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90 Day Supply Drug List 04-01-20 V2.Indd Your 2020 90 Day Supply Drug List Brand and/or generic may be excluded from coverage. Lower-cost options are available and covered. Brand may be excluded from coverage. Lower-cost options are available and covered. Medications subject to change without notice. This is not a complete list of medications, and not all medications listed may be covered under your plan. Review your benefit plan documents to see what medications are covered under your plan. Where differences are noted between this list and your benefit plan documents, the benefit plan documents will govern. Please refer tomyuhc.com ® for information on specific drugs included in this program or call the member phone number listed on your health plan ID card. Brand Drug Name Generic Drug Name ADHD INTUNIV guanfacine hcl (adhd) ANTI-INFECTIVES, MISC PLAQUENIL hydroxychloroquine sulfate ASTHMA / COPD ACCOLATE zafirlukast ADVAIR DISKUS, ADVAIR HFA, AIRDUO fluticasone-salmeterol AEROSPAN flunisolide hfa ALVESCO ciclesonide ANORO ELLIPTA umeclidinium-vilanterol ARCAPTA NEOHALER indacaterol maleate ARNUITY ELLIPTA fluticasone furoate (inhalation) ASMANEX TWISTHALER, ASMANEX HFA mometasone furoate (inhalation) ATROVENT HFA ipratropium bromide hfa BEVESPI AEROSPHERE glycopyrrolate-formoterol fumarate BREO ELLIPTA fluticasone furoate-vilanterol 90 Day Supply Drug List Effective 04-01-20 1 Brand Drug Name Generic Drug Name BROVANA arformoterol tartrate COMBIVENT RESPIMAT ipratropium-albuterol DALIRESP roflumilast DUAKLIR aclidinium-formoterol DULERA mometasone furoate-formoterol fumarate dihydrate ELIXOPHYLLIN, THEO-24, THEOCHRON theophylline FLOVENT DISKUS, ARMONAIR RESPICLICK fluticasone propionate (inhalation) FLOVENT HFA fluticasone propionate hfa INCRUSE ELLIPTA umeclidinium bromide IPRATROPIUM BROMIDE ipratropium bromide PERFOROMIST formoterol fumarate PULMICORT FLEXHALER, PULMICORT budesonide (inhalation) QVAR beclomethasone dipropionate QVAR REDIHALER beclomethasone dipropionate hfa SEEBRI NEOHALER, LONHALA MAGNAIR glycopyrrolate (inhalation) SEREVENT DISKUS salmeterol xinafoate SINGULAIR montelukast sodium SPIRIVA HANDIHALER, SPIRIVA RESPIMAT tiotropium bromide monohydrate STRIVERDI RESPIMAT olodaterol hcl SYMBICORT budesonide-formoterol fumarate dihydrate TRELEGY ELLIPTA fluticasone-umeclidinium-vilanterol TUDORZA PRESSAIR aclidinium bromide UTIBRON NEOHALER indacaterol maleate-glycopyrrolate ZYFLO, ZYFLO CR zileuton BLOOD CLOT PREVENTION / STROKE PREVENTION AGGRENOX aspirin-dipyridamole BEVYXXA betrixaban maleate BRILINTA ticagrelor DIPYRIDAMOLE dipyridamole EFFIENT prasugrel hcl ELIQUIS apixaban PLAVIX clopidogrel bisulfate 90 Day Supply Drug List Effective 04-01-20 2 Brand Drug Name Generic Drug Name PLETAL cilostazol PRADAXA dabigatran etexilate mesylate SAVAYSA edoxaban tosylate XARELTO rivaroxaban ZONTIVITY vorapaxar sulfate BLOOD DISORDERS TRENTAL TAB 400MG pentoxifylline BLOOD GLUCOSE MONITORING GLUCOSE BLOOD TEST STRIP glucose blood test strip CARDIOVASCULAR ACCUPRIL quinapril hcl ACCURETIC quinapril-hydrochlorothiazide ACEBUTOLOL HCL acebutolol hcl ACEON perindopril erbumine ADALAT CC, PROCARDIA, PROCARDIA XL, NIFEDIAC CC, AFEDITAB CR, nifedipine NIFEDICAL XL ALDACTAZIDE spironolactone & hydrochlorothiazide ALTACE ramipril AMILORIDE HCL amiloride hcl AMILORIDE/HYDROCHLOROTHIAZIDE amiloride & hydrochlorothiazide ATACAND candesartan cilexetil ATACAND HCT candesartan cilexetil-hydrochlorothiazide AVALIDE irbesartan-hydrochlorothiazide AVAPRO irbesartan AZOR amlodipine besylate-olmesartan medoxomil BENICAR olmesartan medoxomil BENICAR HCT olmesartan medoxomil-hydrochlorothiazide BETAPACE AF sotalol hcl (afib/afl) BETAPACE, SORINE sotalol hcl BETAXOLOL HCL betaxolol hcl BIDIL isosorbide dinitrate-hydralazine hcl 90 Day Supply Drug List Effective 04-01-20 3 Brand Drug Name Generic Drug Name BUMEX bumetanide BYSTOLIC nebivolol hcl BYVALSON nebivolol-valsartan CADUET amlodipine besylate-atorvastatin calcium CALAN, CALAN SR, ISOPTIN SR, verapamil hcl VERELAN PM, VERELAN CAPTOPRIL captopril CAPTOPRIL/HYDROCHLOROTHIAZIDE captopril & hydrochlorothiazide CARDIZEM diltiazem hcl CARDIZEM LA, CARDIZEM CD, diltiazem hcl coated beads DILTIAZEM CD, MATZIM LA, CARTIA XT CARDURA doxazosin mesylate CAROSPIR, ALDACTONE spironolactone CATAPRES, CATAPRES TTS clonidine hcl CHLORTHALIDONE chlorthalidone CLORPRES clonidine & chlorthalidone COREG carvedilol COREG CR carvedilol phosphate CORGARD nadolol CORLANOR ivabradine hcl CORZIDE nadolol & bendroflumethiazide COZAAR losartan potassium DEMADEX torsemide DIOVAN valsartan DIOVAN HCT valsartan-hydrochlorothiazide DIURIL chlorothiazide DYAZIDE, MAXZIDE triamterene & hydrochlorothiazide DYRENIUM triamterene EDARBI azilsartan medoxomil EDARBYCLOR azilsartan medoxomil-chlorthalidone EDECRIN ethacrynic acid ENTRESTO sacubitril-valsartan EPANED, VASOTEC enalapril maleate 90 Day Supply Drug List Effective 04-01-20 4 Brand Drug Name Generic Drug Name EPROSARTAN MESYLATE eprosartan mesylate EXFORGE amlodipine besylate-valsartan EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide FELODIPINE ER felodipine FLECAINIDE ACETATE flecainide acetate FOSINOPRIL SODIUM fosinopril sodium FOSINOPRIL SODIUM/ fosinopril sodium & hydrochlorothiazide HYDROCHLOROTHIAZIDE GUANFACINE HCL guanfacine hcl HEMANGEOL, INDERAL LA propranolol hcl HYDRALAZINE HCL hydralazine hcl HYZAAR losartan potassium & hydrochlorothiazide INDAPAMIDE indapamide INNOPRAN XL, INDERAL XL propranolol hcl sustained-release beads INSPRA eplerenone ISORDIL TITRADOSE, DILATRATE SR isosorbide dinitrate ISOSORBIDE MONONITRATE, ISOSORBIDE isosorbide mononitrate MONONITRATE ER ISRADIPINE isradipine KAPSPARGO SPRINKLE, TOPROL XL, metoprolol succinate FIRST METOPROLOL KATERZIA amlodipine benzoate LABETALOL HCL labetalol hcl LANOXIN, DIGITEK, DIGOX digoxin LASIX furosemide LOPRESSOR metoprolol tartrate LOPRESSOR HCT, DUTOPROL metoprolol & hydrochlorothiazide LOTENSIN benazepril hcl LOTENSIN HCT benazepril & hydrochlorothiazide LOTREL amlodipine besylate-benazepril hcl MAVIK trandolapril METHYCLOTHIAZIDE methyclothiazide METHYLDOPA methyldopa METHYLDOPA/HYDROCHLOROTHIAZIDE methyldopa & hydrochlorothiazide 90 Day Supply Drug List Effective 04-01-20 5 Brand Drug Name Generic Drug Name METOLAZONE metolazone MEXILETINE HCL mexiletine hcl MICARDIS telmisartan MICARDIS HCT telmisartan-hydrochlorothiazide MICROZIDE, EZIDE hydrochlorothiazide MINIPRESS prazosin hcl MINOXIDIL minoxidil MOEXIPRIL HCL moexipril hcl MOEXIPRIL/HYDROCHLOROTHIAZIDE moexipril-hydrochlorothiazide MULTAQ dronedarone hcl NICARDIPINE HCL nicardipine hcl NIMODIPINE nimodipine NITRO-DUR, NITRO-BID, NITRO-TIME, nitroglycerin MINITRAN NORPACE CR, NORPACE disopyramide phosphate NORVASC amlodipine besylate PACERONE amiodarone hcl PINDOLOL pindolol PRESTALIA perindopril arginine-amlodipine besylate PROPRANOLOL/HYDROCHLOROTHIAZIDE propranolol & hydrochlorothiazide QBRELIS, PRINIVIL, ZESTRIL lisinopril QUINIDINE GLUCONATE quinidine gluconate QUINIDINE SULFATE quinidine sulfate RANEXA ranolazine RYTHMOL SR propafenone hcl SULAR nisoldipine TARKA trandolapril-verapamil hcl TEKTURNA aliskiren fumarate TEKTURNA HCT aliskiren-hydrochlorothiazide TENORETIC atenolol & chlorthalidone TENORMIN atenolol TERAZOSIN HCL terazosin hcl TIAZAC, TAZTIA XT diltiazem hcl extended release beads 90 Day Supply Drug List Effective 04-01-20 6 Brand Drug Name Generic Drug Name TIKOSYN dofetilide TIMOLOL MALEATE timolol maleate olmesartan medoxomil-amlodipine- TRIBENZOR hydrochlorothiazide TWYNSTA telmisartan-amlodipine VASERETIC enalapril maleate & hydrochlorothiazide ZEBETA bisoprolol fumarate ZESTORETIC lisinopril & hydrochlorothiazide ZIAC bisoprolol & hydrochlorothiazide CHOLESTEROL LOWERING AGENTS ALTOPREV, MEVACOR lovastatin COLESTID colestipol hcl CRESTOR, EZALLOR SRPINKLE rosuvastatin calcium FIBRICOR fenofibric acid FLOLIPID, ZOCOR simvastatin LESCOL XL, LESCOL fluvastatin sodium LIPITOR atorvastatin calcium LIVALO pitavastatin calcium LOFIBRA fenofibrate micronized LOPID gemfibrozil LOVAZA, TRIKLO omega-3-acid ethyl esters NEXLETOL bempedoic acid NIASPAN, NIACOR niacin (antihyperlipidemic) PRAVACHOL pravastatin sodium QUESTRAN cholestyramine QUESTRAN LIGHT, PREVALITE cholestyramine light TRICOR, FENOGLIDE, LIPOFEN, TRIGLIDE fenofibrate TRILIPIX choline fenofibrate VASCEPA icosapent ethyl VYTORIN ezetimibe-simvastatin WELCHOL colesevelam hcl ZETIA ezetimibe ZYPITAMAG pitavastatin magnesium 90 Day Supply Drug List Effective 04-01-20 7 Brand Drug Name Generic Drug Name CONTRACEPTION AMETHYST levonorgestrel-ethinyl estradiol (continuous) BALCOLTRA levonorgestrel-ethinyl estradiol-ferrous bisglycinate CRYSELLE-28, ELINEST, LOW-OGESTREL, norgestrel & ethinyl estradiol OGESTREL CYCLESSA, VELIVET, CAZIANT, CESIA desogestrel-ethinyl estradiol (triphasic) DESOGEN, RECLIPSEN, APRI, EMOQUETTE, ISIBLOOM, JULEBER, desogestrel & ethinyl estradiol CYRED, SOLIA, ENSKYCE ENPRESSE-28, MYZILRA, LEVONEST, levonorgestrel-eth estradiol (triphasic) TRIVORA-28 ESTROSTEP FE, TRI-LEGEST FE, TILIA FE norethindrone acetate-ethinyl estradiol-fe FALESSA levonorgestrel-ethinyl estradiol & folic acid FEMCON FE, GENERESS FE, LAYOLIS FE, ZENCHENT FE, WYMZYA FE, norethindrone & ethinyl estradiol-fe KAITLIB FE KELNOR, ZOVIA ethynodiol diacet & eth estrad LESSINA, PORTIA-28, AVIANE, ORSYTHIA, VIENVA, ALTAVERA, FALMINA, AUBRA, CHATEAL, AUBRA EQ, CHATEAL EQ, levonorgestrel & eth estradiol DELYLA, LUTERA, LEVORA 0.15/30- 28, SRONYX, MARLISSA, KURVELO, LARISSIA, LILLOW norethindrone acetate-ethinyl estradiol-fe fum LO LOESTRIN FE (biphasic) LOESTRIN 1.5/30-21, LOESTRIN 1/20-21, JUNEL 1/20, JUNEL
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