Preventive Medicine Reducing your out-of-pocket costs for the medicine you need - 2021 Advanced Control Plan - Aetna
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Preventive Medicine Reducing your out-of-pocket costs for the medicine you need 2021 Advanced Control Plan – Aetna 05.03.957.1C (01/21)
Forget your deductible – just pay your copay or coinsurance when buying
certain medication.
Preventive Medicine List effective January 1, 2021 Key
Advanced Control Plan – Aetna UPPERCASE Brand-name medicine
lowercase italics Generic medicine
Drug class Drug name
ANALGESICS – NARCOTIC buprenorphine ZUBSOLV
buprenorphine/naloxone
ANTIASTHMATIC ADVAIR DISKUS FLOVENT DISKUS SPIRIVA RESPIMAT
ADVAIR HFA FLOVENT HFA STIOLTO RESPIMAT
albuterol ipratropium STRIVERDI RESPIMAT
albuterol er ipratropium/albuterol SYMBICORT
albuterol hfa levalbuterol terbutaline
ANORO ELLIPTA metaproterenol THEOCHRON
ARNUITY ELLIPTA montelukast theophylline
BREO ELLIPTA PERFOROMIST theophylline er
BREZTRI AEROSPHERE PULMICORT FLEXHALER TRELEGY ELLIPTA
budesonide QVAR REDIHALER YUPELRI
cromolyn SPIRIVA HANDIHALER zafirlukast
DALIRESP
ANTICOAGULANTS ELIQUIS warfarin
enoxaparin XARELTO
heparin
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 TRINTELLIX
doxepin mirtazapine odt venlafaxine
duloxetine nortriptylin venlafaxine er
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.
2Drug class Drug name
ANTIDIABETIC acarbose GVOKE HYPOPEN 1-PACK pioglitazone-glimepiride
BAQSIMI GVOKE PFS pioglitazone/metformin
BASAGLAR KWIKPEN HUMULIN products RYBELSUS
chlorpropamide JANUMET SOLIQUA 100/33
FARXIGA JANUMET XR SYMLINPEN 120
FIASP products JANUVIA SYMLINPEN 60
glimepiride JARDIANCE SYNJARDY
glipizide LEVEMIR products SYNJARDY XR
glipizide er metformin TOUJEO products
glipizide/metformin metformin er TRESIBA products
GLUCAGEN HYPOKIT miglitol TRIJARDY XR
GLUCAGON NOVOLIN products TRULICITY
EMERGENCY KIT NOVOLOG products VICTOZA
glucose OZEMPIC XIGDUO XR
GLYXAMBI pioglitazone XULTOPHY
ANTIDOTES naltrexone
ANTIHYPERLIPIDEMIC atorvastatin fenofibrate micronized NEXLIZET
cholestyramine fenofibric acid dr niacin er
cholestyramine light fluvastatin omega-3-acid ethyl esters
colesevelam fluvastatin er pravastatin
colestipol gemfibrozil rosuvastatin
ezetimibe lovastatin simvastatin
ezetimibe/simvastatin NEXLETOL VASCEPA
fenofibrate
ANTIHYPERTENSIVE aliskiren fosinopril olmesartan
amlodipine/benazepril fosinopril/hctz olmesartan/hctz
amlodipine/valsartan guanfacine phenoxybenzamine
amlodipine/valsartan/hctz hydralazine prazosin
atenolol/chlorthalidone irbesartan propranolol/hctz
benazepril irbesartan/hctz quinapril
benazepril/hctz lisinopril quinapril/hctz
bisoprolol/hctz lisinopril/hctz ramipril
candesartan losartan TEKTURNA HCT
candesartan/hctz losartan/hctz telmisartan
captopril methyldopa telmisartan/hctz
captopril/hctz methyldopa/hctz terazosin
clonidine metoprolol/hctz trandolapril
doxazosin minoxidil trandolapril/verapamil er
enalapril moexipril valsartan
enalapril/hctz moexipril/hctz valsartan/hctz
BETA BLOCKERS acebutolol labetalol propranolol
atenolol metoprolol propranolol er
betaxolol metoprolol er sotalol
bisoprolol nadolol sotalol af
carvedilol pindolol timolol
CALCIUM BLOCKERS amlodipine isradipine nisoldipine er
diltiazem nicardipine verapamil
diltiazem er nifedipine er verapamil er
felodipine er nimodipine verapamil sr
DIABETIC DIAGNOSTIC BD INSULIN SYRINGES AND PEN NEEDLES
PRODUCTS and SUPPLIES LANCETS, LANCET DEVICES
ONETOUCH BLOOD GLUCOSE TEST STRIPS
3Drug class Drug name
DIURETICS acetazolamide furosemide spironolactone
amiloride hctz spironolactone/hctz
amiloride/hctz indapamide torsemide
bumetanide methazolamide triamterene
chlorothiazide methyclothiazide triamterene/hctz
chlorthalidone metolazone
MINERALS & sodium fluoride
ELECTROLYTES
MISCELLANEOUS alendronate ibandronate raloxifene
ENDOCRINE calcitonin pamidronate zoledronic acid
MISCELLANEOUS anagrelide clopidogrel
HEMATOLOGICAL aspirin/dipyridamole er dipyridamole
BRILINTA
cilostazol
MISCELLANEOUS bupropion er (sr)
PSYCHOTHERAPEUTIC
AND NEUROLOGICAL
AGENTS
PEDIATRIC MULTI pediatric multivitamin/fluoride
VITAMINS W/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
4Please 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. Policy forms issued in Missouri include: AL HGrpPol 01R5, HI HGrpAG 05, HO HGrpPol 04. Policy forms issued in Oklahoma include: AL COC00010, HC COC00010. ©2021 Aetna Inc. 05.03.957.1C (01/21)
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