Preventive Medications for HSA or HRA Plans - Aetna

1 Preventive Medications for HSA or HRA Plans 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. If you have any questions about your pharmacy, please visit Aetna 's secure website at If you don't have access to our website, call the Member Services number on your ID card. Preventive Medications List StdV2F7 LOWEST TIER Preferred generic Medications MIDDLE TIER Preferred brand-name Medications HIGHEST TIER Non-preferred Medications ACE INHIBITORS (hypertension, diabetes)

2 BENAZEPRIL ALTACE ACCUPRIL CAPTOPRIL ACEON ENALAPRIL CAPOTEN FOSINOPRIL LOTENSIN LISINOPRIL MAVIK QUINAPRIL MONOPRIL PRINIVIL UNIVASC VASOTEC ZESTRIL ANTI-HYPERLIPIDEMICS (high cholesterol) CHOLESTYRAMINE ADVICOR ALTOCOR COLESTIPOL CRESTOR ALTOPREV FENOFIBRATE LESCOL ANTARA GEMFIBROZIL LESCOL XL CHOLESTIN LOVASTATIN LOFIBRA CHOLOXIN PRAVASTATIN NIASPAN ER COLESTID PREVALITE TRICOR LIPEX SIMVASTATIN TRIGLIDE LIPITOR VYTORIN LOPID WELCHOL LORELCO ZETIA MEVACOR NIASPAN PRAVACHOL PROBUCOL QUESTRAN ZOCOR ANTI-DIABETIC DRUGS (diabetes)

3 ACETOHEXAMIDE ACTOS AMARYL CHLORABETIC ACTOSPLUS MET APIDRA CHLORPROPAMIDE AVANDAMET BYETTA GLIMEPIRIDE AVANDARYL DIABETA GLIPIZIDE AVANDIA DIABINESE GLIPIZIDE ER HUMALOG DYMELOR GLIPIZIDE XL HUMALOG MIX EXUBERA GLUCAGON HUMULIN L FORTAMET GLUCOSE TAB HUMULIN N GLIBENCLAMID GLYBURIDE/ METFORMIN HUMULIN R GLUCAGEN GLYBURIDE LANTUS GLUCOPHAGE GLYCRON LEVEMIR GLUCOPHAGE XL METFORMIN NOVOLOG MIX GLUCOSE (ALL OTHERS) METFORMIN XR NOVOLOG GLUCOTROL TOLAZAMIDE PRANDIN GLUCOTROL XL TOLBUTAMIDE PROGLYCEM GLUCOVANCE STARLIX GLYNASE GLYSET ILETIN I L ILETIN I N ILETIN I R ILETIN II N ILETIN II R METAGLIP NOVOLIN L

4 NOVOLIN N NOVOLIN R PRECOSE RIOMET RELION 70/30 RELION N RELION R RELION MIX RIOMET SYMLIN TOLINASE VELOSULIN BR LOWEST TIER Preferred generic Medications MIDDLE TIER Preferred brand-name Medications HIGHEST TIER Non-preferred Medications OSTEOPOROSIS DRUGS (osteoporosis)

5 FORTICAL ACTONEL BONIVA FORTEO CALCIMAR FOSAMAX DIDRONEL FOSAMAX PLUS MIACALCIN SKELID BETA-BLOCKERS (hypertension) ACEBUTOLOL COREG BETAPACE ATENOLOL BETAPACE AF BETAXOLOL BLOCADREN BISOPROLOL CARTROL LABETALOL CORGARD METOPROLOL INDERAL NADOLOL INDERAL LA PINDOLOL INNOPRAN XL PROPRANOLOL KERLONE SORINE LEVATOL SOTALOL LOPRESSOR TIMOLOL SECTRAL TENORMIN TOPROL XL TRANDATE ZEBETA

6 CALCIUM CHANNEL BLOCKERS (heart disease, hypertension) AFEDITAB ADALAT CARTIA XT ADALAT CC DILT-CD CALAN DILTIA XT CALAN SR DILTIAZEM CARDENE DILTIAZEM CD CARDENE SR DILTIAZEM ER CARDIZEM DILTIAZEM SR CARDIZEM CD FELODIPINE CARDIZEM LA ISRADAPINE COVERA-HS NICARDIPINE DILACOR XR NIFEDIAC CC DYNACIRC NIFEDICAL XL DYNACIRC CR NIFEDIPINE ISOPTIN NIFEDIPINE SR ISOPTIN SR TAZTIA XT NORVASC VERAPAMIL PLENDIL VERAPAIMIL SR PROCARDIA PROCARDIA XL SULAR

7 TIAZAC VASCOR VERELAN VERELAN PM LOWEST TIER Preferred generic Medications MIDDLE TIER Preferred brand-name Medications HIGHEST TIER Non-preferred Medications BLOOD THINNING AGENTS (coronary artery disease, heart disease) ANAGRELIDE AGGRENOX AGRYLIN CILOSTAZOL ARIXTRA CLOPIDOGREL COUMADIN DIPYRIDAMOLE FRAGMIN JANTOVEN LOVENOX TICLOPIDINE ORGARAN WARFARIN PERSANTINE PLAVIX PLETAL TICLID PEDIATRIC VITAMINS W/FLOURIDE TRI-A-VITE TRI-VI-FLOR TRI-VITAMIN/ FLORIDE TRI-VITA BET

8 PRENATAL MULTIVITAMIN W/FE, FA MATERNITY-90 MYNATAL NATAMAR RX NUTRACARE ORIGINAL TAB PRENATAL PERRY PRENATAL PRENATAL/FE PRENATAL/ZN TERNAMAR VITA-NATAL Preventive Medications for HSA or HRA Plans 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.

9 If you have any questions about your pharmacy, please visit Aetna 's secure website at If you don't have access to our website, call the Member Services number on your ID card. Preventive Medications List StdV2F7 LOWEST TIER Preferred generic Medications MIDDLE TIER Preferred brand-name Medications HIGHEST TIER Non-preferred Medications DIURETICS (hypertension) ACETAZOLAMIDE ALDACTAZIDE AMILORIDE/HYDRO- CHLOROTHIAZIDE ALDACTONE AMILORIDE A-NURIC DIUR BUMETANIDE BUMEX CHLOROTHIAZIDE DEMADEX CHLORTHALIIDONE DIAMOX DIAQUA DIURIL FUROSEMIDE DYAZIDE HYDROCHLORO- THAZIDE DYRENIUM INDAPAMIDE EDECRIN METHAZOLAMIDE ENDURON METHYCLOTHIAZIDE ESIDRIX METOLAZONE HYDRODIURIL SPIRONOLACTONE/HYDROCHLORO- THIAZIDE HYDRO-TABS SPIRONOLACTONE HYGROTON TORSEMIDE INTROL TRIAMTERINE/HYD.

10 ROCHLOROTHIAZIDE ISMOTIC TRICHLORMETH- IAZIDE LASIX LOZOL MAXZIDE MICROZIDE MIDAMOR MODURETIC MYKROX THALITONE WASSER ZAROXOLYN DIABETIC SUPPLIES (diabetes) BD INSULIN SYR ACCUCHEK BD LANCET ASCENSIA BD PEN NEEDLES ASSURE FREESTYLE TEST STRIPS AUTOLET ONE TOUCH TEST STRIPS GLUCOMETER PRESCISION TEST STRIPS INSULIN SYRINGES (ALL OTHER BRANDS) MONOJECT SYR