Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2014 Chronic and Preventive Medicine List TIER ONE ACE inhibitors (hypertension, diabetes) benazepril benazepril/hctz captopril captopril/hctz enalapril enalapril/hctz fosinopril fosinopril/hctz lisinopril lisinopril/hctz moexipril moexipril/hctz perindopril quinapril quinapril/hctz ramipril trandolapril ACCUPRIL ACCURETIC ACEON ALTACE LOTENSIN LOTENSIN HCT MAVIK PRINIVIL PRINZIDE UNIRETIC UNIVASC VASERETIC VASOTEC ZESTORETIC ZESTRIL ACE inhibitors/calcium channel blocker combination (hypertension/diabetes) amlodipine/ benazepril LOTREL TARKA Angiotensin ii receptor antagonists (hypertension) candesartan candesartan/hctz eprosartan irbesartan irbesartan/hctz losartan losartan/hctz valsartan valsartan/hctz EXFORGE EXFORGE HCT MICARDIS MICARDIS HCT ATACAND ATACAND HCT AVALIDE AVAPRO AZOR BENICAR BENICAR HCT COZAAR DIOVAN DIOVAN HCT EDARBI EDARBYCLOR HYZAAR TEVETEN TEVETEN HCT TRIBENZOR TWYNSTA VALTURNA Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. 05.03.398.1 C (9/13)
Antiadrenergic antihypertensives (hypertension) clonidine doxazosin guanabenz guanfacine methyldopa methyldopa/hctz prazosin reserpine terazosin CARDURA CATAPRES CATAPRES-TTS CLORPRES MINIPRESS NEXICLON XR TENEX VECAMYL Antianginal agents (heart disease) amyl nitrite isosorbide dinitrate isosorbide dinitrate ER isosorbide mononitrate isosorbide mononitrate ER minitran nitro-time nitroglycerin nitroglycerin CR nitroglycerin SL NITROSTAT RANEXA DILATRATE SR IMDUR ISORDIL MONOKET NITRO-BID NITRO-DUR NITROLINGUAL NITROMIST Antiasthmatics (asthma) albuterol albuterol/ ipratropium aminophylline budesonide inhalation suspension cromolyn ipratropium inhaler levalbuterol inhalation solution montelukast terbutaline theochron theophylline er zafirlukast ASMANEX COMBIVENT RESPIMAT DULERA FLOVENT DISKUS FLOVENT HFA FORADIL PERFOROMIST PROAIR HFA PROVENTIL HFA QVAR SEREVENT DISKUS SPIRIVA SYMBICORT XOLAIR ACCOLATE ACCUNEB ADVAIR DISKUS ADVAIR HFA ALVESCO ARCAPTA NEOHALER ATROVENT HFA BREO ELLIPTA BROVANA COMBIVENT DALIRESP DUONEB ELIXOPHYLLIN LUFYLLIN MAXAIR AUTOHALER metaproterenol PULMICORT FLEXHALER PULMICORT RESPULES SINGULAIR THEO-24 TUDORZA VENTOLIN HFA VOSPIRE ER XOPENEX XOPENEX HFA ZYFLO ZYFLO CR Antidepressants (depression) amitriptyline amitriptyline/ chlodiazepoxide amoxapine budeprion budeprion XL buproprion buproprion SR citalopram clomipramine desipramine doxepin escitalopram fluoxetine fluoxetine delayed release fluvoxamine imipramine maprotiline mirtazapine mirtazapine ODT nortriptyline paroxetine paroxetine ER phenelzine protriptyline sertraline tranylcypromine trazodone trimipramine venlafaxine venlafaxine ER (cap) venlafaxine SR (tab) WELLBUTRIN XL ANAFRANIL APLENZIN CELEXA CYMBALTA EFFEXOR XR EMSAM FLUOXETINE 60 mg FORVIVO LEXAPRO LUVOX CR MARPLAN NARDIL nefazodone NORPRAMIN OLEPTRO PAMELOR PARNATE PAXIL PAXIL CR PEXEVA PRISTIQ PROZAC PROZAC WEEKLY REMERON REMERON SOLUTAB SURMONTIL TOFRANIL TOFRANIL PM VENLAFAXINE ER (tab) VIIBRYD VIIBRYD KIT VIVACTIL WELLBUTRIN WELLBUTRIN SR ZOLOFT
Antidiabetic drugs (diabetes) acarbose chlorpropamide glimepiride glipizide glipizide er glipizide xl glipizide/metformin glucose tab glyburide glyburide micronized glyburide/ metformin metformin metformin er nateglinide pioglitazone pioglitazone/ metformin pioglitazone/ glimepiride repaglinide tolazamide tolbutamide BYDUREON CYCLOSET HUMALOG HUMULIN JANUMET JANUMET XR JANUVIA JENTADUETO JUVISYNC KOMBIGLYZE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN NOVOLOG ONGLYZA PROGLYCEM SYMLIN SYMLINPEN TRADJENTA VICTOZA ACTOPLUS MET ACTOPLUS MET XR ACTOS AMARYL APIDRA AVANDAMET AVANDARYL AVANDIA BYETTA DIABETA DIABINESE DUETACT FORTAMET GLUCAGEN GLUCAGON GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVANCE GLUMETZA GLYNASE GLYSET INVOKANA KAZANO KORLYM METAGLIP NESINA NOVOLIN OSENI PRANDIN PRANDIMET PRECOSE RELION RIOMET STARLIX Antihyperlipidemics (high cholesterol) amlodipine/ atorvastatin atorvastatin cholestyramine cholestyramine light colestipol fenofibrate fenofibrate delayed-release fenofibrate micronized fenofibric acid fluvastatin gemfibrozil lovastatin pravastatin prevalite simvastatin CRESTOR LIPTRUZET LOVAZA NIASPAN SIMCOR WELCHOL ZETIA ANTARA ADVICOR ALTOPREV CADUET COLESTID FENOGLIDE FIBRICOR LESCOL LESCOL XL LIPITOR LIPOFEN LIVALO LOFIBRA LOPID MEVACOR PRAVACHOL QUESTRAN QUESTRAN LITE TRICOR TRIGLIDE TRILIPIX VYTORIN ZOCOR Antipsychotics (mental illness) chlorpromazine clozapine compro fluphenazine haloperidol lithium lithium carbonate lithium carbonate ER lithium citrate loxapine olanzapine olanzapine/ fluoxetine olanzapine ODT perphenazine perphenazine/ amitriptyline prochlorperazine quetiapine risperidone risperidone ODT thioridazine thiothixene trifluoperazine ziprasidone SEROQUEL XR ABILIFY ABILIFY DISC CLOZARIL EQUETRO FANAPT FAZACLO GEODON INVEGA LATUDA LITHOBID LOXITANE ORAP RISPERDAL RISPERDAL M SAPHRIS SEROQUEL SYMBYAX ZYPREXA ZYPREXA ZYDIS
Beta-blockers (hypertension) acebutolol atenolol atenolol/ chlorthalidone betaxolol bisoprolol bisoprolol/hctz carvedilol labetalol metoprolol metoprolol/hctz nadolol nadolol/ bendroflumethiazide pindolol propranolol propranolol SR propranolol/hctz sorine sotalol, sotalol AF timolol BYSTOLIC COREG CR DUTOPROL BETAPACE BETAPACE AF COREG CORGARD CORZIDE INDERAL LA INNOPRAN XL KERLONE LEVATOL LOPRESSOR LOPRESSOR HCT metoprolol sr SECTRAL TENORETIC TENORMIN TOPROL XL TRANDATE ZEBETA ZIAC Blood thinning agents anagrelinde cilostazol clopidogrel dipyridamole enoxaparin fondaparinux jantoven ticlopidine warfarin AGGRENOX EFFIENT PRADAXA XARELTO AGRYLIN ARIXTRA BRILINTA COUMADIN ELIQUIS FRAGMIN IPRIVASK LOVENOX PERSANTINE PLAVIX PLETAL Cardiac glycosides (heart disease) digoxin LANOXIN Calcium channel blockers (heart disease, hypertension) afeditab amlodipine amlodipine/ benazepril cartia xt dilt-cd dilt-xr diltiazem diltiazem cd diltiazem Cr diltiazem er diltiazem sr diltiazem XT felodipine isradapine matzim la nicardipine nifediac cc nifedical xl nifedipine nifedipine cr nifedipine er nifedipine sr nimodipine nisoldipine taztia xt verapamil verapamil Cr verapamil er verapamil sr ADALAT CC CADUET CALAN CALAN SR CARDENE SR CARDIZEM CARDIZEM CD CARDIZEM LA COVERA-HS DILACOR XR DYNACIRC CR ISOPTIN SR LOTREL NIMOTOP NORVASC NYMALIZE PROCARDIA PROCARDIA XL SULAR TARKA TIAZAC VERELAN VERELAN PM VERELAN SR Direct renin inhibitor (hypertension) AMTURNIDE TEKAMLO TEKTURNA TEKTURNA HCT
Diabetic supplies (diabetes) insulin syringes any generic lancets any generic pen needles any generic BD INSULIN SYRINGES BD LANCETS BD PEN NEEDLES FREESTYLE GLUCOSE TEST FREESTYLE INSULINX FREESTYLE LITE BASIC FAST TAKE GLUCOSE TEST PROFILE ULTRA VERIO VERIO IQ PRECISION Q-I-D PRECISION SOF-TACT PRECISION XTRA KETONE TEST SURESTEP ALL OTHER INSULIN SYRINGES ALL OTHER LANCETS ALL OTHER PEN NEEDLES ALL OTHER Diuretics (hypertension) acetazolamide amiloride amiloride/hctz bumetanide chlorothiazide chlorthalidone eplere furosemide hydrochlorothiazide indapamide methazolamide methyclothiazide metolazone spironolactone spironolactone/ hctz torsemide triamterene/hctz ALDACTAZIDE ALDACTONE DEMADEX DIAMOX DIURIL DYAZIDE DYRENIUM EDECRIN INSPRA LASIX MAXZIDE MICROZIDE MIDAMOR THALITONE ZAROXOLYN Miscellaneous antihypertensives (hypertension) hydralazine hydralazine/hctz minoxidil DIBENZYLINE DEMSER Osteoporosis drugs (osteoporosis) alendronate calcitonin etidronate fortical ibandronate pamidronate ACTONEL ATELVIA EVISTA AREDIA BINOSTO BONIVA DIDRONEL FORTEO FOSAMAX FOSAMAX + D GANITE MIACALCIN INJ MIACALCIN SPRAY PROLIA RECLAST SKELID XGEVA ZOMETA
Prenatal multivitamin with chewable multivitamin/ multiple vitamins/ poly-vitamin/ tri-vitamin/ vitamins A/D/C/ Prenatal multivitamin with iron and folic acid mynatal tab MYNATAL CAP Smoking cessation medications (tobacco cessation) buproban buproban sr bupropion bupropion SR CHANTIX NICOTROL INHALER NICOTROL NS ZYBAN Please remember that this is not a complete list of medications covered under your plan. Because there are thousands of medications included in your pharmacy benefit, we only list the most common ones. Certain drugs such as those for smoking cessation or vitamins may not be covered by your particular pharmacy plan. Diabetic supplies may be covered under your medical plan. If you have any questions about your pharmacy benefits, please visit www.aetna.com and log in to your Aetna Navigator member website. If you don t have access to our website, call the toll-free number on your member ID card. To check coverage and copay information for a specific medicine, visit www.aetna.com and log in to Aetna Navigator. For more details, please call the toll-free number on your member ID card. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. This is not an inclusive list. Products that are not represented on this list may be subject to plan-specific copayment or coinsurance. Void where prohibited by law. Specific prescription benefits plan design may not cover certain categories or may be subject to additional charges or restrictions, regardless of their appearance in this document. Aetna may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. Information is believed to be accurate as of the production date; however, it is subject to change. For questions, please call the toll-free number on your member ID card. www.aetna.com 2013 Aetna Inc. 05.03.398.1 C (9/13)