HIGH DEDUCTIBLE PLAN?
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- Lisa Stephens
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1 HIGH DEDUCTIBLE PLAN? WE HAVE YOU COVERED. CerpassRx 2019 Preventative Medicine List
2 Preventive medications are defined as those prescribed to prevent the occurrence of a chronic disease or condition for those indiviudals with risk factors, or to prevent the recurrence of a disease or condition. Your plan values the impact these medications have on your health. You do not need to meet any deductible for preventive medications and your prescription benefits are paid immediately for these products. This list contains examples of preventive medications organized by therapy class. Medications may be added to or removed from the list periodically and the list is not all inclusive. Anticoagulant and Hematological AGGRENOX SAVAYSA cilostazol BRILINTA XARELTO clopidogrel dipyridamole EFFIENT ZONTIVITY jantoven PRADAXA Anticonvulsant anagrelide warfarin ELIQUIS carbamazepine levetiracetam APTIOM carbamazepine ER levetiracetam ER BANZEL divalproex oxcarbazepine BRIVIACT divalproex DR phenobarbital CELONTIN divalproex ER phenytoin FYCOMPA epitol primidone GABITRIL ethosuximide tiagabine topiramate ONFI felbamate gabapentin topiramate ER lamotrigine lamotrigine ER Antidiabetic valproic acid zonisamide PEGANONE POTIGA SPRITAM VIMPAT acarbose ACTOPLUS MET XR LANTUS alogliptin AFREZZA LANTUS SOLOSTAR chlorpropamide BYETTA OZEMPIC BYDUREON SYMLIN PEN glimepiride glipizide glipizide er glipizide xl glipizide/metformin glyburide CYCLOSET GLYXAMBI HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/50 glyburide micronized HUMALOG MIX 50/50 KWIKPEN glyburide/metformin HUMALOG MIX 75/25 metformin HUMALOG MIX 75/25 KWIKPEN metformin er HUMULIN 70/30 miglitol HUMULIN 70/30 KWIKPEN nateglinide HUMULIN N pioglitazone HUMULIN N KWIKPEN pioglitazone/glimepiride HUMULIN R pioglitazone/metformin repaglinide HUMULIN R U-500 HUMULIN R U-500 KWIKPEN repaglinide/metformin INVOKAMET tolazamide INVOKANA INVOKANA XR JANUMET JANUMET XR tolbutamide JANUVIA JARDIANCE JENTADUETO JENTADUETO XR SYNJARDY TOUJEO TRADJENTA TRULICITY
3 Asthma albuterol ADVAIR DISKUS SEREVENT DISKUS albuterol ER ADVAIR HFA SPIRIVA HANDIHALER budesonide cromolyn AEROSPAN SPIRIVA RESPIMAT ANORO ELLIPTA ARCAPTA NEOHALER STIOLTO RESPIMAT ipratropium ipratropium/albuterol ARNUITY ELLIPTA SYMBICORT levalbuterol ATROVENT HFA metaproterenol montelukast BREO ELLIPTA THEO-24 VENTOLIN HFA terbutaline COMBIVENT RESPIMAT BROVANA theochron DALIRESP theophylline FLOVENT DISKUS theophylline CR theophylline ER FLOVENT HFA INCRUSE ELLIPTA theophylline SR PERFOROMIST zafirlukast PROAIR HFA PROAIR RESPICLICK PULMICORT FLEXHALER Cardiovasular STRIVERDI RESPIMAT acebutolol acetazolamide acetazolamide ER afeditab CR amiloride/hctz amiloride amiodarone amlodipine amlodipine/atorvastatin amlodipine/benazapril amlodipine/olmesartan digoxin ALDACTAZIDE ditl-xr BIDIL diltiazem diltiazem CD BYSTOLIC diltiazem ER CARDIZEM LA disopyramide CLORPRES dofetilide COREG CR doxazosin enalapril DILATRATE SR enalapril/hctz DUTOPROL eplerenone DYRENIUM amlodipine/olmesartan/hctz eprosartan amlodipine/valsartan ethacrynic acid BYVALSON DIURIL EDARBI EDARBYCLOR amlodipine/valsartan/hctz ezide atenolol atenolol/chlorthalidone ENTRESTO felodipine ER EPANED benazapril flecainide HEMANGEOL fosinopril INNOPRAN XL benazapril/hctz betaxolol bisoprolol fosinopril/hctz furosemide hydralazine budesonide bisoprolol/hctz hydrochlorothiazide bumetanide irbesartan candesartan candesartan/hctz indapamide irbesartan/hctz isosorbide dinitrate LANOXIN LEVATOL MULTAQ NITRO-BID NITRO-DUR NITROMIST NORPACE CR PRESTALIA captopril captopril/hctz/carvediol isosorbide dinitrate ER chlorothiazide isosorbide dinitrate SA RANEXA isosorbide mononitrate isosorbide mononitrate ER isradipine TEKTURNA chlorthalidone clonidine digitek digox isosorbide dinitrate ER labetalol QBRELIS SOTYLIZE TEKTURNA HCT
4 Cardiovasular lisinopril lisinopril/hctz pindolol losartan losartan/hctz propafenone matzim LA propranolol methazolamide propranolol er methyclothiazide propranolol/hctz methyldopa methyldopa/hctz quinapril metolazone quinidine metoprolol succinate ER prazosin propafenone er quinapril/hctz quinidine gluconate cr metoprolol tartrate quinidine gluconate er metoprolol/hctz ramipril mexilietine sorine minitran sotalol minoxidil spironolactone moexipril spironolactone/hctz moexipril/hctz taztia xt nadolol telmisartan nadolol/bendroflumethiazide telmisartan/amlodipine nicardipine telmisartan/hctz nifediac CC nifedical XL nifedipine nifedipine ER nimodipine nisoldipine nisoldipine ER nitro-time nitroglycerin nitroglycerin ER nitroglycerin lingual nitroglycerin transdermal olmesartan olmesartan/hctz pacerone terazosin timolol torsemide trandolapril trandolapril/verapamil trandolapril/verapamil er triamterene/hctz valsartan valsartan/hctz verapamil verapamil cr verapamil er verapamil sa verapamil sr perindopril Cholesterol atorvastatin cholestyramine cholestyramine light colesevelam colestipol ezetimibe ezetimibe/simvastatin fenofibrate fenofibric acid fenofibric acid DR fluvastatin fluvastatin ER gemfibrozil lovastatin niacin ER omega-3-acid pravastatin prevalite rosuvastatin simvastatin ALTOPREV ANTARA LIPOFEN LIVALO TRIGLIDE VASCEPA
5 Contraceptives altavera juleber alyacen 1/35 alyacen 7/7/7 amethia junel 1/20 amethia lo junel fe 1/20 amethyst apri aranelle ashlyna aubra aviane azurette balziva bekyree blisovi fe 1/20 blisovi 24 fe blisovi fe 1.5/30 briellyn camila junel fe 1.5/30 kaitlib fe kariva camrese camrese lo caziant cesia chateal cryselle-28 cyclafem 1/35 cyclafem 7/7/7 cyred dasetta 1/35 dasetta 7/7/7 daysee deblitane delyla desogestrel/ethinyl estradiol drospirenone/ethinyl estradiol elinest emoquette enpresse-28 enskyce errin estarylla falmina gianvi gildagia gildess 1/20 gildess 1.5/30 gildess fe 1/20 gildess 24 fe gildess fe 1.5/30 heather introvale jencycla jolessa jolivette junel 1.5/30 junel fe 24 kelnor 1/35 kimidiss kurvelo larin larin 1/20 larin 1.5/30 larin fe 1.5/30 larissia layolis fe leena lessina levonest levonorgestrel/ethinyl estradiol levora 0.15/30-28 lomedia 24 fe loryna low-ogestrel lutera lyza marlissa medroxyprogesterone acetate microgestin 1/20 microgestin 1.5/30 microgestin fe microgestin 24 fe microgestin fe 1.5/30 mono-linya mononessa myzilra necon 0.5/35-28 necon 1/35 necon 1/50-28 necon 10/11-28 necon 7/7/7 nikki nora-be norethindrone norethindrone acetate/ethinyl estradiol norgestimate/ethinyl estradiol norlyroc nortrel 0.5/35 (28) nortrel 1/35 nortrel 7/7/7 ocella ogestrel FALESSA NATAZIA NUVARING QUARTETTE
6 Contraceptives orsythia philith pimtra tri-lo-sprintec pirmella 1/35 trinessa pirmella 7/7/7 portia-28 previfem progesterone reclipsen setlakin sharobel solia sprintec-28 sronyx syeda tarina FE 1/20 tilia FE tri-estarylla trinessa lo tri-legest FE Tri-linyah Tri-lo-estarylla Tri-lo-marzia Estrogens & Estrogen Combination Products covaryx covaryx hs eemt esterified estrogens/ methyltestosterone estradiol estradiol/norethindrone estropipate fyavolv Osteoporosis tri-previfem tri-sprintec trivora-28 velivet vestura vienva viorele vyfemla wymzya FE xulane zarah zenchent zenchent FE zovia 1/35E zovia 1/50E jinteli lopreeza mimvey mimvey lo norethindrone acetate/ ethinyl estradiol ALORA ANGELIQUE CLIMARA PRO COMBIPATCH DIVIGEL DUAVEE ELESTRIN jevantique lo EVAMIST MENEST MENOSTAR alendronate BINOSTO calcitonin ibandronate raloxifene FORTICAL FOSAMAX PLUS D risendronate Ulcer cimetidine esomeprazole famotidine lansoprazole misoprostol nizatidine omeprazole omeprazole/sodium bicarbonate pantoprazole rabeprazole ranitidine sucralfate DEXILANT MINIVELLE PREFEST PREMARIN PREMPHASE PREMPRO
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Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document Excluding Valsartan / Ramipril Prior authorization criteria logic: a description
SelectHealth Advantage 2018 Step Therapy Criteria. Previous trial on at least ONE: Generic topical acne treatment. Previous trial on: alendronate
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EmblemHealth City of New York Affordable Care Act Coverage Guidelines Starting July 1, 2016, the medications listed below will be covered for City of New York members with Medical Coverage. You will pay