lowest tier

2011 Preventive Medications List for HSA or HRA plans
TIER ONE
TIER TWO
TIER THREE
Preferred generic
Preferred brand-name
Non-preferred
medications
medications
medications
ACE INHIBITORS (hypertension, diabetes)
amlodipine/benazepril
ACCUPRIL
ACCURETIC
benazepril
ACEON
benazepril/hctz
ALTACE
captopril
CAPOTEN
captopril/hctz
CAPOZIDE
enalapril
LOTENSIN
enalapril/hctz
LOTENSIN HCT
fosinopril
LOTREL
fosinopril/hctz
MAVIK
lisinopril
MONOPRIL
lisinopril/hctz
MONOPRIL HCT
moexipril
PRINIVIL
moexipril/hctz
PRINZIDE
perindopril
TARKA
quinapril
UNIRETIC
quinaretic
UNIVASC
ramipril
VASERETIC
trandolapril
trandolapril/verapamil CR
VASOTEC
ZESTORETIC
ZESTRIL
ANGIOTENSIN II RECEPTOR ANTAGONISTS (hypertension)
DIOVAN
ATACAND
losartan
DIOVAN HCT
ATACAND HCT
losartan/hctz
EXFORGE
AVALIDE
EXFORGE HCT
AVAPRO
VALTURNA
AZOR
BENICAR
BENICAR HCT
COZAAR
HYZAAR
MICARDIS
MICARDIS HCT
TEVETEN
TEVETEN HCT
TRIBENZOR
TWYNSTA
ANTIADRENERGIC ANTIHYPERTENSIVES (hypertension)
CARDURA
clonidine
CATAPRES
doxazosin
CATAPRES-TTS
guanabenz
CLORPRES
guanfacine
MINIPRESS
methyldopa
TENEX
methyldopa/hctz
prazosin
reserpine
terazosin
MISCELLANEOUS ANTIHYPERTENSIVES (hypertension)
DIBENZYLINE
DEMSER
hydralazine
hydralazine/hctz
minoxidil
TIER ONE
TIER TWO
TIER THREE
Preferred generic
Preferred brand-name
Non-preferred
medications
medications
medications
ANTIHYPERLIPIDEMICS (high cholesterol)
ANTARA
ALTOPREV
cholestyramine
cholestyramine light
CRESTOR
ADVICOR
LESCOL
CADUET
colestipol
LESCOL XL
COLESTID
fenofibrate
fenofibrate micronized
LOVAZA
FENOGLIDE
NIASPAN
FIBRICOR
fenofibric acid
SIMCOR
LIPITOR
gemfibrozil
TRILIPIX
LIPOFEN
lovastatin
VYTORIN
LIPOFEN
pravastatin
WELCHOL
LIVALO
prevalite
ZETIA
LOFIBRA
simvastatin
LOPID
MEVACOR
PRAVACHOL
QUESTRAN
QUESTRAN LITE
TRICOR
TRIGLIDE
ZOCOR
DIURETICS (hypertension)
ALDACTAZIDE
acetazolamide
ALDACTONE
amiloride
DEMADEX
amiloride/hctz
DIAMOX
bumetanide
DIURIL
chlorothiazide
DYAZIDE
chlorthalidone
DYRENIUM
eplerenone
EDECRIN
furosemide
INSPRA
hydrochlorothiazide
INTROL
indapamide
LASIX
methazolamide
MAXZIDE
methyclothiazide
MICROZIDE
metolazone
MIDAMOR
spironolactone
THALITONE
spironolactone/hctz
ZAROXOLYN
torsemide
triamterine/hctz
BLOOD THINNING AGENTS (stroke prevention)
AGGRENOX
AGRYLIN
anagrelinde
FRAGMIN
ARIXTRA
cilostazol
PLAVIX
COUMADIN
dipyridamole
EFFIENT
enoxaparin
INNOHEP
jantoven
IPRIVASK
ticlopidine
LOVENOX
warfarin
PERSANTINE
PLETAL
DIRECT RENIN INHIBITOR (hypertension)
TEKTURNA
TEKAMLO
TEKTURNA HCT
TIER ONE
TIER TWO
TIER THREE
Preferred generic
Preferred brand-name
Non-preferred
medications
medications
medications
BETA-BLOCKERS (hypertension)
BYSTOLIC
BETAPACE
acebutolol
COREG CR
BETAPACE AF
atenolol
atenolol/chlorthalidone
CARTROL
COREG
betaxolol
CORGARD
bisoprolol
CORZIDE
bisoprolol/hctz
INDERAL LA
carvedilol
INNOPRAN XL
labetalol
KERLONE
metoprolol
LEVATOL
metoprolol/hctz
LOPRESSOR
nadolol
LOPRESSOR HCT
nadolol/
bendroflumethazine
metoprolol SR
SECTRAL
pindolol
TENORETIC
propranolol
TENORMIN
propranolol SR
TOPROL XL
propranolol/hctz
TRANDATE
sorin
ZEBETA
sotalol
ZIAC
sotalol AF
timolol
CALCIUM CHANNEL BLOCKERS (heart disease, hypertension)
ADALAT CC
afeditab
CADUET
amlodipine
amlodipine/benazepril
CALAN
CALAN SR
cartia XT
CARDENE
dilt-CD
CARDENE SR
diltiazem
CARDIZEM
diltiazem CD
CARDIZEM CD
diltiazem ER
CARDIZEM LA
diltiazem SR
COVERA-HS
dilt-XR
DILACOR XR
felodipine
DYNACIRC CR
isradapine
ISOPTIN SR
nicardapine
LOTREL
nifediac CC
NIMOTOP
nifedical XL
NORVASC
nifedipine
PROCARDIA
nifedipine CR
PROCARDIA XL
nifedipine ER
SULAR
nifedipine SR
TARKA
nimodipine
TIAZAC
nisoldipine
VERELAN
taztia XT
trandolapril/verapamil CR
VERELAN PM
VERELAN SR
verapamil
verapamil ER
verapamil SR
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 drug such as
those for smoking cessation drug may not be covered by your particular pharmacy plan. Diabetic or asthma supplies may be covered under your medical plan. If you have any questions about your pharmacy benefit, please visit
Aetna's secure website at www.aetna.com. If you don't have access to our website, call the Member Services number on your ID card.
Preventive Medications List 2011
2011 Preventive Medications List for HSA or HRA plans
TIER ONE
TIER TWO
TIER THREE
Preferred generic
Preferred brand-name
Non-preferred
medications
medications
medications
ANTIASTHMATICS (asthma)
ADVAIR DISKUS
ACCOLATE
albuterol
ACCUNEB
albuterol/ipratropium ADVAIR HFA
ASMANEX
ADRENALIN
aminophylline
AEROBID-M
budesonide inhalation DULERA
FLOVENT DISKUS ALVESCO
suspesion
FLOVENT HFA
ATROVENT HFA
copd
FORADIL
BRETHINE
cromolyn
PERFOROMIST
BRONCAP
dg 200
PROAIR HFA
BRONCODUR
difil G forte
PROVENTIL HFA
BRONCOMAR-1
difil-G (400 tab)
dilex-G (100 liq, 200 tab) PULMICORT RESPULES BRONDIL
SEREVENT DISKUS
BROVANA
dyflex-G
SINGULAIR
COMBIVENT
dy-G
SPIRIVA
DILEX-G (200 syp, 400 tab)
dyphyllin-GG
SYMBICORT
DUONEB
ipratropium inhaler
XOLAIR
DYLIX
terbutaline
ED-BRON G
theochron
ELIXOPHYLLIN
theophylline ER
JAY-PHYL
LUFYLLIN
LUFYLLIN-GG
MAXAIR AUTOHALER
metaproterenol
PULMICORT FLEXHALER
QVAR
THEO-24
UNIPHYL
VENTOLIN HFA
VOSPIRE ER
XOPENEX
XOPENEX HFA
ZYFLO
ZYFLO CR
ASTHMA SUPPLIES (asthma)
AEROCHAMBER
ASSESS PEAK FLOW
BREATHANCER
ELLIPSE
EZ-SPACER
INSPIREASE
MICROCHAMBER
OPTIHALER
SMOKING CESSATION MEDICATIONS (Tobacco Cessation)
CHANTIX
buproban
NICOTROL INHALER
buproban SR
NICOTROL NS
bupropion
ZYBAN
bupropion SR
TIER ONE
TIER TWO
TIER THREE
Preferred generic
Preferred brand-name
Non-preferred
medications
medications
medications
ANTIDIABETIC DRUGS (diabetes)
ACTOPLUS MET
ACTOPLUS MET XR
acarbose
ACTOS
AMARYL
chlorpropamide
AVANDAMET
APIDRA
glimepiride
AVANDARYL
DIABETA
glipizide
AVANDIA
FORTAMET
glipizide ER
BYETTA
GLUCAGEN
glipizide XL
DUETACT
GLUCAGON
glipizide/metformin
HUMALOG products
GLUCOPHAGE
glucose tab
HUMULIN products GLUCOPHAGE XR
glyburide
GLUCOTROL
glyburide micronized JANUMET
GLUCOTROL XL
glyburide/metformin JANUVIA
LANTUS
GLUCOVANCE
glycron
LANTUS SOLOSTAR GLUMETZA
metformin
LEVEMIR
GLYCRON
metformin ER
LEVEMIR FLEXPEN GLYNASE
nateglinide
NOVOLOG products
GLYSET
tolazamide
PRANDIN
METAGLIP
tolbutamide
PROGLYCEM
NOVOLIN products
SYMLIN
ONGLYZA
SYMLINPEN
PRANDIMET
PRECOSE
RELION products
RIOMET
STARLIX
VICTOZA
DIABETIC SUPPLIES (diabetes)
ASCENSIA
BD insulin syringes
BD lancets
ACCUCHEK
BD pen needles
ASSURE
FREESTYLE
AUTOLET
glucose test strips
glucose test strips
FREESTYLE LITE
(all other brands)
glucose test strips
insulin syringes
ONE TOUCH FAST TAKE
(all other brands)
glucose test strips
lancets
ONE TOUCH ULTRA
(all other brands)
glucose test strips
MONOJECT SYRINGE
PRECISION Q-I-D
PRESTIGE
glucose test strips
SOFTCLIX
PRECISION SOF-TACT UNISTIK
glucose test strips
PRECISION XTRA
glucose test strips
PRECISION XTRA
ketone test strips
SURESTEP
glucose test strips
TIER ONE
TIER TWO
TIER THREE
Preferred generic
Preferred brand-name
Non-preferred
medications
medications
medications
OSTEOPOROSIS DRUGS (osteoporosis)
ACTONEL
AREDIA
alendronate
ACTONEL with CALCIUM BONIVA
calcitonin
EVISTA
DIDRONEL
etidronate
FORTEO
FOSAMAX
fortical
FOSAMAX + D
pamidronate
GANITE
MIACALCIN
PROLIA
RECLAST
SKELID
ZOMETA
PEDIATRIC VITAMINS with FLUORIDE
chewable multivit/fluoride
multiple vitamins/fluoride
poly-vitamin/fluoride
tri-vitamin/fluoride
vitamins A/D/C/fluoride
PRENATAL MULTIVITAMIN with IRON and FOLIC ACID
MYNATAL
vita-natal
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 drug such as
those for smoking cessation drug may not be covered by your particular pharmacy plan. Diabetic or asthma supplies may be covered under your medical plan. If you have any questions about your pharmacy benefit, please visit
Aetna's secure website at www.aetna.com. If you don't have access to our website, call the Member Services number on your ID card.
Preventive Medications List 2011