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Preventive Drug List

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Preventive Drug List navitus.com Share a Clear View Preventive Drug List Updated July 2021 Your health plan is making an effort to reduce your health care costs by giving you tools to help you stay healthy and productive. Below are the medications included on your Preventive Drug List. These medications help protect against or manage some high risk medical conditions. Taking these medications as directed by your prescriber can help avoid serious health problems. That may mean fewer doctor visits and hospitalizations, reducing your total health care costs. In the drug list below, generic drugs are shown in lowercase type. Brand name drugs are shown in uppercase type. Antiasthmatic/Bronchodilators theophylline soln ADVAIR DISKUS INHALER *generic Wixela only for wixela inhaler *brand Advair Diskus only for non-HDHP plans* HDHPs* ADVAIR HFA INHALER Anticoagulant albuterol/ipratropium neb soln ELIQUIS TAB aminophylline tab PRADAXA CAP ARNUITY ELLIPTA INHALER warfarin tab ASMANEX HFA INHALER XARELTO TAB ASMANEX INHALER Antidiabetics budesonide inh susp acarbose tab FLOVENT DISKUS INHALER chlorpropamide tab FLOVENT HFA INHALER glimepiride tab fluticasone/salmeterol inhaler glipizide ER tab ipratropium neb soln glipizide tab METAPROTERENOL SYRUP glipizide/metformin tab montelukast chew tab glyburide micronized tab montelukast tab glyburide tab THEOCHRON glyburide/metformin tab theophylline CR tab metformin ER tab theophylline ER tab metformin tab • Note: The list is subject to change and not all drugs listed may be covered on your formulary. Please refer to your Navitus formulary for a complete list of covered products. CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | www.navitus.com N3935-1019 navitus.com Share a Clear View NOVOLIN N rosuvastatin tab 5mg NOVOLIN N FLEXPEN simvastatin tab NOVOLIN R Antihypertensives NOVOLIN R FLEXPEN acebutolol cap pioglitazone tab acetazolamide ER cap repaglinide tab acetazolamide tab tolazamide tab amiloride tab Antihyperlipidemics amiloride/hydrochlorothiazide tab atorvastatin tab 10mg amlodipine tab atorvastatin tab 20mg amlodipine/atorvastatin tab atorvastatin tab 40mg amlodipine/benazepril cap atorvastatin tab 80mg amlodipine/olmesartan tab cholestyramine lite powder amlodipine/valsartan tab cholestyramine lite powder pack amlodipine/valsartan/ cholestyramine powder hydrochlorothiazide tab cholestyramine powder pack atenolol tab colesevelam pack atenolol/chlorthalidone tab colesevelam tab benazepril tab colestipol granule betaxolol tab colestipol powder bisoprolol tab colestipol tab bisoprolol/hydrochlorothiazide tab ezetimibe tab bumetanide tab ezetimibe/simvastatin tab carvedilol tab fenofibrate cap 67mg, 134mg, 200mg chlorothiazide tab fenofibrate tab 48mg, 54mg, 145mg, CHLORTHALIDONE TAB 160mg clonidine patch fenofibric acid DR cap clonidine tab fluvastatin cap diltiazem ER cap gemfibrozil tab diltiazem ER tab lovastatin tab diltiazem tab omega-3-acid ethyl esters cap doxazosin tab pravastatin tab enalapril/hydrochlorothiazide tab rosuvastatin tab 10mg eplerenone tab rosuvastatin tab 20mg ethacrynic tab rosuvastatin tab 40mg felodipine ER tab • Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products. CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | www.navitus.com navitus.com Share a Clear View FUROSEMIDE SOLN propranolol ER cap furosemide soln PROPRANOLOL SOLN furosemide tab propranolol tab guanfacine IR tab propranolol/hydrochlorothiazide tab hydralazine tab sotalol AF tab hydrochlorothiazide cap sotalol tab hydrochlorothiazide tab spironolactone tab indapamide tab spironolactone/hydrochlorothiazide tab irbesartan tab terazosin cap isradipine cap timolol maleate tab labetalol tab torsemide tab lisinopril tab trandolapril/verapamil ER tab lisinopril/hydrochlorothiazide tab triamterene cap losartan tab triamterene/hydrochlorothiazide cap losartan/hydrochlorothiazide tab TRIAMTERENE/HYDROCHLOROTHIAZIDE methazolamide tab CAP 50-25mg METHYCLOTHIAZIDE TAB triamterene/hydrochlorothiazide tab methyldopa tab valsartan tab methyldopa/hydrochlorothiazide tab valsartan/hydrochlorothiazide tab metolazone tab verapamil SR cap metoprolol ER tab verapamil SR cap metoprolol tab VERAPAMIL SR CAP 360mg metoprolol/hydrochlorothiazide tab verapamil SR tab minoxidil tab verapamil tab nadolol tab Antiplatelet nadolol/bendroflumethiazide tab anagrelide cap nicardipine cap cilostazol tab nifedipine cap clopidogrel tab 75mg nifedipine ER tab dipyridamole tab nimodipine cap prasugrel tab nisoldipine ER tab ticlopidine tab olmesartan tab Osteoporosis olmesartan/hydrochlorothiazide tab alendronate tab pindolol tab ALENDRONATE TAB 40MG prazosin cap calcitonin nasal spray • Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products. CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | www.navitus.com navitus.com Share a Clear View ibandronate tab 150mg risedronate DR tab risedronate tab • Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products. CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | www.navitus.com navitus.com Share a Clear View Health Care Reform Contraceptive Drugs Comprehensive List - Updated January 2021 The Affordable Care Act (ACA) requires most health plans to pay for certain preventive services at no cost to you. Contraceptives are included as a preventive service under the ACA. The following contraceptive drugs are available with a $0 copayment. Generic drugs are shown in lowercase type. Brand drugs are shown in uppercase type. afirmelle tab azurette tab aftera tab balziva tab altavera tab bekyree tab alyacen 1/35 tab blisovi 24 fe tab alyacen 7/7/7 tab blisovi fe 1.5/30 tab amethia lo tab blisovi fe 1/20 tab amethia tab briellyn tab amethyst tab camila tab apri tab camrese lo tab aranelle tab camrese tab ashlyna tab caziant tab aubra eq tab CERVICAL CAP aubra tab cesia tab aurovela 1.5/30 tab chateal eq tab aurovela 1/20 tab chateal tab aurovela 24 fe tab CONTRACEPTIVE FILM aurovela fe 1.5/30 tab CONTRACEPTIVE FOAM aurovela fe 1/20 tab CONTRACEPTIVE GEL aviane tab cryselle-28 tab ayuna tab cyclafem 1/35 tab • Note: This list is subject to change. Also, not all medications may be covered on your formulary. Please refer to your Navitus formulary for a complete list of covered products. • This requirement applies to all non-grandfathered plans with an effective date on or after August 1, 2012. CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | www.navitus.com N3993-0121 navitus.com Share a Clear View cyclafem 7/7/7 tab gildagia tab cyred eq tab gildess 1.5/30 tab cyred tab gildess 1/20 tab dasetta 1/35 tab gildess 24 fe tab dasetta 7/7/7 tab gildess fe 1.5/30 tab daysee tab gildess fe 1/20 tab deblitane tab hailey 1.5/30 tab delyla tab hailey 24 fe tab DEPO-SUBQ PROVERA 104 hailey fe 1.5/30 tab desogestrel/ethinyl estra tab hailey fe 1/20 tab drospirenone/ethinyl estr tab heather tab econtra ez tab iclevia tab econtra one-step tab incassia tab elinest tab introvale tab ELLA TAB isibloom tab emoquette tab jaimiess tab ENCARE jasmiel tab enpresse-28 tab jencycla tab enskyce tab jolessa tab errin tab jolivette tab estarylla tab juleber tab ethynodiol diacetate/ethi tab junel 1.5/30 tab fallback solo tab junel 1/20 tab falmina tab junel fe 1.5/30 tab fayosim tab junel fe 1/20 tab FEMALE CONDOMS junel fe 24 tab femynor tab kaitlib fe tab gianvi tab kalliga tab • Note: This list is subject to change. Also, not all medications may be covered on your formulary. Please refer to your Navitus formulary for a complete list of covered products. • This requirement applies to all non-grandfathered plans with an effective date on or after August 1, 2012. CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | www.navitus.com navitus.com Share a Clear View kariva tab lojaimiess tab kelnor 1/35 tab lomedia 24 fe tab kelnor 1/50 tab loryna tab kimidess tab low-ogestrel tab kurvelo tab lutera tab KYLEENA IUD lyza tab larin 1.5/30 tab marlissa tab larin 1/20 tab medroxyprogesterone aceta larin 24 fe tab microgestin 1.5/30 tab larin fe 1.5/30 tab microgestin 1/20 tab larin fe 1/20 tab microgestin 24 fe tab larissia tab microgestin fe 1.5/30 tab layolis fe tab microgestin fe 1/20 tab leena tab microgestin fe tab lessina tab mili tab levonest tab MIRENA IUD levonorgestrel and ethiny tab mono-linyah tab LEVONORGESTREL TAB mononessa tab levonorgestrel tab my choice tab levonorgestrel/ethinyl es tab my way tab levora 0.15/30-28 tab myzilra tab LILETTA IUD necon 0.5/35-28 tab lillow tab necon 1/35 tab lo-zumandimine tab necon 7/7/7 tab loestrin 1.5/30-21 tab new day tab loestrin 1/20-21 tab next choice one dose tab loestrin fe 1.5/30 tab next choice tab loestrin fe 1/20 tab nikki tab • Note: This list is subject to change. Also, not all medications may be covered on your formulary. Please refer to your Navitus formulary for a complete list of covered products. • This requirement applies to all non-grandfathered plans with an effective date on or after August 1, 2012. CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | www.navitus.com navitus.com Share a Clear View nora-be tab PLAN B TAB norethindrone & ethinyl e tab portia-28 tab norethindrone acetate/eth tab preventeza tab norethindrone tab previfem tab norethindrone/ethinyl est tab quasense tab norgestimate/ethinyl estr tab react tab norgestrel/ethinyl estrad tab reclipsen tab norlyda tab rivelsa tab norlyroc tab setlakin tab nortrel 0.5/35 (28) tab sharobel tab nortrel 1/35 (28) tab simliya tab nortrel 1/35 tab simpesse tab nortrel 7/7/7 tab SKYLA IUD NUVARING solia tab nylia 7/7/7 tab sprintec 28 tab nymyo tab sronyx tab ocella tab syeda tab opcicon one-step tab take action tab option 2 tab tarina 24 fe tab orsythia tab tarina fe 1/20 eq tab ORTHO DIAPHRAGM tarina fe 1/20 tab ORTHO EVRA tilia fe tab PARAGARD INTRAUTERINE COP IUD TODAY SPONGE philith tab tri-estarylla tab pimtrea tab tri-legest fe tab pirmella 1/35 tab tri-linyah tab pirmella 7/7/7 tab tri-lo-estarylla tab PLAN B ONE-STEP TAB tri-lo-marzia tab • Note: This list is subject to change.
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