may 2022 core drug list
TRANSCRIPT
Therapeutic Drug Classes Requirements & Limits
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Pharmacy | PDL | Core Preventive
2022 Preventive Drug List for Consumer Driven Health Plans Core List
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 member ID card. This list may not be all-inclusive. Brand and generic drugs may not always be available due to market changes.
This list applies to UnitedHealthcare and Oxford medical plans. It is correct as of January 1, 2022 and is subject to change after this date. The next anticipated update will occur with the next PDL cycle.
CDH preventive drug lists may also be used with non-CDH plans
Effective May 1, 2022
Therapeutic Drug Classes Requirements & Limits
Breast Cancer Prevention
Anastrozole
Arimidex
Aromasin
Exemestane
Fareston
Femara
Letrozole
Soltamox
Tamoxifen
Toremifene
E
E
E
E
E
Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy
Aggrenox
Arixtra E
Aspirin-Dipyridamole
Bevyxxa
Brilinta
Cilostazol
Clopidogrel
Coumadin
Dipyridamole
Effient E
Eliquis
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Enoxaparin
Fragmin
Fondaparinux
Heparin
Jantoven
Lovenox E
Persantine
Plavix E
Pletal
Pradaxa
Prasugrel
Savaysa
Ticlopidine
Warfarin
Xarelto
Zontivity
g Cardiovascular/Heart Disease: High Blood Pressure
Accupril E
Accuretic
Acebutolol
Aceon
Adalat CC
Afeditab
Aldactazide
Aldactone E
Aliskiren
Altace E
Amiloride
Amiloride-Hydrochlorothiazide
Amlodipine
Amlodipine-Benazepril
Amlodipine-Olmesartan E
Amlodipine-Olmesartan-Hydrochlorothiazide
E
Amlodipine-Valsartan
Amlodipine-Valsartan-Hydrochlorothiazide E
Amturnide E
Atacand E
Atacand HCT E
Atenolol
Atenolol-Chlorthalidone
Avalide E
Avapro E
Azor E
Benazepril
Benazepril-Hydrochlorothiazide
Benicar E
Benicar HCT 1
E
Betaxolol
Bidil
Bisoprolol
Bisoprolol-Hydrochlorothiazide
Bumetanide
Bystolic E
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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Therapeutic Drug Classes Requirements Therapeutic Drug Classes Requirements & Limits & Limits
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Bold type = Brand-name drug E = May be excluded from coverage or subject to prior [Plain type = Generic drug] authorization (sometimes referred to as precertification) 1Coverage is provided for oral formulations
Carvedilol
Carvedilol ER E
Catapres
Catapres TTS E
Chlorothiazide
Clonidine
Clonidine Patch
Clorpress
Conjupri E
Coreg E
Coreg CR E
Corgard
Corzide
Covera HS
Cozaar E
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 E
Edarbi
Edarbyclor
Edecrin E
Enalapril
Enalapril-Hydrochlorothiazide
Epaned
Eplerenone
Eprosartan
Ethacrynic Acid
Exforge E
Exforge HCT E
Felodipine ER
Fosinopril
Fosinopril-Hydrochlorothiazide
Furosemide
Guanfacine
Hydralazine
Hydrochlorothiazide
Hyzaar E
Indapamide
Inderal
Inderal LA E
Inderal XL E
Innopran XL E
Inspra E
Irbesartan
Irbesartan-Hydrochlorothiazide
Isoptin SR
Isradipine
Kapspargo
Katerzia
Labetalol
Lasix
Levatol
Lisinopril
Lisinopril-Hydrochlorothiazide
Lopressor
Lopressor HCT
3
Therapeutic Drug Classes Requirements Therapeutic Drug Classes Requirements & Limits & Limits
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Losartan
Losartan-Hydrochlorothiazide
Lotensin
Lotensin HCT
Lotrel E
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
Nebivolol E
Nicardipine
Nifedipine
Nifedipine ER
Nimodipine
Nisoldipine
Norvasc E
Olmesartan
Olmesartan-Hydrochlorothiazide
Perindopril
Pindolol
Prazosin
Prestalia E
Prinivil
Procardia
Procardia XL E
Propranolol
Propranolol-Hydrochlorothiazide
Qbrelis
Quinapril
Quinapril-Hydrochlorothiazide
Ramipril
Reserpine
Sectral
Spironolactone
Spironolactone-Hydrochlorothiazide
Sular
Tarka E
Taztia XT
Tekturna
Tekturna HCT
Telmisartan
Telmisartan-Amlodipine E
Telmisartan-Hydrochlorothiazide
Tenex
Tenoretic E
Tenormin E
Terazosin
Teveten
Teveten HCT
Thalitone 15 mg E
Thalitone 25 mg
Tiazac 1Timolol
4
Therapeutic Drug Classes Requirements Therapeutic Drug Classes Requirements & Limits & Limits
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Bold type = Brand-name drug E = May be excluded from coverage or subject to prior [Plain type = Generic drug] authorization (sometimes referred to as precertification) 1Coverage is provided for oral formulations
Toprol XL E
Torsemide
Trandate
Trandolapril
Trandolapril-Verapamil
Triamterene
Triamterene-Hydrochlorothiazide
Tribenzor
Twynsta
Uniretic
Univasc
Valsartan
Valsartan-Hydrochlorothiazide
Vaseretic
Vasotec
Verapamil
Verapamil ER
Verelan
Verelan PM
Zaroxolyn
Zebeta
Zestoretic
Zestril
Ziac
Cardiovascular/Heart Disease: High Chol
Altoprev
Antara
Atorvastatin
Cholestyramine
Cholestyramine Light
Choline Fenofibrate
Colesevelam Tablets, Powder for Suspension
E
E
E
E
E
E
esterol
E
E
E
E
CB
Colestid
Colestipol
Crestor E
Ezallor Sprinkle
Ezetimibe
Ezetimibe/Rosuvastain E
Fenofibrate 30, 43, 50, 67, 75, 90, 130, 134, 150, 200 mg Capsule
E
Fenofibrate 40, 48, 120 mg Tablet E
Fenofibrate 54, 145, 160 mg Tablet
Fenofibric Acid E
Fenoglide E
Fibricor E
Flolipid
Fluvastatin
Fluvastatin ER
Gemfibrozil
Icosapent E
Lescol
Lescol XL E
Lipitor E
Lipofen E
Livalo E
Lofibra E
Lopid
Lovastatin
Lovaza E
Mevacor
Nexletol
Nexlizet
Niacin Extended-Release
Niacor E
Niaspan E
Omega-3 Acid Ethyl Esters
Pravachol E
Pravastatin
Prevalite
5
Therapeutic Drug Classes Requirements Therapeutic Drug Classes Requirements & Limits & Limits
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B
Bold type = Brand-name drug E = May be excluded from coverage or subject to prior [Plain type = Generic drug] authorization (sometimes referred to as precertification) 1Coverage is provided for oral formulations
Questran
Questran Light
Rosuvastatin
Roszet E
Simvastatin
Simvastatin/Ezetimibe
Tricor E
Triglide E
Trilipix E
Vascepa E
Vytorin E
Welchol
Zetia E
Zocor E
Zypitamag E
B Immunosuppressant: Organ Rejection
Astagraf XL E
Azasan
Azathioprine
Cellcept E
Cyclosporine
Envarsus XR E
Everolimus
Gengraf
Imuran E
Mycophenolate
Mycophenolic Acid
Myfortic E
Neoral E
Prograf
Rapamune E
Sandimmune E
Sirolimus
Tacrolimus
Zortress E
Musculoskeletal: Osteoporosis
Vitamins
Actonel E
Alendronate
Atelvia E
Binosto E
Boniva E
Calcitonin (Salmon)
Didronel
Etidronate
Evista E
Forteo E
Fortical
Fosamax
Fosamax Plus D
Ibandronate
Miacalcin
Raloxifene
Risedronate
Teriparatide
Tymlos
Pediatric Fluoride 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
6
IndexA
Accupril ................................................. 2Accuretic ............................................... 2Acebutolol ............................................. 2Aceon .................................................... 2Actonel .................................................. 6Adalat CC .............................................. 2Afeditab ................................................. 2Aggrenox ............................................... 1Aldactazide ........................................... 2Aldactone .............................................. 2Alendronate........................................... 6Aliskiren ................................................. 2Altace ..................................................... 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 ............................................. 2
Benazepril-Hydrochlorothiazide ......... 2Benicar .................................................. 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 .............................................. 5
Conjupri ................................................ 3Coreg ..................................................... 3Coreg 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 .................................................. 3Efment ..................................................... 1Eliquis .................................................... 1Enalapril ................................................. 3Enalapril-Hydrochlorothiazide ............. 3Enoxaparin ............................................ 2Envarsus XR .......................................... 6Epaned .................................................. 3Eplerenone ............................................ 3Eprosartan ............................................ 3Ethacrynic Acid ..................................... 3Etidronate .............................................. 6Everolimus ............................................. 6Evista ..................................................... 6
7
Exemestane .......................................... 1Exforge .................................................. 3Exforge HCT ......................................... 3Ezallor Sprinkle ..................................... 5Ezetimibe ........................................... 5, 6Ezetimibe/Rosuvastain ........................ 5
F
Fareston ................................................ 1Felodipine ER ........................................ 3Femara................................................... 1Fenofibrate 40, 48, 120 mg Tablet ...... 5Fenofibrate 30, 43, 50, 67, 75, 90, 130,
134, 150, 200 mg Capsule ....................... 5
Fenofibrate 54, 145, 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 .............................................. 3Inderal XL .............................................. 3
Innopran XL ........................................... 3Inspra ..................................................... 3Irbesartan .............................................. 3Irbesartan-Hydrochlorothiazide .......... 3Isoptin SR .............................................. 3Isradipine ............................................... 3
J
Jantoven ................................................ 2
K
Kapspargo ............................................. 3Katerzia .................................................. 3
L
Labetalol ................................................ 3Lasix....................................................... 3Lescol .................................................... 5Lescol XL ............................................... 5Letrozole ................................................ 1Levatol ................................................... 3Lipitor ..................................................... 5Lipofen ................................................... 5Lisinopril ................................................ 3Lisinopril-Hydrochlorothiazide ............ 3Livalo...................................................... 5Lofibra ................................................... 5Lopid ...................................................... 5Lopressor .............................................. 3Lopressor HCT ..................................... 3Losartan ................................................ 4Losartan-Hydrochlorothiazide ............ 4Lotensin ................................................. 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 ............................... 4
Metoprolol-Hydrochlorothiazide ......... 4Mevacor ................................................. 5Miacalcin ............................................... 6Micardis ................................................. 4Micardis HCT ........................................ 4Microzide ............................................... 4Midamor ................................................ 4Minipress ............................................... 4Minoxidil ................................................ 4Moexipril ................................................ 4Moexipril-Hydrochlorothiazide ............ 4Mycophenolate ..................................... 6Mycophenolic Acid ............................... 6Myfortic ................................................. 6
N
Nadolol .................................................. 4Nadolol-Bendroflumethazide .............. 4Neoral .................................................... 6Nebivolol .............................................. 4Nexletol .................................................. 5Nexlizet .................................................. 5Niacin Extended-Release .................... 5Niacor .................................................... 5Niaspan ................................................. 5Nicardipine ............................................ 4Nifedipine .............................................. 4Nifedipine ER ........................................ 4Nimodipine ............................................ 4Nisoldipine ............................................ 4Norvasc ................................................. 4
O
Olmesartan ........................................... 4Olmesartan-Hydrochlorothiazide........ 4Omega-3 Acid Ethyl Esters .................. 5
P
Pediatric Fluoride Preparations .......... 6Perindopril ............................................. 4Persantine ............................................. 2Pindolol .................................................. 4Plavix ...................................................... 2Pletal ...................................................... 2Pradaxa ................................................. 2Prasugrel ............................................... 2Pravachol ............................................... 5Pravastatin ............................................ 5Prazosin ................................................. 4Prenatal Vitamins ................................. 6
8
Prestalia ................................................. 4Prevalite ................................................. 5Prinivil .................................................... 4Procardia ............................................... 4Procardia XL ......................................... 4Prograf ................................................... 6Propranolol ........................................... 4Propranolol-Hydrochlorothiazide ........ 4
Q
Qbrelis ................................................... 4Questran ................................................ 6Questran Light ...................................... 6Quinapril ................................................ 4Quinapril-Hydrochlorothiazide ............ 4
R
Raloxifene ............................................. 6Ramipril ................................................. 4Rapamune ............................................. 6Reserpine .............................................. 4Risedronate ........................................... 6Rosuvastatin ......................................... 6Roszet .................................................... 5
S
Sandimmune ......................................... 6Savaysa ................................................. 2Sectral ................................................... 4Simvastatin ............................................ 6Simvastatin/Ezetimibe ......................... 6Sirolimus ................................................ 6Soltamox ............................................... 1Spironolactone ..................................... 4Spironolactone-
Hydrochlorothiazide ......................... 4Sular ....................................................... 4
T
Tacrolimus ............................................. 6Tamoxifen .............................................. 1Tarka ...................................................... 4Taztia XT ................................................ 4Tekturna ................................................ 4Tekturna HCT ........................................ 4Telmisartan............................................ 4Telmisartan-Amlodipine ....................... 4Telmisartan-Hydrochlorothiazide ........ 4Tenex ..................................................... 4
Tenoretic ................................................ 4Tenormin ............................................... 4Terazosin ............................................... 4Teriparatide ........................................... 6Teveten .................................................. 4Teveten HCT ......................................... 4Thalitone 15 mg .................................... 4Thalitone 25 mg .................................... 4Tiazac .................................................... 4Ticlopidine ............................................. 2Timolol ................................................... 4Toprol XL ............................................... 5Toremifene ............................................ 1Torsemide ............................................. 5Trandate ................................................ 5Trandolapril ........................................... 5Trandolapril-Verapamil ......................... 5Triamterene ........................................... 5Triamterene-Hydrochlorothiazide ....... 5Tribenzor ............................................... 5Tricor ...................................................... 6Triglide ................................................... 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
Y
Z
Zaroxolyn ............................................... 5Zebeta ................................................... 5Zestoretic .............................................. 5Zestril ..................................................... 5Zetia ....................................................... 6Ziac ........................................................ 5Zocor ..................................................... 6Zontivity ................................................. 2Zortress ................................................. 6Zypitamag ............................................. 6
9
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Learn more
Call the toll-free phone number on your member ID card to speak with customer service.
Visit the member website listed on your member ID card to look up the price of drugs covered by your plan, find lower-cost options and more.
This plan includes plan participants for a self-funded plan administered by Oxford. 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.
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12/21 ©2022 United HealthCare Services, Inc. WF5978676-A_2022 Preventive Core List