January 2021 Preventive Medication List for Consumer

Pharmacy | PDL | Core Plus

2021 Preventive Medication List for Consumer Driven Health Plans Core Plus List

This is a list of Preventive Medications that may be covered under your plan. If your plan covers these Preventive Medications, your insurance benefit is applied before you meet your deductible.

Some medications may have other requirements or limits depending on your benefit plan and are noted below. To find out if a drug is covered, please check your plan benefits on the health plan’s member website. Or, call the toll-free phone number on your health plan ID card. This list may not be all-inclusive. Brand and generic drugs may not always be available due to market changes.

This list applies to UnitedHealthcare and Oxford medical plans. It is correct as of August 1, 2020 and is subject to change after this date. The next anticipated update will occur with the next PDL cycle.

CDH preventive drug lists may also be used with non-CDH plans

Effective January 1, 2021

Therapeutic Drug Classes Requirements & Limits

Breast Cancer Prevention

g Anastrozole

B Arimidex E

B Aromasin

g Exemestane

B Fareston

B Femara E

g Letrozole

B Soltamox E

g Tamoxifen

g Toremifene


Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy

B Aggrenox

B Arixtra

g Aspirin-Dipyridamole

B Bevyxxa

B Brilinta

g Cilostazol

g Clopidogrel

B Coumadin

g Dipyridamole

B Effient E

B Eliquis

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)1Coverage is provided for oral formulations

Bold type = Brand-name drug[Plain type = Generic drug]1Coverage is provided for oral formulations

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

2


g Enoxaparin

B Fragmin

g Fondaparinux

g Heparin

g Jantoven

B Lovenox E

B Persantine

B Plavix E

B Pletal

B Pradaxa

g Prasugrel

B Savaysa

g Ticlopidine

g Warfarin

B Xarelto

B Zontivity

Cardiovascular/Heart Disease: High Blood Pressure

B Accupril

B Accuretic

g Acebutolol

B Aceon

B Adalat CC

g Afeditab

B Aldactazide

B Aldactone

g Aliskiren

B Altace

g Amiloride

g Amiloride-Hydrochlorothiazide

g Amlodipine

g Amlodipine-Benazepril

g Amlodipine-Olmesartan E

g Amlodipine-Olmesartan-Hydrochlorothiazide

E


g Amlodipine-Valsartan

g Amlodipine-Valsartan-Hydrochlorothiazide E

B Amturnide E

B Atacand

B Atacand HCT

g Atenolol

g Atenolol-Chlorthalidone

B Avalide

B Avapro

B Azor E

g Benazepril

g Benazepril-Hydrochlorothiazide

B Benicar E

B Benicar HCT E

g Betaxolol1

B Bidil

g Bisoprolol

g Bisoprolol-Hydrochlorothiazide

g Bumetanide

B Bystolic E

B Byvalson

B Calan

B Calan SR

g Candesartan

g Candesartan-Hydrochlorothiazide

g Captopril

g Captopril-Hydrochlorothiazide

B Cardene SR

B Cardizem E

B Cardizem CD E

B Cardizem LA E

B Cardura

B Carospir

g Cartia XT



3


g Carvedilol

g Carvedilol ER E

B Catapres

B Catapres TTS

g Chlorothiazide

g Clonidine

g Clonidine Patch

B Clorpress

B Coreg

B Coreg CR E

B Corgard

B Corzide

B Covera HS

B Cozaar

B Demadex

B Dilacor XR

g Dilt CD

g Dilt XR

g Diltia XT

g Diltiazem

g Diltiazem ER

g Diltzac ER

B Diovan E

B Diovan HCT E

B Diuril

g Doxazosin

B Dutoprol E

B Dyazide

B Dynacirc CR

B Dyrenium

B Edarbi

B Edarbyclor

B Edecrin

g Enalapril

g Enalapril-Hydrochlorothiazide


B Epaned

g Eplerenone

g Eprosartan

g Ethacrynic Acid

B Exforge E

B Exforge HCT E

g Felodipine ER

g Fosinopril

g Fosinopril-Hydrochlorothiazide

g Furosemide

g Guanfacine

g Hydralazine

g Hydrochlorothiazide

B Hyzaar

g Indapamide

B Inderal

B Inderal LA E

B Inderal XL E

B Innopran XL E

B Inspra

g Irbesartan

g Irbesartan-Hydrochlorothiazide

B Isoptin SR

g Isradipine

B Kapspargo

B Katerzia

g Labetalol

B Lasix

B Levatol

g Lisinopril

g Lisinopril-Hydrochlorothiazide

B Lopressor

B Lopressor HCT

g Losartan

g Losartan-Hydrochlorothiazide



4


B Lotensin

B Lotensin HCT

B Lotrel

g Matzim LA

B Mavik

B Maxzide

g Methyclothiazide

g Methyldopa

g Methyldopa-Hydrochlorothiazide

g Metolazone

g Metoprolol 37.5, 75 mg E

g Metoprolol-Hydrochlorothiazide

g Metoprolol Succinate

g Metoprolol Tartrate

B Micardis E

B Micardis HCT E

B Microzide

B Midamor

B Minipress

g Minoxidil

g Moexipril

g Moexipril-Hydrochlorothiazide

g Nadolol

g Nadolol-Bendroflumethazide

g Nicardipine

g Nifedipine

g Nifedipine ER

g Nimodipine

g Nisoldipine

B Norvasc E

g Olmesartan

g Olmesartan-Hydrochlorothiazide

g Perindopril

g Pindolol

g Prazosin


B Prestalia E

B Prinivil

B Procardia

B Procardia XL

g Propranolol

g Propranolol-Hydrochlorothiazide

B Qbrelis

g Quinapril

g Quinapril-Hydrochlorothiazide

g Ramipril

g Reserpine

B Sectral

g Spironolactone

g Spironolactone-Hydrochlorothiazide

B Sular

B Tarka

g Taztia XT

B Tekturna

B Tekturna HCT

g Telmisartan

g Telmisartan-Amlodipine E

g Telmisartan-Hydrochlorothiazide

B Tenex

B Tenoretic E

B Tenormin E

g Terazosin

B Teveten

B Teveten HCT

B Thalitone

B Tiazac

g Timolol1

B Toprol XL

g Torsemide

B Trandate

g Trandolapril



5


g Trandolapril-Verapamil

g Triamterene

g Triamterene-Hydrochlorothiazide

B Tribenzor E

B Twynsta E

B Uniretic

B Univasc

g Valsartan

g Valsartan-Hydrochlorothiazide

B Vaseretic E

B Vasotec E

g Verapamil

g Verapamil ER

B Verelan

B Verelan PM

B Zaroxolyn

B Zebeta

B Zestoretic E

B Zestril E

B Ziac

Cardiovascular/Heart Disease: High Cholesterol

B Altoprev E

B Antara E

g Atorvastatin

g Cholestyramine

g Cholestyramine Light

g Choline Fenofibrate E

g Colesevelam Tablets, Powder for Suspension

E

B Colestid

g Colestipol

B Crestor E

B Ezallor Sprinkle

g Ezetimibe


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

E

g Fenofibrate 40, 48, 120 mg Tablet E

g Fenofibrate 54, 145, 160 mg Tablet

g Fenofibric Acid E

B Fenoglide E

B Fibricor E

B Flolipid

g Fluvastatin

g Fluvastatin ER

g Gemfibrozil

B Lescol

B Lescol XL E

B Lipitor E

B Lipofen E

B Livalo E

B Lofibra E

B Lopid

g Lovastatin

B Lovaza E

B Mevacor

B Nexletol

B Nexlizet

g Niacin Extended-Release

B Niacor

B Niaspan

g Omega-3 Acid Ethyl Esters

B Pravachol

g Pravastatin

g Prevalite

B Questran

B Questran Light

g Rosuvastatin

g Simvastatin



6


g Simvastatin-Ezetimibe

B Tricor E

B Triglide E

B Trilipix E

B Vascepa

B Vytorin E

B Welchol

B Zetia E

B Zocor

B Zypitamag E

Depression: Selective Serotonin Reuptake Inhibitors (SSRIs)1

B Celexa E

g Citalopram

g Escitalopram

g Fluoxetine Capsules

g Fluoxetine 10 mg, 20 mg Tablets

g Fluoxetine 60 mg Tablets E

g Fluvoxamine

g Fluvoxamine Extended-Release

B Lexapro E

g Paroxetine

g Paroxetine Extended-Release

B Paxil

B Paxil CR

B Pexeva E

B Prozac E

g Sertraline

B Zoloft E

Diabetes: Diabetic Supplies

B Accu-Chek Guide Meters

B Accu-Chek Guide Test Strips

B Contour Next EZ Meters

B Contour Next Meters

B Contour Next One Meters


B Contour Next Test Strips

g Diabetic Testing - Lancets

Insulin Needles/Syringes

B OneTouch Diabetic Meters

B OneTouch Diabetic Test Strips

Diabetes: Insulin

B Admelog, Admelog SoloStar E

B Afrezza E

B Apidra, Apidra SoloStar E

B Basaglar E

B Fiasp, Fiasp FlexTouch E

B Humalog

B Humalog Junior

B Humalog Mix 50/50

B Humalog Mix 75/25

B Humulin 50/50

B Humulin 70/30

B Humulin N

B Humulin R

B Insulin Aspart E

B Insulin Aspart Protamine/Insulin Aspart E

B Insulin Lispro E

B Insulin Lispro Jr. E

B Insulin Lispro Protamine/Insulin Lispro 75/25

E

B Lantus

B Levemir E

B Lyumjev E

B Novolin 70/30 E

B Novolin N E

B Novolin R E

B Novolog, Novolog FlexPen E

B Novolog Mix 70/30 E

B Soliqua

B Toujeo



7


B Tresiba E

Diabetes: Non-Insulin

g Acarbose

B ACTOplus Met

B ACTOplus Met XR

B Actos E

B Adlyxin

B Alogliptin E

B Alogliptin-Metformin E

B Alogliptin-Pioglitazone E

B Amaryl

B Avandia

B Bydureon

B Bydureon BCise

B Byetta

B Cycloset

B Diabeta

B Duetact

B Farxiga E

B Fortamet E

g Glimepiride

g Glipizide

g Glipizide ER

g Glipizide-Metformin

B Glucophage

B Glucophage XR

B Glucotrol

B Glucotrol XL

B Glucovance

B Glumetza E

g Glyburide

g Glyburide Micronized

g Glyburide-Metformin

B Glynase


B Glyset

B Glyxambi

B Invokamet E

B Invokamet XR E

B Invokana E

B Janumet E

B Janumet XR E

B Januvia E

B Jardiance

B Jentadueto

B Jentadueto XR

B Kazano

B Kombiglyze XR

g Metformin

g Metformin ER (generic Fortamet) E

g Metformin ER (generic Glucophage XR)

g Metformin ER (generic Glumetza) E

g Metformin Solution (generic Riomet)

g Miglitol

g Nateglinide

B Nesina

B Onglyza

B Oseni

B Ozempic

g Pioglitazone

g Pioglitazone-Glimepiride

g Pioglitazone-Metformin

B PrandiMet

B Prandin

B Precose

B Qtern E

g Repaglinide

g Repaglinide-Metformin

B Riomet



8


B Riomet ER

B Rybelsus

B Segluromet E

B Starlix

B Steglatro E

B Steglujan E

B SymlinPen

B Synjardy

B Synjardy XR

g Tolbutamide

B Tradjenta

B Trijardy XR

B Trulicity

B Victoza

B Xigduo XR E

B Xultophy E

Immunosuppressant: Organ Rejection

B Astagraf XL E

B Azasan

g Azathioprine

B Cellcept E

g Cyclosporine

B Envarsus XR E

g Everolimus

g Gengraf

B Imuran E

g Mycophenolate

g Mycophenolic Acid

B Myfortic E

B Neoral E

B Prograf

B Rapamune E

B Sandimmune E

g Sirolimus


g Tacrolimus

B Zortress

Musculoskeletal: Osteoporosis

B Actonel

g Alendronate

B Atelvia E

B Binosto E

B Boniva

g Calcitonin (Salmon)

B Didronel

g Etidronate

B Evista E

B Forteo E

B Fortical

g Ibandronate

B Miacalcin

g Raloxifene

g Risedronate

B Teriparatide

B Tymlos

Respiratory: Asthma/COPD

B Accolate

B Accuneb

B Advair Diskus

B Advair HFA

B Albuterol HFA (generic ProAir HFA, Proventil HFA)

B Albuterol HFA (Ventolin HFA authorized generic)

E

B AirDuo RespiClick E

g Albuterol Nebulized Solution

g Albuterol Oral Tablet

B Alvesco E

g Aminophylline

B Anoro Ellipta



9


B ArmonAir RespiClick E

B Arnuity Ellipta

B Asmanex HFA E

B Asmanex Twisthaler E

B Atrovent HFA

B Bevespi Aerosphere

B Breo Ellipta

B Brovana

B Budesonide/Formoterol (Symbicort Authorized Generic)

E

g Budesonide Nebulized Solution

B Combivent Respimat

g Cromolyn

B Daliresp

B Duaklir Pressair E

B Dulera E

B Duoneb

B Elixophyllin

B Flovent Diskus

B Flovent HFA

g Fluticasone/Salmeterol Diskus E

g Fluticasone/Salmeterol RespiClick

B Foradil

B Gastrocrom

B Incruse Ellipta E

g Ipratropium

g Ipratropium/Albuterol

B Levalbuterol HFA

g Levalbuterol Nebulized Solution

B Lonhala Magnair E

B Lufyllin

g Metaproterenol

g Montelukast

B Perforomist


B ProAir Digihaler E

B Proair HFA

B Proair RespiClick

B Proventil HFA

B Pulmicort Flexhaler

B Pulmicort Nebulized Solution E

B QVAR Redihaler E

B Serevent Diskus

B Singulair E

B Spiriva HandiHaler

B Spiriva Respimat

B Stiolto Respimat E

B Striverdi Respimat

B Symbicort

g Terbutaline

B Theo-24

g Theophylline

g Theophylline/Guaifenesin

B Trelegy Ellipta

B Tudorza Pressair E

B Ventolin HFA

B VoSpire ER

B Xopenex HFA

B Xopenex Nebulized Solution E

B Yupelri

B Zafirlukast

B Zyflo

B Zyflo CR

Vitamins

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

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

Index

10

A

Acarbose ............................................... 7Accolate ................................................ 8Accu-Chek Guide Meters .................... 6Accu-Chek Guide Test Strips .............. 6Accuneb ................................................ 8Accupril ................................................. 2Accuretic ............................................... 2Acebutolol ............................................. 2Aceon .................................................... 2Actonel .................................................. 8ACTOplus Met ...................................... 7ACTOplus Met XR ................................ 7Actos ...................................................... 7Adalat CC .............................................. 2Adlyxin ................................................... 7Admelog, Admelog SoloStar ............... 6Advair Diskus ........................................ 8Advair HFA ............................................ 8Afeditab ................................................. 2Afrezza ................................................... 6Aggrenox ............................................... 1AirDuo RespiClick ................................ 8Albuterol HFA ........................................ 8Albuterol Nebulized Solution............... 8Albuterol Oral Tablet ............................ 8Aldactazide ........................................... 2Aldactone .............................................. 2Alendronate........................................... 8Aliskiren ................................................. 2Alogliptin ............................................... 7Alogliptin-Metformin............................. 7Alogliptin-Pioglitazone ......................... 7Altace ..................................................... 2Altoprev ................................................. 5Alvesco .................................................. 8Amaryl ................................................... 7Amiloride ............................................... 2Amiloride-Hydrochlorothiazide ........... 2Aminophylline ....................................... 8Amlodipine ............................................ 2Amlodipine-Benazepril ........................ 2Amlodipine-Olmesartan....................... 2Amlodipine-Olmesartan-

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

Hydrochlorothiazide ......................... 2Amturnide .............................................. 2

Anastrozole ........................................... 1Anoro Ellipta .......................................... 8Antara .................................................... 5Apidra, Apidra SoloStar ....................... 6Arimidex ................................................ 1Arixtra .................................................... 1ArmonAir RespiClick ............................ 9Arnuity Ellipta ........................................ 9Aromasin ............................................... 1Asmanex HFA ....................................... 9Asmanex Twisthaler ............................. 9Aspirin-Dipyridamole............................ 1Astagraf XL ........................................... 8Atacand ................................................. 2Atacand HCT ........................................ 2Atelvia .................................................... 8Atenolol ................................................. 2Atenolol-Chlorthalidone ....................... 2Atorvastatin ........................................... 5Atrovent HFA ......................................... 9Avalide ................................................... 2Avandia .................................................. 7Avapro ................................................... 2Azasan ................................................... 8Azathioprine .......................................... 8Azor ........................................................ 2

B

Basaglar ................................................ 6Benazepril ............................................. 2Benazepril-Hydrochlorothiazide ......... 2Benicar .................................................. 2Benicar HCT.......................................... 2Betaxolol ............................................... 2Bevespi Aerosphere ............................. 9Bevyxxa ................................................. 1Bidil ........................................................ 2Binosto .................................................. 8Bisoprolol .............................................. 2Bisoprolol-Hydrochlorothiazide .......... 2Boniva .................................................... 8Breo Ellipta ............................................ 9Brilinta.................................................... 1Brovana ................................................. 9Budesonide Nebulized Solution ......... 9Budesonide/Formoterol ...................... 9Bumetanide ........................................... 2Bydureon ............................................... 7Bydureon BCise .................................... 7

Byetta .................................................... 7Bystolic .................................................. 2Byvalson ................................................ 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 ........................................ 3Celexa .................................................... 6Cellcept ................................................. 8Chlorothiazide ....................................... 3Cholestyramine .................................... 5Cholestyramine Light ........................... 5Choline Fenofibrate .............................. 5Cilostazol ............................................... 1Citalopram ............................................. 6Clonidine ............................................... 3Clonidine Patch .................................... 3Clopidogrel ........................................... 1Clorpress ............................................... 3Colesevelam Tablets, Powder for

Suspension ........................................ 5Colestid ................................................. 5Colestipol .............................................. 5Combivent Respimat............................ 9Contour Next EZ Meters ...................... 6Contour Next Meters ............................ 6Contour Next One Meters ................... 6Contour Next Test Strips ..................... 6Coreg ..................................................... 3Coreg CR .............................................. 3Corgard ................................................. 3Corzide .................................................. 3Coumadin .............................................. 1

11

Covera HS ............................................. 3Cozaar ................................................... 3Crestor ................................................... 5Cromolyn ............................................... 9Cycloset ................................................. 7Cyclosporine ......................................... 8

D

Daliresp ................................................. 9Demadex ............................................... 3Diabeta .................................................. 7Diabetic Testing - Lancets ................... 6Didronel ................................................. 8Dilacor XR ............................................. 3Dilt CD ................................................... 3Dilt XR .................................................... 3Diltia XT ................................................. 3Diltiazem ................................................ 3Diltiazem ER .......................................... 3Diltzac ER .............................................. 3Diovan .................................................... 3Diovan HCT ........................................... 3Dipyridamole ......................................... 1Diuril ....................................................... 3Doxazosin .............................................. 3Duaklir Pressair .................................... 9Duetact .................................................. 7Dulera .................................................... 9Duoneb .................................................. 9Dutoprol ................................................. 3Dyazide .................................................. 3Dynacirc CR .......................................... 3Dyrenium ............................................... 3

E

Edarbi .................................................... 3Edarbyclor ............................................. 3Edecrin .................................................. 3Effient ..................................................... 1Eliquis .................................................... 1Elixophyllin ............................................ 9Enalapril ................................................. 3Enalapril-Hydrochlorothiazide ............. 3Enoxaparin ............................................ 2Envarsus XR .......................................... 8Epaned .................................................. 3Eplerenone ............................................ 3Eprosartan ............................................ 3Escitalopram ......................................... 6Ethacrynic Acid ..................................... 3Etidronate .............................................. 8

Everolimus ............................................. 8Evista ..................................................... 8Exemestane .......................................... 1Exforge .................................................. 3Exforge HCT ......................................... 3Ezallor Sprinkle ..................................... 5Ezetimibe ............................................... 5

F

Fareston ................................................ 1Farxiga ................................................... 7Felodipine ER ........................................ 3Femara................................................... 1Fenofibrate 40, 48, 120 mg Tablet ...... 5Fenofibrate 43, 50, 67, 130, 134,

150, 200 mg Capsule ....................... 5Fenofibrate 54, 145, 160 mg Tablet .... 5Fenofibric Acid ...................................... 5Fenoglide ............................................... 5Fiasp, Fiasp FlexTouch ......................... 6Fibricor .................................................. 5Flolipid ................................................... 5Flovent Diskus ...................................... 9Flovent HFA ........................................... 9Fluoxetine 10 mg, 20 mg Tablets ........ 6Fluoxetine 60 mg Tablets ..................... 6Fluoxetine Capsules ............................. 6Fluticasone/Salmeterol Diskus ........... 9Fluticasone/Salmeterol RespiClick .... 9Fluvastatin ............................................. 5Fluvastatin ER ....................................... 5Fluvoxamine .......................................... 6Fluvoxamine Extended-Release ......... 6Fondaparinux ........................................ 2Foradil .................................................... 9Fortamet ................................................ 7Fortamet) ............................................... 7Forteo .................................................... 8Fortical ................................................... 8Fosinopril ............................................... 3Fosinopril-Hydrochlorothiazide ........... 3Fragmin.................................................. 2Furosemide ........................................... 3

G

Gastrocrom ........................................... 9Gemfibrozil ............................................ 5Gengraf .................................................. 8Glimepiride ............................................ 7Glipizide ................................................. 7Glipizide ER ........................................... 7

Glipizide-Metformin .............................. 7Glucophage .......................................... 7Glucophage XR .................................... 7Glucotrol ................................................ 7Glucotrol XL .......................................... 7Glucovance ........................................... 7Glumetza ............................................... 7Glyburide ............................................... 7Glyburide Micronized ........................... 7Glyburide-Metformin ............................ 7Glynase .................................................. 7Glyset ..................................................... 7Glyxambi ............................................... 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.................................................... 8Incruse Ellipta ....................................... 9Indapamide ........................................... 3Inderal .................................................... 3Inderal LA .............................................. 3Inderal XL .............................................. 3Innopran XL ........................................... 3Inspra ..................................................... 3Insulin Aspart ........................................ 6Insulin Aspart Protamine/

Insulin Aspart .................................... 6Insulin Lispro ......................................... 6Insulin Lispro Jr. .................................... 6Insulin Lispro Protamine/Insulin

Lispro 75/25 ...................................... 6Invokamet .............................................. 7Invokamet XR ........................................ 7Invokana ................................................ 7Ipratropium ............................................ 9Ipratropium/Albuterol ........................... 9

12

Irbesartan .............................................. 3Irbesartan-Hydrochlorothiazide .......... 3Isoptin SR .............................................. 3Isradipine ............................................... 3

J

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

K

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

L

Labetalol ................................................ 3Lantus .................................................... 6Lasix....................................................... 3Lescol .................................................... 5Lescol XL ............................................... 5Letrozole ................................................ 1Levalbuterol HFA .................................. 9Levalbuterol Nebulized Solution ......... 9Levatol ................................................... 3Levemir .................................................. 6Lexapro.................................................. 6Lipitor ..................................................... 5Lipofen ................................................... 5Lisinopril ................................................ 3Lisinopril-Hydrochlorothiazide ............ 3Livalo...................................................... 5Lofibra ................................................... 5Lonhala Magnair ................................... 9Lopid ...................................................... 5Lopressor .............................................. 3Lopressor HCT ..................................... 3Losartan ................................................ 3Losartan-Hydrochlorothiazide ............ 3Lotensin ................................................. 4Lotensin HCT ........................................ 4Lotrel ...................................................... 4Lovastatin .............................................. 5Lovaza ................................................... 5Lovenox ................................................. 2Lufyllin ................................................... 9

Lyumjev ................................................. 6

M

Matzim LA ............................................. 4Mavik ..................................................... 4Maxzide ................................................. 4Metaproterenol ..................................... 9Metformin .............................................. 7Metformin ER ........................................ 7Metformin Solution ............................... 7Methyclothiazide .................................. 4Methyldopa ........................................... 4Methyldopa-Hydrochlorothiazide ....... 4Metolazone ........................................... 4Metoprolol 37.5, 75 mg ........................ 4Metoprolol Succinate ........................... 4Metoprolol Tartrate ............................... 4Metoprolol-Hydrochlorothiazide ......... 4Mevacor ................................................. 5Miacalcin ............................................... 8Micardis ................................................. 4Micardis HCT ........................................ 4Microzide ............................................... 4Midamor ................................................ 4Miglitol ................................................... 7Minipress ............................................... 4Minoxidil ................................................ 4Moexipril ................................................ 4Moexipril-Hydrochlorothiazide ............ 4Montelukast .......................................... 9Mycophenolate ..................................... 8Mycophenolic Acid ............................... 8Myfortic ................................................. 8

N

Nadolol .................................................. 4Nadolol-Bendroflumethazide .............. 4Nateglinide ............................................ 7Neoral .................................................... 8Nesina .................................................... 7Nexletol .................................................. 5Nexlizet .................................................. 5Niacin Extended-Release .................... 5Niacor .................................................... 5Niaspan ................................................. 5Nicardipine ............................................ 4Nifedipine .............................................. 4Nifedipine ER ........................................ 4Nimodipine ............................................ 4Nisoldipine ............................................ 4Norvasc ................................................. 4

Novolin 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

Paroxetine ............................................. 6Paroxetine Extended-Release ............. 6Paxil ....................................................... 6Paxil CR ................................................. 6Pediatric Flouride Preparations .......... 9Perforomist ........................................... 9Perindopril ............................................. 4Persantine ............................................. 2Pexeva ................................................... 6Pindolol .................................................. 4Pioglitazone .......................................... 7Pioglitazone-Glimepiride ..................... 7Pioglitazone-Metformin ....................... 7Plavix ...................................................... 2Pletal ...................................................... 2Pradaxa ................................................. 2PrandiMet .............................................. 7Prandin .................................................. 7Prasugrel ............................................... 2Pravachol ............................................... 5Pravastatin ............................................ 5Prazosin ................................................. 4Precose ................................................. 7Prenatal Vitamins ................................. 9Prestalia ................................................. 4Prevalite ................................................. 5Prinivil .................................................... 4ProAir Digihaler ..................................... 9ProAir HFA.........................................8, 9Proair RespiClick .................................. 9Procardia ............................................... 4Procardia XL ......................................... 4Prograf ................................................... 8Propranolol ........................................... 4

13

Propranolol-Hydrochlorothiazide ........ 4Proventil HFA ....................................8, 9Prozac .................................................... 6Pulmicort 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 ............................................... 7, 8Riomet ER ............................................. 8Risedronate ........................................... 8Rosuvastatin ......................................... 5Rybelsus ................................................ 8

S

Sandimmune ......................................... 8Savaysa ................................................. 2Sectral ................................................... 4Segluromet ............................................ 8Serevent Diskus .................................... 9Sertraline ............................................... 6Simvastatin ............................................ 5Simvastatin-Ezetimibe .......................... 6Singulair................................................. 9Sirolimus ................................................ 8Soliqua ................................................... 6Soltamox ............................................... 1Spiriva HandiHaler................................ 9Spiriva Respimat .................................. 9Spironolactone ..................................... 4Spironolactone-Hydrochlorothiazide . 4Starlix ..................................................... 8Steglatro ................................................ 8Steglujan ............................................... 8Stiolto Respimat ................................... 9Striverdi Respimat ................................ 9Sular ....................................................... 4

Symbicort .............................................. 9SymlinPen ............................................. 8Synjardy ................................................. 8Synjardy XR ........................................... 8

T

Tacrolimus ............................................. 8Tamoxifen .............................................. 1Tarka ...................................................... 4Taztia XT ................................................ 4Tekturna ................................................ 4Tekturna HCT ........................................ 4Telmisartan............................................ 4Telmisartan-Amlodipine ....................... 4Telmisartan-Hydrochlorothiazide ........ 4Tenex ..................................................... 4Tenoretic ................................................ 4Tenormin ............................................... 4Terazosin ............................................... 4Terbutaline ............................................ 9Teriparatide ........................................... 8Teveten .................................................. 4Teveten HCT ......................................... 4Thalitone ................................................ 4Theo-24 ................................................. 9Theophylline.......................................... 9Theophylline/Guaifenesin .................... 9Tiazac .................................................... 4Ticlopidine ............................................. 2Timolol ................................................... 4Tolbutamide .......................................... 8Toprol XL ............................................... 4Toremifene ............................................ 1Torsemide ............................................. 4Toujeo .................................................... 6Tradjenta ............................................... 8Trandate ................................................ 4Trandolapril ........................................... 4Trandolapril-Verapamil ......................... 5Trelegy Ellipta ........................................ 9Tresiba ................................................... 7Triamterene ........................................... 5Triamterene-Hydrochlorothiazide ....... 5Tribenzor ............................................... 5Tricor ...................................................... 6Triglide ................................................... 6Trijardy XR ............................................. 8Trilipix..................................................... 6Trulicity .................................................. 8Tudorza Pressair ................................... 9Twynsta ................................................. 5

Tymlos ................................................... 8

U

Uniretic .................................................. 5Univasc .................................................. 5

V

Valsartan ............................................... 5Valsartan-Hydrochlorothiazide ............ 5Vascepa ................................................. 6Vaseretic ................................................ 5Vasotec .................................................. 5Ventolin HFA .....................................8, 9Verapamil .............................................. 5Verapamil ER ........................................ 5Verelan ................................................... 5Verelan PM ............................................ 5Victoza ................................................... 8VoSpire ER ............................................ 9Vytorin ................................................... 6

W

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

X

Xarelto ................................................... 2Xigduo XR ............................................. 8Xopenex HFA ........................................ 9Xopenex Nebulized Solution ............... 9Xultophy ................................................. 8

Y

Yupelri .................................................... 9

Z

Zafirlukast ............................................. 9Zaroxolyn ............................................... 5Zebeta ................................................... 5Zestoretic .............................................. 5Zestril ..................................................... 5Zetia ....................................................... 6Ziac ........................................................ 5Zocor ..................................................... 6Zoloft ..................................................... 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 their 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

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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.

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

http://www.hhs.gov/ocr/office/file/index.html

Learn more.

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.

This plan includes plan participants for a self-funded plan administered by Oxford.

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.

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8/20 ©2021 United HealthCare Services, Inc. WF3273499-B_2021 Preventive Core Plus List

Documents

January 2021 Preventive Medication List for Consumer