PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Update: July 1,

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1 Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details or ask Member Services if you have this benefit. How to use this list: Brand medicines are in ALL CAPS (e.g., DALIRESP ORAL TABLET) Generic medicines are in lower italics (e.g., furosemide oral tablet) Prior authorization Step therapy Quantity limit Age Edit Please note: If your drug requires,, or, you must meet the coverage criteria for the drug to be covered at your preventive benefit. Drug Alcohol Dependency Alcohol Dependency acamprosate oral tablet,delayed release (dr/ec) disulfiram oral tablet Asthma & COPD Asthma & COPD, Other ATROVENT HFA INHALATION HFA ROSOL INHALER cromolyn inhalation solution for nebulization DALIRESP ORAL TABLET ipratropium bromide inhalation solution montelukast oral granules in packet montelukast oral tablet montelukast oral tablet,chewable Bronchodilators, Inhaled More Details INCRUSE ELLIPTA INHALATION BLIER WITH DEVICE 62.5 MCG/ACTUATION SEREVENT DISKUS INHALATION BLIER WITH DEVICE SPIRIVA RESPIMAT INHALATION MI SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE RIVERDI RESPIMAT INHALATION MI Bronchodilators, Oral Last Update: July 1,

2 theophylline oral tablet extended release theophylline oral tablet extended release 12 hr Combination Agents, Inhaled ADVAIR DISKUS INHALATION BLIER WITH DEVICE ADVAIR HFA INHALATION HFA ROSOL INHALER ANORO ELLIPTA INHALATION BLIER WITH DEVICE BREO ELLIPTA INHALATION BLIER WITH DEVICE COMBIVENT RESPIMAT INHALATION MI DULERA INHALATION HFA ROSOL INHALER fluticasone-salmeterol inhalation aerosol powdr breath activated ipratropium-albuterol inhalation solution for nebulization IOLTO RESPIMAT INHALATION MI Corticosteroids, Inhaled ARNUITY ELLIPTA INHALATION BLIER WITH DEVICE ASMANEX HFA INHALATION HFA ROSOL INHALER ASMANEX TWIHALER INHALATION ROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) budesonide inhalation suspension for nebulization FLOVENT DISKUS INHALATION BLIER WITH DEVICE FLOVENT HFA INHALATION HFA ROSOL INHALER ; PULMICORT FLEXHALER INHALATION ROSOL POWDR BREATH ACTIVATED QVAR INHALATION ROSOL Behavioral Health Antipsychotic aripiprazole oral solution aripiprazole oral tablet aripiprazole oral tablet,disintegrating chlorpromazine oral tablet clozapine oral tablet clozapine oral tablet,disintegrating fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet haloperidol lactate oral concentrate haloperidol oral tablet loxapine succinate oral capsule olanzapine oral tablet olanzapine oral tablet,disintegrating perphenazine oral tablet Last Update: July 1, ; ; ;

3 quetiapine oral tablet quetiapine oral tablet extended release 24 hr risperidone oral solution risperidone oral tablet risperidone oral tablet,disintegrating thioridazine oral tablet thiothixene oral capsule trifluoperazine oral tablet VERSACLOZ ORAL SUSPENSION ziprasidone hcl oral capsule Bipolar Disorder lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution 8 meq/5 ml Depression, Atypical Antidepressants bupropion hcl oral tablet bupropion hcl oral tablet extended release 12 hr bupropion hcl oral tablet extended release 24 hr mirtazapine oral tablet Depression, Maois phenelzine oral tablet tranylcypromine oral tablet Depression, Serotonin Modulators nefazodone oral tablet trazodone oral tablet Depression, Snris duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet Depression, Ssris citalopram oral solution citalopram oral tablet escitalopram oxalate oral solution escitalopram oxalate oral tablet fluoxetine oral capsule fluoxetine oral solution fluvoxamine oral tablet paroxetine hcl oral tablet XIL ORAL SUSPENSION ; ; ; Last Update: July 1,

4 sertraline oral concentrate sertraline oral tablet Depression, Tricyclic & Tetracyclic Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 25 mg, 50 mg, 75 mg amitriptyline oral tablet 150 mg clomipramine oral capsule desipramine oral tablet doxepin oral capsule imipramine hcl oral tablet nortriptyline oral capsule nortriptyline oral solution Blood Thinner Anticoagulants ELIQUIS ORAL TABLET jantoven oral tablet PRADAXA ORAL CAPSULE warfarin oral tablet XARELTO ORAL TABLET XARELTO ORAL TABLETS,DOSE CK Platelet Inhibitors anagrelide oral capsule aspirin-dipyridamole oral capsule, er multiphase 12 hr BRILINTA ORAL TABLET cilostazol oral tablet clopidogrel oral tablet 75 mg dipyridamole oral tablet EFFIENT ORAL TABLET ZONTIVITY ORAL TABLET Cancer Cancer, Serms tamoxifen oral tablet Diabetes Diabetes, Alpha-Glucosidase Inhibitors acarbose oral tablet miglitol oral tablet Diabetes, Biguanides metformin oral tablet metformin oral tablet extended release 24 hr Diabetes, Dpp-4 Inhibitor / Biguanide Combinations JENTADUETO ORAL TABLET Last Update: July 1,

5 JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG Diabetes, Dpp-4 Inhibitors TRADJENTA ORAL TABLET Diabetes, Glp-1 Agonists BYDUREON SUBCUTANEOUS PEN INJECTOR BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML TRULICITY SUBCUTANEOUS PEN INJECTOR VICTOZA 2-K SUBCUTANEOUS PEN INJECTOR VICTOZA 3-K SUBCUTANEOUS PEN INJECTOR Diabetes, Intermediate-Acting Insulins HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN N SUBCUTANEOUS SUSPENSION Diabetes, Long-Acting Insulins BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN LEVEMIR SUBCUTANEOUS SOLUTION Diabetes, Meglitinides nateglinide oral tablet repaglinide oral tablet Diabetes, Other Oral Agents CYCLOSET ORAL TABLET Diabetes, Pre-Mixed Insulins HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG MIX SUBCUTANEOUS SUSPENSION HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG MIX SUBCUTANEOUS SUSPENSION HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN 70/30 SUBCUTANEOUS SUSPENSION Diabetes, Rapid-Acting Insulins HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG SUBCUTANEOUS CARTRIDGE HUMALOG SUBCUTANEOUS SOLUTION Diabetes, Rescue Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN GLUCAGEN INJECTION RECON SOLN GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT Diabetes, Sglt2 Inhibitor / Biguanide Combinations INVOKAMET ORAL TABLET Last Update: July 1,

6 INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR SYNJARDY ORAL TABLET SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR Diabetes, Sglt2 Inhibitors INVOKANA ORAL TABLET JARDIANCE ORAL TABLET Diabetes, Short-Acting Insulins HUMULIN R U-100 INJECTION SOLUTION HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION Diabetes, Sulfonylurea / Biguanide Combination glipizide-metformin oral tablet Diabetes, Sulfonylureas glimepiride oral tablet glipizide oral tablet glipizide oral tablet extended release 24hr Diabetes, Thiazolidinedione / Biguanide Combinations pioglitazone-metformin oral tablet Diabetes, Thiazolidinedione / Sulfonylurea Combinations pioglitazone-glimepiride oral tablet Diabetes, Thiazolidinediones pioglitazone oral tablet Heart Health Blood Pressure, ACEI & ARB amlodipine-benazepril oral capsule amlodipine-valsartan oral tablet amlodipine-valsartan-hcthiazid oral tablet benazepril oral tablet benazepril-hydrochlorothiazide oral tablet captopril oral tablet captopril-hydrochlorothiazide oral tablet enalapril maleate oral tablet enalapril-hydrochlorothiazide oral tablet fosinopril oral tablet fosinopril-hydrochlorothiazide oral tablet irbesartan oral tablet irbesartan-hydrochlorothiazide oral tablet lisinopril oral tablet lisinopril-hydrochlorothiazide oral tablet losartan oral tablet Last Update: July 1,

7 losartan-hydrochlorothiazide oral tablet moexipril oral tablet moexipril-hydrochlorothiazide oral tablet mg, mg moexipril-hydrochlorothiazide oral tablet mg perindopril erbumine oral tablet quinapril oral tablet quinapril-hydrochlorothiazide oral tablet ramipril oral capsule trandolapril oral tablet valsartan oral tablet valsartan-hydrochlorothiazide oral tablet Blood Pressure, Beta Blockers atenolol oral tablet atenolol-chlorthalidone oral tablet bisoprolol fumarate oral tablet bisoprolol-hydrochlorothiazide oral tablet carvedilol oral tablet COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR labetalol oral tablet metoprolol succinate oral tablet extended release 24 hr metoprolol ta-hydrochlorothiaz oral tablet metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol oral tablet propranolol oral capsule,extended release 24 hr propranolol oral tablet propranolol-hydrochlorothiazid oral tablet Blood Pressure, Calcium Channel Blockers amlodipine oral tablet amlodipine-benazepril oral capsule amlodipine-valsartan oral tablet amlodipine-valsartan-hcthiazid oral tablet cartia xt oral capsule,extended release 24hr diltiazem hcl oral capsule, extended release diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet dilt-xr oral capsule,ext release degradable 120 mg, 180 mg nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr Last Update: July 1,

8 taztia xt oral capsule, extended release 120 mg, 180 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release Blood Pressure, Other clonidine hcl oral tablet clonidine transdermal patch weekly doxazosin oral tablet guanfacine oral tablet hydralazine oral tablet methyldopa oral tablet minoxidil oral tablet prazosin oral capsule reserpine oral tablet terazosin oral capsule Cholesterol Lowering, Bile Acid Resins cholestyramine (with sugar) oral powder cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder cholestyramine light oral powder in packet colestipol oral tablet Cholesterol Lowering, Other ezetimibe oral tablet Cholesterol Lowering, Statins atorvastatin oral tablet 10 mg, 20 mg atorvastatin oral tablet 40 mg, 80 mg lovastatin oral tablet 10 mg lovastatin oral tablet 20 mg, 40 mg pravastatin oral tablet rosuvastatin oral tablet 10 mg, 5 mg rosuvastatin oral tablet 20 mg, 40 mg simvastatin oral tablet 10 mg, 20 mg simvastatin oral tablet 40 mg simvastatin oral tablet 5 mg simvastatin oral tablet 80 mg Diuretics amiloride oral tablet amiloride-hydrochlorothiazide oral tablet bumetanide oral tablet chlorothiazide oral tablet Last Update: July 1,

9 chlorthalidone oral tablet 25 mg, 50 mg eplerenone oral tablet furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet indapamide oral tablet metolazone oral tablet spironolactone oral tablet spironolacton-hydrochlorothiaz oral tablet torsemide oral tablet triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet Heart Health, Other ENTREO ORAL TABLET Triglyceride Lowering fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized oral tablet fenofibrate oral tablet 160 mg, 54 mg gemfibrozil oral tablet omega-3 acid ethyl esters oral capsule VASCE ORAL CAPSULE Smoking Cessation Nicotine Replacement nicotine (polacrilex) buccal gum nicotine (polacrilex) buccal lozenge nicotine transdermal patch 24 hour NICOTROL INHALATION CARTRIDGE NICOTROL NS NASAL SPRAY,NON-ROSOL Smoking Cessation, Other buproban oral tablet extended release 12 hr CHANTIX ORAL TABLET CHANTIX ARTING MONTH BOX ORAL TABLETS,DOSE CK Vitamins And Minerals Vitamins And Minerals completenate oral tablet,chewable inatal ultra oral tablet mynatal plus oral tablet mynate 90 plus oral tablet extended release o-cal prenatal oral tablet Last Update: July 1,

10 prenaplus oral tablet prenatabs fa oral tablet prenatabs rx oral tablet prenatal low iron oral tablet prenatal plus (calcium carb) oral tablet prenatal plus oral tablet trinate oral tablet vinate care oral tablet,chewable vinate one oral tablet Weight Loss Weight Loss ALLI ORAL CAPSULE phentermine oral capsule 15 mg, 30 mg, 37.5 mg phentermine oral tablet XENICAL ORAL CAPSULE Last Update: July 1,

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