Preventive Chronic Medications for HRA Plans LOWEST MIDDLE TIER

Preventive & Chronic Medications for HRA Plans LOWEST MIDDLE TIER HIGHEST TIER Preferred TIER NonPreferred brand-name preferred generic medications medications medications ACE INHIBITORS (hypertension, diabetes) BENAZEPRIL CAPTOPRIL ENALAPRIL FOSINOPRIL LISINOPRIL MOEXIPRIL QUINAPRIL TRANDOLAPRIL ALTACE ACCUPRIL ACEON CAPOTEN LOTENSIN MAVIK MONOPRIL PRINIVIL UNIVASC VASOTEC ZESTRIL LOWEST TIER Preferred generic medications DIGITEK DIGOXIN MIDDLE TIER Preferred brand-name medications HIGHEST TIER Nonpreferred medications LOWEST TIER Preferred generic medications AMITRIPTYLINE AMOXAPINE BUPRIOPION BUPRIOPION SR CITALOPRAM CLOMIPRAMINE DESIPRAMINE DOXEPIN FLUOXETINE FLUVOXAMINE IMIPRAMINE MAPROTILINE MIRTAZAPINE NORTRIPTYLINE PAROXETINE PROTRIPTYLINE SERTRALINE TRAZODONE MIDDLE TIER Preferred brand-name medications HIGHEST TIER Nonpreferred medications CARDIOTONICS (heart disease) CRYSTODIGIN LANOXICAPS LANOXIN ANTI-DEPRESSANTS (mental illness) CYMBALTA EFFEXOR XR WELLBUTRIN XL ANAFRANIL ASENDIN AVENTYL CELEXA EFFEXOR ELAVIL LEXAPRO MARPLAN NARDIL NORPRAMIN PAMELOR PARNATE PAXIL PAXIL CR PEXEVA PROZAC PROZAC WEEKLY BETA-BLOCKERS (hypertension) ACEBUTOLOL ATENOLOL BETAXOLOL BISOPROLOL LABETALOL METOPROLOL NADOLOL PINDOLOL PROPRANOLOL SORINE SOTALOL TIMOLOL COREG COREG CR BETAPACE BETAPACE AF CARTROL CORGARD INDERAL INDERAL LA INNOPRAN XL KERLONE LEVATOL LOPRESSOR METOPROLOL SR SECTRAL TENORMIN TOPROL XL TRANDATE ZEBETA ANTI-HYPERLIPIDEMICS (high cholesterol) CHOLESTYRAMINE COLESTIPOL FENOFIBRATE GEMFIBROZIL LOVASTATIN PRAVASTATIN PREVALITE SIMVASTATIN ADVICOR ANTARA CRESTOR LESCOL LESCOL XL NIASPAN ER TRICOR VYTORIN WELCHOL ZETIA ALTOPREV CHOLESTIN COLESTID LIPEX LIPITOR LOFIBRA LOPID LOVAZA MEVACOR PRAVACHOL QUESTRAN TRIGLIDE ZOCOR PROBUCOL QUESTRAN ZOCOR RAPIFLUX REMERON SARAFEM SINEQUAN SURMONTIL TOFRANIL TOFRANIL-PM VIVACTIL ZOLOFT CALCIUM CHANNEL BLOCKERS (heart disease, hypertension) AFEDITAB AMLODIPINE CARTIA XT DILT-CD DILTIA XT DILTIAZEM DILTIAZEM CD DILTIAZEM ER DILTIAZEM SR DILTIAZEM XT FELODIPINE ISRADAPINE NICARDIPINE NIFEDIAC CC NIFEDICAL XL NIFEDIPINE NIFEDIPINE SR NIMODIPINE TAZTIA XT VERAPAMIL VERAPAIMIL SR CARDIZEM LA ADALAT ADALAT CC CALAN CALAN SR CARDENE CARDENE SR CARDIZEM CARDIZEM CD COVERA-HS DILACOR XR DYNACIRC DYNACIRC CR ISOPTIN ISOPTIN SR NIMOTOP NORVASC PLENDIL PROCARDIA PROCARDIA XL SULAR TIAZAC VERELAN VERELAN PM ANTI-DIABETIC DRUGS (diabetes) CHLORPROPAMIDE GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER GLIPIZIDE XL GLIPIZIDE/ METFORMIN GLUCAGON GLUCOSE TAB GLYBURIDE/ METFORMIN GLYBURIDE GLYCRON METFORMIN METFORMIN XR TOLAZAMIDE TOLBUTAMIDE ACTOS ACTOSPLUS MET AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT HUMALOG PRODUCT HUMULIN PRODUCT JANUMET JANUVIA LANTUS LEVEMIR NOVOLOG PRODUCT AMARYL APIDRA DIABETA DIABINESE EXUBERA FORTAMET GLUCAGEN GLUCOPHAGE GLUCOPHAGE XL GLUCOSE (ALL OTHERS) GLUCOTROL GLUCOTROL XL GLUCOVANCE GLUMETZA GLYNASE GLYSET ILETIN PRODUCT METAGLIP MICRONASE NOVOLIN PRODUCT PRECOSE RELION PRODUCT ANTI-PSYCHOTICS (mental illness) AMITRIPTYLINE/ PERPHENAZINE AMITRIPTYLINE/ CHLORDIAZEPOXIDE CHLORPROMAZINE CLOZAPINE FLUPHENAZINE HALOPERIDOL LITHIUM LITHONATE LITHOTABS LOXAPINE PERPHENAZINE PROCHLORPERAZINE THIORIDAZINE THIOTHIXENE TRIFLUOPERAZINE VENLAFAXINE HCL RISPERDAL SEROQUEL SEROQUEL XR ZYPREXA ABILIFY CLOZARIL COMPAZINE EQUETRO ESKALITH CR FAZACLO GEODON INVEGA LIMBITROL LITHOBID LOXITANE MOBAN NAVANE ORAP PROLIXIN SYMBYAX THORAZINE PRANDIN PROGLYCEM STARLIX SYMLIN ANTI-ANGINAL AGENTS (heart disease) AMYL NITRITE DILATRATE SR DIPYRIDAMOLE ISOSORBIDE DINITRATE NITROSTAT BIDIL IMDUR ISMO ISORDIL MINITRAN MI-TRATES MONOKET NITROBID NITRO-DUR NITROGARD NITROL NITROLINGUAL PERSANTINE TOLINASE VELOSULIN BR ISOSORBIDE MONONITRATE OSTEOPOROSIS DRUGS (osteoporosis) FORTICAL ACTONEL FORTEO FOSAMAX FOSAMAX PLUS BONIVA CALCIMAR DIDRONEL MIACALCIN SKELID NITREK NITROGLYCERIN NITROQUICK NITROTAB NITRO-TIME NITRO-TRANSDERMAL ANTI-HYPERLIPIDEMIC & CALCIUM CHANNEL BLOCKER COMBINATION (high cholesterol & hypertension) CADUET 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. 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 & Chronic Medications List_StdV28 Preventive & Chronic Medications for HRA Plans LOWEST MIDDLE TIER HIGHEST TIER Preferred TIER NonPreferred brand-name preferred generic medications medications medications DIURETICS (hypertension) ACETAZOLAMIDE AMILORIDE/ HYDROCHLOROTHIAZIDE AMILORIDE BUMETANIDE CHLOROTHIAZIDE CHLORTHALIIDONE LOWEST TIER Preferred generic medications AMIODIPINE/ BENAZEPRIL ATENOLOL/ CHLOROTHIAZIDE BENAZEPRIL/ HYDROCHLOROTHIAZIDE BISOPRLOL/ HYDROCHLOROTHIAZIDE CAPTOPRIL/ HYDROCHLOROTHIAZIDE CHLOROTHAZIDE/ METHYLDOPA CHLOROTHAZIDE/ RESERPINE CLONIDINE/ CHLOROTHAZIDE CLONIDINE CLORPRES DOXAZOSIN ENALAPRIL/ HYDROCHLOROTHIAZIDE FOSINOPRIL/ HYDROCHLOROTHIAZIDE GUANABENZ GUANFACINE HYDROCHLOROTHIAZIDE/ RESERPINE HYDRALAZINE/ HYDROCHLOROTHIAZIDE HYDRALAZINE/ RESERPINE HYDRALAZINE LISINOPRILHYDROCHLOROTHIAZIDE METHYLDOPA/ HYDROCHLOROTHIAZIDE METHYLDOPA METOPROLOL/ HYDROCHLOROTHIAZIDE MINOXIDIL MOEXIPRIL/ HYDROCHLOROTHIAZIDE PRAZOSIN PROPRANOLOL/ HYDROCHLOROTHIAZIDE QUINARETIC RESERPINE/ CHLOROTHIAZIDE MIDDLE TIER Preferred brand-name medications ANTI-HYPERTENSIVES COZAAR DIBENZYLINE DIOVAN DIOVAN HCT HYZAAR HIGHEST TIER Nonpreferred medications LOWEST TIER Preferred generic medications AIRET ALBUTEROL ALBUTEROL SULFATE/IPRATRO MIDDLE TIER Preferred brand-name medications HIGHEST TIER Nonpreferred medications ALDACTAZIDE ALDACTONE BUMEX DEMADEX DIAMOX DIURIL DYAZIDE DYRENIUM EDECRIN HYDRO-TABS INSPRA INTROL ISMOTIC LASIX MAXZIDE MICROZIDE THALITONE WASSER ZAROXOLYN MAXZIDE MICROZIDE MIDAMOR MODURETIC MYKROX THALITONE WASSER ZAROXOLYN ACCURETIC ATACAND ATACAND HCT AVALIDE AVAPRO BENICAR BENICAR HCT CAPOZIDE CARDURA CARDURA XL CATAPRES CATAPRES-TTS CLORPRES CORZIDE DEMSER GUANABENZ GUANFACINE HYTRIN INDERIDE INSPRA INVERSINE LEXXEL LOPRESS HCT LOTENSIN HCT LOTREL MICARDIS MICARDIS HCT MINIPRESS MINOXIDIL MONOPRIL HCT PRINZIDE TARKA TEKTURNA TENEX TENORETIC TEVETEN TEVETEN HCT TIMOLIDE UNIRETIC VASERETIC ZESTORETIC ANTI-ASTHMATICS (asthma) ADVAIR DISKUS ADRAIR HFA ASMANEX BRONCAP COMBIVENT DUONEB ELIXOPHYLLIN FORADIL FLOVENT DISKUS FLOVENT HFA FORADIL MAXAIR PROVENTIL HFA PULMICORT RESPULES SEREVENT DIS SINGULAIR SPIRIVA SYMBICORT ACCOLATE ACCUNEB ADRENALIN AEROBID AEROBID-M ALUPENT ASMA ATROVENT ATROVENT HFA AZMACORT BRETHINE BRONCOMAR-1 BROVANA DIFIL-G DYLIX DYPHYLLIN-GG ED-BRON G ELIXOPHYL GG FLUNISOLIDE INTAL LUFYLLIN LUFYLLIN-GG MAXAIR NEPHRON PANFIL-G PROVENTIL INHALER PROVENTIL REPITAB PULMICORT FLEXHALER PULMICORT INHALER PULMICORT TURBOHALER QUIBRON QVAR THEO-24 THEOCHRON THEOLAIR-SR THEOMAR GG TILADE UNIPHYL VENTOLIN HFA XOLAIR XOPENEX XOPENEX HFA ZYFLO UNIPHYL VAPONEFRIN VENTOLIN VENTOLIN HFA XOLAIR XOPENEX FUROSEMIDE HYDROCHLOROTHAZIDE INDAPAMIDE METHAZOLAMIDE METHYCLOTHIAZIDE METOLAZONE SPIRONOLACTONE /HYDROCHLOROTHIAZIDE SPIRONOLACTONE TORSEMIDE TRIAMTERINE/ HYDROCHLOROTHIAZIDE AMINOPHYLLINE COPD CROMOLYN SOD DG 200 DIFIL G FORTE DILEX-G DYFLEX-G DY-G DYPHYLLIN-GG IPRATROPIUM ISOETHARINE JAY-PHYL MICRONEFRIN TERBUTALINE THEOCAP THEOCHRON THEOPHYLLINE BLOOD THINNING AGENTS (coronary artery disease, heart disease) ANAGRELIDE CILOSTAZOL DIPYRIDAMOLE JANTOVEN TICLOPIDINE WARFARIN AGGRENOX PLAVIX AGRYLIN ARIXTRA COUMADIN FRAGMIN LOVENOX ORGARAN PERSANTINE PLETAL TICLID PRENATAL MULTIVITAMIN W/FE, FA MATERNITY-90 NATAMAR RX ORIGINAL TAB PRENATAL PRENATAL/FE PRENATAL/ZN TERNAMAR VITA-NATAL MYNATAL NUTRACARE PERRY PRENATAL RESERPINE TERAZOSIN ASTHMA SUPPLIES (asthma) AEROCHAMBER ASSESS PEAK FLOW DIABETIC SUPPLIES (diabetes) BD INSULIN SYRINGE BD LANCET BD PEN NEEDLES FREESTYLE TEST STRIPS ONE TOUCH TEST STRIPS PRESCISION TEST STRIPS ACCUCHEK ASCENSIA ASSURE AUTOLET GLUCOMETER INSULIN SYRINGES (ALL OTHER BRANDS) MONOJECT SYRINGE PRESTIGE SOFTCLIX TEST STRIPS (ALL OTHER BRANDS) UNISTIK BREATHANCER ELLIPSE EZ-SPACER INSPIREASE MICROCHAMBER OPTIHALER PEDIATRIC VITAMINS W/FLOURIDE TRI-A-VITE TRI-VITAMIN/ FLORIDE TRI-VITA BET TRI-VI-FLOR 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. 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 & Chronic Medications List_StdV28