Chronic Medicine. Reduced out-of-pocket costs for the medicine you need Value and Value Plus plans

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1 Chronic Medicine Reduced 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 Chronic Medicine List Value and Value Plus plans Drug Class ANTIANGINAL AGENTS isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er 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 minitran nitroglycerin RANEXA 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 ANTIDEPRESSANTS amitriptyline hcl amoxapine bupropion hcl bupropion hcl er bupropion hcl sr bupropion hcl xl citalopram hydrobromide clomipramine hcl desipramine hcl desvenlafaxine er doxepin hcl duloxetine hcl escitalopram oxalate fluoxetine dr fluoxetine hcl ANTIDIABETIC acarbose 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 fluvoxamine fluvoxamine er imipramine hcl maprotiline hcl mirtazapine mirtazapine odt nortriptyline hcl paroxetine hcl paroxetine hcl er phenelzine sulfate protriptyline hcl sertraline hcl tranylcypromine sulfate trazodone hcl venlafaxine hcl venlafaxine hcl er 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 doxazosin mesylate enalapril enalapril/hctz fosinopril fosinopril/hctz guanfacine hcl hydralazine hcl irbesartan irbesartan/hctz lisinopril lisinopril fluvastatin gemfibrozil lovastatin niacin er omega-3-acid ethyl esters pravastatin prevalite rosuvastatin calcium simvastatin VASCEPA lisinopril/hctz 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 ANTIPSYCHOTICS aripiprazole aripiprazole odt chlorpromazine hcl clozapine clozapine odt compro fluphenazine hcl haloperidol lithium lithium carbonate lithium carbonate er loxapine loxapine succinate BETA BLOCKERS acebutolol hcl atenolol bisoprolol fumarate carvedilol labetalol hcl metoprolol succinate er metoprolol tartrate nadolol CALCIUM BLOCKERS afeditab cr amlodipine cartia xt dilt-xr diltiazem cd diltiazem hcl diltiazem hcl cd diltiazem hcl er felodipine er isradipine CARDIOTONICS digitek DIAGNOSTIC PRODUCTS FREESTYLE BLOOD GLUCOSE TEST STRIPS ketone urine test strips olanzapine olanzapine odt perphenazine prochlorperazine quetiapine fumarate risperidone risperidone m-tab risperidone odt thioridazine hcl thiothixene trifluoperazine hcl ziprasidone hcl 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 digoxin ONETOUCH BLOOD GLUCOSE TEST STRIPS PRECISION BLOOD GLUCOSE TEST STRIPS

6 DIURETICS acetazolamide amiloride hcl amiloride/hctz bumetanide chlorothiazide chlorthalidone furosemide hydrochlorothiazide MEDICAL DEVICES BD INSULIN SYRINGES AND PEN NEEDLES MISCELLANEOUS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS perphenazine/amitriptyline MISCELLANEOUS CARDIOVASCULAR ENTRESTO indapamide methazolamide metolazone spironolactone pironolactone/hctz torsemide triamterene/hctz lancets

7 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 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 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 Oklahoma include: HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23, GR-29N. Policy form issued in Missouri include: AL HGrpPol 01R5, HI HGrpAg 01, HO HGrpPol 01. ta Aetna Inc (06/18)

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