CORE PLUS Preventive List 1-1-19 v4 - Commvault

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Bold type = Brand-name drug[Plain type = Generic drug]

E = May be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)

*Coverage is provided for oral formulations

Therapeutic Drug Classes Requirements & Limits

Breast Cancer Prevention

Anastrozole

Arimidex E

Aromasin

Exemestane

Fareston

Femara E

Letrozole

Soltamox E

Tamoxifen


Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy

Aggrenox

Arixtra

Aspirin-Dipyridamole

Bevyxxa

Brilinta

Cilostazol

Clopidogrel

Coumadin

Dipyridamole

Effient E

Eliquis

2019 Preventive Drug List forConsumer Driven Health PlansCore Plus ListEffective Jan. 1, 2019

This document is a list of Preventive Medications that may be covered under your benefit plan. If your plan includes these Preventive Medications, your insurance benefit is applied before you meet your deductible for the below drugs.

Some medications may have additional requirements or limits depending on your benefit plan and are noted below. To confirm your plan coverage for a specific drug, please view your plan benefits on your health plan’s member website or call the toll-free phone number on your health plan ID card. This list is intended as a reference and may not be all-inclusive. Brand-name or generic availability may not be current due to changes in the market.

This list applies to members of UnitedHealthcare and Oxford medical plans. It is accurate as of Jan. 1, 2019 and is subject to change after this date. The next anticipated update will be July 1, 2019.

Core Plus Drug List

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Enoxaparin

Fragmin

Fondaparinux

Heparin

Jantoven

Lovenox

Persantine

Plavix E

Pletal

Pradaxa

Prasugrel

Savaysa

Ticlopidine

Warfarin

Xarelto

Zontivity

Cardiovascular/Heart Disease: High Blood Pressure

Accupril

Accuretic

Acebutolol

Aceon

Adalat CC

Afeditab

Aldactazide

Aldactone

Altace

Amiloride

Amiloride-Hydrochlorothiazide

Amlodipine

Amlodipine-Benazepril

Amlodipine-Olmesartan E

Amlodipine-Olmesartan-Hydrochlorothiazide E

Amlodipine-Valsartan


Amlodipine-Valsartan-Hydrochlorothiazide E

Amturnide E

Atacand

Atacand HCT

Atenolol

Atenolol-Chlorthalidone

Avalide

Avapro

Azor E

Benazepril

Benazepril-Hydrochlorothiazide

Benicar E

Benicar HCT E

Betaxolol*

Bidil

Bisoprolol

Bisoprolol-Hydrochlorothiazide

Bumetanide

Bystolic

Byvalson

Calan

Calan SR

Candesartan

Candesartan-Hydrochlorothiazide

Captopril

Captopril-Hydrochlorothiazide

Cardene SR

Cardizem E

Cardizem CD E

Cardizem LA E

Cardura

Carospir

Cartia XT

3





Carvedilol

Carvedilol ER E

Catapres

Catapres TTS

Chlorothiazide

Clonidine

Clonidine Patch

Clorpress

Coreg

Coreg CR E

Corgard

Corzide

Covera HS

Cozaar

Demadex

Dilacor XR

Dilt CD

Dilt XR

Diltia XT

Diltiazem

Diltiazem ER

Diltzac ER

Diovan E

Diovan HCT E

Diuril

Doxazosin

Dutoprol E

Dyazide

Dynacirc CR

Dyrenium

Edarbi

Edarbyclor

Edecrin

Enalapril


Enalapril-Hydrochlorothiazide

Epaned

Eplerenone

Eprosartan

Ethacrynic Acid

Exforge E

Exforge HCT E

Felodipine ER

Fosinopril

Fosinopril-Hydrochlorothiazide

Furosemide

Guanfacine

Hydralazine

Hydrochlorothiazide

Hyzaar

Indapamide

Inderal

Inderal LA E

Innopran XL

Inspra

Irbesartan

Irbesartan-Hydrochlorothiazide

Isoptin SR

Isradipine

Kapspargo E

Labetalol

Lasix

Levatol

Lisinopril

Lisinopril-Hydrochlorothiazide

Lopressor

Lopressor HCT

Losartan

Losartan-Hydrochlorothiazide

4





Lotensin

Lotensin HCT

Lotrel

Matzim LA

Mavik

Maxzide

Methyclothiazide

Methyldopa

Methyldopa-Hydrochlorothiazide

Metolazone

Metoprolol 37.5, 75 mg E

Metoprolol-Hydrochlorothiazide

Metoprolol Succinate

Metoprolol Tartrate

Micardis E

Micardis HCT E

Microzide

Midamor

Minipress

Minoxidil

Moexipril

Moexipril-Hydrochlorothiazide

Nadolol

Nadolol-Bendroflumethazide

Nicardipine

Nifedipine

Nifedipine ER

Nimodipine

Nisoldipine

Norvasc

Olmesartan

Olmesartan-Hydrochlorothiazide

Perindopril

Pindolol


Prazosin

Prestalia E

Prinivil

Procardia

Procardia XL

Propranolol

Propranolol-Hydrochlorothiazide

Qbrelis E

Quinapril

Quinapril-Hydrochlorothiazide

Ramipril

Reserpine

Sectral

Spironolactone

Spironolactone-Hydrochlorothiazide

Sular

Tarka

Taztia XT

Tekturna

Tekturna HCT

Telmisartan

Telmisartan-Amlodipine E

Telmisartan-Hydrochlorothiazide

Tenex

Tenoretic E

Tenormin E

Terazosin

Teveten

Teveten HCT

Thalitone

Tiazac

Timolol*

Toprol XL

Torsemide

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Trandate

Trandolapril

Trandolapril-Verapamil

Triamterene-Hydrochlorothiazide

Tribenzor E

Twynsta E

Uniretic

Univasc

Valsartan

Valsartan-Hydrochlorothiazide

Vaseretic E

Vasotec E

Verapamil

Verapamil ER

Verelan

Verelan PM

Zaroxolyn

Zebeta

Zestoretic E

Zestril E

Ziac

Cardiovascular/Heart Disease: High Cholesterol

Altoprev E

Antara E

Atorvastatin

Cholestyramine

Cholestyramine Light

Choline Fenofibrate E

Colesevelam Tablets, Powder for Suspension E

Colestid

Colestipol

Crestor E

Ezetimibe


Fenofibrate 43, 50, 67, 130, 134, 150, 200 mg Capsule E

Fenofibrate 40, 48, 120, 145 mg Tablet E

Fenofibrate 54, 160 mg Tablet

Fenofibric Acid E

Fenoglide E

Fibricor E

Flolipid

Fluvastatin

Fluvastatin ER

Gemfibrozil

Lescol

Lescol XL E

Lipitor E

Lipofen E

Livalo E

Lofibra E

Lopid

Lovastatin

Lovaza E

Mevacor

Niacin Extended-Release

Niacor

Niaspan

Omega-3 Acid Ethyl Esters

Pravachol

Pravastatin

Prevalite

Questran

Questran Light

Rosuvastatin

Simvastatin

Simvastatin-Ezetimibe

Tricor E

6





Triglide E

Trilipix E

Vascepa

Vytorin E

Welchol

Zetia E

Zocor

Zypitamag E

Diabetes: Diabetic Supplies

Contour Next EZ Meters

Contour Next Meters

Contour Next One Meters

Contour Next Test Strips

Diabetic Testing - Lancets

Insulin Needles/Syringes

OneTouch Diabetic Meters

OneTouch Diabetic Test Strips

Diabetes: Insulin

Admelog, Admelog SoloStar E

Afrezza E

Apidra, Apidra SoloStar E

Basaglar

Fiasp, Fiasp FlexTouch E

Humalog

Humalog Junior

Humalog Mix 50/50

Humalog Mix 75/25

Humulin 50/50

Humulin 70/30

Humulin N

Humulin R

Lantus E

Levemir

Novolin 70/30 E


Novolin N E

Novolin R E

Novolog, Novolog FlexPen E

Novolog Mix 70/30 E

Soliqua

Toujeo E

Tresiba

Diabetes: Non-Insulin

Acarbose

ACTOplus Met

ACTOplus Met XR

Actos E

Adlyxin

Alogliptin E

Alogliptin-Metformin E

Alogliptin-Pioglitazone E

Amaryl

Avandia

Bydureon

Bydureon BCise

Byetta

Cycloset

Diabeta

Duetact

Farxiga E

Fortamet E

Glimepiride

Glipizide

Glipizide ER

Glipizide-Metformin

Glucophage

Glucophage XR

Glucotrol

Glucotrol XL

7





Glucovance

Glumetza E

Glyburide

Glyburide Micronized

Glyburide-Metformin

Glynase

Glyset

Glyxambi

Invokamet

Invokamet XR

Invokana

Janumet

Janumet XR

Januvia

Jardiance

Jentadueto

Jentadueto XR

Kazano

Kombiglyze XR

Metformin

Metformin ER (generic Fortamet) E

Metformin ER (generic Glucophage XR)

Metformin ER (generic Glumetza) E

Miglitol

Nateglinide

Nesina

Onglyza

Oseni

Ozempic

Pioglitazone

Pioglitazone-Glimepiride

Pioglitazone-Metformin

PrandiMet


Prandin

Precose

Qtern E

Repaglinide

Repaglinide-Metformin

Riomet

Segluromet E

Starlix

Steglatro E

Steglujan E

SymlinPen

Synjardy

Synjardy XR

Tolbutamide

Tradjenta

Trulicity

Victoza

Xigduo XR E

Xultophy E

Immunosuppressant: Organ Rejection

Astagraf XL E

Azasan

Azathioprine

Cellcept E

Cyclosporine

Envarsus XR E

Gengraf

Imuran E

Mycophenolate

Mycophenolic Acid

Myfortic E

Neoral E

Prograf E

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Rapamune E

Sandimmune E

Sirolimus

Tacrolimus

Zortress

Musculoskeletal: Osteoporosis

Actonel

Alendronate

Atelvia E

Binosto E

Boniva

Calcitonin (Salmon)

Didronel

Etidronate

Evista E

Forteo

Fortical

Ibandronate

Miacalcin

Raloxifene

Risedronate

Tymlos

Respiratory: Asthma/COPD

Accolate

Accuneb

Advair Diskus

Advair HFA

AirDuo RespiClick E

Albuterol Nebulized Solution

Albuterol Oral Tablet

Alvesco

Aminophylline

Anoro Ellipta


Arcapta Neohaler

ArmonAir RespiClick E

Arnuity Ellipta

Asmanex HFA

Asmanex Twisthaler

Atrovent HFA

Bevespi Aerosphere

Breo Ellipta

Brovana

Budesonide Nebulized Solution

Combivent Respimat

Cromolyn

Daliresp

Dulera E

Duoneb

Elixophyllin

Flovent Diskus

Flovent HFA

Fluticasone/Salmeterol RespiClick

Foradil

Gastrocrom

Incruse Ellipta

Ipratropium

Ipratropium/Albuterol

Levalbuterol HFA

Levalbuterol Nebulized Solution E

Lonhala Magnair

Lufyllin

Metaproterenol

Montelukast

Perforomist

Proair HFA

Proair RespiClick

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Proventil HFA

Pulmicort Flexhaler

Pulmicort Nebulized Solution

QVAR Redihaler

Seebri NeoHaler

Serevent Diskus

Singulair E

Spiriva HandiHaler

Spiriva Respimat

Stiolto Respimat E

Striverdi Respimat

Symbicort

Terbutaline

Theo-24

Theophylline

Theophylline/Guaifenesin

Trelegy Ellipta

Tudorza Pressair

Utibron NeoHaler E

Ventolin HFA

VoSpire ER

Xopenex HFA

Xopenex Nebulized Solution E

Zafirlukast

Zyflo

Zyflo CR


Vitamins

Pediatric Flouride Preparations (for example: Florvite, Poly-Vi-Flor, Tri-Vi-Flor) - Brand Name and Generic Products

Prenatal Vitamins (for example: Citranatal Assure, Prenate DHA, Stuartnatal) - Brand Name and Generic Products

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IndexIndexA

Acarbose .................................................... 6Accolate ...................................................... 8Accuneb ...................................................... 8Accupril ....................................................... 2Accuretic ..................................................... 2Acebutolol .................................................. 2Aceon .......................................................... 2Actonel ........................................................ 8ACTOplus Met ........................................... 6ACTOplus Met XR .................................... 6Actos ............................................................ 6Adalat CC ................................................... 2Adlyxin ......................................................... 6Admelog, Admelog SoloStar ................. 6Advair Diskus ............................................. 8Advair HFA.................................................. 8Afeditab ....................................................... 2Afrezza......................................................... 6Aggrenox .................................................... 1AirDuo RespiClick .................................... 8Albuterol Nebulized Solution ................. 8Albuterol Oral Tablet ................................ 8Aldactazide ................................................ 2Aldactone ................................................... 2Alendronate ................................................ 8Alogliptin ..................................................... 6Alogliptin-Metformin ................................ 6Alogliptin-Pioglitazone ............................. 6Altace ........................................................... 2Altoprev ....................................................... 5Alvesco ........................................................ 8Amaryl ......................................................... 6Amiloride ..................................................... 2Amiloride-Hydrochlorothiazide ............. 2Aminophylline ............................................ 8Amlodipine ................................................. 2Amlodipine-Benazepril ............................ 2Amlodipine-Olmesartan .......................... 2Amlodipine-Olmesartan-

Hydrochlorothiazide ............................. 2Amlodipine-Valsartan .............................. 2Amlodipine-Valsartan-

Hydrochlorothiazide ............................. 2Amturnide ................................................... 2Anastrozole ................................................ 1Anoro Ellipta ............................................... 8Antara .......................................................... 5

Apidra, Apidra SoloStar .......................... 6Arcapta Neohaler ..................................... 8Arimidex ...................................................... 1Arixtra .......................................................... 1ArmonAir RespiClick ............................... 8Arnuity Ellipta ............................................. 8Aromasin ..................................................... 1Asmanex HFA ............................................ 8Asmanex Twisthaler ................................. 8Aspirin-Dipyridamole ............................... 1Astagraf XL ................................................. 7Atacand ....................................................... 2Atacand HCT ............................................. 2Atelvia .......................................................... 8Atenolol ....................................................... 2Atenolol-Chlorthalidone .......................... 2Atorvastatin ................................................ 5Atrovent HFA .............................................. 8Avalide ......................................................... 2Avandia........................................................ 6Avapro ......................................................... 2Azasan......................................................... 7Azathioprine ............................................... 7Azor .............................................................. 2

B

Basaglar ...................................................... 6Benazepril .................................................. 2Benazepril-Hydrochlorothiazide ........... 2Benicar ........................................................ 2Benicar HCT .............................................. 2Betaxolol ..................................................... 2Bevespi Aerosphere................................. 8Bevyxxa....................................................... 1Bidil .............................................................. 2Binosto ........................................................ 8Bisoprolol .................................................... 2Bisoprolol-Hydrochlorothiazide ............ 2Boniva .......................................................... 8Breo Ellipta ................................................. 8Brilinta.......................................................... 1Brovana ....................................................... 8Budesonide Nebulized Solution ........... 8Bumetanide ................................................ 2Bydureon .................................................... 6Bydureon BCise ........................................ 6Byetta .......................................................... 6Bystolic ........................................................ 2

Byvalson ..................................................... 2

C

Calan ............................................................ 2Calan SR ..................................................... 2Calcitonin (Salmon) .................................. 8Candesartan .............................................. 2Candesartan-Hydrochlorothiazide ....... 2Captopril ..................................................... 2Captopril-Hydrochlorothiazide .............. 2Cardene SR................................................ 2Cardizem..................................................... 2Cardizem CD ............................................. 2Cardizem LA .............................................. 2Cardura ....................................................... 2Carospir....................................................... 2Cartia XT ..................................................... 2Carvedilol .................................................... 3Carvedilol ER ............................................. 3Catapres ..................................................... 3Catapres TTS ............................................ 3Cellcept ....................................................... 7Chlorothiazide ........................................... 3Cholestyramine ......................................... 5Cholestyramine Light .............................. 5Choline Fenofibrate .................................. 5Cilostazol .................................................... 1Clonidine ..................................................... 3Clonidine Patch ......................................... 3Clopidogrel ................................................. 1Clorpress .................................................... 3Colesevelam Tablets, Powder for

Suspension ............................................ 5Colestid ....................................................... 5Colestipol .................................................... 5Combivent Respimat ............................... 8Contour Next EZ Meters ......................... 6Contour Next Meters ............................... 6Contour Next One Meters ...................... 6Contour Next Test Strips ........................ 6Core Plus Drug List .................................. 1Coreg ........................................................... 3Coreg CR .................................................... 3Corgard ....................................................... 3Corzide ........................................................ 3Coumadin ................................................... 1Covera HS .................................................. 3Cozaar ......................................................... 3

11

Crestor ......................................................... 5Cromolyn .................................................... 8Cycloset ...................................................... 6Cyclosporine .............................................. 7

D

Daliresp ....................................................... 8Demadex .................................................... 3Diabeta ........................................................ 6Diabetic Testing - Lancets ...................... 6Didronel ....................................................... 8Dilacor XR ................................................... 3Dilt CD ......................................................... 3Dilt XR .......................................................... 3Diltia XT ....................................................... 3Diltiazem ..................................................... 3Diltiazem ER ............................................... 3Diltzac ER ................................................... 3Diovan .......................................................... 3Diovan HCT ................................................ 3Dipyridamole .............................................. 1Diuril ............................................................. 3Doxazosin ................................................... 3Duetact ........................................................ 6Dulera .......................................................... 8Duoneb ....................................................... 8Dutoprol ...................................................... 3Dyazide ....................................................... 3Dynacirc CR ............................................... 3Dyrenium .................................................... 3

E

Edarbi .......................................................... 3Edarbyclor .................................................. 3Edecrin ........................................................ 3Effient ........................................................... 1Eliquis .......................................................... 1Elixophyllin .................................................. 8Enalapril ...................................................... 3Enalapril-Hydrochlorothiazide ............... 3Enoxaparin ................................................. 2Envarsus XR ............................................... 7Epaned ........................................................ 3Eplerenone ................................................. 3Eprosartan .................................................. 3Ethacrynic Acid ......................................... 3Etidronate ................................................... 8Evista ........................................................... 8Exemestane ............................................... 1Exforge ........................................................ 3Exforge HCT .............................................. 3

Ezetimibe .................................................... 5

F

Fareston ...................................................... 1Farxiga ......................................................... 6Felodipine ER ............................................ 3Femara ........................................................ 1Fenofibrate 40, 48, 120, 145 mg

Tablet ....................................................... 5Fenofibrate 43, 50, 67, 130, 134,

150, 200 mg Capsule.......................... 5Fenofibrate 54, 160 mg Tablet .............. 5Fenofibric Acid .......................................... 5Fenoglide .................................................... 5Fiasp, Fiasp FlexTouch ............................ 6Fibricor ........................................................ 5Flolipid ......................................................... 5Flovent Diskus ........................................... 8Flovent HFA ................................................ 8Fluticasone/Salmeterol RespiClick ...... 8Fluvastatin .................................................. 5Fluvastatin ER ............................................ 5Fondaparinux............................................. 2Foradil .......................................................... 8Fortamet .................................................6, 7Forteo .......................................................... 8Fortical ......................................................... 8Fosinopril .................................................... 3Fosinopril-Hydrochlorothiazide ............. 3Fragmin ....................................................... 2Furosemide ................................................ 3

G

Gastrocrom ................................................ 8Gemfibrozil ................................................. 5Gengraf ....................................................... 7Glimepiride ................................................. 6Glipizide ...................................................... 6Glipizide ER ................................................ 6Glipizide-Metformin .................................. 6Glucophage ...........................................6, 7Glucophage XR .....................................6, 7Glucotrol ..................................................... 6Glucotrol XL ............................................... 6Glucovance ................................................ 7Glumetza .................................................... 7Glyburide .................................................... 7Glyburide Micronized .............................. 7Glyburide-Metformin ................................ 7Glynase ....................................................... 7Glyset ........................................................... 7

Glyxambi ..................................................... 7Guanfacine ................................................. 3

H

Heparin ........................................................ 2Humalog ..................................................... 6Humalog Junior......................................... 6Humalog Mix 50/50 ................................. 6Humalog Mix 75/25 ................................. 6Humulin 50/50 .......................................... 6Humulin 70/30 .......................................... 6Humulin N ................................................... 6Humulin R ................................................... 6Hydralazine ................................................ 3Hydrochlorothiazide ................................. 3Hyzaar ......................................................... 3

I

Ibandronate ................................................ 8Imuran ......................................................... 7Incruse Ellipta ............................................ 8Indapamide ................................................ 3Inderal .......................................................... 3Inderal LA ................................................... 3Innopran XL................................................ 3Inspra ........................................................... 3Insulin Needles/Syringes ........................ 6Invokamet ................................................... 7Invokamet XR ............................................ 7Invokana ...................................................... 7Ipratropium ................................................. 8Ipratropium/Albuterol .............................. 8Irbesartan ................................................... 3Irbesartan-Hydrochlorothiazide ............ 3Isoptin SR ................................................... 3Isradipine .................................................... 3

J

Jantoven ...................................................... 2Janumet ...................................................... 7Janumet XR ............................................... 7Januvia ........................................................ 7Jardiance .................................................... 7Jentadueto ................................................. 7Jentadueto XR ........................................... 7

K

Kapspargo .................................................. 3Kazano ........................................................ 7Kombiglyze XR .......................................... 7

12

L

Labetalol ..................................................... 3Lantus .......................................................... 6Lasix ............................................................. 3Lescol .......................................................... 5Lescol XL .................................................... 5Letrozole ..................................................... 1Levalbuterol HFA ...................................... 8Levalbuterol Nebulized Solution ........... 8Levatol ......................................................... 3Levemir ........................................................ 6Lipitor ........................................................... 5Lipofen ........................................................ 5Lisinopril ...................................................... 3Lisinopril-Hydrochlorothiazide .............. 3Livalo ............................................................ 5Lofibra ......................................................... 5Lonhala Magnair ....................................... 8Lopid ............................................................ 5Lopressor ................................................... 3Lopressor HCT .......................................... 3Losartan ...................................................... 3Losartan-Hydrochlorothiazide ............... 3Lotensin ...................................................... 4Lotensin HCT ............................................. 4Lotrel ............................................................ 4Lovastatin ................................................... 5Lovaza ......................................................... 5Lovenox ....................................................... 2Lufyllin ......................................................... 8

M

Matzim LA .................................................. 4Mavik ........................................................... 4Maxzide....................................................... 4Metaproterenol .......................................... 8Metformin ................................................... 7Metformin ER ............................................. 7Methyclothiazide ....................................... 4Methyldopa ................................................ 4Methyldopa-Hydrochlorothiazide ......... 4Metolazone ................................................. 4Metoprolol 37.5, 75 mg ........................... 4Metoprolol Succinate ............................... 4Metoprolol Tartrate ................................... 4Metoprolol-Hydrochlorothiazide ........... 4Mevacor ...................................................... 5Miacalcin ..................................................... 8Micardis....................................................... 4Micardis HCT ............................................. 4

Microzide .................................................... 4Midamor ...................................................... 4Miglitol ......................................................... 7Minipress .................................................... 4Minoxidil ...................................................... 4Moexipril ..................................................... 4Moexipril-Hydrochlorothiazide .............. 4Montelukast ............................................... 8Mycophenolate ......................................... 7Mycophenolic Acid .................................. 7Myfortic ....................................................... 7

N

Nadolol ........................................................ 4Nadolol-Bendroflumethazide ................ 4Nateglinide ................................................. 7Neoral .......................................................... 7Nesina ......................................................... 7Niacin Extended-Release ....................... 5Niacor .......................................................... 5Niaspan ....................................................... 5Nicardipine ................................................. 4Nifedipine ................................................... 4Nifedipine ER ............................................. 4Nimodipine ................................................. 4Nisoldipine.................................................. 4Norvasc ....................................................... 4Novolin 70/30 ............................................ 6Novolin N .................................................... 6Novolin R .................................................... 6Novolog Mix 70/30 .................................. 6Novolog, Novolog FlexPen ..................... 6

O

Olmesartan ................................................ 4Olmesartan-Hydrochlorothiazide ......... 4Omega-3 Acid Ethyl Esters .................... 5OneTouch Diabetic Meters ..................... 6OneTouch Diabetic Test Strips .............. 6Onglyza ....................................................... 7Oseni ............................................................ 7Ozempic ...................................................... 7

P

Pediatric Flouride Preparations ............. 9Perforomist ................................................. 8Perindopril .................................................. 4Persantine .................................................. 2Pindolol ....................................................... 4Pioglitazone ............................................... 7Pioglitazone-Glimepiride ........................ 7

Pioglitazone-Metformin ........................... 7Plavix ............................................................ 2Pletal ............................................................ 2Pradaxa ....................................................... 2PrandiMet ................................................... 7Prandin ........................................................ 7Prasugrel ..................................................... 2Pravachol .................................................... 5Pravastatin .................................................. 5Prazosin ...................................................... 4Precose ....................................................... 7Prenatal Vitamins ...................................... 9Prestalia ...................................................... 4Prevalite ....................................................... 5Prinivil .......................................................... 4Proair HFA .................................................. 8Proair RespiClick ...................................... 8Procardia .................................................... 4Procardia XL .............................................. 4Prograf ......................................................... 7Propranolol ................................................. 4Propranolol-Hydrochlorothiazide ......... 4Proventil HFA ............................................. 9Pulmicort Flexhaler .................................. 9Pulmicort Nebulized Solution ................ 9

Q

Qbrelis ......................................................... 4Qtern ............................................................ 7Questran ..................................................... 5Questran Light ........................................... 5Quinapril ..................................................... 4Quinapril-Hydrochlorothiazide .............. 4QVAR Redihaler ........................................ 9

R

Raloxifene ................................................... 8Ramipril ....................................................... 4Rapamune .................................................. 8Repaglinide ................................................ 7Repaglinide-Metformin ........................... 7Reserpine ................................................... 4Riomet ......................................................... 7Risedronate ................................................ 8Rosuvastatin .............................................. 5

S

Sandimmune ............................................. 8Savaysa ....................................................... 2Sectral ......................................................... 4Seebri NeoHaler ....................................... 9

13

Segluromet ................................................. 7Serevent Diskus ........................................ 9Simvastatin ................................................. 5Simvastatin-Ezetimibe ............................. 5Singulair ...................................................... 9Sirolimus ..................................................... 8Soliqua ........................................................ 6Soltamox ..................................................... 1Spiriva HandiHaler ................................... 9Spiriva Respimat ....................................... 9Spironolactone .......................................... 4Spironolactone-Hydrochlorothiazide ... 4Starlix ........................................................... 7Steglatro ...................................................... 7Steglujan ..................................................... 7Stiolto Respimat ........................................ 9Striverdi Respimat .................................... 9Sular ............................................................. 4Symbicort ................................................... 9SymlinPen ................................................... 7Synjardy ...................................................... 7Synjardy XR ................................................ 7

T

Tacrolimus .................................................. 8Tamoxifen ................................................... 1Tarka ............................................................ 4Taztia XT ..................................................... 4Tekturna ...................................................... 4Tekturna HCT ............................................ 4Telmisartan ................................................. 4Telmisartan-Amlodipine .......................... 4Telmisartan-Hydrochlorothiazide.......... 4Tenex ........................................................... 4Tenoretic ..................................................... 4Tenormin ..................................................... 4Terazosin..................................................... 4Terbutaline .................................................. 9Teveten ........................................................ 4Teveten HCT .............................................. 4Thalitone ..................................................... 4Theo-24 ....................................................... 9Theophylline .............................................. 9Theophylline/Guaifenesin ...................... 9Tiazac .......................................................... 4Ticlopidine .................................................. 2Timolol* ...................................................... 4Tolbutamide ............................................... 7Toprol XL..................................................... 4Torsemide ................................................... 4Toujeo .......................................................... 6Tradjenta ..................................................... 7

Trandate ...................................................... 5Trandolapril ................................................ 5Trandolapril-Verapamil ............................ 5Trelegy Ellipta ............................................ 9Tresiba ......................................................... 6Triamterene-Hydrochlorothiazide ......... 5Tribenzor ..................................................... 5Tricor ............................................................ 5Triglide ......................................................... 6Trilipix ........................................................... 6Trulicity ........................................................ 7Tudorza Pressair ....................................... 9Twynsta ....................................................... 5Tymlos ......................................................... 8

U

Uniretic ........................................................ 5Univasc ........................................................ 5Utibron NeoHaler ...................................... 9

V

Valsartan ..................................................... 5Valsartan-Hydrochlorothiazide .............. 5Vascepa ...................................................... 6Vaseretic ..................................................... 5Vasotec ........................................................ 5Ventolin HFA .............................................. 9Verapamil .................................................... 5Verapamil ER ............................................. 5Verelan ........................................................ 5Verelan PM ................................................. 5Victoza ......................................................... 7VoSpire ER ................................................. 9Vytorin ......................................................... 6

W

Warfarin ....................................................... 2Welchol ....................................................... 6

X

Xarelto ......................................................... 2Xigduo XR................................................... 7Xopenex HFA ............................................. 9Xopenex Nebulized Solution ................. 9Xultophy ...................................................... 7

Z

Zafirlukast ................................................... 9Zaroxolyn .................................................... 5Zebeta ......................................................... 5Zestoretic .................................................... 5Zestril ........................................................... 5

Zetia ............................................................. 6Ziac............................................................... 5Zocor ........................................................... 6Zontivity ....................................................... 2Zortress ....................................................... 8Zyflo ............................................................. 9Zyflo CR ...................................................... 9Zypitamag ................................................... 6

Nondiscrimination notice and access to communication servicesUnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in its health programs or activities.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Online: [email protected]

Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

If you are not currently enrolled with UnitedHealthcare or Oxford for pharmacy benefit coverage, you may access your health plan’s member website for additional information during your open enrollment period or you may contact your employer or health plan for additional information.

Medications are categorized by common therapeutic conditions in this reference guide for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines how these medications may be covered for you.

Where differences are noted between this reference guide and your benefit plan documents, the benefit plan documents will govern.

This document applies to commercial group members of UnitedHealthcare and Oxford New Jersey plans.

Insurance coverage provided by or through UnitedHealthcare Insurance Company or Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans (NJ), Inc. Administrative services provided by United HealthCare Services, Inc., Oxford Health Plans LLC, or their affiliates.

Call the toll-free phone number on your health plan ID card to speak with a Customer Service representative.

Visit the member website listed on your health plan ID card to look up the price of drugs covered by your plan, find lower-cost options and more.

For additional information:

©2018 United HealthCare Services, Inc. MT-1181622.0 NY-18-413 76761-0720182019 Preventive Core Plus List 8/18

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CORE PLUS Preventive List 1-1-19 v4 - Commvault