Quality heaith plans :5: benefits
`Heaithlerliving
`Financial well—being
`
`intelligent solutiorm
`
`®
`
`2015 Aetna Pharmacy Plan Drug List
`
`Three Tier Open lndividual Plan
`
`www.aetna.com
`
`n=R2o15—o'1o99 '|R2D15-01097 |PR2015—01‘!00 |PR2O‘l5T-01105
`
`Lapin EX1078 Page
`
`f
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`

`
`Do you have questions?
`Call the toll—free number on your member ID card. Or visit
`www.aetna.com/formulary for the most up—to—date information.
`
`Dear Member:
`
`To help you know how drug. are covered by your plan. we
`are pleased to provide you with a copyofour ANS Aetna
`Pharmacy Plan Drug l.|
`t.
`
`This guide provides helpful informaton about your pharmacy
`benefits p1an.You l'l1.:V want to take this guide w-thyou when
`you see your doctor to talk about what IS covered under your
`plan and what you can expect to pay ‘or your medione.
`
`Many commonly prescribed drugs are listed in th s ciuide Please
`remember this is not a complete l'st ofclrugs covered under your
`plan. Because thousands ofdrugs are l"ClU£l9d in your plurmacy
`benefits plan. we only list the most commonly prescribed ones.
`
`What pharmacy benefits plan do 3 have?
`
`You are enrolled in the Aetna Three Tier Open
`Individual plan.
`
`Here's what that means to you‘
`
`Think of tier as a level Three Tier means you could pay three
`different amounts. depending on the drug you take.
`
`A formulary l5 a list of generic and brand-name drugs that your
`health plan covers. An open formulary means your plan covers
`most prescri,-.it:on drugs. But it may not cover some others.
`
`What can I expect to pay?
`
`with this health benefits and health Insurance plan. the amount
`you pay depends on the drug your doctor prescribes. it's either
`a flat fee or a percent of the prescriptions price.
`
`What you pay Falls into one of these tiers or levels:
`
`Tier One: Generics—You pay the lowest cost for drugs in
`this level. Your plan may Include an additional benefit where
`some Tier 1 drugs would be provided at an even lower cost to
`you. These are considered Value Drugs/Tier la and include
`generics and some over-the— counter brand and generic
`products. These would be available at the lowest cost snare
`indicated in your plan materials.
`
`Tier Two: Preferred Brands — You pay a slightly higher cost
`For drugs in this level.
`
`Tier Three: Non-Preferred Brands — You pay the highest cost
`For drugs in this level.
`
`To find your exact costs
`
`Check your Plan Design and Benefits SUi"\".".‘Ial'y. Ti‘.lS should be
`in your enrollment kit.
`
`Your pharmacy benefits plan may include a program that
`encourages you to choose a generic drug over a brand-name
`drug, in order to help reduce wwat you pay. T' is means that
`ifyou fill a urand-name drug when a generic lS available, that
`in addition to your standard copay or coirwurancn you m..=t
`also pay the u‘-tference in cost between the br..-- .d~name and
`general. drug.
`
`For a summary ofyour pharmacy benefits plar~_ lncludi-g
`our-of-pocket costs. v sit www_ae tna.com and .- =9 in to Aetna
`Nay gator. Or call the toll-free number on your member ID card.
`
`www.aetna.com!FormuIary
`
`Page 2
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`

`
`Where can I find more Formulary information?
`
`Why is the formulary subject to change?
`
`You and yo .r doctor can rearc“ For a drug, ‘ind out i‘ it's covered
`and s- -3 what tier i. ia!'s ur-rler Vriu can also see if there are
`alternatives that cost less. Make sure your doctor knows that
`you pay more For two and three tier drugs. He or she can
`consider this beFore writ ng a prescri‘ iion.
`
`Take these steps:
`
`1. Visit w_ww.aetna.comlformulary. ‘rou arrive at a page trial
`says "Medication hearch."
`
`2. This is where you can learn more about the types of
`drug coverage reviews yOUF drug requires: ll» rigs | -:e
`prei.ertif.r.atlon, sten therapy or cuarrtity limits. You will
`arr re at a menu page wh eieyou can .i
`- w various driiq lists,
`including your Aetna Pharmacy 'r..;n Drug i_...t and more.
`
`How is the formuiary developed?
`
`Aetna's Pharmacy and Therapeutics lP&T) Committee meets
`regularly to review new drugs and new information about
`drugs that are already on the rnarli-at
`t reviews available
`information concerning s.iFety. ef'Fec. rennss and current use
`in the racy The P&T Corn.-~ iiee reviews scii.-ntiric evidence.
`including relevant findings oF Federal governrnerit agencies,
`pharri aceutica, mu nufacturers, medical prnfessio rial
`associatons, nat.onal commissions and peer-reviewecljournals.
`
`0 ur P "rT Committee includes licensed pharmacists and d octors,
`including those who are currentiy in practice and others who are
`Aetna employees. Al' committee meriribers must tell Us if they
`are in a situation that can create a conflict oF'.ntorest or ifthey
`have a Financial stake that l"'l!__}.".[ af.‘i_-.;t their decisions.
`
`Once the l‘SiT Committee completes its c.in.cal review, we
`also corisider overall value (incl-iding cost and rrianufacturer
`rebate arrangements) and other Factors beForr- ad: l’rig or
`removiriq a drug from :l'ie Forrnulary. Aetna Pharmacy Plan
`Drug List shows you recent changes to the guide. For example,
`it could shuwwizat drugs started renu ring coverage reviews .il<e
`precertification, step t-‘iercipy or quantity |
`i-- is Or which drugs
`no longer do. The Pi5rT Corn mi.tee can rriake recommendations
`to change the tier level oFa drug or to place :on our Forniulary
`Fiiclusions List, designating it as a drtg that is no longer covered.
`
`Vie ma . Add or remove drugs for certain reasons. We " grit
`also move a drug From one coverage [Ir
`‘
`~ another.
`
`Here are some reasons w"‘y.
`
`- As branc’ name drugs lose their riatents and generic versions
`become available, the brand-name may be covered at a h gher
`out-oF- pocket cost whle th e generic ma‘, be covered at a lower
`out-oF— pocket cost.
`
`- The Food and Dr..g Administration (FDA) approves many
`new drugs throughout the year.
`- Drugs can be withdrawn from the market or may become
`available without a prescription.
`
`Our website, www.aetna.con1/formulary, reFlects the most
`up-to-date Forrnuiary information - so please visit it ..Ften.
`
`Why do some drugs require prior authorization
`or precertification?
`
`This drug coverage review encourages appropriate and cost-
`ef‘ec;..ie use o.‘ prescription drugs by al'owing Coverage only
`w'ien certain conditions are met.
`
`Reasons For precertification include:
`
`' Compliance with closing guidelines
`- Avoiding duplicate therapies
`
`- Helping health care providers check that a drug is being
`used based on generally accepted medical criteria
`
`The nrecertification program ‘.5 based upon current medical
`I .ndings, FDA-approved manufacturer labeling information,
`and cost and manufacturer rebate arrangements.
`
`lfyour plan requires precertification. you vii” find a list ofdrugs
`that are subject to precertification vi .th this guide. Please keep
`the following in mind:
`
`- Your doctor must contact Aetna to request approval of
`coverage for these drugs,
`' lFwe approve the request, we will '1oHFy your doctor. The
`drug will Llien be covered at the arinilcable out~oF—pocket
`cost under your plan. You w'i.i also be notilied ofappro wls
`where the state requires notification to "iel'l'llJEl'S.
`
`|Fthe request is denied,you and y :u' doctor will be notified.
`You can stiil purchase the drug, -‘-i it ft,
`the Fi_.ll price.
`
`www,aetna.r:omJ'formuIary
`
`Page 3
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`

`
`Why do some drugs have quantity limits?
`
`Saving on prescriptions
`
`This drug coverage review limits coverage o'.1uantities for
`certain dr. .95. These I mits heiri your coctor and Phal'iT|aC|a[
`check that your prescribed drug 5 used correctly and sui ciy.
`
`We use medical gu delines and FDA-approved recommendations
`rrom drug makers to set these coverage iirnits. The quantity Iirnit
`program includes:
`
`- Dose Efficiency Edits — Limit coverage of prescriptions to one
`dose per day for drugs that are approved For once— daily dosing.
`- Maximum Daily Dose - A message is sent to he pharmacy
`ifa prescription is less than the minimum or higher than the
`maximum allowed dose.
`
`- Quantity Limits Over Time — L mit coverage of prescriptions
`to a specific number ofunits in a defined amount oftime.
`
`What is step therapy?
`
`This drug coverage review promotes the appropriate use
`CF equally effective but lower-cost drugs first Prerequisite
`drugs are FDA-approved and treat the same condition as
`the corresponding step therapy drugs.
`
`What is therapeutic duplication?
`
`Therapeutr: duplication means that two or more drugs of
`the same type are prescribed at the same time. This can occur
`when two doctors prescribe similar drugs or when your doctor
`switches from one drug to another drug in the same class
`without cancelling the first prescription.
`
`it is rare that you should ever need two drugs From the same
`class to treat a medical condition. Since serious side effects
`
`may occur, we help bring such ClUpllLiJi.iDl'lS to your pharmacists
`and doctors attention.
`
`Learn more about drug coverage reviews
`
`lfyou have a medical need For a drug that requires prccertifcatiori,
`quantity limits or step therapy. your doctor can ask for a medical
`exception. The list ofdrugs requiring preceriificat on, quantity
`limits or step therapy is subject to change Find the most
`up- :o—o..ite information at www.aetna.comIformula ry.
`
`You may be able to save with generic drugs
`
`Generic drugs are approved by the U.S. Food and Dr..g
`Administ:-iiion lFDAJ and proven ;o be,ust as sa re and effective
`5." brand—name drugs. T ney contain the same active ingredients
`ir the same amounts as the brand name products. The
`
`difference .. that generics may be a different color, shape or size.
`
`Whe appropriate your doctor may decide to prescribe. or allow
`sut-r‘ r.u'
`» ii with, a generic drug. Please talk to your doctor to
`find out I‘ a generic is right foryou.
`
`Here are some other tips to pay less out ofpocket ‘oryour
`prescription drugs:
`
`' Ask yourdoctor ‘ 3 consider prescri'r- ng generic drugs
`ins ‘cad rifln'ano- name drugs.
`
`- Ask youi doctor to consider prescrib ng drugs that are
`on the Aetna Pharmacy Plan Drug List.
`
`' Check to see ifyour plan .nciude5 our mail-order pharmacy
`service Depending upor your plan. mail order may save you
`money. bee Aetna Kit Home Deiivciy‘ .n ll .35 guide ‘or details.
`- Remind your doctor to check your plan to make sure you
`get maximum coverage.
`
`What is Aetna Rx Home Delivery?
`
`Ch eck your riian documents to see ‘if your plan includes
`our Aetna Rx Home Delivery moi!-order pharmacy ‘is Fills
`presc: ip;ions for maintenance medic iie. This type of medicine
`is used regularly, to treat conditions .i~-2 al'lhf|'ti5, asthma,
`diabetes or high c‘ i"-lesterol. lfyou need th is type ofdrug, you
`can get up to a 90-day supp -2, or the max.-num supoly allowed
`by yui..r p..,=n, and free delivery 'ig"Il2 to yocr ma..‘l.iox.
`
`You also get:
`° Qu-ck, confidential service
`
`- Free standard shipping
`- Pharrnac ' ts who c"~eck all prescriptions For accuracy
`and can answer questions any time
`
`It's easy and fast to order- choose one of these ways:
`
`1. Mail — Get a new prescription fror your doctor, Mail
`your new prescription to Aetna Rx Home Del'.very w .th
`a completed orrler forrri. You can access the form online.
`Visit ww\iv.aetna.corn and 3'19 in to Aetna Nuiiiqator,
`your secure member website Orynu can go right to
`www.aetnanavigator.corn. Once ogged in. riick the
`link to ‘Aetna Pharmacy".
`
`2. Fax — Give your rioctor the Aetna Rx Home Delivery fax
`number: 1- SH 2 10-3317. Your doctor can fax in the
`
`prerrr.p..0n. Make sure your doctor includes your member
`‘D number. yo.. r date ofuirth and your ma. ng address on
`‘.:ie fax cover sheet. Only a doctor may fax a prescription.
`
`3. Phone — To help make tr-asy to get started. you can also
`choose to use our Act." iRx Courtesy Start“ program. Call
`the toll-free number all your member ID card Ask u< to rnac '1
`out to your doctor. We can l""‘.lJ'eSlL a new 9u i:.:. prescription
`ony-~ii
`)L‘l"
`if ‘I ur ioctor rt‘ ll l'l""dy1Ui’1<Cl'l€~.iult. a vi;i.t
`before he or -he i.
`I ivrize you 3 nr_ii. p|‘€"CI'|pl.lO|'1. After we
`reach out to your doctor. ninase ailow time _u;, to 7 day’-i ror
`i.s to re-'.-we a reply fo he p this process rruve quickly, please
`alert your doctor to expect our call.
`
`I’ your pres-rr? 7-tinn is for a contro rid mec'.ic.ne_ a written
`prescrip; on from your doctor may be needed.
`
`Gene - Iy. ‘fyour order is compiete-,y uui. ' receive your
`Fl'IP(" N-rt vi thin I i-‘4day5 from wh-' " Aeir i Rx Home De’ .ery
`rec.
`/E -yui. r order
`rou can requestexpeditr-d delivery for or
`.id:.‘..;.onal charge.
`
`www.aetna.com/formulary
`
`Page 4
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`

`
`What is Aetna Specialty Pharmacy?
`
`Aetna SDt:‘CITill.)’ Pharmacy is Ar.-tna's in—huuse specialty
`p‘1'=.rmaCy. It cm ffi your nrescnptien specialty medit ne.
`These types of drugs may be injected. infused er taken by
`mouth. Specialty medicine oFL.=rv needs specia;
`; sruqe and
`har*r‘l'ng. It must be deliver-;-.1 qu.cl-'.ly. And a nurse or pharmacist
`should monitor you Gui mg your treatrnr.-. -t. Use Aetna Specia.ty
`Pharmacy to get this medicine sent right tr: your maflhnxl
`You atS-J get;
`
`- Free delivery that is reliable, secure and sent anywhere
`you choose
`
`* Extra help when you need it— like uuection training and
`side effect monitoring
`- Proactive outreach to Confirm your refills
`- Free Standard sunplies
`
`- Nurses and pharmacists who can help you 24 "Iours a day,
`every my
`
`It's easy and fast to order - choose one of these ways:
`- Fax —Ynur doctor may ‘ax your prescripL.un to
`1-866-FAX-ASRX (1-866-329-2779).
`
`° Mail -- You or your doctor may mail yaur pmscrmtinn order to;
`Aetna Specialty Pharmacy. 503 bunport Lane. Orlando. F L 32809.
`Ifynu ma I in your own prescription, please send it along 9. ith
`a completed Patient Prnfii-2 Form. To access this ‘arm, visit
`ww-w.AetnaSpecialI:yRx.corn and click “Specialty pharmacy"
`How to enroll.”
`
`- Phone — Your doctor may also call and speak to one
`of ou r reg: stered pharmacists at 1 4366-182-ASRX
`(1 -866-732-2779} during normal business hours of
`8 am. until 7 p.m. ET.
`
`To transfer an existing prescription order to be filled by
`Aetna Specualty Pharmacy, cull toll -Free at 1-866-353-1892.
`
`www.aetna.comlFormu|ary
`
`Page 5
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`

`
`Need more information?
`
`Visit www.aetna.com/Formulary or call the
`appropriate toIl—Free number on your member ID card.
`
`rerai_,e. Plan Features
`
`Please note thai if» ur i:- ‘I’! ption drug benefits plan char ;es, the nformation herein may no longer apply,
`A copay: - Ient is a I" :’ Fee. Coinsurance is a percentage it ‘l erate ihfil Aetna negotiates with the plan snonsor for rovered prescriptions exi V .r as required bylaw
`to be otherwise 7
`2 drugs on the Preferred Drug List are so 1ier;; in manufacturer rebates. Coins .-rani.e is calculates before any :eI:ia'es are subtracted. That
`means It may be possible "W yuuri nst nfa preferred r:iri.3 to be higher than your cost ofa non-preferred drug.
`Heal’ n benefits anu health insurance ,.-‘ans are offer-rl. administered aiidlr-r underwritten by Aetna Heaitii ‘nt Ar.-Ina Heallh insurance Company ofNew Yr rli,
`Ae'na Health "1‘l'l'-'InCE Company aiidiiv Aerna Life Insurance Company liletna). In F.:~ri:Ia. by Aetna Heaith In
`an it.
`- Aetna Life Insurance Company
`i
`Marylin. 1, by Ae;na HP?" 1 lnc.. 151 Farnii: 5'
`1 Avenii-, Hortio cl, CT “5156 Each insurer h is sole tlnznt at '5 '.pons'ibili'_y for its
`"\'n products. Aetna Pharmacy
`Mariagerr~enI:re'—rstnanInteinaIbi.i_- mes: uiiitofAetiiaHenlrhivianrigement,LLC.Aetna5per'Ia|:yPharmnryrefer5toAetnaSpeciaityP'1ari'- iry,, I,f__asubsldIary
`ofAetna Inc
`.-. r- :h is a
`Pl. Ii rt nharrnacy that operates '-'iri.-u.,h specialty pnarmacy prescription fuifiliiiii rt
`Not ail ' Ml" ‘i serviri . are covered. See plan documents for a l nmpictu description ofbenelits, ext
`1'‘
`~ is. limitations and conditions of
`and avaiiabnizy
`.iy iai y by In
`itlrin and are subject to chani_.e
`SP~ Drugs listed die ni-I
`< :--d by our Aetna's Specialty Health Lare Mananement“ nurse E--Irn. Mer-hers ri-re . i-. he support of this team thruugl-ii .iit ‘ he ei~'2-i-
`course of therapy ' us in ' ii er'1pi... I A 'sp|"-' I’ Caper‘
`I-3 provision this means in»: half ciFa one month s ruppiy r‘ medicine . .i
`‘Mi at a timr
`'.; Iii fill
`r‘
`r
`- 1sii-igallows the nurse :ear to 4|!!!’ more support, incl-Ii" ng more I'i,‘l
`.v up tr monitor response ti: tfealme uaiij I
`-tar‘
`il ri.-acti.
`or
`"E-er-feC[5.T‘!i5
`help - pieiier twasterl merli
`vie and saves members rn i-I--v ii :hi.-ir medicine i
`r dose changes between l'i'is This I‘ t is r ,' 2.‘ -ini
`rive and 5 subject to change.
`Aetna IELEIVUS reuiites ‘. r
`-1 dlug man-ilai:ti_---rs that n ay be taker
`win account n deterrrmii .9 Aetr-1'; Preferred Drug Llst Rebates do N. t iedi e the amount a
`member pays the pharma vfoi L’
`rered .1rescriptiuns.lnforrr 3' n is su:
`i-
`ti..i change. For more infurrnatiuii about Aetna plans, refer to wiii-w,aetr I i.i.iiii.
`The drirns El‘ "re Preferred l
`g L
`r,F rrr ;l -iry Exclusions -‘recei: " ration Quantity L:'r: t and Step Therapy Listsare sumac: to change The quantity Iim Is and
`step therapy dn 3 coverage review pi
`,-rams arr rint available n ail service areas. For example step therapy ;.:
`:rams "in nor appiy tc Fi.
`';,i-iiisiired merr. --rs in
`I
`. Iiaria. ‘ - ep ;herapy doesr-r . apply to ‘HI y- nsured members in Newlersey However. these programs are available to sr-I’ funced plans
`;
`lnacrnrrfrncewith ‘atela i.
`mrriefcialilu .
`‘
`i'e.*lrriembersin Liiur
`I
`is. ant: TexasIexceptFederalE"'Iplnvr-e-i
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`c
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`r 'iieIi~ihera y Li
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`C..inl[II‘|UE‘ -have
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`-.Iri-inwn as “pre-service
`iiti'izati:.iii review
`is 1 3 ‘verification’ as defined 7yTexaslaw
`' who are 'ern.iiinq
`‘tyee Heaflh Benefit than mvnt
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`e with *
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`Page 6
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`

`
`2015 Aetna Pharmacy Plan Drug List ~ Three Tier Open Individual Plan
`
`Table of Contents
`
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`Page 8
`
`

`
`2015 Aetna Pharmacy Plan Drug List - Three Tier Open Individual Plan
`
`Drug Status
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`Drug Details
`=
`# =—' Brand-name drug expected to
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`20|5 Aetna Pharmaey Plan Drug list - Three Tier Open Individual Plan
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`Page 10
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`Page 11
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`
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`Tier I
`Tier 1
`Tier 1
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`-
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`NUVIGH. ORAL TABLET I50 MG. 200 MG, 250
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`2015 Actna Pharmacy Plan Drug List - Three T1er()pen Individual Pian
`(bpdaled 08/O1/20* R)
`
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`
`METHYLIN ORAL SOLUTION 10 MG/SML, 5
`MG/SML
`METHYLIN ORAL TABLET CHEWABLE
`methylphenidate halter Tea)
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`me!/2y1phem‘dare hcl er +'fa)T
`methylphenidate hc! er oralTobie! extendedreIea5e"‘
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`methyflaherridufe hcl oral tabir-.r
`merhylpheniddie ho! oral Iabimr chewable
`
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`
`_
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`Drug Name
`RITALIN LA ORAL CAPSULE EXTENDED
`RELEASE 74 HOUR 10 MG, 20 MG, 30 MG, 40 MG
`RIIALIN SR
`*'*A;\-TII-1BlCIDES*
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`2015 Aema Pharmacy P'an Drug Lisl — Three Tier Open Individual Plan
`(Updated U810]/2U} S)
`
`6
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`Page 12
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`
`2!)! 5 Aeina Pharmacy Plan Drug List - Three Tier Open Individual Plan
`(Updatcd 03/0112015)
`
`Page 13
`
`

`
`Drug Name
`indomethacin er
`
` indomerhacin om!
`
`T
`__
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`
`Drug Details
`Drug Siafus
`___..____..._.___,_4...____
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`lier I
`ketoprofen er
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`kewroiacrromerhamineorai
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`MELOXICAM COMFORT PAC
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`meloxicam oraf tablet
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`NALF ON ORAL. CAPSULI-1400 MG
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`NAPROXEN COMFORT PAC
`naproxen oigirsuspension
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`nuproxen sodium oral table: 2 75 mg
`nupr;ciiiei1—.$_(Jdium oral tablet 550 mg
`uoxaprazin
`piroxicumgal capsule I0 mg
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`iroxicum oral capsule 20 mg
`PONSTEL
`
`SPRIX
`
`sulindac oral
`
`toimetin sodium
`
`VOLTA