2021 Preventive medicationsand your plan

Managing your health with preventive medications

Your pharmacy benefit plan includes special coverage for preventive medications. These medications help protect against or manage a medical condition, such as:

• Preventing blood clots and reducing the risk of a stroke

• Preventing heart disease and reducing high blood pressure

• Preventing osteoporosis (a disease that leads to an increased risk of bone fracture)

Your health is important. Taking preventive medications as told by your healthcare provider can help you avoid serious illness and high healthcare costs.

In this drug list, brand-name medications are shown in UPPERCASE (for example, LANOXIN) and generic medications in lowercase (for example, digoxin).

Special coverage for preventive medications

The drugs on your plan’s preventive medications list do not have a deductible. This means you’ll pay your copayment/coinsurance or nothing at all, depending on your plan. It can save you money and get the medications you need to help you live a healthier life.

Preventive medications are a group of products in your plan’s formulary which tells you what medications your plan covers.

Please note that most medications on the formulary have a deductible, but preventive medications do not. To check the cost of any medication, see your benefit handbook or contact customer service at the member phone number on your ID card.

Potential savings with generic medications

To get the most from your benefits, ask your doctor if a generic medication is right for you. Generics normally cost less than brand medications, and the Food and Drug Administration (FDA) requires them to be just as safe and effective.

Quality drives our decisions

A group of doctors and pharmacists meets often to review medications and coverage under pharmacy benefit plans. They also suggest which medications should be on your plan’s preventive medications list.

A list of covered preventive medications begins on the next page. Medications are listed by therapeutic category. For questions on injectable preventive medications administered by your doctor or healthcare provider, please call the number on your ID card.

2021 Preventive Medication List

Expanded listing by therapeutic category

AGENTS FOR CHEMICAL DEPENDENCY

acamprosate calciumbuprenorphine sublingualbuprenorphine/naloxone

ANTIARRHYTHMIC AGENTS

amiodaronedisopyramidedofetilideflecainideMULTAQPaceronepropafenonepropafenone ersotalolsotalol AF

ANTICONVULSANTS

APTIOMBANZELBRIVIACTcarbamazepinecarbamazepine erCELONTINclobazamclonazepamDIACOMIT

divalproex sodium drdivalproex sodium erEpitolethosuximidefelbamateFYCOMPAlamotriginelamotrigine erlevetiracetamlevetiracetam er oxcarbazepinePEGANONEphenobarbitalphenytoinphenytoin sodium extended

releaseprimidonetiagabinetopiramatetopiramate ervalproic acidvigabatrinVIMPATzonisamide

ANTIDEPRESSANTS

amitriptylineamoxapineAPLENZINbupropion erbupropion xlcitalopramclomipraminedesipraminedesvenlafaxine erdoxepinduloxetine dr

ANTIMALARIAL AGENTS

atovaquone/proguanilchloroquinemefloquineprimaquine

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

sublingualDepadedisulfiramnaltrexoneSUBLOCADEVIVITROLZUBSOLV

EMSAMescitalopramFETZIMAfluoxetinefluoxetine 60mgfluoxetine dr fluvoxaminefluvoxamine er imipramine HCl imipramine pamoateIrenkamaprotilineMARPLANmirtazapinenortriptylineparoxetine paroxetine er PEXEVAphenelzineprotriptylinesertralinetranylcyprominetrazodonetrimipramineTRINTELLIXvenlafaxinevenlafaxine erVIIBRYD

ANTIOBESITY AGENTS

ANTIPSYCHOTICS

perphenazine PERSERISprochlorperazine quetiapine fumarate quetiapine fumarate erREXULTIRISPERDAL CONSTArisperidone risperidone odtSAPHRISSYMBYAX thioridazine thiothixene trifluoperazine VERSACLOZVRAYLARziprasidone ZYPREXA RELPREVVZYPREXA ZYDIS

ASTHMA AND COPD

levalbuterolLONHALA MAGNAIRmetaproterenol montelukast PEAKFLOW METERS‡

BOWEL PREPARATIONS

CANCER

anastrozole AROMASINEVISTAexemestane FARESTON FEMARA letrozole

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

benzphetaminediethylpropiondiethylpropion erphendimetrazinephendimetrazine erphentermineQSYMIASAXENDAXENICAL

ACCOLATEADVAIR DISKUS ADVAIR HFA albuterol sulfatealbuterol sulfate eralbuterol sulfate hfaANORO ELLIPTA ARCAPTA NEOHALERARNUITY ELLIPTAATROVENT HFABREO ELLIPTABROVANA budesonide COMBIVENT RESPIMATcromolyn DALIRESP difil-g forteELIXOPHYLLINFLOVENT DISKUSFLOVENT HFA FLUTICASONE PROPIONATE/

ABILIFY MAINTENAABILIFY MYCITEADASUVE aripiprazolearipiprazole odtARISTADAARISTADA INITIOCAPLYTAchlorpromazine clozapine clozapine odtCLOZARIL comproEQUETRO FANAPTFAZACLOfluphenazine fluphenazine decanoateGEODONhaloperidol INVEGAINVEGA SUSTENNAINVEGA TRINZALATUDA loxapine molindoneNUPLAZIDolanzapine olanzapine odtolanzapine / fluoxetine paliperidone er

SALMETEROLfluticasone/salmeterol diskusipratropiumipratropium / albuterolisoproterenol aer

PERFOROMISTPULMICORT FLEXHALERSEREVENT DISKUSSPIRIVA HANDIHALER SPIRIVA RESPIMATSTIOLTO RESPIMATSTRIVERDI RESPIMATSYMBICORT terbutaline THEO-24theophylline theophylline CRtheophylline ERTRELEGY ELLIPTAwixela inhub XOPENEX CONCENTRATEYUPELRIzafirlukast zileuton ERZYFLO ZYFLO CR

COLYTE GAVILYTEpeg 3350/electrolytesPREPOPIKSUPREP

raloxifeneSOLTAMOXtamoxifen toremifene

CARDIOVASCULAR/ HEART DISEASE

Anti-Anginal Agents

DILATRATE SRGONITROISORDIL TITRADOSEisosorbide dinitrateisosorbide dinitrate ERisosorbide mononitrate isosorbide mononitrate ERminitranNITRO-BIDNITRO-DURnitroglycerin nitroglycerin ernitroglycerin lingualnitroglycerin transdermalNITROLINGUAL PUMPSPRAYNITROMISTnitro-timepetnranolazine er

Anticoagulants

AGGRENOX ARIXTRA SP

aspirin 81mgaspirin/dipyridamoleBEVYXXABRILINTA cilostazol clopidogrel COUMADIN dipyridamole DURLAZAEFFIENT ELIQUIS enoxaparin SP

fondaparinux SP

FRAGMIN SP

heparin jantoven

Cardiac Glycosides

digitekdigoxdigoxinLANOXIN

High Blood Pressure

ACCUPRILACCURETIC acebutolol ADALAT CC afeditab CRALDACTAZIDE ALDACTONE amiloride amiloride / hctz amlodipine amlodipine / benazeprilamlodipine / valsartan amlodipine / olmesartanamlodipine / valsartan / hctzATACAND HCT atenolol atenolol/chlorthalidone AVALIDE benazepril benazepril / hctz BETAPACE betaxolol BIDILbisoprolol bisoprolol / hctz BLOOD PRESSURE MONITORS ‡

bumetanide BUMEXBYSTOLIC BYVALSON

FIRST - METOPROLOL ‡

fosinopril fosinopril / hctz furosemide

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

LOVENOX SP PLETAL PRADAXA prasugrelSAVAYSA warfarin XARELTOZONTIVITY

CALAN CALAN SR candesartan candesartan / hctz captoprilcaptopril / hctzCARDIZEM CARDIZEM CD CARDURA CAROSPIRcartia XT carvedilol carvedilol erCATAPRES chlorothiazide chlorthalidone clonidine clonidine patch CORGARD CORZIDE DEMADEX DEMSERDIBENZYLINEdiltiazem CD diltiazemdiltiazem ERDIURIL doxazosin DUTOPROL DYRENIUM EDARBI EDARBYCLOR EDECRIN enalapril enalapril / hctz EPANED eplerenone eprosartan ethacrynic acidezide felodipine ERFIRST - ATENOLOL ‡

guanfacine HEMANGEOLhydralazine hydrochlorothiazideindapamide INSPRA irbesartan irbesartan / hctz isradipine labetalol lisinopril lisinopril / hctz LOPRESSOR LOPRESSOR HCT losartan potassiumlosartan potassium / hctz LOTENSIN LOTENSIN HCTmatzim LA MAXZIDE MAXZIDE-25methyclothiazide methyldopa methyldopa / hctz metolazone metoprolol erMETOPROLOL ER / HCTZmetoprololmetoprolol / hctzMINIPRESS minoxidil tabletmoexipril nadolol nadolol / bendroflumethiazide nicardipine nifedipine nifedipine ERnimodipine nisoldipine ERNYMALIZE olmesartanolmesartan / amlodipine / hctzolmesartan / hctzperindopril phenoxybenzaminepindolol prazosin

PRESTALIAPROCARDIA PROCARDIA XL propranolol propranolol ERpropranolol / hctz QBRELISquinapril quinapril / hctz ramipril sotalol SOTYLIZEspironolactone spironolactone / hctz SULAR TARKA taztia XT TEKTURNA TEKTURNA HCT telmisartan telmisartan / amlodipine telmisartan / hctz TENORETIC terazosin TIAZAC timolol (tablet) torsemide trandolapril trandolapril / verapamil ertriamterenetriamterene / hctz TWYNSTA valsartanvalsartan / hctz VASERETIC VASOTEC VECAMYL verapamil verapamil ER verapamil SRVERELAN VERELAN PM ZESTORETIC ZIAC

High Cholesterol

ALTOPREV

amlodipine / atorvastatin ANTARA atorvastatin CADUETcholestyramine cholestyramine litecolesevelamcolestipol EZALLOR SPRINKLEezetimibeezetimibe / simvastatinfenofibrate fenofibrate micronizedfenofibric acidfenofibric acid drFENOGLIDE FIBRICOR FLOLIPIDfluvastatin fluvastatin ergemfibrozil JUXTAPID SP LIPOFEN LOPID lovastatin NEXLETOLNEXLIZETniacin (Rx only)niacin ERniacor omega-3-acid ethyl estersPRALUENT pravastatin prevalite REPATHA REPATHA SURECLICK rosuvastatinsimvastatin TRILIPIX VASCEPA

CONTRACEPTIVES ‡

This section lists contraceptive categories. Please note that brands and generics are eligible dependent upon your benefit plan formulary.

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

CONTRACEPTIVE PATCHCONTRACEPTIVE RING

(VAGINAL)EMERGENCY CONTRACEPTIVESIMPLANT CONTRACEPTIVEINJECTABLE CONTRACEPTIVEIUDsORAL CONTRACEPTIVES

DIABETES

Insulin

AFREZZAHUMALOG HUMALOG JUNIOR KWIKPENHUMALOG KWIKPENHUMALOG MIX 50 / 50HUMALOG MIX 50 / 50

KWIKPENHUMALOG MIX 75 / 25HUMALOG MIX 75 / 25

KWIKPENHUMULIN 70 / 30 HUMULIN 70 / 30 KWIKPENHUMULIN NHUMULIN N KWIKPENHUMULIN RHUMULIN R U-500LANTUS LANTUS SOLOSTAR TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR

Non-insulin

acarbose ACTOPLUS MET ACTOPLUS MET XRACTOS AMARYL AVANDIABYDUREON BYDUREON BCISEBYDUREON PENBYETTA chlorpropamide CONTOUR MONITORCONTOUR NEXT MONITOR KIT

CYCLOSET DUETACT FARXIGAglimepiride glipizide glipizide ER glipizide XL glipizide/metforminGLUCOTROL GLUCOTROL XL GLUCOVANCE glyburideglyburide / metformin glyburide micronized GLYNASE GLYSET GLYXAMBI JANUMET JANUMET XR JANUVIA JARDIANCEJENTADUETOJENTADUETO XRmetformin metformin ER (not mod or osm)miglitolnateglinide OZEMPICpioglitazone pioglitazone / metformin pioglitazone / glimepridePRANDIN PRECOSE repaglinide repaglinide / metforminRIOMET RYBELSUSSOLIQUA 100 / 33STARLIX SYMLINPENSYNJARDYSYNJARDY XRtolazamide tolbutamide TRADJENTA TRULICITY VICTOZA

XIGDUO XRXULTOPHY

DIAGNOSTIC AGENTS AND SUPPLIES

BLOOD GLUCOSE MONITORSBLOOD GLUCOSE TEST STRIPSCONTROL SOLUTIONSINSULIN DELIVERY DEVICESINSULIN PUMP SUPPLIESINSULIN SYRINGES AND NEEDLESKETONE BLOOD TEST STRIPSLANCETSLANCET DEVICESURINE TESTING STRIPS

ESTROGENS

ACTIVELLAALORAamabelz ANGELIQCLIMARA PROCOMBIPATCHcovaryx covaryx HSDIVIGELdottiDUAVEEeemt eemt HSELESTRINesterified estrogens/

methltestosteroneesterified estrogens/

methltestosterone dsesterified estrogens/

methltestosterone hsestradiolestradiol/norethindrone acetateESTROGELEVAMISTFEMHRT LOW DOSEfyavolvjintelilopreeza MENESTMENOSTAR

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

mimvey mimvey lonorethindrone acetate/ethinyl

estradiolPREFESTPREMARINPREMPHASEPREMPRO

GASTROINTESTINAL-ULCER DRUGS‡

ACIPHEX SPRINKLEAXIDcimetidineCYTOTECDEXILANTesomeprazole magnesiumESOMEPRAZOLE STRONTIUMfamotidineFIRST-LANSOPRAZOLE ‡

FIRST-OMEPRAZOLE ‡

lansoprazole lansoprazole/amoxicillin/

clarithromycinmisoprostolNEXIUM GRAnizatidineOMECLAMOX -PAKomeprazolepantoprazole pantoprazole drPEPCIDPREVPACPRILOSECPROTONIX PAKPYLERArabeprazolesucralfateTALICIA

HEMATOLOGIC AGENTS

JIVI SP

KOGENATE FS SP

KOVALTRY SP

NOVOEIGHT SP

NUWIQ SP

HIV/AIDS

abacavirabacavir / lamivudine abacavir / lamivudine /

zidovudineAPTIVUSatazanavirBIKTARVYCIMDUOCOMBIVIR COMPLERA CRIXIVAN DELSTRIGO didanosine DOVATOEDURANT efavirenzefavirenz/lamivudine/tenofovirEMTRIVA EPIVIR EPZICOM EVOTAZ fosamprenavirFUZEON GENVOYAINTELENCE INVIRASE ISENTRESS ISENTRESS HDJULUCA KALETRA lamivudine lamivudine / zidovudine LEXIVA lopinavir / ritonavir nevirapine nevirapine ER NORVIR ODEFSEY PIFELTROPREZCOBIX PREZISTA RESCRIPTOR RETROVIR REYATAZ

ritonavir SELZENTRY stavudine STRIBILD SUSTIVA SYMFI SYMFI LO SYMTUZA tenofovir TIVICAY TRIUMEQ TRIZIVIR TROGARZO TYBOST VIDEX PEDIATRIC VIDEX EC VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD ZERIT ZIAGEN zidovudine

MISCELLANEOUS

cholecalciferol (D3)

MULTIPLE SCLEROSIS AGENTS

AUBAGIO SP

BETASERON SP

GILENYA SP

glatiramer SP

MAVENCLAD SP

MAYZENT SP

REBIF SP

TECFIDERA SP

TYSABRI SP

OSTEOPOROSIS

ACTONEL alendronate ATELVIA BINOSTO BONIVA calcitonincalcitonin -salmon

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

etidronate diEVENITYEVISTA FORTEO SP FOSAMAX FOSAMAX + D ibandronateNATPARA SP

risedronaterisedronate drTYMLOSzoledronic acid 5 mg/100 ml

OTHER ANTIHYPERTENSIVE AGENTS

aliskirenguanabenz

RESPIRATORY AGENTS

cromolyn sodium nebulizer solution

SMOKING DETERRENTS ‡

bupropion erCHANTIX NICODERM CQNICORETTEnicotine gum / lozenge / patchNICOTROL INH / NSZYBAN

SUPPLIES

SPACER DEVICES

TRANSPLANT ‡

ASTAGRAF XL AZASAN azathioprine CELLCEPT cyclosporine cyclosporine modified ENVARSUS XRgengraf IMURAN mycophenolate mycophenolate delayed releasemycophenolic acid DR MYFORTIC NEORAL PROGRAF RAPAMUNE SANDIMMUNE sirolimus tacrolimus ZORTRESS

VITAMINS & ELECTROLYTES ‡

Pediatric vitamins with fluoride

(for example; POLY-VI-FLOR, tri-vit / fl)

generic productsBRAND NAME PRODUCTS

Prenatal multivitamins with iron and folic acid

(for example; OB COMPLETE, prenatabs RX)

generic productsBRAND NAME PRODUCTSfolic acid

Preventive Premium

This list is should be used as a reference and may not include all medications. Brand or generic availability may not be current because of market changes. Using generics may be required based on your plan benefit.

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SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule