2014 Preventive Medicine List
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Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2014 Preventive Medicine List 05.03.393.1 F (2/14) TIER ONE Preferred generic medicine TIER TWO Preferred brand-name medicine TIER THREE Nonpreferred medicine none ACCUPRIL ACCURETIC ACEON ALTACE LOTENSIN LOTENSIN HCT MAVIK PRINIVIL PRINZIDE 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 UNIRETIC UNIVASC VASERETIC VASOTEC ZESTORETIC ZESTRIL ACE inhibitors/calcium channel blocker combination (hypertension/diabetes) amlodipine/ benazepril none LOTREL TARKA Angiotensin II receptor antagonists (hypertension) EXFORGE EXFORGE HCT MICARDIS MICARDIS HCT candesartan candesartan/HCTZ eprosartan irbesartan irbesartan/HCTZ losartan losartan/HCTZ valsartan valsartan/HCTZ ATACAND ATACAND HCT AVALIDE AVAPRO AZOR BENICAR BENICAR HCT COZAAR DIOVAN DIOVAN HCT EDARBI EDARBYCLOR HYZAAR TEVETEN TEVETEN HCT TRIBENZOR TWYNSTA VALTURNA CARDURA CATAPRES CATAPRES-TTS CLORPRES MINIPRESS NEXICLON XR TENEX VECAMYL Anti-adrenergic antihypertensives (hypertension) clonidine doxazosin guanabenz guanfacine methyldopa methyldopa/HCTZ prazosin reserpine terazosin none Miscellaneous antihypertensives (hypertension) hydralazine hydralazine/HCTZ 2 minoxidil DIBENZYLINE DEMSER 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. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. TIER ONE Preferred generic medicine TIER TWO Preferred brand-name medicine TIER THREE Nonpreferred medicine 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 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 PRODUCTS OSENI PRANDIN PRANDIMET PRECOSE RELION PRODUCTS RIOMET STARLIX 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 Anti-asthmatics (asthma) albuterol albuterol/ ipratropium aminophylline budesonide inhalation suspension cromolyn ipratropium inhaler levalbuterol inhalation solution montelukast terbutaline theochron theophylline ER zafirlukast 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 PRODUCTS HUMULIN PRODUCTS JANUMET JANUMET XR JANUVIA JENTADUETO JUVISYNC KOMBIGLYZE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN NOVOLOG PRODUCTS ONGLYZA PROGLYCEM SYMLIN SYMLINPEN TRADJENTA VICTOZA Antihyperlipidemics (high cholesterol) amlodipine/ atorvastatin atorvastatin cholestyramine cholestyramine light colestipol fenofibrate fenofibrate delayedrelease fenofibrate micronized fenofibric acid fluvastatin gemfibrozil lovastatin pravastatin prevalite simvastatin CRESTOR LIPTRUZET LOVAZA NIASPAN SIMCOR WELCHOL ZETIA 3 TIER ONE Preferred generic medicine TIER TWO Preferred brand-name medicine TIER THREE Nonpreferred medicine 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 SECTRAL TENORETIC TENORMIN TOPROL XL TRANDATE ZEBETA ZIAC jantoven ticlopidine warfarin AGGRENOX EFFIENT PRADAXA XARELTO AGRYLIN ARIXTRA BRILINTA COUMADIN ELIQUIS FRAGMIN IPRIVASK LOVENOX PERSANTINE PLAVIX PLETAL none 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 none AMTURNIDE TEKAMLO TEKTURNA TEKTURNA HCT Beta-blockers (hypertension) acebutolol atenolol atenolol/ chlorthalidone betaxolol bisoprolol bisoprolol/HCTZ carvedilol labetalol metoprolol metoprolol ER Blood thinning agents anagrelide cilostazol clopidogrel dipyridamole enoxaparin fondaparinux 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 Direct renin inhibitor (hypertension) none 4 TIER ONE Preferred generic medicine TIER TWO Preferred brand-name medicine TIER THREE Nonpreferred medicine none ALDACTAZIDE ALDACTONE DEMADEX DIAMOX DIURIL DYAZIDE DYRENIUM EDECRIN INSPRA Diuretics (hypertension) acetazolamide amiloride amiloride/HCTZ bumetanide chlorothiazide chlorthalidone eplerenone furosemide hydrochlorothiazide indapamide methazolamide methyclothiazide metolazone spironolactone spironolactone/HCTZ torsemide triamterene/HCTZ LASIX MAXZIDE MICROZIDE MIDAMOR THALITONE ZAROXOLYN 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 STRIPS FREESTYLE INSULINX– GLUCOSE TEST STRIPS FREESTYLE LITE– GLUCOSE TEST STRIPS ONETOUCH BASIC– GLUCOSE TEST STRIPS ONETOUCH FAST TAKE–GLUCOSE TEST STRIPS ONETOUCH PROFILE– GLUCOSE TEST STRIPS ONETOUCH VERIO– GLUCOSE TEST STRIPS ONETOUCH VERIO IQ–GLUCOSE TEST STRIPS ONETOUCH ULTRA–GLUCOSE TEST STRIPS PRECISION Q-I-D– GLUCOSE TEST STRIPS PRECISION SOFTACT–GLUCOSE TEST STRIPS PRECISION XTRA– KETONE TEST STRIPS SURESTEP– GLUCOSE TEST STRIPS GLUCOSE TEST STRIPS–ALL OTHER BRANDS INSULIN SYRINGES–ALL OTHER BRANDS LANCETS–ALL OTHER BRANDS PEN NEEDLES–ALL OTHER BRANDS 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 5 TIER ONE Preferred generic medicine TIER TWO Preferred brand-name medicine TIER THREE Nonpreferred medicine none none Prenatal multivitamin with fluoride chewable multivitamin/ fluoride multiple vitamins/ fluoride poly-vitamin/fluoride trivitamin/fluoride vitamins A/D/C/ fluoride Prenatal multivitamin with iron and folic acid mynatal tab none MYNATAL CAP Smoking cessation medications (tobacco cessation) buproban buproban SR bupropion bupropion SR 6 none CHANTIX NICOTROL INHALER NICOTROL NS ZYBAN 7 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 secure 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 your secure member website. For more details, please call the toll-free number on your member ID card. 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 ©2014 Aetna Inc. 05.03.393.1 F (2/14)
