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Preventive Medications List Effective: July 1, 2013

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Preventive Medications List Effective: July 1, 2013 Preventive Medications List Effective: July 1, 2013 In addition to a healthy lifestyle, preventive medications can help people avoid many illnesses and conditions. A consumer-directed health (CDH) plan that includes preventive medications can help support the goal of ongoing good health. This list provides examples of your plan’s preventive medications. The medications are categorized based on the medical conditions that they are used to prevent. Coverage prior to the deductible being met may not be provided for every dosage form of a listed medication. Please call Member Services at 877.223.4721. This list is periodically reviewed and updated to ensure that the drugs listed meet the criteria for inclusion. This list includes medications sometimes used for prevention and sometimes for treatment. PDL8745C Preventive Medications List ANEMIA IN CHILDREN CANCER TREATMENT, SIDE FERROUS SULFATE LIQUID DROPS FOR EFFECTS FROM INFANTS (SUCH AS FER-IN-SOL) ARANESP ASTHMA DARBEPOETIN ALFA EPOGEN, PROCRIT SINGULAIR EPOETIN ALFA MONTELUKAST NEUPOGEN ACCOLATE FILGRASTIM ZAFIRLUKAST DEPO-PROVERA ZYFLO CR MEDROXYPROGESTERONE ZILEUTON MESNEX BONE DISEASE AND FRACTURES MESNA NEULASTA FOSAMAX, FOSAMAX PLUS D PEGFILGRASTIM ALENDRONATE LEUKINE FORTICAL, MIACALCIN SARGRAMOSTIM CALCITONIN XGEVA CAVITIES DENOSUMAB PEDIATRIC FLUORIDE VITAMIN BONIVA DROPS IBANDRONATE PREVIDENT EVISTA RALOXIFENE SODIUM FLUORIDE ACTONEL COLONOSCOPY PREPARATION RISEDRONATE RECLAST COLYTE, GOLYTELY, HALFLYTELY, ZOLEDRONIC ACID NULYTELY, TRILYTE, MOVIPREP POLYETHYLENE GLYCOL BREAST CANCER RECURRENCE VISICOL, OSMOPREP, SUPREP TAMOXIFEN SODIUM PHOSPHATE SALTS ARIMIDEX DIABETES, COMPLICATIONS OF ANASTROZOLE AROMASIN INSULINS: EXEMESTANE NOVOLOG, NOVOLOG 70/30 FEMARA ASPART, ASPART PROTAMINE MIX LETROZOLE LEVEMIR DETEMIR LANTUS, LANTUS SOLOSTAR GLARGINE Preventive Medications List APIDRA, APIDRA SOLOSTAR ESTROGEN REPLACEMENT AND GLULISINE OTHER HORMONES HUMULIN, NOVOLIN PREMARIN INSULIN HUMALOG, 50/50, 75/25 CONJUGATED ESTROGEN TABLETS PREMPRO, PREMPHASE LISPRO, LISPRO PROTAMINE MIX CONJUGATED ESTROGEN/ NON-INSULIN MEDICINES: MEDROXYPROGESTERONE BYETTA ESTRACE ESTRADIOL TABLETS EXENATIDE AMARYL CLIMARA ESTRADIOL TRANSDERMAL GLIMEPIRIDE GLUCOTROL, METAGLIP ESTRADERM ESTRADIOL TRANSDERMAL GLIPIZIDE AND COMBINATIONS DIABETA, GLYNASE, GLUCOVANCE VIVELLE DOT ESTRADIOL TRANSDERMAL GLYBURIDE AND COMBINATIONS TRADJENTA DIVIGEL ESTRADIOL, GEL LINAGLIPTIN VICTOZA EVAMIST ESTRADIOL, TRANSDERMAL SPRAY LIRAGLUTIDE FORTAMET, GLUCOPHAGE, COMBIPATCH GLUMETZA, RIOMET ESTRADIOL/NORETHINDRONE, TRANSDERMAL METFORMIN MAKENA STARLIX HYDROXYPROGESTERONE CAPROATE NATEGLINIDE PROVERA ACTOS, DUETACT, ACTOPLUS MET MEDROXYPROGESTERONE PIOGLITAZONE AND COMBINATIONS CRINONE, PROMETRIUM SYMLIN PROGESTERONE PRAMLINTIDE CENESTIN PRANDIN SYNTHETIC CONJUGATED ESTROGENS, A REPAGLINIDE ENJUVIA AVANDIA, AVANDAMET, SYNTHETIC CONJUGATED ESTROGENS, B AVANDARYL ROSIGLITAZONE AND COMBINATIONS GOUT ONGLYZA, KOMBIGLYZE XR ZYLOPRIM SAXAGLIPTIN AND COMBINATIONS ALLOPURINOL JANUVIA, JANUMET COLCRYS SITAGLIPTIN AND COMBINATIONS COLCHICINE Preventive Medications List GUM DISEASE ZOCOR ARESTIN SIMVASTATIN MINOCYCLINE OTHER AGENTS: HEART DISEASE AND STROKE PREVALITE, QUESTRAN BLOOD THINNER MEDICINES: CHOLESTYRAMINE WELCHOL ASPIRIN, 81 MG OR 325 MG COLESEVELAM HEPARIN COLESTID AGGRENOX COLESTIPOL ASA/DIPYRIDAMOLE ZETIA PLAVIX EZETIMIBE CLOPIDOGREL VYTORIN FRAGMIN EZETIMIBE/SIMVASTATIN DALTEPARIN FENOGLIDE, LIPOFEN, TRICOR, LOVENOX ANTARA, TRIGLIDE ENOXAPARIN FENOFIBRATE ARIXTRA TRILIPIX FONDAPARINUX FENOFIBRIC ACID EFFIENT LOPID PRASUGREL GEMFIBROZIL XARELTO NIACOR, NIASPAN ER RIVAROXABAN NIACIN ` BRILINTA ADVICOR TICAGRELOR NIACIN/LOVASTATIN COUMADIN, JANTOVEN SIMCOR WARFARIN NIACIN ER/SIMVASTATIN CHOLESTEROL LOWERING LOVAZA MEDICINES OMEGA-3-ACID ETHYL ESTERS HIGH BLOOD PRESSURE HMG-COA REDUCTASE MEDICINES INHIBITORS: ACE INHIBITORS AND LIPITOR COMBINATIONS: ATORVASTATIN MEVACOR, ALTOPREV LOTENSIN, LOTENSIN HCT LOVASTATIN BENAZEPRIL PRAVACHOL VASOTEC, VASERETIC PRAVASTATIN ENALAPRIL CRESTOR MONOPRIL, MONOPRIL HCT ROSUVASTATIN FOSINOPRIL Preventive Medications List PRINIVIL, PRINZIDE, ZESTRIL, CALCIUM CHANNEL BLOCKERS: ZESTORETIC NORVASC LISINOPRIL ACCUPRIL, ACCURETIC AMLODIPINE CARDIZEM, CARDIZEM LA, QUINAPRIL CARTIA XT, TIAZAC ER ACE RECEPTOR BLOCKERS AND DILTIAZEM COMBINATIONS: ADALAT CC, PROCARDIA EDARBI NIFEDIPINE SULAR AZILSARTAN ATACAND, ATACAND HCT NISOLDIPINE CALAN, COVERA HS, ISOPTIN SR, CANDESARTAN TEVETEN, TEVETEN HCT VERELAN VERAPAMIL EPROSARTAN AVAPRO, AVALIDE DIURETICS AND COMBINATIONS: IRBESARTAN COZAAR, HYZAAR HYDROCHLOROTHIAZIDE INDAPAMIDE LOSARTAN BENICAR, BENICAR HCT MIDAMOR AMILORIDE OLMESARTAN MICARDIS, MICARDIS HCT ZAROXOLYN METOLAZONE TELMISARTAN DIOVAN, DIOVAN HCT ALDACTONE SPIRONOLACTONE VALSARTAN DYAZIDE, MAXZIDE BETA BLOCKERS AND TRIAMTERENE-HCTZ COMBINATIONS: HIGH BLOOD PRESSURE TENORMIN, TENORETIC MEDICINES, MISCELLANEOUS: ATENOLOL HYDRALAZINE ZEBETA, ZIAC TEKTURNA, TEKTURNA HCT, BISOPROLOL LOPRESSOR, TOPROL XL TEKAMLO, AMTURNIDE, METOPROLOL VALTURNA BYSTOLIC ALISKIREN AND COMBINATIONS NEBIVOLOL LOTREL INDERAL LA, INNOPRAN XL AMLODIPINE/BENAZEPRIL PROPRANOLOL AZOR AMLODIPINE/OLMESARTAN TRIBENZOR AMLODIPINE/OLMESARTAN/ HYDROCHLOROTHIAZIDE Preventive Medications List TWYNSTA VIRUS AMLODIPINE/TELMISARTAN AMANTADINE EXFORGE ZOVIRAX AMLODIPINE/VALSARTAN ACYCLOVIR EXFORGE HCT FAMVIR AMLODIPINE/VALSARTAN/ FAMCICLOVIR HYDROCHLOROTHIAZIDE FOSCAVIR COREG, COREG CR FOSCARNET CARVEDILOL CATAPRES, CLORPRES CYTOVENE GANCICLOVIR CLONIDINE CARDURA TAMIFLU OSELTAMIVIR DOXAZOSIN HYTRIN VALTREX VALACYCLOVIR TERAZOSIN VALCYTE INFECTION VALGANCICLOVIR RELENZA FUNGAL ZANAMIVIR MEPRON KIDNEY DISEASE, HIGH ATOVAQUONE NEBUPENT, PENTAM PHOSPHATE LEVELS PENTAMIDINE PHOSLO, PHOSLYRA NOXAFIL CALCIUM ACETATE POSACONAZOLE FOSRENOL LANTHANUM MALARIA RENVELA, RENAGEL PRIMAQUINE SEVELAMER COARTEM ARTEMETHER/LUMEFANTRINE NAUSEA AND DIZZINESS MALARONE PROCHLORPERAZINE ATOVAQUONE/PROGUANIL PROMETHAZINE PLAQUENIL EMEND HYDROXYCHLOROQUINE APREPITANT DARAPRIM ANZEMET PYRIMETHAMINE DOLASETRON MARINOL DRONABINOL SANCUSO GRANISETRON Preventive Medications List ANTIVERT MISCELLANEOUS AGENTS: MECLIZINE ZOFRAN, ZOFRAN ODT PYLERA BISMUTH/METRONIDAZOLE/ ONDANSETRON TETRACYCLINE TRANSDERM-SCOP, SCOPACE CARAFATE SCOPOLAMINE SUCRALFATE OBESITY* PROTON PUMP INHIBITORS: DIETHYLPROPION XENICAL NEXIUM ORLISTAT ESOMEPRAZOLE BONTRIL PREVACID PHENDIMETRAZINE LANSOPRAZOLE ADIPEX-P, IONAMIN PROTONIX PHENTERMINE PANTOPRAZOLE ACIPHEX PREGNANCY RABEPRAZOLE BIRTH CONTROL MEDICINES VITAMINS OR MINERALS, LOW TAKEN BY MOUTH BIRTH CONTROL DEVICES: LEVELS OF DIAPHRAGMS, SKIN PATCH SYSTEMS, PRESCRIPTION PRENATAL VITAMINS INJECTABLE BIRTH CONTROL VITAMINS: B12, K SMOKING-CESSATION THERAPY ZYBAN BUPROPION NICOTROL NICOTINE PRODUCTS CHANTIX VARENICLINE ULCER DISEASE H2-ANTAGONISTS: CIMETIDINE PEPCID FAMOTIDINE AXID NIZATIDINE ZANTAC RANITIDINE *Prior authorization is required. Express Scripts manages your prescription benefit for your employer, plan sponsor, or health plan. Please note: Brand names are shown in italics in each category. All rights in the product names of all third-party products appearing here, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. PDL8745C List 1+2 10.12 *0000000PDL8745C* *0000000PDL8745C*.
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