHW 250400 CALC CHEWABL CHW 600 PLUS EASY FIBER/ CHW CALCIUM LAX DIET SUP TAB 500MG MINI ENEMA ENE 100/5ML NAT FIBER POW 58.6% CYCLOPHOSPH CAP 25MG CYCLOPHOSPH CAP 50MG CYCLOSERINE CAP 250MG CYTO B7 LIQ 5MG/ML DEWEES CARMI LIQ DEXFERRUM SDV 50MG/ML DIALYVITE TAB DIALYVITE TAB 3000 DIALYVITE TAB 5000 DIALYVITE TAB 800 DIALYVITE TAB 800/IRON DIALYVITE 80 TAB ZINC 15 DIALYVITE TAB SUPREM D VITAMIN D3 TAB 50000UNT DIALYVITE/ TAB ZINC DICLOFENAC GEL 3% DIPHENHYDRAM CAP 50MG DIPHENHYDRAM INJ 50MG/ML DIPHENHYDRAM INJ 50MG/ML CALC/VIT D3 CHW DISNEY DIURIL SUS 250/5ML D-NATURAL-5 CAP DOCUSOL PLUS ENE 20283 DOXERCALCIF CAP 0.5MCG DOXERCALCIF CAP 1MCG DOXERCALCIF CAP 2.5MCG DOXERCALCIF AMP 4MCG/2ML DOXYCYCLINE CAP 75MG DRONABINOL CAP
2.5MG DRONABINOL CAP 5MG DRONABINOL CAP 10MG E-400 CAP SELENIUM E600 CAP 600UNIT ECEE PLUS TAB ELITE-OB TAB ELIXOPHYLLIN ELX 80/15ML ENEMA READY- ENE TO-USE ENEMEEZ MINI ENE E-OIL OIL 30000UNT EPANED SOL 1MG/ML EPINEPHRINE INJ 0.15MG EPSOM SALT GRA EPSOM SALT GRA EQL CALCIUM CAP VIT D CALC GUMMIES CHW CHILD CHILD-MULTI CHW VITAMINS EQUALACTIN CHW 625MG ERIVEDGE CAP 150MG ESSENT ONE TAB DAILY EZFE 200 CAP 200MG E-Z-GAS II GRA FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG FE C TAB TAB 100-250 FENOFIBRATE CAP 50MG FENOFIBRATE CAP 150MG FENOFIBRATE CAP 43MG FENOFIBRATE CAP 43MG FENOFIBRATE CAP 130MG FENOFIBRATE CAP 130MG FENOFIBRIC TAB 35MG FENOFIBRIC TAB 105MG FENOLDOPAM INJ 10MG/ML FEOSOL TAB 45MG FERAHEME VIA 510/17ML FERIVA CAP 75-1MG FERIVA TAB 21/7 FERIVAFA CAP FERRALET 90 TAB FERRAPLUS 90 TAB FERRETTS IPS SOL FERREX 150 CAP FORTE PL FERREX 150 CAP PLUS FERREX 28 TAB
FERRIMIN 150 TAB FERROCITE TAB PLUS FERROUS FUM TAB 29MG FERROUS SULF TAB 140MG CR FERROUS SULF SYP 300/5ML FIBER CHOICE CHW 1.5GM FIBER LAXATV TAB 625MG FIBER POWDER POW FIBER THERAP TAB 500MG FIBER-STAT LIQ FLAREX SUS 0.1% OP FLAVOR PLUS LIQ FLEET LIQUID ENE GLYCERIN FLUOCINOLONE POW ACETONID FML OIN 0.1% OP FOLBEE PLUS TAB FOLBEE PLUS TAB CZ FOLGARD TAB FOLGARD OS TAB FOLIC ACID TAB 400MCG FOLINIC-PLUS TAB 4-502MG FOLITAB 500 TAB FOLIVANE-F CAP FOLIVANE-PLS CAP FOLTANX TAB FOLTRIN CAP FOLTX TAB FORADIL CAP AEROLIZE FORADIL CAP AEROLIZE FORTEO PEN 600/2.4 FOSRENOL CHW 500MG FOSRENOL CHW 750MG FOSRENOL CHW 1000MG FOSRENOL POW 750MG FOSRENOL POW 1000MG FUSION CAP FUSION PLUS CAP GAVILYTE-H KIT FLAV PKS GAVISCON CHW GAVISCON SUS GENTAMICIN POW SULFATE GILENYA CAP 0.5MG GLYCERIN LIQ GLYCERIN SUP 1GM GLYCOPHOS SOL 1MM/ML ANT/ANTI-GAS CHW 1000-60 GOLYTELY POW 1 GAL
PK GOOD START LIQ WATER GYNOL II GEL 3% HECTOROL INJ 2MCG/ML HEMANGEOL SOL 4.28/ML HEMATOGEN CAP HEMATOGEN FA CAP HEMATRON LIQ HEMOCYTE-F TAB HOMOCYSTEINE TAB FORMULA HONEY BEARS CHW IRON-ZIN HUMALOG MIX INJ 50/50KWP HUMIRA SYN 10MG/0.2 HUMULIN INJ 70/30KWP HUMULIN N INJ U100KWP HYCAMTIN CAP 0.25MG HYCAMTIN CAP 1MG HYDRALAZINE INJ 20MG/ML HYDROCIL INS POW 95% HYDROCORT AC POW HYDROCORT POW HYDROCORT/ CRE ALOE 1% HYDROMORPHON LIQ 1MG/ML HYFIBER WITH LIQ FOS I.L.X. B-12 ELX INCRELEX VIA 40MG/4ML INCRUSE ELPT INH 62.5MCG INCRUSE ELPT INH 62.5MCG INFUVITE INJ INJECTAFER VIA 750/15ML INTEGRA CAP INTRON-A SOL MDV 18MU/3ML INTRON-A SOL MDV 25MU/2.5 INTRON-A POW VIA 10 MIL U INTRON-A POW VIA 18 MIL U INTRON-A POW VIA 50 MIL U IRON TAB 18MG IRON TAB 28MG IRON 21/7 MIS IRON CHEWS CHW PEDIATRI IRON FORMULA CAP IRON UP LIQ IS 24/6 MIS
Aetna Better Health® of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207 1-866-316-3784 Formulary Additions Continued
JAKAFI TAB 5MG JAKAFI TAB 10MG JAKAFI TAB 15MG JAKAFI TAB 20MG JAKAFI TAB 25MG JUNEL (24) TAB 1/20FE KOBEE TAB KONDREMUL EMU 50% KONSYL POW 60.3% KONSYL POW 71.67% KONSYL POW 28.3% KONSYL POW 60.3% KONSYL-D POW 52.3% KP B COMPLEX TAB /C KP CALCIUM CAP 600+D KP CA/MG/ZN TAB DIPHENHYDRAM CAP 50MG FOLIC ACID TAB 800MCG KP VITAMIN E CAP 100UNIT KRISTALOSE PAK 10GM KRISTALOSE PAK 20GM LAMISIL AF AER 1% LAMIVUDINE TAB 100MG LANTUS SOLO PEN 100U/ML LETAIRIS TAB 5MG LETAIRIS TAB 5MG LETAIRIS TAB 10MG LETAIRIS TAB 10MG LEUCOVORIN POW CALCIUM LEUPROLIDE KIT 2 WEEK LINEZOLID TAB 600MG LINEZOLID SUS 100/5ML LIQUAFIBER LIQ 5GM/15ML LIQUID CALCI CAP WITH D3 LIQ CA/VIT D CAP 600MG LIQUI-E LIQ 400/15ML L-METHYL-MC TAB NAC LO LOESTRIN TAB FE 1/10 LOCALNESIUM TAB LOCALNESIUM TAB -C LYDIA PINKHA TAB M2 B125 TAB TR MAG-AL LIQ MAG-DELAY TAB MAGINEX TAB 615 MG MAGNEBIND TAB 300 MAGNEBIND TAB 400 MAGNESIUM CAP 400MG MAGNESIUM CL VIA 20% MAG CITRATE SOL
GRAPE MAG CITRATE TAB 100MG MAGNESIUM CAP 300MG MAGNESIUM TAB 30MG MAGNESIUM GL TAB 500MG MAGNESIUM GL TAB 550MG MAGNESIUM GL TAB 500MG MAG OXIDE CAP 400MG MAGNESIUM SU INJ 50% MAGNESIUM SU INJ 2/50ML MAGNESIUM SU INJ 4/100ML MAGNESIUM SU INJ 20/500ML MAGNESIUM SU INJ 40/1000 MAGNESIUM SU INJ 80MG/ML MG SO4/D5W INJ 10MG/ML MAGONATE TAB 500MG MAGONATE LIQ 1000/5ML MAG-TAB SR TAB 84MG MAXARON TAB FORTE MAXFE TAB MEPERIDINE TAB 50MG MEPERIDINE TAB 100MG MEPERIDINE SOL 50MG/5ML MERIBIN CAP 5MG METAMUCIL WAF METAMUCIL WAF CINNAMON METAMUCIL POW 55.46% METAMUCIL POW 58.12% METAMUCIL POW 28% METANX CAP MILLGUARD TAB MINASTRIN 24 CHW FE MINERAL OIL MOTION SICK TAB 50MG MOVIPREP SOL MULTI-DELYN LIQ /IRON MULTIGEN TAB MULTIGEN TAB FOLIC MULTIGEN TAB PLUS MYKIDZ IRON SUS 10MG/2ML MYKIDZ IRON SUS 15/1.5ML MYNATE 90 TAB PLUS NAPROXEN CR TAB
100U/ML NOVOLOG70/30 PEN F/P MIX NOVOLOG 5'S CRT 100U/ML NUFERA TAB NU-IRON 150 CAP 150MG NUTRISOURCE CAN FIBER NUTRIVIT LIQ 800-15-1 OBSTETRIX PAK DHA OBSTETRIX EC TAB OCTREOTIDE VIA 50MCG/ML OCTREOTIDE VIA 100MCG OCTREOTIDE VIA 0.2MG/ML OCTREOTIDE VIA 1MG/ML OMEGA-3-ACID CAP 1GM(L) OMEGA-3-ACID CAP 1GM OPTIMAL-D CAP 50000UNT ORAL SALINE SOL LAXATIVE ORPHENADRINE TAB 100MG ER OS-CAL EXTRA TAB D3 OSMOPREP TAB 1.5GM OSTEO-PORETI TAB PA WOMENS PAK VITAPAK PARICALCITOL INJ 2MCG/ML PARICALCITOL INJ 5MCG/ML PARVA-CAL TAB 500MG PARVA-CAL TAB 250-100 SORBITOL MIS LOLLIPOP PEDIA-LAX CHW 400MG PEDIA-LAX SUP 2.8GM PEDIALAX FBR CHW GUMMIES PERFECT IRON TAB 25MG PHILLIPS CHW 311MG PHOSLYRA SOL PHOS-NAK POW PACKET PHOSPHOLINE SOL 0.125%OP PODIAPN CAP POLYSACCHARI CAP IRON POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG POTABA CAP 500MG POT PHOSPHAT INJ
Aetna Better Health® of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207 1-866-316-3784 Formulary Additions Continued
POT PHOSPHAT INJ 3MM/ML POT PHOSPHAT INJ 150MM/50 PREDNISOLONE SOL 5MG/5ML PREFERA OB TAB 28-61MG PREFERA OB TAB PRELIEF TAB PRENATAL MUL CAP +DHA PRENATE AM TAB 1MG PREPOPIK PAK ORANGE PRIMAQUINE TAB 26.3MG PROFE CAP 180MG PROFERRIN ES TAB 12 MG PROFERRIN- TAB FORTE CALCIUM+D3 TAB 600800 PROPARACAINE SOL 0.5% OP PROSTATE CAP 140MG PROTECTIRON TAB PULMOZYME SOL 1MG/ML PYRIMETHAMIN POW RA B-COMPLEX TAB VIT C TR RA BIOTIN CAP 2500MCG RA BIOTIN TAB 1000MCG RA CA/BORON TAB RA CA/MG/ZN/ TAB CU RA CORAL CAP CALCIUM FIBER WEIGHT CHW MANAGEME RA OYS SHL/D TAB 250MG RA SENNA CAP 8.6MG SLOW RELEASE TAB 45MG RA VITAMIN E OIL 28000UNT RANEXA TAB 500MG RANEXA TAB 1000MG RASPBERRY SYP RENAGEL TAB 400MG
RENAGEL TAB 800MG REVLIMID CAP 20MG RX SUPPORT TAB HEARTBUR SAFYRAL TAB SCOOBY-DOO CHW SENNA LEAVES MIS SENNA PROMPT CAP 9500MG SE-TAN PLUS CAP SLOW MAGNES/ TAB CALCIUM SLOW IRON TAB 50MG SLOW-MAG TAB CALCIUM 600 CHW +D/MINER CALCIUM SOFT CHW MLK CHOC SM CALCIUM CHW SM CA/MG/ZN TAB SM CORAL CAL TAB 1000MG SM ESTROPLUS TAB EX ST SM IRON TAB 45MG MINERAL OIL ENE SM VIT B-1 TAB 100MG FERRIC GLUCO INJ 12.5/ML SOD PHOSPHAT INJ 3MM/ML SOLUBLE FIB POW THERAPY SORBITOL POW STIMATE SOL 1.5MG/ML SUCLEAR KIT SUPER B-100 TAB TR SUPER B-COMP TAB IRON/C SUPER CAL/ TAB MAG SUPERVITE LIQ SUPERVITE EC TAB SUPPORT-500 CAP SUPREP BOWEL SOL PREP TACROLIMUS OIN 0.03% TACROLIMUS OIN 0.1% TANDEM CAP TARON FORTE CAP TARON-BC PAK TECFIDERA CAP 120MG TECFIDERA CAP 240MG
TECFIDERA MIS STARTER TEKTURNA TAB 150MG TEKTURNA TAB 300MG TEKTURNA HCT TAB 150-12.5 TEKTURNA HCT TAB 150-25MG TEKTURNA HCT TAB 300-12.5 TEKTURNA HCT TAB 300-25MG TESTOST CYP MDV 100MG/ML ANTACID EXTR CHW 675-135 EYE ALLERGY SOL RELIEF THERAFLU DT LIQ WARM RLF TINIDAZOLE TAB 250MG TINIDAZOLE TAB 500MG TL GARD RX TAB TL-HEM 150 TAB TOBI PODHALR CAP 28MG TODAY SPONGE MIS TOLTERODINE CAP 2MG ER TOLTERODINE CAP 4MG ER TOTAL B/C TAB TRACLEER TAB 62.5MG TRACLEER TAB 62.5MG TRACLEER TAB 125MG TRACLEER TAB 125MG TRECATOR-FC TAB 250MG TRIAMCINOLON POW ACETONID TRIGELS-F CAP FORTE TRI-LO- TAB SPRINTEC TRIPHROCAPS CAP TRI-TABS DHA MIS TRI-VI-FLORO SUS 0.25/ML TRI-VI-FLORO SUS 0.5MG/ML TUMS CHW DEL CHW 1177MG UDAMIN SP TAB ULTRA MAN TAB UNIFIBER POW UPCAL D POW
UPCAL D POW URO-MAG CAP 140MG VALGANCICLOV TAB 450MG VANCOMYCIN INJ 750MG VCF VAGINAL AER CONTRACP VELPHORO CHW 500MG VENOFER VIA 20MG/ML VERAPAMIL PM CAP 100MG24H VERAPAMIL PM CAP 200MG24H VITAL-D RX TAB VITAMAX PED DRO VITAMIN B-1 TAB 50MG VITAMIN B-1 TAB 100MG VITAMIN B-2 TAB 25MG VITAMIN E CAP 200IU VITAMIN E CAP 1000UNIT VITAMIN E TAB 100UNIT VITAMIN E DRO 15/0.3ML VITA-PLUS E CAP 400UNIT VITA-PLUS G CAP VITA-RESPA TAB VITRON-C TAB 65-125 WAL-FLU LIQ 10-5-325 WAL-MUCIL CAP PLUS CA WEE CARE SUS 15/1.25 WHEAT GERM OIL XARELTO TAB 10MG XARELTO TAB 15MG XARELTO TAB 20MG XTANDI CAP 40MG ZENCHENT FE CHW 0.4MG-35 ZOLMITRIPTAN TAB 2.5MG ZOLMITRIPTAN TAB 5MG ZOLMITRIPTAN ODT 2.5 MG ZOLMITRIPTAN ODT 5MG ZYTIGA TAB 250MG
Aetna Better Health® of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207 1-866-316-3784
The following medications will be removed from the common formulary and will no longer be formulary agents effective June 1, 2016: 6ML LUER LOK MIS 20GX1" 6ML LUER LOK MIS 21GX1.25 6ML LUER LOK MIS 22GX1" 6ML LUER LOK MIS 22GX1.25 6ML LUER LOK MIS 23GX1" 6ML LL SYRNG MIS 20GX1.5" 6ML LL SYRNG MIS 21GX1" 6ML LL SYRNG MIS 22GX1.5" A+D PREVENT OIN ACETAMINOPHE TAB 650MG ACETAMIN JR TAB 160MG RT ACYCLOVIR OIN 5% ALBENZA TAB 200MG ALBUSTIX TES STRIPS ALBUTEROL TAB 4MG ER ALBUTEROL TAB 8MG ER ALCLOMETASON CRE 0.05% ALCLOMETASON OIN 0.05% ALENDRONATE SOL 70/75ML ALFUZOSIN ER TAB 10MG AMCINONIDE CRE 0.1% AMCINONIDE LOT 0.1% AMCINONIDE OIN 0.1% AMETHIA (91) TAB LO AMLOD/ATORVA TAB 2.5/10MG AMLOD/ATORVA TAB 2.5/20MG AMLOD/ATORVA TAB 2.5/40MG AMLOD/ATORVA TAB 5/10MG AMLOD/ATORVA TAB 5/20MG AMLOD/ATORVA TAB 5/40MG AMLOD/ATORVA TAB 5/80MG AMLOD/ATORVA TAB 10/10MG AMLOD/ATORVA TAB 10/20MG AMLOD/ATORVA TAB 10/40MG AMLOD/ATORVA TAB
10/80MG AML/VAL/HCT5 TAB 160-12.5 AML/VAL/HC10 TAB 160-12.5 AML/VAL/HC10 TAB 160-25 AML/VAL/HC10 TAB 320-25 ANDRODERM DIS 2MG/24HR ANDRODERM DIS 4MG/24HR ANDROGEL 1% PAK 25MG ANDROGEL1.62 PUM 20.25ACT ANTACID SUS ULTRA ST ANTI-NAUSEA SOL 1ML SYRINGE MIS 23GX1" AVANDAMET TAB 2500MG AVANDAMET TAB 21000MG AVANDAMET TAB 4500MG AVANDAMET TAB 41000MG AVANDARYL TAB 4-1MG AVANDARYL TAB 4/2MG AVANDARYL TAB 4/4MG AVANDARYL TAB 8-2MG AVANDARYL TAB 8/4MG AVANDIA TAB 2MG AVANDIA TAB 4MG AVANDIA TAB 8MG AVAR CLEANSE EMU 105% AZASAN TAB 75 MG AZASAN TAB 100MG AZELASTINE SPR NSL.15% AZOPT SUS 1% OP BD 1CC SYR 26GX5/8" BD ECLIP 1ML SYN 27GX1/2" BD ECLIP 1ML SYN 30GX1/2" BD INS 1CC SYN 27X5/8 BD INS 1CC SYN 26GX.5" BD INS 2CC SYN 27.5X5/8 BD INTEG 1ML SYN 25GX5/8" BD PR GL 1ML MIS 20GX1" BD SFGL INS SYN 27GX5/8"
BARACLUDE SOL .05MG/ML INSULIN SYRG MIS 0.3/28G INSULIN SYRG MIS 1ML/25G INSULIN SYRG MIS 2ML/29G INSULIN SYRG MIS 1ML/25G BENAZEPR HCT TAB 56.25MG BENAZEPR HCT TAB 1012.5 BENAZEPR HCT TAB 2025MG BENICAR TAB 5MG BENICAR TAB 20MG BENICAR TAB 40MG BENICAR HCT TAB 2012.5 BENICAR HCT TAB 4012.5 BENICAR HCT TAB 4025MG BENZIQ WASH LIQ 5.25% BETAMETH DIP OIN 0.05% BETOPTIC-S SUS 0.25% OP BIMATOPROST SOL 0.03% OP BIOTUSS LIQ BP 10-1 EMU WSH BP CLEANSING LOT 4% BP CLEANSING EMU 104% MULTINATAL TAB PLUS MULTINATAL CHW PLUS BP WASH LIQ 2.5% BROMPHENIRAM CHW 12MG BUT/APAP/CAF CAP 300 BUT/APAP/CAF CAP 300W/COD BUTORPHANOL SPR NASAL BYETTA PEN 5MCG BYETTA PEN 10MCG CAFERGOT TAB 1100MG CAMRESE TAB CANASA SUP 1000MG CAPTOPR/HCTZ TAB 2515MG CAPTOPR/HCTZ TAB 2525MG CAPTOPR/HCTZ TAB 50-
15MG CAPTOPR/HCTZ TAB 5025MG CAPZASIN-P CRE 0.035% CARB/ENTACAP TAB LEVO 50 CARB/ENTACAP TAB LEVO 75 CARB/ENTACAP TAB LEVO 100 CARB/ENTACAP TAB LEVO 125 CARB/ENTACAP TAB LEVO 150 CARB/ENTACAP TAB LEVO 200 CARISOPRODOL TAB 250MG CARISOPR/ASA TAB 200325 CARISOPR/ASA TAB W/COD CEFTIN SUS 125/5ML CEFTIN SUS 250/5ML CEFTRIAXONE INJ 1GM CEFTRIAXONE INJ 2GM CEPHALEXIN TAB 250MG CEPHALEXIN TAB 500MG CHILD APAP TAB 80MG CHLD ASAFREE ELX 80/2.5ML CHILD COMPLE CHW ALLERGY CHLORHEX GLU SOL 20% CHO MAG TRIS TAB 1000MG CICLOPIROX GEL 0.77% CICLOPIROX SHA 1% CICLOPIROX SUS 0.77% TS CICLOPIROX KIT 8% SOL CILOXAN OIN 0.3% OP CIPRO HC SUS OTIC CIPROFLOXACN TAB 500MG ER CIPROFLOXACN TAB 1000M ER CLARITHROMYC TAB 500MG ER CLEOCIN VAG OVU 100MG CLIMARA PRO DIS WEEKLY CLINDAMYCIN AER 1% CLINDAMY/BEN GEL 15%(B) CLINITEST TES CHLD RES Formulary Deletions Continued
Aetna Better Health® of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207 1-866-316-3784 Formulary Deletions Continued
CLOBETASOL AER .05%FOAM CLOBETASOL GEL 0.05% CLOBETASOL LOT 0.05% CLOBETASOL SHA 0.05% CLOBETASOL CRE EMOL.05% CLONIDIN-TTS DIS 0.1/24HR CLONIDIN-TTS DIS 0.2/24HR CLONIDIN-TTS DIS 0.3/24HR CLOTRIM/BETA LOT 1%0.05% COLOCORT ENE 100MG COMBIGAN SOL 0.2/0.5% COMBIPATCH DIS .05/.14 COMBIPATCH DIS .05/.25 CONDYLOX GEL 0.5% CORTAID SPR 1% CORTIC-ND SOL OTIC CORTIFOAM AER RECTAL CORTISONE AC TAB 25MG CREME DE OIL MENTHE CUPRIMINE CAP 250MG CUTAR OIL 7.5% CVS VIT B-6 TAB 200MG CYCLOPHOSPH TAB 25MG CYCLOPHOSPH TAB 50MG CYTRA-3 SYP VITAMIN D3 CHW 1000UNIT D3 DOTS TAB 2000UNIT DANTROLENE CAP 25MG DANTROLENE CAP 50MG DANTROLENE CAP 100MG DAYTIME PE CAP COLD/FLU DEMAREST CRE DRICORT DEMECLOCYCL TAB 150MG DEMECLOCYCL TAB 300MG DESONIDE CRE 0.05% DESONIDE LOT 0.05% DESONIDE OIN 0.05% DESOXIMETAS CRE 0.05% DESOXIMETAS CRE 0.25%
DESOXIMETAS GEL 0.05% DESOXIMETAS OIN 0.05% DESOXIMETAS OIN 0.25% DM/CPM/PE DRO DIASTIX TES STRIPS DIFLORASONE CRE 0.05% DIFLORASONE OIN 0.05% DIFLUNISAL TAB 500MG DIHYDROERGOT SPR 8X4MG/ML DILTIAZEM ER CAP 60MG/12 DILTIAZEM ER CAP 90MG/12 DILTIAZEM ER CAP 120MG/12 DILTIAZEM CD CAP 360/24HR DIPENTUM CAP 250MG DONEPEZIL ODT 10MG DONEPEZIL ODT 5MG DOXYCYCL HYC TAB 150MG DR DOXYCYCL HYC TAB 100MG DR DOXYCYC MONO TAB 75MG DOXYCYC MONO TAB 150MG DUREX MIS REALFEEL E.S.P. SUS 200-600 1ML SYRINGE MIS 25GX1" ED CHLORPED SYP JR PAIN RELIEF TAB 325MG EF INSULIN SYRG MIS 0.5/28G INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 1ML/28G INSULIN SYRG MIS 1ML/29G EMEND CAP 40MG EMEND BIFLD KIT 80MG2DAY EMEND CAP 125MG6'S EMEND TRIFLD KIT 12580MG ENDACOF-C LIQ 210/5ML ENOXAPARIN MDV 300MG/3M ENTACAPONE TAB 200MG ENTRE-B SUS 6-10MG/5 EPINASTINE DRO 0.05%
EQ ASPIRIN TAB 500MG EC EQL NATURAL POW FIBER ERGOMAR SUB 2MG ERY PAD 2% ERYPED SUS 400/5ML ERYTHROCIN TAB 250MG ERYTHROMYCIN GEL 2% ESTRING VAG RING 2MG ETODOLAC CAP 200MG ETODOLAC CAP 300MG ETODOLAC TAB 400MG ETODOLAC TAB 500MG ETODOLAC ER TAB 400MG ETODOLAC ER TAB 500MG ETODOLAC ER TAB 600MG EXELON DIS 4.6MG/24 EXELON DIS 9.5MG/24 EXELON DIS 13.3/24 EXTAVIA INJ KIT 0.3MG FAMOTIDINE SUS 40MG/5ML FEMCAP MIS 26MM FEMCAP MIS 30MM FEMRING MIS .05MG/24 FEMRING MIS 0.1MG/24 FENTANYL OT LOZ 200MCG FENTANYL OT LOZ 400MCG FENTANYL OT LOZ 600MCG FENTANYL OT LOZ 800MCG FENTANYL OT LOZ 1200MCG FENTANYL OT LOZ 1600MCG FIRST AID OIN ANTIBIOT FISH OIL CAP 435MG FISH OIL CAP 1400MG FLOVENT HFA INH 44MCG/AC FLOVENT HFA INH 110MCG/A FLOVENT HFA INH 220MCG/A FLUOCINOLONE SOL 0.01% FLUOCINOLONE CRE 0.01% FLUOCINOLONE CRE 0.025% FLUOCINOLONE OIN 0.025% FLUOCINONIDE CRE 0.1% FLUOCINONIDE GEL
0.05% FLUORABON DRO FLUOR-A-DAY CHW 0.25MG F FLUOR-A-DAY CHW 0.5MG F FLUOR-A-DAY CHW 1MG F FLUORIDEX DD PST SENSITIV FLUOROPLEX CRE 1% FLUOROURACIL SOL 2% FLUOROURACIL SOL 5% FLURA-DROPS DRO 4DRP=1MG FLURBIPROFEN TAB 100MG FLUTICASONE CRE 0.05% FOSINOP/HCTZ TAB 10/12.5 FOSINOP/HCTZ TAB 20/12.5 FRAGMIN INJ 10000/ML FRAGMIN INJ 2500/0.2 FRAGMIN INJ 5000/0.2 FRAGMIN INJ 7500/0.3 FRAGMIN INJ 12500UNT FRAGMIN INJ 15000UNT FRAGMIN INJ 18000UNT FRAGMIN MDV 25000/ML GALANTAMINE TAB 4MG GALANTAMINE TAB 8MG GALANTAMINE TAB 12MG GALANTAMINE CAP ER 8MG GALANTAMINE CAP ER 16MG GALANTAMINE CAP ER 24MG GATIFLOXACIN SOL 0.5% GLUCOSE CHW 5GM GLYCERIN LIQ GRAFCO SILVR MIS NIT APPL HEADACHE TAB 25500MG HEMRIL-30 SUP 30MG HEPAGAM B INJ HEPARIN SOD SYN 5000/0.5 HEPARIN SOD MDV 20000/ML HYDROC/APAP TAB 2.5325 HYDROC/HOMAT TAB 51.5MG HYDROCORT SOL BUT 0.1%
Aetna Better Health® of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207 1-866-316-3784 Formulary Deletions Continued
HC BUTYRATE CRE 0.1% HC BUTYRATE OIN 0.1% HC BUTYRATE CRE 0.1% HC VALERATE OIN 0.2% HC/IODOQUINO CRE 11% HYDROMORPHON TAB 8MG HYPERHEP B SYR S/D HYPERSAL3.5% NEB 4ML X 60 IMPLANON IMP 68MG INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 0.5/27G IONIL-T SHA 1% IRON TAB 28MG IVERMECTIN TAB 3MG JOHNSONS POW BABY KARIDIUM DRO 0.125MG KLOR-CON-25 POW 25MEQ KLOR-CON M15 TAB INSULIN SYRG MIS 0.3/30G INSULIN SYRG MIS 0.5/29G KP OMEGA-3 CAP 1200MG LANOXIN TAB 0.0625MG LANOXIN TAB 0.1875MG LESCOL XL TAB 80MG LEUKINE VIA 250MCG LEVALBUTEROL NEB 1.25/0.5 LEVALBUTEROL NEB 0.31/3ML LEVALBUTEROL NEB 0.63/3ML LEVALBUTEROL NEB 1.25/3ML LEVEMIR VIA 100U/ML LEVOBUNOLOL SOL 0.25% OP LEVOFLOXACIN SOL 25MG/ML LIDOCAINE OIN 5% LIDOCAINE SOL 4% LIDOCAINE SOL TOPCL 4% LIDOCAINE LOT 3% LIDOCAINE/HC KIT 20X7GM LIDOCAINE/HC KIT 3%1% LIDO/PRILOCN KIT 2.52.5% LIOTHYRONINE TAB 25MCG LIOTHYRONINE TAB
50MCG LITTLE TUMMY DRO LAXATIVE LUMIGAN SOL 0.01% OP MACRODANTIN CAP 25MG MAPAP APAP LIQ 500/15ML MATZIM LA TAB 240MG/24 MATZIM LA TAB 360MG/24 MATZIM LA TAB 420MG/24 MECLOFEN SOD CAP 50MG MECLOFEN SOD CAP 100MG MEGACE ES SUS 625/5ML MELOXICAM SUS 7.5/5ML M-END DM LIQ M-END WC LIQ METAPROTEREN SYP 10MG/5ML METAXALONE TAB 800MG METHOXSALEN CAP 10MG METHYLTESTOS CAP 10MG METOPRL/HCTZ TAB 100-50MG METRONIDAZOL CAP 375MG METRONIDAZOL GEL 0.75% METRONIDAZOL GEL 1% METRONIDAZOL LOT 0.75% MICONAZOLE 3 CRE 4% MICRHOGAM PL SYN 50MCG MIGERGOT SUP 2/100 MIGRAINE TAB FORMULA MINOCYCLINE TAB 50MG MINOCYCLINE TAB 75MG MINOCYCLINE TAB 100MG MINOCYCLINE TAB 45MG ER MINOCYCLINE TAB 90MG ER MINOCYCLINE TAB 135MG ER MIRENA IUD SYSTEM MODERIBA TAB 200MG MODERIBA PAK 600/DAY
MODERIBA PAK 1000/DAY MOEXIPRIL TAB 7.5MG MOEXIPRIL TAB 15MG MOEXIPR/HCTZ TAB 7.512.5 MOEXIPR/HCTZ TAB 1512.5 MOEXIPR/HCTZ TAB 1525MG INSULIN SYRG MIS 1ML/27G 6ML SYRINGE MIS 21GX1.5" MORPHINE SUL SUP 5MG MORPHINE SUL SUP 10MG MORPHINE SUL SUP 20MG MORPHINE SUL SUP 30MG MORPHINE (K) CAP 10MG ER MORPHINE (K) CAP 20MG ER MORPHINE SUL CAP 30MG ER MORPHINE (K) CAP 50MG ER MORPHINE SUL CAP 60MG ER MORPHINE SUL CAP 80MG ER MORPHINE SUL CAP 100MG ER MOTRIN PM TAB 20038MG MOZOBIL VIA 24MG/1.2 MUCUS-DM TAB 30600MG MULTAQ TAB 400MG MULTISTIX 10 TES SG STRIP MUPIROCIN CRE 2% NADOLOL/BEND TAB 405MG NADOLOL/BEND TAB 805MG NALTREXONE TAB 50MG NAMENDA SOL 10MG/5ML NAPROXEN SOD TAB 275MG NAPROXEN SOD TAB 550MG NASAL MIST AER 0.9% NASOHIST DRO 12MG/ML NEBUSAL 6% NEB 4MLX60 NEOTUSS LIQ NEUAC GEL 1.2-5%
NEULASTA INJ 6MG/0.6M NEULASTA ONP KIT 6MG/0.6M NEUMEGA INJ 5MG SOD FLUORIDE SOL 0.2%GRAP NIACIN POW USP/NF NIACIN TAB 500MG TR NISOLDIPINE TAB 8.5MG ER NISOLDIPINE TAB 17MG ER NISOLDIPINE TAB 20MG ER NISOLDIPINE TAB 30MG ER NISOLDIPINE TAB 34MG ER NISOLDIPINE TAB 40MG ER NISOLDIPINE TAB ER25.5MG NITRATEST TES PAPER NIZATIDINE CAP 150MG NIZATIDINE CAP 300MG NIZATIDINE SOL 15MG/ML NON-ASPIRIN CHW 160MG JR NYSTAT ORAL POW 50MILU NYSTAT/TRIAM CRE NYSTAT/TRIAM OIN OFLOXACIN TAB 300MG OLOPATADINE SOL 0.1% OP OMEGA-3 FISH CAP 300MG OMEPRAZOLE + SUS SYRSPEND OMNIFLEX DPR OMNITROPE VIA 5.8MG ORTHO COIL DPR KIT 50 ORTHO COIL DPR KIT 100 ORTHO COIL DPR KIT 105 ORTHO FLAT DPR KIT 55 ORTHO FLAT DPR KIT 60 ORTHO FLAT DPR KIT 65 ORTHO FLAT DPR KIT 70 ORTHO FLAT DPR KIT 75 ORTHO FLAT DPR KIT 80 ORTHO FLAT DPR KIT 85 ORTHO FLAT DPR KIT 90 ORTHO FLAT DPR KIT 95 OXAPROZIN TAB 600MG OXYCODONE CAP 5MG OXYCODONE TAB 10MG OXYCODONE TAB 15MG OXYCODONE TAB 20MG OXYCODONE TAB 30MG
Aetna Better Health® of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207 1-866-316-3784 Formulary Deletions Continued
OXYCODONE CON 100/5ML OXYCOD/APAP TAB 2.5325 OXYCOD/ASA TAB OXYMORPHONE TAB HCL 5MG OXYMORPHONE TAB HCL 10MG OXYMORPHONE TAB 5MG ER OXYMORPHONE TAB 7.5MG ER OXYMORPHONE TAB 10MG ER OXYMORPHONE TAB 15MG ER OXYMORPHONE TAB 20MG ER OXYMORPHONE TAB 30MG ER OXYMORPHONE TAB 40MG ER OYST SHELL/D TAB 600MG PANOXYL-8 LIQ CREM WSH PERINDOPRIL TAB 8MG PHENYLEPHRIN SOL 10% OP PHENYTEK CAP 200MG PHENYTEK CAP 300MG PILOCARPINE TAB 7.5MG PIOGLITA/MET TAB 15/500MG PIOGLITA/MET TAB 15/850MG PIOGLIT/GLIM TAB 302MG PIOGLIT/GLIM TAB 304MG PNEUMOVAX-23 INJ /1 DOSE PNV-DHA CAP PNV-SELECT TAB POT CHLORIDE TAB 20MEQ ER POT CITRATE TAB 15MEQ PRAMOXINE-HC DRO AQ OTIC PRANDIMET TAB 1500MG PRANDIMET TAB 2500MG PREDNICARBAT CRE 0.1% PREDNICARBAT OIN 0.1% PREFEST TAB PRENATAL 19 TAB
PRENTIF MIS 22MM PRENTIF MIS 25MM PRENTIF MIS 28MM PRENTIF MIS 31MM PRENTIF MIS FITTING PREVACID SOL ODT 15MG PREVACID SOL ODT 30MG PRIFTIN TAB 150MG PROCTOFOAM AER HC 1% PROCTOSOL HC CRE 2.5% PROMACTA TAB 12.5MG PROMACTA TAB 25MG PROMACTA TAB 50MG PROMACTA TAB 75MG PROMETH VC SYP 6.255/5 PROMETH VC SYP /CODEINE PROPANTHELIN TAB 15MG PROPRAN/HCTZ TAB 40/25 PROPRAN/HCTZ TAB 80/25 PTS PANEL TES KET STRP PYRIDOSTIGM TAB 60MG INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/30G INSULIN SYRG MIS 1ML/29G INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 1ML/30G QUINIDINE GL TAB 324MG CR RA ASPIRIN TAB 500MG RA CALCIUM TAB HI-CAL RA CALCIUM TAB HIGH POT GUMMY VIT/ CHW MINERALS HEARING AID MIS BATTERY RA THERAPETC SHA SHAMPOO RAPAMUNE SOL 1MG/ML REBETOL SOL 40MG/ML REBIF PFS 22/0.5 REBIF PFS 44/0.5 REBIF 12'S SOL TITRATIO REBIF REBIDO SYN 22/0.5 REBIF REBIDO SYN 44/0.5
REBIF REBIDO INJ TITRATN INSULIN SYRG MIS 0.3/30G RELPAX TAB 20MG RELPAX TAB 40MG REMICADE INJ 100MG RESERPINE TAB 0.1MG RESERPINE TAB 0.25MG RHEUMATREX TAB 2.5MG2X4 RHOGAM PLUS SYN 300MCG RHOPHYLAC INJ 1500/2ML RIBASPHERE TAB 400MG RIBASPHERE TAB 600MG RIBAVIRIN CAP 200MG#56 RIDAURA CAP 3MG RIFAMATE CAP RILUZOLE TAB 50MG ROBITUSSIN LIQ 15MG/5ML ROPINIROLE TAB 2MG ER ROPINIROLE TAB 4MG ER ROPINIROLE TAB 6MG ER ROPINIROLE TAB 8MG ER ROPINIROLE TAB 12MG ER SALICYLIC AC CRE 6% SALICYLIC AC GEL 6% SALICYLIC AC LOT 6% SALICYLIC AC SHA 6% SALSALATE TAB 500MG SALSALATE TAB 750MG SAVELLA TAB 12.5MG SAVELLA TAB 25MG SAVELLA TAB 50MG SAVELLA TAB 100MG SAVELLA MIS TITR PAK SB FIB LAX POW 30% SB FIB LAX POW 33% SCALACORT LOT 2% SCALPICIN LIQ 3% SE BPO WASH LIQ 7% SELECT-OB TAB CHEW/PO SELECT-OB+ PAK DHA SELEGILINE TAB 5MG SM SORE LOZ THROAT SOD CHLORIDE NEB 3% 15ML SODIUM CHLOR NEB 10% SOD FLUORIDE TAB 0.5MG F SOD FLUORIDE TAB 1MG
F SOD SUL/SULF LIQ 94.5% SOD SUL/SULF SUS 105% SOD SUL/SULF LOT 105% SOD SUL/SULF PAD 104% SOD SUL/SULF PAD 105% SOLTAMOX SOL 10MG/5ML SOMATULINE INJ 60/0.2ML SOMATULINE INJ 90/0.3ML SOMATULINE SYN 120/.5ML SORBITOL SOL 70% SPORANOX SOL 10MG/ML STAN FLUORID CON 0.63%MNT SULFACETAMID SUS 10% SODIUM SULFA LIQ 10% WASH SULFADIAZINE TAB 500MG SUMATRIPTAN SPR 5MG/ACT SUMATRIPTAN SPR 20MG/ACT SUMATRIPTAN KIT 6MG 2'S SUNRISE NEB CPM #2655D SUPRAX CHW 100MG SUPRAX CHW 200MG SUPRAX SUS 100/5ML SUPRAX SUS 200/5ML SYSTANE BAL SOL RESTOR TARGRETIN GEL 1% TARON-C DHA CAP INSULIN SYRG MIS 0.3/30G TERUMO INS SYN 0.5/30G INSULIN SYRG MIS 1ML/30G TESTOST(A) PAK 50MG/1% TESTOST(A) PUM 1%12.5MG TGQ 50PSE/3 SYP BRM/30DM THALOMID CAP 50MG THALOMID CAP 100MG THALOMID CAP 150MG THALOMID CAP 200MG THERAPEUTIC SHA THERATEARS SOL OP
Aetna Better Health® of Michigan 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207 1-866-316-3784 Formulary Deletions Continued
THINPRO SYN 0.5/31G THINPRO SYN 0.3/31G THINPRO SYN 1ML/31G TICLOPIDINE TAB 250MG TOBREX OIN 0.3% OP TOLMETIN SOD CAP 400MG TOLMETIN SOD TAB 200MG TOLMETIN SOD TAB 600MG TOLNAFTATE CRE 1% TREXALL TAB 5MG TREXALL TAB 7.5MG TREXALL TAB 10MG TREXALL TAB 15MG
TRIAMINIC SYP CHILD TRICITRATES SOL TRIMETHOBENZ CAP 300MG TROJAN MIS NATULAMB TROJAN MIS NAT LAMB TROSPIUM CL CAP 60MG ER TRUZONE PEAK MIS FLOW MTR TUSNEL C SYP TYZEKA TAB 600MG ULESFIA LOT 5% 2PK 1 ML SYRINGE MIS 22X11/2 VAGIFEM VAG TAB 10MCG VANCOMYCIN CAP
