city of austin prev expanded list w addendum 714 7

City of Austin Preventive Drug List for Consumer Driven Health PlansExpanded List

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E May be excluded from coverage. *Coverage is provided for oral formulations. Bold type = Brand name drug [Plain type = Generic drug]

City of Austin Preventive Drug List for Consumer Driven Health Plans

Alphabetical Listing – Expanded List

A

Abacavir Abacavir-Lamivudine-

Zidovudine AbilifyAcarboseAccolateAccunebAccuprilAccureticAcebutololAceonActonelACTOplus MetACTOplus Met XRActos EAdalat CCAdvair DiskusAdvair HFAAdvicorAfeditabAggrenoxAlbuterol Nebulized

SolutionAlbuterol Oral TabletAldactazideAldactoneAlendronateAltaceAltoprev EAlvescoAmarylAmilorideAmiloride-

HydrochlorothiazideAminophyllineAmlodipine Amlodipine-BenazeprilAmturnide EAnastrozoleAnoro Ellipta AntaraApidraAptivusArcapta NeohalerArimidex EArixtraAromasinAsmanex TwisthalerAstagraf XL E AtacandAtacand HCTAtelvia E AtenololAtenolol-ChlorthalidoneAtriplaAtorvastatin Atrovent HFAAubagioAvalideAvandametAvandarylAvandiaAvaproAvonexAzasanAzathioprineAzor E

B

Benazepril Benazepril-

HydrochlorothiazideBenicarBenicar HCTBetaseronBetaxolol*BidilBinosto EBisoprololBisoprolol-

HydrochlorothiazideBonivaBreo Ellipta BrilintaBrovanaBudesonideBumetanideBydureon ByettaBystolic

C

CalanCalan SRCalcitonin (Salmon)Candesartan Candesartan-

HydrochlorothiazideCaptopril Captopril-

HydrochlorothiazideCardene SRCardizemCardizem CDCardizem LACardura Cardura XLCartia XTCarvedilolCatapres Catapres TTSCellceptChlorothiazideChlorpromazineCholestyramineCholestyramine LightCholine Fenofibrate E CilostazolClonidine Clonidine PatchClopidogrel ClorpressClozapineClozarilColestidColestipolCombivent RespimatCombivirCompleraCopaxoneCoregCoreg CR ECorgardCorzideCoumadinCovera HS

CozaarCrestorCrixivanCromolynCycloset Cyclosporine

D

Daliresp DemadexDiabetaDiabetic Meters - Control

Solutions Diabetic Test StripsDiabetic Testing - Lancets DidanosineDidronelDilacor XRDilt CDDilt XRDiltia XTDiltiazemDiltiazem ERDiltzac ERDiovanDiovan HCT EDipyridamoleDiurilDoxazosinDuetactDuleraDuonebDutoprol DyazideDynacirc CRDyrenium

E

EdarbiEdarbyclor EdecrinEdurant EffientEliquisElixophyllinEmtrivaEnalaprilEnalapril-

HydrochlorothiazideEnoxaparinEpaned E EpivirEplerenoneEprosartan EpzicomEtidronateEvistaExemestaneExforge EExforge HCT EExtavia E

F

FanaptFarestonFarxiga FazaCloFelodipine ERFemara EFenofibrateFenofibrate 48, 145 mg E Fenofibrate Micronized Fenofibric AcidFenoglideFibricorFlovent DiskusFlovent HFAFluphenazineFluvastatin FondaparinuxForadilFortametForteoForticalFosamaxFosamax Plus DFosinopril Fosinopril-

HydrochlorothiazideFragminFurosemideFuzeon

G

GastrocromGemfibrozilGengrafGeodon EGilenyaGlimepirideGlipizideGlipizide ERGlipizide-MetforminGlucophageGlucophage XRGlucotrol Glucotrol XLGlucovanceGlumetzaGlyburideGlyburide MicronizedGlyburide-MetforminGlynaseGlysetGuanfacine

H

HaloperidolHecoria HeparinHumalogHumalog Mix 50/50Humalog Mix 75/25Humulin 50/50Humulin 70/30Humulin NHumulin RHydralazineHydrochlorothiazideHyzaar

I

Ibandronate ImuranIndapamideInderalInderal LAInnopran XLInspraInsulin Needles/SyringesIntelenceInvegaInviraseInvokana IpratropiumIpratropium/AlbuterolIrbesartanIrbesartan -

Hydrochlorothiazide IsentressIsoptin SRIsradipine

J

JantovenJanumetJanumet XR JanuviaJentadueto

K

KaletraKazanoKombiglyze XR



Alphabetical Listing – Expanded List

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L

LabetalolLamivudineLamivudine-ZidovudineLantusLasixLatuda LescolLescol XLLetrozoleLevalbuterol Nebulized

Solution ELevatol LevemirLexivaLipitor ELipofenLiptruzet E LisinoprilLisinopril-

HydrochlorothiazideLivalo Lofibra LopidLopressorLopressor HCTLosartanLosartan-

HydrochlorothiazideLotensin Lotensin HCTLotrelLovastatinLovazaLovenoxLoxapineLufyllin

M

Matzim LA MavikMaxzideMetaproterenolMetformin Metformin ERMethyclothiazideMethyldopaMethyldopa-

HydrochlorothiazideMetolazoneMetoprolol SuccinateMetoprolol TartrateMetoprolol-

HydrochlorothiazideMevacorMiacalcinMicardisMicardis HCTMicrozideMidamorMinipressMinoxidilMobanMoexipril Moexipril-

HydrochlorothiazideMontelukast

MycophenolateMycophenolic Acid Myfortic

N

NadololNadolol-

BendroflumethazideNateglinideNeoralNevirapine NesinaNexiclon XR ENiacin

Extended-Release NiacorNiaspanNicardipineNifedipineNifedipine ERNimodipineNisoldipineNorvascNorvirNovolin 70/30Novolin N Novolin RNovologNovolog Mix 70/30

O

olanzapine OnglyzaOseni

P

Pediatric Flouride Preparations

PerforomistPerindoprilPerphenazinePersantinePioglitazonePioglitazone-GlimepiridePioglitazone-MetforminPindololPlavix EPletalPradaxaPrandiMetPrandinPravacholPravastatinPrazosinPrecosePrenatal VitaminsPrevalitePrezistaPrinivilProair HFAProcardiaProcardia XLPrografPropranololPropranolol-

HydrochlorothiazideProventil HFA

PulmicortPulmicort Flexhaler

Q

QuestranQuestran LightQuetiapine QuinaprilQuinapril-

HydrochlorothiazideQVAR

R

RamiprilRapamuneRebifRepaglinide RescriptorReserpineRetrovirReyatazRiometRisperdal ERisperidone

S

SandimmuneSaphrisSectralSelzentrySerevent DiskusSeroquel ESeroquel XRSimcorSimvastatinSingulair ESirolimus Soltamox ESpirivaSpironolactone Spironolactone-

HydrochlorothiazideStarlixStavudineStribildSularSustivaSymbicort ESymlinPen

T

TacrolimusTamiflu TamoxifenTarkaTaztia XTTecfidera Tekamlo ETekturnaTekturna HCTTelmisartanTelmisartan-Amlodipine ETelmisartan-

Hydrochlorothiazide Tenex

TenoreticTenorminTerazosinTerbutalineTeveten Teveten HCTThalitoneTheo-24TheochronTheophyllineTheophylline/GuaifenesinThioridazineThiothixeneTiazacTiclopidineTimolol*Tivicay TolbutamideToprol XLTorsemideTradjenta TrandateTrandolaprilTrandolapril-Verapamil Triamterene-

HydrochlorothiazideTribenzor ETricor ETrifluoperazineTriglideTrilipix ETrizivirTruvadaTudorza PressairTwynsta E

U

UnireticUnivasc

V

Valsartan-Hydrochlorothiazide

VascepaVasereticVasotecVentolin HFAVerapamilVerapamil ERVerelanVerelan PMVersacloz VictozaVidexVidex ECViraceptViramuneViramune XRVireadVoSpire ERVytorin

W

WarfarinWelchol

X

XareltoXopenex HFAXopenex Nebulized

Solution E

Z

ZafirlukastZaroxolynZebetaZeritZestoretic ZestrilZetiaZiacZiagenZidovudineZiprasidone ZocorZortress ZyfloZyflo CRZyprexa E

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Listing by Therapeutic Category – Expanded List

Anti-Infectives - Antivirals Tamiflu

Anti-Infectives - HIV/AIDS Abacavir-Lamivudine-Zidovudine Abacavir AptivusAtriplaCombivirCompleraCrixivanDidanosineEdurant EmtrivaEpivirEpzicomFuzeonIntelenceInviraseIsentressKaletraLamivudineLamivudine-ZidovudineLexivaNevirapine NorvirPrezistaRescriptorRetrovirReyatazSelzentryStavudineStribildSustivaTivicay TrizivirTruvadaVidexVidex ECViraceptViramuneViramune XRVireadZeritZiagenZidovudine

Breast Cancer Prevention AnastrozoleArimidex EAromasinExemestaneFarestonFemara ELetrozoleSoltamox ETamoxifen

Cardiovascular/Heart Disease - Blood Clot/Platelet Therapy AggrenoxArixtraBrilintaCilostazolClopidogrel CoumadinDipyridamole

EffientEliquisEnoxaparinFondaparinuxFragminHeparinJantovenLovenoxPersantinePlavix EPletalPradaxaTiclopidineWarfarinXarelto

Cardiovascular/Heart Disease - High Blood Pressure AccuprilAccureticAcebutololAceonAdalat CCAfeditabAldactazideAldactoneAltaceAmilorideAmiloride-HydrochlorothiazideAmlodipine Amlodipine-BenazeprilAmturnide EAtacandAtacand HCTAtenololAtenolol-ChlorthalidoneAvalideAvaproAzor EBenazepril Benazepril-HydrochlorothiazideBenicarBenicar HCTBetaxolol*BidilBisoprololBisoprolol-HydrochlorothiazideBumetanideBystolicCalanCalan SRCandesartan Candesartan-HydrochlorothiazideCaptopril Captopril-HydrochlorothiazideCardene SRCardizemCardizem CDCardizem LACardura Cardura XLCartia XTCarvedilolCatapres Catapres TTSChlorothiazideClonidine

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Clonidine PatchClorpressCoregCoreg CR ECorgardCorzideCovera HSCozaarDemadexDilacor XRDilt CDDilt XRDiltia XTDiltiazemDiltiazem ERDiltzac ERDiovanDiovan HCT EDiurilDoxazosinDutoprol DyazideDynacirc CRDyreniumEdarbiEdarbyclor EdecrinEnalapril Enalapril-HydrochlorothiazideEpaned E EplerenoneEprosartan Exforge EExforge HCT EFelodipine ERFosinopril Fosinopril-HydrochlorothiazideFurosemideGuanfacineHydralazineHydrochlorothiazideHyzaarIndapamideInderalInderal LAInnopran XLInspraIrbesartanIrbesartan - Hydrochlorothiazide Isoptin SRIsradipinelabetalolLasixLevatol LisinoprilLisinopril-HydrochlorothiazideLopressorLopressor HCTLosartanLosartan-HydrochlorothiazideLotensin Lotensin HCTLotrelMatzim LA MavikMaxzide

MethyclothiazideMethyldopaMethyldopa-HydrochlorothiazideMetolazoneMetoprolol SuccinateMetoprolol TartrateMetoprolol-HydrochlorothiazideMicardisMicardis HCTMicrozideMidamorMinipressMinoxidilMoexipril Moexipril-HydrochlorothiazideNadololNadolol-BendroflumethazideNexiclon XR E NicardipineNifedipineNifedipine ERNimodipineNisoldipineNorvascPerindoprilPindololPrazosinPrinivilProcardiaProcardia XLPropranololPropranolol-HydrochlorothiazideQuinaprilQuinapril-HydrochlorothiazideRamiprilReserpineSectralSpironolactone Spironolactone-HydrochlorothiazideSularTarkaTaztia XTTekamlo ETekturnaTekturna HCTTelmisartanTelmisartan-Amlodipine E Telmisartan-Hydrochlorothiazide TenexTenoreticTenorminTerazosinTeveten Teveten HCTThalitoneTiazacTimolol*Toprol XLTorsemideTrandateTrandolaprilTrandolapril-VerapamilTriamterene-HydrochlorothiazideTribenzor ETwynsta E Uniretic

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UnivascValsartan-Hydrochlorothiazide Valturna E VasereticVasotecVerapamilVerapamil ERVerelanVerelan PMZaroxolynZebetaZestoretic ZestrilZiac

Cardiovascular/Heart Disease - High Cholesterol AdvicorAltoprev EAntaraAtorvastatin CholestyramineCholestyramine LightCholine Fenofibrate E ColestidColestipolCrestorFenofibrateFenofibrate 48, 145 mg E Fenofibrate Micronized Fenofibric AcidFenoglideFibricorFluvastatin GemfibrozilLescolLescol XLLipitor ELipofenLiptruzet E Livalo Lofibra LopidLovastatinLovazaMevacorNiacin Extended-Release NiacorNiaspanPravacholPravastatinPrevaliteQuestranQuestran LightSimcorSimvastatinTricor ETriglideTrilipix EVascepaVytorinWelcholZetiaZocor

Central Nervous System - Multiple Sclerosis AubagioAvonexBetaseronCopaxoneExtavia EGilenyaRebifTecfidera

Central Nervous System - Psychosis AbilifyChlorpromazineClozapineClozarilFanaptFazaCloFluphenazineGeodon EHaloperidolInvegaLatuda LoxapineMobanOlanzapine PerphenazineQuetiapine Risperdal ERisperidoneSaphrisSeroquel ESeroquel XRThioridazineThiothixeneTrifluoperazineVersacloz Ziprasidone Zyprexa E

Endocrine/Diabetes - Diabetic Supplies Diabetic Meters - Control SolutionsDiabetic Test StripsDiabetic Testing - Lancets Insulin Needles/Syringes

Endocrine/Diabetes - Insulin ApidraHumalogHumalog Mix 50/50Humalog Mix 75/25Humulin 50/50Humulin 70/30Humulin NHumulin RLantusLevemirNovolin 70/30Novolin N Novolin RNovologNovolog Mix 70/30

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Endocrine/Diabetes - Non-Insulin AcarboseACTOplus MetACTOplus Met XRActos EAmarylAvandametAvandarylAvandiaBydureon ByettaCycloset DiabetaDuetactFarxiga FortametGlimepirideGlipizideGlipizide ERGlipizide-MetforminGlucophageGlucophage XRGlucotrol Glucotrol XLGlucovanceGlumetzaGlyburideGlyburide MicronizedGlyburide-MetforminGlynaseGlysetInvokana JanumetJanumet XR JanuviaJentadueto KazanoKombiglyze XRMetformin Metformin ERNateglinideNesinaOnglyzaOseniPioglitazonePioglitazone-GlimepiridePioglitazone-MetforminPrandiMetPrandinPrecoseRepaglinide RiometStarlixSymlinPenTolbutamideTradjenta Victoza

Immunosuppressant - Organ Rejection Astagraf XL E AzasanAzathioprineCellceptCyclosporineGengrafHecoria ImuranMycophenolateMycophenolic Acid MyforticNeoralPrografRapamuneSandimmuneSirolimus TacrolimusZortress

Musculoskeletal - Osteoporosis ActonelAlendronateAtelvia E Binosto EBonivaCalcitonin (salmon)DidronelEtidronateEvistaForteoForticalFosamaxFosamax Plus DIbandronate Miacalcin

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Respiratory - Asthma/COPD AccolateAccunebAdvair DiskusAdvair HFAAlbuterol Nebulized SolutionAlbuterol Oral TabletAlvescoAminophyllineAnoro Ellipta Arcapta NeohalerAsmanex TwisthalerAtrovent HFABreo Ellipta BrovanaBudesonideCombivent RespimatCromolynDaliresp Dulera DuonebElixophyllinFlovent DiskusFlovent HFAForadilIpratropiumIpratropium/AlbuterolLevalbuterol Nebulized Solution ELufyllinMetaproterenolMontelukast PerforomistProair HFAProventil HFAPulmicort

Pulmicort FlexhalerQVARSerevent DiskusSingulair ESpirivaSymbicort ETerbutalineTheo-24TheochronTheophyllineTheophylline/GuaifenesinTudorza PressairVentolin HFAVoSpire ERXopenex HFAXopenex nebulized solution E ZafirlukastZyfloZyflo CR

Vitamins Pediatric Flouride Preparations (for example: Florvite, Poly-Vi-Flor,

Tri-Vi-Flor) - Brand Name and Generic ProductsPrenatal Vitamins (for example: Citranatal Assure, Prenate DHA,

Stuartnatal) - Brand Name and Generic Products

If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting myuhc.com® or by calling the toll-free member phone number on the back of your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access myuhc.com for additional information during your open enrollment period or you may contact your employer or health plan for additional information.Medications are categorized by common therapeutic conditions in this reference guide for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines how these medications may be covered for you. Where differences are noted between this reference guide and your benefit plan documents, the benefit plan documents will govern.

E May be excluded from coverage.*Coverage is provided for oral formulations. Bold type = Brand name drug [Plain type = Generic drug]

Clinical programs such as Notification/Prior Authorization, Step Therapy and Supply Limits may apply to listed medications based off your benefit plan. This list 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. The list will be updated annually.

©2014 United HealthCare Services, Inc.

For the most current PDL updates, visit myuhc.com or call toll-free member phone number on the back of your health plan ID card.

City of Austin Preventive Expanded List

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Addendum

Preventive Care Medications100% Plan Paid

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Preventive Care Medications

100% Plan PaidThese medications and supplements will be covered at 100% Plan Paid when: Prescribed by a health care professional Age and/or gender appropriate Filled at a network pharmacy

Most medications are available over-the-counter (OTC) except for prescription fluoride. All brands are covered by the pharmacy benefit.

OTC Medication/Supplement Gender Age Reason

Aspirin - 81, 162 & 325 mg BothMen age 45-79Women age 55-79

Prevent cardiovascular disease

Folic acid 400 & 800 mcg Women Childbearing age Prevent birth defects

Iron liquid supplement BothChildren age 0-1 year

Prevent anemia due to iron deficiency

Vitamin D - 400 & 1,000 units Both Age 65 and over Fall risk prevention

Rx Medication/Supplement Gender Age Reason

Fluoride tablets, solution(not toothpaste, rinses)

BothChildren age 0-6 years

Prevent dental cavities if water source is deficient in fluoride

Over-the-Counter (OTC) Contraceptives for Women

These contraceptives are available over-the-counter (OTC) and will be covered at 100% Plan Paid when: Prescribed by a health care professional Filled at a network pharmacy

Male contraceptives are not covered under the Patient Protection and Affordable Care Act (PPACA).

Contraceptive films

Contraceptive foams

Contraceptive gels

Emergency contraceptives (generic for Plan B, generic for Plan B One-Step)

Female Condoms

For our members

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Prescription Hormonal Contraceptives

Brand and Generic Hormonal ContraceptivesAltaveraAlyacenAlyacen 1/35AmethiaAmethia LoAmethystApriAranelleAubraAvianeAzuretteBalzivaBriellynCamilaCamreseCamrese LoCaziantCesiaChatealCryselleCyclafemCyclafem 1/35DasettaDasetta 1/35DayseeDesogestrel/Ethinyl EstradiolDrospirenone/Ethinyl EstradiolElinestEmoquetteEnpresseEnskyceErrinEstaryllaFalminaGianviGildagiaGildessGildess FEHeatherIntrovaleJencyclaJolessaJolivetteJunelJunel FEJunel FeKarivaKelnorKurvelo


Brand and Generic Hormonal ContraceptivesLarinLarin FELeena LessinaLevonestLevonorgestrel/Ethinyl EstradiolLevora-28LoMedia 24 FE LorynaLow-OgestrelLuteraLyzaMarlissaMedroxyprogesterone Acetate MicrogestinMicrogestin FEModiconMono-LinyahMononessaMyzilraNataziaNeconNecon 0.5/35Necon 1/35Necon 1/50 Necon 10/11 Nora-BENorethindroneNorethindrone/Ethinyl EstradiolNorgestimate/Ethinyl EstradiolNorgestrel/Ethinyl EstradiolNortrelNortrel 0.5/35Nortrel 1/35OcellaOgestrelOrsythiaPhilithPimtreaPirmellaPortiaPrevifemQuasenseReclipsenSoliaSprintecSronyxSyedaTilia FE

Bold type = Brand name drug [Plain type = Generic drug]

12www.myuhc.com


Brand and Generic Hormonal ContraceptivesTri-EstaryllaTri-Legest FE Tri-LinyahTri-PrevifemTri-SprintecTrinessaTrivora-28VelivetVesturaVioreleVyfemlaWera Wymzya FEXulane ZarahZenchentZenchent FEZeosa Zovia 1/35E Zovia 1/50E

Prescription Emergency Contraceptives

Brand Emergency ContraceptivesEllaGeneric Emergency ContraceptivesLevonorgestrel, Next Choice (generic Plan B)My Way, Next Choice One Dose (generic Plan B One-Step)

Prescription Diaphragms

Brand DiaphragmsFemcapOrtho All-FlexOrtho-Diaphragm

Breast Cancer Preventive MedicationsFor women who are at increased risk for breast cancer but have not had breast cancer, these preventive medications are available at 100% plan paid. To qualify, a woman must: Be age 35 or older At increased risk for the first occurrence of breast

cancer – after risk assessment and counseling Obtain Prior Authorization

Most plans cover these medications at normal cost-share for the treatment of breast cancer, to prevent breast cancer recurrence and for other indications. They are available at 100% plan paid to prevent the first occurrence of breast cancer if a Prior Authorization is obtained. If a woman qualifies, she can receive these drugs at 100% plan paid for up to five years, minus any time she has been taking them for prevention.

raloxifene

tamoxifen

Bold type = Brand name drug [Plain type = Generic drug]

Please note this list is subject to change.

Always refer to your benefit plan materials to determine your coverage for medications and cost-share. Some medications listed on the PDL may not be covered under your specific benefit. Where differences are noted, the benefit plan documents will govern.

All branded medications are trademarks or registered trademarks of their respective owners.

M51372-OO 7/14 © 2014 United HealthCare Services, Inc.

city of austin prev expanded list w addendum 714 7

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