navitus.com Share a Clear View Expanded Preventive Drug List Updated January 2018 Your employer 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 your employer has chosen to be 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. ANTIANGINAL AGENTS albuterol neb soln 0.5% isosorbide dinitrate SL tab albuterol neb soln 0.63mg isosorbide dinitrate tab albuterol neb soln 1.25mg isosorbide mononitrate ER tab albuterol sulfate ER tab isosorbide mononitrate tab albuterol sulfate syrup nitroglycerin lingual spray albuterol sulfate tab nitroglycerin patch albuterol/ipratropium neb soln nitroglycerin SL tab aminophylline tab nitroglycerin SR cap budesonide inh susp ANTIARRHYTHMICS ipratropium neb soln amiodarone tab levalbuterol neb soln disopyramide cap montelukast chew tab disopyramide ER cap montelukast granule pack dofetilide cap montelukast tab flecainide tab terbutaline sulfate tab mexiletine cap theophylline CR tab propafenone ER cap theophylline ER tab propafenone tab theophylline soln quinidine gluconate CR tab zafirlukast tab ANTIASTHMATIC AND BRONCHODILATOR zileuton ER tab AGENTS ANTICOAGULANTS albuterol neb soln 0.083% enoxaparin inj • 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 N3935-0418 navitus.com Share a Clear View fondaparinux inj topiramate sprinkle cap warfarin tab topiramate tab ANTICONVULSANTS valproic acid cap carbamazepine chew tab valproic acid syrup carbamazepine ER cap zonisamide cap carbamazepine ER tab ANTIDEPRESSANTS carbamazepine susp amitriptyline tab carbamazepine tab bupropion ER tab clonazepam ODT bupropion tab clonazepam tab bupropion XL tab divalproex ER tab citalopram soln divalproex sodium DR tab citalopram tab divalproex sprinkle cap clomipramine cap ethosuximide cap desipramine tab ethosuximide soln doxepin cap felbamate susp doxepin conc felbamate tab duloxetine EC cap gabapentin cap escitalopram soln gabapentin soln escitalopram tab gabapentin tab fluoxetine cap lamotrigine chew tab fluoxetine soln lamotrigine ER tab fluoxetine tab lamotrigine ODT fluvoxamine ER cap lamotrigine ODT kit fluvoxamine tab lamotrigine tab imipramine pamoate cap levetiracetam ER tab imipramine tab levetiracetam soln mirtazapine ODT levetiracetam tab mirtazapine tab oxcarbazepine susp nefazodone tab 50mg, 250mg oxcarbazepine tab nortriptyline cap phenytoin cap paroxetine ER tab phenytoin chew tab paroxetine tab phenytoin susp phenelzine tab primidone tab protriptyline tab tiagabine tab sertraline conc • 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 sertraline tab fenofibrate tab tranylcypromine tab fluvastatin cap trazodone tab gemfibrozil tab trimipramine cap lovastatin tab venlafaxine ER cap omega-3-acid ethyl esters cap venlafaxine ER tab pravastatin tab ANTIDIABETICS rosuvastatin tab acarbose tab rosuvastatin tab 20mg glimepiride tab simvastatin tab glipizide ER tab ANTIHYPERTENSIVES glipizide tab amlodipine/benazepril cap glipizide/metformin tab amlodipine/valsartan tab glyburide micronized tab amlodipine/valsartan/ glyburide tab hydrochlorothiazide tab glyburide/metformin tab atenolol/chlorthalidone tab metformin ER tab benazepril tab metformin tab benazepril/hydrochlorothiazide tab miglitol tab bisoprolol/hydrochlorothiazide tab nateglinide tab candesartan tab pioglitazone tab candesartan/hydrochlorothiazide tab pioglitazone/glimepiride tab captopril tab pioglitazone/metformin tab clonidine patch repaglinide tab clonidine tab tolazamide tab doxazosin tab ANTIHYPERLIPIDEMICS enalapril tab atorvastatin tab enalapril/hydrochlorothiazide tab cholestyramine lite powder eplerenone tab cholestyramine lite powder pack fosinopril tab cholestyramine powder fosinopril/hydrochlorothiazide tab cholestyramine powder pack guanfacine IR tab colestipol granule hydralazine tab colestipol powder packet irbesartan tab colestipol tab irbesartan/hydrochlorothiazide tab ezetimibe/simvastatin tab lisinopril tab fenofibrate cap lisinopril/hydrochlorothiazide 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 losartan tab acebutolol cap losartan/hydrochlorothiazide tab atenolol tab methyldopa tab betaxolol tab methyldopa/hydrochlorothiazide tab bisoprolol tab metoprolol/hydrochlorothiazide tab carvedilol tab minoxidil tab labetalol tab moexipril tab metoprolol ER tab moexipril/hydrochlorothiazide tab metoprolol tab nadolol/bendroflumethiazide tab nadolol tab perindopril tab pindolol tab phenoxybenzamine cap propranolol ER cap prazosin cap propranolol tab propranolol/hydrochlorothiazide tab sotalol AF tab quinapril tab sotalol tab quinapril/hydrochlorothiazide tab timolol maleate tab ramipril cap CALCIUM CHANNEL BLOCKERS telmisartan tab amlodipine tab telmisartan/amlodipine tab diltiazem ER cap terazosin cap diltiazem ER tab trandolapril tab diltiazem tab trandolapril/ verapamil ER tab felodipine ER tab valsartan tab isradipine cap valsartan/hydrochlorothiazide tab nicardipine cap ANTINEOPLASTICS AND ADJUNCTIVE nifedipine cap THERAPIES nifedipine ER tab anastrozole tab nimodipine cap bicalutamide tab nisoldipine ER tab exemestane tab verapamil SR cap flutamide cap verapamil SR tab letrozole tab verapamil tab megestrol susp CARDIAC GLYCOSIDES megestrol tab digoxin soln nilutamide tab digoxin tab tamoxifen tab CARDIOVASCULAR AGENTS - MISC. BETA BLOCKERS amlodipine/atorvastatin 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 CONTRACEPTIVES NATAZIA TAB amethyst tab necon tab apri tab necon tab 1/50 aranelle tab norethindrone tab aviane tab NORINYL TAB 1/50 BEYAZ TAB nortrel tab CERVICAL CAP NUVARING cesia tab OGESTREL TAB CONCEPTROL GEL PARAGARD IUD CONTRACEPTIVE FILM PLAN B TAB CONTRACEPTIVE FOAM TODAY SPONGE CONTRACEPTIVE GEL tri-legest tab CONTRACEPTIVE SUPP tri-nessa (LO) tab cryselle tab vcf vaginal gel DEPO-PROVERA SC INJ 104MG wymzya FE tab DIAPHRAGM XULANE PATCH ELLA TAB YASMIN TAB enpresse tab YAZ TAB FEMALE CONDOMS DIABETIC SUPPLIES jolessa tab/ amethia tab alcohol pads junel FE tab blood/urine test strips junel tab lancet devices and lancets kariva tab needles and syringes kelnor tab DIURETICS levonorgestrel tab acetazolamide ER cap LEVONORGESTREL TAB 0.75MG acetazolamide tab LEVONORGESTREL/ETHINYL ESTRADIOL amiloride tab TAB amiloride/hydrochlorothiazide tab LO LOESTRIN TAB bumetanide tab LO MINASTRIN 24 FE CHEW TAB chlorothiazide tab LOESTRIN 24 FE TAB ethacrynic tab medroxyprogesterone inj furosemide tab mibelas chew tab hydrochlorothiazide cap MIRENA IUD hydrochlorothiazide tab mononessa tab indapamide 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 methazolamide tab LURIDE SOLN metolazone tab phospha 250 neutral tab spironolactone tab potassium bicarbonate effer tab spironolactone/hydrochlorothiazide tab potassium chloride effer tab torsemide tab potassium chloride ER cap triamterene/hydrochlorothiazide cap potassium chloride micro tab triamterene/hydrochlorothiazide tab potassium chloride powder packet ENDOCRINE AND METABOLIC AGENTS - potassium chloride soln MISC. sodium fluoride chew tab alendronate tab SODIUM FLUORIDE LOZENGE calcitonin nasal spray sodium fluoride soln etidronate disodium tab 200mg SODIUM FLUORIDE TAB ibandronate tab 150mg zinc sulfate cap risedronate DR tab MOUTH/THROAT/DENTAL AGENTS risedronate tab chlorhexidine gluconate soln GOUT AGENTS sodium fluoride cream allopurinol tab sodium fluoride gel colchicine/probenecid tab sodium fluoride paste probenecid tab sodium fluoride rinse HEMATOLOGICAL AGENTS - MISC. sodium fluoride/potassium nitrate paste anagrelide cap triamcinolone in orabase paste aspirin/dipyridamole cap PSYCHOTHERAPEUTIC COMBINATION cilostazol tab AGENTS clopidogrel tab 75mg chlordiazepoxide/amitriptyline tab dipyridamole tab olanzapine/ fluoxetine cap pentoxifylline ER tab SMOKING CESSATION LAXATIVES bupropion SR tab lactulose soln CHANTIX PAK peg 3350/electrolytes soln CHANTIX TAB trilyte soln NICODERM PATCH MINERALS & ELECTROLYTES NICORETTE GUM FLUORABON SOLN NICORETTE LOZENGE FLUOR-A-DAY CHEW TAB nicotine gum LURIDE CHEW TAB NICOTINE KIT • 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 nicotine lozenge MENVEO INJ nicotine patch M-M-R II INJ NICOTROL INHALER PNEUMOVAX INJ NICOTROL NASAL