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Reduced out-of-pocket costs for the medicine you need 2021 Aetna Standard Plan

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©2013 Aetna Inc. XX.XX.XXX.X (X/13) 54.03.905.1A (1/21) Forget your deductible – just pay your copay or coinsurance when buying certain medication.

January 1, 2021 Key Chronic and Preventive Medicine List UPPERCASE Brand-name medicine Aetna Standard Plan lowercase italics Generic medicine

Drug class Drug name

ANALGESICS – NARCOTIC buprenorphine ZUBSOLV buprenorphine/naloxone

ANTIANGINAL AGENTS isosorbide dinitrate minitran nitroglycerin isosorbide mononitrate NITRO-DUR ranolazine er isosorbide mononitrate er

ANTIASTHMATIC ADVAIR HFA FLOVENT HFA SPIRIVA RESPIMAT albuterol ipratropium STIOLTO RESPIMAT albuterol er ipratropium/albuterol STRIVERDI RESPIMAT albuterol hfa levalbuterol SYMBICORT ANORO ELLIPTA levalbuterol hfa terbutaline ARNUITY ELLIPTA metaproterenol theophylline BREO ELLIPTA montelukast theophylline cr BREZTRI AEROSPHERE PERFOROMIST theophylline er budesonide PULMICORT FLEXHALER TRELEGY ELLIPTA cromolyn QVAR REDIHALER YUPELRI DALIRESP SEREVENT DISKUS zafirlukast difil-g forte SPIRIVA HANDIHALER zileuton er FLOVENT DISKUS

ANTICOAGULANTS ELIQUIS FRAGMIN warfarin enoxaparin heparin XARELTO fondaparinux jantoven

ANTIDEPRESSANTS amitriptyline escitalopram paroxetine amoxapine fluoxetine paroxetine er bupropion fluoxetine dr phenelzine bupropion er (sr) fluvoxamine protriptyline bupropion er (xl) fluvoxamine er sertraline citalopram imipramine tranylcypromine clomipramine maprotiline trazodone desipramine mirtazapine trimipramine DESVENLAFAXINE ER mirtazapine odt TRINTELLIX desvenlafaxine er nefazodone venlafaxine doxepin nortriptylin venlafaxine er duloxetine

Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and 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. Drug class Drug name

ANTIDIABETIC acarbose GVOKE HYPOPEN 2-PACK pioglitazone/metformin BAQSIMI GVOKE PFS repaglinide BASAGLAR KWIKPEN HUMULIN products RYBELSUS FARXIGA JANUMET SOLIQUA 100/33 FIASP products JANUMET XR SYMLINPEN 120 glimepiride JANUVIA SYMLINPEN 60 glipizide JARDIANCE SYNJARDY glipizide er LEVEMIR products SYNJARDY XR glipizide xl metformin tolbutamide glipizide/metformin metformin er TOUJEO products GLUCAGEN HYPOKIT miglitol TRESIBA products GLUCAGON EMERGENCY KIT nateglinide TRIJARDY XR glyburide NOVOLIN products TRULICITY glyburide micronized NOVOLOG products VICTOZA glyburide/metformin OZEMPIC XIGDUO XR GLYXAMBI pioglitazone XULTOPHY GVOKE HYPOPEN 1-PACK pioglitazone-glimepiride

ANTIDOTES naltrexone

ANTIHYPERLIPIDEMIC atorvastatin FENOFIBRIC ACID niacin er cholestyramine fenofibric acid dr omega-3-acid ethyl esters cholestyramine light fluvastatin PRALUENT colesevelam fluvastatin er pravastatin colestipol gemfibrozil prevalite ezetimibe lovastatin rosuvastatin ezetimibe/simvastatin NEXLETOL simvastatin fenofibrate NEXLIZET VASCEPA fenofibrate micronized

ANTIHYPERTENSIVE aliskiren fosinopril olmesartan/hctz amlodipine/benazepril fosinopril/hctz perindopril amlodipine/olmesartan guanfacine phenoxybenzamine amlodipine/valsartan hydralazine prazosin amlodipine/valsartan/hctz irbesartan propranolol/hctz atenolol/chlorthalidone irbesartan/hctz quinapril benazepril lisinopril quinapril/hctz benazepril/hctz lisinopril/hctz ramipril bisoprolol/hctz losartan TEKTURNA HCT candesartan losartan/hctz telmisartan candesartan/hctz methyldopa telmisartan/amlodipine captopril methyldopa/hctz telmisartan/hctz captopril/hctz metoprolol/hctz terazosin clonidine minoxidil trandolapril doxazosin moexipril trandolapril/verapamil er enalapril olmesartan valsartan enalapril/hctz olmesartan/amlodipine/hctz valsartan/hctz eplerenone Drug class Drug name

ANTIPSYCHOTICS ABILIFY MAINTENA lithium quetiapine aripiprazole lithium er quetiapine er aripiprazole odt loxapine risperidone chlorpromazine molindone risperidone odt clozapine olanzapine thioridazine clozapine odt olanzapine odt thiothixene compro paliperidone er trifluoperazine fluphenazine perphenazine VRAYLAR haloperidol PERSERIS ziprasidone LATUDA prochlorperazine

BETA BLOCKERS acebutolol labetalol propranolol er atenolol metoprolol sorine betaxolol metoprolol er sotalol bisoprolol nadolol sotalol af BYSTOLIC pindolol timolol carvedilol propranolol

CALCIUM BLOCKERS amlodipine isradipine nisoldipine er cartia xt nicardipine taztia xt dilt-xr nifedipine verapamil diltiazem nifedipine er verapamil er diltiazem er nimodipine verapamil sr felodipine er

CARDIOTONICS digitek digoxin digox LANOXIN

DIABETIC DIAGNOSTIC BD INSULIN SYRINGES ONETOUCH ULTRA PRODUCTS and SUPPLIES AND PEN NEEDLES ONETOUCH VERIO LANCETS, LANCET DEVICES TEST STRIPS

DIURETICS acetazolamide ethacrynic acid spironolactone acetazolamide er furosemide spironolactone/hctz amiloride hctz torsemide amiloride/hctz indapamide triamterene bumetanide methazolamide triamterene/hctz chlorthalidone metolazone

MISCELLANEOUS amlodipine/atorvastatin CORLANOR CARDIOVASCULAR BIDIL ENTRESTO

MISCELLANEOUS alendronate ibandronate risedronate dr ENDOCRINE calcitonin salmon risedronate zoledronic acid

MISCELLANEOUS anagrelide cilostazol dipyridamole HEMATOLOGICAL aspirin/dipyridamole er clopidogrel prasugrel BRILINTA

MISCELLANEOUS chlordiazepoxide/amitriptyline PSYCHOTHERAPEUTIC olanzapine/fluoxetine and NEUROLOGICAL perphenazine/amitriptyline AGENTS Drug class Drug name

PEDIATRIC MULTI VITAMINS MULTIVITAMIN/FLUORIDE pediatric multivitamin/fluoride/iron with FLUORIDE pediatric multivitamin/fluoride

PRENATAL VITAMINS CITRANATAL 90 DHA CITRANATAL BLOOM DHA CITRANATAL RX CITRANATAL ASSURE CITRANATAL DHA prenatal vitamins CITRANATAL B-CALM CITRANATAL HARMONY TRINATE CITRANATAL BLOOM CITRANATAL MEDLEY

Please remember that this is not a complete list of drugs covered under your plan. Products may be subject to plan-specific copayment or coinsurance, additional charges or other restrictions. Certain drugs, such as those for infertility, erectile dysfunction, weight loss, smoking cessation or vitamins, may not be covered by your particular pharmacy plan. Diabetic supplies may be covered under your medical plan. To check coverage and copay information for a specific drug, please visit the website on your member ID card and log in to your member website. If you don’t have access to our website, call the toll-free number on your member ID card. Information is believed to be accurate as of the production date; however, it is subject to change.

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