2020 preventive medication list for consumer driven health

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2020 Preventive Medication List forConsumer Driven Health PlansCore Plus ListCDH preventive drug lists may also be used with non-CDH plans

Effective July 1, 2020

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 February 1, 2020 and is subject to change after this date. The next anticipated update will occur with the next PDL cycle.

Core Plus Drug List

Requirements Therapeutic Drug Classes & Limits

Breast Cancer Prevention

Anastrozole

Arimidex E

Aromasin

Exemestane

Fareston

Femara E

Letrozole

Soltamox E

Tamoxifen

Toremifene


Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy

Aggrenox

Arixtra

Aspirin-Dipyridamole

Bevyxxa

Brilinta

Cilostazol

Clopidogrel

Coumadin

Dipyridamole

Effient E

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)

*Coverage is provided for oral formulations1 SSRIs are included only for employer groups who have specifically requested coverage.

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Enoxaparin

Fragmin

Fondaparinux

Heparin

Jantoven

Lovenox E

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

Aliskiren

Altace

Amiloride

Amiloride-Hydrochlorothiazide

Amlodipine

Amlodipine-Benazepril

Amlodipine-Olmesartan E

Amlodipine-Olmesartan- EHydrochlorothiazide


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

Katerzia 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 E

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

5





Trandate

Trandolapril

Trandolapril-Verapamil

Triamterene

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 ESuspension

Colestid

Colestipol

Crestor E

Ezallor Sprinkle


Ezetimibe

Fenofibrate 43, 50, 67, 130, 134, 150, E200 mg Capsule

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

Simvastatin Suspension (Flolipid EAuthorized Generic)

6





Tricor E

Triglide E

Trilipix E

Vascepa

Vytorin E

Welchol

Zetia E

Zocor

Zypitamag E

Depression: Selective Serotonin Reuptake Inhibitors (SSRIs)1

Celexa E

Citalopram

Escitalopram

Fluoxetine Capsules

Fluoxetine 10 mg, 20 mg Tablets

Fluoxetine 60 mg Tablets E

Fluvoxamine

Fluvoxamine Extended-Release

Lexapro E

Paroxetine

Paroxetine Extended-Release

Paxil

Paxil CR

Pexeva

Prozac E

Sertraline

Zoloft 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 E

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

Insulin Aspart E

Insulin Aspart Protamine/Insulin Aspart E

Insulin Lispro E

Lantus

Levemir E

Novolin 70/30 E

Novolin N E

Novolin R E

Novolog, Novolog FlexPen E

Novolog Mix 70/30 E

Soliqua

Toujeo

Tresiba E

Diabetes: Non-Insulin

Acarbose

ACTOplus Met

ACTOplus Met XR

Actos E

Adlyxin

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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

Glucovance

Glumetza E

Glyburide

Glyburide Micronized

Glyburide-Metformin

Glynase

Glyset

Glyxambi

Invokamet

Invokamet XR

Invokana

Janumet E

Janumet XR E

Januvia E


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

Rybelsus

Segluromet E

Starlix

Steglatro E

Steglujan E

SymlinPen

Synjardy

Synjardy XR

Tolbutamide

Tradjenta

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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

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

Albuterol HFA (ProAir HFA, Proventil HFA authorized generic)

Albuterol HFA (Ventolin HFA authorized Egeneric)

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/Formoterol (Symbicort EAuthorized Generic)

Budesonide Nebulized Solution

Combivent Respimat

Cromolyn

Daliresp

Duaklir Pressair E

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Dulera E

Duoneb

Elixophyllin

Flovent Diskus

Flovent HFA

Fluticasone/Salmeterol Diskus E

Fluticasone/Salmeterol RespiClick

Foradil

Gastrocrom

Incruse Ellipta

Ipratropium

Ipratropium/Albuterol

Levalbuterol HFA

Levalbuterol Nebulized Solution

Lonhala Magnair E

Lufyllin

Metaproterenol

Montelukast

Perforomist

Proair HFA

Proair RespiClick

Proventil HFA

Pulmicort Flexhaler

Pulmicort Nebulized Solution E

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 E

Utibron NeoHaler E

Ventolin HFA

VoSpire ER

Xopenex HFA

Xopenex Nebulized Solution E

Yupelri

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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IndexA

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 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 ................................................... 2Anastrozole ................................................ 1

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

B

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

Bydureon BCise ........................................ 7Byetta .......................................................... 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 ............................... 8Contour Next EZ Meters ......................... 6Contour Next Meters ............................... 6Contour Next One Meters ...................... 6Contour Next Test Strips ........................ 6Coreg ........................................................... 3Coreg CR .................................................... 3Corgard ....................................................... 3

11

Corzide ........................................................ 3Coumadin ................................................... 1Covera HS .................................................. 3Cozaar ......................................................... 3Crestor ......................................................... 5Cromolyn .................................................... 8Cycloset ...................................................... 7Cyclosporine .............................................. 8

D

Daliresp ....................................................... 8Demadex .................................................... 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 ........................................ 8Duetact ........................................................ 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 .............................................. 6

Ethacrynic Acid ......................................... 3Etidronate ................................................... 8Evista ........................................................... 8Exemestane ............................................... 1Exforge ........................................................ 3Exforge HCT .............................................. 3Ezallor Sprinkle ......................................... 5Ezetimibe .................................................... 5

F

Fareston ...................................................... 1Farxiga ......................................................... 7Felodipine 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 ........................................... 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 ..................................................... 7Forteo .......................................................... 8Fortical ......................................................... 8Fosinopril .................................................... 3Fosinopril-Hydrochlorothiazide ............. 3Fragmin ....................................................... 2Furosemide ................................................ 3

G

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

Glipizide ER ................................................ 7Glipizide-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 ................................................... 3Innopran XL................................................ 3Inspra ........................................................... 3Insulin Aspart ............................................ 6Insulin Aspart Protamine/

Insulin Aspart ......................................... 6 Insulin Lispro .............................................. 6Insulin Needles/Syringes ........................ 6Invokamet ................................................... 7Invokamet XR ............................................ 7Invokana ...................................................... 7Ipratropium ................................................. 9Ipratropium/Albuterol .............................. 9Irbesartan ................................................... 3Irbesartan-Hydrochlorothiazide ............ 3

12

Isoptin 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

M

Matzim LA .................................................. 4Mavik ........................................................... 4Maxzide....................................................... 4Metaproterenol .......................................... 9Metformin ................................................... 7Metformin ER ............................................. 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 ......................................................... 7Niacin Extended-Release ....................... 5Niacor .......................................................... 5Niaspan ....................................................... 5Nicardipine ................................................. 4Nifedipine ................................................... 4Nifedipine ER ............................................. 4Nimodipine ................................................. 4Nisoldipine.................................................. 4Norvasc ....................................................... 4Novolin 70/30 ............................................ 6Novolin N .................................................... 6Novolin R .................................................... 6Novolog Mix 70/30 .................................. 6

Novolog, 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 HFA ..............................................8, 9Proair RespiClick ...................................... 9Procardia .................................................... 4Procardia XL .............................................. 4Prograf ......................................................... 8Propranolol ................................................. 4Propranolol-Hydrochlorothiazide ......... 4Proventil HFA .........................................8, 9Prozac ........................................................ 6Pulmicort Flexhaler .................................. 9Pulmicort Nebulized Solution ................ 9

13

Q

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

R

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

S

Sandimmune ............................................. 8Savaysa ....................................................... 2Sectral ......................................................... 4Seebri NeoHaler ....................................... 9Segluromet ................................................. 7Serevent Diskus ........................................ 9Sertraline..................................................... 6Simvastatin ................................................. 5Simvastatin-Ezetimibe ............................. 5Simvastatin Suspension ......................... 5Singulair ...................................................... 9Sirolimus ..................................................... 8Soliqua ........................................................ 6Soltamox ..................................................... 1Spiriva HandiHaler ................................... 9Spiriva Respimat ....................................... 9Spironolactone .......................................... 4Spironolactone-Hydrochlorothiazide ... 4Starlix ........................................................... 7Steglatro ...................................................... 7Steglujan ..................................................... 7Stiolto Respimat ........................................ 9Striverdi Respimat .................................... 9Sular ............................................................. 4Symbicort ...............................................8, 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..................................................... 4Toremifene ................................................. 1Torsemide ................................................... 4Toujeo .......................................................... 6Tradjenta ..................................................... 7Trandate ...................................................... 5Trandolapril ................................................ 5Trandolapril-Verapamil ............................ 5Trelegy Ellipta ............................................ 9Tresiba ......................................................... 6Triamterene ............................................... 5Triamterene-Hydrochlorothiazide ......... 5Tribenzor ..................................................... 5Tricor ............................................................ 6Triglide ......................................................... 6Trilipix ........................................................... 6Trulicity ........................................................ 8Tudorza Pressair ....................................... 9Twynsta ....................................................... 5Tymlos ......................................................... 8

U

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

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 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.

For additional information:

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.

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

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.

©2020 United HealthCare Services, Inc. 19-13084 WF2128770-A2020 Preventive Core Plus List 4/20

2020 preventive medication list for consumer driven health

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