Quick viewing(Text Mode)

Preventive Therapy Drug List

Preventive Therapy Drug List

Preventive Therapy List (Brand name in CAPS and generic in lower case) (08/01/18) ANTI-INFECTIVES phenytoin AF ANTIRETROVIRAL AGENTS phenytoin sodium extended Pacerone TRUVADA 200/300 mg primidone BETAPACE tiagabine BETAPACE AF topiramate MULTAQ / topiramate ext-rel NORPACE ANTIPLATELETS valproic acid NORPACE CR ANTICOAGULANTS vigabatrin RYTHMOL SR enoxaparin zonisamide SORINE fondaparinux Epitol SOTYLIZE warfarin APTIOM TIKOSYN Jantoven BANZEL ARIXTRA BRIVIACT ORAL ANTIANGINAL AGENTS BEVYXXA CARBATROL COUMADIN CELONTIN isosorbide dinitrate ext-rel COUMADIN INJECTION DEPAKENE ELIQUIS DEPAKOTE isosorbide mononitrate ext-rel FRAGMIN DEPAKOTE ER DILATRATE-SR IPRIVASK DILANTIN ISORDIL LOVENOX FELBATOL PRADAXA FYCOMPA SL and chewable formulations are not included SAVAYSA GABITRIL on this list. XARELTO KEPPRA KEPPRA XR TRANSDERMAL/TOPICAL ANTIANGINAL AGGREGATION INHIBITORS KLONOPIN AGENTS aspirin 81 mg LAMICTAL nitroglycerin transdermal clopidogrel LAMICTAL XR Minitran dipyridamole MYSOLINE NITRO-BID dipyridamole ext-rel/aspirin ONFI NITRO-DUR prasugrel OXTELLAR XR AGGRENOX PEGANONE BRILINTA PHENYTEK ANTIHYPERLIPIDEMICS CLOPIDOGREL KIT QUDEXY XR atorvastatin DURLAZA ROWEEPRA cholestyramine EFFIENT SABRIL colesevelam PLAVIX SPRITAM colestipol YOSPRALA TEGRETOL ezetimibe ZONTIVITY TEGRETOL-XR fenofibrate TOPAMAX fenofibric acid Over-the-Counter (OTC) products require a prescription. TRILEPTAL fenofibric acid delayed-rel Coverage may vary by plan. TROKENDI XR fluvastatin VIMPAT fluvastatin ext-rel ZARONTIN gemfibrozil carbamazepine ZONEGRAN lovastatin carbamazepine ext-rel niacin ext-rel clonazepam CARDIOVASCULAR CONDITIONS - pravastatin divalproex sodium delayed-rel rosuvastatin divalproex sodium ext-rel OTHER simvastatin ethosuximide ANTIARRHYTHMIC AGENTS Niacor felbamate amiodarone Prevalite lamotrigine disopyramide ALTOPREV lamotrigine ext-rel dofetilide ANTARA levetiracetam flecainide COLESTID levetiracetam ext-rel CRESTOR oxcarbazepine propafenone ext-rel FENOGLIDE phenobarbital sotalol FIBRICOR

Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications.

This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894B 080118

FLOLIPID TRESIBA PRANDIN KYNAMRO TRULICITY PRECOSE LESCOL XL VICTOZA QTERN LIPITOR XULTOPHY RIOMET LIPOFEN SEGLUROMET LIVALO Over-the-Counter (OTC) products require a prescription. STARLIX LOPID Coverage may vary by plan. STEGLATRO NIASPAN STEGLUJAN ORAL DIABETES AGENTS PRAVACHOL SYNJARDY acarbose QUESTRAN/QUESTRAN LIGHT SYNJARDY XR alogliptin TRICOR TRADJENTA alogliptin/metformin TRIGLIDE XIGDUO XR alogliptin/pioglitazone TRILIPIX chlorpropamide WELCHOL glimepiride HEMATOLOGIC AGENTS ZETIA glipizide ADVATE ZOCOR glipizide ext-rel ADYNOVATE ZYPITAMAG glipizide/metformin AFSTYLA

glyburide ALPHANATE COMBINATION ANTIHYPERLIPIDEMICS glyburide, micronized ALPHANINE SD /atorvastatin glyburide/metformin ALPROLIX ezetimibe/simvastatin metformin BEBULIN CADUET metformin ext-rel BENEFIX VYTORIN miglitol CORIFACT

nateglinide ELOCTATE DIABETES pioglitazone FEIBA DIAGNOSTIC AGENTS AND SUPPLIES pioglitazone/glimepiride HELIXATE FS GLUCOSE MONITORS - ALL pioglitazone/metformin HEMOFIL M BLOOD GLUCOSE STRIPS - ALL repaglinide HUMATE-P CONTROL SOLUTIONS repaglinide/metformin IDELVION INSULIN SYRINGES, INFUSION SETS, tolbutamide IXINITY AND NEEDLES - ALL ACTOPLUS MET KOATE-DVI KETONE BLOOD TEST STRIPS - ALL ACTOPLUS MET XR KOGENATE FS LANCETS, LANCET DEVICES ACTOS KOVALTRY OMNIPOD INSULIN INFUSION PUMP AMARYL MONOCLATE-P URINE TESTING STRIPS - ALL D-CARE DM2 KIT MONONINE V-GO INSULIN DELIVERY DEVICE DUETACT NOVOEIGHT FARXIGA NUWIQ Over-the-Counter (OTC) products require a prescription. FORTAMET PROFILNINE SD Coverage may vary by plan GLUCOPHAGE RECOMBINATE

GLUCOPHAGE XR RIXUBIS INHALED DIABETES AGENTS GLUCOTROL TRETTEN AFREZZA GLUCOTROL XL XYNTHA

GLUCOVANCE INJECTABLE DIABETES AGENTS ADLYXIN GLUMETZA HYPERTENSION ADMELOG GLYNASE ACE INHIBITORS/ANGIOTENSIN II RECEPTOR GLYSET APIDRA ANTAGONISTS AND COMBINATION AGENTS GLYXAMBI BASAGLAR KWIKPEN amlodipine/benazepril BYDUREON INVOKAMET benazepril BYETTA INVOKAMET XR benazepril/hydrochlorothiazide INVOKANA FIASP candesartan JANUMET HUMALOG candesartan/hydrochlorothiazide JANUMET XR HUMULIN captopril LANTUS JANUVIA captopril/hydrochlorothiazide JARDIANCE LEVEMIR enalapril JENTADUETO NOVOLIN enalapril/hydrochlorothiazide JENTADUETO XR NOVOLOG eprosartan OZEMPIC KAZANO fosinopril KOMBIGLYZE XR SOLIQUA fosinopril/hydrochlorothiazide METAGLIP SYMLINPEN irbesartan NESINA TANZEUM irbesartan/hydrochlorothiazide TOUJEO ONGLYZA lisinopril OSENI

Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications.

This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894B 080118

lisinopril/hydrochlorothiazide /bendroflumethiazide hydrochlorothiazide losartan indapamide losartan/hydrochlorothiazide methyclothiazide moexipril propranolol ext-rel spironolactone/hydrochlorothiazide moexipril/hydrochlorothiazide propranolol/hydrochlorothiazide triamterene/hydrochlorothiazide olmesartan maleate ALDACTAZIDE olmesartan/hydrochlorothiazide BYSTOLIC DIURIL perindopril BYVALSON DYAZIDE quinapril COREG MAXZIDE quinapril/hydrochlorothiazide COREG CR MICROZIDE ramipril CORGARD telmisartan CORZIDE OTHER ANTIHYPERTENSIVE AGENTS telmisartan/hydrochlorothiazide DUTOPROL amlodipine/olmesartan trandolapril INDERAL LA amlodipine/telmisartan trandolapril/ ext-rel LEVATOL amlodipine/valsartan/ valsartan LOPRESSOR hydrochlorothiazide valsartan/hydrochlorothiazide LOPRESSOR HCT ACCUPRIL TENORETIC clonidine transdermal ACCURETIC TENORMIN ALTACE TOPROL-XL ATACAND TRANDATE ATACAND HCT ZIAC AVALIDE methyldopa/hydrochlorothiazide AVAPRO CHANNEL BLOCKERS AND BENICAR COMBINATION AGENTS olmesartan/amlodipine/ BENICAR HCT amlodipine hydrochlorothiazide COZAAR AZOR DIOVAN diltiazem ext-rel CATAPRES DIOVAN HCT diltiazem XR CATAPRES-TTS EDARBI felodipine ext-rel EXFORGE EDARBYCLOR isradipine EXFORGE HCT EPANED nicardipine TEKTURNA HYZAAR TEKTURNA HCT LOTENSIN nifedipine ext-rel TRIBENZOR LOTENSIN HCT nisoldipine ext-rel TWYNSTA LOTREL verapamil MICARDIS verapamil ext-rel IMMUNIZING AGENTS MICARDIS HCT Afeditab CR ALLERGENIC EXTRACTS PRESTALIA Cartia XT ALLERGENIC EXTRACTS - ALL PRINIVIL Dilt-XR QBRELIS Matzim LA IMMUNIZATIONS TARKA Nifediac CC - ALL VASERETIC Taztia XT VASOTEC ADALAT CC ZESTORETIC CALAN MENTAL HEALTH ZESTRIL CALAN SR CARDIZEM BETA-BLOCKERS AND COMBINATION CARDIZEM CD AGENTS CARDIZEM LA bupropion ISOPTIN SR bupropion ext-rel NORVASC citalopram atenolol/chlorthalidone PROCARDIA PROCARDIA XL desipramine SULAR desvenlafaxine ext-rel bisoprolol/hydrochlorothiazide TIAZAC VERELAN duloxetine delayed-rel carvedilol phosphate ext-rel VERELAN PM escitalopram fluoxetine fluoxetine delayed-rel metoprolol succinate ext-rel amiloride/hydrochlorothiazide fluvoxamine metoprolol/hydrochlorothiazide chlorothiazide HCl nadolol chlorthalidone imipramine pamoate

Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications.

This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894B 080118

BUNAVAIL thiothixene PROBUPHINE nortriptyline trifluoperazine SUBLOCADE paroxetine HCl ziprasidone SUBOXONE FILM paroxetine HCl ext-rel ABILIFY VIVITROL phenelzine ABILIFY MAINTENA ZUBSOLV protriptyline ARISTADA sertraline CLOZARIL ANTI-OBESITY AGENTS tranylcypromine EQUETRO benzphetamine FANAPT diethylpropion FAZACLO diethylpropion ext-rel venlafaxine GEODON phendimetrazine venlafaxine ext-rel HALDOL phendimetrazine ext-rel Irenka HALDOL DECANOATE phentermine ANAFRANIL INVEGA ADIPEX-P APLENZIN INVEGA SUSTENNA BELVIQ CELEXA INVEGA TRINZA BELVIQ XR CYMBALTA LATUDA CONTRAVE DESVENLAFAXINE ER REXULTI LOMAIRA EFFEXOR XR RISPERDAL QSYMIA EMSAM RISPERDAL CONSTA REGIMEX FETZIMA SAPHRIS SAXENDA FLUOXETINE 60 mg SEROQUEL XENICAL FORFIVO XL SEROQUEL XR KHEDEZLA VERSACLOZ BOWEL PREPARATIONS LEXAPRO VRAYLAR peg 3350/electrolytes MARPLAN ZYPREXA Gavilyte NARDIL ZYPREXA ZYDIS CLENPIQ NORPRAMIN COLYTE OLEPTRO OBSESSIVE COMPULSIVE DISORDER GOLYTELY PAMELOR fluvoxamine ext-rel MOVIPREP PARNATE NULYTELY PAXIL OSTEOPOROSIS OSMOPREP PAXIL CR alendronate PREPOPIK PEXEVA calcitonin SUPREP PRISTIQ calcitonin/salmon PROZAC ibandronate SMOKING DETERRENTS REMERON raloxifene bupropion ext-rel SURMONTIL risedronate nicotine polacrilex TOFRANIL zoledronic acid 5 mg/100 mL nicotine transdermal TRINTELLIX ACTONEL CHANTIX VENLAFAXINE ER ATELVIA NICODERM CQ VIIBRYD BINOSTO NICORETTE GUM WELLBUTRIN SR BONIVA NICORETTE LOZENGE WELLBUTRIN XL BONIVA INJECTION NICOTROL INHALER ZOLOFT EVISTA NICOTROL NS FOSAMAX ZYBAN FOSAMAX PLUS D aripiprazole MIACALCIN NASAL SPRAY Over-the-Counter (OTC) products require a prescription. Coverage may vary by plan. PROLIA RECLAST MISCELLANEOUS fluphenazine decanoate cholecalciferol (D3) haloperidol PREVENTIVE CARE SERVICES AGENTS FOR CHEMICAL DEPENDENCY Over-the-Counter (OTC) products require a prescription. acamprosate calcium Coverage may vary by plan. olanzapine orally disintegrating tabs buprenorphine sublingual buprenorphine/naloxone sublingual RESPIRATORY DISORDERS perphenazine disulfiram RESPIRATORY AGENTS naltrexone budesonide suspension quetiapine ext-rel Depade cromolyn sodium nebulizer solution ANTABUSE fluticasone/

Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications.

This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894B 080118

montelukast MALARONE OCREVUS zafirlukast PRIMAQUINE PLEGRIDY zileuton ext-rel REBIF ACCOLATE DENTAL CARIES PREVENTION TECFIDERA ADVAIR sodium fluoride TYSABRI ADVAIR HFA PEDIATRIC MULTIVITAMINS WITH ZINBRYTA AIRDUO RESPICLICK FLUORIDE - ALL MARKETED ALVESCO PRODUCTS WOMEN'S HEALTH ARNUITY ELLIPTA ANTIESTROGENS ASMANEX HEREDITARY ANGIOEDEMA AGENTS tamoxifen ASMANEX HFA CINRYZE SOLTAMOX BREO ELLIPTA HAEGARDA CINQAIR AROMATASE INHIBITORS DULERA IMMUNOSUPPRESSIVE AGENTS anastrozole FASENRA cyclosporine caps exemestane FLOVENT DISKUS mycophenolate mofetil letrozole FLOVENT HFA mycophenolate sodium delayed-rel ARIMIDEX NUCALA sirolimus AROMASIN PULMICORT tacrolimus FEMARA PULMICORT FLEXHALER Gengraf QVAR ASTAGRAF XL CONTRACEPTIVES SINGULAIR CELLCEPT CONTRACEPTIVES - ALL SPIRIVA RESPIMAT 1.25 mcg ENVARSUS XR PRESCRIPTION FORMULATIONS SYMBICORT MYFORTIC SYNAGIS NEORAL Over-the-Counter (OTC) emergency contraceptive XOLAIR NULOJIX products require a prescription. Coverage may vary by ZYFLO PROGRAF plan. ZYFLO CR RAPAMUNE SANDIMMUNE PRENATAL SUPPLIES ZORTRESS folic acid SPACER DEVICES PRENATAL VITAMINS SPACER SUPPLIES MULTIPLE SCLEROSIS AGENTS - PRESCRIPTION glatiramer AUBAGIO Over-the-Counter (OTC) products require a prescription. VARIOUS CONDITIONS Coverage may vary by plan. ANTI-MALARIAL AGENTS AVONEX BETASERON atovaquone/proguanil chloroquine COPAXONE mefloquine EXTAVIA GILENYA LEMTRADA

Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications.

This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894B 080118

Top View