Additional Drug Coverage
Additional prescription drug coverage Your plan includes extra coverage for certain drugs and supplies as shown below. This is not a complete list of prescription drugs and supplies covered by our plan. For a complete list, please call Customer Service toll-free at (866) 868-0609 (TTY: 711), 7 a.m. – 7 p.m. CT, Monday – Friday and 7 a.m. – 3 p.m. CT, Saturday. Lower-cost Medicare prescription drugs and supplies Your plan covers some of your Medicare prescription drugs and supplies at a $0 copay. If you have questions, call us toll-free at (866) 868-0609 (TTY: 711), 7 a.m. – 7 p.m. CT, Monday – Friday and 7 a.m. – 3 p.m. CT, Saturday. These drugs and supplies are part of your Medicare prescription drug coverage.1
Breast cancer preventive medications PEG-3350/NaCl/Na Bicarbonate/KCl TriLyte Anastrozole Exemestane Certain diabetic supplies for the Raloxifene administration of insulin Tamoxifen Insulin Syringes & Pen Needles Certain cholesterol-lowering medications Shingles vaccine Atorvastatin 10mg & 20mg Tablet Shingrix Lovastatin 10mg, 20mg & 40mg Tablet Zostavax Simvastatin 5mg, 10mg, 20mg & 40mg Tablet Tobacco cessation medications Certain colon prep products Buproban 150mg GaviLyte-C Chantix GaviLyte-G Nicotrol Inhaler PEG-3350/Electrolytes Nicotrol Nasal Spray
Y0066_200527_081500_C Lower-cost non-Medicare over-the-counter drugs These drugs are covered in addition to the drugs in your plan’s drug list (formulary).2 Your plan covers these over-the-counter drugs at a $0 copay.
Certain colon preparation products Tobacco cessation medications Bisacodyl Tablets Nicotine Gum Magnesium Citrate Solution Nicotine Lozenges Polyethylene Glycol Powder Nicotine Patches
1Information about the appeals and grievance process for these prescription drugs and supplies can be found in your Evidence of Coverage.
2This non-Medicare drug coverage is in addition to your Medicare drug coverage. Unlike your Medicare drug coverage, you cannot file a Medicare appeal or grievance for non-Medicare drug coverage. If you have questions, please call us toll-free at (866) 868-0609 (TTY: 711), 7 a.m. – 7 p.m. CT, Monday – Friday and 7 a.m. – 3 p.m. CT, Saturday. Bonus Drug List The Plan offers a bonus drug list. The prescription drugs on this list are covered in addition to the drugs on the plan’s drug list (formulary). The drug tier for each prescription drug is shown on the list. Although you pay the same copay for these drugs as shown in the Summary of Benefits and Evidence of Coverage, the amount you pay for these additional prescription drugs does not apply to your Medicare Part D out-of-pocket costs. Payments for these additional prescription drugs (made by you or the plan) are treated differently than payments made for other prescription drugs. Coverage for the prescription drugs on the bonus drug list is in addition to your Part D drug coverage. Unlike your Part D drug coverage, you are unable to file a Medicare appeal or grievance for drugs on the bonus drug list. If you have questions, please call us toll-free at (866) 868-0609 (TTY: 711), 7 a.m. – 7 p.m. CT, Monday – Friday and 7 a.m. – 3 p.m. CT, Saturday. If you get Extra Help from Medicare to pay for your prescription drugs, it will not apply to the drugs on this bonus drug list. This is not a complete list of the prescription drugs available to you or the restrictions and limitations that may apply through the bonus drug list. If your drug has any coverage rules or limits, there will be code(s) in the “Coverage Rules or Limits on use” column of the chart. The codes and what they mean are shown below. If you have questions about drug coverage, please call us toll- free at (866) 868-0609 (TTY: 711), 7 a.m. – 7 p.m. CT, Monday – Friday and 7 a.m. – 3 p.m. CT, Saturday. QL - Quantity limits The plan only covers a certain amount of this drug for one copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug.
MME - Morphine milligram equivalent Additional quantity limits may apply across all drugs in the opioid class used for the treatment of pain. This additional limit is called a cumulative morphine milligram equivalent (MME), and is designed to monitor safe dosing levels of opioids for individuals who may be taking more than one opioid drug for pain management. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.
7D - Seven-Day limit An opioid drug used for the treatment of acute pain may be limited to a seven-day supply for members with no recent history of opioid use. This limit is intended to minimize long-term opioid use. For members who are new to the plan, and have a recent history of using opioids, the limit may be overridden by having the pharmacy contact the plan.
DL - Dispensing limit Dispensing limits apply to this drug. This drug is limited to a one- month supply per prescription.
Y0066_200527_081500_C Drug Drug Name Coverage Rules or Limits on use Tier Analgesics - drugs to treat urinary tract pain Phenazopyridine 1 Anticoagulants - drugs to prevent clotting Heparin Lock Flush 1 Fertility agents - drugs to treat ovulation disorders Clomiphene Citrate 1
Ganirelix Injection 1
Menopur Injection 3
Ovidrel Injection 3 Gastrointestinal agents - drugs to treat bowel, intestine and stomach conditions Clidinium & Chlordiazepoxide 1
Hyoscyamine Sulfate 1 Genitourinary agents - drugs to treat bladder, genital and kidney conditions Erectile Dysfunction
QL (maximum of 8 cartridges per 30 Edex 3 days)
QL (maximum of 8 tablets per 30 Sildenafil (25 mg, 50 mg, 100 mg) 1 days)
QL (maximum of 8 tablets per 30 Tadalafil 1 days)
QL (maximum of 8 tablets per 30 Vardenafil 1 days) Sexual Desire Disorder
Addyi 3 QL (maximum of 1 tablet per day) Urinary Tract Infection Methenamine/Hyoscamine/Methyl Blue/Sod 1 Phosphate/Phenyl Salicylate 81.6 mg Tab Hormonal agents - hormone replacement/modifying drugs
Bold type = Brand name drug Plain type = Generic drug Drug Drug Name Coverage Rules or Limits on use Tier Thyroid Supplement Armour Thyroid 3
NP Thyroid 1 Nutritional supplements - drugs to treat vitamin & mineral deficiencies Potassium Supplement K-Phos Tab 3 Potassium Bicarbonate Effervescent Tab 25 1 mEq Virt-Phos 250 Neutral 1 Vitamins and Minerals Cyanocobalamin Injection (Vitamin B12) 1
Folic Acid 1mg (Rx only) 1
Galzin 3
Phytonadione 1
Vitamin D 50,000 unit (Rx only) 1 Otic agents - drugs to treat ear conditions Ear Infection Cortane-B Otic Drops 3 Respiratory tract agents - drugs to treat allergies, cough, cold and lung conditions Cough and Cold Benzonatate 1 Brompheniramine/Pseudoephedrine/ 1 Dextromethorphan Syrup
Guaifenesin/Codeine Syrup 1 DL Hydrocodone Polst/Chlorpheniramine ER Susp 1 DL (generic for Tussionex)
Hydrocodone/Homatropine 1 DL
Bold type = Brand name drug Plain type = Generic drug Drug Drug Name Coverage Rules or Limits on use Tier Promethazine/Codeine Syrup 1 DL Promethazine/Dextromethorphan Syrup 1 Respiratory Inhalants Sodium Chloride Nebulizer Solution 1
Bold type = Brand name drug Plain type = Generic drug
BDL: TX - ERS Maintenance Drug List The following drugs and supplies may be dispensed in quantities up to but not more than a 90-day supply for members covered under the HealthSelect Medicare Rx plan. Prior authorization may be required for certain drugs. See your Evidence of Coverage for information about copays. Medications in this list are subject to change without notice. If your drug is not included in this Maintenance Drug List or to confirm that your drugs and supplies are covered, please call Customer Service toll-free at (866) 868-0609, (TTY: 711), 7 a.m. – 7 p.m. CT, Monday – Friday and 7 a.m. – 3 p.m. CT, Saturday.
Drug Name Drug Name Abacavir Solution & Tablet Allopurinol Tablet Abacavir/Lamivudine Tablet Alora Patch Abacavir/Lamivudine/Zidovudine Tablet Alosetron Tablet Abilify Maintena Alphagan P Ophthalmic Solution Acamprosate DR Tablet Alyq Tablet Acarbose Tablet Amantadine Capsule, Syrup & Tablet Acebutolol Capsule Ambrisentan Tablet Acetazolamide ER Capsule & Tablet Amiloride Tablet Actemra Injection Amiloride/Hydrochlorothiazide Tablet Actimmune Injection Amiodarone Tablet Addyi Tablet Amitriptyline Tablet Adefovir Dipivoxil Tablet Amlodipine Tablet Adempas Tablet Amlodipine/Atorvastatin Tablet Advair HFA Amlodipine/Benazepril Capsule Adzenys XR-ODT Tablet Amlodipine/Olmesartan Tablet Afrezza Amlodipine/Valsartan Tablet Aimovig Injection Amlodipine/Valsartan/Hydrochlorothiazide Tablet Albuterol Inhalation, Syrup & (ER) Tablet Amoxapine Tablet Alcohol Pads Amphetamine/Dextroamphetamine ER Capsule Alendronate Solution & Tablet & Tablet Alfuzosin ER Tablet Anagrelide Capsule Aliskiren Tablet Anastrozole Tablet
Y0066_200527_081500_C Drug Name Drug Name Androderm Patch Azasan Tablet Angeliq Tablet Azathioprine Tablet Anoro Ellipta Azopt Ophthalmic Suspension Aplenzin Tablet Banzel Suspension & Tablet Apri Tablet Benazepril Tablet Aptensio XR Capsule Benazepril/Hydrochlorothiazide Tablet Aptiom Tablet Benlysta Injection Aptivus Capsule & Solution Benztropine Tablet Arcalyst Injection Betaseron Arcapta Neohaler Betaxolol Ophthalmic Solution & Tablet Aripiprazole Solution & (ODT) Tablet Bethkis Solution Armodafinil Tablet Betimol Ophthalmic Solution Armour Thyroid Tablet Betoptic-S Ophthalmic Suspension Arnuity Ellipta Bevyxxa Capsule Aspirin/Dipyridamole Capsule Bijuva Capsule Astagraf XL Capsule Biktarvy Tablet Atazanavir Capsule Bimatoprost Ophthalmic Solution Atenolol Tablet Bisoprolol Fumarate Tablet Atenolol/Chlorthalidone Tablet Bisoprolol/Hydrochlorothiazide Tablet Atomoxetine Capsule Bosentan Tablet Atorvastatin Tablet Breo Ellipta Atripla Tablet Brilinta Tablet Atrovent HFA Brimonidine Ophthalmic Solution Aubagio Tablet Briviact Oral Solution & Tablet Auryxia Tablet Bromocriptine Capsule & Tablet Austedo Tablet Brovana Inhalation Avandia Tablet Budesonide Inhalation Avonex Bumetanide Tablet Drug Name Drug Name Bupropion (ER, SR & XL) Tablet Chloroquine Tablet Bydureon Injection Chlorothiazide Tablet Bystolic Tablet Chlorpromazine Tablet Calcitonin Spray Chlorthalidone Tablet Calcitriol Capsule & Solution Cholbam Capsule Calcium Acetate Capsule & Tablet Cholestyramine (Light) Powder Candesartan Tablet Cilostazol Tablet Candesartan/Hydrochlorothiazide Tablet Cimduo Tablet Caplyta Capsule Cimetidine Solution & Tablet Captopril Tablet Cimzia Captopril/Hydrochlorothiazide Tablet Cinacalcet Tablet Carbaglu Tablet Cinqair Injection Carbamazepine ER Capaule, Suspension & Citalopram Solution & Tablet (ER) Tablet Climara Pro Patch Carbidopa Tablet Clobazam Tablet Carbidopa/Levodopa (ER & ODT) Tablet Clomipramine Tablet Carbidopa/Levodopa/Entacapone Tablet Clonidine Patch & (ER) Tablet Cardizem LA Tablet Clopidrogel Tablet Cardura XL Tablet Colesevelam Tablet Carospir Suspension Colestipol Granules & Tablet Carteolol Ophthalmic Solution Combigan Ophthalmic Solution Cartia XL Capsule Combipatch Carvedilol ER Capsule & Tablet Combivent Respimat Celecoxib Capsule Complera Tablet Celontin Capsule Corlanor Tablet Cerdelga Capsule Cosentyx Injection Cevimeline Capsule Cotempla Tablet Chlordiazepoxide/Amitriptyline Tablet Creon Capsule Drug Name Drug Name Crixivan Capsule Diclofenac/Misoprostol Tablet Cromolyn Inhalation & Oral Concentrate Didanosine Capsule Crysvita Injection Diflunisal Tablet Cuvposa Solution Digoxin Oral Solution & Tablet Cyclomydril Ophthalmic Solution Dilantin Capsule Cyclopentolate Ophthalmic Solution Dilatrate SR Capsule Cycloset Tablet Diltiazem CD & ER Capsule and (ER) Tablet Cyclosporine Capsule & Solution Dilt-XR Capsule Cystadane Powder for Oral Solution Dipyridamole Tablet Cystagon Capsule Disopyramide Capsule Cystaran Ophthalmic Solution Disulfiram Tablet Dalfampridine ER Tablet Diuril Suspension Daliresp Tablet Divalproex Capsule, DR & ER Tablet Dapsone Tablet Divigel Darifenacin ER Tablet Dofetilide Capsule Daytrana Patch Donepezil (ODT) Tablet Deferasirox Tablet Dorzolamide Ophthamic Solution Delstrigo Tablet Dorzolamide/Timolol Ophthamic Solution Descovy Tablet Dotti Patch Desipramine Tablet Dovato Tablet Desmopressin Nasal Spray & Tablet Doxazosin Tablet Desogestrel/Ethinyl Estradiol Tablet Doxepin Capsule & Concentrate Desvenlafaxine ER Tablet Doxercalciferol Capsule Dexmethylphenidate ER Capsule & Tablet Drospirenone/Ethinyl Estradiol Tablet Dextroamphetamine ER Capsule, Solution & Drospirenone/Ethinyl Estradiol/Levomefolate Tablet Tablet Diazoxide Suspension Drizalma Capsule Diclofenac (DR & ER) Tablet Droxia Capsule Drug Name Drug Name Duavee Tablet Equetro Capsule Duloxetine Capsule Ergoloid Mesylates Tablet Duopa Suspension Esbriet Capsule & Tablet Dupixent Injection Escitalopram Solution & Tablet Dutasteride Capsule Esomeprazole Granules Dutasteride/Tamsulosin Capsule Estradiol Patch, Tablet & Vaginal Cream Dyanavel XR Suspension Estradiol/Norethindrone Tablet Edarbi Tablet Estring Edarbyclor Tablet Estrogel Edurant Tablet Ethacrynic Acid Tablet Efavirenz Capsule & Tablet Ethosuximide Capsule & Solution Egrifta Solution Ethynodiol Diacetate/Ethinyl Estradiol Tablet Elestrin Gel Etodolac Capsule & (ER) Tablet Eliquis Tablet Euthyrox Tablets Elixophyllin Elixir Evamist Spray Emgality Injection Evekeo (ODT) Tablet Emsam Patch Everolimus Tablet Emtriva Capsule & Solution Evotaz Tablet Enalapril Tablet Exemestane Tablet Enalapril/Hydrochlorothiazide Tablet Ezallor Capsule Enbrel Injection Ezetimibe Tablet Entacapone Tablet Ezetimibe/Simvastatin Tablet Entecavir Tablet Famotidine Suspension & Tablet Entresto Tablet Farxiga Tablet Envarsus XR Tablet Fasenra Injection Epidiolex Solution Febuxostat Tablet Epitol Tablet Felbamate Suspension & Tablet Eplerenone Tablet Felodipine ER Tablet Drug Name Drug Name Femring Galafold Capsule Fenofibrate Capsule & Tablet Galantamine ER Capsule, Solution & Tablet Fenofibric Acid DR Capsule & Tablet Ganciclovir Injection Ferriprox Tablet Gattex Powder for Injection Fetzima Capsule Gauze Pads Finasteride Tablet Gelnique Gel Flavoxate Tablet Gemfibrozil Tablet Flecainide Tablet Gengraf Capsule & Solution Flolipid Suspension Genotropin Injection Flovent Diskus & HFA Genvoya Tablet Fludrocortisone Tablet Gilenya Capsule Fluoxetine (DR) Capsule, Solution & Tablet Glatiramer Injection Fluphenazine Concentrate, Elixir & Tablet Glatopa Injection Flurbiprofen Tablet Glimepiride Tablet Fluticasone/Salmeterol Inhaler Glipizide (ER & XL) Tablet Fluvastatin Capsule & ER Tablet Glipizide/Metformin Tablet Fluvoxamine ER Capsule & Tablet Glyburide Tablet Folic Acid Tablet Glyburide/Metformin Tablet Forfivo XL Tablet Glyxambi Tablet Forteo Injection Gonitro Sublingual Powder Fosamax + D Tablet Gralise Tablet Fosamprenavir Tablet Grastek Sublingual Tablet Fosinopril Tablet Guanfacine Tablet Fosinopril/Hydrochlorothiazide Tablet Haloperidol Concentrate & Tablet Furosemide Solution & Tablet Hemangeol Oral Solution Fuzeon Injection Hetlioz Capsule Fycompa Suspension & Tablet Homatropaire Ophthamic Solution Gabapentin Capsule, Solution & Tablet Homatropine Ophthamic Solution Drug Name Drug Name Horizant Tablet Ipratropium Bromide/Albuterol Inhalation Humalog Irbesartan Tablet Humira Injection Irbesartan/Hydrochlorothiazide Tablet Humulin Isentress Suspension & (HD) Tablet Hydralazine Tablet Isoniazid Syrup & Tablet Hydrochlorothiazide Capsule & Tablet Isopto Atropine Ophthamic Solution Hydroxychloroquine Sulfate Tablet Isosorbide (ER) Tablet Hyoscyamine Solution & Tablets Isradipine Capsule Ibandronate Tablet Jadenu Sprinkles & Tablet Ibuprofen Tablet Janumet (XR) Tablet Ilumya Solution Januvia Tablet Imipramine HCl Tablet Jardiance Tablet Imipramine Pamoate Capsule Jentadueto (XR) Tablet Imvexxy Suppository Jornay PM Capsule Inbrija Capsule Juluca Tablet Increlex Injection Juxtapid Capsule Incruse Ellipta Kaletra Tablet Indapamide Tablet Kalydeco Granules & Tablet Indocin Suppository & Suspension Ketoprofen (ER) Capsule Indomethacin (ER) Capsule Kevzara Injection Ingrezza Capsule Kineret Injection Insulin Syringes Klor-Con Capsule & ER Tablet Intelence Tablet Korlym Tablet Intrarosa Suppository K-Phos Tablet Intron A Injection Kuvan Powder for Solution & Tablet Invirase Capsule & Tablet Labetalol Tablet Ipratropium Bromide Inhalation & Nasal Lactulose Solution Solution Lamivudine Solution & Tablet Drug Name Drug Name Lamivudine/Zidovudine Tablet Lokelma Powder for Suspension Lamotrigine (ER & ODT) Tablet Lonhala Solution for Inhalation Lanoxin Tablet Lopinavir/Ritonavir Solution Lansoprazole DR Capsule & ODT Losartan Tablet Lanthanum Tablet Losartan/Hydrochlorothiazide Tablet Lantus Lovastatin Tablet Latanoprost Ophthalmic Soluton Loxapine Capsule Latuda Tablet Lumigan Ophthalmic Solution Leflunomide Tablet Lyrica CR Tablet Letrozole Tablet Maprotiline Tablet Levalbuterol Inhalation Marplan Tablet Levetiracetam Solution & (ER) Tablet Matzim LA Tablet Levobunolol Ophthalmic Solution Mayzent Tablet Levocarnitine Solution & Tablet Meclofenamate Capsule Levonorgestrel/Ethinyl Estradiol Tablet Medroxyprogesterone Acetate Tablet Levo-T Tablet Mefloquine Tablet Levothyroxine Tablet Megestrol Suspension Levoxyl Tablet Meloxicam Tablet Linzess Capsule Memantine ER Capsule, Solution & Tablet Liothyronine Tablet Menest Tablet Lipofen Capsule Menostar Patch Lisinopril Tablet Mesalamine Tablet Lisinopril/Hydrochlorothiazide Tablet Metadate ER Tablet Lithium Carbonate Capsule, Solution & (ER) Metaproterenol Syrup & Tablet Tablet Metformin (ER) Tablet Lithostat Tablet Methamphetamine Tablet Livalo Tablet Methazolamide Tablet Lo Loestrin Tablet Methimazole Tablet Drug Name Drug Name Methitest Tablet Nadolol Tablet Methyldopa Tablet Nadolol/Bendroflumethiazide Tablet Methyldopa/Hydrochlorothiazide Tablet Namzaric Capsule Methylphenidate CD & ER Capsule, Solution Naproxen Suspension and (CR, DR & ER) and (ER) Tablet Tablet Methyltestosterone Capsule Naproxen/Esomeprazole Tablet Metolazone Tablet Nascobal Nasal Solution Metoprolol (ER) Tablet Natazia Tablet Metoprolol/Hydrochlorothiazide Tablet Nateglinide Tablet Mexiletine Capsule Natesto Gel Miglitol Tablet Natpara Injection Miglustat Capsule Nature-Throid Tablet Minoxidil Tablet Nefazodone Tablet Mirtazapine (ODT) Tablet Neupro Patch Misoprostol Tablet Nevirapine (ER) Tablet Modafinil Tablet Niacin ER Tablet Moexipril Tablet Nicardipine Capsule Molindone Tablet Nifedipine Capsule & ER Tablet Montelukast Granules & Tablet Nisoldipine ER Tablet Motegrity Tablet Nitisinone Capsule Multaq Tablet Nitro-Bid Ointment Myalept Injection Nitroglycerin Aerosol, ER Capsule, Patch, Spray & Sublingual Tablet Mycophenolate Capsule, Suspension & Tablet Nityr Tablet Mycophenolic Acid DR Tablet Nizatidine Capsule & Solution Mydayis Capsule Nocdurna Sublingual Tablet Myrbetriq Tablet Norethindrone Tablet Mytesi Tablet Norethindrone/Ethinyl Estradiol (Fe) Tablet Nabumetone Tablet Norethindrone/Mestranol Tablet Drug Name Drug Name Norgestimate/Ethinyl Estradiol Tablet Orfadin Suspension Norgestrel/Ethinyl Estradiol Tablet Orkambi Tablet Norpace CR Capsule Osphena Tablet Nortriptyline Capsule Otezla Tablet Norvir Oral Solution & Powder for Suspension Otrexup Injection Noxafil Injection & Suspension Oxaprozin Tablet Nourianz Tablet Oxcarbazepine Tablet & Suspension NP Thyroid Tablet Oxybutynin Syrup and (ER) Tablet Nucala Injection Oxytrol Patch Nuedexta Capsule Ozempic Injection Nuplazid Tablet Paliperidone ER Tablet Ocaliva Tablet Palynziq Injection Octreotide Injection Pantoprazole (DR) Tablet Odactra Sublingual Tablet Paricalcitol Capsule Odefsey Tablet Paroxetine Capsule & (ER) Tablet Ofev Capsule Paxil Susp Olanzapine (ODT) Tablet Peganone Tablet Olanzapine/Fluoxetine Capsule Pen Needles Olmesartan Tablet Pentasa Capsule Olmesartan/Amlodipine/Hydrochlorothiazide Pentoxifylline ER Tablet Tablet Perforomist Inhalation Omega-3-Acid Ethyl Esters Capsule Perindopril Tablet Omeprazole Capsule Perphenazine Tablet Onpattro Solution Perphenazine/Amitriptyline Tablet Opsumit Tablet Pexeva Tablet Oralair IR Sublingual Tablet Phenelzine Tablet Orencia Injection Phenobarbital Elixir & Tablet Orenitram Tablet Phenytion EX Capsule, Suspension & Tablet Drug Name Drug Name Phoslyra Solution Prezista Suspension &Tablet Phospholine Iodide Ophthalmic Solution Prilosec Powder Phosphorous Tablet Primidone Tablet Pifeltro Tablet Probenecid Tablet Pilocarpine Ophthalmic Solution & Tablet Probenecid/Colchicine Tablet Pimozide Tablet Prochlorperazine Tablet Pindolol Tablet Procysbi Capsule Pioglitazone Tablet Progesterone Capsule Pioglitazone/Glimepiride Tablet Prograf Granule Pioglitazone/Metformin Tablet Promacta Tablet Piroxicam Capsule Propafenone ER Capsule & Tablet Posaconazole Tablet Propranolol ER Capsule, Solution & Tablet Potassium Chloride ER Capsule, Packets, Propranolol/Hydrochlorothiazide Tablet Solution and CR, ER & SR Tablet Propylthiouracil Tablet Pradaxa Capsule Protonix Granules for Suspension Praluent Injection Protriptyline Tablet Pramiprexole (ER) Tablet Pulmicort Inhaler Prasugrel Tablet Pulmozyme Solution Pravastatin Tablet Quetiapine (ER) Tablet Prazosin Capsule Quillivant Suspension Prefest Tablet Quinapril Tablet Pregabalin Capsule Quinapril/Hydrochlorothiazide Tablet Premarin Tablet & Vaginal Cream Quinidine Gluconate CR & ER Tablet Premphase Tablet Quinidine Sulfate Tablet Prempro Tablet Rabeprazole Tablet Prevalite Radicava Injection Prevymis Tablet Ragwitek Sublingual Tablet Prezcobix Tablet Raloxifene Tablet Drug Name Drug Name Ramipril Capsule Ruzurgi Tablet Ranitidine Capsule, Syrup & Tablet Rybelsus Tablet Ranolazine ER Tablet Rytary Capsule Rasagiline Tablet Sandimmune Solution Rasuvo Injection Saphris Sublingual Tablet Ravicti Liquid Savaysa Tablet Rayaldee Capsule Savella Tablet Rebif Injection Secuado Patch Reblozyl Injection Selegiline Capsule & Tablet Relexxii Tablet Selzentry Solution & Tablet Repaglinide Tablet Serevent Diskus Repatha Injection Serostim Injection Rescriptor Tablet Sertraline Concentrate & Tablet Restasis Ophthalmic Emulsion Sevelamer Powder for Suspension & Tablet Rexulti Tablet Signifor (LAR) Injection Reyataz Powder for Suspension Sildenafil Tablet Rhopressa Ophthalmic Solution Siliq Injection Ridaura Capsule Silodosin Capsule Riluzole Tablet Simbrinza Ophthalmic Suspension Rinvoq Tablets Simponi Injection & Aria Solution Risedronate (DR) Tablet Simvastatin Tablet Risperidone Solution and (ODT) Tablet Sirolimus Tablet Ritonavir Tablet Skyrizi Injection Rivastigmine Capsule & Patch Sodium Fluoride Oral Solution & (Chewable) Tablet Rocklatan Ophthalmic Solution Sodium Phenylbutyrate Oral Powder & Tablet Ropinirole (ER) Tablet Solifenacin Tablet Rosuvastatin Tablet Soliqua Injection Roweepra Tablet Drug Name Drug Name Soltamox Oral Solution SymlinPen Somavert Injection Sympazan Dissolving Film Sorine Tablet Symtuza Tablet Sotalol (AF) Tablet Synjardy (XR) Tablet Sotylize Oral Solution Tacrolimus Capsule Spinraza Injection Tadalafil Tablet Spiriva HandiHaler & Respimat Takhzyro Injection Spironolactone Tablet Taltz Injection Spironolactone/Hydrochlorothiazide Tablet Tamoxifen Tablet Spravato Nasal Solution Tamsulosin Capsule Spritam Tablet Tavalisse Tablet Stavudine Capsule Taztia XT Capsule Stelara Injection Tecfidera Capsule Stimate Nasal Solution Tegsedi Injection Stiolto Respimat Tekturna (HCT) Tablet Strensiq Injection Telmisartan Tablet Stribild Tablet Telmisartan/Amlodipine Tablet Striverdi Respimat Telmisartan/Hydrochlorothiazide Tablet Subvenite Tablet Temixys Tablet Sucraid Solution Tenofovir Tablet Sucralfate Suspension & Tablet Terazosin Capsule Sulfasalazine (DR) Tablet Terbutaline Tablet Sulindac Tablet Testosterone Gel Sunosi Tablet Tetrabenazine Tablet Sylatron Injection Thalomid Capsule Symbicort Aerosol Theo-24 Capsule Symdeko Tablet Theophylline Soluton, CR & ER Tablet Symfi (Lo) Tablet Thiola EC Tablet Drug Name Drug Name Thioridazine Tablet Trifluoperazine Tablet Thiothixene Capsule Trihexyphenidyl Elixir & Tablet Tiagabine Tablet Trijardy XR Tablet Tiglutik Suspension Trikafta Tablet Timolol Ophthalmic Gel & Solution, Tablet Trimipramine Capsule Timoptic Ocudose Ophthalmic Solution Trintellix Tablet Tirosint Capsule Triumeq Tablet Tivicay Tablet Trogarzo Injection Tobramycin Inhalation Solution Trospium ER Capsule Tolbutamide Tablet Trulicity Injection Tolcapone Tablet Truvada Tablet Tolmetin Capsule & Tablet Tybost Tablet Tolterodine ER Capsule & Tablet Tymlos Injection Topiramate (ER) Capsule & Tablet Tyvaso Inhalation Toremifene Tablet Unithroid Tablet Torsemide Tablet Uptravi Tablet Toujeo Ursodiol Capsule & Tablet Toviaz Tablet Valganciclovir Oral Solution & Tablet Tradjenta Tablet Valproic Acid Capsule & Solution Trandolapril Tablet Valsartan Tablet Trandolapril/Verapamil ER Tablet Valsartan/Hydrochlorothiazide Tablet Tranylcypromine Tablet Vascepa Capsule Travoprost Ophthalmic Solution Vecamyl Tablet Trazodone Tablet Veltassa Powder for Suspension Trelegy Inhaler Vemlidy Tablet Tremfya Injection Venlafaxine ER Capsule & (ER) Tablet Triamterene/Hydrochlorothiazide Capsule & Ventavis Inhalation Tablet Ventolin Inhaler Drug Name Drug Name Verapamil ER & SR Capsule, (ER) Tablet Xeljanz (XR) Tablet Viberzi Tablet Xelpros Ophthalmic Solution Victoza Injection Xermelo Tablet Videx Oral Solution Xifaxin Tablet Vigabatrin Powder for Solution Xigduo XR Tablet Vigadrone Powder for Suspension Xiidra Ophthalmic Solution Viibryd Tablet Xultophy Injection Vimpat Oral Soluton & Tablet Xuriden Oral Granules Viracept Tablet Xyosted Injection Viread Powder & Tablet Yuvafem Vaginal Tablet Vitamin D Capsule Zafirlukast Tablet Vraylar Capsule Zelapar Tablet Vyndamax Capsule Zenpep Capsule Vyndaqel Capsule Zenzedi Tablet Vyvanse Capsule & Tablet Zidovudine Capsule, Syrup & Tablet Wakix Tablet Zileuton ER Tablet Warfarin Tablet Ziprasidone Capsule Wixela Inhaler Zonisamide Capsule Xadago Tablet Zontivity Tablet Xarelto Tablet Zorbtive Injection Xcopri Tablet Zurampic Tablet This is not a complete list of prescription drugs and supplies covered by our plan. For a complete list, please call us toll-free at (866) 868-0609 (TTY: 711), 7 a.m. – 7 p.m. CT, Monday – Friday and 7 a.m. – 3 p.m. CT, Saturday.
This information is not a complete description of benefits. Contact UnitedHealthcare Customer Service for more information. Limitations, copays, and restrictions may apply. Benefits and/or copay/coinsurance may change each plan/benefit year. The drug list may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call our Customer Service number on the cover.
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