2018 Preventive medications and your plan

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2018 Preventive medications and your plan
2018 Preventive medications and your plan

Managing your health with preventive medications
Your pharmacy benefit plan includes special coverage for preventive
medications. These drugs 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 directed by your
health care provider can help you avoid serious illness and high health care costs.
2018 Preventive medications and your plan

Special coverage for preventive medications
Drugs on your plan’s list of preventive medications are not subject to a
deductible. You’ll pay your copayment/coinsurance or nothing at all, depending
on your plan. So you can save money and get the medications you need to help
you live a healthier life.
Preventive medications are a subset of products included within your plan’s
formulary, or list of prescription drugs, which tells you what medications your
plan covers.
Please note that most medications on the Formulary are subject to a deductible.
Preventive medications are an exception. To check the cost of any medication,
refer to your benefit handbook or contact customer service at the toll-free
member phone number on your benefit plan 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
Our committee of independent doctors and pharmacists meets regularly to
review medications and consider how they should be covered by your pharmacy
benefit plan. They also recommend which medications should be on your plan’s
list of preventive medications.

A list of covered preventive medications begins on the next page. Medications
are listed by therapeutic category. To help you tell generic and brand drugs
apart, all generics start with a lowercase letter. For questions on injectable dose
forms of preventive medications administered by your healthcare provider, please
call the number on the back of your membership card for more information.

OptumRx | optumrx.com
2018 Preventive medication list

Expanded listing by therapeutic category
                                                                                                      Proair HFA
    ANTIPSYCHOTICS                                 ASTHMA AND COPD
                                                                                                      Proair Respiclick
    Abilify                                        Accolate                                           Proventil HFA +
    Adasuve                                        Advair Diskus                                      Pulmicort +
    aripiprazole                                   Advair HFA                                         Pulmicort Flexhaler
    Aristada                                       Aerospan                                           Qvar +
    chlorpromazine                                 AirDuo +                                           Seebri Neohaler
    clozapine                                      albuterol neb/syp/tab                              Serevent Diskus
    Clozaril                                       albuterol ER                                       Singulair +
    Equetro                                        Alvesco +                                          Spiriva
    Fanapt                                         Anoro Ellipta                                      Stiolto Respimat
    Fazaclo                                        Arcapta                                            Striverdi Respimat
    fluphenazine                                   Armonair                                           Symbicort
    Geodon                                         Arnuity ELPT                                       terbutaline
    haloperidol                                    Asmanex +                                          Theo-24 CR / ER
    Invega                                         Asmanex HFA +                                      theochron CR
    Latuda                                         Atrovent HFA                                       theophylline
    loxapine                                       Bevespi                                            theophylline CR / ER
    molindone                                      Breo Ellipta                                       Tudorza Pres +
    Nuplazid                                       Brovana                                            Utibron Neohaler
    olanzapine                                     budesonide suspension                              Ventolin HFA
    olanzapine / fluoxetine                        Combivent Respimat                                 Vospire ER
    paliperidone ER                                cromolyn nebulizer solution                        Xopenex HFA +
    perphenazine                                   Daliresp                                           Xopenex Solution
    prochlorperazine                               Dulera +                                           zafirlukast
    quetiapine                                     Elixophyllin                                       Zyflo
    Rexulti                                        Flovent Diskus                                     Zyflo CR
    Risperdal                                      Flovent HFA                                        CANCER
    risperidone                                    Fluticasone INH Salmeter
    Saphris                                        Foradil                                            anastrozole
    Seroquel                                       Incruse ELPT                                       Arimidex
    Seroquel XR                                    ipratropium inhalation solution                    Aromasin SP
    Symbyax                                        ipratropium / albuterol                            Evista
    thioridazine                                   isoproterenol                                      exemestane SP
    thiothixene                                    Levalbuterol AER +                                 Fareston
    trifluoperazine                                levalbuterol neb                                   Femara SP
    Vraylar                                        metaproterenol                                     letrozole SP
    Versacloz                                      montelukast                                        raloxifene
    ziprasidone                                                                                       Soltamox
                                                   Perforomist Neb
    Zyprexa                                                                                           tamoxifen
SP
   Oral and self-injectable Specialty medications may be subject to limitations based on plan benefit design
+
  Products excluded from the Premium Prescription Drug List
‡
  Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule.
2018 Preventive medications and your plan

                                                       Pradaxa                                           Betapace AF
    CARDIOVASCULAR/
                                                       prasugrel                                         betaxolol
    HEART DISEASE
                                                       Savaysa                                           Bidil
    Anti-Anginal Agents                                ticlopidine                                       bisoprolol
                                                       warfarin                                          bisoprolol / hctz
    Dilatrate SR                                       Xarelto                                           bumetanide
    Gonitro                                            Yosprala                                          Bumex
    Isordil                                            Zontivity                                         Bystolic
    isosorb dinitrate                                                                                    Byvalson
    isosorbide dinitrate ER                            Cardiac Glycosides                                Caduet
    isosorbide mononitrate                                                                               Calan
                                                       digitek
    isosorbide mononitrate ER                                                                            Calan SR
                                                       digox
    minitran                                                                                             candesartan
                                                       digoxin
    Nitro-Bid                                                                                            candesartan / hctz
                                                       Lanoxin
    Nitro-Dur                                                                                            captopril
    nitroglycerin                                      High Blood Pressure                               captopril / hctz
    Nitrolingual SPR                                                                                     Cardizem
    Nitromist                                          Accupril
                                                       Accuretic                                         Cardizem CD
    Nitrostat +                                                                                          Cardizem LA
    nitro-time                                         acebutolol
                                                       Aceon                                             Cardura
    petn                                                                                                 cartia XT
    Ranexa                                             Adalat CC
                                                       afeditab CR                                       carvedilol
    Anticoagulants                                     Aldactazide                                       Catapres
                                                       Aldactone                                         Catapres TTS
    Aggrenox                                                                                             chlorothiazide
    Arixtra SP                                         Altace
                                                       amiloride                                         chlorthalidone
    ASA/dipyrida                                                                                         clonidine
    ASA/Dipyridamole                                   amiloride / hctz
                                                       amlodipine                                        Clorpres
    Brilinta                                                                                             Coreg
    cilostazol                                         amlodipine / atorvastatin
                                                                                                         Coreg CR
    clopidogrel                                        amlodipine / benazepril                           Corgard
    Coumadin                                           amlodipine / olmesartan                           Corzide
    dipyridamole                                       amlodipine / valsartan                            Cozaar
    Durlaza                                            Atacand                                           Demadex
    Effient                                            Atacand hct                                       Demser
    Eliquis                                            atenol / chlorthalidone                           Dibenzyline
    enoxaparin SP                                      atenolol                                          dilt-XR
    fondaparinux SP                                    Avalide                                           diltiazem
                                                       Avapro                                            diltiazem CD
    Fragmin SP
                                                       Azor +                                            diltiazem ER
    heparin
                                                       benazepril                                        Diovan +
    jantoven
                                                       benazepril / hctz                                 Diovan HCT +
    Lovenox SP
                                                       Benicar +                                         Diuril
    Persantine
                                                       Benicar HCT +                                     doxazosin
    Plavix
                                                       Betapace                                          Dutoprol
    Pletal

SP
      Oral and self-injectable Specialty medications may be subject to limitations based on plan benefit design
+
     Products excluded from the Premium Prescription Drug List
‡
     Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule.

OptumRx | optumrx.com
Dyazide                                            Maxzide-25                                        reserpine
    Dyrenium                                           methyclothiazide                                  Sectral
    Edarbi                                             methyldopa                                        sotalol
    Edarbyclor                                         methyldopa / hctz                                 sotalol AF
    Edecrin                                            metolazone                                        Sotylize
    enalapril                                          Metopro/HCTZ                                      spironolactone
    enalapril / hctz                                   metoprolol                                        spironolactone / hctz
    Epaned                                             metoprolol ER                                     Sular
    eplerenone                                         metoprolol / hctz                                 Tarka
    eprosartan                                         Micardis                                          taztia XT
    ethacrynic acid                                    Micardis HCT                                      Tekamlo
    Exforge                                            Microzide                                         Tekturna
    Exforge HCT                                        Minipress                                         Tekturna HCT
    ezide                                              minoxidil                                         telmisartan
    felodipine ER                                      moexipril                                         telmisartan / amlodipine
    fosinopril                                         moexipril / hctz                                  telmisartan / hctz
    fosinopril / hctz                                  nadolol                                           Tenex
    furosemide                                         nadolol / bendroflumethiazide                     Tenoretic
    guanfacine                                         nicardipine                                       Tenormin
    Hemangeol                                          nifedical XL                                      terazosin
    hydralazine                                        nifedipine                                        Tiazac
    hydrochlorothiazide                                nifedipine ER                                     timolol (tablet)
    Hyzaar                                             nimodipine                                        Toprol XL +
    indapamide                                         nisoldipine                                       torsemide
    Inderal LA                                         nisoldipine ER                                    trandolapril
    Inderal XL                                         Norvasc +                                         trandolapril / verapamil
    Innopran XL                                        Nymalize                                          triamterene / hctz
    Inspra                                             olmesartan                                        Tribenzor +
    irbesartan                                         olmesartan/amlo/hctz                              Twynsta
    irbesartan / hctz                                  olmesartan/hctz                                   valsartan
    isradipine                                         perindopril                                       valsartan / hctz
    labetalol                                          phenoxybenzamine                                  Vaseretic
    Lasix                                              pindolol                                          Vasotec
    lisinopril                                         prazosin hcl                                      Vecamyl
    lisinopril / hctz                                  Prestalia                                         verapamil
    Lopressor                                          Prinivil                                          verapamil ER / SR
    Lopressor HCT                                      Procardia                                         Verelan
    losartan                                           Procardia XL                                      Verelan PM
    losartan / hctz                                    propranolol                                       Zebeta
    Lotensin                                           propranolol ER                                    Zestoretic
    Lotensin HCT                                       propranolol / hctz                                Zestril
    Lotrel                                             Qbrelis                                           Ziac
    matzim LA                                          quinapril
    Mavik                                              quinapril / hctz
    Maxzide                                            ramipril

SP
      Oral and self-injectable Specialty medications may be subject to limitations based on plan benefit design
+
     Products excluded from the Premium Prescription Drug List
‡
     Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule.
2018 Preventive medications and your plan

                                                       Tricor                                            Alogliptin +
    High cholesterol
                                                       Triglide                                          Alogliptin/Metformin +
    Altoprev                                           Trilipix                                          Alogliptin/Pioglitazone +
    Antara                                             Vascepa                                           Amaryl
    atorvastatin                                       Vytorin +                                         Bydureon
    cholestyramine                                     Welchol                                           Byetta
    cholestyramine lite                                Zetia +                                           chlorpropamide
    Colestid                                           Zocor                                             Cycloset
    colestipol                                                                                           Diabeta
                                                       CONTRACEPTIVES ‡
    Crestor +                                                                                            Duetact
    ezetimibe                                          Contraceptive patch                               Farxiga +
    ezetim/simva                                       Contraceptive ring (Nuvaring)                     Fortamet
    fenofibrate                                        Emergency Contraceptives                          glimepiride
    fenofibric                                         Implant contraceptive                             glipizide
    fenofibric DR                                      Injectable contraceptive                          glipizide / metformin
    Fenoglide                                          IUDs                                              glipizide ER
    Fibricor                                           Oral contraceptives                               glipizide XL
    fluvastatin                                                                                          Glucophage
                                                       DIABETES                                          Glucophage XR
    gemfibrozil
    Juxtapid SP                                                                                          Glucotrol
                                                       Insulin
    Kynamro SP                                                                                           Glucotrol XL
                                                       Afrezza                                           Glucovance
    Lescol                                             Apidra +                                          Glumetza +
    Lescol XL                                          Basaglar +                                        glyburide
    Lipitor +                                          Humalog                                           glyburide / metformin
    Lipofen                                            Humalog KwikPen                                   glyburide micronized
    Livalo                                             Humalog Mix                                       Glynase
    Lofibra                                            Humulin                                           Glyset
    Lopid                                              Lantus                                            Glyxambi
    lovastatin                                         Lantus Solostar                                   Invokamet
    Lovaza +                                           Levemir +                                         Invokamet XR
    Mevacor                                            Novolin +                                         Invokana
    niacin ER (Rx)                                     Novolin Relion +                                  Janumet
    niacor                                             Novolog +                                         Janumet XR
    Niaspan ER                                         Novolog Mix +                                     Januvia
    omega-3-acid (Rx)                                  Toujeo                                            Jardiance
    Praluent SP                                        Tresiba Flex +                                    Jentadueto
    Pravachol                                                                                            Jentadueto XR
    pravastatin                                        Non-insulin                                       Kazano +
    prevalite                                                                                            Kombiglyze XR +
    Questran                                           acarbose
                                                       Actoplus Met                                      metformin
    Questran Lite                                                                                        metformin ER
                                                       Actoplus Met XR
    Repatha SP                                                                                           miglitol
                                                       Actos
    rosuvastatin                                                                                         nateglinide
                                                       Adlyxin +
    simvastatin                                                                                          Nesina +

SP
      Oral and self-injectable Specialty medications may be subject to limitations based on plan benefit design
+
     Products excluded from the Premium Prescription Drug List
‡
     Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule.

OptumRx | optumrx.com
Onglyza +                                          estradiol (oral tabs, patch)                      PrevPac
    Oseni +                                            estrog/mtest                                      Prilosec
    pioglitazone                                       estropipate                                       Protonix
    pioglitazone / glimepride                          Evamist                                           Pylera
    pioglitazone / metformin                           Femhrt                                            ranitidine
    Prandin                                            fyavolv                                           sucralfate
    Precose                                            jevantique                                        Zantac
    repaglinide                                        jinteli                                           Zegerid
    Riomet                                             lopreeza
                                                                                                         HIV/AIDS
    Soliqua                                            Menest
    Starlix                                            Menostar                                          abaca/lamivu SP
    Symlin                                             mimvey                                            abacavir SP
    Synjardy                                           mimvey lo
    Synjardy XR                                        Minivelle                                         abacavir / lamivudine /
    Tanzeum +                                          noreth/ethin                                          zidovudine SP
    tolazamide                                         Prefest                                           Aptivus SP
    tolbutamide                                        Premphase                                         Atripla SP
    Tradjenta                                          Premarin (oral tab)                               Combivir SP
    Trulicity                                          Prempro                                           Complera SP
    Victoza                                            Vivelle-Dot +                                     Crixivan SP
    Xigduo XR +                                                                                          Descovy SP
                                                       GASTROINTESTINAL-ULCER                            didanosine SP
    Xultophy
                                                       DRUGS‡                                            Edurant SP
    ESTROGENS                                          Aciphex +                                         Emtriva SP
                                                       Axid                                              Epivir SP
    Activella
                                                       Carafate +                                        Epzicom SP
    Alora
                                                       cimetidine                                        Evotaz SP
    amabelz
                                                       Cytotec                                           Fuzeon SP
    Angeliq
                                                       Dexilant                                          Genvoya SP
    Climara
                                                       esomeprazole                                      Intelence SP
    Climara Pro
                                                       Esomeprazole                                      Invirase SP
    Combipatch
    covaryx                                                24.65mg and 49.3mg                            Isentress SP
    covaryx HS                                         famotidine                                        Kaletra SP
    Divigel                                            lanso/amox/clarith                                lamivudine SP
    Duavee                                             lansoprazole                                      lamivudine / zidovudine SP
    eemt                                               misoprostol
                                                       Nexium +                                          Lexiva SP
    eemt HS                                                                                              lopin/riton sol SP
    Elestrin                                           nizatidine
                                                       Omeclamox                                         nevirapine SP
    Enjuvia                                                                                              nevirapine ER SP
    est estrogen mtest                                 omeppi
                                                       omepra/bicar                                      Norvir SP
    est estrogen mtest HS                                                                                Odefsey SP
    estra/noreth                                       omeprazole
                                                       pantoprazole                                      Prezcobix SP
    Estrace (oral tab)                                                                                   Prezista SP
    estrad val                                         Pepcid
                                                       Prevacid +                                        Rescriptor SP

SP
      Oral and self-injectable Specialty medications may be subject to limitations based on plan benefit design
+
     Products excluded from the Premium Prescription Drug List
‡
     Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule.
2018 Preventive medications and your plan

    Retrovir SP                                     Forteo SP                                          Myfortic SP
    Reyataz SP                                      Fosamax                                            Neoral SP
    Selzentry SP                                    Fosamax + D                                        Prograf SP
    stavudine SP                                                                                       Rapamune SP
                                                    ibandronate
    Stribild SP                                                                                        Sandimmune SP
                                                    Miacalcin Spray
    Sustiva SP                                                                                         sirolimus SP
                                                    raloxifene
    Tivicay SP                                                                                         tacrolimus cap SP
                                                    risedronate
    Triumeq SP                                                                                         Zortress SP
    Trizivir SP                                     SMOKING DETERRENTS ‡
    Truvada SP                                                                                         VITAMINS & ELECTROLYTES
    Tybost SP                                       buproban
                                                    bupropion                                          Pediatric vitamins
    Videx SP                                                                                           with fluoride
    Videx EC SP                                     Chantix
    Viracept SP                                     Nicoderm CQ                                        (for example; Poly-Vi-Flor,
    Viramune SP                                     Nicorette                                              Tri-Vi-Flor)
    Viramune XR SP                                  nicotine gum/lozenge/patch                         Generic Products
    Viread SP                                       Nicotrol Inh / NS                                  Brand Name Products
    Vitekta SP                                      Zyban
                                                                                                       Prenatal multivitamins
    Zerit SP                                                                                           with iron and folic acid
                                                    TRANSPLANT
    Ziagen SP
    zidovudine SP                                   Astagraf XL SP                                     (for example; OB Complete,
                                                    Azasan                                                 prenatabs FA)
    OSTEOPOROSIS                                                                                       Generic Products
                                                    azathioprine
    Actonel                                         Cellcept SP                                        Brand Name Products
    alendronate                                     cyclosporine SP
    Atelvia                                         cyclosporine modified SP
    Binosto                                         Envarsus XR SP
    Boniva                                          gengraf SP
    calcitonin spray                                Imuran
    etidronate                                      mycophenolate SP
    Evista                                          mycophenolic DR SP

SP
  Oral and self-injectable Specialty medications may be subject to limitations based on plan benefit design
+
  Products excluded from the Premium Prescription Drug List
‡
  Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule.

This list is intended as a reference and may not be all-inclusive.
Brand or generic availability may not be current due to changes in the market.
Use of generics may be required depending upon plan design.

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©2018 Optum, Inc. All rights reserved. ORX2523_180101 68551-092017                                                   Preventive Standard
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