2021 Preventive medications and your plan - Optum RX
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2021 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.
2021 Preventive medication list
Expanded listing by therapeutic category
olanzapine DALIRESP
ANTIDEPRESSANTS
olanzapine odt difil-g forte
citalopram olanzapine / fluoxetine ELIXOPHYLLIN
escitalopram paliperidone er FLOVENT DISKUS
fluoxetine perphenazine FLOVENT HFA
fluoxetine dr PERSERIS ‡ FLUTICASONE PROPIONATE/
fluvoxamine prochlorperazine SALMETEROL INH
fluvoxamine er quetiapine fluticasone/salmeterol diskus
paroxetine quetiapine er ipratropium
paroxetine er REXULTI ipratropium / albuterol
PEXEVA RISPERDAL CONSTA ‡ isoproterenol aer
sertraline risperidone levalbuterol neb
risperidone odt LONHALA MAGNAIR
ANTIPSYCHOTICS SAPHRIS metaproterenol
ABILIFY MAINTENA ‡ SYMBYAX montelukast
ABILIFY MYCITE ‡ thioridazine PEAKFLOW METERS‡
ADASUVE thiothixene PERFOROMIST
aripiprazole trifluoperazine PULMICORT FLEXHALER
aripiprazole odt VERSACLOZ SEREVENT DISKUS
ARISTADA ‡ VRAYLAR SPIRIVA HANDIHALER
ARISTADA INITIO ‡ ziprasidone SPIRIVA RESPIMAT
CAPLYTA ZYPREXA RELPREVV ‡ STIOLTO RESPIMAT
chlorpromazine ZYPREXA ZYDIS STRIVERDI RESPIMAT
clozapine SYMBICORT
ASTHMA AND COPD
clozapine odt terbutaline
CLOZARIL ACCOLATE THEO-24
compro ADVAIR DISKUS theophylline
EQUETRO ADVAIR HFA theophylline CR
FANAPT albuterol sulfate theophylline ER
FAZACLO albuterol sulfate er TRELEGY ELLIPTA
fluphenazine albuterol sulfate hfa wixela inhub
GEODON ANORO ELLIPTA XOPENEX NEB
haloperidol ARCAPTA NEOHALER XOPENEX CONCENTRATE
INVEGA ARNUITY ELLIPTA YUPELRI
INVEGA SUSTENNA ‡ ATROVENT HFA zafirlukast
INVEGA TRINZA ‡ BREO ELLIPTA zileuton ER
LATUDA BROVANA ZYFLO
loxapine budesonide sus ZYFLO CR
molindone COMBIVENT RESPIMAT
NUPLAZID cromolyn
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 ruleEFFIENT BLOOD PRESSURE MONITORS ‡
CANCER
ELIQUIS bumetanide
anastrozole enoxaparin SP BUMEX
AROMASIN fondaparinux SP BYSTOLIC
EVISTA FRAGMIN SP BYVALSON
exemestane heparin CALAN
FARESTON jantoven CALAN SR
FEMARA LOVENOX SP candesartan
letrozole PLETAL candesartan / hctz
raloxifene PRADAXA captopril
SOLTAMOX prasugrel captopril / hctz
tamoxifen SAVAYSA CARDIZEM
toremifene warfarin CARDIZEM CD
XARELTO CARDURA
CARDIOVASCULAR/ ZONTIVITY CAROSPIR
HEART DISEASE cartia XT
Cardiac Glycosides carvedilol
Anti-Anginal Agents
digitek carvedilol er
DILATRATE SR digox CATAPRES
GONITRO digoxin chlorothiazide
ISORDIL TITRADOSE LANOXIN chlorthalidone
isosorbide dinitrate clonidine
isosorbide dinitrate ER High Blood Pressure CORGARD
isosorbide mononitrate ACCUPRIL DEMADEX
isosorbide mononitrate ER ACCURETIC DEMSER
minitran acebutolol DIBENZYLINE
NITRO-BID ADALAT CC dilt-xr
NITRO-DUR afeditab CR diltiazem CD
nitroglycerin ALDACTAZIDE diltiazem
nitroglycerin er ALDACTONE diltiazem ER
nitroglycerin lingual aliskiren DIURIL
nitroglycerin transdermal amiloride doxazosin
NITROLINGUAL PUMPSPRAY amiloride / hctz DUTOPROL
NITROMIST amlodipine DYRENIUM
nitro-time amlodipine / benazepril EDARBI
petn amlodipine / valsartan EDARBYCLOR
ranolazine er amlodipine / olmesartan EDECRIN
amlodipine / valsartan / hctz enalapril
Anticoagulants
ATACAND HCT enalapril / hctz
AGGRENOX atenolol EPANED
ARIXTRA SP atenolol/chlorthalidone eplerenone
aspirin/dipyridamole AVALIDE eprosartan
BEVYXXA benazepril ethacrynic acid
BRILINTA benazepril / hctz ezide
cilostazol BETAPACE felodipine ER
clopidogrel betaxolol tablet FIRST - ATENOLOL ‡
COUMADIN BIDIL FIRST - METOPROLOL ‡
dipyridamole bisoprolol fosinopril
DURLAZA bisoprolol / hctz 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 ruleguanfacine propranolol ER colestipol
HEMANGEOL propranolol / hctz EZALLOR SPRINKLE
hydralazine QBRELIS ezetimibe
hydrochlorothiazide quinapril ezetimibe / simvastatin
indapamide quinapril / hctz fenofibrate
INSPRA ramipril fenofibrate micronized
irbesartan sotalol fenofibric acid
irbesartan / hctz SOTYLIZE fenofibric acid dr
isradipine spironolactone FENOGLIDE
labetalol spironolactone / hctz FIBRICOR
lisinopril SULAR FLOLIPID
lisinopril / hctz TARKA fluvastatin
LOPRESSOR taztia XT fluvastatin er
LOPRESSOR HCT TEKTURNA gemfibrozil
losartan potassium TEKTURNA HCT JUXTAPID SP
losartan potassium / hctz telmisartan LIPOFEN
LOTENSIN telmisartan / amlodipine LOPID
LOTENSIN HCT telmisartan / hctz lovastatin
matzim LA TENORETIC NEXLETOL
MAXZIDE terazosin NEXLIZET
MAXZIDE-25 tiadylt er niacin (Rx only)
methyclothiazide TIAZAC niacin ER
methyldopa timolol (tablet) niacor
methyldopa / hctz torsemide omega-3-acid ethyl esters
metolazone trandolapril PRALUENT
metoprolol er trandolapril / verapamil er pravastatin
METOPROLOL ER / HCTZ triamterene prevalite
metoprolol triamterene / hctz REPATHA
metoprolol / hctz TWYNSTA REPATHA SURECLICK
MINIPRESS valsartan rosuvastatin
minoxidil tablet valsartan / hctz simvastatin
moexipril VASERETIC TRILIPIX
nadolol VASOTEC VASCEPA
nadolol / bendroflumethiazide VECAMYL
CONTRACEPTIVES ‡
nicardipine verapamil
nifedipine verapamil ER This section lists contraceptive
nifedipine ER verapamil SR categories. Please note that
nimodipine VERELAN brands and generics are eligible
nisoldipine ER VERELAN PM dependent upon your benefit
NYMALIZE ZESTORETIC plan formulary.
olmesartan ZIAC
olmesartan / amlodipine / hctz CONTRACEPTIVE PATCH
High cholesterol CONTRACEPTIVE VAGINAL
olmesartan / hctz
perindopril ALTOPREV RING
phenoxybenzamine amlodipine / atorvastatin EMERGENCY CONTRACEPTIVES
pindolol ANTARA IMPLANT CONTRACEPTIVE
prazosin atorvastatin INJECTABLE CONTRACEPTIVE
PRESTALIA CADUET IUDs
PROCARDIA cholestyramine ORAL CONTRACEPTIVES
PROCARDIA XL cholestyramine lite
propranolol colesevelam
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 ruleglyburide / metformin eemt HS
DIABETES
glyburide micronized ELESTRIN
Insulin GLYNASE esterified estrogens/
GLYSET methltestosterone
AFREZZA GLYXAMBI esterified estrogens/
HUMALOG JANUMET methltestosterone ds
HUMALOG JUNIOR KWIKPEN JANUMET XR esterified estrogens/
HUMALOG KWIKPEN JANUVIA methltestosterone hs
HUMALOG MIX 50 / 50 JARDIANCE estradiol
HUMALOG MIX 50 / 50 JENTADUETO estradiol/norethindrone acetate
KWIKPEN JENTADUETO XR ESTROGEL
HUMALOG MIX 75 / 25 metformin EVAMIST
HUMALOG MIX 75 / 25 metformin ER (not mod or osm) FEMHRT LOW DOSE
KWIKPEN miglitol fyavolv
HUMULIN 70 / 30 nateglinide jinteli
HUMULIN 70 / 30 KWIKPEN OZEMPIC lopreeza
HUMULIN N pioglitazone MENEST
HUMULIN N KWIKPEN pioglitazone / metformin MENOSTAR
HUMULIN R pioglitazone / glimepride mimvey
HUMULIN R U-500 PRANDIN mimvey lo
LANTUS PRECOSE MINIVELLE
LANTUS SOLOSTAR repaglinide norethindrone acetate/ethinyl
TOUJEO MAX SOLOSTAR repaglinide / metformin estradiol
TOUJEO SOLOSTAR RIOMET PREFEST
Non-insulin RYBELSUS PREMARIN
SOLIQUA 100 / 33 PREMPHASE
acarbose STARLIX PREMPRO
ACTOPLUS MET SYMLINPEN
ACTOPLUS MET XR SYNJARDY GASTROINTESTINAL-ULCER
ACTOS SYNJARDY XR DRUGS‡
AMARYL tolazamide ACIPHEX SPRINKLE
AVANDIA tolbutamide AXID
BYDUREON TRADJENTA CARAFATE SUS
BYDUREON BCISE TRULICITY cimetidine
BYDUREON PEN VICTOZA CYTOTEC
BYETTA XIGDUO XR DEXILANT
chlorpropamide XULTOPHY esomeprazole magnesium
CYCLOSET ESOMEPRAZOLE STRONTIUM
CONTOUR MONITOR ESTROGENS
famotidine
CONTOUR NEXT MONITOR KIT ACTIVELLA FIRST-LANSOPRAZOLE ‡
DUETACT ALORA FIRST-OMEPRAZOLE ‡
FARXIGA amabelz lansoprazole
glimepiride ANGELIQ lansoprazole odt
glipizide CLIMARA PRO lansoprazole/amoxicillin/
glipizide ER COMBIPATCH clarithromycin
glipizide XL covaryx misoprostol
glipizide/metformin covaryx HS NEXIUM GRA
GLUCOTROL DIVIGEL nizatidine
GLUCOTROL XL dotti OMECLAMOX -PAK
GLUCOVANCE DUAVEE omeprazole
glyburide eemt pantoprazole
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 rulepantoprazole dr PREZCOBIX
SMOKING DETERRENTS ‡
PEPCID PREZISTA
PRILOSEC RESCRIPTOR bupropion er
PROTONIX PAK RETROVIR CHANTIX
PYLERA REYATAZ NICODERM CQ
rabeprazole tab ritonavir NICORETTE
sucralfate SELZENTRY nicotine gum / lozenge / patch
TALICIA stavudine NICOTROL INH / NS
STRIBILD ZYBAN
HIV/AIDS
SUSTIVA
SYMFI TRANSPLANT ‡
abacavir
abacavir / lamivudine SYMFI LO ASTAGRAF XL SP
abacavir / lamivudine / SYMTUZA AZASAN
zidovudine tenofovir azathioprine
APTIVUS TIVICAY CELLCEPT SP
atazanavir TRIUMEQ cyclosporine SP
BIKTARVY TRIZIVIR cyclosporine modified SP
CIMDUO TROGARZO ENVARSUS XR SP
COMBIVIR TYBOST everolimus SP
COMPLERA VIDEX PEDIATRIC gengraf SP
CRIXIVAN VIDEX EC IMURAN
DELSTRIGO VIRACEPT mycophenolate SP
didanosine VIRAMUNE mycophenolic acid DR SP
DOVATO VIRAMUNE XR MYFORTIC SP
EDURANT VIREAD NEORAL SP
efavirenz ZERIT PROGRAF SP
efavirenz/lamivudine/tenofovir ZIAGEN RAPAMUNE SP
EMTRIVA zidovudine SANDIMMUNE SP
EPIVIR sirolimus SP
OSTEOPOROSIS
EPZICOM tacrolimus SP
EVOTAZ ACTONEL ZORTRESS SP
fosamprenavir alendronate
FUZEON ATELVIA VITAMINS & ELECTROLYTETS‡
GENVOYA BINOSTO Pediatric vitamins
INTELENCE BONIVA with fluoride
INVIRASE calcitonin -salmon
ISENTRESS etidronate di (for example; POLY-VI-FLOR,
ISENTRESS HD EVENITY SP tri-vit / fl)
JULUCA EVISTA generic products
KALETRA FORTEO SP BRAND NAME PRODUCTS
lamivudine FOSAMAX Prenatal multivitamins
lamivudine / zidovudine FOSAMAX + D with iron and folic acid
LEXIVA ibandronate
lopinavir / ritonavir NATPARA SP Brands and generics are eligible
nevirapine raloxifene dependent upon your
nevirapine ER risedronate benefit plan formulary.
NORVIR risedronate dr
ODEFSEY TYMLOS SP
PIFELTRO
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 ruleThis 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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