2012 Preventive Drug List for Consumer Driven Health Plans Core List
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1 2012 Preventive Drug List for Consumer Driven Health Plans Core List
2 Alphabetical Listing Core List A C E J N Accupril Accuretic acebutolol Aceon Actonel Adalat CC Advicor Afeditab Aggrenox Aldactazide Aldactone alendronate Altace Altoprev amiloride amiloridehydrochlorothiazide amlodipine amlodipine-benazepril Amturnide E anastrozole Antara Arimidex Arixtra Aromasin Atacand Atacand HCT atenolol atenolol-chlorthalidone Avalide Avapro Azasan azathioprine Azor B benazepril benazeprilhydrochlorothiazide Benicar Benicar HCT betaxolol* Bidil bisoprolol bisoprololhydrochlorothiazide Boniva Brilinta bumetanide Bystolic Calan Calan SR calcitonin (salmon) Capoten Capozide captopril captoprilhydrochlorothiazide Cardene SR Cardizem Cardizem CD Cardizem LA Cardizem SR Cardura Cardura XL Cartia XT carvedilol Catapres Catapres TTS Cellcept chlorothiazide cholestyramine cholestyramine light cilostazol clonidine clonidine patch Clorpress Colestid colestipol Coreg Coreg CR E Corgard Corzide Coumadin Covera HS Cozaar Crestor cyclosporine D Demadex Didronel Dilacor XR Dilt CD Dilt XR Diltia XT diltiazem diltiazem ER Diltzac ER Diovan Diovan HCT dipyridamole Diuril doxazosin Dyazide Dynacirc CR Dyrenium Edecrin Effient enalapril enalaprilhydrochlorothiazide Enduron enoxaparin eplerenone etidronate Evista exemestane Exforge Exforge HCT F Fareston felodipine ER Femara fenofibrate Fenoglide Fibricor fondaparinux Forteo Fortical Fosamax Fosamax plus D fosinopril fosinoprilhydrochlorothiazide Fragmin furosemide G gemfibrozil Gengraf guanabenz guanfacine H heparin hydralazine Hydra-zide hydrochlorothiazide Hytrin Hyzaar I Imuran indapamide Inderal Inderal LA Inderide Innohep Innopran XL Inspra Isoptin SR isradipine Jantoven L labetalol Lasix Lescol Lescol XL letrozole Lipitor Lipofen lisinopril lisinoprilhydrochlorothiazide Locholest Locholest Light Lopid Lopressor Lopressor HCT losartan losartanhydrochlorothiazide Lotensin Lotensin HCT Lotrel lovastatin Lovaza Lovenox M Mavik Maxzide methyclothiazide methyldopa methyldopahydrochlorothiazide metolazone metoprolol succinate metoprolol tartrate metoprololhydrochlorothiazide Mevacor Miacalcin Micardis Micardis HCT Microzide Midamor Minipress minoxidil moexipril moexiprilhydrochlorothiazide Monopril Monopril HCT mycophenolate Myfortic nadolol nadololbendroflumethazide Neoral Niacor Niaspan nicardipine nifedipine nifedipine ER nimodipine nisoldipine Norvasc O Oretic P Pediatric Flouride Preparations perindopril Persantine pindolol Plavix Pletal Pradaxa Pravachol pravastatin prazosin Prenatal Vitamins Prevalite Prinivil Prinzide Procardia Procardia XL Prograf propranolol propranololhydrochlorothiazide Q Questran Questran Light quinapril quinaprilhydrochlorothiazide Quinaretic R ramipril Rapamune reserpine 2
3 Alphabetical Listing Core List S Sandimmune Sectral Simcor simvastatin spironolactone spironolactonehydrochlorothiazide Sular T tacrolimus tamoxifen Tarka Taztia XT Tekamlo E Tekturna Tekturna HCT Tenex Tenoretic Tenormin terazosin Teveten Teveten HCT Thalitone Tiazac ticlopidine timolol* Toprol XL torsemide Trandate trandolapril trandolapril-verapamil triamterenehydrochlorothiazide Tribenzor E Tricor E Triglide Trilipix E Twynsta E W warfarin Welchol X Xarelto Z Zaroxolyn Zebeta Zestoretic Zestril Zetia Ziac Zocor Zortress U Uniretic Univasc V Valturna E Vaseretic Vasotec verapamil verapamil ER Verelan Verelan PM Vytorin 3
4 Listing by Therapeutic Category Core List Breast Cancer Prevention anastrozole Arimidex Aromasin exemestane letrozole Fareston Femara tamoxifen Cardiovascular/Heart Disease - Blood Clot/Platelet Therapy Aggrenox Arixtra Brilinta cilostazol Coumadin dipyridamole Effient enoxaparin Fragmin fondaparinux heparin Innohep Jantoven Lovenox Persantine Plavix Pletal Pradaxa ticlopidine warfarin Xarelto Cardiovascular/Heart Disease - High Blood Pressure Accupril Accuretic acebutolol Aceon Adalat CC Afeditab Aldactazide Aldactone Altace amiloride amiloride-hydrochlorothiazide amlodipine amlodipine-benazepril Amturnide E Atacand Atacand HCT atenolol atenolol-chlorthalidone Avalide Avapro Azor benazepril benazepril-hydrochlorothiazide Benicar Benicar HCT betaxolol* Bidil bisoprolol bisoprolol-hydrochlorothiazide bumetanide Bystolic Calan Calan SR Capoten Capozide captopril captopril-hydrochlorothiazide Cardene SR Cardizem Cardizem CD Cardizem LA Cardizem SR Cardura Cardura XL Cartia XT carvedilol Catapres Catapres TTS chlorothiazide clonidine clonidine patch Clorpress Coreg Coreg CR E Corgard Corzide Covera HS Cozaar Demadex Dilacor XR Dilt CD Dilt XR Diltia XT diltiazem diltiazem ER Diltzac ER Diovan Diovan HCT Diuril doxazosin Dyazide Dynacirc CR Dyrenium Edecrin enalapril enalapril-hydrochlorothiazide Enduron eplerenone Exforge Exforge HCT felodipine ER fosinopril fosinopril-hydrochlorothiazide furosemide guanabenz guanfacine hydralazine Hydra-zide hydrochlorothiazide Hytrin Hyzaar indapamide Inderal 4
5 Listing by Therapeutic Category Core List Inderal LA Inderide Innopran XL Inspra Isoptin SR isradipine labetalol Lasix lisinopril lisinopril-hydrochlorothiazide Lopressor Lopressor HCT losartan losartan-hydrochlorothiazide Lotensin Lotensin HCT Lotrel Mavik Maxzide methyclothiazide methyldopa methyldopa-hydrochlorothiazide metolazone metoprolol succinate metoprolol tartrate metoprolol-hydrochlorothiazide Micardis Micardis HCT Microzide Midamor Minipress minoxidil moexipril moexipril-hydrochlorothiazide Monopril Monopril HCT nadolol nadolol-bendroflumethazide nicardipine nifedipine nifedipine ER nimodipine nisoldipine Norvasc Oretic perindopril pindolol prazosin Prinivil Prinzide Procardia Procardia XL propranolol propranolol-hydrochlorothiazide quinapril quinapril-hydrochlorothiazide Quinaretic ramipril reserpine Sectral spironolactone spironolactone-hydrochlorothiazide Sular Tarka Taztia XT Tekamlo E Tekturna Tekturna HCT Tenex Tenoretic Tenormin terazosin Teveten Teveten HCT Thalitone Tiazac timolol* Toprol XL torsemide Trandate trandolapril trandolapril-verapamil triamterene-hydrochlorothiazide Tribenzor E Twynsta E Uniretic Univasc Valturna E Vaseretic Vasotec verapamil verapamil ER Verelan Verelan PM Zaroxolyn Zebeta Zestoretic Zestril Ziac Cardiovascular/Heart Disease - High Cholesterol Advicor Altoprev Antara cholestyramine cholestyramine light Colestid colestipol Crestor fenofibrate Fenoglide Fibricor gemfibrozil Lescol Lescol XL Lipitor Lipofen Locholest Locholest Light Lopid lovastatin Lovaza Mevacor Niacor Niaspan Pravachol pravastatin Prevalite Questran Questran Light 5
6 Listing by Therapeutic Category Core List Simcor simvastatin Tricor E Triglide Trilipix E Vytorin Welchol Zetia Zocor Immunosuppressant - Organ Rejection Azasan azathioprine Cellcept cyclosporine Gengraf Imuran mycophenolate Myfortic Neoral Prograf Rapamune Sandimmune tacrolimus Zortress Musculoskeletal - Osteoporosis Actonel alendronate Boniva calcitonin (salmon) Didronel etidronate Evista Forteo Fortical Fosamax Fosamax plus D Miacalcin Vitamins Pediatric Flouride Preparations (for example: Florvite, Poly-Vi-Flor, Tri-Vi-Flor) - Brand Name and Generic Products Prenatal Vitamins (for example: Citranatal Assure, Prenate DHA, Stuartnatal) - Brand Name and Generic Products If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting myuhc.com or by calling the toll-free member phone number on the back of your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access myuhc.com for additional information during your open enrollment period or you may contact your employer or health plan for additional information. Medications are categorized by common therapeutic conditions in this reference guide for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines how these medications may be covered for you. Where differences are noted between this reference guide and your benefit plan documents, the benefit plan documents will govern. Generic medications are noted in lower case lettering. Clinical programs such as Notification, ProgressionRX and Supply Limits may apply to listed medications based off your benefit plan. UnitedHealthcare will work with our customers to help them understand the potential impact within their benefit plan and will provide consultation as necessary. UnitedHealthcare does not indemnify employers for the application of these preventive medications or specific medications under the benefit plan. This list is intended as a reference and may not be all-inclusive. Brand or generic availability may not be current due to changes in the market. The list will be updated annually United HealthCare Services, Inc. Created August, For the most current PDL updates, visit myuhc.com or call toll-free member phone number on the back of your health plan ID card Core List 1/12 6
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