2021 Preventive Medications and Your Plan

2021 Preventive medications and your plan

Managing your health with preventive medications Your pharmacy benefit plan includes special coverage for generic preventive medications. These medications help protect against or manage a medical condition, such as: • Preventing blood clots and reducing the risk of a stroke • Preventing heart disease and reducing high blood pressure • Preventing osteoporosis (a disease that leads to an increased risk of bone fracture) Your health is important. Taking preventive medications as told by your healthcare provider can help you avoid serious illness and high healthcare costs. Special coverage for generic preventive medications The drugs on your plan’s preventive medications list do not have a deductible. This means you’ll pay your copayment/coinsurance or nothing at all, depending on your plan. It can save you money and get the medications you need to help you live a healthier life. Your plan only offers this special coverage for generic drugs on the preventive medications list. Preventive medications are a group of products in your plan’s formulary which tells you what medications your plan covers. Please note that most medications on the formulary have a deductible, but generic preventive medications do not. To check the cost of any medication, see your benefit handbook or contact customer service at the member phone number on your ID card.

Quality drives our decisions A group of doctors and pharmacists meets often to review medications and suggest coverage under pharmacy benefit plans. They also recommend which medications should be on plan’s generic preventive medications list.

A list of generic preventive medications begins on the next page. Medications are listed by therapeutic category. Your specific plan may not cover all of the drugs. Please see your plan’s formulary for coverage details. Oral and self-injectable Specialty medications are labled with an SP note and may have limitations based on your plan benefit. For questions on injectable dose forms of preventive medications driven by your healthcare provider, please call the member phone number on your ID card. Generic medications by therapeutic category

albuterol sulfate hfa ranolazine er ANTIDEPRESSANTS budesonide sus Anticoagulants citalopram cromolyn escitalopram difil-g forte aspirin / dipyridamole fluoxetine fluticasone / salmeterol diskus cilostazol fluoxetine dr ipratropium clopidogrel fluvoxamine ipratropium / albuterol dipyridamole fluvoxamine er isoproteren aer enoxaparin SP paroxetine levalbuterol neb fondaparinux SP paroxetine er metaproterenol heparin sertraline montelukast jantoven terbutaline prasugrel ANTIPSYCHOTICS theophylline warfarin aripiprazole theophylline cr Cardiac Glycosides aripiprazole odt theophylline er chlorpromazine wixela inhub digitek clozapine zafirlukast digox clozapine odt zileuton er digoxin compro CANCER High blood pressure fluphenazine haloperidol anastrozole acebutolol loxapine exemestane aliskiren molindone letrozole amiloride olanzapine raloxifene amiloride / hctz olanzapine odt tamoxifen amlodipine olanzapine / fluoxetine toremifene amlodipine / benazepril paliperidone er CARDIOVASCULAR/ amlodipine / valsartan perphenazine amlodipine/olmesartan HEART DISEASE prochlorperazine medoxomil quetiapine Anti-Anginal Agents amlodipine / valsartan / hctz quetiapine er atenolol isosorbide dinitrate risperidone atenolol / chlorthalidone isosorbide dinitrate er risperidone odt benazepril isosorbide mononitrate thioridazine benazepril / hctz isosorbide mononitrate er thiothixene betaxolol tablet minitran trifluoperazine bisoprolol nitroglycerin ziprasidone bisoprolol / hctz nitroglycerin er bumetanide ASTHMA AND COPD nitroglycerin lingual candesartan nitroglycerin transdermal albuterol sulfate candesartan / hctz nitro-time albuterol sulfate er captopril petn

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit ‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule captopril / hctz nimodipine fenofibric acid DR cartia xt nisoldipine er fluvastatin carvedilol olmesartan fluvastatin er carvedilol er olmesartan / amlodipine / hctz gemfibrozil chlorothiazide olmesartan / hctz lovastatin chlorthalidone perindopril niacin (Rx only) clonidine phenozybenzamine niacin er diltiazem cd pindolol niacor diltiazem prazosin omega-3-acid ethyl esters diltiazem er propranolol pravastatin dilt-XR propranolol er prevalite doxazosin propranolol / hctz rosuvastatin enalapril quinapril simvastatin enalapril / hctz quinapril / hctz CONTRACEPTIVES ‡ eplerenone ramipril eprosartan sotalol generic contraceptive patch ethacrynic acid spironolactone generic emergency ezide spironolactone / hctz contraceptives felodipine er taztia xt generic injectable contraceptive fosinopril telmisartan generic oral contraceptives fosinopril / hctz telmisartan / amlodipine generic vaginal ring furosemide telmisartan / hctz contraceptive guanfacine terazosin hydralazine tiadylt er DIABETES hydrochlorothiazide timolol (tablet) Non-insulin indapamide torsemide irbesartan trandolapril acarbose irbesartan / hctz trandolapril / verapamil er chlorpropamide isradipine triamterene glimepiride labetalol triamterene / hctz glipizide lisinopril valsartan glipizide er lisinopril / hctz valsartan / hctz glipizide xl losartan potassium verapamil glipizide/metformin losartan potassium / hctz verapamil er glyburide matzim la verapamil sr glyburide micronized methyclothiazide glyburide/metformin High cholesterol methyldopa metformin methyldopa / hctz amlodipine/atorvastatin metformin er (not mod or osm) metolazone atorvastatin miglitol metoprolol er cholestyramine nateglinide metoprolol cholestyramine light pioglitazone minoxidil tablet colesevelam pioglitazone / metformin moexipril colestipol pioglitazone / glimepride nadolol ezetimibe repaglinide nadolol / bendroflumethiazide ezetimibe / simvastatin repaglinide/metformin nicardipine fenofibrate tolazamide nifedipine fenofibrate micronized tolbutamide nifedipine er fenofibric acid

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit ‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule misoprostol ibandronate ESTROGENS nizatidine raloxifene amabelz omeprazole risedronate covaryx pantoprazole risedronate dr pantoprazole dr covaryx hs SMOKING DETERRENTS ‡ dotti rabeprazole tab eemt sucralfate bupropion er eemt hs HIV/AIDS nicotine gum esterified estrogens/ nicotine lozenge methltestosterone abacavir nicotine patch abacavir / lamivudine esterified estrogens/ TRANSPLANT ‡ methltestosterone ds abacavir / lamivudine / esterified estrogens/ zidovudine azathioprine methltestosterone hs atazanavir cyclosporine SP estradiol didanosine cyclosporine modifiedSP estradiol/norethindrone acetate efavirenz everolimus SP fyavolv efavirenz/lamivudine/tenofovir gengraf SP jinteli fosamprenavir mycophenolate SP lopreeza lamivudine mycophenolic acid dr SP mimvey lamivudine / zidovudine sirolimus SP mimvey lo lopinavir / ritonavir tacrolimus cap SP nevirapine norethindrone acetate/ethinyl VITAMINS & HEMATINICS ‡ estradiol nevirapine ER ritonavir Pediatric vitamins GASTROINTESTINAL-ULCER stavudine with fluoride DRUGS ‡ tenofovir Generic Products cimetidine zidovudine Prenatal multivitamins esomeprazole magnesium OSTEOPOROSIS with iron and folic acid famotidine lansoprazole alendronate Generic Products lansoprazole/amoxicillin/ calcitonin-salmon etidronate di clarithromycin

This list should be used as a reference and may not include all medications. Brand or generic availability may not be current due to changes in the market.

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