Intelligent solutions
05.03.397.1 C (10/13)
TIER ONE
Preferred generic medicine
TIER TWO
Preferred brand-name medicine
TIER THREE
Nonpreferred medicine
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 none 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 none LOTRELTARKA
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
2014 Chronic Medicine List
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.
Antiadrenergic antihypertensives (hypertension) clonidine doxazosin guanabenz guanfacine methyldopa methyldopa/HCTZ prazosin reserpine terazosin none 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 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 XL 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 PRODUCTS HUMULIN PRODUCTS JANUMET JANUMET XR JANUVIA JENTADUETO JUVISYNC KOMBIGLYZE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN NOVOLOG PRODUCTS 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 PRODUCTS OSENI PRANDIN PRANDIMET PRECOSE RELION PRODUCTS 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
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 none 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
Cardiac glycosides (heart disease)
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 ULTRA–GLUCOSE TEST STRIPS ONETOUCH VERIO– GLUCOSE TEST STRIPS ONETOUCH VERIO IQ–GLUCOSE TEST STRIPS PRECISION Q-I-D– GLUCOSE TEST STRIPS PRECISION SOF-TACT–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
Direct renin inhibitor (hypertension)
none none AMTURNIDE
TEKAMLO TEKTURNA TEKTURNA HCT Diuretics (hypertension) acetazolamide amiloride amiloride/HCTZ bumetanide chlorothiazide chlorthalidone eplerenone furosemide hydrochlorothiazide indapamide methazolamide methyclothiazide metolazone spironolactone spironolactone/HCTZ torsemide triamterene/HCTZ none ALDACTAZIDE ALDACTONE DEMADEX DIAMOX DIURIL DYAZIDE DYRENIUM EDECRIN INSPRA LASIX MAXZIDE MICROZIDE MIDAMOR THALITONE ZAROXOLYN
Miscellaneous antihypertensives (hypertension) hydralazine
hydralazine/HCTZ minoxidil
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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.
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©2013 Aetna Inc. 05.03.397.1 C (10/13)
