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Additional Drug Coverage

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Additional Drug Coverage 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 1-888-803-9217, TTY 711, 8 a.m. – 8 p.m. local time, Monday – Friday. Lower-cost Medicare prescription drugs and supplies Your plan covers some of your Medicare prescription drugs and supplies at a lower drug copay than in your drug list (formulary). The amount you pay for these prescription drugs and supplies does apply to your Medicare prescription drug out-of-pocket costs. Payments for these prescription drugs (made by you or the plan) are treated the same as payments made for drugs in your plan’s drug list (formulary).1 These drugs and supplies are part of your Medicare prescription drug coverage.1 Birth Control Alogliptin Tablet Alogliptin/Metformin Tablet All contraceptive medications and devices Alogliptin/Pioglitazone Tablet Blood Glucose Meters, Test Strips and Amaryl Tablet Lancets Apidra Injection ACCU-CHEK® Aviva Plus Test Strips Avandia Tablet ACCU-CHEK® Guide Meter & Test Strip Baqsimi Nasal Powder ACCU-CHEK® Guide Me Meter & Test Strip Basaglar Injection ACCU-CHEK® SmartView Test Strips Bydureon Injection Lancets Byetta Injection Lancing devices Cycloset Tablet OneTouch Ultra® Test Strips Diazoxide Suspension ™ OneTouch Verio® Flex Meter & Test Strips Duetact Tablet ™ OneTouch Verio® Reflect Meter & Test Strips Farxiga Tablet Diabetes drugs and supplies Fiasp Injection Acarbose Tablet Gauze Pads 2"X2" Actoplus Met (XR) Tablet Glimepiride Tablet Actos Tablet Glipizide (ER & XL) Tablet Adlyxin Injection Glipizide/Metformin Tablet Admelog Injection Glucagen Hypokit Afrezza Inhalation Powder Glucagon Emergency Kit Alcohol Swabs Glucophage (XR) Tablet Y0066_200527_081500_C Glucotrol (XL) Tablet Pioglitazone/Glimepiride Tablet Glyburide (Micronized) Tablet Pioglitazone/Metformin Tablet Glyburide/Metformin Tablet Prandin Tablet Glynase Tablet Precose Tablet Glyset Tablet Proglycem Suspension Glyxambi Tablet Qtern Tablet Gvoke Injection Repaglinide Tablet Humalog Injection Riomet Solution Humulin Injection Rybelsus Tablet InPen Insulin Pen Segluromet Tablet Insulin Syringes Soliqua Injection Invokamet (XR) Tablet Starlix Tablet Invokana Tablet Steglatro Tablet Janumet (XR) Tablet Steglujan Tablet Januvia Tablet Symlinpen Injection Jardiance Tablet Synjardy (XR) Tablet Jentadueto (XR) Tablet Tolbutamide Tablet Kazano Tablet Toujeo Injection Kombiglyze XR Tablet Tradjenta Tablet Korlym Tablet Tresiba Injection Lantus Injection Trijardy XR Tablet Levemir Injection Trulicity Injection Metformin (ER) Tablet V-Go Device Miglitol Tablet Victoza Injection Myxredlin Xigduo XR Tablet Nateglinide Tablet Xultophy Injection Nesina Tablet Tobacco Cessation Novolin Injection Bupropion 150 SR Tablet Novolog Injection Chantix Tablet Omnipod System Nicotrol Inhaler Onglyza Tablet Nicotrol Nasal Spray Oseni Tablet Zyban 150mg SR Tablet Ozempic Injection Vaccines Pen Needles Pioglitazone Tablet All vaccines Bold type = Brand name drug Plain type = Generic drug The drugs listed below to treat asthma or COPD, heart disease/heart failure, hypertension and cholesterol are available at a reduced copay. See your Evidence of Coverage for information about copays. Asthma or Chronic Obstructive Pulmonary Nucala Injection Disease (COPD) Perforomist Inhalation Accolate Tablets Proair HFA & Respiclick Advair Diskus & HFA Proventil HFA Airduo Respiclick Pulmicort Flexhaler & Inhalation Albuterol Inhalation, Syrup and (ER) Tablet Qvar Inhaler & RediHaler Alvesco Inhaler Seebri Neohaler Aminophylline Injection Serevent Diskus Anoro Ellipta Singulair Granules & (Chewable) Tablets Arcapta Neohaler Spiriva Handihaler & Respimat Arnuity Ellipta Stiolto Respimat Asmanex HFA & Twisthaler Striverdi Respimat Atrovent HFA Symbicort Inhaler Bevespi Aerosphere Terbutaline Injection & Tablet Breo Ellipta Theo-24 CR & ER Capsule Brovana Inhalation Theophylline Injection, Oral Solution, CR & ER Tablet Budesonide Inhalation Trelegy Ellipta Cinqair Injection Tudorza Pressair Combivent Respimat Utibron Neohaler Cromolyn Inhalation Ventolin HFA Daliresp Tablet Wixela Inhub Duaklir Inhaler Xolair Injection Dulera Inhaler Xopenex HFA & Inhalation Dupixent Injection Yupelri Inhalation Elixophyllin Elixir Zafirlukast Tablet Fasenra Injection Zileuton ER Tablet Flovent Diskus & HFA Zyflo (CR) Tablet Fluticasone Propionate/Salmeterol Diskus & HFA Hyperlipidemia (high cholesterol) Incruse Ellipta Altoprev ER Tablet Ipratropium Bromide Inhalation Antara Capsule Ipratropium Bromide/Albuterol Inhalation Atorvastatin Tablet Levalbuterol Inhalation Cholestyramine (Light) Powder Levalbuterol Tartrate HFA Colesevelam Tablet Lonhala Magnair Solution Colestid Granules & Tablet Metaproterenol Syrup & Tablet Colestipol Granules & Tablet Montelukast Granules & (Chewable) Tablet Crestor Tablet Ezallor Sprinkle Capsule Heart Disease or Heart Failure Ezetimibe Tablet Acetazolamide ER Capsule, Injection and Tablet Ezetimibe/Simvastatin Tablet Aldactazide Tablet Fenofibrate Tablet & Capsule Aldactone Tablet Fenofibric Acid DR Capsule & Tablet Amiloride Tablet Fenoglide Tablet Amiloride/Hydrochlorothiazide Tablet Fibricor Tablet Amlodipine/Atorvastatin Tablet Flolipid Suspension Betapace (AF) Tablet Fluvastatin Capsule & ER Tablet Bidil Tablet Gemfibrozil Tablet Bumetanide Injection & Tablet Juxtapid Capsule Bumex Tablet Lescol XL Tablet Caduet Tablet Lipitor Tablet Carospir Suspension Lipofen Capsule Chlorothiazide Injection & Tablet Livalo Tablet Chlorthalidone Tablet Lopid Tablet Corlanor Tablet Lovastatin Tablet Digitek Tablet Lovaza Capsule Digox Tablet Nexletol Tablet Digoxin Injection, Oral Solution & Tablet Nexlizet Tablet Diuril Suspension Niacin (ER) Tablet Dyazide Capsule Niacor Tablet Dyrenium Capsule Niaspan ER Tablet Edecrin Tablet Omega-3-Acid Ethyl Esters Capsule Eplerenone Tablet Praluent Injection Ethacrynate Sodium Injection Pravachol Tablet Ethacrynic Acid Tablet Pravastatin Tablet Furosemide Injection, Oral Solution & Tablet Prevalite Powder Hydrochlorothiazide Capsule & Tablet Questran (Light) Powder Indapamide Tablet Repatha Injection Inspra Tablet Rosuvastatin Tablet Isoproterenol Injection Simvastatin Tablet Isuprel Injection Tricor Tablet Lanoxin Injection & Tablet Triglide Tablet Lasix Tablet Trilipix Capsule Mannitol Injection Vascepa Capsule Maxzide Tablet Vytorin Tablet Methazolamide Welchol Packet and Tablet Metolazone Tablet Zetia Tablet Osmitrol Injection Zocor Tablet Sodium Diuril Injection Zypitamag Tablet Sodium Edecrin Injection Sorine Tablet Cardura Tablet Sotalol Injection & (AF) Tablet Cartia XT Capsule Sotylize Solution Carvedilol ER Capsule & Tablet Spironolactone Tablet Catapres Tablet & TTS Patch Spironolactone/Hydrochlorothiazide Tablet Cleviprex IV Emulsion Torsemide Tablet Clonidine Tablet & Patch Triamterene/Hydrochlorothiazide Capsule & Coreg CR Capsule & Tablet Tablet Corgard Tablet Hypertension (high blood pressure) Corlopam Injection Accupril Tablet Cozaar Tablet Accuretic Tablet Diltiazem CD & ER Capsule, Injection, & (ER) Tablet Acebutolol Capsule Dilt-XR Capsule Aliskiren Tablet Diovan (HCT) Tablet Altace Capsule Doxazosin Tablet Amlodipine Tablet Dutoprol Tablet Amlodipine/Benazepril Capsule Edarbi Tablet Amlodipine/Olmesartan Tablet Edarbyclor Tablet Amlodipine/Valsartan Tablet Enalapril Tablet Amlodipine/Valsartan/Hydrochlorothiazide Tablet Enalapril/Hydrochlorothiazide Tablet Atacand (HCT) Tablet Enalaprilat Injection Atenolol Tablet Entresto Tablet Atenolol/Chlorthalidone Tablet Epaned Solution Avalide Tablet Esmolol Injection Avapro Tablet Exforge (HCT) Tablet Azor Tablet Felodipine ER Tablet Benazepril Tablet Fosinopril Tablet Benazepril/Hydrochlorothiazide Tablet Fosinopril/Hydrochlorothiazide Tablet Benicar (HCT) Tablet Guanfacine Tablet Betaxolol Tablet Hemangeol Oral Solution Bisoprolol Tablet Hydralazine Injection & Tablet Bisoprolol/Hydrochlorothiazide Tablet Hyzaar Tablet Brevibloc Injection & IV Solution Inderal LA and XL Capsule Bystolic Tablet Innopran XL Capsule Calan (SR) Tablet Irbesartan Tablet Candesartan Tablet Irbesartan/Hydrochlorothiazide Tablet Candesartan/Hydrochlorothiazide Tablet Isradipine Capsule Captopril Tablet Kapspargo Capsule Captopril/Hydrochlorothiazide Tablet Katerzia Suspension Cardene IV Solution Labetalol Tablet & Injection Cardizem (LA) Tablet & CD Capsule Lisinopril Tablet Lisinopril/Hydrochlorothiazide Tablet Sular Tablet Lopressor (HCT) Tablet Tarka CR Tablet Losartan Tablet Taztia XT Capsule Losartan/Hydrochlorothiazide Tablet Tekturna Tablet Lotensin (HCT) Tablet Tekturna (HCT) Tablet Lotrel Capsule Telmisartan Tablet Matzim LA Tablet Telmisartan/Amlodipine Tablet Methyldopa Tablet Telmisartan/Hydrochlorothiazide Tablet Methyldopa/Hydrochlorothiazide Tablet Tenoretic Tablet Metoprolol Succinate ER Tablet Tenormin Tablet Metoprolol Tartrate Injection & (HCT) Tablet Terazosin Capsule Metoprolol/Hydrochlorothiazide Tablet Tiazac Capsule Micardis (HCT) Tablet Timolol Maleate Tablet Minipress Capsule Toprol XL Tablet Minoxidil Tablet Trandolapril Tablet Moexipril Tablet Trandolapril/Verapamil ER Tablet Nadolol Tablet Tribenzor Tablet Nadolol/Bendroflumethiazide Tablet Twynsta Tablet Nicardipine Capsule & Injection Valsartan Tablet Nifedipine Capsule & ER Tablet Valsartan/Hydrochlorothiazide Tablet Nimodipine Capsule Vaseretic Tablet Nisoldipine ER Tablet Vasotec Tablet Nitropress Injection Vecamyl Tablet
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