2018 Preventive Medications Standard Formulary
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- Christopher Briggs
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1 2018 Preventive Medications Standard Formulary Coverage Beyond Your Deductible Preventive Medication List products aren t subject to a deductible. You ll pay a copay or nothing at all, depending on your plan. So you ll save money and get the medications you need to help you live well. What could be easier? To check the cost of a medication, refer to your benefit handbook or contact customer service at the toll-free member phone number on your benefit plan ID card. Quality Driven and Cost-Conscious Medications As the pharmacy benefit manager for your benefit plan, Magellan Rx Management strives to offer you access to a broad choice of medications at a reasonable price. The Preventive Medication List is a subset of products included within your plan s preferred, or formulary, medication list, which tells you what medications your plan covers. Please note that most formulary medications are subject to a deductible. Preventive Medication List products are an exception. For a complete copy of your formulary listing, call customer service. Proactive Therapy Preventive medications help protect against or manage a medical condition. They may provide prenatal care, prevent osteoporosis or reduce risk of blood clots, stroke and heart disease. Taking preventive medications as directed by your doctor can help avoid serious health problems. That may mean fewer doctor visits and hospitalizations, reducing your total health care costs. Money Saving Generics To get the most from your benefits, ask your doctor if there s a generic medication that s right for you. Generics normally cost less than brand medications, and the Food and Drug Administration (FDA) requires them to be just as safe and effective. For More Information If you have questions or would like additional information on the Preventive Medication List, please contact customer service at the toll-free member phone number on your ID card. A list of covered preventive medications begins on the next page. Medications are listed by therapeutic category. They are indicated by: Generics: Lower case italic. For example, acarbose Brands are capitalized and not italics. For example, Abilify Oral and self-injectable Specialty medications are denoted by SP superscript and may be subject to limitations based on plan benefit design.
2 2018 Preventive Medication List Therapeutic Category ANTIASTHMATICS Accolate Advair Diskus Advair HFA Aerospan albuterol sulfate Alvesco aminophylline Anoro Ellipta Arcapta Neohaler Arnuity Ellipta Asmanex Asmanex HFA Atrovent HFA Breo Ellipta Brovana budesonide Combivent Respimat cromolyn sodium Dulera Elixophyllin Flovent Diskus Flovent HFA Foradil ipratropium bromide ipratropium-albuterol levalbuterol concentrate levalbuterol hcl levalbuterol tartrate hfa metaproterenol sulfate montelukast sodium Perforomist Proair HFA Proventil HFA Pulmicort Pulmicort Flexhaler Qvar Serevent Diskus Singulair Spiriva Spiriva Respimat Stiolto Respimat Symbicort terbutaline sulfate Theo-24 theochron theophylline Tudorza Pressair Ventolin HFA Vospire Er Xopenex Xopenex Hfa zafirlukast zileuton er Zyflo Zyflo Cr ANTICOAGULANTS Arixtra SP Coumadin Eliquis enoxaparin sodium SP fondaparinux sodium SP Fragmin SP heparin flush heparin lock heparin sodium jantoven Lovenox SP monoject prefill Pradaxa warfarin sodium Xarelto ANTIHYPERGLYCEMICS acarbose Actoplus Met Actoplus Met Xr Actos alogliptin alogliptin-metformin alogliptin-pioglitazone Amaryl Apidra Apidra Solostar Avandamet Avandia Basaglar Kwikpen U-100 Bydureon Byetta chlorpropamide Cycloset Diabeta Duetact Farxiga glimepiride glipizide glipizide er glipizide xl glipizide-metformin Glucophage Glucophage Xr Glucotrol Glucotrol Xl Glucovance glyburide glyburide micronized glyburide-metformin hcl Glynase Glyset Glyxambi Humalog Humalog Mix Humalog Mix Humulin Humulin N Humulin R Invokamet Invokamet Xr Invokana Janumet Janumet Xr Januvia Jardiance Jentadueto Jentadueto Xr Kazano Kombiglyze Xr Lantus Levemir metformin hcl metformin hcl er miglitol nateglinide Nesina Novolin Novolin N Novolin R Novolog Novolog Mix Onglyza Oseni pioglitazone hcl pioglitazone-glimepiride pioglitazone-metformin Prandimet Prandin Precose repaglinide repaglinide-metformin hcl Riomet Starlix Symlinpen Tanzeum tolazamide tolbutamide Toujeo Solostar Tradjenta Tresiba Flextouch Trulicity Victoza Xigduo Xr ANTINEOPLASTICS anastrozole Arimidex Aromasin exemestane Fareston Femara letrozole Soltamox tamoxifen citrate ANTIPLATELET DRUGS Aggrenox aspirin-dipyridamole er Brilinta cilostazol clopidogrel dipyridamole Effient Persantine Plavix Magellan Rx Management, LLC. All rights reserved. Standard_MRX0387_0118
3 Pletal prasugrel hcl ticlopidine hcl ANTIVIRALS abacavir SP abacavir-lamivudine SP abacavir-lamivudine-zidovudine SP Aptivus SP Atripla SP Combivir SP Complera SP Crixivan SP didanosine SP Edurant SP Emtriva SP Epivir SP Epivir Hbv SP Epzicom SP fosamprenavir calcium SP Fuzeon SP Intelence SP Invirase SP Isentress SP Isentress Hd SP Kaletra SP lamivudine SP lamivudine hbv SP lamivudine-zidovudine SP Lexiva SP nevirapine SP nevirapine er SP Norvir SP Prezista SP Rescriptor SP Retrovir SP Reyataz SP Selzentry SP stavudine SP Stribild SP Sustiva SP Tivicay SP Trizivir SP Truvada SP Videx SP Videx Ec SP Viracept SP Viramune SP Viramune Xr SP Viread SP Zerit SP Ziagen SP zidovudine SP AUTONOMIC DRUGS Dibenzyline CARDIAC DRUGS Adalat Cc afeditab cr amlodipine besylate Calan Calan Sr Cardene I.V. Cardene Sr Cardizem Cardizem Cd Cardizem La cartia xt diltiazem 12hr er diltiazem 24hr cd diltiazem 24hr er diltiazem er diltiazem hcl dilt-xr felodipine er isradipine matzim la nicardipine hcl nicardipine hcl-d5w nifedical xl nifedipine nifedipine er nimodipine nisoldipine Norvasc Nymalize Procardia Procardia Xl Sular taztia xt Tiazac verapamil er verapamil er pm verapamil hcl verapamil sr Verelan Verelan Pm CARDIOVASCULAR Accupril Accuretic acebutolol hcl Aceon Advicor Altace Altoprev amlodipine besylate-benazepril amlodipine-atorvastatin amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hctz Antara Atacand Atacand Hct atenolol atenolol-chlorthalidone atorvastatin calcium Avalide Avapro Azor benazepril hcl benazepril-hydrochlorothiazide Benicar Benicar Hct Betapace Betapace Af betaxolol hcl Bidil bisoprolol fumarate bisoprolol-hydrochlorothiazide Bystolic Caduet candesartan cilexetil candesartan-hydrochlorothiazid captopril captopril-hydrochlorothiazide Cardura Cardura Xl carvedilol carvedilol er Catapres Catapres-TTS cholestyramine cholestyramine light clonidine clonidine hcl Clorpres Colestid colestipol hcl Coreg Coreg Cr Corgard Corzide Cozaar Crestor Demser Diovan Diovan Hct doxazosin mesylate Dutoprol Edarbi Edarbyclor enalapril maleate enalaprilat enalapril-hydrochlorothiazide Epaned eprosartan mesylate esmolol hcl Exforge Exforge Hct ezetimibe ezetimibe-simvastatin fenofibrate fenofibric acid Fenoglide Fibricor fluvastatin er fluvastatin sodium fosinopril sodium fosinopril-hydrochlorothiazide gemfibrozil guanfacine hcl hydralazine hcl Magellan Rx Management, LLC. All rights reserved. Standard_MRX0387_0118
4 Hyzaar Inderal La Inderal Xl Innopran Xl irbesartan irbesartan-hydrochlorothiazide Juxtapid SP Kynamro SP labetalol hcl Lescol Lescol Xl Levatol Lipitor Lipofen lisinopril lisinopril-hydrochlorothiazide Livalo Lofibra Lopid Lopressor Lopressor Hct losartan potassium losartan-hydrochlorothiazide Lotensin Lotensin Hct Lotrel lovastatin Mavik methyldopa methyldopa-hydrochlorothiazide methyldopate hcl metoprolol succinate metoprolol tartrate metoprolol-hydrochlorothiazide Micardis Micardis Hct Minipress minoxidil moexipril hcl moexipril-hydrochlorothiazide nadolol nadolol-bendroflumethiazide niacin er Niacor Niaspan olmesartan medoxomil olmesartan-amlodipine-hctz olmesartan-hydrochlorothiazide perindopril erbumine pindolol Pravachol pravastatin sodium prazosin hcl prevalite Prinivil propranolol hcl propranolol hcl er propranolol-hydrochlorothiazid Questran Questran Light quinapril hcl quinapril-hydrochlorothiazide ramipril reserpine rosuvastatin calcium Sectral Simcor simvastatin sorine sotalol sotalol af Tarka Tekamlo Tekturna Tekturna Hct telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid Tenex Tenoretic Tenormin terazosin hcl timolol maleate Toprol Xl trandolapril trandolapril-verapamil er Tribenzor Tricor Triglide Trilipix Twynsta valsartan valsartan-hydrochlorothiazide Vaseretic Vasotec Vecamyl SP Vytorin Welchol Zebeta Zestoretic Zestril Zetia Ziac Zocor CNS DRUGS Ampyra SP Aubagio SP Avonex SP Avonex Pen SP Betaseron SP Copaxone SP Extavia SP Gilenya SP Rebif SP Rebif Rebidose SP Tecfidera SP CONTRACEPTIVES trinessa trinessa lo TESTING SUPPLIES Control Solution for Diabetic Meters Diabetic Test Strips Diabetic Testing Lancets Insulin Pen Needles and Syringes DIAGNOSTIC Accu-Chek Aviva Accu-Chek Aviva Plus Accu-Chek Compact Accu-Chek Compact Plus Strips Accu-Chek Guide Test Strip Accu-Chek Smartview Various other test strips and meters DIURETICS Aldactazide Aldactone amiloride hcl amiloride-hydrochlorothiazide bumetanide chlorothiazide chlorthalidone Demadex Diuril Dyazide Dyrenium Edecrin eplerenone ethacrynic acid furosemide hydrochlorothiazide indapamide Inspra Lasix Maxzide Maxzide-25 Mg methyclothiazide metolazone Microzide spironolactone spironolactone-hctz torsemide triamterene-hydrochlorothiazid GASTROINTESTINAL compazine compro Lovaza omega-3 acid ethyl esters prochlorperazine prochlorperazine edisylate prochlorperazine maleate triklo Vascepa HORMONES calcitonin-salmon Fortical Miacalcin Spray Miacalcin SP Magellan Rx Management, LLC. All rights reserved. Standard_MRX0387_0118
5 IMMUNOSUPPRESSANTS Astagraf Xl SP Azasan azathioprine Cellcept SP cyclosporine SP cyclosporine modified SP gengraf SP Imuran mycophenolate mofetil SP mycophenolic acid SP Myfortic SP Neoral SP Prograf SP Rapamune SP Sandimmune SP sirolimus SP tacrolimus SP Zortress SP IRON REPLACEMENT Focalgin Dss MISC Actonel alendronate sodium Atelvia Binosto Boniva etidronate disodium Evista Forteo SP Fosamax Fosamax Plus D ibandronate sodium Osphena raloxifene hcl Reclast SP risedronate sodium zoledronic acid SP Zometa SP PRE-NATAL VITAMINS Atabex Ec Elite Ob Dha Elite-Ob Elite-Ob 400 Focalgin Ca Folbecal Levomefolate Dha Macnatal Cn Dha Maxinate Mynatal Mynatal Advance Mynatal Plus Mynatal-Z Mynate 90 Plus Obstetrix Ec Obstetrix One Obtrex Dha O-Cal Fa Pnv 29-1 Pnv-Dha + Docusate Pnv-Omega Prena1 Chew Prena1 Pearl Prena1 True Prenaissance Next Prenatabs Rx Prenatal Low Iron Prenatal-U Preplus Pretab Provida Ob R-Natal Ob Tricare Prenatal Trinate Tri-Tabs Dha Triveen-One Triveen-U Trust Natal Dha Venatal Complete Dha Vinate Dha Vinate Dha Rf Vinate Gt Vinate Ii Vinate One Vinate Pn Care Vinate Ultra Vinate-M Virt-Advance Virt-Nate Virt-Nate Dha Virt-Pn Virt-Pn Dha Virt-Pn Plus Vitaspire Vitatrue Viva Dha Vol-Tab Rx Vp-Ch-Pnv Vp-Heme Ob Vp-Heme One Vp-Pnv-Dha PSYCHOTHERAPEUTIC DRUGS Abilify Abilify Maintena Adasuve aripiprazole aripiprazole odt chlorpromazine hcl clozapine clozapine odt Clozaril Equetro Fanapt Fazaclo fluphenazine decanoate fluphenazine hcl Geodon guanfacine hcl er Haldol haloperidol haloperidol decanoate Invega Invega Sustenna Latuda loxapine olanzapine olanzapine odt olanzapine-fluoxetine hcl paliperidone er perphenazine quetiapine fumarate quetiapine fumarate er Risperdal Risperdal Consta Risperdal M-Tab risperidone risperidone odt Saphris Seroquel Seroquel Xr Symbyax thioridazine hcl thiothixene trifluoperazine hcl Versacloz ziprasidone hcl Zyprexa Zyprexa Relprevv Zyprexa Zydis VITAMINS Escavite Lq multivitamin with fluoride multivitamin-iron-fluoride Mykidz Iron Fl Poly-Vi-Flor Poly-Vi-Flor With Iron Quflora Tri-Vi-Flor vitamins a,c,d and fluoride Magellan Rx Management, LLC. All rights reserved. Standard_MRX0387_0118
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