2020 Preventive medications and your plan
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2020 Preventive medications
and 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.
2020 Preventive medication list
Expanded listing by therapeutic category
molindone ATROVENT HFA
ANTIDEPRESSANTS
NUPLAZID BREO ELLIPTA
citalopram olanzapine BROVANA
escitalopram olanzapine odt budesonide
fluoxetine olanzapine / fluoxetine COMBIVENT RESPIMAT
fluoxetine dr paliperidone er cromolyn
fluvoxamine perphenazine DALIRESP
PERSERIS difil-g forte
fluvoxamine er
prochlorperazine ELIXOPHYLLIN
paroxetine
quetiapine fumarate FLOVENT DISKUS
paroxetine er quetiapine fumarate er FLOVENT HFA
PEXEVA REXULTI FLUTICASONE PROPIONATE/
sertraline RISPERDAL CONSTA SALMETERO
RISPERDAL M-TAB fluticasone/salmeterol diskus
ANTIPSYCHOTICS risperidone INCRUSE ELLIPTA
ABILIFY MAINTENA risperidone m-tab ipratropium
ABILIFY MYCITE risperidone odt ipratropium / albuterol
ADASUVE SAPHRIS isoproterenol aer
aripiprazole SYMBYAX levalbuterol
aripiprazole odt thioridazine LONHALA MAGNAIR
ARISTADA thiothixene metaproterenol
ARISTADA INITIO trifluoperazine montelukast
chlorpromazine VERSACLOZ PEAKFLOW METERS‡
clozapine VRAYLAR PERFOROMIST
clozapine odt ziprasidone PROAIR HFA
CLOZARIL ZYPREXA RELPREVV PROAIR RESPICLICK
compro ZYPREXA ZYDIS PULMICORT FLEXHALER
EQUETRO SEREVENT DISKUS
ASTHMA AND COPD
FANAPT SPIRIVA HANDIHALER
FAZACLO ACCOLATE SPIRIVA RESPIMAT
fluphenazine ADVAIR DISKUS STIOLTO RESPIMAT
GEODON ADVAIR HFA STRIVERDI RESPIMAT
haloperidol AEROSPAN SYMBICORT
INVEGA albuterol sulfate terbutaline
INVEGA SUSTENNA albuterol sulfate er THEO-24
INVEGA TRINZA ANORO ELLIPTA theochron
LATUDA ARCAPTA NEOHALER theophylline
loxapine ARNUITY ELLIPTA theophylline CR
theophylline ER
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 ruleTRELEGY ELLIPTA amlodipine
Anticoagulants
VENTOLIN HFA amlodipine / benazepril
wixela inhub AGGRENOX amlodipine / valsartan
XOPENEX ARIXTRA SP amlodipine / olmesartan
XOPENEX CONCENTRATE aspirin/dipyridamole amlodipine / valsartan / hctz
zafirlukast BEVYXXA ATACAND HCT
zileuton ER BRILINTA atenolol
ZYFLO cilostazol atenolol/chlorthalidone
ZYFLO CR clopidogrel AVALIDE
COUMADIN benazepril
CANCER
dipyridamole benazepril / hctz
anastrozole DURLAZA BETAPACE
ARIMIDEX EFFIENT betaxolol
AROMASIN ELIQUIS bisoprolol
exemestane enoxaparin SP bisoprolol / hctz
FARESTON fondaparinux SP BLOOD PRESSURE MONITORS ‡
FEMARA FRAGMIN SP bumetanide
letrozole heparin BUMEX
raloxifene jantoven BYSTOLIC
SOLTAMOX LOVENOX SP BYVALSON
tamoxifen PLETAL CALAN
toremifene PRADAXA CALAN SR
prasugrel candesartan
CARDIOVASCULAR/ SAVAYSA candesartan / hctz
HEART DISEASE warfarin captopril
XARELTO captopril / hctz
Anti-Anginal Agents
XARELTO STARTER PACK CARDIZEM
DILATRATE SR YOSPRALA CARDIZEM CD
GONITRO ZONTIVITY CARDURA
ISORDIL TITRADOSE CAROSPIR
isosorbide dinitrate Cardiac Glycosides cartia XT
isosorbide dinitrate ER digitek carvedilol
isosorbide mononitrate digox CATAPRES
isosorbide mononitrate ER digoxin chlorothiazide
minitran LANOXIN chlorthalidone
NITRO-BID clonidine
NITRO-DUR High Blood Pressure CLORPRES
nitroglycerin ACCUPRIL CORGARD
nitroglycerin er ACCURETIC CORZIDE
nitroglycerin lingual acebutolol DEMADEX
nitroglycerin transdermal ADALAT CC DEMSER
NITROLINGUAL PUMPSPRAY afeditab CR DIBENZYLINE
NITROMIST ALDACTAZIDE diltiazem CD
nitro-time ALDACTONE diltiazem
petn amiloride diltiazem ER
ranolazine er amiloride / hctz DIURIL
doxazosin
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 ruleDUTOPROL MINIPRESS trandolapril
DYRENIUM minoxidil tablet trandolapril / verapamil er
EDARBI moexipril triamterene
EDARBYCLOR moexipril / hctz triamterene / hctz
EDECRIN nadolol TWYNSTA
enalapril nadolol / bendroflumethiazide valsartan
enalapril / hctz nicardipine valsartan / hctz
EPANED nifedipine VASERETIC
eplerenone nifedipine ER VASOTEC
eprosartan nimodipine VECAMYL
ethacrynic acid nisoldipine verapamil
ezide nisoldipine ER verapamil ER
felodipine ER NYMALIZE verapamil SR
FIRST - ATENOLOL ‡ olmesartan VERELAN
FIRST - METOPROLOL ‡ olmesartan / amlodipine / hctz VERELAN PM
fosinopril olmesartan / hctz ZESTORETIC
fosinopril / hctz perindopril ZIAC
furosemide phenoxybenzamine
High cholesterol
guanfacine pindolol
HEMANGEOL prazosin ALTOPREV
hydralazine PRESTALIA amlodipine / atorvastatin
hydrochlorothiazide PROCARDIA ANTARA
indapamide PROCARDIA XL atorvastatin
INSPRA propranolol CADUET
irbesartan propranolol ER cholestyramine
irbesartan / hctz propranolol / hctz cholestyramine lite
isradipine QBRELIS colesevelam
labetalol quinapril colestipol
lisinopril quinapril / hctz ezetimibe
lisinopril / hctz ramipril ezetimibe / simvastatin
LOPRESSOR sotalol fenofibrate
LOPRESSOR HCT SOTYLIZE fenofibrate micronized
losartan potassium spironolactone fenofibric acid
losartan potassium / hctz spironolactone / hctz fenofibric acid dr
LOTENSIN SULAR FENOGLIDE
matzim LA TARKA FIBRICOR
MAXZIDE taztia XT FLOLIPID
MAXZIDE-25 TEKTURNA fluvastatin
methyclothiazide TEKTURNA HCT fluvastatin er
methyldopa telmisartan gemfibrozil
methyldopa / hctz telmisartan / amlodipine JUXTAPID SP
metolazone telmisartan / hctz KYNAMRO SP
metoprolol er TENORETIC LIPOFEN
METOPROLOL ER / HCTZ terazosin LIVALO
metoprolol TIAZAC LOPID
metoprolol / hctz timolol (tablet) lovastatin
MICROZIDE torsemide niacin ER
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 ruleniacor HUMULIN 70 / 30 JANUMET
omega-3-acid ethyl esters HUMULIN 70 / 30 KWIKPEN JANUMET XR
PRALUENT HUMULIN N JANUVIA
pravastatin HUMULIN N KWIKPEN JARDIANCE
prevalite HUMULIN R JENTADUETO
REPATHA HUMULIN R U-500 JENTADUETO XR
REPATHA SURECLICK LANTUS metformin
rosuvastatin LANTUS SOLOSTAR metformin ER (not mod or osm)
simvastatin TOUJEO MAX SOLOSTAR miglitol
TRIGLIDE TOUJEO SOLOSTAR nateglinide
triklo ONETOUCH VERIO KIT W/
TRILIPIX Non-insulin DEVICE ‡
VASCEPA acarbose ONETOUCH ULTRA 2 ‡
ACTOPLUS MET ONETOUCH ULTRA MINI ‡
CONTRACEPTIVES ‡
ACTOPLUS MET XR ONETOUCH VERIO FLEX
This section lists contraceptive ACTOS SYSTEM ‡
categories. Please note that AMARYL ONETOUCH VERIO IQ SYSTEM ‡
brands and generics are eligible AVANDIA ONETOUCH VERIO SYNC
dependent upon your benefit BYDUREON SYSTEM ‡
plan formulary. BYDUREON BCISE OZEMPIC
BYDUREON PEN pioglitazone
CONTRACEPTIVE PATCH pioglitazone / metformin
BYETTA
CONTRACEPTIVE RING pioglitazone / glimepride
chlorpropamide
(NUVARING) PRANDIN
CYCLOSET
EMERGENCY CONTRACEPTIVES PRECOSE
DUETACT
IMPLANT CONTRACEPTIVE repaglinide
glimepiride
INJECTABLE CONTRACEPTIVE repaglinide / metformin
glipizide
IUDs RIOMET
glipizide ER
ORAL CONTRACEPTIVES SOLIQUA 100 / 33
glipizide XL
glipizide/metformin STARLIX
DIABETES
GLUCOTROL SYMLINPEN 120
Insulin GLUCOTROL XL SYMLINPEN 60
GLUCOVANCE SYNJARDY
AFREZZA
glyburide SYNJARDY XR
HUMALOG
glyburide / metformin tolazamide
HUMALOG JUNIOR KWIKPEN
glyburide micronized tolbutamide
HUMALOG KWIKPEN
GLYNASE TRADJENTA
HUMALOG MIX 50 / 50
GLYSET TRULICITY
HUMALOG MIX 50 / 50
GLYXAMBI VICTOZA
KWIKPEN
INVOKAMET XULTOPHY 100 / 3.6
HUMALOG MIX 75 / 25
HUMALOG MIX 75 / 25 INVOKAMET XR ESTROGENS
KWIKPEN INVOKANA
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 ruleAXID EPIVIR SP
ACTIVELLA
cimetidine EPZICOM SP
ALORA
CYTOTEC EVOTAZ SP
amabelz
DEXILANT fosamprenavir SP
ANGELIQ
ESOMEPRAZOLE STRONTIUM FUZEON SP
BIEST / PROGESTERONE
famotidine GENVOYA SP
CLIMARA PRO
FIRST-LANSOPRAZOLE ‡ INTELENCE SP
COMBIPATCH
FIRST-OMEPRAZOLE ‡ INVIRASE SP
covaryx
lansoprazole ISENTRESS SP
covaryx HS
lansoprazole odt ISENTRESS HD SP
DIVIGEL
lansoprazole/amoxicillin/ JULUCA SP
dotti
clarithromycin KALETRA SP
DUAVEE
misoprostol lamivudine SP
eemt
nizatidine lamivudine / zidovudine SP
eemt HS
OMECLAMOX -PAK LEXIVA SP
ELESTRIN
omeprazole lopinavir / ritonavir SP
esterified estrogens/
pantoprazole nevirapine SP
methltestosterone
pantoprazole dr nevirapine ER SP
esterified estrogens/
PEPCID NORVIR SP
methltestosterone ds
PREVPAC ODEFSEY SP
esterified estrogens/
PRILOSEC PREZCOBIX SP
methltestosterone hs PYLERA PREZISTA SP
estradiol rabeprazole RESCRIPTOR SP
estradiol/norethindrone acetate ranitidine RETROVIR SP
ESTROGEL sucralfate REYATAZ SP
estropipate ZANTAC ritonavir SP
EVAMIST SELZENTRY SP
FEMHRT LOW DOSE HIV/AIDS
stavudine SP
fyavolv abacavir SP STRIBILD SP
jevantique lo abacavir / lamivudine SP SUSTIVA SP
jinteli abacavir / lamivudine / SYMFI SP
lopreeza zidovudine SP SYMFI LO SP
MENEST APTIVUS SP SYMTUZA SP
MENOSTAR atazanavir SP tenofovir SP
mimvey BIKTARVY SP TIVICAY SP
mimvey lo CIMDUO SP TRIUMEQ SP
norethindrone acetate/ethinyl COMBIVIR SP TRIZIVIR SP
estradiol COMPLERA SP TROGARZO SP
PREFEST CRIXIVAN SP TRUVADA SP
PREMARIN DELSTRIGO SP TYBOST SP
PREMPHASE DESCOVY SP VIDEX PEDIATRIC SP
PREMPRO didanosine SP VIDEX EC SP
GASTROINTESTINAL-ULCER DOVATO SP VIRACEPT SP
DRUGS‡ EDURANT SP VIRAMUNE SP
efavirenz SP VIRAMUNE XR SP
ACIPHEX SPRINKLE EMTRIVA SP VIREAD SP
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 ruleZERIT SP nicotine gum / lozenge / patch generic products
ZIAGEN SP NICOTROL INH / NS BRAND NAME PRODUCTS
zidovudine SP ZYBAN
Prenatal multivitamins
OSTEOPOROSIS TRANSPLANT ‡
with iron and folic acid
ACTONEL ASTAGRAF XL SP (for example; OB COMPLETE,
alendronate AZASAN prenatabs RX)
ATELVIA azathioprine generic products
BINOSTO CELLCEPT SP BRAND NAME PRODUCTS
BONIVA cyclosporine SP
calcitonin -salmon cyclosporine modified SP
etidronate di ENVARSUS XR SP
EVISTA gengraf SP
FORTEO SP IMURAN
FOSAMAX mycophenolate SP
FOSAMAX + D mycophenolic acid DR SP
ibandronate MYFORTIC SP
risedronate NEORAL SP
risedronate dr PROGRAF SP
RAPAMUNE SP
SMOKING DETERRENTS ‡
SANDIMMUNE SP
bupropion er sirolimus SP
CHANTIX tacrolimus SP
NICODERM CQ ZORTRESS SP
NICORETTE
VITAMINS & ELECTROLYTETS‡
Pediatric vitamins
with fluoride
(for example; POLY-VI-FLOR,
tri-vit / fl)
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
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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