The Alliance Health Plan Preventive Drug List 2018
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1 The Alliance Health Plan Preventive Drug List 2018 Drug Category Drug Sub-Category Drug Name(s) asprin / dipyriadmole (Aggrenox) Anticoagulants / Antiplatelets Antiemetics / Antivertigo Agents Antiestrogens Anti-infectives Antimalarials Anti-ulcer agents H2-antagonists clopidogrel dipyriadmole warfarin dolasetron (Anzemet) granisetron (Sancuso) meclizine ondansetron prochlorperazine promethazine Transderm Scop trimethobenzamide anastrozole exemestane letrozole tamoxifen raloxifene (Evista) atovaquone (Mepron) atovaquone/proguanil chloroquine hydroxychloroquine mefloquine primaquine phosphate (Primaquine) quinine (Qualaquin) cimetidine famotidine nizatidine ranitidine Page 1
2 Anti-ulcer agents Antivirals Arthritis / Pain Proton pump inhibitors Miscellaneous esomeprazole (Nexium) lansoprazole omeprazole pantoprazole metoclopramide HCl tablet metoclopramide HCl solution misoprostol sucralfate acyclovir amantadine famciclovir foscarnet ganciclovir rimantadine valacyclovir valganciclovir (Valcyte) methylprednisolone sodium succinate powder for injection methylprednisolone acetate suspension for injection methylprednisolone prednisolone acetate suspension (generic Pred Forte) prednisone indomethacin naproxen naproxen delayed-release naproxen sodium diclofenac sodium diclofenac sodium ext-release diclofenac solution etodolac ibuprofen suspension ibuprofen Page 2
3 Arthritis / Pain Asthma therapies Blood Pressure / Heart Health ACE Inhibitors ketoprofen ketorolac ophthalmic soln meloxicam nabumetone piroxicam sulindac montelukast zafirlukast albuterol sulfate tablet albuterol sulfate syrup albuterol sulfate inhalant solution aminophylline tablet budesonide inhalant suspension (Pulmicort Respules) terbutaline theophylline ext-release tabs cromolyn sodium solution cromolyn sodium inhalant solution ipratropium bromide solution ipratropium bromide inhalant solution ipratropium/albuterol sulfate benazepril benazepril-hctz captopril captopril-hctz enalapril enalapril-hctz fosinopril fosinopril-hctz lisinopril lisinopril- HCTZ moexipril Page 3
4 Blood Pressure/Heart Health ACE Inhibitors Angiotensin II receptor blockers Beta-Blockers moexipril-hctz perindopril quinapril quinapril-hctz ramipril trandolapril eprosartan mesylate (600mg only) irbesartan irbesartan-hctz losartan losartan-hctz olmesartan (Benicar) olmesartan-hctz (Benicar HCT) telmisartan (Micardis) telmisartan-hctz (Micardis HCT) valsartan valsartan-hctz acebutolol atenolol atenolol/chlorthalidone betaxolol bisoprolol bisoprolol-hctz labetalol metoprolol metoprolol- HCTZ nadolol pindolol propranolol sotalol sotalol AF Page 4
5 Blood Pressure/Heart Health Beta-Blockers Calcium Channel Blockers Thiazide diuretics and related diuretics Miscellaneous timolol amlodipine diltiazem felodipine nicardipine nifedipine nisoldipine verapamil verapamil ext. release amiloride amiloride-hctz chlorothiazide chlorthalidone eplerenone furosemide hydrochlorothiazide indapamide methyclothiazide spironolactone spironolactone- HCTZ triamterene triamterene-hctz clonidine doxazosin digoxin guanfacine hydralazine methyldopa methyldopa-hctz prazosin terazosin Page 5
6 Blood Pressure/Heart Health Bowel evacuant products Calcium Replacement products Cancer (adjunctive agents) Cholesterol- lowering agents Contraceptives Miscellaneous Polyethylene glycol 3350 combination products HMG-coA reductase inhibitors Non-Oral amlodipine/benazepril amlodipine/valsartan (Exforge) amlodipine/valsartan/hydrochlorothiazide (Exforge HCT) trandolapril/verapamil (Tarka) Colyte Trilyte Gavilyte sodium phosphate salts calcium acetate amifostine dexrazoxane Neupogen leucovorin mesna (Mesnex) atorvastatin/amlodipine cholestyramine colestipol fenofibrate (Antara, Fenoglide, Lipofen, TriCor, Triglide) fenofibric acid (TriLipix) gemfibrozil atorvastatin fluvastatin pravastatin simvastatin niacin (Niaspan) omega-3-acid ethyl esters (Lovaza) medroxyprogesterone 150mg injectable Apri (generic only) Estrostep Fe (generic only) Lybrel (generic only) Ortho Tri-Cyclen (generic only) Page 6
7 Contraceptives Diabetes Oral Insulins Oral Ovcon (generic only) Seasonale (generic only) TriNessa (generic only) Trivora (generic only) Yasmin (generic only) Seasonique (generic only) YAZ (generic only) insulin aspart (NovologR) insulin aspart protamine human/insulin aspart (NovologR 70/30) insulin detemir (LevemirR) insulin lispro (HumalogR) insulin regular (Humulin RR) insulin NPH (Humulin NR) insulin NPH and insulin regular (Humulin 70/30R) insulin NPL/insulin lispro (Humalog 50/50R, Humalog MIX 75/25R) insulin glargine (LantusR, Lantus SolostarR) insulin glulisine (ApidaR, Apidra SolstarR) acarbose glimeprimide glipizide glipizide ext-release glyburide glyburide, micronized glyburide/metformin metformin HCl metformin ext-release nateglinide Accu-Chek test strips One Touch test strips SureStep test strips Page 7
8 Diabetes Estrogen replacement products Fluoride preparations, oral and topical Gout Heparin / low molecular weight heparin products Iron replacement agents Mental Health SureStep Pro test strips Supplies Insulin pen needles BD Ultrafine Insulin syringes BD Lancet device BD Lancets BD Lancets - Microlet esterified estrogens/methyltestosterone estradiol (Climara, Estraderm, Vivelle, Vivelle DOT) estradiol gel (Divigel) ethinyl estradiol/norethindrone (Femhrt) Cavarest Gel (generic only) Easygel (generic only) EtheDent (generic only) Fluoritab (generic only) Neutragard (generic only) Phos-Flur (generic only) sodium fluoride (generic only) Gel-Kam (generic only) PreviDent Rinse (generic only) allopurinol colchicine (Colcrys) heparin Low-molecular-weight heparin enoxaparin fondaparinux FoliTab (generic only) Foltrin (generic only) Niferex Forte (generic only) bupropion citalopram fluoxetine Page 8
9 Mental Health Osteoporosis Phosphate / potassium replacement products Prenatal vitamins Prescription vitamins lamotrigine buspirone divalproex lithium alendronate calcitonin etidronate ibandronate (Boniva) generic oral, brand injectable only raloxifene (Evista) potassium bicarbonate/citric acid potassium chloride potassium phosphate potassium and sodium phosphate sodium phosphate Nata chew (generic only) Natafort (generic only) Natelle (generic only) Pre Care (generic only) Prenatal Plus (generic only) Prenatal RX (generic only) Prima Care (generic only) Vitafol-OB (generic only) multivitamin with fluoride Strovite Advance (generic only) Strovite Plus (generic only) Theragran (generic only) Therobec (generic only) Therobec Plus (generic only) medroxyprogesterone norethindrone norethindrone acetate Page 9
10 Progestins Smoking cessation products Vaccines Vitamins Weight loss agents Zinc replacement products Nicotine Products Vitamin B products Vitamin B1 products Vitamin B6 products Vitamin B12 products Vitamin D products Vitamin K products progesterone progesterone, micronized (Crinone, Endometrin) bupropion (generic for Zyban only) Nicotrol Inhaler Nicotrol Nasal Spray seasonal influenza vaccines (free at participating retail pharmacies, not through mail service) Folgard RX (generic only) Foltx (generic only) thiamine pyridoxine cyanocobalamin injection cyanocobalamin/folic acid (Foltrate) calcitriol ergocalciferol phytonadione (Mephyton) benzphetamine diethylpropion phendimetrazine phentermine zinc sulfate Page 10
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