2018 Preventive medications and your plan
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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.comDyazide 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.comOnglyza + 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 StandardYou can also read
