2017 Aetna IH CB IVL Exchange Formulary

154 Pages·2017·1.83 MB·Albanian

Plan for
your health
2017 Innovation Health Leap® plan drug guide
Four-tier closed formulary
my.innovation-health.com
62.32.372.1-IH S (8/17)
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat
people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language
assistance.

If you need a qualified interpreter, written information in other formats, translation or other services,
call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a
protected class noted above, you can also file a grievance with the Civil Rights Coordinator by
contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: [phone] (CA HMO customers: 860-262-7705), [email protected].

You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or
at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F,
HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group
of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and
their affiliates (Aetna).
TTY: 711
For language assistance in your language call the number listed on your ID card at no cost. (English)
Para obtener asistencia lingüística en español, llame sin cargo al número que figura en su tarjeta de
identificación. (Spanish)
欲取得繁體中文語言協 助，請撥打您 ID 卡上所列的號碼，無需付費。(Chinese)
Pour une assistance linguistique en français appeler le numéro indiqué sur votre carte d'identité sans frais.
(French)
Para sa tulong sa wika na nasa Tagalog, tawagan ang nakalistang numero sa iyong ID card nang walang
bayad. (Tagalog)
(Navajo)
Benötigen Sie Hilfe oder Informationen auf Deutsch? Rufen Sie kostenlos die auf Ihrer
Versicherungskarte aufgeführte Nummer an. (German)
Për asistencë në gjuhën shqipe telefononi falas në numrin e regjistruar në kartën tuaj të identitetit (ID).
(Albanian)
ለአማርኛ ቋንቋ እገዛ በመታወቅያዎ ላይ በተጠቀሰው ቁጥር በነጻ ይደውሉ (Amharic)
)cibarA(.ةيفريعتلا كتقاطب يف ركوذملا يناجملا مقلرا ىلعلاصتلاا ءجرلا ،)ةيبرعلا ةغللا( ي ةفدعاسملل

Լեզվի ցուցաբերած աջակցության (հայերեն) Զանգահարեք թիվը նշված է ձեր ID քարտի
առանց գնով: (Armenian)
Niba urondera uwugufasha mu Kirundi, twakure ku busa ku inomero iri ku ikarata karangamuntu yawe.
(Bantu-Kirundi)
Alang sa pag-abag sa pinulongan sa (Binisayang Sinugboanon) tawga ang numero nga gilista sa imong
kard sa kailhanan nga walay bayad. (Bisayan-Visayan)
বাাংলায় ভাষা সহায়তার জন্য আপন্ার আইডি কার্িে যে ন্ম্বরটি তাডলকাভুক্ত রর্য়র্ে ডবন্ামর্ুলয তার্ত কল করুন্।
(Bengali-Bangala)
ေငကြ ုန္က်ခံစရာမလိုဘဲ (ျမန္မာဘာသာစကား) ျဖင့္ ဘာသာစကားအကူအညီရယူရန္ သင့္အိုင္ဒီကတ္
ေပၚတြင္ ေပးထားသည့္ဖုန္းနံပါတ္ကိုေခၚဆိုပါ။ (Burmese)
Per rebre assistència en (català), truqui al número de telèfon gratuït que apareix a la seva targeta
d’identificació. (Catalan)
Para ayuda gi fino’ (Chamoru), ågang I numiru ni mangaige gi iyo-mu ‘ID card’, sin gåstu.. (Chamorro)
ᎾᏍᎩᎾ ᎦᏬᏂᎯᏍᏗ ᏗᏂᏍᏕᎵᏍᎩ ᎾᎿᎢ (ᏣᎳᎩ) ᏫᏏᎳᏛᎥᎦ ᎾᏍᎩ ᏗᏎᏍᏗ ᏕᎦᏅᏛ ᎤᎾᎢ ᏣᏤᎵ ᎦᎪᏟᏍᏗ
ᏆᎾᏲᏍᏗ ᎤᎾᎢ Ꮭ ᎪᎱᏍᏗ ᏧᎬᏩᎵᏗ ᏂᎨᏒᎾ. (Cherokee)
(Chahta) anumpa ya apela a chi bvnna hokmvt chi holisso kallo iskitini ma holhtena yvt takanli. Na aivlli
keyu ho ish I paya hinla. (Choctaw)
Tajaajila afaan Oromiffa argachuuf lakkoofsota bilbilaa waraqaa eenyummaa keessan irra jiran irratti
bilisaan bilbilaa. (Cushite)
Bel voor tolk- en vertaaldiensten in het Nederlands gratis naar het nummer dat op uw identiteitskaart
vermeld staat. (Dutch)
Pou jwenn asistans nan lang Kreyòl Ayisyen, rele nimewo a yo endike nan kat idantifikasyon ou gratis.
(French Creole)
Για γλωσσική βοήθεια στα Ελληνικά καλέστε χωρίς χρέωση τον αριθμό που αναγράφεται στην κάρτα
αναγνώρισης. (Greek)
(Gujarati) ગજુ રાતીમા ાંભાષા સહાય માટે તમારા આઈડી કાડડ પર લખલે નબાં ર પર કોઈ ખર્ ડવગર કૉલ કરો.
No ke kōkua ma ka ʻōlelo Hawaiʻi e kahea aku i ka helu kelepona ma kāu kaleka ID,
kāki ʻole ʻia kēia kōkua nei. (Hawaiian)
(Hindi) हिन्दी में भाषा सिायता के लिए, अपन ेआईडी काड डपर हदय ेगय ेनम्बर पर मफ्ु त कॉि करें।
Yog xav tau kev pab txhais lus Hmoob hu dawb tau rau tus xov tooj ntawm koj daim npav. (Hmong)
Maka enyemaka asụsụ na Igbo kpọọnọmba edepụtara na kaadị ID gị na akwụghị ụgwọ ọ bụla. (Ibo)
Para iti tulong ti pagsasao iti pagsasao tawagan ti numero a nakalista iti ID card yo nga awan ti bayadan
yo. (Ilocano)
Untuk bantuan dalam bahasa Indonesia, silakan hubungi nomor yang tercantum di kartu ID Anda tanpa
dikenakan biaya. (Indonesian)
Per ricevere assistenza linguistica in italiano, può chiamare gratuitamente il numero riportato sulla Sua
scheda identificativa. (Italian)
日本語で援助をご希望の方は、IDカードに記載されている番号まで無料でお電話ください。
(Japanese)
v>w>frRp>Rw>fuwdRusd.ft*D>f usd.f ud;eD>f*H>fw>fuGJ;vDRCmfv>evmH ftk.fo; t.f'H.fu; tvdR v>wtd.f'D;w>fv>mfbl.fv>mfphRb.f (Karen)
한국어로 언어 지원을 받고 싶으시면 보험 ID 카드에 수록된 무료 통화번호로 전화해 주십시오.
(Korean)
Ɓɛ ́ m̀ ké gboǦkpáǦkpá dyé ɖé Ɓǎsɔ́ɔ̀ wùɖùǔn wɛ̃ɛǡɖá nɔ̀ɓà ɓɛ́ɔ cééà ɓó nì dyíǦdyoìnǦ„ɛ̃̀ɔ̀̃ɔ̃ɛɓó pídyi.
ሺ)h”s—iǦdruƒK•(• ƒ.نሻەکبیدنەويەپ ادناتۆخ یساێنپیتراکەلوارسوونیياڕۆخ یەرامژ ەب نامز ەبنامز ەبراديدنەوێپینيونرێ ینترگرەو ۆب
ຖ້ າທ່ ານຕ້ ອງການຄວາມຊ່ ວຍເຼືຫ ອໃນການແປພາສາລາວ,
ກະລຸ ນາໂທຫາໝາຍເລກ ່ທລະບຸ ໃນບັ ດປະ ຈາຕົ ວຂອງທ່ ານໂດຍ ່ບເສຍຄ່ າໂທ. (Laotian)
तील भाषा ( मराठी) सहाय्यासाठी तमु च्या आयडी काडवड र सचू िबद्ध करण्यात आलल्े या क्रमाांकावर
कोणत्याही खिाडशिवाय कॉल करा. (Marathi)
Ñan bōk jipañ ilo Kajin Majol kwon kallok nōmba eo ej walok ilo kaat in ID eo aṃ ejjelok wōnān.
(Marshallese)

Ohng palien sawas en soun kawewe ni omw lokaia Ponape koahl nempe me sansal pohn noumw ID
koard ni sohte isais. (Micronesian-Pohnpeian)

សម្រាបជ់ ំនួយភាសាជា ភាសាខ្មែរ
សូមទូរស័ព្ទតាមលេមខ្ែេានលៅលេើប័ណ្ណសាា េ់សាជិករបស់អ្នកលោយឥតគិតថ្លៃ។ (Mon-Khmer,
Cambodian)

(नेपािी) मा ननिःशल्ु क भाषा सिायता पाउनका िागग तपाईंको पररचय-पत्रमा उल्िेख गररएको नम्बरमा फोन
गनिुड ोस ्। (Nepali)
Tën kuɔɔny ë thok ë Thuɔŋjäŋ cɔl akuën cï reec ë kaaddu kɔ̈u kecïn aɣöc.(Nilotic-Dinka)
For språkassistanse på norsk, ring nummeret på ID-kortet ditt kostnadsfritt. (Norwegian)
Fer Helfe in Deitsch, ruf die Fonnummer aa die uff dei ID Kaarde iss. Es Aaruf koschtet nix.
(Pennsylvania Dutch)
یسليگنا .ديريگبسامتتسا هدمآ امش یايساشن تراکیور ربەک یا هرامش ایبا ەنيزه چيه نودب ی،سرافنابز ەبی يام نه ار یارب
)naiureP(
Aby uzyskać pomoc w języku polskim, zadzwoń bezpłatnie pod numer podany na karcie ID. (Polish)
Para obter assistência linguística em português ligue para o número grátis listado no seu cartão de
identificação. (Portuguese)
(Punjabi) ਪੰਜਾਬੀ ਵ ਿੱਚ ਭਾਸ਼ਾਈ ਸਹਾਇਤਾ ਲਈ ਆਪਣ ੇਆਈਡੀ ਕਾਰਡ ਤ ੇਵ ਿੱਤ ੇਨੰ ਬਰ ਤ ੇਕਾਲ ਕਰੋ।
Pentru asistenţă lingvistică în româneşte telefonaţi la numărul gratuit indicat pe cardul dvs. de membru de
la Aetna. (Romanian)
Чтобы получить помощь русскоязычного переводчика, позвоните по бесплатному номеру,
указанному в вашей ID-карте удостоверения личности. (Russian)
Mo fesoasoani tau gagana I le Gagana Samoa vala’au le numera o lo’o lisiina I luga o lau pepa ID e aunoa
ma se totogi. (Samoan)
Za jezičnu pomoć na hrvatskom jeziku pozovite besplatan broj naveden na poleđini Vaše identifikacijske
kartice. (Serbo-Croatian)
Fii yo on heɓu balal e ko yowitii e haala Pular noddee e ɗii numero ji lintaaɗi ka kaydi dantite mon. Njodi
woo fawaaki on. (Sudanic-Fulfulde)
Ukihitaji usaidizi katika lugha ya Kiswahili piga simu kwa nambari iliyoorodheshwa kwenye
Kitambulisho chako bila malipo. (Swahili)
ܳ ܳ ܳ ܳ ܽ ܳ ܶ ܳ ܽ ܰ ܰ ܳ ܶ
ܐܡܩܪ ܟܠ ܐܗ ܐܝܝܪܘܣ ܐܢܫܠܒ ܐܬܘܢܪܕܥܡ ܬ ܢ ܐ ܐܥܒ ܢܐ
ܳ ܰ ܰ ܽ ܳ ܽ ܰ ܰ ܰ ܰ ܽ ܰ
) (.ܢܓܡܘ ܟܬܘܝܡܘܢܩܕ ܐܣܝܛܪܟ ܠܠܥ ܚܝܼܺܟܫܕ ܢܘܦܝܠܬܕ
Syriac-Assyrian
( ) (Telugu)
భాషతోసాయంకొరకుఎల ంటిఖరచులేకుండామీఐడికారుచమీదఉన్నన ంబరచకుకాల్చయే ండి తెలుగు
ส ำหรับควำมช่วยเหลือทำงด้ำนภำษำเป็น (ภำษำไทย) โทรหมำยเลขที่แสดงไว้บนบตั รประจ ำตวั ของทำ่ น ฟรีไม่มีคำ่ ใช้จำ่ ย (Thai)
Kapau ‘oku fiema’u hā tōkoni ‘i he lea faka-Tonga telefoni ki he fika ‘oku lisi ‘i ho’o kaati ID ‘o ‘ikai hā
tōtōngi (Tongan)
Ren áninnisin chiakú ren (Kapasen Chuuk) kopwe kékkééri ena nampaan tengewa aa makketiw wóón
noumw ena chéén taropween ID nge esapw kamé ngonuk. (Turkese)
(Dilde) dil yardım için sayı hiçbir ücret ödemeden kimlik kartı listelenen diyoruz. (Turkish)
Щоб отримати допомогу перекладача української мови, зателефонуйте за безкоштовним номером,
наданим у вашій ID-картці посвідчення особи. (Ukrainian)
)u irU( ۔ںيرک لاک فتمرپر بمن جرد رپڈراک IDےنپاےيلےکتنواعم یناسل ںيم ودرُا
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(Vietnamese)
. לאצפא ןופ ײרפ לטראק טעטיטנעדיא רעײא ףױא טײטש סאװ רעמונ םעד טפור שידיא ןיא ףליה ךארפש ראפ
)Yiddish(
Fún ìrànlọwọ nípa èdè (Yorùbá) pe nọmbà tí a kọ sórí káàdì ìdánimọ rẹ láì san owó kankan rárá. (Yoruba)
ICNnaeltel eodu rmti.o oCrroe nh tinaecfoat ridnmfloairntmioean®t?io n,
call X-XXX-XXX-XXXX
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or visit www.aetna.com
Visit my.innovation-health.com or call the
toll-free number on your digital member ID card.
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Please note that if your prescription drug benefits plan changes, the information here may no longer apply. For more
information, visit your secure member website.
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The drugs listed in the drug guide, prior authorization, quantity limit and step therapy lists are subject to change. The
facessunt
quantity limits and step therapy drug coverage review programs are not available in all service areas.
Not all health services are covered.
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Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy
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providing prescription services by mail. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary
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of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment.
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Aetna receives rebates from drug manufacturers that may be taken into account in determining our drug list.
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This material is for information only. It contains only a partial, general description of plan benefits or programs and does
Snuotb choenasdti tute a contract. See coverage policy documents for a complete description of benefits, exclusions, limitations
Banodd yc oconpdyit imonosd oipf iccoiuvre, rtaegmeq. Pulaamn ,f eeat teunrteisss aen qdu aavtuairl amboilidty may vary by location and are subject to change. Providers are
eintd qeupibenudste fnatc ceornfetrruacmto erts qaunads asraem n oqtu aeg veonltesn ot fq Aueet neal . Provider participation may change without notice. Aetna does not
mproolvuidpeta ctuarr,e a olirg egnuta, riannt teeren aamcc ensast itbou hs eeavlethle sses revricfeersc. iIansf ormation is subject to change.
uFonrt omtaotraet uinr?f ormation about your plan, refer to my.innovation-health.com.
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*©F20o1o7 tInnnoovteation Health Holdings, LLC my.innovation-health.com
62.32.372.1--IH S (8/17)
7
2017 Innovation Health Leap Drug Guide - Four Tier Closed Formulary
Table of Contents
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*......................................................5
*AMEBICIDES*..........................................................................................................................................6
*AMINOGLYCOSIDES*............................................................................................................................6
*ANALGESICS - ANTI-INFLAMMATORY*..........................................................................................7
*ANALGESICS - NONNARCOTIC*.........................................................................................................8
*ANALGESICS - OPIOID*........................................................................................................................ 9
*ANDROGENS-ANABOLIC*.................................................................................................................12
*ANORECTAL AGENTS*.......................................................................................................................12
*ANTHELMINTICS*...............................................................................................................................13
*ANTIANGINAL AGENTS*...................................................................................................................13
*ANTIANXIETY AGENTS*....................................................................................................................13
*ANTIARRHYTHMICS*.........................................................................................................................14
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*..............................................................14
*ANTICOAGULANTS*...........................................................................................................................16
*ANTICONVULSANTS*......................................................................................................................... 17
*ANTIDEMENTIA AGENT COMBINATIONS***...............................................................................19
*ANTIDEPRESSANTS*...........................................................................................................................19
*ANTIDIABETICS*..................................................................................................................................20
*ANTIDIARRHEALS*.............................................................................................................................23
*ANTIDOTES AND SPECIFIC ANTAGONISTS*.................................................................................23
*ANTIDOTES*..........................................................................................................................................23
*ANTIEMETICS*.....................................................................................................................................24
*ANTIFUNGALS*....................................................................................................................................24
*ANTIHISTAMINES*..............................................................................................................................25
*ANTIHYPERLIPIDEMICS*..................................................................................................................26
*ANTIHYPERTENSIVES*.......................................................................................................................27
*ANTI-INFECTIVE AGENTS - MISC.*..................................................................................................29
*ANTIMALARIALS*...............................................................................................................................30
*ANTIMYASTHENIC AGENTS*...........................................................................................................31
*ANTIMYASTHENIC/CHOLINERGIC AGENTS*..............................................................................31
*ANTIMYCOBACTERIAL AGENTS*...................................................................................................31
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*.................................................................31
*ANTI-OBESITY AGENT COMBINATIONS**.....................................................................................36
*ANTIPARKINSON AGENTS*.............................................................................................................. 36
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*.....................................................................................36
*ANTIRETROVIRALS ADJUVANTS***...............................................................................................38
*ANTISEPTICS & DISINFECTANTS*...................................................................................................38
*ANTIVIRALS*........................................................................................................................................38
*ASSORTED CLASSES*..........................................................................................................................41
*BETA BLOCKERS*................................................................................................................................42
*BIOLOGICALS MISC*...........................................................................................................................43
*CALCIUM CHANNEL BLOCKERS*................................................................................................... 43
*CARDIOTONICS*..................................................................................................................................45
*CARDIOVASCULAR AGENTS - MISC.*.............................................................................................45
*CEPHALOSPORINS*.............................................................................................................................45
*CHEMICALS*.........................................................................................................................................46
*CONTRACEPTIVES*.............................................................................................................................46
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*CORTICOSTEROIDS*........................................................................................................................... 52
*COUGH/COLD/ALLERGY*..................................................................................................................53
*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***..............................................................54
*CYSTIC FIBROSIS AGENT - COMBINATIONS***............................................................................54
*DERMATOLOGICALS*........................................................................................................................54
*DIAGNOSTIC PRODUCTS*................................................................................................................. 61
*DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS*.................................................65
*DIGESTIVE AIDS*.................................................................................................................................71
*DIRECT-ACTING P2Y12 INHIBITORS***..........................................................................................71
*DIURETICS*...........................................................................................................................................72
*ENDOCRINE AND METABOLIC AGENTS - MISC.*........................................................................72
*ESTROGENS*.........................................................................................................................................75
*ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB***..............................76
*FLUOROQUINOLONES*......................................................................................................................76
*GASTROINTESTINAL AGENTS - MISC.*..........................................................................................76
*GENITOURINARY AGENTS - MISCELLANEOUS*.........................................................................78
*GOUT AGENTS*....................................................................................................................................78
*HEMATOLOGICAL AGENTS - MISC.*...............................................................................................78
*HEMATOPOIETIC AGENTS*...............................................................................................................79
*HEMOSTATICS*....................................................................................................................................80
*HEPATITIS C AGENT - COMBINATIONS***....................................................................................80
*HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS**...................................................81
*HYPNOTICS*..........................................................................................................................................81
*INTERLEUKIN ANTAGONISTS***....................................................................................................81
*LAXATIVES*..........................................................................................................................................81
*MACROLIDES*......................................................................................................................................82
*MEDICAL DEVICES*............................................................................................................................83
*MIGRAINE PRODUCTS*......................................................................................................................98
*MINERALS & ELECTROLYTES*........................................................................................................98
*MOUTH/THROAT/DENTAL AGENTS*............................................................................................101
*MULTIVITAMINS*..............................................................................................................................101
*MUSCULOSKELETAL THERAPY AGENTS*..................................................................................105
*NASAL AGENTS - SYSTEMIC AND TOPICAL*..............................................................................106
*NEUROMUSCULAR AGENTS*.........................................................................................................106
*NUTRIENTS*........................................................................................................................................106
*OPHTHALMIC AGENTS*...................................................................................................................106
*OREXIN RECEPTOR ANTAGONISTS***.........................................................................................111
*OTIC AGENTS*....................................................................................................................................111
*OXABOROLE-RELATED ANTIFUNGALS - TOPICAL***.............................................................111
*OXYTOCICS*........................................................................................................................................111
*PASSIVE IMMUNIZING AGENTS - COMBINATIONS***.............................................................111
*PASSIVE IMMUNIZING AGENTS*...................................................................................................111
*PCSK9 INHIBITORS***.......................................................................................................................112
*PENICILLINS*......................................................................................................................................112
*PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS***...................................................113
*PHOSPHODIESTERASE 4 (PDE4) INHIBITORS***.........................................................................113
*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS**......................................................113
*POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS***.....................................................113
*POTASSIUM REMOVING AGENTS***.............................................................................................113
*PROGESTINS*......................................................................................................................................113
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*PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS***..........................................113
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*..........................................113
*RESPIRATORY AGENTS - MISC.*....................................................................................................116
*SEROTONIN 1A RECEPT AGONIST/SEROTONIN 2A RECEPT ANTAG***...............................116
*SEROTONIN MODULATORS***.......................................................................................................116
*SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***......................................................116
*SINUS NODE INHIBITORS**.............................................................................................................116
*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***.....................116
*SULFONAMIDES*...............................................................................................................................116
*TETRACYCLINES*..............................................................................................................................117
*THYROID AGENTS*...........................................................................................................................117
*ULCER DRUGS*..................................................................................................................................117
*URINARY ANTI-INFECTIVES*.........................................................................................................119
*URINARY ANTISPASMODICS*........................................................................................................119
*VAGINAL PRODUCTS*......................................................................................................................120
*VASOPRESSORS*.................................................................................................................................121
*VITAMINS*...........................................................................................................................................121
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