core preventive list 1-1-19 v8
TRANSCRIPT
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Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)
*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
Therapeutic Drug Classes Requirements & Limits
Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy
Aggrenox
Arixtra
Aspirin-Dipyridamole
Bevyxxa
Brilinta
Cilostazol
Clopidogrel
Coumadin
Dipyridamole
Effient E
Eliquis
2019 Preventive Drug List forConsumer Driven Health PlansCore ListEffective Jan. 1, 2019
This document is a list of Preventive Medications that may be covered under your benefit plan. If your plan includes these Preventive Medications, your insurance benefit is applied before you meet your deductible for the below drugs.
Some medications may have additional requirements or limits depending on your benefit plan and are noted below. To confirm your plan coverage for a specific drug, please view your plan benefits on your health plan’s member website or call the toll-free phone number on your health plan ID card. This list is intended as a reference and may not be all-inclusive. Brand-name or generic availability may not be current due to changes in the market.
This list applies to members of UnitedHealthcare and Oxford medical plans. It is accurate as of Jan. 1, 2019 and is subject to change after this date. The next anticipated update will be July 1, 2019.
Core Drug List
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Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)
*Coverage is provided for oral formulations
Therapeutic Drug Classes Requirements & Limits
Enoxaparin
Fragmin
Fondaparinux
Heparin
Jantoven
Lovenox
Persantine
Plavix E
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
Therapeutic Drug Classes Requirements & Limits
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
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Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)
*Coverage is provided for oral formulations
Therapeutic Drug Classes Requirements & Limits
Carvedilol
Carvedilol ER E
Catapres
Catapres TTS
Chlorothiazide
Clonidine
Clonidine Patch
Clorpress
Coreg
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
Therapeutic Drug Classes Requirements & Limits
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 E
Labetalol
Lasix
Levatol
Lisinopril
Lisinopril-Hydrochlorothiazide
Lopressor
Lopressor HCT
Losartan
Losartan-Hydrochlorothiazide
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Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)
*Coverage is provided for oral formulations
Therapeutic Drug Classes Requirements & Limits
Lotensin
Lotensin HCT
Lotrel
Matzim LA
Mavik
Maxzide
Methyclothiazide
Methyldopa
Methyldopa-Hydrochlorothiazide
Metolazone
Metoprolol 37.5, 75 mg E
Metoprolol-Hydrochlorothiazide
Metoprolol Succinate
Metoprolol Tartrate
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
Therapeutic Drug Classes Requirements & Limits
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
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Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)
*Coverage is provided for oral formulations
Therapeutic Drug Classes Requirements & Limits
Trandate
Trandolapril
Trandolapril-Verapamil
Triamterene-Hydrochlorothiazide
Tribenzor E
Twynsta E
Uniretic
Univasc
Valsartan
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
Therapeutic Drug Classes Requirements & Limits
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
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Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)
*Coverage is provided for oral formulations
Therapeutic Drug Classes Requirements & Limits
Triglide E
Trilipix E
Vascepa
Vytorin E
Welchol
Zetia E
Zocor
Zypitamag E
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
Therapeutic Drug Classes Requirements & Limits
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
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
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IndexIndexA
Accupril ....................................................... 2Accuretic ..................................................... 2Acebutolol .................................................. 2Aceon .......................................................... 2Actonel ........................................................ 6Adalat CC ................................................... 2Afeditab ....................................................... 2Aggrenox .................................................... 1Aldactazide ................................................ 2Aldactone ................................................... 2Alendronate ................................................ 6Altace ........................................................... 2Altoprev ....................................................... 5Amiloride ..................................................... 2Amiloride-Hydrochlorothiazide ............. 2Amlodipine ................................................. 2Amlodipine-Benazepril ............................ 2Amlodipine-Olmesartan .......................... 2Amlodipine-Olmesartan-
Hydrochlorothiazide ............................. 2Amlodipine-Valsartan .............................. 2Amlodipine-Valsartan-
Hydrochlorothiazide ............................. 2Amturnide ................................................... 2Anastrozole ................................................ 1Antara .......................................................... 5Arimidex ...................................................... 1Arixtra .......................................................... 1Aromasin ..................................................... 1Aspirin-Dipyridamole ............................... 1Astagraf XL ................................................. 6Atacand ....................................................... 2Atacand HCT ............................................. 2Atelvia .......................................................... 6Atenolol ....................................................... 2Atenolol-Chlorthalidone .......................... 2Atorvastatin ................................................ 5Avalide ......................................................... 2Avapro ......................................................... 2Azasan......................................................... 6Azathioprine ............................................... 6Azor .............................................................. 2
B
Benazepril .................................................. 2Benazepril-Hydrochlorothiazide ........... 2
Benicar ........................................................ 2Benicar HCT .............................................. 2Betaxolol ..................................................... 2Bevyxxa....................................................... 1Bidil .............................................................. 2Binosto ........................................................ 6Bisoprolol .................................................... 2Bisoprolol-Hydrochlorothiazide ............ 2Boniva .......................................................... 6Brilinta.......................................................... 1Bumetanide ................................................ 2Bystolic ........................................................ 2Byvalson ..................................................... 2
C
Calan ............................................................ 2Calan SR ..................................................... 2Calcitonin (Salmon) .................................. 6Candesartan .............................................. 2Candesartan-Hydrochlorothiazide ....... 2Captopril ..................................................... 2Captopril-Hydrochlorothiazide .............. 2Cardene SR................................................ 2Cardizem..................................................... 2Cardizem CD ............................................. 2Cardizem LA .............................................. 2Cardura ....................................................... 2Carospir....................................................... 2Cartia XT ..................................................... 2Carvedilol .................................................... 3Carvedilol ER ............................................. 3Catapres ..................................................... 3Catapres TTS ............................................ 3Cellcept ....................................................... 6Chlorothiazide ........................................... 3Cholestyramine ......................................... 5Cholestyramine Light .............................. 5Choline Fenofibrate .................................. 5Cilostazol .................................................... 1Clonidine ..................................................... 3Clonidine Patch ......................................... 3Clopidogrel ................................................. 1Clorpress .................................................... 3Colesevelam Tablets, Powder for
Suspension ............................................ 5Colestid ....................................................... 5Colestipol .................................................... 5Coreg ........................................................... 3
Coreg CR .................................................... 3Corgard ....................................................... 3Corzide ........................................................ 3Coumadin ................................................... 1Covera HS .................................................. 3Cozaar ......................................................... 3Crestor ......................................................... 5Cyclosporine .............................................. 6
D
Demadex .................................................... 3Didronel ....................................................... 6Dilacor XR ................................................... 3Dilt CD ......................................................... 3Dilt XR .......................................................... 3Diltia XT ....................................................... 3Diltiazem ..................................................... 3Diltiazem ER ............................................... 3Diltzac ER ................................................... 3Diovan .......................................................... 3Diovan HCT ................................................ 3Dipyridamole .............................................. 1Diuril ............................................................. 3Doxazosin ................................................... 3Dutoprol ...................................................... 3Dyazide ....................................................... 3Dynacirc CR ............................................... 3Dyrenium .................................................... 3
E
Edarbi .......................................................... 3Edarbyclor .................................................. 3Edecrin ........................................................ 3Effient ........................................................... 1Eliquis .......................................................... 1Enalapril ...................................................... 3Enalapril-Hydrochlorothiazide ............... 3Enoxaparin ................................................. 2Envarsus XR ............................................... 6Epaned ........................................................ 3Eplerenone ................................................. 3Eprosartan .................................................. 3Ethacrynic Acid ......................................... 3Etidronate ................................................... 6Evista ........................................................... 6Exemestane ............................................... 1Exforge ........................................................ 3Exforge HCT .............................................. 3
8
Ezetimibe .................................................... 5
F
Fareston ...................................................... 1Felodipine 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 .......................................... 5Fenoglide .................................................... 5Fibricor ........................................................ 5Flolipid ......................................................... 5Fluvastatin .................................................. 5Fluvastatin ER ............................................ 5Fondaparinux............................................. 2Forteo .......................................................... 6Fortical ......................................................... 6Fosamax ..................................................... 6Fosamax Plus D ........................................ 6Fosinopril .................................................... 3Fosinopril-Hydrochlorothiazide ............. 3Fragmin ....................................................... 2Furosemide ................................................ 3
G
Gemfibrozil ................................................. 5Gengraf ....................................................... 6Guanfacine ................................................. 3
H
Heparin ........................................................ 2Hydralazine ................................................ 3Hydrochlorothiazide ................................. 3Hyzaar ......................................................... 3
I
Ibandronate ................................................ 6Imuran ......................................................... 6Indapamide ................................................ 3Inderal .......................................................... 3Inderal LA ................................................... 3Innopran XL................................................ 3Inspra ........................................................... 3Irbesartan ................................................... 3Irbesartan-Hydrochlorothiazide ............ 3Isoptin SR ................................................... 3Isradipine .................................................... 3
J
Jantoven ...................................................... 2
K
Kapspargo .................................................. 3
L
Labetalol ..................................................... 3Lasix ............................................................. 3Lescol .......................................................... 5Lescol XL .................................................... 5Letrozole ..................................................... 1Levatol ......................................................... 3Lipitor ........................................................... 5Lipofen ........................................................ 5Lisinopril ...................................................... 3Lisinopril-Hydrochlorothiazide .............. 3Livalo ............................................................ 5Lofibra ......................................................... 5Lopid ............................................................ 5Lopressor ................................................... 3Lopressor HCT .......................................... 3Losartan ...................................................... 3Losartan-Hydrochlorothiazide ............... 3Lotensin ...................................................... 4Lotensin HCT ............................................. 4Lotrel ............................................................ 4Lovastatin ................................................... 5Lovaza ......................................................... 5Lovenox ....................................................... 2
M
Matzim LA .................................................. 4Mavik ........................................................... 4Maxzide....................................................... 4Methyclothiazide ....................................... 4Methyldopa ................................................ 4Methyldopa-Hydrochlorothiazide ......... 4Metolazone ................................................. 4Metoprolol 37.5, 75 mg ........................... 4Metoprolol Succinate ............................... 4Metoprolol Tartrate ................................... 4Metoprolol-Hydrochlorothiazide ........... 4Mevacor ...................................................... 5Miacalcin ..................................................... 6Micardis....................................................... 4Micardis HCT ............................................. 4Microzide .................................................... 4Midamor ...................................................... 4
Minipress .................................................... 4Minoxidil ...................................................... 4Moexipril ..................................................... 4Moexipril-Hydrochlorothiazide .............. 4Mycophenolate ......................................... 6Mycophenolic Acid .................................. 6Myfortic ....................................................... 6
N
Nadolol ........................................................ 4Nadolol-Bendroflumethazide ................ 4Neoral .......................................................... 6Niacin Extended-Release ....................... 5Niacor .......................................................... 5Niaspan ....................................................... 5Nicardipine ................................................. 4Nifedipine ................................................... 4Nifedipine ER ............................................. 4Nimodipine ................................................. 4Nisoldipine.................................................. 4Norvasc ....................................................... 4
O
Olmesartan ................................................ 4Olmesartan-Hydrochlorothiazide ......... 4Omega-3 Acid Ethyl Esters .................... 5
P
Pediatric Flouride Preparations ............. 6Perindopril .................................................. 4Persantine .................................................. 2Pindolol ....................................................... 4Plavix ............................................................ 2Pletal ............................................................ 2Pradaxa ....................................................... 2Prasugrel ..................................................... 2Pravachol .................................................... 5Pravastatin .................................................. 5Prazosin ...................................................... 4Prenatal Vitamins ...................................... 6Prestalia ...................................................... 4Prevalite ....................................................... 5Prinivil .......................................................... 4Procardia .................................................... 4Procardia XL .............................................. 4Prograf ......................................................... 6Propranolol ................................................. 4Propranolol-Hydrochlorothiazide ......... 4
9
Q
Qbrelis ......................................................... 4Questran ..................................................... 5Questran Light ........................................... 5Quinapril ..................................................... 4Quinapril-Hydrochlorothiazide .............. 4
R
Raloxifene ................................................... 6Ramipril ....................................................... 4Rapamune .................................................. 6Reserpine ................................................... 4Risedronate ................................................ 6Rosuvastatin .............................................. 5
S
Sandimmune ............................................. 6Savaysa ....................................................... 2Sectral ......................................................... 4Simvastatin ................................................. 5Simvastatin/Ezetimibe ............................. 5Sirolimus ..................................................... 6Soltamox ..................................................... 1Spironolactone .......................................... 4Spironolactone-Hydrochlorothiazide ... 4Sular ............................................................. 4
T
Tacrolimus .................................................. 6Tamoxifen ................................................... 1Tarka ............................................................ 4Taztia XT ..................................................... 4Tekturna ...................................................... 4Tekturna HCT ............................................ 4Telmisartan ................................................. 4Telmisartan-Amlodipine .......................... 4Telmisartan-Hydrochlorothiazide.......... 4Tenex ........................................................... 4Tenoretic ..................................................... 4Tenormin ..................................................... 4Terazosin..................................................... 4Teveten ........................................................ 4Teveten HCT .............................................. 4Thalitone ..................................................... 4Tiazac .......................................................... 4Ticlopidine .................................................. 2Timolol ......................................................... 4Toprol XL..................................................... 4Torsemide ................................................... 4
Trandate ...................................................... 5Trandolapril ................................................ 5Trandolapril-Verapamil ............................ 5Triamterene-Hydrochlorothiazide ......... 5Tribenzor ..................................................... 5Tricor ............................................................ 5Triglide ......................................................... 6Trilipix ........................................................... 6Twynsta ....................................................... 5Tymlos ......................................................... 6
U
Uniretic ........................................................ 5Univasc ........................................................ 5
V
Valsartan ..................................................... 5Valsartan-Hydrochlorothiazide .............. 5Vascepa ...................................................... 6Vaseretic ..................................................... 5Vasotec ........................................................ 5Verapamil .................................................... 5Verapamil ER ............................................. 5Verelan ........................................................ 5Verelan PM ................................................. 5Vytorin ......................................................... 6
W
Warfarin ....................................................... 2Welchol ....................................................... 6
X
Xarelto ......................................................... 2
Z
Zaroxolyn .................................................... 5Zebeta ......................................................... 5Zestoretic .................................................... 5Zestril ........................................................... 5Zetia ............................................................. 6Ziac............................................................... 5Zocor ........................................................... 6Zontivity ....................................................... 2Zortress ....................................................... 6Zypitamag ................................................... 6
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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 or Oxford for pharmacy benefit coverage, you may access your health plan’s member website 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.
This document applies to commercial group members of UnitedHealthcare and Oxford New York plans.
Insurance coverage provided by or through UnitedHealthcare Insurance Company of New York or Oxford Health Insurance, Inc. Administrative services provided by UnitedHealthcare Service LLC, Oxford Health Plans LLC, or their affiliates.
©2018 United HealthCare Services, Inc. MT-1181623.0 NY-18-414 76757-0720182019 Preventive Core List 5/18
Call the toll-free phone number on your health plan 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: