expanded preventive list 7-1-19...

1

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

E = May be excluded from coverage *Coverage is provided for oral formulations

Therapeutic Drug Classes Requirements & Limits

Breast Cancer Prevention

Anastrozole

Arimidex E

Aromasin

Exemestane

Fareston

Femara E

Letrozole

Soltamox E

Tamoxifen

Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy

Aggrenox

Arixtra

Aspirin-Dipyridamole

Bevyxxa


Brilinta

Cilostazol

Clopidogrel

Coumadin

Dipyridamole

Effient E

Eliquis

Enoxaparin

Fondaparinux

Fragmin

Heparin

Jantoven

Lovenox

Persantine

Plavix E

2019 Preventive Drug List forConsumer Driven Health PlansExpanded ListEffective July 1, 2019

This is a list of Preventive Medications that may be covered under your plan. If your plan covers these Preventive Medications, your insurance benefit is applied before you meet your deductible.

Some medications may have other requirements or limits depending on your benefit plan and are noted below. To find out if a drug is covered, please check your plan benefits on the health plan’s member website. Or, call the toll-free phone number on your health plan ID card. This list may not be all-inclusive. Brand and generic drugs may not always be available due to market changes.

Expanded Drug List

2




Pletal

Pradaxa

Prasugrel

Savaysa

Ticlopidine

Warfarin

Xarelto

Zontivity

Cardiovascular/Heart Disease: High Blood Pressure

Accupril

Accuretic

Acebutolol

Aceon

Adalat CC

Afeditab

Aldactazide

Aldactone

Altace

Amiloride

Amiloride-Hydrochlorothiazide

Amlodipine

Amlodipine-Benazepril

Amlodipine-Olmesartan E

Amlodipine-Olmesartan-Hydrochlorothiazide E

Amlodipine-Valsartan

Amlodipine-Valsartan-Hydrochlorothiazide E

Amturnide E

Atacand

Atacand HCT

Atenolol

Atenolol-Chlorthalidone

Avalide

Avapro


Azor E

Benazepril

Benazepril-Hydrochlorothiazide

Benicar E

Benicar HCT E

Betaxolol*

Bidil

Bisoprolol

Bisoprolol-Hydrochlorothiazide

Bumetanide

Bystolic

Byvalson

Calan

Calan SR

Candesartan

Candesartan-Hydrochlorothiazide

Captopril

Captopril-Hydrochlorothiazide

Cardene SR

Cardizem E

Cardizem CD E

Cardizem LA E

Cardura

Carospir

Cartia XT

Carvedilol

Carvedilol ER E

Catapres

Catapres TTS

Chlorothiazide

Clonidine

Clonidine Patch

Clorpress

Coreg

3




Coreg CR E

Corgard

Corzide

Covera HS

Cozaar

Demadex

Dilacor XR

Dilt CD

Dilt XR

Diltia XT

Diltiazem

Diltiazem ER

Diltzac ER

Diovan E

Diovan HCT E

Diuril

Doxazosin

Dutoprol E

Dyazide

Dynacirc CR

Dyrenium

Edarbi

Edarbyclor

Edecrin

Enalapril

Enalapril-Hydrochlorothiazide

Epaned

Eplerenone

Eprosartan

Ethacrynic Acid

Exforge E

Exforge HCT E

Felodipine ER

Fosinopril


Fosinopril-Hydrochlorothiazide

Furosemide

Guanfacine

Hydralazine

Hydrochlorothiazide

Hyzaar

Indapamide

Inderal

Inderal LA E

Innopran XL

Inspra

Irbesartan

Irbesartan - Hydrochlorothiazide

Isoptin SR

Isradipine

Kapspargo

Labetalol

Lasix

Levatol

Lisinopril

Lisinopril-Hydrochlorothiazide

Lopressor

Lopressor HCT

Losartan

Losartan-Hydrochlorothiazide

Lotensin

Lotensin HCT

Lotrel

Matzim LA

Mavik

Maxzide

Methyclothiazide

Methyldopa

Methyldopa-Hydrochlorothiazide

4




Metolazone

Metoprolol 37.5, 75 mg E

Metoprolol Succinate

Metoprolol Tartrate

Metoprolol-Hydrochlorothiazide

Micardis E

Micardis HCT E

Microzide

Midamor

Minipress

Minoxidil

Moexipril

Moexipril-Hydrochlorothiazide

Nadolol

Nadolol-Bendroflumethazide

Nicardipine

Nifedipine

Nifedipine ER

Nimodipine

Nisoldipine

Norvasc

Olmesartan

Olmesartan-Hydrochlorothiazide

Perindopril

Pindolol

Prazosin

Prestalia E

Prinivil

Procardia

Procardia XL

Propranolol

Propranolol-Hydrochlorothiazide

Qbrelis E

Quinapril


Quinapril-Hydrochlorothiazide

Ramipril

Reserpine

Sectral

Spironolactone

Spironolactone-Hydrochlorothiazide

Sular

Tarka

Taztia XT

Tekturna

Tekturna HCT

Telmisartan

Telmisartan-Amlodipine E

Telmisartan-Hydrochlorothiazide

Tenex

Tenoretic E

Tenormin E

Terazosin

Teveten

Teveten HCT

Thalitone

Tiazac

Timolol*

Toprol XL

Torsemide

Trandate

Trandolapril

Trandolapril-Verapamil

Triamterene-Hydrochlorothiazide

Tribenzor E

Twynsta E

Uniretic

Univasc

Valsartan

5




Valsartan-Hydrochlorothiazide

Vaseretic E

Vasotec E

Verapamil

Verapamil ER

Verelan

Verelan PM

Zaroxolyn

Zebeta

Zestoretic E

Zestril E

Ziac

Cardiovascular/Heart Disease: High Cholesterol

Altoprev E

Antara E

Atorvastatin

Cholestyramine

Cholestyramine Light

Choline Fenofibrate E

Colesevelam Tablets, Powder for Suspension E

Colestid

Colestipol

Crestor E

Ezetimibe

Fenofibrate 43, 50 , 67,130, 134, 150, 200 mg Capsule E

Fenofibrate 40, 48, 120, 145 mg Tablet E

Fenofibrate 54, 160 mg Tablet

Fenofibric Acid E

Fenoglide E

Fibricor E

Flolipid

Fluvastatin


Fluvastatin ER

Gemfibrozil

Lescol

Lescol XL E

Lipitor E

Lipofen E

Livalo E

Lofibra E

Lopid

Lovastatin

Lovaza E

Mevacor

Niacin Extended-Release

Niacor

Niaspan

Omega-3 Acid Ethyl Esters

Pravachol

Pravastatin

Prevalite

Questran

Questran Light

Rosuvastatin

Simvastatin

Simvastatin/Ezetimibe

Tricor E

Triglide E

Trilipix E

Vascepa

Vytorin E

Welchol

Zetia E

Zocor

Zypitamag E

6




Central Nervous System: Mental Health

Abilify, Abilify Mycite E

Aripiprazole

Chlorpromazine

Clozapine

Clozaril

Fanapt

FazaClo

Fluphenazine

Geodon E

Haloperidol

Invega E

Latuda

Loxapine

Molindone

Olanzapine

Paliperidone ER

Perphenazine

Quetiapine

Quetiapine ER

Rexulti

Risperdal E

Risperidone

Saphris

Seroquel E

Seroquel XR E

Thioridazine

Thiothixene

Trifluoperazine

Vraylar

Versacloz E

Ziprasidone

Zyprexa E


Central Nervous System: Multiple Sclerosis

Aubagio

Avonex

Betaseron

Copaxone E

Extavia E

Gilenya

glatiramer acetate [Mylan only (generic Copaxone)]

Glatopa E

Plegridy

Rebif

Tecfidera

Diabetes: Diabetic Supplies

Contour Next EZ Meters

Contour Next Meters

Contour Next One Meters

Contour Next Test Strips

Diabetic Testing - Lancets

Insulin Needles/Syringes

OneTouch Diabetic Meters

OneTouch Diabetic Test Strips

Diabetes: Insulin

Admelog, Admelog SoloStar E

Afrezza E

Apidra, Apidra SoloStar E

Basaglar

Fiasp, Fiasp FlexTouch E

Humalog

Humalog Junior

Humalog Mix 50/50

Humalog Mix 75/25

Humulin 50/50

Humulin 70/30

7




Humulin N

Humulin R

Lantus E

Levemir

Novolin 70/30 E

Novolin N E

Novolin R E

Novolog E

Novolog Mix 70/30 E

Soliqua

Toujeo E

Tresiba

Diabetes: Non-Insulin

Acarbose

ACTOplus Met

ACTOplus Met XR

Actos E

Adlyxin

Alogliptin E

Alogliptin-Metformin E

Alogliptin-Pioglitazone E

Amaryl

Avandia

Bydureon

Bydureon BCise

Byetta

Cycloset

Diabeta

Duetact

Farxiga E

Fortamet E

Glimepiride

Glipizide

Glipizide ER


Glipizide-Metformin

Glucophage

Glucophage XR

Glucotrol

Glucotrol XL

Glucovance

Glumetza E

Glyburide

Glyburide Micronized

Glyburide-Metformin

Glynase

Glyset

Glyxambi

Invokamet

Invokamet XR

Invokana

Janumet

Janumet XR

Januvia

Jardiance

Jentadueto

Jentadueto XR

Kazano

Kombiglyze XR

Metformin

Metformin ER (generic Fortamet) E

Metformin ER (generic Glucophage XR)

Metformin ER (generic Glumetza) E

Miglitol

Nateglinide

Nesina

Onglyza

Oseni

Ozempic

8




Pioglitazone

Pioglitazone-Glimepiride

Pioglitazone-Metformin

PrandiMet

Prandin

Precose

Qtern E

Repaglinide

Repaglinide-Metformin

Riomet

Segluromet E

Starlix

Steglatro E

Steglujan E

SymlinPen

Synjardy

Synjardy XR

Tolbutamide

Tradjenta

Trulicity

Victoza

Xigduo XR E

Xultophy E

HIV

Abacavir

Abacavir-Lamivudine

Abacavir-Lamivudine-Zidovudine

Aptivus

Atazanavir

Atripla E

Biktarvy

Cimduo

Combivir

Complera


Crixivan

Delstrigo

Descovy

Didanosine

Edurant

Efavirenz

Emtriva

Epivir

Epzicom E

Evotaz

Fosamprenavir

Fuzeon

Genvoya

Intelence

Invirase

Isentress

Isentress HD

Juluca

Kaletra

Lamivudine

Lamivudine-Zidovudine

Lexiva

Lopinavir-Ritonavir

Nevirapine

Nevirapine Extended-Release E

Norvir Tablet E

Odefsey

Pifeltro

Prezcobix

Prezista

Rescriptor

Retrovir

Reyataz E

Ritonavir

9




Selzentry

Stavudine

Stribild

Sustiva

Symfi

Symfi Lo

Symtuza E

Tenofovir

Tivicay

Triumeq

Trizivir

Truvada

Videx

Videx EC

Viracept

Viramune E

Viramune XR E

Viread E

Viteka

Zerit

Ziagen

Zidovudine

Immunosuppressant: Organ Rejection

Astagraf XL E

Azasan

Azathioprine

Cellcept E

Cyclosporine

Envarsus XR E

Gengraf

Imuran E

Mycophenolate

Mycophenolic Acid

Myfortic E

Neoral E


Prograf E

Rapamune E

Sandimmune E

Sirolimus

Tacrolimus

Zortress

Musculoskeletal: Osteoporosis

Actonel

Alendronate

Atelvia E

Binosto E

Boniva

Calcitonin (salmon)

Didronel

Etidronate

Evista E

Forteo

Fortical

Fosamax

Fosamax Plus D

Ibandronate

Miacalcin

Raloxifene

Risedronate

Tymlos

Respiratory: Asthma/COPD

Accolate

Accuneb

Advair Diskus

Advair HFA

AirDuo RespiClick E

Albuterol HFA (ProAir HFA authorized generic)

Albuterol HFA (Ventolin HFA authorized generic) E

Albuterol Nebulized Solution

10




Albuterol Oral Tablet

Alvesco

Aminophylline

Anoro Ellipta

Arcapta Neohaler

ArmonAir RespiClick E

Arnuity Ellipta

Asmanex HFA

Asmanex Twisthaler

Atrovent HFA

Bevespi Aerosphere

Breo Ellipta

Brovana

Budesonide Nebulized Solution

Combivent Respimat

Cromolyn

Daliresp

Dulera E

Duoneb

Elixophyllin

Flovent Diskus

Flovent HFA

Fluticasone/Salmeterol RespiClick

Foradil

Gastrocrom

Incruse Ellipta

Ipratropium

Ipratropium/Albuterol

Levalbuterol HFA

Levalbuterol Nebulized Solution

Lonhala Magnair

Lufyllin

Metaproterenol

Montelukast

Perforomist


Proair HFA

Proair RespiClick

Proventil HFA

Pulmicort Flexhaler

Pulmicort Nebulized Solution

QVAR Redihaler

Seebri NeoHaler

Serevent Diskus

Singulair E

Spiriva HandiHaler

Spiriva Respimat

Stiolto Respimat E

Striverdi Respimat

Symbicort

Terbutaline

Theo-24

Theophylline

Theophylline/Guaifenesin

Trelegy Ellipta

Tudorza Pressair

Utibron NeoHaler E

Ventolin HFA

VoSpire ER

Yupelri E

Xopenex HFA

Xopenex Nebulized Solution E

Zafirlukast

Zyflo

Zyflo CR

Vitamins

Pediatric Flouride Preparations (for example: Florvite, Poly-Vi-Flor, Tri-Vi-Flor) - Brand Name and Generic Products

Prenatal Vitamins (for example: Citranatal Assure, Prenate DHA, Stuartnatal) - Brand Name and Generic Products

11

IndexIndexA

Abacavir ...................................................... 8Abacavir-Lamivudine ............................... 8Abacavir-Lamivudine-Zidovudine ......... 8Abilify ........................................................... 6Abilify Mycite ............................................. 6Acarbose .................................................... 7Accolate ...................................................... 9Accuneb ...................................................... 9Accupril ....................................................... 2Accuretic ..................................................... 2Acebutolol .................................................. 2Aceon .......................................................... 2Actonel ........................................................ 9ACTOplus Met ........................................... 7ACTOplus Met XR .................................... 7Actos ............................................................ 7Adalat CC ................................................... 2Adlyxin ......................................................... 7Admelog, Admelog SoloStar ................. 6Advair Diskus ............................................. 9Advair HFA.................................................. 9Afeditab ....................................................... 2Afrezza......................................................... 6Aggrenox .................................................... 1AirDuo RespiClick .................................... 9Albuterol HFA (ProAir HFA

authorized generic) ............................. 9Albuterol HFA (Ventolin HFA

authorized generic) ............................. 9Albuterol Nebulized Solution ................. 9Albuterol Oral Tablet .............................. 10Aldactazide ................................................ 2Aldactone ................................................... 2Alendronate ................................................ 9Alogliptin ..................................................... 7Alogliptin-Metformin ................................ 7Alogliptin-Pioglitazone ............................. 7Altace ........................................................... 2Altoprev ....................................................... 5Alvesco ...................................................... 10Amaryl ......................................................... 7Amiloride ..................................................... 2Amiloride-Hydrochlorothiazide ............. 2Aminophylline .......................................... 10Amlodipine ................................................. 2Amlodipine-Benazepril ............................ 2Amlodipine-Olmesartan .......................... 2

Amlodipine-Olmesartan-Hydrochlorothiazide ............................. 2

Amlodipine-Valsartan .............................. 2Amlodipine-Valsartan-

Hydrochlorothiazide ............................. 2Amturnide ................................................... 2Anastrozole ................................................ 1Anoro Ellipta ............................................. 10Antara .......................................................... 5Apidra, Apidra SoloStar .......................... 6Aptivus ......................................................... 8Arcapta Neohaler ................................... 10Arimidex ...................................................... 1Aripiprazole ................................................ 6Arixtra .......................................................... 1ArmonAir RespiClick ............................. 10Arnuity Ellipta ........................................... 10Aromasin ..................................................... 1Asmanex HFA .......................................... 10Asmanex Twisthaler ............................... 10Aspirin-Dipyridamole ............................... 1Astagraf XL ................................................. 9Atacand ....................................................... 2Atacand HCT ............................................. 2Atazanavir ................................................... 8Atelvia .......................................................... 9Atenolol ....................................................... 2Atenolol-Chlorthalidone .......................... 2Atorvastatin ................................................ 5Atripla........................................................... 8Atrovent HFA ............................................ 10Aubagio ....................................................... 6Avalide ......................................................... 2Avandia........................................................ 7Avapro ......................................................... 2Avonex ......................................................... 6Azasan......................................................... 9Azathioprine ............................................... 9Azor .............................................................. 2

B

Basaglar ...................................................... 6Benazepril .................................................. 2Benazepril-Hydrochlorothiazide ........... 2Benicar ........................................................ 2Benicar HCT .............................................. 2Betaseron ................................................... 6Betaxolol ..................................................... 2

Bevespi Aerosphere............................... 10Bevyxxa....................................................... 1Bidil .............................................................. 2Biktarvy ....................................................... 8Binosto ........................................................ 9Bisoprolol .................................................... 2Bisoprolol-Hydrochlorothiazide ............ 2Boniva .......................................................... 9Breo Ellipta ............................................... 10Brilinta.......................................................... 1Brovana ..................................................... 10Budesonide Nebulized Solution ......... 10Bumetanide ................................................ 2Bydureon .................................................... 7Bydureon BCise ........................................ 7Byetta .......................................................... 7Bystolic ........................................................ 2Byvalson ..................................................... 2

C

Calan ............................................................ 2Calan SR ..................................................... 2Calcitonin (salmon) ................................... 9Candesartan .............................................. 2Candesartan-Hydrochlorothiazide ....... 2Captopril ..................................................... 2Captopril-Hydrochlorothiazide .............. 2Cardene SR................................................ 2Cardizem..................................................... 2Cardizem CD ............................................. 2Cardizem LA .............................................. 2Cardura ....................................................... 2Carospir....................................................... 2Cartia XT ..................................................... 2Carvedilol .................................................... 2Carvedilol ER ............................................. 2Catapres ..................................................... 2Catapres TTS ............................................ 2Cellcept E ................................................... 9Chlorothiazide ........................................... 2Chlorpromazine ........................................ 6Cholestyramine ......................................... 5Cholestyramine Light .............................. 5Choline Fenofibrate .................................. 5Cilostazol .................................................... 1Cimduo ........................................................ 8Clonidine ..................................................... 2Clonidine Patch ......................................... 2

12

Clopidogrel ................................................. 1Clorpress .................................................... 2Clozapine .................................................... 6Clozaril ......................................................... 6Colesevelam Tablets, Powder for

Suspension ............................................ 5Colestid ....................................................... 5Colestipol .................................................... 5Combivent Respimat ............................. 10Combivir ...................................................... 8Complera .................................................... 8Contour Next EZ Meters ......................... 6Contour Next Meters ............................... 6Contour Next One Meters ...................... 6Contour Next Test Strips ........................ 6Copaxone ................................................... 6Coreg .......................................................2, 3Coreg CR .................................................... 3Corgard ....................................................... 3Corzide ........................................................ 3Coumadin ................................................... 1Covera HS .................................................. 3Cozaar ......................................................... 3Crestor ......................................................... 5Crixivan ....................................................... 8Cromolyn .................................................. 10Cycloset ...................................................... 7Cyclosporine .............................................. 9

D

Daliresp ..................................................... 10Delstrigo ..................................................... 8Demadex .................................................... 3Descovy ...................................................... 8Diabeta ........................................................ 7Diabetic Testing - Lancets ...................... 6Didanosine ................................................. 8Didronel ....................................................... 9Dilacor XR ................................................... 3Dilt CD ......................................................... 3Dilt XR .......................................................... 3Diltia XT ....................................................... 3Diltiazem ..................................................... 3Diltiazem ER ............................................... 3Diltzac ER ................................................... 3Diovan .......................................................... 3Diovan HCT ................................................ 3Dipyridamole .............................................. 1Diuril ............................................................. 3Doxazosin ................................................... 3

Duetact ........................................................ 7Dulera ........................................................ 10Duoneb ..................................................... 10Dutoprol ...................................................... 3Dyazide ....................................................... 3Dynacirc CR ............................................... 3Dyrenium .................................................... 3

E

Edarbi .......................................................... 3Edarbyclor .................................................. 3Edecrin ........................................................ 3Edurant ........................................................ 8Efavirenz ...................................................... 8Effient ........................................................... 1Eliquis .......................................................... 1Elixophyllin ................................................ 10Emtriva ........................................................ 8Enalapril ...................................................... 3Enalapril-Hydrochlorothiazide ............... 3Enoxaparin ................................................. 1Envarsus XR ............................................... 9Epaned ........................................................ 3Epivir ............................................................ 8Eplerenone ................................................. 3Eprosartan .................................................. 3Epzicom ...................................................... 8Ethacrynic Acid ......................................... 3Etidronate ................................................... 9Evista ........................................................... 9Evotaz .......................................................... 8Exemestane ............................................... 1Exforge ........................................................ 3Exforge HCT .............................................. 3Extavia ......................................................... 6Ezetimibe .................................................... 5

F

Fanapt.......................................................... 6Fareston ...................................................... 1Farxiga ......................................................... 7FazaClo ....................................................... 6Felodipine ER ............................................ 3Femara ........................................................ 1Fenofibrate 40, 48, 120, 145 mg

Tablet ....................................................... 5Fenofibrate 43, 50 , 67,130, 134,

150, 200 mg Capsule.......................... 5Fenofibrate 54, 160 mg Tablet .............. 5Fenofibric Acid .......................................... 5

Fenoglide .................................................... 5Fiasp, Fiasp FlexTouch ............................ 6Fibricor ........................................................ 5Flolipid ......................................................... 5Flovent Diskus ......................................... 10Flovent HFA .............................................. 10Fluphenazine ............................................. 6Fluticasone/Salmeterol RespiClick .... 10Fluvastatin .................................................. 5Fluvastatin ER ............................................ 5Fondaparinux............................................. 1Foradil ........................................................ 10Fortamet ..................................................... 7Forteo .......................................................... 9Fortical ......................................................... 9Fosamax ..................................................... 9Fosamax Plus D ........................................ 9Fosamprenavir ........................................... 8Fosinopril .................................................... 3Fosinopril-Hydrochlorothiazide ............. 3Fragmin ....................................................... 1Furosemide ................................................ 3Fuzeon ......................................................... 8

G

Gastrocrom .............................................. 10Gemfibrozil ................................................. 5Gengraf ....................................................... 9Genvoya ...................................................... 8Geodon ....................................................... 6Gilenya ......................................................... 6glatiramer acetate ..................................... 6Glatopa ........................................................ 6Glimepiride ................................................. 7Glipizide ...................................................... 7Glipizide ER ................................................ 7Glipizide-Metformin .................................. 7Glucophage ............................................... 7Glucophage XR ......................................... 7Glucotrol ..................................................... 7Glucotrol XL ............................................... 7Glucovance ................................................ 7Glumetza .................................................... 7Glyburide .................................................... 7Glyburide Micronized .............................. 7Glyburide-Metformin ................................ 7Glynase ....................................................... 7Glyset ........................................................... 7Glyxambi ..................................................... 7Guanfacine ................................................. 3

13

H

Haloperidol ................................................. 6Heparin ........................................................ 1Humalog ..................................................... 6Humalog Junior......................................... 6Humalog Mix 50/50 ................................. 6Humalog Mix 75/25 ................................. 6Humulin 50/50 .......................................... 6Humulin 70/30 .......................................... 6Humulin N ................................................... 7Humulin R ................................................... 7Hydralazine ................................................ 3Hydrochlorothiazide ................................. 3Hyzaar ......................................................... 3

I

Ibandronate ................................................ 9Imuran ......................................................... 9Incruse Ellipta .......................................... 10Indapamide ................................................ 3Inderal .......................................................... 3Inderal LA ................................................... 3Innopran XL................................................ 3Inspra ........................................................... 3Insulin Needles/Syringes ........................ 6Intelence ..................................................... 8Invega .......................................................... 6Invirase ........................................................ 8Invokamet ................................................... 7Invokamet XR ............................................ 7Invokana ...................................................... 7Ipratropium ............................................... 10Ipratropium/Albuterol ............................ 10Irbesartan ................................................... 3Irbesartan - Hydrochlorothiazide .......... 3Isentress ...................................................... 8Isentress HD .............................................. 8Isoptin SR ................................................... 3Isradipine .................................................... 3

J

Jantoven ...................................................... 1Janumet ...................................................... 7Janumet XR ............................................... 7Januvia ........................................................ 7Jardiance .................................................... 7Jentadueto ................................................. 7Jentadueto XR ........................................... 7Juluca .......................................................... 8

K

Kaletra ......................................................... 8Kapspargo .................................................. 3Kazano ........................................................ 7Kombiglyze XR .......................................... 7

L

Labetalol ..................................................... 3Lamivudine ................................................. 8Lamivudine-Zidovudine .......................... 8Lantus .......................................................... 7Lasix ............................................................. 3Latuda ......................................................... 6Lescol .......................................................... 5Lescol XL .................................................... 5Letrozole ..................................................... 1Levalbuterol HFA .................................... 10Levalbuterol Nebulized Solution ......... 10Levatol ......................................................... 3Levemir ........................................................ 7Lexiva ........................................................... 8Lipitor ........................................................... 5Lipofen ........................................................ 5Lisinopril ...................................................... 3Lisinopril-Hydrochlorothiazide .............. 3Livalo ............................................................ 5Lofibra ......................................................... 5Lonhala Magnair ..................................... 10Lopid ............................................................ 5Lopinavir-Ritonavir .................................... 8Lopressor ................................................... 3Lopressor HCT .......................................... 3Losartan ...................................................... 3Losartan-Hydrochlorothiazide ............... 3Lotensin ...................................................... 3Lotensin HCT ............................................. 3Lotrel ............................................................ 3Lovastatin ................................................... 5Lovaza ......................................................... 5Lovenox ....................................................... 1Loxapine ..................................................... 6Lufyllin ....................................................... 10

M

Matzim LA .................................................. 3Mavik ........................................................... 3Maxzide....................................................... 3Metaproterenol ........................................ 10Metformin ................................................... 7Metformin ER ............................................. 7

Methyclothiazide ....................................... 3Methyldopa ................................................ 3Methyldopa-Hydrochlorothiazide ......... 3Metolazone ................................................. 4Metoprolol 37.5, 75 mg ........................... 4Metoprolol Succinate ............................... 4Metoprolol Tartrate ................................... 4Metoprolol-Hydrochlorothiazide ........... 4Mevacor ...................................................... 5Miacalcin ..................................................... 9Micardis....................................................... 4Micardis HCT ............................................. 4Microzide .................................................... 4Midamor ...................................................... 4Miglitol ......................................................... 7Minipress .................................................... 4Minoxidil ...................................................... 4Moexipril ..................................................... 4Moexipril-Hydrochlorothiazide .............. 4Molindone................................................... 6Montelukast ............................................. 10Mycophenolate ......................................... 9Mycophenolic Acid .................................. 9Myfortic ....................................................... 9

N

Nadolol ........................................................ 4Nadolol-Bendroflumethazide ................ 4Nateglinide ................................................. 7Neoral .......................................................... 9Nesina ......................................................... 7Nevirapine .................................................. 8Nevirapine Extended-Release ............... 8Niacin Extended-Release ....................... 5Niacor .......................................................... 5Niaspan ....................................................... 5Nicardipine ................................................. 4Nifedipine ................................................... 4Nifedipine ER ............................................. 4Nimodipine ................................................. 4Nisoldipine.................................................. 4Norvasc ....................................................... 4Norvir Tablet ............................................... 8Novolin 70/30 ............................................ 7Novolin N .................................................... 7Novolin R .................................................... 7Novolog ....................................................... 7Novolog Mix 70/30 .................................. 7

14

O

Odefsey ....................................................... 8Olanzapine ................................................. 6Olmesartan ................................................ 4Olmesartan-Hydrochlorothiazide ......... 4Omega-3 Acid Ethyl Esters .................... 5OneTouch Diabetic Meters ..................... 6OneTouch Diabetic Test Strips .............. 6Onglyza ....................................................... 7Oseni ............................................................ 7Ozempic ...................................................... 7

P

Paliperidone ER ........................................ 6Pediatric Flouride Preparations ........... 10Perforomist ............................................... 10Perindopril .................................................. 4Perphenazine ............................................ 6Persantine .................................................. 1Pifeltro ........................................................ 8Pindolol ....................................................... 4Pioglitazone ............................................... 8Pioglitazone-Glimepiride ........................ 8Pioglitazone-Metformin ........................... 8Plavix ............................................................ 1Plegridy ....................................................... 6Pletal ............................................................ 2Pradaxa ....................................................... 2PrandiMet ................................................... 8Prandin ........................................................ 8Prasugrel ..................................................... 2Pravachol .................................................... 5Pravastatin .................................................. 5Prazosin ...................................................... 4Precose ....................................................... 8Prenatal Vitamins .................................... 10Prestalia ...................................................... 4Prevalite ....................................................... 5Prezcobix .................................................... 8Prezista ........................................................ 8Prinivil .......................................................... 4Proair HFA ................................................ 10Proair RespiClick .................................... 10Procardia .................................................... 4Procardia XL .............................................. 4Prograf ......................................................... 9Propranolol ................................................. 4Propranolol-Hydrochlorothiazide ......... 4Proventil HFA ........................................... 10Pulmicort Flexhaler ................................ 10Pulmicort Nebulized Solution .............. 10

Q

Qbrelis ......................................................... 4Qtern ............................................................ 8Questran ..................................................... 5Questran Light ........................................... 5Quetiapine .................................................. 6Quetiapine ER ........................................... 6Quinapril ..................................................... 4Quinapril-Hydrochlorothiazide .............. 4QVAR Redihaler ...................................... 10

R

Raloxifene ................................................... 9Ramipril ....................................................... 4Rapamune .................................................. 9Rebif ............................................................. 6Repaglinide ................................................ 8Repaglinide-Metformin ........................... 8Rescriptor ................................................... 8Reserpine ................................................... 4Retrovir ........................................................ 8Rexulti .......................................................... 6Reyataz........................................................ 8Riomet ......................................................... 8Risedronate ................................................ 9Risperdal ..................................................... 6Risperidone ................................................ 6Ritonavir ...................................................... 8Rosuvastatin .............................................. 5

S

Sandimmune ............................................. 9Saphris ........................................................ 6Savaysa ....................................................... 2Sectral ......................................................... 4Seebri NeoHaler ..................................... 10Segluromet ................................................. 8Selzentry ..................................................... 9Serevent Diskus ...................................... 10Seroquel ...................................................... 6Seroquel XR ............................................... 6Simvastatin ................................................. 5Simvastatin/Ezetimibe ............................. 5Singulair .................................................... 10Sirolimus ..................................................... 9Soliqua ........................................................ 7Soltamox ..................................................... 1Spiriva HandiHaler ................................. 10Spiriva Respimat ..................................... 10Spironolactone .......................................... 4Spironolactone-Hydrochlorothiazide ... 4

Starlix ........................................................... 8Stavudine .................................................... 9Steglatro ...................................................... 8Steglujan ..................................................... 8Stiolto Respimat ...................................... 10Stribild ......................................................... 9Striverdi Respimat .................................. 10Sular ............................................................. 4Sustiva ......................................................... 9Symbicort ................................................. 10Symfi ............................................................ 9Symfi Lo ...................................................... 9SymlinPen ................................................... 8Symtuza ...................................................... 9Synjardy ...................................................... 8Synjardy XR ................................................ 8

T

Tacrolimus .................................................. 9Tamoxifen ................................................... 1Tarka ............................................................ 4Taztia XT ..................................................... 4Tecfidera ..................................................... 6Tekturna ...................................................... 4Tekturna HCT ............................................ 4Telmisartan ................................................. 4Telmisartan-Amlodipine .......................... 4Telmisartan-Hydrochlorothiazide.......... 4Tenex ........................................................... 4Tenofovir ..................................................... 9Tenoretic ..................................................... 4Tenormin ..................................................... 4Terazosin..................................................... 4Terbutaline ................................................ 10Teveten ........................................................ 4Teveten HCT .............................................. 4Thalitone ..................................................... 4Theo-24 ..................................................... 10Theophylline ............................................ 10Theophylline/Guaifenesin .................... 10Thioridazine ............................................... 6Thiothixene ................................................. 6Tiazac .......................................................... 4Ticlopidine .................................................. 2Timolol ......................................................... 4Tivicay .......................................................... 9Tolbutamide ............................................... 8Toprol XL..................................................... 4Torsemide ................................................... 4Toujeo .......................................................... 7Tradjenta ..................................................... 8

15

Trandate ...................................................... 4Trandolapril ................................................ 4Trandolapril-Verapamil ............................ 4Trelegy Ellipta .......................................... 10Tresiba ......................................................... 7Triamterene-Hydrochlorothiazide ......... 4Tribenzor ..................................................... 4Tricor ............................................................ 5Trifluoperazine ........................................... 6Triglide ......................................................... 5Trilipix ........................................................... 5Triumeq ....................................................... 9Trizivir ........................................................... 9Trulicity ........................................................ 8Truvada........................................................ 9Tudorza Pressair ..................................... 10Twynsta ....................................................... 4Tymlos ......................................................... 9

U

Uniretic ........................................................ 4Univasc ........................................................ 4Utibron NeoHaler .................................... 10

V

Valsartan ..................................................... 4Valsartan-Hydrochlorothiazide .............. 5Vascepa ...................................................... 5Vaseretic ..................................................... 5Vasotec ........................................................ 5Ventolin HFA ............................................ 10Verapamil .................................................... 5Verapamil ER ............................................. 5Verelan ........................................................ 5Verelan PM ................................................. 5Versacloz .................................................... 6Victoza ......................................................... 8Videx ............................................................ 9Videx EC ..................................................... 9Viracept ....................................................... 9Viramune .................................................... 9Viramune XR .............................................. 9Viread .......................................................... 9Viteka ........................................................... 9VoSpire ER ............................................... 10Vraylar .......................................................... 6Vytorin ......................................................... 5

W

Warfarin ....................................................... 2Welchol ....................................................... 5

X

Xarelto ......................................................... 2Xigduo XR................................................... 8Xopenex HFA ........................................... 10Xopenex Nebulized Solution ............... 10Xultophy ...................................................... 8

Y

Yupelri ........................................................ 10

Z

Zafirlukast ................................................. 10Zaroxolyn .................................................... 5Zebeta ......................................................... 5Zerit .............................................................. 9Zestoretic .................................................... 5Zestril ........................................................... 5Zetia ............................................................. 5Ziac............................................................... 5Ziagen .......................................................... 9Zidovudine .................................................. 9Ziprasidone ................................................ 6Zocor ........................................................... 5Zontivity ....................................................... 2Zortress ....................................................... 9Zyflo ........................................................... 10Zyflo CR .................................................... 10Zypitamag ................................................... 5Zyprexa ........................................................ 6

Nondiscrimination notice and access to communication servicesUnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Online: [email protected]

Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

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.

©2019 United HealthCare Services, Inc. 81167-0120192019 Preventive Expanded List 1/19

Call the toll-free phone number on your ID card to speak with a Customer Service representative.

Visit the member website listed on your health plan ID card to look up the price of drugs covered by your plan, find lower-cost options and more.

For additional information:

expanded preventive list 7-1-19...

Documents