Chronic Medicine Reduced out-of-pocket costs for the medicine you need - 2022 Standard Opt Out Plan - Aetna
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Chronic Medicine Reduced out-of-pocket costs for the medicine you need 2022 Standard Opt Out Plan – Aetna 858231-01-01 (10/21)
Forget your deductible – just pay your copay or coinsurance when buying
certain medication.
Chronic Medicine List effective January 1, 2022 Key
Standard Opt Out Plan – Aetna UPPERCASE Brand-name medicine
lowercase italics Generic medicine
Drug class Drug name
ANTIANGINAL AGENTS isosorbide dinitrate isosorbide mononitrate er ranolazine er
isosorbide dinitrate er NITRO-DUR
isosorbide mononitrate nitroglycerin
ANTIASTHMATIC ADVAIR DISKUS DALIRESP SEREVENT DISKUS
ADVAIR HFA FLOVENT DISKUS SPIRIVA HANDIHALER
albuterol FLOVENT HFA SPIRIVA RESPIMAT
albuterol er fluticasone/salmeterol STIOLTO RESPIMAT
albuterol hfa fluticasone/ STRIVERDI RESPIMAT
ANORO ELLIPTA salmeterol diskus SYMBICORT
ARNUITY ELLIPTA formoterol terbutaline
ASMANEX HFA INCRUSE ELLIPTA theochron
ASMANEX TWISTHALER ipratropium theophylline
ATROVENT HFA ipratropium/albuterol theophylline er
BEVESPI AEROSPHERE levalbuterol TRELEGY ELLIPTA
BREO ELLIPTA levalbuterol hfa wixela inhub
BREZTRI AEROSPHERE metaproterenol YUPELRI
budesonide montelukast zafirlukast
budesonide/ PERFOROMIST
formoterol dihydrate PULMICORT FLEXHALER
cromolyn QVAR REDIHALER
ANTIDEPRESSANTS amitriptyline FETZIMA paroxetine
amoxapine fluoxetine paroxetine er
ANAFRANIL fluoxetine dr phenelzine
bupropion fluvoxamine er protriptyline
bupropion er (sr) imipramine sertraline
bupropion er (xl) maprotiline TOFRANIL
citalopram mirtazapine tranylcypromine
clomipramine mirtazapine odt trazodone
desipramine NARDIL trimipramine
desvenlafaxine er NORPRAMIN TRINTELLIX
doxepin nortriptylin venlafaxine
duloxetine PAMELOR venlafaxine er
escitalopram PARNATE VIIBRYD
Health benefits and health insurance plans are offered, underwritten and/or administered by Aetna Health Inc.,
Aetna Health of California Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company,
Aetna Health Assurance Pennsylvania Inc. and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna
Health Inc. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole
financial responsibility for its own products. Aetna is the brand name used for products and services provided by
one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
2Drug class Drug name
ANTIDIABETIC acarbose HUMULIN R U-500 pioglitazone
alogliptin INSULIN ASPART pioglitazone-glimepiride
alogliptin/metformin INSULIN LISPRO pioglitazone/metformin
alogliptin/pioglitazone INVOKAMET PRECOSE
BAQSIMI INVOKAMET XR QTERN
BASAGLAR KWIKPEN INVOKANA repaglinide
chlorpropamide JANUMET repaglinide/metformin
FARXIGA JANUMET XR RYBELSUS
FIASP products JANUVIA SOLIQUA 100/33
glimepiride JARDIANCE SYMLINPEN 120
glipizide JENTADUETO SYMLINPEN 60
glipizide er JENTADUETO XR SYNJARDY
glipizide/metformin LANTUS products SYNJARDY XR
GLUCAGEN HYPOKIT LEVEMIR products tolbutamide
GLUCAGON LYUMJEV TOUJEO products
EMERGENCY KIT LYUMJEV KWIKPEN TRADJENTA
glucose metformin TRESIBA products
GLYXAMBI metformin er TRIJARDY XR
GVOKE HYPOPEN 1-PACK miglitol TRULICITY
GVOKE PFS nateglinide VICTOZA
HUMALOG products NOVOLIN products XIGDUO XR
HUMULIN N NOVOLOG products XULTOPHY
HUMULIN 70/30 OZEMPIC
ANTIHYPERLIPIDEMIC atorvastatin fenofibrate micronized niacin er
cholestyramine fenofibric acid dr omega-3-acid ethyl esters
cholestyramine light fluvastatin pravastatin
colesevelam fluvastatin er rosuvastatin
colestipol gemfibrozil simvastatin
ezetimibe lovastatin VASCEPA
ezetimibe/simvastatin NEXLETOL
fenofibrate NEXLIZET
ANTIHYPERTENSIVE aliskiren eplerenone olmesartan
amlodipine/benazepril eprosartan olmesartan/amlodipine/hctz
amlodipine/olmesartan fosinopril olmesartan/hctz
amlodipine/valsartan fosinopril/hctz perindopril
amlodipine/valsartan/hctz guanfacine phenoxybenzamine
atenolol/chlorthalidone hydralazine prazosin
benazepril INSPRA propranolol/hctz
benazepril/hctz irbesartan quinapril
bisoprolol/hctz irbesartan/hctz quinapril/hctz
candesartan lisinopril ramipril
candesartan/hctz lisinopril/hctz TARKA
captopril losartan TEKTURNA HCT
captopril/hctz losartan/hctz telmisartan
CATAPRES LOTREL telmisartan/amlodipine
CATAPRES-TTS-1 methyldopa telmisartan/hctz
CATAPRES-TTS-2 methyldopa/hctz terazosin
CATAPRES-TTS-3 metoprolol/hctz trandolapril
clonidine metyrosine trandolapril/verapamil er
doxazosin minoxidil valsartan
enalapril moexipril valsartan/hctz
enalapril/hctz moexipril/hctz ZIAC
3Drug class Drug name
ANTIPSYCHOTICS ABILIFY MAINTENA LATUDA quetiapine er
aripiprazole lithium RISPERDAL CONSTA
ARISTADA lithium er risperidone
ARISTADA INITIO LITHOBID risperidone odt
asenapine sl loxapine thioridazine
chlorpromazine olanzapine thiothixene
clozapine olanzapine odt trifluoperazine
clozapine odt paliperidone er VRAYLAR
compro perphenazine ziprasidone
fluphenazine prochlorperazine
haloperidol quetiapine
BETA BLOCKERS acebutolol labetalol propranolol er
atenolol metoprolol sotalol
betaxolol metoprolol er sotalol af
bisoprolol nadolol timolol
BYSTOLIC pindolol
carvedilol propranolol
CALCIUM BLOCKERS amlodipine matzim la verapamil
diltiazem nicardipine verapamil er
diltiazem er nifedipine er verapamil sr
felodipine er nimodipine
isradipine nisoldipine er
CARDIOTONICS digoxin
LANOXIN
DIABETIC DIAGNOSTIC ACCU-CHEK BLOOD DEXCOM G6 OMNIPOD STARTER KIT
PRODUCTS and SUPPLIES GLUCOSE TEST STRIPS LANCETS, LANCET V-GO 20 KIT
BD INSULIN SYRINGES AND DEVICES V-GO 30 KIT
PEN NEEDLES ONETOUCH BLOOD V-GO 40 KIT
DEXCOM G4 GLUCOSE TEST STRIPS
DEXCOM G5 OMNIPOD 5 PACK
DIURETICS acetazolamide chlorthalidone metolazone
acetazolamide er ethacrynic acid spironolactone
ALDACTONE furosemide spironolactone/hctz
amiloride hctz torsemide
amiloride/hctz indapamide triamterene
bumetanide methazolamide triamterene/hctz
chlorothiazide methyclothiazide
MISCELLANEOUS amlodipine/atorvastatin CORLANOR
CARDIOVASCULAR BIDIL ENTRESTO
MISCELLANEOUS chlordiazepoxide/amitriptyline
PSYCHOTHERAPEUTIC perphenazine/amitriptyline
AND NEUROLOGICAL
AGENTS
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, HO GrpPolAmend- ThirdPartyPay 01. Policy forms issued in Oklahoma include: AL COC00010, HC COC00010. ©2021 Aetna Inc. 858231-01-01 (10/21)
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