2022 Preventive Medication List for Consumer Driven Health

Therapeutic Drug Classes Requirements & Limits

g B

B B

B g

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B B

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B

Bold type = Brand-name drug[Plain type = Generic drug]E = May be excluded from coverage1Coverage is provided for oral formulations.2SSRIs are included only for employer groups who have specifically requested coverage.

Pharmacy | PDL | Expanded Drug List

2022 Preventive Medication List for Consumer Driven Health Plans Expanded List

This is a list of Preventive Medications that may be covered under your plan. If your plan covers these Preventive Medications, your insurance benefit is applied before you meet your deductible.

Some medications may have other requirements or limits depending on your benefit plan and are noted below. To find out if a drug is covered, please check your plan benefits on the health plan’s member website. Or, call the toll-free phone number on your member ID card. This list may not be all-inclusive. Brand and generic drugs may not always be available due to market changes.

CDH preventive drug lists may also be used with non-CDH plans

Effective May 1, 2022


g Breast Cancer Prevention

Anastrozole

Arimidex E

Aromasin E

Exemestane

Fareston E

Femara E

Letrozole

Soltamox E

Tamoxifen

Toremifene

B Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy Cg

Aspirin-Dipyridamole

Bevyxxa

Brilinta

Cilostazol

Clopidogrel

Coumadin

Dipyridamole

Effient E

Eliquis

Enoxaparin

Fondaparinux

Fragmin

Aggrenox

Arixtra E

Heparin

Jantoven

Therapeutic Drug Classes Requirements Therapeutic Drug Classes Requirements & Limits & Limits

B B

B g

B g

B B

B B

g B

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Bg

B

Bold type = Brand-name drug E = May be excluded from coverage or subject to prior [Plain type = Generic drug] authorization (sometimes referred to as precertification) 1 2 Coverage is provided for oral formulations SSRIs are included only for employer groups who have

Lovenox E

Persantine

Plavix E

Pletal

Pradaxa

Prasugrel

Savaysa

Ticlopidine

Warfarin

Xarelto

Zontivity

Cardiovascular/Heart Disease: High Blood Pressure

Accupril E

Accuretic

Acebutolol

Aceon

Adalat CC

Afeditab

Aldactazide

Aldactone E

Aliskiren

Altace E

Amiloride

Amiloride-Hydrochlorothiazide

Amlodipine

Amlodipine-Benazepril

Amlodipine-Olmesartan E

Amlodipine-Olmesartan-Hydrochlorothiazide

E

Atacand HCT E

Atenolol

Atenolol-Chlorthalidone

Avalide E

Avapro E

Azor E

Benazepril

Benazepril-Hydrochlorothiazide

Benicar E

Benicar HCT 1

E

Betaxolol

Bidil

Bisoprolol

Bisoprolol-Hydrochlorothiazide

Bumetanide

Bystolic E

Byvalson

Calan

Calan SR

Candesartan

Candesartan-Hydrochlorothiazide

Captopril

Captopril-Hydrochlorothiazide

Cardene SR

Cardizem E

Cardizem CD E

Cardizem LA E

Cardura

Amlodipine-Valsartan

Amlodipine-Valsartan-Hydrochlorothiazide E

Amturnide E

Atacand E

Carospir

Cartia XT

Carvedilol

Carvedilol ER E

specifically requested coverage.2


B g

B B

g g

g g

g g

B B

B B

B g

B g

B g

B g

B g

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B g

B B

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g B

g B

g B

g B

B g

B g

B B

g g

B B

B B

B g

B B

B B

B g

B g

g B


Catapres

Catapres TTS E

Chlorothiazide

Clonidine

Clonidine Patch

Clorpress

Conjupri E

Coreg E

Coreg CR E

Corgard

Corzide

Covera HS

Cozaar E

Demadex

Dilacor XR

Dilt CD

Dilt XR

Diltia XT

Diltiazem

Diltiazem ER

Diltzac ER

Diovan E

Diovan HCT E

Diuril

Doxazosin

Dutoprol E

Dyazide

Dynacirc CR

Dyrenium E

Edarbi

Edarbyclor

Edecrin E

Enalapril

Enalapril-Hydrochlorothiazide

Epaned

Eplerenone

Eprosartan

Ethacrynic Acid

Exforge E

Exforge HCT E

Felodipine ER

Fosinopril

Fosinopril-Hydrochlorothiazide

Furosemide

Guanfacine

Hydralazine

Hydrochlorothiazide

Hyzaar E

Indapamide

Inderal

Inderal LA E

Inderal XL E

Innopran XL E

Inspra E

Irbesartan

Irbesartan - Hydrochlorothiazide

Isoptin SR

Isradipine

Kapspargo

Katerzia

Labetalol

Lasix

Levatol

Lisinopril

Lisinopril-Hydrochlorothiazide

Lopressor



B g

g g

g g

B g

B g

B B

g B

B B

B B

g g

g g

g B

g g

g g

g g

g g

g B

B g

B g

B B

B B

B g

g B

g B

g g

g g

g g

g B

g B

g B

g g

g B

g B

B


Lopressor HCT

Losartan

Losartan-Hydrochlorothiazide

Lotensin

Lotensin HCT

Lotrel E

Matzim LA

Mavik

Maxzide

Methyclothiazide

Methyldopa

Methyldopa-Hydrochlorothiazide

Metolazone

Metoprolol 37.5, 75 mg E

Metoprolol Succinate

Metoprolol Tartrate

Metoprolol-Hydrochlorothiazide

Micardis E

Micardis HCT E

Microzide

Midamor

Minipress

Minoxidil

Moexipril

Moexipril-Hydrochlorothiazide

Nadolol

Nadolol-Bendroflumethazide

Nebivolol E

Nicardipine

Nifedipine

Nifedipine ER

Nimodipine

Nisoldipine

Norvasc E

Olmesartan

Olmesartan-Hydrochlorothiazide

Perindopril

Pindolol

Prazosin

Prestalia E

Prinivil

Procardia

Procardia XL E

Propranolol

Propranolol-Hydrochlorothiazide

Qbrelis E

Quinapril

Quinapril-Hydrochlorothiazide

Ramipril

Reserpine

Sectral

Spironolactone

Spironolactone-Hydrochlorothiazide

Sular

Tarka E

Taztia XT

Tekturna

Tekturna HCT

Telmisartan

Telmisartan-Amlodipine E

Telmisartan-Hydrochlorothiazide

Tenex

Tenoretic E

Tenormin E

Terazosin

Teveten

Teveten HCT



B g

B B

B

Bg

gB

Bg

BB

gg

Bg

gg

gg

Bg

Bg

BB

BB

gB

gg

Bg

Bg

gg

gB

gB

BB

BB

BB

BB

BB

Bg

B

BB

BB

gB

gg

g


Thalitone 15 mg E

Thalitone 25 mg

Tiazac 1 Timolol

Toprol XL

Torsemide

Trandate

Trandolapril

Trandolapril-Verapamil

Triamterene

E

Triamterene-Hydrochlorothiazide

Tribenzor E

Twynsta E

Uniretic

Univasc

Valsartan

Valsartan-Hydrochlorothiazide

Vaseretic E

Vasotec E

Verapamil

Verapamil ER

Verelan

Verelan PM

Zaroxolyn

Zebeta

Zestoretic E

Zestril E

Ziac

Cardiovascular/Heart Disease: High Cholesterol

Altoprev E

Antara E

Atorvastatin

Cholestyramine

Cholestyramine Light

Choline Fenofibrate E

Colesevelam Tablets, Powder for Suspension

E

Colestid

Colestipol

Crestor E

Ezallor Sprinkle

Ezetimibe

Ezetimibe/Rosuvastain E

Fenofibrate 30, 43, 50, 67, 75, 90, 130, 134, 150, 200 mg Capsule

E

Fenofibrate 40, 48, 120 mg Tablet E

Fenofibrate 54, 145, 160 mg Tablet

Fenofibric Acid E

Fenoglide E

Fibricor E

Flolipid

Fluvastatin

Fluvastatin ER

Gemfibrozil

Icosapent E

Lescol

Lescol XL E

Lipitor E

Lipofen E

Livalo E

Lofibra E

Lopid

Lovastatin

Lovaza E

Mevacor

Nexletol

Nexlizet

Niacin Extended-Release



B B

B B

g g

B B

g g

g g

B g

B g

g g

B g

g B

g B

B g

B B

B B

B B

B B

B g

B g

B g

B B

B

B g

g g

g

B B

g B

g B

B B

B g

B g

g g

B B

g


Niacor E

Niaspan E

Omega-3 Acid Ethyl Esters

Pravachol E

Pravastatin

Prevalite

Questran

Questran Light

Rosuvastatin

Roszet E

Simvastatin

Simvastatin/Ezetimibe

Tricor E

Triglide E

Trilipix E

Vascepa E

Vytorin E

Welchol

Zetia E

Zocor E

Zypitamag E

Central Nervous System: Mental Health

Abilify, Abilify Mycite E

Aripiprazole

Asenapine E

Caplyta

Chlorpromazine

Clozapine

Clozaril

Fanapt

FazaClo

Fluphenazine

Geodon E

Haloperidol

Central Nervous System: Multiple Sclerosis

Invega E

Latuda

Loxapine

Lybalvi E

Molindone

Olanzapine

Paliperidone ER

Perphenazine

Quetiapine

Quetiapine ER

Rexulti

Risperdal E

Risperidone

Saphris

Secuado E

Seroquel E

Seroquel XR E

Thioridazine

Thiothixene

Trifluoperazine

Vraylar

Versacloz E

Ziprasidone

Zyprexa E

Aubagio

Avonex

Bafiertam

Betaseron

Copaxone E

Dimethyl Fumarate (generic Tecfidera)

Extavia E

Gilenya



g B

g B

B B

B B

B g

B g

B B

B B

B

B B

B B

B

B

BB

gB

gB

gB

gB

gB

gB

gB

BB

gB

gB

BB

BB

BB

BB

B

g B

B B

B

B B

B B


Glatiramer Acetate (generic Copaxone)

Glatopa

Kesimpta

Mavenclad

Mayzent

Plegridy

Ponvory E

Rebif E

Tecfidera E

Vumerity E

Zeposia

Depression: Selective Serotonin Reuptake Inhibitors 2 (SSRIs)

Celexa E

Citalopram

Escitalopram

Fluoxetine Capsules

Fluoxetine 10 mg, 20 mg Tablets

Fluoxetine 60 mg Tablets E

Fluvoxamine

Fluvoxamine Extended-Release

Lexapro E

Paroxetine

Paroxetine Extended-Release

Paxil E

Paxil CR E

Pexeva E

Prozac E

Sertraline Capsules 150 mg, 200 mg E

Sertraline Tablets

Zoloft E

Diabetes: Diabetic Supplies

Accu-Chek Guide Meters

Accu-Chek Guide Test Strips

Diabetes: Insulin

Contour Next EZ Meters

Contour Next Meters

Contour Next One Meters

Contour Next Test Strips

Diabetic Testing - Lancets

Insulin Needles/Syringes

OneTouch Diabetic Meters

OneTouch Diabetic Test Strips

Admelog, Admelog SoloStar E

Afrezza E

Apidra, Apidra SoloStar E

Basaglar E

Fiasp, Fiasp FlexTouch E

Humalog

Humalog Junior

Humalog Mix 50/50

Humalog Mix 75/25

Humulin 50/50

Humulin 70/30

Humulin N

Humulin R

Insulin Aspart E

Insulin Aspart Protamine/Insulin Aspart E

Insulin Glargine E

Insulin Lispro E

Insulin Lispro Jr. E

Insulin Lispro Protamine/Insulin Lispro 75/25

E

Lantus

Levemir E

Lyumjev

Novolin 70/30 E

Novolin N E



B B

B B

B B

B g

B g

B g

B B

B

g B

B B

B B

B B

B B

B B

B B

BB

BB

BB

BB

BB

gB

gB

gB

gB

gB

gB

gg

Bg

Bg

Bg

BB

gB

gB


Novolin R E

Novolog E

Novolog Mix 70/30 E

Semglee E

Soliqua

Toujeo

Tresiba E

Diabetes: Non-Insulin

Acarbose

ACTOplus Met

ACTOplus Met XR

Actos E

Adlyxin

Alogliptin E

Alogliptin-Metformin

Alogliptin-Pioglitazone

E

E

Amaryl E

Avandia

Bydureon

Bydureon BCise

Byetta

Cycloset

Diabeta

Duetact

Farxiga E

Fortamet E

Glimepiride

Glipizide

Glipizide ER

Glipizide-Metformin

Glucophage

Glucophage XR

Glucotrol

Glucotrol XL

Glucovance

Glumetza E

Glyburide

Glyburide Micronized

Glyburide-Metformin

Glynase

Glyset

Glyxambi

Invokamet E

Invokamet XR E

Invokana E

Janumet E

Janumet XR E

Januvia E

Jardiance

Jentadueto

Jentadueto XR

Kazano

Kombiglyze XR

Metformin

Metformin ER (generic Fortamet) E

Metformin ER (generic Glucophage XR)

Metformin ER (generic Glumetza) E

Metformin Solution (generic Riomet)

Miglitol

Nateglinide

Nesina

Onglyza

Oseni

Ozempic

Pioglitazone

Pioglitazone-Glimepiride



g B

B B

B B

B B

B B

g g

g B

B B

B g

B g

B

gB

Bg

Bg

B

B B

B B

g B

B g

B B

B g

B B

B B

B B

B

g B

g B

g B

B B

g g

B g

B B

B g


Pioglitazone-Metformin

PrandiMet

Prandin

Precose

Qtern E

Repaglinide

Repaglinide-Metformin

Riomet E

Riomet ER

Rybelsus

Segluromet

Starlix

E

Steglatro

Steglujan

SymlinPen

E

E

Synjardy

Synjardy XR

Tolbutamide

Tradjenta

Trijardy XR

Trulicity

Victoza

Xigduo XR E

Xultophy E

HIV

Abacavir

Abacavir-Lamivudine

Abacavir-Lamivudine-Zidovudine

Aptivus

Atazanavir

Atripla E

Biktarvy

Cimduo

Combivir

Complera

Crixivan

Delstrigo

Descovy E

Didanosine

Dovato

Edurant

Efavirenz

Efavirenz-Emtricitabine-Tenofovir Disoproxil Fumarate (generic Atripla)

E

Efavirenz-Lamivudine (generic Symfi, Symfi Lo)

Emtricitabine

Emtricitabine-Tenofovir Disoproxil Fumarate (generic Truvada)

Emtriva

Epivir

Epzicom E

Etravirine

Evotaz

Fosamprenavir

Fuzeon

Genvoya

Intelence

Invirase

Isentress

Isentress HD

Juluca

Kaletra

Lamivudine

Lamivudine-Zidovudine

Lexiva E

Lopinavir-Ritonavir



g B

g B

B B

B g

B

B B

B B

B g

B B

B g

B B

B g

B g

g B

B g

B g

B B

B B

B B

B B

g B

B g

B g

B B

B

B B

B g

B B

B B

B B

B g

B B

B g


Nevirapine

Nevirapine Extended-Release

Norvir Tablet E

Odefsey

Pifeltro

Prezcobix

Prezista

Rescriptor

Retrovir

Reyataz E

Ritonavir

Rukobia

Selzentry

Stavudine

Stribild

Sustiva E

Symfi

Symfi Lo

Symtuza E

Temixys E

Tenofovir

Tivicay

Tivicay PD

Triumeq

Trizivir E

Truvada E

Videx

Videx EC

Viracept

Viramune E

Viramune XR E

Viread E

Viteka

Immunosuppressant: Organ Rejection

Musculoskeletal: Osteoporosis

Vocabria E

Zerit

Ziagen

Zidovudine

Astagraf XL E

Azasan

Azathioprine

Cellcept E

Cyclosporine

Envarsus XR E

Everolimus

Gengraf

Imuran E

Mycophenolate

Mycophenolic Acid

Myfortic E

Neoral E

Prograf

Rapamune E

Sandimmune E

Sirolimus

Tacrolimus

Zortress E

Actonel E

Alendronate

Atelvia E

Binosto E

Boniva E

Calcitonin (salmon)

Didronel

Etidronate



B B Bevespi Aerosphere

B B Breo Ellipta

B B Breztri Aerosphere

B B Brovana

B B Budesonide/Formoterol (Symbicort EAuthorized Generic)g

g Budesonide Nebulized SolutionB

B Combivent Respimatg

g Cromolyng

B DalirespB

B Duaklir Pressair EB

B Dulera E

B DuonebB

B ElixophyllinB

B Flovent DiskusB

B Flovent HFAB

g Fluticasone/Salmeterol Diskus EB

g Fluticasone/Salmeterol RespiClickB

B ForadilB

g Formoterol Nebulized SolutionB B Gastrocrom E

B Incruse Ellipta Eg

g Ipratropiumg

g Ipratropium/AlbuterolB

B Levalbuterol HFAg

g Levalbuterol Nebulized Solution B

B Lonhala Magnair Eg

B LufyllinB

g MetaproterenolB

g MontelukastB

B PerforomistB

B ProAir Digihaler EB

B Proair HFA EB

B Proair RespiClick E


Evista E

Forteo E

Fortical

Fosamax

Fosamax Plus D

Ibandronate

Miacalcin

Raloxifene

Risedronate

Teriparatide

Tymlos

Respiratory: Asthma/COPD

Accolate

Accuneb

Advair Diskus

Advair HFA

AirDuo Digihaler

AirDuo RespiClick

Albuterol HFA (generic ProAir HFA, Proventil HFA)

E

E

Albuterol HFA (Ventolin HFA authorized generic)

E

Albuterol Nebulized Solution

Albuterol Oral Tablet

Alvesco E

Aminophylline

Anoro Ellipta

Arformoterol Nebulized Solution

ArmonAir Digihaler E

ArmonAir RespiClick E

Arnuity Ellipta

Asmanex HFA E

Asmanex Twisthaler E

Atrovent HFA



B

B

B

B

B

B

B

B

B

B

B

g

B

g

g

B

B

B

B

B

B

B

g

B

B

g

g


Proventil HFA E

Pulmicort Flexhaler

Pulmicort Nebulized Solution E

QVAR Redihaler E

Serevent Diskus

Singulair E

Spiriva HandiHaler

Spiriva Respimat

Stiolto Respimat

Striverdi Respimat

Symbicort

Terbutaline

Theo-24

Theophylline

Theophylline/Guaifenesin

Trelegy Ellipta

Tudorza Pressair E

Ventolin HFA E

VoSpire ER

Yupelri

Xopenex HFA

Xopenex Nebulized Solution E

Zafirlukast

Zyflo

Zyflo CR

Vitamins

Pediatric Flouride Preparations (for example: Florvite, Poly-Vi-Flor, Tri-Vi-Flor) - Brand Name and Generic Products

Prenatal Vitamins (for example: Citranatal Assure, Prenate DHA, Stuartnatal) - Brand Name and Generic Products


IndexA

Abacavir ................................................ 9Abacavir-Lamivudine............................ 9Abacavir-Lamivudine-Zidovudine ....... 9Abilify, Abilify Mycite ............................ 6Acarbose ............................................... 8Accolate .............................................. 11Accu-Chek Guide Meters .................... 7Accu-Chek Guide Test Strips .............. 7Accuneb .............................................. 11Accupril ................................................. 2Accuretic ............................................... 2Acebutolol ............................................. 2Aceon .................................................... 2Actonel ................................................ 10ACTOplus Met ...................................... 8ACTOplus Met XR ................................ 8Actos ...................................................... 8Adalat CC .............................................. 2Adlyxin ................................................... 8Admelog, Admelog SoloStar ............... 7Advair Diskus ...................................... 11Advair HFA .......................................... 11Afeditab ................................................. 2Afrezza ................................................... 7Aggrenox ............................................... 1AirDuo Digihaler ................................. 11AirDuo RespiClick .............................. 11Albuterol HFA ...................................... 11Albuterol Nebulized Solution ............ 11Albuterol Oral Tablet .......................... 11Aldactazide ........................................... 2Aldactone .............................................. 2Alendronate......................................... 10Aliskiren ................................................. 2Alogliptin ............................................... 8Alogliptin-Metformin............................. 8Alogliptin-Pioglitazone ......................... 8Altace ..................................................... 2Altoprev ................................................. 5Alvesco ................................................ 11Amaryl ................................................... 8Amiloride ............................................... 2Amiloride-Hydrochlorothiazide ........... 2Aminophylline ..................................... 11Amlodipine ............................................ 2Amlodipine-Benazepril ........................ 2Amlodipine-Olmesartan....................... 2

Amlodipine-Olmesartan-Hydrochlorothiazide ......................... 2

Amlodipine-Valsartan ........................... 2Amlodipine-Valsartan-

Hydrochlorothiazide ......................... 2Amturnide .............................................. 2Anastrozole ........................................... 1Anoro Ellipta ........................................ 11Antara .................................................... 5Apidra, Apidra SoloStar ....................... 7Aptivus ................................................... 9Arformoterol Nebulized Solution ...... 11Arimidex ................................................ 1Aripiprazole ........................................... 6Arixtra .................................................... 1ArmonAir Digihaler ............................. 11ArmonAir RespiClick .......................... 11Arnuity Ellipta ...................................... 11Aromasin ............................................... 1Asenapine ............................................. 6Asmanex HFA ..................................... 11Asmanex Twisthaler ........................... 11Aspirin-Dipyridamole............................ 1Astagraf XL ......................................... 10Atacand ................................................. 2Atacand HCT ........................................ 2Atazanavir .............................................. 9Atelvia .................................................. 10Atenolol ................................................. 2Atenolol-Chlorthalidone ....................... 2Atorvastatin ........................................... 5Atripla .................................................... 9Atrovent HFA ....................................... 11Aubagio ................................................. 6Avalide ................................................... 2Avandia .................................................. 8Avapro ................................................... 2Avonex ................................................... 6Azasan ................................................. 10Azathioprine ........................................ 10Azor ........................................................ 2

B

Bafiertam ............................................... 6Basaglar ................................................ 7Benazepril ............................................. 2Benazepril-Hydrochlorothiazide ......... 2Benicar .................................................. 2Benicar HCT.......................................... 2

Betaseron .............................................. 6Betaxolol ............................................... 2Bevespi Aerosphere ........................... 11Bevyxxa ................................................. 1Bidil ........................................................ 2Biktarvy ................................................. 9Binosto ................................................ 10Bisoprolol .............................................. 2Bisoprolol-Hydrochlorothiazide .......... 2Boniva .................................................. 10Breo Ellipta .......................................... 11Breztri Aerosphere ............................. 11Brilinta.................................................... 1Brovana ............................................... 11Budesonide Nebulized Solution ....... 11Budesonide/Formoterol .................... 11Bumetanide ........................................... 2Bydureon ............................................... 8Bydureon BCise .................................... 8Byetta .................................................... 8Bystolic .................................................. 2Byvalson ................................................ 2

C

Calan ...................................................... 2Calan SR ............................................... 2Calcitonin (salmon) ............................. 10Candesartan ......................................... 2Candesartan-Hydrochlorothiazide ..... 2Caplyta .................................................. 6Captopril ................................................ 2Captopril-Hydrochlorothiazide ............ 2Cardene SR ........................................... 2Cardizem ............................................... 2Cardizem CD ......................................... 2Cardizem LA ......................................... 2Cardura .................................................. 2Carospir ................................................. 2Cartia XT ............................................... 2Carvedilol .............................................. 2Carvedilol ER ........................................ 2Catapres ................................................ 3Catapres TTS ........................................ 3Celexa .................................................... 7Cellcept E ............................................ 10Chlorothiazide ....................................... 3Chlorpromazine .................................... 6Cholestyramine .................................... 5Cholestyramine Light ........................... 5

13

Choline Fenofibrate .............................. 5Cilostazol ............................................... 1Cimduo .................................................. 9Citalopram ............................................. 7Clonidine ............................................... 3Clonidine Patch .................................... 3Clopidogrel ........................................... 1Clorpress ............................................... 3Clozapine .............................................. 6Clozaril ................................................... 6Colesevelam Tablets, Powder for

Suspension ........................................ 5Colestid ................................................. 5Colestipol .............................................. 5Combivent Respimat.......................... 11Combivir ................................................ 9Complera ............................................... 9Conjupri ................................................. 3Contour Next EZ Meters ...................... 7Contour Next Meters ............................ 7Contour Next One Meters ................... 7Contour Next Test Strips ..................... 7Copaxone .......................................... 6, 7Coreg ..................................................... 3Coreg CR .............................................. 3Corgard ................................................. 3Corzide .................................................. 3Coumadin .............................................. 1Covera HS ............................................. 3Cozaar ................................................... 3Crestor ................................................... 5Crixivan .................................................. 9Cromolyn ............................................. 11Cycloset ................................................. 8Cyclosporine ....................................... 10

D

Daliresp ............................................... 11Delstrigo ................................................ 9Demadex ............................................... 3Descovy ................................................. 9Diabeta .................................................. 8Diabetic Testing - Lancets ................... 7Didanosine ............................................ 9Didronel ............................................... 10Dilacor XR ............................................. 3Dilt CD ................................................... 3Dilt XR .................................................... 3Diltia XT ................................................. 3Diltiazem ................................................ 3Diltiazem ER .......................................... 3

Diltzac ER .............................................. 3Dimethyl Fumarate ............................... 6Diovan .................................................... 3Diovan HCT ........................................... 3Dipyridamole ......................................... 1Diuril ....................................................... 3Dovato ................................................... 9Doxazosin .............................................. 3Duaklir Pressair .................................. 11Duetact .................................................. 8Dulera .................................................. 11Duoneb ................................................ 11Dutoprol ................................................. 3Dyazide .................................................. 3Dynacirc CR .......................................... 3Dyrenium ............................................... 3

E

Edarbi .................................................... 3Edarbyclor ............................................. 3Edecrin .................................................. 3Edurant .................................................. 9Efavirenz ................................................ 9Efavirenz-Emtricitabine-Tenofovir

Disoproxil Fumarate ......................... 9Efavirenz-Lamivudine ........................... 9Efment ..................................................... 1Eliquis .................................................... 1Elixophyllin .......................................... 11Emtricitabine ......................................... 9Emtricitabine-Tenofovir Disoproxil

Fumarate ............................................ 9Emtriva ................................................... 9Enalapril ................................................. 3Enalapril-Hydrochlorothiazide ............. 3Enoxaparin ............................................ 1Envarsus XR ........................................ 10Epaned .................................................. 3Epivir ...................................................... 9Eplerenone ............................................ 3Eprosartan ............................................ 3Epzicom ................................................. 9Escitalopram ......................................... 7Ethacrynic Acid ..................................... 3Etidronate ............................................ 10Etravirine ............................................... 9Everolimus ........................................... 10Evista ................................................... 11Evotaz .................................................... 9Exemestane .......................................... 1Exforge .................................................. 3

Exforge HCT ......................................... 3Extavia ................................................... 6Ezallor Sprinkle ..................................... 5Ezetimibe ........................................... 5, 6Ezetimibe/Rosuvastain ........................ 5

F

Fanapt .................................................... 6Fareston ................................................ 1Farxiga ................................................... 8FazaClo.................................................. 6Felodipine ER ........................................ 3Femara................................................... 1Fenofibrate 40, 48, 120 mg Tablet ...... 5Fenofibrate 30, 43, 50 , 67, 75, 90,

130, 134, 150, 200 mg Capsule ....... 5Fenofibrate 54, 145, 160 mg Tablet .... 5Fenofibric Acid ...................................... 5Fenoglide ............................................... 5Fiasp, Fiasp FlexTouch ......................... 7Fibricor .................................................. 5Flolipid ................................................... 5Flovent Diskus .................................... 11Flovent HFA ......................................... 11Fluoxetine 10 mg, 20 mg Tablets ........ 7Fluoxetine 60 mg Tablets ..................... 7Fluoxetine Capsules ............................. 7Fluphenazine ........................................ 6Fluticasone/Salmeterol Diskus ......... 11Fluticasone/Salmeterol RespiClick .. 11Fluvastatin ............................................. 5Fluvastatin ER ....................................... 5Fluvoxamine .......................................... 7Fluvoxamine Extended-Release ......... 7Fondaparinux ........................................ 1Foradil .................................................. 11Formoterol Nebulized Solution ......... 11Fortamet ................................................ 8Forteo .................................................. 11Fortical ................................................. 11Fosamax .............................................. 11Fosamax Plus D .................................. 11Fosamprenavir ...................................... 9Fosinopril ............................................... 3Fosinopril-Hydrochlorothiazide ........... 3Fragmin.................................................. 1Furosemide ........................................... 3Fuzeon ................................................... 9

G

Gastrocrom ......................................... 11

14

Gemfibrozil ............................................ 5Gengraf ................................................ 10Genvoya................................................. 9Geodon .................................................. 6Gilenya ................................................... 6Glatiramer Acetate ............................... 7Glatopa .................................................. 7Glimepiride ............................................ 8Glipizide ................................................. 8Glipizide ER ........................................... 8Glipizide-Metformin .............................. 8Glucophage .......................................... 8Glucophage XR .................................... 8Glucotrol ................................................ 8Glucotrol XL .......................................... 8Glucovance ........................................... 8Glumetza ............................................... 8Glyburide ............................................... 8Glyburide Micronized ........................... 8Glyburide-Metformin ............................ 8Glynase .................................................. 8Glyset ..................................................... 8Glyxambi ............................................... 8Guanfacine ............................................ 3

H

Haloperidol ............................................ 6Heparin .................................................. 1Humalog ................................................ 7Humalog Junior .................................... 7Humalog Mix 50/50 .............................. 7Humalog Mix 75/25 .............................. 7Humulin 50/50 ...................................... 7Humulin 70/30 ...................................... 7Humulin N ............................................. 7Humulin R .............................................. 7Hydralazine ........................................... 3Hydrochlorothiazide ............................. 3Hyzaar.................................................... 3

I

Ibandronate ......................................... 11Icosapent .............................................. 5Imuran.................................................. 10Incruse Ellipta ..................................... 11Indapamide ........................................... 3Inderal .................................................... 3Inderal LA .............................................. 3Inderal XL .............................................. 3Innopran XL ........................................... 3Inspra ..................................................... 3

Insulin Aspart ........................................ 7Insulin Aspart Protamine/

Insulin Aspart .................................... 7Insulin Glargine .................................... 7Insulin Lispro ......................................... 7Insulin Lispro Jr. .................................... 7Insulin Lispro Protamine/Insulin

Lispro 75/25 ...................................... 7Insulin Needles/Syringes ..................... 7Intelence ................................................ 9Invega .................................................... 6Invirase .................................................. 9Invokamet .............................................. 8Invokamet XR ........................................ 8Invokana ................................................ 8Ipratropium .......................................... 11Ipratropium/Albuterol ......................... 11Irbesartan .............................................. 3Irbesartan - Hydrochlorothiazide ........ 3Isentress ................................................ 9Isentress HD ......................................... 9Isoptin SR .............................................. 3Isradipine ............................................... 3

J

Jantoven ................................................ 1Janumet ................................................. 8Janumet XR ........................................... 8Januvia .................................................. 8Jardiance ............................................... 8Jentadueto ............................................ 8Jentadueto XR ...................................... 8Juluca .................................................... 9

K

Kaletra ................................................... 9Kapspargo ............................................. 3Katerzia .................................................. 3Kazano ................................................... 8Kesimpta ............................................... 7Kombiglyze XR ..................................... 8

L

Labetalol ................................................ 3Lamivudine ............................................ 9Lamivudine-Zidovudine ....................... 9Lantus .................................................... 7Lasix....................................................... 3Latuda .................................................... 6Lescol .................................................... 5Lescol XL ............................................... 5

Letrozole ................................................ 1Levalbuterol HFA ................................ 11Levalbuterol Nebulized Solution ....... 11Levatol ................................................... 3Levemir .................................................. 7Lexapro.................................................. 7Lexiva ..................................................... 9Lipitor ..................................................... 5Lipofen ................................................... 5Lisinopril ................................................ 3Lisinopril-Hydrochlorothiazide ............ 3Livalo...................................................... 5Lofibra ................................................... 5Lonhala Magnair ................................. 11Lopid ...................................................... 5Lopinavir-Ritonavir ................................ 9Lopressor .......................................... 3, 4Lopressor HCT ..................................... 4Losartan ................................................ 4Losartan-Hydrochlorothiazide ............ 4Lotensin ................................................. 4Lotensin HCT ........................................ 4Lotrel ...................................................... 4Lovastatin .............................................. 5Lovaza ................................................... 5Lovenox ................................................. 2Loxapine ................................................ 6Lufyllin ................................................. 11Lybalvi ................................................... 6Lyumjev ................................................. 7

M

Matzim LA ............................................. 4Mavenclad ............................................. 7Mavik ..................................................... 4Maxzide ................................................. 4Mayzent ................................................. 7Metaproterenol ................................... 11Metformin .............................................. 8Metformin ER ........................................ 8Metformin Solution ............................... 8Methyclothiazide .................................. 4Methyldopa ........................................... 4Methyldopa-Hydrochlorothiazide ....... 4Metolazone ........................................... 4Metoprolol 37.5, 75 mg ........................ 4Metoprolol Succinate ........................... 4Metoprolol Tartrate ............................... 4Metoprolol-Hydrochlorothiazide ......... 4Mevacor ................................................. 5Miacalcin ............................................. 11

15

Micardis ................................................. 4Micardis HCT ........................................ 4Microzide ............................................... 4Midamor ................................................ 4Miglitol ................................................... 8Minipress ............................................... 4Minoxidil ................................................ 4Moexipril ................................................ 4Moexipril-Hydrochlorothiazide ............ 4Molindone ............................................. 6Montelukast ........................................ 11Mycophenolate ................................... 10Mycophenolic Acid ............................. 10Myfortic ............................................... 10

N

Nadolol .................................................. 4Nadolol-Bendroflumethazide .............. 4Nateglinide ............................................ 8Nebivolol .............................................. 4Neoral .................................................. 10Nesina .................................................... 8Nevirapine ........................................... 10Nevirapine Extended-Release .......... 10Nexletol .................................................. 5Nexlizet .................................................. 5Niacin Extended-Release .................... 5Niacor .................................................... 6Niaspan ................................................. 6Nicardipine ............................................ 4Nifedipine .............................................. 4Nifedipine ER ........................................ 4Nimodipine ............................................ 4Nisoldipine ............................................ 4Norvasc ................................................. 4Norvir Tablet ........................................ 10Novolin 70/30 ........................................ 7Novolin N ............................................... 7Novolin R ............................................... 8Novolog ................................................. 8Novolog Mix 70/30 ............................... 8

O

Odefsey ............................................... 10Olanzapine ............................................ 6Olmesartan ........................................... 4Olmesartan-Hydrochlorothiazide........ 4Omega-3 Acid Ethyl Esters .................. 6OneTouch Diabetic Meters .................. 7OneTouch Diabetic Test Strips ............ 7Onglyza ................................................. 8

Oseni...................................................... 8Ozempic ................................................ 8

P

Paliperidone ER .................................... 6Paroxetine ............................................. 7Paroxetine Extended-Release ............. 7Paxil ....................................................... 7Paxil CR ................................................. 7Pediatric Flouride Preparations ........ 12Perforomist ......................................... 11Perindopril ............................................. 4Perphenazine ........................................ 6Persantine ............................................. 2Pexeva ................................................... 7Pifeltro ................................................. 10Pindolol .................................................. 4Pioglitazone .......................................... 8Pioglitazone-Glimepiride ..................... 8Pioglitazone-Metformin ....................... 9Plavix ...................................................... 2Plegridy.................................................. 7Pletal ...................................................... 2Ponvory ................................................. 7Pradaxa ................................................. 2PrandiMet .............................................. 9Prandin .................................................. 9Prasugrel ............................................... 2Pravachol ............................................... 6Pravastatin ............................................ 6Prazosin ................................................. 4Precose ................................................. 9Prenatal Vitamins ............................... 12Prestalia ................................................. 4Prevalite ................................................. 6Prezcobix ............................................. 10Prezista ................................................ 10Prinivil .................................................... 4ProAir Digihaler ................................... 11Proair HFA ........................................... 11ProAir HFA, Proventil HFA ................. 11Proair RespiClick ................................ 11Procardia ............................................... 4Procardia XL ......................................... 4Prograf ................................................. 10Propranolol ........................................... 4Propranolol-Hydrochlorothiazide ........ 4Proventil HFA ................................ 11, 12Prozac .................................................... 7Pulmicort Flexhaler ............................ 12Pulmicort Nebulized Solution ............ 12

Q

Qbrelis ................................................... 4Qtern ...................................................... 9Questran ................................................ 6Questran Light ...................................... 6Quetiapine ............................................. 6Quetiapine ER ....................................... 6Quinapril ................................................ 4Quinapril-Hydrochlorothiazide ............ 4QVAR Redihaler .................................. 12

R

Raloxifene ........................................... 11Ramipril ................................................. 4Rapamune ........................................... 10Rebif ...................................................... 7Repaglinide ........................................... 9Repaglinide-Metformin ........................ 9Rescriptor ............................................ 10Reserpine .............................................. 4Retrovir ................................................ 10Rexulti .................................................... 6Reyataz ................................................ 10Riomet ............................................... 8, 9Riomet ER ............................................. 9Risedronate ......................................... 11Risperdal ............................................... 6Risperidone ........................................... 6Ritonavir .............................................. 10Rosuvastatin ......................................... 6Roszet .................................................... 6Rukobia ............................................... 10Rybelsus ................................................ 9

S

Sandimmune ....................................... 10Saphris .................................................. 6Savaysa ................................................. 2Sectral ................................................... 4Secuado ................................................ 6Segluromet ............................................ 9Selzentry .............................................. 10Semglee ................................................ 8Serevent Diskus .................................. 12Seroquel ................................................ 6Seroquel XR .......................................... 6Sertraline Tablets.................................. 7Sertraline Capsules 150 mg,

200 mg .............................................. 7Simvastatin ............................................ 6Simvastatin/Ezetimibe ......................... 6

16

Singulair............................................... 12Sirolimus .............................................. 10Soliqua ................................................... 8Soltamox ............................................... 1Spiriva HandiHaler.............................. 12Spiriva Respimat ................................ 12Spironolactone ..................................... 4Spironolactone-

Hydrochlorothiazide ......................... 4Starlix ..................................................... 9Stavudine ............................................ 10Steglatro ................................................ 9Steglujan ............................................... 9Stiolto Respimat ................................. 12Stribild ................................................. 10Striverdi Respimat .............................. 12Sular ....................................................... 4Sustiva ................................................. 10Symbicort ...................................... 11, 12Symfi ................................................ 9, 10Symfi Lo........................................... 9, 10Symfi, Symfi Lo ..................................... 9SymlinPen ............................................. 9Symtuza ............................................... 10Synjardy ................................................. 9Synjardy XR ........................................... 9

T

Tacrolimus ........................................... 10Tamoxifen .............................................. 1Tarka ...................................................... 4Taztia XT ................................................ 4Tecfidera............................................ 6, 7Tekturna ................................................ 4Tekturna HCT ........................................ 4Telmisartan............................................ 4Telmisartan-Amlodipine ....................... 4Telmisartan-Hydrochlorothiazide ........ 4Temixys................................................ 10Tenex ..................................................... 4Tenofovir .............................................. 10Tenoretic ................................................ 4Tenormin ............................................... 4Terazosin ............................................... 4Terbutaline .......................................... 12Teriparatide ......................................... 11Teveten .................................................. 4Teveten HCT ......................................... 4Thalitone 15 mg .................................... 5Thalitone 25 mg .................................... 5Theo-24 ............................................... 12

Theophylline........................................ 12Theophylline/Guaifenesin .................. 12Thioridazine .......................................... 6Thiothixene ............................................ 6Tiazac .................................................... 5Ticlopidine ............................................. 2Timolol ................................................... 5Tivicay .................................................. 10Tivicay PD............................................ 10Tolbutamide .......................................... 9Toprol XL ............................................... 5Toremifene ............................................ 1Torsemide ............................................. 5Toujeo .................................................... 8Tradjenta ............................................... 9Trandate ................................................ 5Trandolapril ........................................... 5Trandolapril-Verapamil ......................... 5Trelegy Ellipta ...................................... 12Tresiba ................................................... 8Triamterene ........................................... 5Triamterene-Hydrochlorothiazide ....... 5Tribenzor ............................................... 5Tricor ...................................................... 6Trifluoperazine ...................................... 6Triglide ................................................... 6Trijardy XR ............................................. 9Trilipix..................................................... 6Triumeq ............................................... 10Trizivir ................................................... 10Trulicity .................................................. 9Truvada ............................................ 9, 10Tudorza Pressair ................................. 12Twynsta ................................................. 5Tymlos ................................................. 11

U

Uniretic .................................................. 5Univasc .................................................. 5

V

Valsartan ............................................... 5Valsartan-Hydrochlorothiazide ............ 5Vascepa ................................................. 6Vaseretic ................................................ 5Vasotec .................................................. 5Ventolin HFA ................................. 11, 12Verapamil .............................................. 5Verapamil ER ........................................ 5Verelan ................................................... 5Verelan PM ............................................ 5

Versacloz ............................................... 6Victoza ................................................... 9Videx .................................................... 10Videx EC .............................................. 10Viracept ............................................... 10Viramune ............................................. 10Viramune XR ....................................... 10Viread .................................................. 10Viteka ................................................... 10Vocabria .............................................. 10VoSpire ER .......................................... 12Vraylar .................................................... 6Vumerity ................................................ 7Vytorin ................................................... 6

W

Warfarin ................................................. 2Welchol .................................................. 6

X

Xarelto ................................................... 2Xigduo XR ............................................. 9Xopenex HFA ...................................... 12Xopenex Nebulized Solution ............. 12Xultophy ................................................. 9

Y

Yupelri .................................................. 12

Z

Zafirlukast ........................................... 12Zaroxolyn ............................................... 5Zebeta ................................................... 5Zeposia .................................................. 7Zerit ...................................................... 10Zestoretic .............................................. 5Zestril ..................................................... 5Zetia ....................................................... 6Ziac ........................................................ 5Ziagen .................................................. 10Zidovudine .......................................... 10Ziprasidone ........................................... 6Zocor ..................................................... 6Zoloft ..................................................... 7Zontivity ................................................. 2Zortress ............................................... 10Zyflo ..................................................... 12Zyflo CR ............................................... 12Zypitamag ............................................. 6Zyprexa .................................................. 6

17

Nondiscrimination notice and access to communication servicesUnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in their health programs or activities.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Online: [email protected]

Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your member ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your member ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at

Learn more

Call the toll-free phone number on your member ID card to speak with customer service.

Visit the member website listed on your member ID card to look up the price of drugs covered by your plan, find lower-cost options and more.

If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access myuhc.com for additional information during your open enrollment period or you may contact your employer or health plan for additional information. Medications are categorized by common therapeutic conditions in this reference guide for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines how these medications may be covered for you.

Where differences are noted between this reference guide and your benefit plan documents, the benefit plan documents will govern.

12/21 ©2022 United HealthCare Services, Inc. WF5978676-E_2022 Preventive Expanded List

Documents

2022 Preventive Medication List for Consumer Driven Health