2013 Aetna Medicare Prescription Drugs that Require Step Therapy ...

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SMOKING CESSATIONProducts AffectedChantixChantix Continuing Month PakChantix Starting Month PakDetailsCriteriaA documented trial of 6 weeks of Buproban (bupropion SR)11

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DIABETIC SUPPLIESProducts AffectedBd Insulin SyringeSafetyglide/1ml/29g X 1/2"Bd Insulin SyringeUltrafine/0.3ml/31g X 5/16"Bd Insulin SyringeUltrafine/0.5ml/30g X 1/2"Bd Insulin Syringe Ultrafine/1ml/31gX 5/16" Bd Pen Needle/ultrafine/29g X12.7mm V-go 20 V-go 30 V-go 40DetailsCriteriaA documented concurrent use of an insulin product or Byetta or Bydureonor Symlin or Victoza within the past 120 days10

SMOKING CESSATIONProducts AffectedChantixChantix Continuing Month PakChantix Starting Month PakDetailsCriteriaA documented trial of 6 weeks of Buproban (bupropion SR)11

Page 4: ATYPICAL ANTIPSYCHOTICProducts Affe
Page 7 and 8: LIDODERMProducts Affected Lidocaine
Page 9: SOMATOSTATIN ANALOGSProducts Affect
Page 13: INDEXBBd Insulin Syringe Safetyglid

2013 Aetna Medicare Prescription Drugs that Require Step Therapy ...

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