Expanded Preventive List 1-1-18 v2 · Altace Altoprev E Alvesco Amaryl Amiloride Amiloride-Hydrochlorothiazide Aminophylline Amlodipine Amlodipine-Benazepril Amlodipine-Olmesartan

2018 Preventive Drug List for Consumer Driven Health PlansExpanded List

2www.myuhc.com

E May be excluded from coverage. *Coverage is provided for oral formulations. Bold type = Brand name drug [Plain type = Generic drug]

2018 Preventive Drug List for Consumer Driven Health Plans

Alphabetical Listing – Expanded List

A

Abacavir Abacavir-Lamivudine Abacavir-Lamivudine-

Zidovudine Abilify EAcarboseAccolateAccunebAccuprilAccureticAcebutololAceonActonelACTOplus MetACTOplus Met XRActos EAdalat CCAdlyxinAdvair DiskusAdvair HFAAfrezza E Aerospan AfeditabAggrenoxAirDuo Respiclick E Albuterol Nebulized

SolutionAlbuterol Oral TabletAldactazideAldactoneAlendronateAlogliptin EAlogliptin-

Metformin E Alogliptin-Pioglitazone E

AltaceAltoprev EAlvescoAmarylAmilorideAmiloride-

HydrochlorothiazideAminophyllineAmlodipine Amlodipine-BenazeprilAmlodipine-Olmesartan E Amlodipine-Olmesartan-

Hydrochlorothiazide EAmlodipine-ValsartanAmlodipine-Valsartan-

Hydrochlorothiazide EAmturnide EAnastrozoleAnoro Ellipta Antara EApidraAptivusArcapta NeohalerArimidex EAripiprazole ArixtraArnuity ElliptaAromasinAsmanex HFA Asmanex TwisthalerAspirin-Dipyridamole Astagraf XL E

AtacandAtacand HCTAtelvia E AtenololAtenolol-ChlorthalidoneAtriplaAtorvastatin Atrovent HFAAubagioAvalideAvandiaAvaproAvonexAzasanAzathioprineAzor E

B

Basaglar Benazepril Benazepril-

HydrochlorothiazideBenicar EBenicar HCT EBetaseronBetaxolol*Bevespi Aerosphere BidilBinosto EBisoprololBisoprolol-

HydrochlorothiazideBonivaBreo Ellipta BrilintaBrovanaBudesonideBumetanideBydureon ByettaBystolicByvalson E

C

CalanCalan SRCalcitonin (Salmon)Candesartan Candesartan-

HydrochlorothiazideCaptopril Captopril-

HydrochlorothiazideCardene SRCardizem ECardizem CD ECardizem LA ECardura Cartia XTCarvedilolCatapres Catapres TTSCellcept EChlorothiazideChlorpromazineCholestyramineCholestyramine LightCholine Fenofibrate E Cilostazol

Clonidine Clonidine PatchClopidogrel ClorpressClozapineClozarilColestidColestipolCombivent RespimatCombivirCompleraCopaxoneCoregCoreg CR ECorgardCorzideCoumadinCovera HSCozaarCrestor ECrixivanCromolynCycloset Cyclosporine

D

Daliresp DemadexDescovy DiabetaDiabetic Testing - Lancets DidanosineDidronelDilacor XRDilt CDDilt XRDiltia XTDiltiazemDiltiazem ERDiltzac ERDiovan EDiovan HCT EDipyridamoleDiurilDoxazosinDuetactDulera EDuonebDutoprol EDyazideDynacirc CRDyrenium

E

EdarbiEdarbyclor EdecrinEdurant EffientEliquisElixophyllinEmtrivaEnalaprilEnalapril-

HydrochlorothiazideEnoxaparinEnvarsus XR E Epaned Epivir

EplerenoneEprosartan Epzicom EEthacrynic Acid EtidronateEvista EEvotaz ExemestaneExforge EExforge HCT EExtavia EEzetimibe

F

FanaptFarestonFarxiga FazaCloFelodipine ERFemara EFenofibrate 43, 50 ,

67,130, 134, 150, 200 mg Capsule E

Fenofibrate 40, 48, 120, 145 mg Tablet E

Fenofibrate 54, 160 mg Tablet

Fenofibric Acid EFenoglide EFibricor EFlovent DiskusFlovent HFAFluphenazineFluticasone/Salmeterol

Respiclick Fluvastatin Fluvastatin ER FondaparinuxForadilFortamet EForteoForticalFosamaxFosamax Plus DFosinopril Fosinopril-

HydrochlorothiazideFragminFurosemideFuzeon

G

GastrocromGemfibrozilGengrafGenvoya Geodon EGilenyaGlatopa E GlimepirideGlipizideGlipizide ERGlipizide-MetforminGlucophageGlucophage XRGlucotrol Glucotrol XLGlucovanceGlumetza E

GlyburideGlyburide MicronizedGlyburide-MetforminGlynaseGlysetGlyxambi EGuanfacine

H

HaloperidolHeparinHumalogHumalog Mix 50/50Humalog Mix 75/25Humulin 50/50Humulin 70/30Humulin NHumulin RHydralazineHydrochlorothiazideHyzaar

I

Ibandronate Imuran EIncruse ElliptaIndapamideInderalInderal LA EInnopran XLInspraInsulin Needles/SyringesIntelenceInvega EInviraseInvokamet Invokamet XRInvokana IpratropiumIpratropium/AlbuterolIrbesartanIrbesartan -

Hydrochlorothiazide IsentressIsentress HD Isoptin SRIsradipine

J

JantovenJanumetJanumet XR JanuviaJardiance JentaduetoJentadueto XR

K

KaletraKazanoKombiglyze XR

L

LabetalolLamivudineLamivudine-ZidovudineLantus ELasixLatuda



Alphabetical Listing – Expanded List

3www.myuhc.com

LescolLescol XL ELetrozoleLevalbuterol HFA Levalbuterol Nebulized

Solution ELevatol LevemirLexivaLipitor ELipofen ELisinoprilLisinopril-

HydrochlorothiazideLivalo ELofibra ELopidLopinavir-Ritanavir LopressorLopressor HCTLosartanLosartan-

HydrochlorothiazideLotensin Lotensin HCTLotrelLovastatinLovaza ELovenoxLoxapineLufyllin

M

Matzim LA MavikMaxzideMetaproterenolMetformin Metformin ER (generic

Fortamet) E Metformin ER (generic

Glucophage XR)Metformin ER (generic

Glumetza) E MethyclothiazideMethyldopaMethyldopa-

HydrochlorothiazideMetolazoneMetoprolol 37.5, 75 mg E Metoprolol SuccinateMetoprolol TartrateMetoprolol-

HydrochlorothiazideMevacorMiacalcinMicardis EMicardis HCT EMicrozideMidamorMiglitol MinipressMinoxidilMoexipril Moexipril-

HydrochlorothiazideMolindone Montelukast

MycophenolateMycophenolic Acid Myfortic E

N

NadololNadolol-

BendroflumethazideNateglinideNeoral ENesinaNevirapine Nevirapine

Extended-Release ENiacin

Extended-Release NiacorNiaspanNicardipineNifedipineNifedipine ERNimodipineNisoldipineNorvascNorvirNovolin 70/30Novolin N Novolin RNovologNovolog Mix 70/30

O

Odefsey Olanzapine Olmesartan Olmesartan-

Hydrochlorothiazide Omega-3 Acid Ethyl

Esters OneTouch Diabetic

MetersOneTouch Diabetic

Test StripsOnglyzaOseni

P

Paliperidone ER Pediatric Flouride

PreparationsPerforomistPerindoprilPerphenazinePersantinePioglitazonePioglitazone-GlimepiridePioglitazone-MetforminPindololPlavix EPlegridy PletalPradaxaPrandiMetPrandinPravacholPravastatinPrazosinPrecose

Prenatal VitaminsPrestalia EPrevalitePrezcobix PrezistaPrinivilProair HFAProair Respiclick ProcardiaProcardia XLPrograf EPropranololPropranolol-

HydrochlorothiazideProventil HFAPulmicortPulmicort Flexhaler

Q

Qbrelis E QuestranQuestran LightQuetiapine Quetiapine ER QuinaprilQuinapril-

HydrochlorothiazideQVAR

R

Raloxifene RamiprilRapamune ERebifRepaglinide Repaglinide-Metformin RescriptorReserpineRetrovirRexulti ReyatazRiometRisedronate Risperdal ERisperidoneRosuvastatin

S

Sandimmune ESaphrisSavaysaSectralSeebri NeoHaler SelzentrySerevent DiskusSeroquel ESeroquel XR ESimvastatinSimvastatin/Ezetimibe Singulair ESirolimus Soliqua Soltamox ESpiriva HandiHalerSpiriva Respimat Spironolactone Spironolactone-

Hydrochlorothiazide

StarlixStavudineStiolto Respimat E StribildStriverdi Respimat SularSustivaSymbicortSymlinPenSynjardySynjardy XR

T

TacrolimusTamoxifenTanzeum TarkaTaztia XTTecfidera TekturnaTekturna HCTTelmisartanTelmisartan-Amlodipine ETelmisartan-

Hydrochlorothiazide TenexTenoretic ETenormin ETerazosinTerbutalineTeveten Teveten HCTThalitoneTheo-24TheochronTheophyllineTheophylline/GuaifenesinThioridazineThiothixeneTiazacTiclopidineTimolol*Tivicay TolbutamideToprol XLTorsemideToujeo E Tradjenta TrandateTrandolaprilTrandolapril-Verapamil Tresiba E Triamterene-

HydrochlorothiazideTribenzor ETricor ETrifluoperazineTriglide ETrilipix ETriumeq TrizivirTrulicity TruvadaTudorza PressairTwynsta ETymlos

U

UnireticUnivascUtibron NeoHaler E

V

Valsartan Valsartan-

Hydrochlorothiazide VascepaVaseretic EVasotec EVentolin HFAVerapamilVerapamil ERVerelanVerelan PMVersacloz EVictozaVidexVidex ECViraceptViramune EViramune XR EVireadViteka VoSpire ERVraylar Vytorin E

W

WarfarinWelchol

X

XareltoXigduo XR EXopenex HFAXopenex Nebulized

Solution EXultophy E

Z

ZafirlukastZaroxolynZebetaZeritZestoretic E Zestril EZetia EZiacZiagenZidovudineZinbryta Ziprasidone ZocorZontivity Zortress ZyfloZyflo CRZyprexa E

4www.myuhc.com



Listing by Therapeutic Category – Expanded List

Breast Cancer Prevention AnastrozoleArimidex EAromasinExemestaneFarestonFemara ELetrozoleSoltamox ETamoxifen

Cardiovascular/Heart Disease - Blood Clot/Platelet Therapy AggrenoxArixtraAspirin-Dipyridamole BrilintaCilostazolClopidogrel CoumadinDipyridamoleEffientEliquisEnoxaparinFondaparinuxFragminHeparinJantovenLovenoxPersantinePlavix EPletalPradaxaSavaysaTiclopidineWarfarinXareltoZontivity

Cardiovascular/Heart Disease - High Blood Pressure AccuprilAccureticAcebutololAceonAdalat CCAfeditabAldactazideAldactoneAltaceAmilorideAmiloride-HydrochlorothiazideAmlodipine Amlodipine-BenazeprilAmlodipine-Olmesartan E Amlodipine-Olmesartan-Hydrochlorothiazide EAmlodipine-ValsartanAmlodipine-Valsartan-Hydrochlorothiazide EAmturnide EAtacandAtacand HCTAtenololAtenolol-ChlorthalidoneAvalideAvaproAzor EBenazepril

Benazepril-HydrochlorothiazideBenicar EBenicar HCT EBetaxolol*BidilBisoprololBisoprolol-HydrochlorothiazideBumetanideBystolicByvalson ECalanCalan SRCandesartan Candesartan-HydrochlorothiazideCaptopril Captopril-HydrochlorothiazideCardene SRCardizem ECardizem CD ECardizem LA ECardura Cartia XTCarvedilolCatapres Catapres TTSChlorothiazideClonidine Clonidine PatchClorpressCoregCoreg CR ECorgardCorzideCovera HSCozaarDemadexDilacor XRDilt CDDilt XRDiltia XTDiltiazemDiltiazem ERDiltzac ERDiovan EDiovan HCT EDiurilDoxazosinDutoprol EDyazideDynacirc CRDyreniumEdarbiEdarbyclor EdecrinEnalapril Enalapril-HydrochlorothiazideEpaned EplerenoneEprosartan Ethacrynic Acid Exforge EExforge HCT EFelodipine ERFosinopril Fosinopril-HydrochlorothiazideFurosemideGuanfacine

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HydralazineHydrochlorothiazideHyzaarIndapamideInderalInderal LA EInnopran XLInspraIrbesartanIrbesartan - Hydrochlorothiazide Isoptin SRIsradipineLabetalolLasixLevatol LisinoprilLisinopril-HydrochlorothiazideLopressorLopressor HCTLosartanLosartan-HydrochlorothiazideLotensin Lotensin HCTLotrelMatzim LA MavikMaxzideMethyclothiazideMethyldopaMethyldopa-HydrochlorothiazideMetolazoneMetoprolol 37.5, 75 mg E Metoprolol SuccinateMetoprolol TartrateMetoprolol-HydrochlorothiazideMicardis EMicardis HCT EMicrozideMidamorMinipressMinoxidilMoexipril Moexipril-HydrochlorothiazideNadololNadolol-BendroflumethazideNicardipineNifedipineNifedipine ERNimodipineNisoldipineNorvascOlmesartan Olmesartan-Hydrochlorothiazide PerindoprilPindololPrazosinPrestalia EPrinivilProcardiaProcardia XLPropranololPropranolol-HydrochlorothiazideQbrelis E QuinaprilQuinapril-HydrochlorothiazideRamiprilReserpineSectralSpironolactone

Spironolactone-HydrochlorothiazideSularTarkaTaztia XTTekturnaTekturna HCTTelmisartanTelmisartan-Amlodipine E Telmisartan-Hydrochlorothiazide TenexTenoretic ETenormin ETerazosinTeveten Teveten HCTThalitoneTiazacTimolol*Toprol XLTorsemideTrandateTrandolaprilTrandolapril-VerapamilTriamterene-HydrochlorothiazideTribenzor ETwynsta E UnireticUnivascValsartan Valsartan-Hydrochlorothiazide Vaseretic EVasotec EVerapamilVerapamil ERVerelanVerelan PMZaroxolynZebetaZestoretic E Zestril EZiac

Cardiovascular/Heart Disease - High Cholesterol Altoprev EAntara EAtorvastatin CholestyramineCholestyramine LightCholine Fenofibrate E ColestidColestipolCrestor EEzetimibeFenofibrate 43, 50 , 67,130, 134, 150, 200 mg Capsule E Fenofibrate 40, 48, 120, 145 mg Tablet E Fenofibrate 54, 160 mg Tablet Fenofibric Acid EFenoglide EFibricor EFluvastatin Fluvastatin ER GemfibrozilLescolLescol XL ELipitor ELipofen ELivalo ELofibra ELopid

6www.myuhc.com




LovastatinLovaza EMevacorNiacin Extended-Release NiacorNiaspanOmega-3 Acid Ethyl Esters PravacholPravastatinPrevaliteQuestranQuestran LightRosuvastatinSimvastatinSimvastatin/Ezetimibe Tricor ETriglide ETrilipix EVascepaVytorin EWelcholZetia EZocor

Central Nervous System - Mental Health Abilify EAripiprazole ChlorpromazineClozapineClozarilFanaptFazaCloFluphenazineGeodon EHaloperidolInvega ELatuda LoxapineMolindone Olanzapine Paliperidone ER PerphenazineQuetiapine Quetiapine ERRexulti Risperdal ERisperidoneSaphrisSeroquel ESeroquel XR EThioridazineThiothixeneTrifluoperazineVraylar Versacloz EZiprasidone Zyprexa E

Central Nervous System - Multiple Sclerosis AubagioAvonexBetaseronCopaxoneExtavia EGilenyaGlatopa E RebifTecfideraZinbryta

Diabetes - Diabetic Supplies Diabetic Testing - Lancets Insulin Needles/SyringesOneTouch Diabetic MetersOneTouch Diabetic Test Strips

Diabetes - Insulin Afrezza E ApidraBasaglar HumalogHumalog Mix 50/50Humalog Mix 75/25Humulin 50/50Humulin 70/30Humulin NHumulin RLantus ELevemirNovolin 70/30Novolin N Novolin RNovologNovolog Mix 70/30Soliqua Toujeo E Tresiba E

Diabetes - Non-Insulin AcarboseACTOplus MetACTOplus Met XRActos EAdlyxinAlogliptin EAlogliptin-Metformin E Alogliptin-Pioglitazone E AmarylAvandiaBydureon ByettaCycloset DiabetaDuetactFarxiga Fortamet EGlimepirideGlipizideGlipizide ERGlipizide-MetforminGlucophageGlucophage XRGlucotrol Glucotrol XLGlucovanceGlumetza EGlyburideGlyburide MicronizedGlyburide-MetforminGlynaseGlysetGlyxambi EInvokamet Invokamet XRInvokana JanumetJanumet XR JanuviaJardiance

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Jentadueto Jentadueto XRKazanoKombiglyze XRMetformin Metformin ER (generic Fortamet) E Metformin ER (generic Glucophage XR)Metformin ER (generic Glumetza) E Miglitol NateglinideNesinaOnglyzaOseniPioglitazonePioglitazone-GlimepiridePioglitazone-MetforminPrandiMetPrandinPrecoseRepaglinide Repaglinide-Metformin RiometStarlixSymlinPenSynjardy Synjardy XR Tanzeum TolbutamideTrulicity Tradjenta VictozaXigduo XR EXultophy E

HIV Abacavir Abacavir-Lamivudine Abacavir-Lamivudine-Zidovudine AptivusAtriplaCombivirCompleraCrixivanDescovy DidanosineEdurant EmtrivaEpivirEpzicom EEvotaz FuzeonGenvoya IntelenceInviraseIsentressIsentress HD KaletraLamivudineLamivudine-ZidovudineLexivaLopinavir-Ritanavir Nevirapine Nevirapine Extended-Release ENorvirOdefsey Prezcobix PrezistaRescriptorRetrovir

ReyatazSelzentryStavudineStribildSustivaTivicay Triumeq TrizivirTruvadaVidexVidex ECViraceptViramune EViramune XR EVireadViteka ZeritZiagenZidovudine

Immunosuppressant - Organ Rejection Astagraf XL E AzasanAzathioprineCellcept ECyclosporineEnvarsus XR E GengrafImuran EMycophenolateMycophenolic Acid Myfortic ENeoral EPrograf ERapamune ESandimmune ESirolimus TacrolimusZortress

Musculoskeletal - Osteoporosis ActonelAlendronateAtelvia E Binosto EBonivaCalcitonin (salmon)DidronelEtidronateEvista EForteoForticalFosamaxFosamax Plus DIbandronate MiacalcinPlegridyRaloxifeneRisedronateTymlos

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If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting myuhc.com® or by calling the toll-free member phone number on your ID card. 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.

E May be excluded from coverage.*Coverage is provided for oral formulations. Bold type = Brand name drug [Plain type = Generic drug]

Clinical programs such as Notification/Prior Authorization, Step Therapy and Supply Limits may apply to listed medications based off your benefit plan. This list is intended as a reference and may not be all-inclusive. Brand or generic availability may not be current due to changes in the market. The list will be updated annually.

©2018 United HealthCare Services, Inc.

Created August, 2017. For the most current PDL updates, visit myuhc.com or call the toll-free member phone number on your health plan ID card.

Preventive Expanded List 1/18

67405-082017

Respiratory - Asthma/COPD AccolateAccunebAdvair DiskusAdvair HFAAerospan AirDuo Respiclick EAlbuterol Nebulized SolutionAlbuterol Oral TabletAlvescoAminophyllineAnoro Ellipta Arcapta NeohalerArnuity ElliptaAsmanex HFA Asmanex TwisthalerAtrovent HFABevespi Aerosphere Breo Ellipta BrovanaBudesonideCombivent RespimatCromolynDaliresp Dulera EDuonebElixophyllinFlovent DiskusFlovent HFAFluticasone/Salmeterol Respiclick ForadilGastrocromIncruse ElliptaIpratropiumIpratropium/AlbuterolLevalbuterol HFA Levalbuterol Nebulized Solution ELufyllinMetaproterenol

Montelukast PerforomistProair HFAProair Respiclick Proventil HFAPulmicortPulmicort FlexhalerQVARSeebri NeoHaler Serevent DiskusSingulair ESpiriva HandiHalerSpiriva Respimat Stiolto Respimat E Striverdi Respimat SymbicortTerbutalineTheo-24TheochronTheophyllineTheophylline/GuaifenesinTudorza PressairUtibron NeoHaler EVentolin HFAVoSpire ERXopenex HFAXopenex Nebulized Solution E ZafirlukastZyfloZyflo CR

Vitamins Pediatric Flouride Preparations (for example: Florvite, Poly-Vi-Flor,

Tri-Vi-Flor) - Brand Name and Generic ProductsPrenatal Vitamins (for example: Citranatal Assure, Prenate DHA,

Stuartnatal) - Brand Name and Generic Products

9

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10

Documents

Expanded Preventive List 1-1-18 v2 · Altace Altoprev E Alvesco Amaryl Amiloride Amiloride-Hydrochlorothiazide Aminophylline Amlodipine Amlodipine-Benazepril Amlodipine-Olmesartan