Transcription of Covered and non-covered drugs - Aetna
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Covered and non-covered drugs - Aetna
Covered and non- Covered drugs drugs not Covered and their Covered alternatives 2018 Standard Formulary Exclusions Drug List C (10/18). Below is a list of medications that will not be Covered without a Key prior authorization for medical necessity. If you continue using one of these drugs without prior approval, you may be required UPPERCASE Brand-name medicine to pay the full cost. Ask your doctor to choose one of the generic lowercase italics Generic medicine or brand formulary options listed below. Category drugs Requiring Prior Authorization for Formulary Options Drug Class Medical Necessity 1. Acromegaly SANDOSTATIN LAR SOMATULINE DEPOT, SOMAVERT. Allergies BECONASE AQ QNASL flunisolide spray, fluticasone spray, mometasone spray, Nasal Steroids / OMNARIS ZETONNA triamcinolone spray, DYMISTA.
candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide . High Blood Pressure * Angiotensin II Receptor Antagonist / Calcium Channel Blocker Combinations .
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