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For more detailed information about Aetna Better Health of Virginia CCC Plus or Medallion/FAMIS 4.0 prescription drug coverage, please review your Member Handbook and other plan materials.

Please click here to view upcoming changes for this formulary.

If you have questions please call Member Services at 1-855-652-8249 for CCC Plus or 1-800-279-1878 for Medallion/FAMIS 4.0 or TTY/TDD: 711 or 1-800-828-1120 if hearing impaired.

To Our Providers: Please click here to initiate an electronic prior authorization (ePA) request


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*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants**Als Agents - Miscellaneous****Alternative Medicines**Amebicides**Aminoglycosides**Analgesic Combinations - Topical****Analgesics - Anti-Inflammatory**Analgesics - Nonnarcotic**Analgesics - Opioid**Androgens-Anabolic**Anorectal Agents**Antacids**Anthelmintics**Antianginal Agents**Antianxiety Agents**Antiarrhythmics**Antiasthmatic And Bronchodilator Agents**Anticoagulants - Misc.****Anticoagulants**Anticonvulsants**Antidementia Agent Combinations****Antidepressants**Antidiabetics**Antidiarrheal/Probiotic Agents**Antidiarrheals**Antidote Combinations****Antidotes And Specific Antagonists**Antidotes**Antiemetics**Antifungals**Antihistamines**Antihyperlipidemics Misc. 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Misc.**Cephalosporin Combinations****Cephalosporins**Chemicals**Cic Agents - Guanylate Cyclase-C (Gc-C) Agonists****Contraceptives**Corticosteroids**Cough/Cold/Allergy**Cyclin-Dependent Kinases (Cdk) Inhibitors****Cystic Fibrosis Agent - Combinations****Dermatologicals**Diagnostic Products**Dietary Products/Dietary Management Products**Digestive Aids**Digestive Enzyme Cartridge****Direct-Acting P2y12 Inhibitors****Diuretics**Endocrine And Metabolic Agents - Misc.**Estrogens**Estrogen-Selective Estrogen Receptor Modulator Comb****Farnesoid X Receptor (Fxr) Agonists****Fentanyl Combinations****Fluoroquinolones**Gastrointestinal Agents - Misc.**General Anesthetics**Genitourinary Agents - Miscellaneous**Glycopeptides****Gout Agents**Hematological Agents - Misc.**Hematopoietic Agents**Hemostatics**Hepatitis C Agent - Combinations****Hereditary Orotic Aciduria Treatment - Agents***Hydromorphone Combinations****Hypnotics**Hypophosphatasia (Hpp) Agents****Ibs Agent - Mu-Opioid Receptor Agonists****Impotence Agent Combinations****In Vitro/Lock Anticoagulants****Insulin-Incretin Mimetic Combinations****Integrin Receptor Antagonists****Interleukin Antagonists****Interleukin-5 Antagonists (Igg1 Kappa)****Interleukin-5 Antagonists (Igg4 Kappa)****Interleukin-6 (Il-6) Antagonists****Laxatives**Leptin Analogues****Lhrh/Gnrh Agonist Analog Combinations****Local Anesthetics-Parenteral**Lymphocyte Function-Associated Antigen-1 (Lfa-1) Antag****Lysosomal Acid Lipase (Lal) Deficiency - Agents****Macrolides**Medical Devices**Migraine Products**Minerals & Electrolytes**Miscellaneous Therapeutic Classes**Mixed Allergenic Extracts****Monobactams****Mouth/Throat/Dental Agents**Mucopolysaccharidosis Iv (Mps Iv) - Agents****Multiple Vitamins & Fluoride-Folic Acid****Multiple Vitamins W/ Minerals & Fluoride-Iron-Folic Acid****Multivitamins**Muscular Dystrophy Agents****Musculoskeletal Therapy Agents**Nasal Agents - Systemic And Topical**Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb****Neurogenic Orthostatic Hypotension (Noh) - Agents****Neuromuscular Agents**Nsaid-Dietary Management Combinations****Nsaid-Vitamins And/Or Minerals Combinations****Nutrients**Oncolytic Viral Agents - Hsv1****Ophthalmic Agents**Orexin Receptor Antagonists****Otic Agents**Oxaborole-Related Antifungals - Topical****Oxytocics**Passive Immunizing Agents - Combinations****Passive Immunizing Agents**Pcsk9 Inhibitors****Pediatric Multiple Vitamins & Minerals W/ Fluoride****Pediatric Multiple Vitamins W/Fluoride-Iron-Zinc****Penicillins**Peritoneal Dialysis Solutions****Pharmaceutical Adjuvants**Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors****Phosphodiesterase 4 (Pde4) Inhibitors - Topical****Phosphodiesterase 4 (Pde4) Inhibitors****Poly (Adp-Ribose) Polymerase (Parp) Inhibitors***Poly (Adp-Ribose) Polymerase (Parp) Inhibitors****Postherpetic Neuralgia (Phn) Combination Agents****Postherpetic Neuralgia (Phn)/Neuropathic Pain Agents****Postherpetic Neuralgia(Phn)/Neuropathic Pain Comb Agents****Potassium Removing Agents****Prenatal Mv & Minerals W/Fa Without Iron****Progestins**Protease-Activated Receptor-1 (Par-1) Antagonists****Protein-Carbohydrate-Lipid With Electrolyte Combinations****Psychotherapeutic And Neurological Agents - Misc.**Pulmonary Fibrosis Agents - Kinase Inhibitors****Pulmonary Fibrosis Agents****Pulmonary Hypertension - Prostacyclin Receptor Agonist****Respiratory Agents - Misc.**Semi Solid Vehicle Combinations***Serotonin 1A Recept Agonist/Serotonin 2A Recept Antag****Serotonin Modulators****Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations****Sinus Node Inhibitors***Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb****Steroids - Mouth/Throat/Dental****Sulfonamides**Surgical Sealants****Tetracyclines**Tetrahydroisoquinolines****Thyroid Agents**Topical Anesthetic Gases****Toxoids**Tryptophan Hydroxylase Inhibitors****Ulcer Drugs**Urinary Anti-Infectives**Urinary Antispasmodics**Vaccines**Vaginal Products**Vasopressors**Vesicoureteral Reflux (Vur) Agent Combinations****Vitamins*
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Formulary Id: 00000000
Formulary Effective Date: 09/01/2019
Updated:
10/2019

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