OptumRx Trinity Health High Deductible Health Plan 2022 .
Trinity Health High Deductible Health Plan2022 Preventive medication listEffective January 1, 2022Managing your health with preventive medicationsYour pharmacy benefit plan includes special coverage for preventive medications.The drugs on your plan’s preventive medications list do not have a deductible. This means you’ll payyour copayment/coinsurance or nothing at all, depending on your plan.To check the cost of any medication, call the number on your member ID card, visit your plan’swebsite on your member ID card, or log on to the OptumRx app.Potential savings with generic medicationsTo get the most from your benefits, ask your doctor if a generic medication is right for you. Genericsnormally cost less than brand medications, and the Food and Drug Administration (FDA) requiresthem to be just as safe and effective.A list of covered preventive medications begins on the next page.Medications are listed by therapeutic category. Where differences are noted between this list andyour benefit plan documents, the benefit plan documents will rule.For questions on injectable preventive medications administered by your doctor or healthcareprovider, please call the number on your ID card.
Trinity Health High Deductible Health Plan2022 Preventive medication listTable of ContentsAnti-Addiction / Substance Abuse Treatment Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Antiarrhythmic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Anticoagulants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Anticonvulsants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Antineoplastics - Drugs for Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Antiplatelets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Antipsychotics - Drugs for Mood Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Antivirals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Cardiovascular Agents - Drugs for Heart and Circulation Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Diabetes - Antidiabetic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Diabetes - Insulins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Electrolytes / Minerals / Metals / Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Hormonal Agents - Selective Estrogen Receptor Modifying Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Hormonal Agents - Sex Hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Immunological Agents - Drugs for Immune System Stimulation or Suppression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Metabolic Bone Disease Agents - Drugs for Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Miscellaneous Therapeutic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Trinity Health High Deductible Health Plan2022 Preventive medication listDrug NameNotesDrug NameAnti-Addiction / Substance Abuse Treatment AgentsAnticonvulsantsAPO-VARENICLINE ORAL TABLET carbamazepinebupropion hcl er (smoking det) oral tabletextended release 12 hour carbamazepine erNICOTROL INHALATION INHALER clonazepamNICOTROL NS NASAL SOLUTION divalproex sodium drclobazamAntiarrhythmic Agentsdivalproex sodium ilidelamotrigineflecainidelamotrigine erpropafenonelevetiracetampropafenone erlevetiracetam ersotalol RIXTRA SUBCUTANEOUS SOLUTIONphenytoinSPphenytoin erELIQUIS DVT/PE STARTER PACK ORAL TABLETTHERAPY PACKprimidonetiagabineELIQUIS ORAL TABLETenoxaparin sodium injection solutionSPenoxaparin sodium subcutaneous solutionSPfondaparinux sodium subcutaneous solutionSPFRAGMIN SUBCUTANEOUS SOLUTIONSPtopiramatetopiramate ervalproic acidvigabatrinzonisamideheparin sodium (porcine) injection solutionAntidepressantsheparin sodium (porcine) injection solutionprefilled syringeamitriptylineheparin sodium (porcine) pf injection solutionamoxapinejantoven oral tabletbupropion erLOVENOX INJECTION SOLUTIONSPbupropion xlLOVENOX SUBCUTANEOUS SOLUTIONSPcitalopram hydrobromide oral solutionPRADAXA ORAL CAPSULEcitalopram hydrobromide oral tabletSAVAYSA ORAL TABLETclomipraminewarfarin sodium oral tabletdesipramineXARELTO ORAL TABLETdesvenlafaxine erXARELTO STARTER PACK ORAL TABLET THERAPYPACKdoxepinduloxetine drBrand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.3Notes
Drug NameNotesDrug Nameescitalopram oxalate oral solutionAntiplateletsescitalopram oxalate oral tabletfluoxetine hcl oral capsuleaspirin-dipyridamole er oral capsule extendedrelease 12 hourfluoxetine hcl oral capsule delayed releaseBRILINTA ORAL TABLETfluoxetine hcl oral solutioncilostazol oral tabletfluoxetine hcl oral tabletclopidogrel bisulfate oral tabletfluvoxamine maleate er oral capsule extendedrelease 24 hourdipyridamole oral tabletNotesfluvoxamine maleate oral tabletDURLAZA ORAL CAPSULE EXTENDED RELEASE 24HOURimipramine HClEFFIENT ORAL TABLETimipramine pamoateprasugrel hcl oral tabletmaprotilineZONTIVITY ORAL TABLETmirtazapineAntipsychotics - Drugs for Mood DisordersnortriptylineABILIFY MAINTENA INTRAMUSCULAR PREFILLEDSYRINGE ABILIFY MAINTENA INTRAMUSCULARSUSPENSION RECONSTITUTED ER olanzapine-fluoxetine hcl oral capsuleparoxetine hcl er oral tablet extended release24 hourABILIFY MYCITE MAINTENANCE KIT ORAL TABLETparoxetine hcl oral tabletABILIFY MYCITE ORAL TABLETPAXIL ORAL SUSPENSIONABILIFY MYCITE STARTER KIT ORAL TABLETPEXEVA ORAL TABLETphenelzineADASUVE INHALATION AEROSOL POWDERBREATH ACTIVATEDprotriptylinearipiprazole oral solutionsertraline hcl oral concentratearipiprazole oral tabletsertraline hcl oral tabletaripiprazole oral tablet dispersibleSYMBYAX ORAL CAPSULE tranylcypromineARISTADA INITIO INTRAMUSCULAR PREFILLEDSYRINGEtrazodoneARISTADA INTRAMUSCULAR PREFILLED SYRINGE trimipramineasenapine maleate sublingual tablet sublingualvenlafaxineCAPLYTA ORAL CAPSULEvenlafaxine erchlorpromazine hcl oral concentrateAntineoplastics - Drugs for Cancerchlorpromazine hcl oral tabletanastrozole oral tabletclozapine oral tabletAROMASIN ORAL TABLETclozapine oral tablet dispersibleexemestane oral tabletCLOZARIL ORAL TABLETFARESTON ORAL TABLETFANAPT ORAL TABLETFEMARA ORAL TABLETFANAPT TITRATION PACK ORAL TABLETletrozole oral tabletfluphenazine hcl oral concentrateSOLTAMOX ORAL SOLUTIONfluphenazine hcl oral elixirtamoxifen citrate oral tabletfluphenazine hcl oral tablettoremifene citrate oral tabletBrand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.4
Drug NameNotesDrug NameGEODON INTRAMUSCULAR SOLUTIONRECONSTITUTED ZYPREXA ZYDIS ORAL TABLET DISPERSIBLEAntiviralsGEODON ORAL CAPSULEabacavir sulfate oral solutionhaloperidol lactate oral concentrateabacavir sulfate oral tablethaloperidol oral tabletabacavir sulfate-lamivudine oral tabletINVEGA ORAL TABLET EXTENDED RELEASE 24HOURabacavir-lamivudine-zidovudine oral tabletINVEGA SUSTENNA INTRAMUSCULARSUSPENSION PREFILLED SYRINGE INVEGA TRINZA INTRAMUSCULAR SUSPENSIONPREFILLED SYRINGE APTIVUS ORAL CAPSULEatazanavir sulfate oral capsuleBIKTARVY ORAL TABLETCIMDUO ORAL TABLETLATUDA ORAL TABLETCOMBIVIR ORAL TABLETloxapine succinate oral capsuleCOMPLERA ORAL TABLETmolindone hcl oral tabletCRIXIVAN ORAL CAPSULENUPLAZID ORAL CAPSULEDELSTRIGO ORAL TABLETNUPLAZID ORAL TABLETDOVATO ORAL TABLETolanzapine intramuscular solution reconstituted EDURANT ORAL TABLETolanzapine oral tabletefavirenz oral capsuleolanzapine oral tablet dispersibleefavirenz oral tabletpaliperidone er oral tablet extended release 24hourefavirenz-emtricitab-tenofovir oral tabletPERSERIS SUBCUTANEOUS PREFILLED SYRINGEefavirenz-lamivudine-tenofovir oral tablet emtricitabine oral capsulequetiapine fumarate er oral tablet extendedrelease 24 houremtricitabine-tenofovir df oral tabletEMTRIVA ORAL CAPSULEquetiapine fumarate oral tabletEMTRIVA ORAL SOLUTIONREXULTI ORAL TABLETRISPERDAL CONSTA INTRAMUSCULARSUSPENSION RECONSTITUTED EREPIVIR ORAL SOLUTION EPIVIR ORAL TABLETrisperidone oral solutionEPZICOM ORAL TABLETrisperidone oral tabletetravirine oral tabletrisperidone oral tablet dispersibleEVOTAZ ORAL TABLETthioridazine hcl oral tabletfosamprenavir calcium oral tabletthiothixene oral capsuleFUZEON SUBCUTANEOUS SOLUTIONRECONSTITUTEDtrifluoperazine hcl oral tabletGENVOYA ORAL TABLETVERSACLOZ ORAL SUSPENSIONINTELENCE ORAL TABLET 100 MG, 200 MGVRAYLAR ORAL CAPSULEINTELENCE ORAL TABLET 25 MGVRAYLAR ORAL CAPSULE THERAPY PACKINVIRASE ORAL TABLETziprasidone hcl oral capsuleziprasidone mesylate intramuscular solutionreconstituted ZYPREXA RELPREVV INTRAMUSCULARSUSPENSION RECONSTITUTED ISENTRESS HD ORAL TABLETISENTRESS ORAL PACKETISENTRESS ORAL TABLETBrand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.5Notes
Drug NameNotesDrug NameISENTRESS ORAL TABLET CHEWABLETIVICAY ORAL TABLETJULUCA ORAL TABLETTIVICAY PD ORAL TABLET SOLUBLEKALETRA ORAL SOLUTIONTRIUMEQ ORAL TABLETKALETRA ORAL TABLETTRIZIVIR ORAL TABLETlamivudine oral solutionTYBOST ORAL TABLETlamivudine oral tablet 150 mg, 300 mgVIRACEPT ORAL TABLETlamivudine-zidovudine oral tabletVIRAMUNE ORAL SUSPENSION 50 MG/5MLLEXIVA ORAL SUSPENSIONLEXIVA ORAL TABLETVIRAMUNE XR ORAL TABLET EXTENDED RELEASE24 HOURlopinavir-ritonavir oral solutionVIREAD ORAL POWDERlopinavir-ritonavir oral tabletVIREAD ORAL TABLET 150 MG, 200 MG, 250 MGnevirapine er oral tablet extended release 24 hourVIREAD ORAL TABLET 300 MGnevirapine oral suspensionZIAGEN ORAL SOLUTIONnevirapine oral tabletZIAGEN ORAL TABLETNORVIR ORAL PACKETzidovudine oral capsuleNORVIR ORAL SOLUTIONzidovudine oral syrupNORVIR ORAL TABLETzidovudine oral tabletODEFSEY ORAL TABLETCardiovascular Agents - Drugs for Heart andCirculation ConditionsPIFELTRO ORAL TABLETACCUPRIL ORAL TABLETPREZCOBIX ORAL TABLETACCURETIC ORAL TABLETPREZISTA ORAL SUSPENSIONacebutolol hcl oral capsulePREZISTA ORAL TABLETALDACTAZIDE ORAL TABLETRETROVIR ORAL CAPSULEALDACTONE ORAL TABLETRETROVIR ORAL SYRUPaliskiren fumarate oral tabletREYATAZ ORAL CAPSULEREYATAZ ORAL PACKETALTOPREV ORAL TABLET EXTENDED RELEASE 24HOURritonavir oral tabletamiloride hcl oral tabletRUKOBIA ORAL TABLET EXTENDED RELEASE 12HOURamiloride-hydrochlorothiazide oral tabletSELZENTRY ORAL SOLUTIONAMLODIPINE BES SYRSPEND SF ORALSUSPENSIONSELZENTRY ORAL TABLETamlodipine besylate oral tabletstavudine oral capsuleamlodipine besylate-benazepril hcl oral capsuleSTRIBILD ORAL TABLETamlodipine besylate-valsartan oral tabletSUSTIVA ORAL CAPSULEamlodipine-atorvastatin oral tabletSUSTIVA ORAL TABLETamlodipine-olmesartan oral tabletSYMFI LO ORAL TABLETamlodipine-valsartan-hctz oral tabletSYMFI ORAL TABLETANTARA ORAL CAPSULESYMTUZA ORAL TABLETATACAND HCT ORAL TABLETtenofovir disoproxil fumarate oral tabletatenolol oral tabletBrand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.6Notes
Drug NameNotesDrug NameATENOLOL SYRSPEND SF ORAL SUSPENSIONcolestipol hcl oral packetatenolol-chlorthalidone oral tabletcolestipol hcl oral tabletatorvastatin calcium oral tabletCORGARD ORAL TABLETAVALIDE ORAL TABLETDEMSER ORAL CAPSULEbenazepril hcl oral tabletDIBENZYLINE ORAL CAPSULEbenazepril-hydrochlorothiazide oral tabletdigitek oral tabletBETAPACE AF ORAL TABLETdigox oral tabletBETAPACE ORAL TABLETdigoxin oral solutionbetaxolol hcl oral tabletdigoxin oral tabletBIDIL ORAL TABLETDILATRATE-SR ORAL CAPSULE EXTENDEDRELEASE 40 MGbisoprolol fumarate oral tabletdiltiazem hcl er beads oral capsule extendedrelease 24 hourbisoprolol-hydrochlorothiazide oral tabletbumetanide oral tabletdiltiazem hcl er coated beads oral capsuleextended release 24 hourBUMEX ORAL TABLETCADUET ORAL TABLETdiltiazem hcl er coated beads oral tablet extendedrelease 24 hourCALAN SR ORAL TABLET EXTENDED RELEASEdiltiazem hcl er oral capsule extended release 12hourcandesartan cilexetil oral tabletcandesartan cilexetil-hctz oral tabletdiltiazem hcl er oral capsule extended release 24hourcaptopril oral tabletCARDIZEM CD ORAL CAPSULE EXTENDEDRELEASE 24 HOURdiltiazem hcl oral tabletdilt-xr oral capsule extended release 24 hourCARDIZEM LA ORAL TABLET EXTENDED RELEASE24 HOUR 120 MGDIURIL ORAL SUSPENSIONCARDIZEM ORAL TABLETdoxazosin mesylate oral tabletCARDURA ORAL TABLETDUTOPROL ORAL TABLET EXTENDED RELEASE 24HOURCAROSPIR ORAL SUSPENSIONDYRENIUM ORAL CAPSULEcartia xt oral capsule extended release 24 hourEDARBI ORAL TABLETcarvedilol oral tabletEDARBYCLOR ORAL TABLETcarvedilol phosphate er oral capsule extendedrelease 24 hourEDECRIN ORAL TABLETchlorthalidone oral tabletenalapril maleate oral tabletcholestyramine light oral packetenalapril-hydrochlorothiazide oral tabletcholestyramine light oral powderEPANED ORAL SOLUTIONcholestyramine oral packeteplerenone oral tabletcholestyramine oral powderethacrynic acid oral tabletclonidine hcl oral tabletEZALLOR SPRINKLE ORAL CAPSULE SPRINKLEclonidine transdermal patch weeklyezetimibe oral tabletcolesevelam hcl oral packetezetimibe-simvastatin oral tabletcolesevelam hcl oral tabletfelodipine er oral tablet extended release 24 hourcolestipol hcl oral granulesfenofibrate micronized oral capsuleBrand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.7Notes
Drug NameNotesDrug Namefenofibrate oral capsulelosartan potassium oral tabletfenofibrate oral tabletlosartan potassium-hctz oral tabletfenofibric acid oral capsule delayed releaseLOTENSIN HCT ORAL TABLETfenofibric acid oral tabletLOTENSIN ORAL TABLETFENOGLIDE ORAL TABLETlovastatin oral tabletFIBRICOR ORAL TABLETmatzim la oral tablet extended release 24 hourFLOLIPID ORAL SUSPENSIONMAXZIDE ORAL TABLETfluvastatin sodium er oral tablet extended release24 hourMAXZIDE-25 ORAL TABLETfluvastatin sodium oral capsulemetolazone oral tabletfosinopril sodium oral tabletfosinopril sodium-hctz oral tabletmetoprolol succinate er oral tablet extendedrelease 24 hourfurosemide oral solutionmetoprolol tartrate oral tabletfurosemide oral tabletmetoprolol-hydrochlorothiazide oral tabletgemfibrozil oral tabletmetyrosine oral capsuleGONITRO SUBLINGUAL PACKETMINIPRESS ORAL CAPSULEguanfacine hcl oral tabletHEMANGEOL ORAL SOLUTIONminitran transdermal patch 24 hour 0.1 mg/hr,0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hrhydralazine hcl oral tabletminoxidil oral tablethydrochlorothiazide oral capsulemoexipril hcl oral tablethydrochlorothiazide oral tabletnadolol oral tableticosapent ethyl oral capsuleNEXLETOL ORAL TABLETindapamide oral tabletNEXLIZET ORAL TABLETINSPRA ORAL TABLETniacin (antihyperlipidemic) oral tabletirbesartan oral tabletniacin er (antihyperlipidemic) oral tablet extendedreleasemethyldopa oral tabletirbesartan-hydrochlorothiazide oral tabletniacor oral tabletISORDIL TITRADOSE ORAL TABLETnicardipine hcl oral capsuleisosorbide dinitrate oral tabletnifedipine er oral tablet extended release 24 hourisosorbide mononitrate er oral tablet extendedrelease 24 hournifedipine er osmotic release oral tablet extendedrelease 24 hourisosorbide mononitrate oral tabletnifedipine oral capsuleisradipine oral capsuleJUXTAPID ORAL CAPSULEnimodipine oral capsuleSPnisoldipine er oral tablet extended release 24 hourlabetalol hcl oral tabletNITRO-BID TRANSDERMAL OINTMENTLANOXIN ORAL TABLETNITRO-DUR TRANSDERMAL PATCH 24 HOURLIPOFEN ORAL CAPSULEnitroglycerin sublingual tablet sublinguallisinopril oral tabletnitroglycerin transdermal patch 24 hourlisinopril-hydrochlorothiazide oral tabletnitroglycerin translingual solutionLOPID ORAL TABLETNITROLINGUAL TRANSLINGUAL SOLUTIONLOPRESSOR ORAL TABLETBrand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.8Notes
Drug NameNotesDrug NameNITROMIST TRANSLINGUAL AEROSOL SOLUTIONspironolactone oral tabletNITRO-TIME ORAL CAPSULE EXTENDED RELEASEspironolactone-hctz oral tabletNYMALIZE ORAL SOLUTIONolmesartan medoxomil oral tabletSULAR ORAL TABLET EXTENDED RELEASE 24HOURolmesartan medoxomil-hctz oral tabletSURE RESULT O3D3 SYSTEM ORAL KITolmesartan-amlodipine-hctz oral tabletTARKA ORAL TABLET EXTENDED RELEASE 2-240MGOMEGA-3 RX COMPLETE ORAL THERAPY PACKtaztia xt oral capsule extended release 24 houromega-3-acid ethyl esters oral capsuleTEKTURNA HCT ORAL TABLETperindopril erbumine oral tabletTEKTURNA ORAL TABLETphenoxybenzamine hcl oral capsuletelmisartan oral tabletpindolol oral tablettelmisartan-amlodipine oral tabletpravastatin sodium oral tablettelmisartan-hctz oral tabletprazosin hcl oral capsuleTENORETIC 100 ORAL TABLETPRESTALIA ORAL TABLETTENORETIC 50 ORAL TABLETprevalite oral packettiadylt er oral capsule extended release 24 hourprevalite oral powderTIAZAC ORAL CAPSULE EXTENDED RELEASE 24HOURPROCARDIA XL ORAL TABLET EXTENDED RELEASE24 HOURtimolol maleate oral tabletpropranolol hcl er oral capsule extended release24 hourtorsemide oral tabletpropranolol hcl oral solutiontrandolapril oral tabletpropranolol hcl oral tablettrandolapril-verapamil hcl er oral tablet extendedreleaseQBRELIS ORAL SOLUTIONtriamterene oral capsulequinapril hcl oral tablettriamterene-hctz oral capsulequinapril-hydrochlorothiazide oral tablettriamterene-hctz oral tabletramipril oral capsuleTRILIPIX ORAL CAPSULE DELAYED RELEASEranolazine er oral tablet extended release 12 hourREPATHA PUSHTRONEX SYSTEM SUBCUTANEOUSSOLUTION CARTRIDGESPREPATHA SUBCUTANEOUS SOLUTION PREFILLEDSYRINGESPREPATHA SURECLICK SUBCUTANEOUS SOLUTIONAUTO- INJECTORSPTWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 8010 MG, 80-5 MGvalsartan oral tabletvalsartan-hydrochlorothiazide oral tabletVASCEPA ORAL CAPSULEVASERETIC ORAL TABLETrosuvastatin calcium oral tabletVASOTEC ORAL TABLETROSZET ORAL TABLETVECAMYL ORAL TABLETsimvastatin oral tabletsorine oral tabletverapamil hcl er oral capsule extended release 24hoursotalol hcl (af) oral tabletverapamil hcl er oral tablet extended releasesotalol hcl oral tabletverapamil hcl oral tabletSOTYLIZE ORAL SOLUTIONVERELAN ORAL CAPSULE EXTENDED RELEASE 24HOURBrand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.9Notes
Drug NameNotesDrug NameVERELAN PM ORAL CAPSULE EXTENDED RELEASE24 HOURNotesnateglinide oral tabletZESTORETIC ORAL TABLETOZEMPIC SUBCUTANEOUS SOLUTION PENINJECTORZIAC ORAL TABLETpioglitazone hcl oral tabletDiabetes - Antidiabetic Agentspioglitazone hcl-glimepiride oral tabletacarbose oral tabletpioglitazone hcl-metformin hcl oral tabletACTOPLUS MET ORAL TABLETPRECOSE ORAL TABLETACTOS ORAL TABLETrepaglinide oral tabletAMARYL ORAL TABLETRIOMET ORAL SOLUTIONBYDUREON BCISE AUTOINJECTORSUBCUTANEOUS AUTO- INJECTORRYBELSUS ORAL TABLETBYETTA 10 MCG PENSOLIQUA SUBCUTANEOUS SOLUTION PENINJECTORBYETTA 5 MCG PENSYMLINPEN 120CYCLOSET ORAL TABLETSYMLINPEN 60DUETACT ORAL TABLETSYNJARDY ORAL TABLETFARXIGA ORAL TABLETglimepiride oral tabletSYNJARDY XR ORAL TABLET EXTENDED RELEASE24 HOURglipizide er oral tablet extended release 24 hourtolbutamide oral tablet 500 mgglipizide oral tabletTRADJENTA ORAL TABLETglipizide xl oral tablet extended release 24 hourTRIJARDY XR ORAL TABLET EXTENDED RELEASE24 HOURglipizide-metformin hcl oral tabletTRULICITY SUBCUTANEOUS SOLUTION PENINJECTORGLUCOTROL XL ORAL TABLET EXTENDEDRELEASE 24 HOURVICTOZAglyburide micronized oral tabletXIGDUO XR ORAL TABLET EXTENDED RELEASE 24HOURglyburide oral tabletglyburide-metformin oral tabletGLYNASE ORAL TABLETXULTOPHY SUBCUTANEOUS SOLUTION PENINJECTORGLYXAMBI ORAL TABLETDiabetes - InsulinsJANUMET ORAL TABLETAFREZZA INHALATION POWDER JANUMET XR ORAL TABLET EXTENDED RELEASE24 HOURHUMALOG KWIKPEN SUBCUTANEOUS SOLUTIONPEN- INJECTOR JANUVIA ORAL TABLETHUMALOG MIX 50/50 KWIKPEN JARDIANCE ORAL TABLETHUMALOG MIX 50/50 VIAL SUBCUTANEOUSSUSPENSION HUMALOG MIX 75/25 KWIKPEN HUMALOG MIX 75/25 VIAL SUBCUTANEOUSSUSPENSION HUMALOG SUBCUTANEOUS SOLUTION HUMALOG SUBCUTANEOUS SOLUTIONCARTRIDGE JENTADUETO ORAL TABLETJENTADUETO XR ORAL TABLET EXTENDEDRELEASE 24 HOURmetformin hcl er oral tablet extended release 24hourmetformin hcl oral solutionmetformin hcl oral tabletmiglitol oral tabletBrand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.10
Drug NameNotesDrug NameNotesHUMALOG U-100 JUNIOR KWIKPENSUBCUTANEOUS SOLUTION PEN-INJECTOR kosher prenatal plus iron oral tablet M-NATAL PLUS ORAL TABLET HUMULIN 70/30 KWIKPEN multi-vitamin/fluoride oral solution HUMULIN 70/30 VIAL SUBCUTANEOUSSUSPENSION multivitamin/fluoride oral tablet chewable HUMULIN N KWIKPEN multi-vitamin/fluoride/iron oral solution HUMULIN N VIAL SUBCUTANEOUS SUSPENSION MYNATAL ORAL CAPSULE HUMULIN R U-500 KWIKPEN MYNATAL PLUS ORAL TABLET HUMULIN R U-500 VIAL SUBCUTANEOUSSOLUTION MYNATAL-Z ORAL TABLET NATALVIT ORAL TABLET HUMULIN R VIAL INJECTION SOLUTION NEONATAL 19 ORAL TABLET LANTUS U-100 SOLOSTAR NEONATAL COMPLETE ORAL TABLET 27-1 MG LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION NEONATAL PLUS ORAL TABLET LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTIONPEN- INJECTOR NESTABS ORAL TABLET NIVA-PLUS ORAL TABLET LYUMJEV VIAL INJECTION SOLUTION OB COMPLETE ORAL TABLET TOUJEO MAX SOLOSTAR SUBCUTANEOUSSOLUTION PEN- INJECTOR OB COMPLETE/DHA ORAL CAPSULE TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTIONPEN- INJECTOR OBSTETRIX DHA ORAL OBSTETRIX EC ORAL TABLET OBSTETRIX ONE ORAL CAPSULE O-CAL PRENATAL ORAL TABLET ONE VITE WOMENS PLUS ORAL TABLET Electrolytes / Minerals / Metals / Vitaminsadc/f (0.5mg/ml) oral solution ATABEX EC ORAL TABLET DELAYED RELEASE ATABEX OB ORAL TABLET CITRANATAL B-CALM ORAL CITRANATAL BLOOM DHA ORAL CITRANATAL MEDLEY ORAL CAPSULE CITRANATAL RX ORAL TABLET C-NATE DHA ORAL CAPSULE COMPLETE NATAL DHA ORAL 29-1-200 & 250MG COMPLETENATE ORAL TABLET CHEWABLEONEVITE ORAL TABLETpnv tabs 29-1 oral tablet pnv-dha oral capsule pnv-dha docusate oral capsule pnv-omega oral capsule pnv-select oral tablet POLY-VI-FLOR ORAL SUSPENSION POLY-VI-FLOR ORAL TABLET CHEWABLE POLY-VI-FLOR/IRON ORAL SUSPENSION CO-NATAL FA ORAL TABLET POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE CONCEPT DHA ORAL CAPSULE PREMESISRX ORAL TABLET CONCEPT OB ORAL CAPSULE PRENA 1 TRUE ORAL ELITE-OB ORAL TABLET PRENA1 ORAL TABLET CHEWABLE FLORIVA ORAL LIQUID FLORIVA ORAL TABLET CHEWABLE PRENA1 PEARL ORAL CAPSULE EXTENDEDRELEASEFLORIVA PLUS ORAL SOLUTION PRENAISSANCE ORAL CAPSULE FOLIVANE-OB ORAL CAPSULE 130-92.4-1 MG PRENAISSANCE PLUS ORAL CAPSULE INATAL GT ORAL TABLET PRENATABS RX ORAL TABLET Brand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.11
Drug NameNotesDrug NameNotesprenatal 19 oral tablet 29-1 mg virt-pn plus oral capsule prenatal 19 oral tablet chewable VITAFOL STRIPS ORAL FILM prenatal oral tablet 27-1 mg vitamins acd-fluoride oral solution prenatal plus iron oral tablet VIVA DHA ORAL CAPSULE prenatal vitamin plus low iron oral tablet vp-pnv-dha oral capsule PRENATAL-U ORAL CAPSULE WESTAB PLUS ORAL TABLET PRENATE AM ORAL TABLET ZATEAN-PN DHA ORAL CAPSULE PRENATVITE PLUS ORAL TABLET ZATEAN-PN PLUS ORAL CAPSULE PRENATVITE RX ORAL TABLET preplus oral tablet Gastrointestinal Agents - Drugs for Acid Refluxand UlcerPRETAB ORAL TABLET ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLEPROVIDA OB ORAL CAPSULE CARAFATE ORAL SUSPENSIONQUFLORA FE PEDIATRIC ORAL LIQUID cimetidine hcl oral solution QUFLORA GUMMIES ORAL TABLET CHEWABLE cimetidine oral tablet QUFLORA PEDIATRIC ORAL SOLUTION CYTOTEC ORAL TABLETQUFLORA PEDIATRIC ORAL TABLET CHEWABLE DEXILANT ORAL CAPSULE DELAYED RELEASE RELNATE DHA ORAL CAPSULE SELECT-OB ORAL TABLET CHEWABLE 29-1 MG esomeprazole magnesium oral capsule delayedreleaseSE-NATAL 19 ORAL TABLET esomeprazole magnesium oral packet SE-NATAL 19 ORAL TABLET CHEWABLE ESOMEPRAZOLE STRONTIUM ORAL CAPSULEDELAYED RELEASE TARON-C DHA ORAL CAPSULE 53.5-38-1 MG famotidine oral suspension reconstituted TARON-PREX ORAL CAPSULE famotidine oral tablet 40 mg famotidine tablet 20 mg oral (rx) THRIVITE 19 ORAL TABLET THRIVITE RX ORAL TABLET FIRST-LANSOPRAZOLE ORAL SUSPENSION TRICARE ORAL TABLET FIRST-OMEPRAZOLE ORAL SUSPENSION TRICARE PRENATAL DHA ONE ORAL CAPSULE lansoprazole oral capsule delayed release TRINATAL RX 1 ORAL TABLET lansoprazole oral tablet delayed release dispersible TRINATE ORAL TABLET misoprostol oral tabletTRIVEEN-DUO DHA ORAL 29-1-200 & 400 MG NEXIUM ORAL PACKET TRI-VI-FLOR ORAL SUSPENSION nizatidine oral capsule TRI-VI-FLORO ORAL SUSPENSION nizatidine oral solution tri-vite/fluoride oral solution omeprazole oral capsule delayed release VINATE DHA RF ORAL CAPSULE OMEPRAZOLE SYRSPEND SF ALKA ORALSUSPENSIONVINATE II ORAL TABLET pantoprazole sodium oral packet VINATE ONE ORAL TABLET pantoprazole sodium oral tablet delayed releasevirt-c dha oral capsule PEPCID ORAL TABLET virt-nate dha oral capsule PRILOSEC ORAL PACKET virt-pn dha oral capsule PROTONIX ORAL PACKET UDAMIN SP ORAL TABLETBrand-name medications are shown in UPPERCASE (for example, CELEXA) and generic medications in lowercase (for example, citalopram). : Refer to benefit plan documents to make sure listed medication is included in your benefit.SP: Oral and self-injectable Specialty medications may have limitations based on your plan benefit.12
Drug NameNotesDrug Namerabeprazole sodium oral tablet delayed release ESTROGEL TRANSDERMAL GELsucralfate oral suspensionEVAMIST TRANSDERMAL SOLUTIONsucralfate oral tabletFEMHRT ORAL TABLETGastrointestinal Agents - Drugs for Bowel, Intestineand Stomach Conditionsfyavolv oral tabletamoxicill-clarithro-lansopraz orallyllana transdermal patch twice weeklyHELIDAC THERAPY ORALMENEST ORAL TABLETOMECLAMOX-PAK ORALMENOSTAR TRANSDERMAL PATCH WEEKLYPYLERA ORAL CAPSULEmimvey oral tabletTALICIA ORAL CAPSULE DELAYED RELEASEMINIVELLE TRANSDERMAL PATCH TWICE WEEKLYHormonal Agents - Selective Estrogen ReceptorModifying AgentsMYFEMBREE ORAL TABLETNotesjinteli oral tabletnorethindrone-eth estradiol oral tabletEVISTA ORAL TABLETORIAHNN ORAL CAPSULE THERAPY PACKOSPHENA ORAL TABLET
DIURIL ORAL SUSPENSION doxazosin mesylate oral tablet DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR DYRENIUM ORAL CAPSULE EDARBI ORAL TABLET EDARBYCLOR ORAL TABLET . cholestyramine oral powder clonidine hcl oral tablet clonidine transdermal patch weekly colesevelam hcl oral packet
Kaiser Permanente LLNL-PRES-xxxxxx 8 High Deductible Health Plan (HDHP) Must live in plan's service area - Californiaonly-No out-of-network coverage (except emergency) Deductible- 1,500individual- 3,000family - must meet cumulative family deductible-After deductible you pay10% Pharmacy-Until deductible is met you pay 100% of drug cost-
Deductible plus 20% coinsurance Deductible plus 20% coinsurance Must meet emergency criteria. Urgent care 50 copay/visit Deductible plus 50% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) Deductible plus 20% coinsurance Deductible plus 50% coinsurance Prior Authorization is required. Physician/surgeon fees
Health Savings are our only quali#ed high-deductible health plans that o"er the tax and savings advantages of Health Savings Accounts (HSA). You pay all costs until your deductible is met. Then you pay a percentage of costs until you meet your out-of-pocket max. This Health Savings Plan is a Quali#ed High Deductible Health Plan that may be coupled
Office Visit 10% after deductible 30% after deductible Emergency Room 150/visit 10% In patient services 10% 30% Outpatient services (surgery, x-rays, blood work) 10% 30% Prescription Drugs Tier Level (After Deductible) Retail (Up to 30-day supply) MailOrder (up to 90-day supply) Rx Deductible 0 Tier 1
500 deductible per auto/unlimited per occurrence 1,000 deductible per auto/unlimited per occurrence 2,500 deductible per auto/unlimited per occurrence 5,000 deductible per auto/unlimited per occurrence Exclude Windstorm Hurricane Hail Exclude Flood 33. List all Business Loca
VSC-01D-SPM-EDS-2012 (rev. 2/15) Page 3 of 11 DEDUCTIBLE: In the event of a Breakdown of any Covered Part(s) listed below, You may be required to pay a Deductible.No Deductible payment is required with respect to Coverage listed in the Additional Benefits of Coverage Section of this Contract.The Deductible type and amou
NO CLAIMS WILL BE PAID WITHOUT PRIOR AUTHORIZATION CLAIMS: 877-414-0134 Page 3 of 16 VMCDR _01/20 Deductible - Means the amount You are required to pay as selected on the Application Page per Covered Repair.No Deductible payment is required with respect to Additional Benefits.If no Deductible is stated on the Application Page, the standard Deductible will be one hundred ( 100)
Before you go, here is a bit of history of 한글 (Hangeul, the Korean alphabet): Korean is the official language of Korea, both North and South. There are around 78 million people who speak Korean around the world. [1] 한글 (the Korean alphabet) was invented by Sejong the Great in the 15th century. Before that time, people
