Kairos Health Arizona Preventive Drug List
Effective July 1, 2020
PLEASE NOTE: Inclusion of preventive medications on this list does not guarantee coverage. Please refer to your formulary for coverage information, or call MaxorPlus at 800-687-0707.
ANAPHYLAXIS ANTIDIABETIC AGENTS ANTIDIABETIC AGENTS
Epi-pen Epinephrine 0.3 mg acarbose glyburide/ Proglycem Synjardy XR Epi-pen Jr. Epinephrine 0.15 mg Actoplus Met metformin Qtern Tanzeum Actoplus Met XR Glynase repaglinide tolazamide Actos Glyset repaglinide/ tolbutamide Adlyxin Glyxambi metformin Toujeo ANTICOAGULANTS Afrezza Humalog Riomet Tradjenta Alogliptin Humulin Soliqua Tresiba Bevyxxa Lovenox Alogliptin/ Invokamet Starlix Trulicity Coumadin Pradaxa Metformin Invokamet XR Steglatro Victoza Eliquis Savaysa Alogliptin/ Invokana Steglujan Xigduo XR enoxaparin warfarin Pioglitazone Janumet Symlin Xultophy Fragmin Xarelto Amaryl Janumet XR Synjardy Apidra Januvia Avandia Jardiance Basaglar Jentadueto ANTIESTROGEN & ANTICONVULSANTS Bydureon Jentadueto XR Byetta Kazano AROMATASE INHIBITORS Aptiom Neurontin chlorpropamide Kombiglyze XR anastrozole Femara Banzel oxcarbazepine Cycloset Korlym Arimidex Ietrozole Briviact Oxtellar XR Duetact Lantus Aromasin Soltamox carbamazepine Peganone Farxiga Levemir exemestane tamoxifen Carbatrol Phenytek Fiasp metformin Fareston Celontin phenytoin Fortamet miglitol Depakene pregabalin glimepiride nateglinide Depakote primidone glipizide Nesina ANTIPLATELET Dilantin Qudexy XR glipizide/ Novolin AGENTS divalproex Spritam metformin Novolog ethosuximide Tegretol Glucagen Onglyza Aggrenox dipyridamole Fycompa Topamax Glucagon Oseni aspirin/ Effient gabapentin topiramate Glucophage Ozempic dipyridamole Plavix Keppra Trileptal Glucophage XR pioglitazone Brilinta prasugrel Keppra XR Trokendi XR Glucose tabs pioglitazone/ cilostazol ticlopidine Lamictal valproic acid Glucotrol glimepiride clopidogrel Yosprala lamotrigine Vimpat Glucotrol XL pioglitazone/ levetiracetam Zarontin Glucovance metformin Lyrica Zonegran Glumetza Prandin Mysoline zonisamide glyburide Precose
Please note: Brand name drugs are listed beginning with a Page 1 capital letter and generic drugs are listed in lower case letters. Kairos Health Arizona Preventive List
CARDIOVASCULAR/HIGH CARDIOVASCULAR/HIGH CHOLESTEROL BLOOD PRESSURE BLOOD PRESSURE LOWERING AGENTS
Accupril Demadex methyldopa/hctz Procardia XL Altoprev Livalo Accuretic Diamox metolazone propranolol amlodipine/ Lofibra acebutolol digoxin metoprolol propranolol/hctz atorvastatin Lopid acetazolamide Dilatrate SR succinate er Qbrelis Antara lovastatin Adalat CC diltiazem metoprolol quinapril atorvastatin Lovaza Afeditab cr Diovan tartrate quinapril/hctz Caduet Niacin Aldactazide Diovan HCT metoprolol/hctz ramipril cholestyramine Niacor Aldactone Diuril Micardis Ranexa Colestid Niaspan Altace doxazosin Micardis HCT reserpine colestipol omega-3-acid amiloride Dutoprol Microzide sotalol Crestor ethyl esters amiloride/hctz Dyazide Minipress Sotylize ezetimibe Pravachol amlodipine Dyrenium Minitran spironolactone ezetimibe/ pravastatin amlodipine/ Edarbi minoxidil sprionolatone/hctz simvastatin Prevalite benazepril Edarbyclor moexipril Sular fenofibrate Questran amlodipine/ Edecrin moexipril/hctz Tarka fenofibric acid rosuvastatin olmesartan enalapril Monopril Taztia XT Fenoglide simvastatin amlodipine/ enalapril/hctz Monopril HCT Tekturna Fibricor Tricor telmisartan Entresto nadolol Tekturna HCT Flolipid Triglide amlodipine/ Epaned nadolol/ telmisartan fluvastatin Trilipix valsartan eplerenone bendro- telmisartan/hctz gemfibrozil Vytorin amlodipine/ Eprosartan flumethiazide Tenoretic Lescol XL Welchol valsartan/hctz ethacrynic acid nicardipine Tenormin Lipitor Zetia Atacand Exforge nifedipine terazosin Liptruzet Zocor Atacand HCT Exforge HCT nimodipine timolol Lipofen atenolol felodipine nisoldipine Toprol XL atenolol/ fosinopril Nitro-Bid ointment torsemide CONTRACEPTIVES chlorthalidone fosinopril/hctz Nitro-Dur Trandate Avalide furosemide nitroglycerin trandolapril Avapro Gonitro Nitrolingual trandolapril/ Depo-Provera Nuvaring Azor guanfacine Pumpspray verapamil Kyleena Paragard benazepril Hemangeol Nitromist triamterene/hctz Liletta Skyla benazepril/hctz hydralazine Nitrostat Tribenzor medroxy- Xulane Benicar hydralazine/hctz Norvasc Twynsta progesterone inj. Oral contraceptives Benicar HCT hydrochlorothiazide Nymalize valsartan Mirena *Brand and generic Betapace Hyzaar olmesartan valsartan/hctz Nexplanon betaxolol indapamide olmesartan/ Vaseretic Bidil Inderal LA amlodipine/hctz Vasotec bisoprolol Innopran XL olmesartan/hctz verapamil DIABETIC SUPPLIES bisoprolol/hctz Inspra perindopril Verelan Bystolic irbesartan pindolol Verelan PM Glucose Test Ketone Test Byvalson irbesartan/hctz prazosin Zestoretic Strips Strips Calan Isoptin SR Prestalia Zestril Insulin Syringes Lancets Calan SR Isordil Prinivil Ziac Pen Needles candesartan isosorbide dinitrate Procardia candesartan/hctz isosorbide captopril mononitrate captopril/hctz isradipine Cardene SR labetalol Cardizem Lanoxin Cardizem CD Lasix Cardizem LA lisinopril Cardura lisinopril/hctz Carospir Lopressor cartia xt Lopressor HCT carvedilol losartan Catapres losartan/hctz Catapres-TTS Lotensin chlorothiazide Lotensin HCT chlorthalidone Lotrel clonidine Maxzide Clorpres methazolamide Coreg methyclothiazide Cozaar methyldopa Please note: Brand name drugs are listed beginning with a Page 2 capital letter and generic drugs are listed in lower case letters. Kairos Health Arizona Preventive List
MENTAL HEALTH OSTEOPOROSIS AGENTS RESPIRATORY AGENTS AGENTS Activella Femhrt Accolate levalbuterol Abilify Norpramin Actonel Forteo Advair Maxair Adasuve nortriptyline alendronate Fosamax Aerospan metaproterenol amitriptyline Nuplazid Alora Fosamax Plus D Airduo montelukast amitriptyline/ olanzapine Atelvia ibandronate albuterol Perforomist perphenazine olanzapine/ Binosto Menest Alvesco ProAir HFA amoxapine fluoxetine Boniva Menostar Anoro Proventil HFA Anafranil paliperidone calcitonin-salmon Miacalcin Arcapta Neohaler Pulmicort Aplenzin Pamelor Climara Minivelle Armonair Qvar aripiprazole Parnate Combipatch norethindrone/ Arnuity Seebri Neohaler bupropion paroxetine Delestrogen ethinyl estradiol Asmanex Serevent Celexa Paxil Depo-Estradiol pamidronate Atrovent HFA Singulair chlordiazepoxide/ Paxil CR Divigel Prefest Bevespi Spiriva amitriptyline perphenazine/ Elestrin Premarin tablets Breo Stiolto citalopram amitriptyline est. estrogens/ Premphase Brovana Striverdi clomipramine Pexeva methyltestosterone Prempro budesonide Symbicort clozapine phenelzine Estrace Provera Combivent terbutaline Clozaril Pristiq estradiol raloxifene cromolyn sodium Trelegy Cymbalta protriptyline estradiol valerate Reclast Dulera Tudorza desipramine Prozac estradiol/ risedronate Duoneb Utibron Neohaler desvenlafaxine quetiapine norethindrone Tymlos Flovent Ventolin HFA doxepin Remeron Estrogel Vivelle-Dot flunisolide Xopenex duloxetine Rexulti estropipate Xgeva fluticasone zafirlukast Effexor Risperdal etidronate zoledronic acid Foradil zileuton Effexor XR risperidone Evamist Zometa Incruse Zyflo Elavil Saphris Evista ipratropium Emsam Sarafem ipratropium/ Equetro Seroquel albuterol escitalopram Seroquel XR Fanapt sertraline Fetzima Surmontil SMOKING CESSATION fluoxetine Symbyax fluphenazine thiothixene fluvoxamine Tofranil bupropion sr Nicotrol Inhaler Forfivo XL tranylcypromine Chantix Nicotrol NS Geodon trazodone nicotine Zyban Haldol Trimipramine haloperidol Trintellix VITAMINS/SUPPLEMENTS imipramine venlafaxine Invega Versacloz folic acid Khedezla Viibryd iron supplements Latuda Vraylar prenatal vitamins Lexapro Wellbutrin loxapine Wellbutrin SR Maprotiline Wellbutrin XL Marplan ziprasidone mirtazapine Zoloft Nardil Zyprexa nefazodone
Federal guidelines for HSA eligible high deductible plans allow coverage of certain preventive medications prior to meeting the deductible. Drugs on this list were evaluated and selected based on IRS guidance and clinical validation to ensure that the indications for which they are commonly prescribed are considered preventive within established guidelines. This list contains examples of preventive medications – it may not include all preventive medications. Some forms (i.e. creams vs. tablets) or some strengths of a drug on this list may not be considered preventive. Certain restrictions including prior authorizations, coverage exclusions, quantity limits, or step therapy requirements may still apply. Please contact MaxorPlus if you have any questions regarding coverage.
Please note: Brand name drugs are listed beginning with a Page 3 capital letter and generic drugs are listed in lower case letters.