Expanded Preventive Drug List Updated January 2018
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1 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 isosorbide dinitrate SL tab isosorbide dinitrate tab isosorbide mononitrate ER tab isosorbide mononitrate tab nitroglycerin lingual spray nitroglycerin patch nitroglycerin SL tab nitroglycerin SR cap ANTIARRHYTHMICS amiodarone tab disopyramide cap disopyramide ER cap dofetilide cap flecainide tab mexiletine cap propafenone ER cap propafenone tab quinidine gluconate CR tab ANTIASTHMATIC AND BRONCHODILATOR AGENTS albuterol neb soln 0.083% albuterol neb soln 0.5% albuterol neb soln 0.63mg albuterol neb soln 1.25mg albuterol sulfate ER tab albuterol sulfate syrup albuterol sulfate tab albuterol/ipratropium neb soln aminophylline tab budesonide inh susp ipratropium neb soln levalbuterol neb soln montelukast chew tab montelukast granule pack montelukast tab terbutaline sulfate tab theophylline CR tab theophylline ER tab theophylline soln zafirlukast tab zileuton ER tab ANTICOAGULANTS 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 N
2 fondaparinux inj warfarin tab ANTICONVULSANTS carbamazepine chew tab carbamazepine ER cap carbamazepine ER tab carbamazepine susp carbamazepine tab clonazepam ODT clonazepam tab divalproex ER tab divalproex sodium DR tab divalproex sprinkle cap ethosuximide cap ethosuximide soln felbamate susp felbamate tab gabapentin cap gabapentin soln gabapentin tab lamotrigine chew tab lamotrigine ER tab lamotrigine ODT lamotrigine ODT kit lamotrigine tab levetiracetam ER tab levetiracetam soln levetiracetam tab oxcarbazepine susp oxcarbazepine tab phenytoin cap phenytoin chew tab phenytoin susp primidone tab tiagabine tab topiramate sprinkle cap topiramate tab valproic acid cap valproic acid syrup zonisamide cap ANTIDEPRESSANTS amitriptyline tab bupropion ER tab bupropion tab bupropion XL tab citalopram soln citalopram tab clomipramine cap desipramine tab doxepin cap doxepin conc duloxetine EC cap escitalopram soln escitalopram tab fluoxetine cap fluoxetine soln fluoxetine tab fluvoxamine ER cap fluvoxamine tab imipramine pamoate cap imipramine tab mirtazapine ODT mirtazapine tab nefazodone tab 50mg, 250mg nortriptyline cap paroxetine ER tab paroxetine tab phenelzine tab protriptyline tab sertraline conc Note: The list is subject to change. Please always refer to your Navitus formulary for a
3 sertraline tab tranylcypromine tab trazodone tab trimipramine cap venlafaxine ER cap venlafaxine ER tab ANTIDIABETICS acarbose tab glimepiride tab glipizide ER tab glipizide tab glipizide/metformin tab glyburide micronized tab glyburide tab glyburide/metformin tab metformin ER tab metformin tab miglitol tab nateglinide tab pioglitazone tab pioglitazone/glimepiride tab pioglitazone/metformin tab repaglinide tab tolazamide tab ANTIHYPERLIPIDEMICS atorvastatin tab cholestyramine lite powder cholestyramine lite powder pack cholestyramine powder cholestyramine powder pack colestipol granule colestipol powder packet colestipol tab ezetimibe/simvastatin tab fenofibrate cap fenofibrate tab fluvastatin cap gemfibrozil tab lovastatin tab omega-3-acid ethyl esters cap pravastatin tab rosuvastatin tab rosuvastatin tab 20mg simvastatin tab ANTIHYPERTENSIVES amlodipine/benazepril cap amlodipine/valsartan tab amlodipine/valsartan/ hydrochlorothiazide tab atenolol/chlorthalidone tab benazepril tab benazepril/hydrochlorothiazide tab bisoprolol/hydrochlorothiazide tab candesartan tab candesartan/hydrochlorothiazide tab captopril tab clonidine patch clonidine tab doxazosin tab enalapril tab enalapril/hydrochlorothiazide tab eplerenone tab fosinopril tab fosinopril/hydrochlorothiazide tab guanfacine IR tab hydralazine tab irbesartan tab irbesartan/hydrochlorothiazide tab lisinopril tab lisinopril/hydrochlorothiazide tab
4 losartan tab losartan/hydrochlorothiazide tab methyldopa tab methyldopa/hydrochlorothiazide tab metoprolol/hydrochlorothiazide tab minoxidil tab moexipril tab moexipril/hydrochlorothiazide tab nadolol/bendroflumethiazide tab perindopril tab phenoxybenzamine cap prazosin cap propranolol/hydrochlorothiazide tab quinapril tab quinapril/hydrochlorothiazide tab ramipril cap telmisartan tab telmisartan/amlodipine tab terazosin cap trandolapril tab trandolapril/ verapamil ER tab valsartan tab valsartan/hydrochlorothiazide tab ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES anastrozole tab bicalutamide tab exemestane tab flutamide cap letrozole tab megestrol susp megestrol tab nilutamide tab tamoxifen tab BETA BLOCKERS acebutolol cap atenolol tab betaxolol tab bisoprolol tab carvedilol tab labetalol tab metoprolol ER tab metoprolol tab nadolol tab pindolol tab propranolol ER cap propranolol tab sotalol AF tab sotalol tab timolol maleate tab CALCIUM CHANNEL BLOCKERS amlodipine tab diltiazem ER cap diltiazem ER tab diltiazem tab felodipine ER tab isradipine cap nicardipine cap nifedipine cap nifedipine ER tab nimodipine cap nisoldipine ER tab verapamil SR cap verapamil SR tab verapamil tab CARDIAC GLYCOSIDES digoxin soln digoxin tab CARDIOVASCULAR AGENTS - MISC. amlodipine/atorvastatin tab
5 CONTRACEPTIVES amethyst tab apri tab aranelle tab aviane tab BEYAZ TAB CERVICAL CAP cesia tab CONCEPTROL GEL CONTRACEPTIVE FILM CONTRACEPTIVE FOAM CONTRACEPTIVE GEL CONTRACEPTIVE SUPP cryselle tab DEPO-PROVERA SC INJ 104MG DIAPHRAGM ELLA TAB enpresse tab FEMALE CONDOMS jolessa tab/ amethia tab junel FE tab junel tab kariva tab kelnor tab levonorgestrel tab LEVONORGESTREL TAB 0.75MG LEVONORGESTREL/ETHINYL ESTRADIOL TAB LO LOESTRIN TAB LO MINASTRIN 24 FE CHEW TAB LOESTRIN 24 FE TAB medroxyprogesterone inj mibelas chew tab MIRENA IUD mononessa tab NATAZIA TAB necon tab necon tab 1/50 norethindrone tab NORINYL TAB 1/50 nortrel tab NUVARING OGESTREL TAB PARAGARD IUD PLAN B TAB TODAY SPONGE tri-legest tab tri-nessa (LO) tab vcf vaginal gel wymzya FE tab XULANE PATCH YASMIN TAB YAZ TAB DIABETIC SUPPLIES alcohol pads blood/urine test strips lancet devices and lancets needles and syringes DIURETICS acetazolamide ER cap acetazolamide tab amiloride tab amiloride/hydrochlorothiazide tab bumetanide tab chlorothiazide tab ethacrynic tab furosemide tab hydrochlorothiazide cap hydrochlorothiazide tab indapamide tab
6 methazolamide tab metolazone tab spironolactone tab spironolactone/hydrochlorothiazide tab torsemide tab triamterene/hydrochlorothiazide cap triamterene/hydrochlorothiazide tab ENDOCRINE AND METABOLIC AGENTS - MISC. alendronate tab calcitonin nasal spray etidronate disodium tab 200mg ibandronate tab 150mg risedronate DR tab risedronate tab GOUT AGENTS allopurinol tab colchicine/probenecid tab probenecid tab HEMATOLOGICAL AGENTS - MISC. anagrelide cap aspirin/dipyridamole cap cilostazol tab clopidogrel tab 75mg dipyridamole tab pentoxifylline ER tab LAXATIVES lactulose soln peg 3350/electrolytes soln trilyte soln MINERALS & ELECTROLYTES FLUORABON SOLN FLUOR-A-DAY CHEW TAB LURIDE CHEW TAB LURIDE SOLN phospha 250 neutral tab potassium bicarbonate effer tab potassium chloride effer tab potassium chloride ER cap potassium chloride micro tab potassium chloride powder packet potassium chloride soln sodium fluoride chew tab SODIUM FLUORIDE LOZENGE sodium fluoride soln SODIUM FLUORIDE TAB zinc sulfate cap MOUTH/THROAT/DENTAL AGENTS chlorhexidine gluconate soln sodium fluoride cream sodium fluoride gel sodium fluoride paste sodium fluoride rinse sodium fluoride/potassium nitrate paste triamcinolone in orabase paste PSYCHOTHERAPEUTIC COMBINATION AGENTS chlordiazepoxide/amitriptyline tab olanzapine/ fluoxetine cap SMOKING CESSATION bupropion SR tab CHANTIX PAK CHANTIX TAB NICODERM PATCH NICORETTE GUM NICORETTE LOZENGE nicotine gum NICOTINE KIT
7 nicotine lozenge nicotine patch NICOTROL INHALER NICOTROL NASAL SPRAY ZYBAN TAB THYROID AGENTS levothyroxine tab liothyronine tab methimazole tab np thyroid tab propylthiouracil tab VACCINES ADACEL/BOOSTRIX INJ AFLURIA INJ AFLURIA/FLUZONE INJ BEXSERO INJ CERVARIX INJ ENGERIX-B INJ ENGERIX-B/RECOMBIVAX-HB FLUAD INJ FLUBLOK INJ FLUCELVAX INJ FLUCELVAX QUAD INJ FLUVIRIN INJ FLUVIRIN PF INJ FLUZONE HIGH DOSE PF INJ FLUZONE INTRADERMAL FLUZONE QUAD INJ FLUZONE/FLUARIX QUAD INJ FLUZONE/FLULAVAL QUAD INJ GARDASIL 9 INJ GARDASIL INJ HAVRIX/VAQTA INJ MENACTRA INJ MENHIBRIX INJ MENOMUNE INJ MENVEO INJ M-M-R II INJ PNEUMOVAX INJ PREVNAR 13 INJ TETANUS-DIPHTHERIA TOXOID INJ TRUMENBA INJ TWINRIX INJ VARIVAX INJ VIVOTIF CAP ZOSTAVAX INJ
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