2019 CDH Preventive Medications - Leidos
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1 This list provides examples of commonly prescribed preventive medications. It is not an all-inclusive list; only examples of medications in each category are listed. This list does not indicate coverage. Please check with your plan administrator and/or benefit information materials if you have questions on coverage. Your cost share will be determined by your plan s drug coverage and formulary plan. Coverage prior to the deductible being met may not be provided for every dosage form of a listed medication. Please note: When feasible, brand names are shown in capitals in each category. If generic is available, it is listed in lowercase next to the brand name. If only generics are available (for example, brands are no longer available), they will only be listed in lowercase. ASTHMA/COPD ACCOLATE (zafirlukast) ADVAIR DISKUS ADVAIR HFA AEROSPAN AIRDUO RESPICLICK albuterol ANORO ELLIPTA ARMONAIR RESPLICLICK ARCAPTA NEOHALER ARNUITY ELLIPTA ASMANEX HFA ASMANEX TWISTHALER ATROVENT HFA BEVESPI AEROSPHERE BREO ELLIPTA BROVANA budesonide CINQAIR COMBIVENT RESPIMAT cromolyn oral inhalation DALIRESP DULERA FASENRA FLOVENT DISKUS FLOVENT HFA FLUTICASONE/SALMETROL INCRUSE ELLIPTA Inhaler assistive devices ipratropium/albuterol oral inhalation ipratropium oral inhalation LONHALA MAGNAIR metaproterenol montelukast Nebulizers NUCALA PROAIR HFA PROAIR RESPICLICK PULMICORT FLEXHALER QVAR SEEBRI NEOHALER SEREVENT DISKUS SPIRIVA RESPIMAT STIOLTO RESPIMAT STRIVERDI RESPIMAT SYMBICORT terbutaline THEO-24 (theophylline) TRELLEGY ELLIPTA TUDORZA PRESSAIR UTIBRON NEOHALER VENTOLIN HFA XOLAIR zileuton ER BONE DISEASE AND FRACTURES ACTONEL, ATELVIA (risedronate) BONIVA (ibandronate) DUAVEE EVISTA (raloxifene) FOSAMAX (alendronate) FOSAMAX D BINOSTO RECLAST (zoledronic acid) BREAST CANCER RECURRENCE anastrozole exemestane letrozole tamoxifen CANCER TREATMENT, SIDE EFFECTS FROM ARANESP EPOGEN NEUPOGEN PROCRIT NEULASTA CAVITIES CLINPRO GEL-KAM PHOS-FLUR PREVIDENT sodium fluoride rinse, gel, cream, paste, tabs and drops stannous fluoride rinse and gel CRP1810_0817 EME49109 DL48344Q
2 COLONOSCOPY PREPARATION* CLENPIQ COLYTE, GOLYTELY, NULYTELY (polyethylene glycol) MOVIPREP OSMOPREP PLENVU PREPOPIK SUPREP DIABETES INSULINS AFREZZA BASAGLAR HUMALOG HUMULIN LANTUS SOLOSTAR LEVEMIR TOUJEO SOLOSTAR TRESIBA INSULIN/GLP-1 RECEPTOR AGONIST SOLIQUA XULTOPHY NON-INSULINS ACTOS (pioglitazone) ACTOPLUS MET (pioglitazone/metformin) ACTOPLUS MET XR ALOGLIPTIN/PIOGLITAZONE AMARYL (glimepiride) AVANDIA AVANDAMET BYETTA BYDUREON chlorpropamide CYCLOSET DUETACT (pioglitazone/glimepiride) FARXIGA FORTAMET (metformin) glipizide/metformin glucose GLUCOTROL XL (glipizide) GLUCOVANCE (glyburide/ metformin) GLYNASE (glyburide) GLYSET (miglitol) GLYXAMBI INVOKAMET INVOKAMET XR INVOKANA JANUVIA JANUMET JANUMET XR JARDIANCE JENTADUETO JENTADUETO XR Lancets Meters Misc. diabetic supplies Needles OSENI OZEMPIC PRANDIN (repaglinide) PRECOSE (acarbose) QTERN repaglinide/metformin SEGLUROMET STARLIX (nateglinide) STEGLATRO STEGLUJAN SYMLINPEN SYNJARDY SYNJARDY XR Syringes Test strips TRADJENTA TRULICITY XIGDUO XR ESTROGEN REPLACEMENT AND OTHER HORMONES PREMARIN PREMPRO PREPHASE estradiol tablets estradiol transdermal medroxyprogesterone FUNGAL MEPRON NEBUPENT NOXAFIL GOUT allopurinol colchicine GUM DISEASE ARESTIN HEART DISEASE AND STROKE BLOOD THINNERS aspirin, 81 mg & 325 mg* AGGRENOX (aspirin/dipyridamole ER) BEVYXXA BRILINTA clopidogrel COUMADIN (warfarin) DURLAZA ER EFFIENT (prasugrel) ELIQUIS PERSANTINE (dipyridamole) ticlopidine XARELTO ZONTIVITY CHOLESTEROL LOWERING HMG-COA REDUCTASE INHIBITORS* atorvastatin LESCOL (fluvastatin) LIVALO lovastatin PRAVACHOL (pravastatin) rosuvastatin simvastatin
3 OTHER AGENTS ANTARA COLESTID (colestipol) ezetimibe ezetimibe/simvastatin LOFIBRA, LIPOFEN (fenofibrate) LOPID (gemfibrozil) NIASPAN (niacin) PRALUENT QUESTRAN (cholestyramine) QUESTRAN LIGHT (cholestyramine light, prevalite) TRIGLIDE TRILIPIX, FIBRICOR (fenofibric acid) WELCHOL (colesevelam) HIGH BLOOD PRESSURE ACE INHIBITORS ACCUPRIL (quinapril) ACEON (perindopril) ALTACE (ramipril) captopril fosinopril LOTENSIN (benazepril) MAVIK (trandolapril) moexipril PRINIVIL, ZESTRIL (lisinopril) VASOTEC (enalapril) ACE INHIBITORS/DIURETIC ACCURETIC (quinapril/hctz) captopril/hctz fosinopril/hctz LOTENSIN HCT (benazepril/hctz) moexipril/hctz VASERETIC (enalapril/hctz) ZESTORETIC (lisinopril/hctz) ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan EDARBI irbesartan losartan olmesartan telmisartan valsartan ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC candesartan/hctz EDARBYCLOR irbesartan/hctz losartan/hctz olmesartan/hctz telmisartan/hctz valsartan/hctz BETA BLOCKERS acebutolol betaxolol bisoprolol BYSTOLIC CORGARD (nadolol) INNOPRAN XL propranolol TENORMIN (atenolol) timolol TOPROL XL, LOPRESSOR (metoprolol) BETA BLOCKER/DIURETIC CORZIDE (nadolol/bendroflumethiazide) LOPRESSOR HCT (metoprolol/hctz) propranolol/hctz TENORETIC (atenolol/chlorthalidone) ZIAC (bisoprolol/hctz) CALCIUM CHANNEL BLOCKERS ADALAT CC, PROCARDIA XL (nifedipine ER) amlodipine CALAN, VERELAN (verapamil) CARDIZEM LA, TIAZAC ER (diltiazem ER) felodipine ER isradipine nicardipine SULAR ER (nisoldipine ER) DIURETICS chlorothiazide chlorthalidone hydrochlorothiazide indapamide metolazone OTHER HIGH BLOOD PRESSURE amlodipine/benazepril amlodipine/olmesartan amlodipine/olmesartan/hctz amlodipine/valsartan amlodipine/valsartan/hctz BYVALSON CADUET (amlodipine/atorvastatin) PRESTALIA TARKA (trandolapril/verapamil) TWYNSTA (amlodipine/telmisartan) MALARIA chloroquine mefloquine MALARONE (atovaquone/ proguanil) PRIMAQUINE
4 MIGRAINE PREVENTION AIMOVIG AJOVY MISC ANTIVIRALS amantadine acyclovir famcicolvir oseltamivir PREVYMIS SYNAGIS TRUVADA 200mg/300mg NAUSEA AND DIZZINESS ANZEMET granisetron meclizine ondasetron prochlorperazine OBESITY ADIPEX-P (phentermine) BELVIQ BELVIQ XR CONTRAVE diethylpropion LOMAIRA phendimetrazine REGIMEX (benzphetamine) SAXENDA XENICAL ULCER DISEASE esomeprazole famotidine lansoparazole omeprazole pantoprazole rantidine VACCINATION* Anthrax, BCG, Cholera, Diphtheria, Haemophilus Influenza B, Hepatitis A and B, Human Papillomavirus, Influenza, Japanese Encephalitis, Measles, Meningococcal, Mumps, Pertussis, Pneumococcal, Poliovirus, Rabies, Rotavirus, Rubella, Tetanus, Typhoid, Varicella, Yellow Fever, Zoster, Zostrix (shingles) VITAMINS OR MINERALS Folic acid* Prenatal vitamins Pediatric multivitamins with fluoride* SMOKING-CESSATION* CHANTIX NICOTROL NICODERM CQ nicotine gum, lozenges and patches ZYBAN (bupropion SR 150mg)
5 *Please note that some of these medications are also subject to the Affordable Care Act (ACA) and may be covered by your plan at 100%. Express Scripts manages your prescription benefit for your employer, plan sponsor, or health plan. For specific questions on coverage, please call the phone number on your member ID card or visit our website express-scripts.com Express Scripts. All Rights Reserved. Express Scripts and the "E" Logo are trademarks of Express Scripts Strategic Development, Inc. All other trademarks are the property of their respective owners.
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