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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
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