expanded preventive list 1-1-20 v1
TRANSCRIPT
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
Toremifene
Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy
Aggrenox
Arixtra
Aspirin-Dipyridamole
Bevyxxa
Therapeutic Drug Classes Requirements & Limits
Brilinta
Cilostazol
Clopidogrel
Coumadin
Dipyridamole
Effient E
Eliquis
Enoxaparin
Fondaparinux
Fragmin
Heparin
Jantoven
Lovenox E
Persantine
Plavix E
2020 Preventive Drug List forConsumer Driven Health PlansExpanded ListCDH preventive drug lists may also be used with non-CDH plans
Effective Jan. 1, 2020
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
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
Pletal
Pradaxa
Prasugrel
Savaysa
Ticlopidine
Warfarin
Xarelto
Zontivity
Cardiovascular/Heart Disease: High Blood Pressure
Accupril
Accuretic
Acebutolol
Aceon
Adalat CC
Afeditab
Aldactazide
Aldactone
Aliskiren
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
Therapeutic Drug Classes Requirements & Limits
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
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
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
Therapeutic Drug Classes Requirements & Limits
Furosemide
Guanfacine
Hydralazine
Hydrochlorothiazide
Hyzaar
Indapamide
Inderal
Inderal LA E
Innopran XL
Inspra
Irbesartan
Irbesartan - Hydrochlorothiazide
Isoptin SR
Isradipine
Kapspargo
Katerzia E
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
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
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 E
Olmesartan
Olmesartan-Hydrochlorothiazide
Perindopril
Pindolol
Prazosin
Prestalia E
Prinivil
Procardia
Procardia XL
Propranolol
Propranolol-Hydrochlorothiazide
Qbrelis E
Quinapril
Therapeutic Drug Classes Requirements & Limits
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
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
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
Ezallor Sprinkle 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
Therapeutic Drug Classes Requirements & Limits
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
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
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
Therapeutic Drug Classes Requirements & Limits
Avonex
Betaseron
Copaxone E
Extavia E
Gilenya
glatiramer acetate [Mylan only (generic Copaxone)]
Glatopa E
Mavenclad E
Mayzent 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
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
Humulin N
Humulin R
Insulin Lispro E
Lantus E
Levemir E
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
Therapeutic Drug Classes Requirements & Limits
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
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
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
Therapeutic Drug Classes Requirements & Limits
Delstrigo
Descovy
Didanosine
Dovato
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
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
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
Therapeutic Drug Classes Requirements & Limits
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, Proventil HFA authorized generic)
Albuterol HFA (Ventolin HFA authorized generic) E
Albuterol Nebulized Solution
10
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
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 Diskus E
Fluticasone/Salmeterol RespiClick
Foradil
Gastrocrom
Incruse Ellipta
Ipratropium
Ipratropium/Albuterol
Levalbuterol HFA
Levalbuterol Nebulized Solution
Lonhala Magnair E
Lufyllin
Metaproterenol
Montelukast
Therapeutic Drug Classes Requirements & Limits
Perforomist
Proair HFA
Proair RespiClick
Proventil HFA
Pulmicort Flexhaler
Pulmicort Nebulized Solution E
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 E
Utibron NeoHaler E
Ventolin HFA
VoSpire ER
Yupelri
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 ................................................ 9Aliskiren ..................................................... 2Alogliptin ..................................................... 7Alogliptin-Metformin ................................ 7Alogliptin-Pioglitazone ............................. 7Altace ........................................................... 2Altoprev ....................................................... 5Alvesco ...................................................... 10Amaryl ......................................................... 7Amiloride ..................................................... 2Amiloride-Hydrochlorothiazide ............. 2Aminophylline .......................................... 10Amlodipine ................................................. 2Amlodipine-Benazepril ............................ 2
Amlodipine-Olmesartan .......................... 2Amlodipine-Olmesartan-
Hydrochlorothiazide ............................. 2Amlodipine-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 ................................................... 6
Betaxolol ..................................................... 2Bevespi 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 ..................................................... 2
12
Clonidine Patch ......................................... 2Clopidogrel ................................................. 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 ............................................................. 3
Dovato ........................................................ 8Doxazosin ................................................... 3Duetact ........................................................ 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 ......................................................... 6Ezallor Sprinkle ........................................ 5Ezetimibe .................................................... 5
F
Fanapt.......................................................... 6Fareston ...................................................... 1Farxiga ......................................................... 7FazaClo ....................................................... 6Felodipine ER ............................................ 3Femara ........................................................ 1Fenofibrate 40, 48, 120, 145 mg
Tablet ....................................................... 5
Fenofibrate 43, 50 , 67, 130, 134, 150, 200 mg Capsule.......................... 5
Fenofibrate 54, 160 mg Tablet .............. 5Fenofibric Acid .......................................... 5Fenoglide .................................................... 5Fiasp, Fiasp FlexTouch ............................ 6Fibricor ........................................................ 5Flolipid ......................................................... 5Flovent Diskus ......................................... 10Flovent HFA .............................................. 10Fluphenazine ............................................. 6Fluticasone/Salmeterol Diskus .......... 10Fluticasone/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 .............................. 7
13
Glyburide-Metformin ................................ 7Glynase ....................................................... 7Glyset ........................................................... 7Glyxambi ..................................................... 7Guanfacine ................................................. 3
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 ........................ 6Insulin Lispro ............................................ 7Intelence ..................................................... 8Invega .......................................................... 6Invirase ........................................................ 8Invokamet ................................................... 7Invokamet XR ............................................ 7Invokana ...................................................... 7Ipratropium ............................................... 10Ipratropium/Albuterol ............................ 10Irbesartan ................................................... 3Irbesartan - Hydrochlorothiazide .......... 3Isentress ...................................................... 8Isentress HD .............................................. 8Isoptin SR ................................................... 3Isradipine .................................................... 3
J
Jantoven ...................................................... 1Janumet ...................................................... 7
Janumet XR ............................................... 7Januvia ........................................................ 7Jardiance .................................................... 7Jentadueto ................................................. 7Jentadueto XR ........................................... 7Juluca .......................................................... 8
K
Kaletra ......................................................... 8Kapspargo .................................................. 3Katerzia ...................................................... 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 .................................................. 3Mavenclad ................................................. 6Mavik ........................................................... 3Maxzide....................................................... 3Mayzent ...................................................... 6Metaproterenol ........................................ 10Metformin ................................................... 7Metformin ER ............................................. 7Methyclothiazide ....................................... 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.................................................. 4
14
Norvasc ....................................................... 4Norvir Tablet ............................................... 8Novolin 70/30 ............................................ 7Novolin N .................................................... 7Novolin R .................................................... 7Novolog ....................................................... 7Novolog Mix 70/30 .................................. 7
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 .................................... 10
Procardia .................................................... 4Procardia XL .............................................. 4Prograf ......................................................... 9Propranolol ................................................. 4Propranolol-Hydrochlorothiazide ......... 4Proventil HFA .......................................9, 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 ................................................. 5
Simvastatin/Ezetimibe ............................. 5Singulair .................................................... 10Sirolimus ..................................................... 9Soliqua ........................................................ 7Soltamox ..................................................... 1Spiriva HandiHaler ................................. 10Spiriva Respimat ..................................... 10Spironolactone .......................................... 4Spironolactone-Hydrochlorothiazide ... 4Starlix ........................................................... 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 ................................................. 6
15
Tiazac .......................................................... 4Ticlopidine .................................................. 2Timolol ......................................................... 4Tivicay .......................................................... 9Tolbutamide ............................................... 8Toprol XL..................................................... 4Toremifene ................................................ 1Torsemide ................................................... 4Toujeo .......................................................... 7Tradjenta ..................................................... 8Trandate ...................................................... 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 ........................................9, 10Verapamil .................................................... 5Verapamil ER ............................................. 5Verelan ........................................................ 5Verelan PM ................................................. 5Versacloz .................................................... 6Victoza ......................................................... 8
Videx ............................................................ 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. 85995-0820192020 Preventive Expanded List 8/19
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: