2020 Preventive Medications For Large Group HSA Qualified Plans

Your pharmacy benefit plan includes special coverage for preventive medications. These drugs help protect against or manage a medical condition, such as:

• Preventing blood clots and reducing the risk of a stroke

• Preventing heart disease and reducing high blood pressure

• Preventing osteoporosis (a disease that leads to an increased risk of bone fracture)

Your health is important. Taking preventive medications as directed by yourhealth care provider can help you avoid serious illness and high health care costs.

Managing your health with preventive medications

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2020 Preventive medications and your plan

Special coverage for preventive medications

Drugs on your plan’s list of preventive medications are not subject to a deductible. You’ll pay your copayment/coinsurance or nothing at all, depending on your plan. So you can save money and get the medications you need to help you live a healthier life.

Preventive medications are a subset of products included within your plan’s formulary, or list of prescription drugs, which tells you what medications your plan covers.

Please note that most medications on the Formulary are subject to a deductible. Preventive medications are an exception. To check the cost of any medication, refer to your benefit handbook or contact customer service at the toll-free member phone number on your benefit plan ID card.

Potential savings with generic medications

To get the most from your benefits, ask your doctor if a generic medication is right for you. Generics normally cost less than brand medications, and the Food and Drug Administration (FDA) requires them to be just as safe and effective.

Quality drives our decisions

Our committee of independent doctors and pharmacists meets regularly to review medications and consider how they should be covered by your pharmacy benefit plan. They also recommend which medications should be on your plan’s list of preventive medications.

A list of covered preventive medications begins on the next page. Medications are listed by therapeutic category. To help you tell generic and brand drugs apart, all generics start with a lowercase letter. For questions on injectable dose forms of preventive medications administered by your healthcare provider, please call the number on the back of your membership card for more information.

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Expanded listing by therapeutic categoryANTIDEPRESSANTSCELEXAcitalopramescitalopramfluoxetinefluoxetine drfluvoxaminefluvoxamine erLEXAPROparoxetinePAXILPAXIL CRparoxetine ERPEXEVAPROZACsertralineZOLOFT

ANTIPSYCHOTICSABILIFYABILIFY MAINTENAABILIFY MYCITEADASUVEaripiprazolearipiprazole odtARISTADAARISTADA INITIOCHLORPROMAZINEclozapineclozapine odtCLOZARILcomproEQUETROFANAPTFAZACLOfluphenazineGEODONhaloperidolINVEGAINVEGA SUSTENNAINVEGA TRINZALATUDAloxapinemolindoneNUPLAZIDolanzapineolanzapine odtolanzapine/fluoxetinepaliperidone erperphenazine

PERSERISprochlorperazinequetiapine fumaratequetiapine fumarate erREXULTIRISPERDALRISPERDAL CONSTARISPERDAL M-TABrisperidonerisperidone m-tabrisperidone odtSAPHRISSEROQUELSEROQUEL XRSYMBYAXthioridazinethiothixenetrifluoperazineVERSACLOZVRAYLARziprasidoneZYPREXAZYPREXA RELPREVVZYPREXA ZYDIS

ASTHMA AND COPDACCOLATEADVAIR DISKUSADVAIR HFAAIRDUO RESPICLICKalbuterol sulfatealbuterol sulfate erALBUTEROL SULFATE HFAALVESCOANORO ELLIPTAARCAPTA NEOHALERARMONAIR RESPICLICKARNUITY ELLIPTAASMANEX HFAASMANEX TWISTHALERATROVENT HFABEVESPI AEROSPHEREBREO ELLIPTABROVANAbudesonideCOMBIVENT RESPIMATcromolynDALIRESPdifil-g forteDULERA

ELIXOPHYLLINFLOVENT DISKUSFLOVENT HFAfluticasone/salmeterol diskusFLUTICASONE PROPIONATE/SALMETEROLINCRUSE ELLIPTAipratropiumipratropium/albuterolisoproterenol aerlevalbuterolLEVALBUTEROL HFALONHALA MAGNAIRmetaproterenolmontelukastPEAK FLOW METERS ‡PERFOROMISTPROAIR HFAPROAIR RESPICLICKPROVENTIL HFAPULMICORTPULMICORT FLEXHALERQVARQVAR REDIHALERSEEBRI NEOHALERSEREVENT DISKUSSINGULAIRSPIRIVA HANDIHALERSPIRIVA RESPIMATSTIOLTO RESPIMATSTRIVERDI RESPIMATSYMBICORTterbutalineTHEO-24theochrontheophyllinetheophylline crtheophylline erTRELEGY ELLIPTATUDORZA PRESSAIRUTIBRON NEOHALERVENTOLIN HFAwixela inhubXOPENEXXOPENEX CONCENTRATEXOPENEX HFAYUPELRIzafirlukastzileuton erZYFLOZYFLO CR

2020 Preventive medication list

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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2020 Preventive medication list (cont.)

CANCERanastrozoleARIMIDEXAROMASINexemestaneFARESTONFEMARAletrozoleraloxifeneSOLTAMOXtamoxifen

toremifene

CARDIOVASCULAR/HEART DISEASEAnti-Anginal Agents

DILATRATE SRGONITROISORDIL TITRADOSEisosorbide dinitrateisosorbide dinitrate erisosorbide mononitrateisosorbide mononitrate erminitranNITRO-BIDNITRO-DURnitroglycerinnitroglycerin ernitroglycerin lingualnitroglycerin transdermalNITROLINGUAL PUMPSPRAYNITROMISTnitro-timepetnranolazine erRANEXA

Anticoagulants

AGGRENOXARIXTRA SPaspirin/dipyridamoleBEVYXXABRILINTAcilostazolclopidogrelCOUMADINdipyridamoleDURLAZAEFFIENTELIQUISenoxaparin SPfondaparinux SP

FRAGMIN SPheparinjantovenLOVENOX SPPLAVIXPLETALPRADAXAprasugrelSAVAYSAwarfarinXARELTOXARELTO STARTER PACKYOSPRALAZONTIVITY

Cardiac Glycosides

digitekdigoxdigoxinLanoxin

High Blood Pressure

ACCUPRILACCURETICacebutololADALAT CCafeditab craliskirenALDACTAZIDEALDACTONEALTACEamilorideamiloride/hctzamlodipineamlodipine/benazeprilamlodipine/olmesartanamlodipine/valsartanamlodipine/valsartan/hctzATACANDATACAND HCTatenololatenolol/chlorthalidoneAVALIDEAVAPROAZORbenazeprilbenazepril /hctzBENICARBENICAR HCTBETAPACEbetaxololbisoprololbisoprolol/hctz

BLOOD PRESSUREMONITORS ‡bumetanideBUMEXBYSTOLICBYVALSONCALANCALAN SRcandesartancandesartan /hctzcaptoprilcaptopril/hctzCARDIZEMCARDIZEM CDCARDIZEM LACARDURACAROSPIRcartia xtcarvedilolCATAPRESCATAPRES-TTSchlorothiazidechlorthalidoneclonidineCLORPRESCOREGCOREG CRCORGARDCORZIDECOZAARDEMADEXDEMSERDIBENZYLINEdiltiazemdiltiazem erdiltiazem cddilt-xrDIOVANDIOVAN HCTDIURILdoxazosinDUTOPROLDYAZIDEDYRENIUMEDARBIEDARBYCLOREDECRINenalaprilenalapril/hctzEPANEDeplerenoneeprosartanethacrynic acid

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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EXFORGEEXFORGE HCTezidefelodipine erFIRST - ATENOLOL ‡FIRST - METOPROLOL ‡fosinoprilfosinopril /hctzfurosemideguanfacinehydralazinehydrochlorothiazideHEMANGEOLHYZAARindapamideINDERAL LAINDERAL XLINNOPRAN XLINSPRAirbesartanirbesartan/hctzisradipineKAPSPARGO SPRINKLEKATERZIAlabetalolLASIXlisinoprillisinopril/hctzLOPRESSORLOPRESSOR HCTlosartan potassiumlosartan potassium/hctzLOTENSINLOTENSIN HCTLOTRELmatzim laMAXZIDEMAXZIDE-25methyclothiazidemethyldopamethyldopa/hctzmetolazonemetoprololmetoprolol erMETOPROLOL ER/HCTZmetoprolol/hctzMICARDISMICARDIS HCTMICROZIDEMINIPRESSminoxidil tabletmoexiprilmoexipril/hctz

nadololnadolol/bendroflumethiazidenicardipinenifedipinenifedipine ernimodipinenisoldipinenisoldipine erNORVASCNYMALIZEolmesartanolmesartan /hctzolmesartan/amlodipine/hctzperindoprilphenoxybenzaminepindololprazosinPRESTALIAPRINIVILPROCARDIAPROCARDIA XLpropranololpropranolol erpropranolol/hctzQBRELISquinaprilquinapril/hctzramiprilsotalolSOTYLIZEspironolactonespironolactone/hctzSULARTARKAtaztia xtTEKTURNATEKTURNA HCTtelmisartantelmisartan/amlodipinetelmisartan/hctzTENORETICTENORMINterazosinTIAZACtimolol tabTOPROL XLtorsemidetrandolapriltrandolapril/verapamil ertriamterenetriamterene/hctzTRIBENZORTWYNSTA

valsartanvalsartan/hctzVASERETICVASOTECVECAMYLverapamilverapamil erverapamil srVERELANVERELAN PMZESTORETICZESTRILZIAC

High cholesterol

ALTOPREVamlodipine/atorvastatinANTARAatorvastatinCADUETcholestyraminecholestyramine lightcolesevelamCOLESTIDCOLESTID FLAVOREDcolestipolCRESTOREZALLOR SPRINKLEezetimibeezetimibe/simvastatinfenofibratefenofibrate micronizedfenofibric acidfenofibric acid drFENOGLIDEFIBRICORFLOLIPIDfluvastatinfluvastatin ergemfibrozilJUXTAPID SPKYNAMRO SPLESCOL XLLIPITORLIPOFENLIVALOLOPIDlovastatinLOVAZAniacin erniacorNIASPANomega-3-acid ethyl esters

2020 Preventive medication list (cont.)

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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2020 Preventive medication list (cont.)

PRALUENTPRAVACHOLpravastatinprevaliteQUESTRANQUESTRAN LIGHTREPATHAREPATHA SURECLICKrosuvastatinsimvastatinTRICORTRIGLIDEtrikloTRILIPIXVASCEPAVYTORINWELCHOLZETIAZOCORZYPITAMAG

CONTRACEPTIVES ‡

This section lists contraceptive categories. Please note thatbrands and generics are eligible.CONTRACEPTIVE PATCHCONTRACEPTIVE RING (NUVARING)EMERGENCY CONTRACEPTIVESIMPLANT CONTRACEPTIVEINJECTABLE CONTRACEPTIVEIUDsORAL CONTRACEPTIVES

DIABETESInsulin

ADMELOGADMELOG SOLOSTARAFREZZAAPIDRAAPIDRA SOLOSTARBASAGLAR KWIKPENFIASPFIASP FLEXTOUCHHUMALOGHUMALOG JUNIOR KWIKPENHUMALOG KWIKPENHUMALOG MIX 50/50HUMALOG MIX 50/50 KWIKPENHUMALOG MIX 75/25HUMALOG MIX 75/25 KWIKPEN

HUMULIN 70/30HUMULIN 70/30 KWIKPENHUMULIN NHUMULIN N KWIKPENHUMULIN RHUMULIN R U-500INSULIN LISPROLANTUSLANTUS SOLOSTARLEVEMIRLEVEMIR FLEXTOUCHNOVOLIN 70/30NOVOLIN 70/30 FLEXPENNOVOLIN 70/30 RELIONNOVOLIN NNOVOLIN N RELIONNOVOLIN RNOVOLIN R RELIONNOVOLOGNOVOLOG FLEXPENNOVOLOG MIX 70/30NOVOLOG MIX 70/30 PREFILLED FLEXPENNOVOLOG PENFILLTOUJEO MAX SOLOSTARTOUJEO SOLOSTARTRESIBATRESIBA FLEXTOUCH

Non-insulin

acarboseACTOPLUS METACTOPLUS MET XRACTOSADLYXINALOGLIPTINALOGLIPTIN / METFORMINALOGLIPTIN / PIOGLITAZONEAMARYLAVANDIABYDUREONBYDUREON BCISEBYDUREON PENBYETTAchlorpropamideCYCLOSETDUETACTFARXIGAFORTAMETglimepirideglipizideglipizide erglipizide xl

glipizide/metforminGLUCOMETERS ‡GLUCOPHAGEGLUCOPHAGE XRGLUCOTROLGLUCOTROL XLGLUCOVANCEGLUMETZAglyburideglyburide micronizedglyburide/metforminGLYNASEGLYSETGLYXAMBIINVOKAMETINVOKAMET XRINVOKANAJANUMETJANUMET XRJANUVIAJARDIANCEJENTADUETOJENTADUETO XRKAZANOKOMBIGLYZE XRmetforminmetformin ermetformin er (mod)metformin er (osm)METFORMIN SOLmiglitolnateglinideNESINAONGLYZAOSENIOZEMPICpioglitazonepioglitazone /metforminpioglitazone-glimepiridePRANDINPRECOSEQTERNrepagliniderepaglinide/metforminRIOMETSEGLUROMETSOLIQUA 100/33STARLIXSTEGLATROSTEGLUJANSYMLINPEN 120SYMLINPEN 60

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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SYNJARDYSYNJARDY XRTANZEUMtolazamidetolbutamideTRADJENTATRULICITYVICTOZAXIGDUO XRXULTOPHY 100/3.6

ESTROGENSACTIVELLAALORAamabelzANGELIQBIEST/PROGESTERONECLIMARACLIMARA PROCOMBIPATCHcovaryxcovaryx HSDIVIGELdottiDUAVEEeemteemt HSELESTRINesterified estrogens/methltestosteroneesterified estrogens/methltestosterone dsesterified estrogens/methltestosterone hsESTRACEestradiolestradiol/norethindrone acetateESTROGELestropipateEVAMISTFEMHRT LOW DOSEfyavolvjevantique lojintelilopreezaMENESTMENOSTARmimveymimvey loMINIVELLEnorethindrone acetate/ethinyl

estradiolPREFESTPREMARINPREMPHASEPREMPROVIVELLE-DOT

GASTROINTESTINAL-ULCER DRUGS‡

ACIPHEXAXIDCARAFATEcimetidineCYTOTECDEXILANTesomeprazole magnesiumESOMEPRAZOLE STRONTIUMfamotidineFIRST-LANSOPRAZOLE ‡FIRST-OMEPRAZOLE ‡lansoprazolelansoprazole odtlansoprazole/amoxicillin/clarithromycinmisoprostolNEXIUMnizatidineOMECLAMOX-PAKomeppiomeprazoleomeprazole /sodium bicarbonatepantoprazolepantoprazole drPEPCIDPREVACIDPREVACID SOLUTABPREVPACPRILOSECPROTONIXPYLERArabeprazoleRABEPRAZOLE DR SPRINKLEranitidinesucralfateZANTACZEGERIDpantoprazolePepcidPrevacid +PrevPacPrilosec

ProtonixPyleraranitidinesucralfateZantacZegerid

HIV/AIDSabacavir SPabacavir / lamivudine SPabacavir / lamivudine / zidovudine SPAPTIVUS SPatazanavir SPATRIPLA SP +BIKTARVY SPCIMDUO SPCOMBIVIR SPCOMPLERA SPCRIXIVAN SPDELSTRIGO SPDESCOVY SPDOVATO SPdidanosine SPEDURANT SPefavirenz SPEMTRIVA SPEPIVIR SPEPZICOM SPEVOTAZ SPfosamprenavir SPFUZEON SPGENVOYA SPINTELENCE SPINVIRASE SPISENTRESS SPISENTRESS HD SPJULUCA SPKALETRA SPlamivudine SPlamivudine / zidovudine SPLEXIVA SPlopinavir / ritonavir SPnevirapine SPnevirapine er SPNORVIR SPODEFSEY SPPIFELTRO SPPREZCOBIX SPPREZISTA SPRESCRIPTOR SP

2020 Preventive medication list (cont.)

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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RETROVIR SPREYATAZ SPritonavir SPSELZENTRY SPstavudine SPSTRIBILD SPSUSTIVA SPSYMFI SPSYMFI LO SPSYMTUZA SPtenofovir SPTIVICAY SPTRIUMEQ SPTRIZIVIR SPTROGARZO SPTRUVADA SPTYBOST SPVIDEX PEDIATRIC SPVIDEX EC SPVIRACEPT SPVIRAMUNE SPVIRAMUNE XR SPVIREAD SPZERIT SPZIAGEN SPzidovudine SP

OSTEOPOROSISACTONELalendronateATELVIABINOSTOBONIVAcalcitonin-salmonetidronate di

EVISTAFORTEO SPFOSAMAXFOSAMAX + Dibandronaterisedronaterisedronate dr

SMOKING DETERRENTS ‡bupropion erCHANTIXNICODERM CQNICORETTEnicotine gum / lozenge / patchNICOTROL INH / NSZYBAN

TRANSPLANTASTAGRAF XL SPAZASANazathioprineCELLCEPT SPcyclosporine SPcyclosporine modified SPENVARSUS XR SPgengraf SPIMURANmycophenolate SPmycophenolic DR SPMYFORTIC SPNEORAL SPPROGRAF SPRAPAMUNE SPSANDIMMUNE SP

sirolimus SPtacrolimus cap SPZORTRESS SP

VITAMINS & ELECTROLYTESPediatric vitamins with fluoride

(for example; POLY-VI-FLOR, tri-vit / fl)generic productsBRAND NAME PRODUCTS

Prenatal multivitamins with iron and folic acid

(for example; OB COMPLETE, prenatabs RX)generic productsBRAND NAME PRODUCTS

2020 Preventive medication list (cont.)

SVHP-3262 Rev. 10/19

This list refers to High Deductible Health Plan medications only. It is intended as a reference and may not be all-inclusive. Brand or generic availability may not be current due to changes in the market. Use of generics may be required depending upon plan design.OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

All Optum trademarks and logos are owned by Optum, Inc. in the U.S. and other jurisdictions. All other trademarks are the property of their respective owners.

©2020 Optum, Inc. All rights reserved. WF1500281_ORX_HDHP preventive select _09092019 68551D-092019

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule