Preventive Medicine. Reducing your out-of-pocket costs for the medicine you need Value and Value Plus plans

Transcription

1 Preventive Medicine Reducing your out-of-pocket costs for the medicine you need Value and Value Plus plans

2 Forget your deductible just pay your copay or coinsurance when buying certain medication. January 1, 2019 Preventive Medicine List Value and Value Plus plans Drug Class ANALGESICS - NARCOTIC buprenorphine hcl subl ANTIASTHMATIC albuterol sulfate albuterol sulfate er ANORO ELLIPTA ASMANEX HFA ASMANEX TWISTHALER BREO ELLIPTA budesonide COMBIVENT RESPIMAT cromolyn difil-g forte DULERA fluticasone propionate/salmeterol INCRUSE ELLIPTA ipratropium bromide ipratropium bromide/albuterol sulfate levalbuterol metaproterenol sulfate montelukast buprenorphine hcl/naloxone hcl subl PROAIR HFA PROAIR RESPICLICK QVAR REDIHALER SEREVENT DISKUS SPIRIVA HANDIHALER SPIRIVA RESPIMAT STIOLTO RESPIMAT SYMBICORT terbutaline sulfate THEO-24 theochron theophylline theophylline cr theophylline er TRELEGY ELLIPTA VENTOLIN HFA zafirlukast Key UPPERCASE lowercase italics Brand-name medicine Generic medicine 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 Assurance 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 Each insurer has sole financial responsibility for its own products. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC.

3 ANTICOAGULANTS anticoagulant citrate anticoagulant citrate dextrose solution a ELIQUIS ELIQUIS STARTER PACK enoxaparin ANTIDIABETIC acarbose ANTIDOTES ADMELOG products alogliptin alogliptin/metformin hcl alogliptin/pioglitazone BASAGLAR KWIKPEN chlorpropamide FARXIGA glimepiride glipizide glipizide er glipizide xl glipizide/metformin hcl GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT glucose glyburide glyburide micronized glyburide/metformin hcl GLYXAMBI HUMALOG products HUMULIN products INVOKAMET INVOKAMET XR naltrexone hcl tabs heparin jantoven warfarin XARELTO XARELTO STARTER PACK INVOKANA JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR LEVEMIR products metformin hcl metformin hcl er miglitol pioglitazone hcl pioglitazone hcl/glimepiride pioglitazone hcl/metformin hcl SOLIQUA SYNJARDY SYNJARDY XR tolazamide TRADJENTA TRESIBA FLEXTOUCH TRULICITY VICTOZA XIGDUO XR XULTOPHY

4 ANTIHYPERLIPIDEMIC atorvastatin calcium cholestyramine cholestyramine light colesevelam hcl colestipol hcl ezetimibe ezetimibe/simvastatin fenofibrate fenofibrate micronized fenofibric acid fenofibric acid dr ANTIHYPERTENSIVE amlodipine/benazepril hcl amlodipine/valsartan amlodipine/valsartan/hctz atenolol/chlorthalidone benazepril hcl benazepril hcl/hctz bisoprolol fumarate/hctz candesartan cilexetil candesartan cilexetil/hctz captopril captopril/hctz clonidine hcl doxazosin mesylate enalapril enalapril/hctz fosinopril fosinopril/hctz guanfacine hcl hydralazine hcl irbesartan irbesartan/hctz lisinopril lisinopril/hctz fluvastatin gemfibrozil lovastatin niacin er omega-3-acid ethyl esters pravastatin prevalite rosuvastatin calcium simvastatin VASCEPA losartan potassium losartan potassium/hctz methyldopa methyldopa/hctz metoprolol/hctz minoxidil moexipril hcl moexipril/hctz olmesartan medoxomil olmesartan medoxomil/hctz prazosin hcl propranolol/hctz quinapril hcl quinapril/hctz ramipril telmisartan telmisartan/hctz terazosin hcl trandolapril trandolapril/verapamil hcl er valsartan valsartan/hctz

5 BETA BLOCKERS acebutolol hcl atenolol bisoprolol fumarate carvedilol labetalol hcl metoprolol succinate er metoprolol tartrate nadolol CALCIUM BLOCKERS afeditab cr amlodipine cartia xt diltiazem cd diltiazem hcl diltiazem hcl cd diltiazem hcl er felodipine er isradipine DIAGNOSTIC PRODUCTS FREESTYLE BLOOD GLUCOSE TEST STRIPS ketone urine test strips DIURETICS acetazolamide amiloride hcl amiloride/hctz bumetanide chlorothiazide chlorthalidone furosemide hydrochlorothiazide MEDICAL DEVICES BD INSULIN SYRINGES AND PEN NEEDLES MINERALS & ELECTROLYTES FLUORABON fluoride fluoritab ludent pindolol propranolol hcl propranolol hcl er sorine sotalol hcl sotalol hcl (af) timolol nicardipine hcl nifedipine nifedipine er nimodipine nisoldipine er taztia xt verapamil hcl verapamil hcl er verapamil hcl sr ONETOUCH BLOOD GLUCOSE TEST STRIPS PRECISION BLOOD GLUCOSE TEST STRIPS indapamide methazolamide metolazone spironolactone spironolactone/hctz torsemide triamterene/hctz lancets nafrinse nafrinse drops sodium fluoride

6 MISCELLANEOUS ENDOCRINE alendronate calcitonin salmon ibandronate MISCELLANEOUS HEMATOLOGICAL anagrelide hcl aspirin/dipyridamole BRILINTA MISCELLANEOUS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS bupropion hcl sr PEDIATRIC MULTI VITAMINS W/FLUORIDE pediatric multivitamin/fluoride pediatric multivitamin/fluoride/iron PRENATAL VITAMINS prenatal vitamins pamidronate disodium raloxifene hcl tabs zoledronic acid cilostazol clopidogrel dipyridamole POLY-VI-FLOR POLY-VI-FLOR/IRON VITAFOL-OB+DHA

7 Some drugs may require prior authorization, step therapy or be formulary excluded for certain members, depending on their pharmacy benefits plan. This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. Brand-name drugs not listed here may be covered by your plan without the use of a generic first. Information provided here is not a substitute for medical advice or treatment. Step therapy does not apply to fully insured members in New Jersey. However, these programs are available to self-funded plans. Discuss this information with your doctor or health care provider. Aetna assumes no liability for the information provided or for any diagnosis or treatment made in reliance thereon, nor is it responsible for the reliability of the content. Subject to state law restrictions. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with Aetna. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. Targeted therapeutic classes, specific drugs and criteria are subject to change. 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, 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, 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. Void in the State of Connecticut. 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. Policy forms issued in Missouri include: AL HGrpPol 01R5, HI HGrpAg 01, HO HGrpPol 01. Policy forms issued in Oklahoma include: HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR- 23, GR-29N. ta Aetna Inc (07/18)