OptumRx 2022 Preventive Medications And Your Plan
2022 Preventive medications and your plan Effective July 1, 2022 Managing your health with preventive medications Your 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 pay your 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’s website on your member ID card, or log on to the Optum Rx app. Potential savings with generic medications To get the most from your benefits, ask your doctor if a generic medication is 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. A list of covered preventive medications begins on the next page. Medications are listed by therapeutic category. Where differences are noted between this list and your benefit plan documents, the benefit plan documents will rule. For questions on injectable preventive medications administered by your doctor or healthcare provider, please call the number on your ID card. This list should be used as a reference and may not include all medications. Using generics may be required based on your plan benefit.
Preventive Premium Drug List Table of Contents ANTI-ADDICTION / SUBSTANCE ABUSE TREATMENT AGENTS. 3 GASTROINTESTINAL AGENTS - DRUGS FOR ACID REFLUX AND ULCER. 12 ANTICOAGULANTS. 3 GASTROINTESTINAL AGENTS - DRUGS FOR BOWEL, INTESTINE AND STOMACH CONDITIONS. 13 ANTIDEPRESSANTS. 3 ANTINEOPLASTICS - DRUGS FOR CANCER. 4 HORMONAL AGENTS - SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS. 13 ANTIPLATELETS. 4 ANTIPSYCHOTICS - DRUGS FOR MOOD DISORDERS. 4 HORMONAL AGENTS - SEX HORMONES AND BIRTH CONTROL. 13 ANTIVIRALS. 5 IMMUNOLOGICAL AGENTS - DRUGS FOR IMMUNE SYSTEM STIMULATION OR SUPPRESSION. 17 BIPOLAR AGENTS - DRUGS FOR MOOD DISORDERS. 6 METABOLIC BONE DISEASE AGENTS DRUGS FOR OSTEOPOROSIS. 17 CARDIOVASCULAR AGENTS - DRUGS FOR HEART AND CIRCULATION CONDITIONS. 6 MISCELLANEOUS THERAPEUTIC AGENTS. 18 DIABETES - ANTIDIABETIC AGENTS. 10 RESPIRATORY TRACT / PULMONARY AGENTS - DRUGS FOR ASTHMA AND OTHER LUNG CONDITIONS. 18 DIABETES - GLUCOSE MONITORING. 11 DIABETES - INSULINS. 11 ELECTROLYTES / MINERALS / METALS / VITAMINS. 11 2
Drug Name Drug Name ANTI-ADDICTION / SUBSTANCE ABUSE TREATMENT AGENTS bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg APO-VARENICLINE ORAL TABLET bupropion hcl oral tablet bupropion hcl er (smoking det) oral tablet extended release 12 hour citalopram hydrobromide oral solution nicotine gum/patch/lozenge DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR citalopram hydrobromide oral tablet NICOTROL INHALATION INHALER NICOTROL NS NASAL SOLUTION desvenlafaxine succinate er oral tablet extended release 24 hour varenicline tartrate oral tablet DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE SPRINKLE ANTICOAGULANTS ARIXTRA SUBCUTANEOUS SOLUTION duloxetine hcl oral capsule delayed release particles ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK escitalopram oxalate oral solution ELIQUIS ORAL TABLET escitalopram oxalate oral tablet enoxaparin sodium injection solution FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR enoxaparin sodium subcutaneous solution fondaparinux sodium subcutaneous solution FRAGMIN SUBCUTANEOUS SOLUTION FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK heparin sodium (porcine) injection solution fluoxetine hcl oral capsule heparin sodium (porcine) injection solution prefilled syringe fluoxetine hcl oral capsule delayed release heparin sodium (porcine) pf injection solution fluoxetine hcl oral tablet fluoxetine hcl oral solution fluvoxamine maleate er oral capsule extended release 24 hour jantoven oral tablet LOVENOX INJECTION SOLUTION fluvoxamine maleate oral tablet LOVENOX SUBCUTANEOUS SOLUTION mirtazapine oral tablet PRADAXA ORAL CAPSULE mirtazapine oral tablet dispersible SAVAYSA ORAL TABLET olanzapine-fluoxetine hcl oral capsule warfarin sodium oral tablet paroxetine hcl er oral tablet extended release 24 hour XARELTO ORAL SUSPENSION RECONSTITUTED paroxetine hcl oral suspension XARELTO ORAL TABLET paroxetine hcl oral tablet XARELTO STARTER PACK ORAL TABLET THERAPY PACK PAXIL ORAL SUSPENSION PEXEVA ORAL TABLET ANTIDEPRESSANTS REMERON ORAL TABLET APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR REMERON SOLTAB ORAL TABLET DISPERSIBLE bupropion hcl er (sr) oral tablet extended release 12 hour SERTRALINE HCL ORAL CAPSULE 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 3
Drug Name Drug Name sertraline hcl oral concentrate ABILIFY MYCITE STARTER KIT ORAL TABLET sertraline hcl oral tablet ADASUVE INHALATION AEROSOL POWDER BREATH ACTIVATED SYMBYAX ORAL CAPSULE venlafaxine hcl er oral capsule extended release 24 hour aripiprazole oral solution venlafaxine hcl er oral tablet extended release 24 hour aripiprazole oral tablet venlafaxine hcl oral tablet ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE aripiprazole oral tablet dispersible ANTINEOPLASTICS - DRUGS FOR CANCER ARISTADA INTRAMUSCULAR PREFILLED SYRINGE anastrozole oral tablet AROMASIN ORAL TABLET asenapine maleate sublingual tablet sublingual exemestane oral tablet CAPLYTA ORAL CAPSULE FARESTON ORAL TABLET chlorpromazine hcl oral concentrate FEMARA ORAL TABLET chlorpromazine hcl oral tablet letrozole oral tablet clozapine oral tablet SOLTAMOX ORAL SOLUTION clozapine oral tablet dispersible tamoxifen citrate oral tablet CLOZARIL ORAL TABLET toremifene citrate oral tablet FANAPT ORAL TABLET ANTIPLATELETS FANAPT TITRATION PACK ORAL TABLET aspirin-dipyridamole er oral capsule extended release 12 hour fluphenazine hcl oral concentrate fluphenazine hcl oral elixir BRILINTA ORAL TABLET fluphenazine hcl oral tablet cilostazol oral tablet GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED clopidogrel bisulfate oral tablet dipyridamole oral tablet GEODON ORAL CAPSULE DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR haloperidol lactate oral concentrate haloperidol oral tablet EFFIENT ORAL TABLET INVEGA HAFYERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE prasugrel hcl oral tablet ZONTIVITY ORAL TABLET INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR ANTIPSYCHOTICS - DRUGS FOR MOOD DISORDERS INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER LATUDA ORAL TABLET ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET loxapine succinate oral capsule molindone hcl oral tablet ABILIFY MYCITE 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 4
Drug Name Drug Name NUPLAZID ORAL CAPSULE atazanavir sulfate oral capsule NUPLAZID ORAL TABLET BIKTARVY ORAL TABLET olanzapine intramuscular solution reconstituted CIMDUO ORAL TABLET olanzapine oral tablet COMBIVIR ORAL TABLET olanzapine oral tablet dispersible COMPLERA ORAL TABLET paliperidone er oral tablet extended release 24 hour DELSTRIGO ORAL TABLET PERSERIS SUBCUTANEOUS PREFILLED SYRINGE EDURANT ORAL TABLET DOVATO ORAL TABLET efavirenz oral capsule quetiapine fumarate er oral tablet extended release 24 hour efavirenz oral tablet efavirenz-emtricitab-tenofovir oral tablet quetiapine fumarate oral tablet REXULTI ORAL TABLET efavirenz-lamivudine-tenofovir oral tablet RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER emtricitabine oral capsule emtricitabine-tenofovir df oral tablet risperidone oral solution EMTRIVA ORAL CAPSULE risperidone oral tablet EMTRIVA ORAL SOLUTION risperidone oral tablet dispersible EPIVIR ORAL SOLUTION thioridazine hcl oral tablet EPIVIR ORAL TABLET thiothixene oral capsule EPZICOM ORAL TABLET trifluoperazine hcl oral tablet etravirine oral tablet VERSACLOZ ORAL SUSPENSION EVOTAZ ORAL TABLET VRAYLAR ORAL CAPSULE fosamprenavir calcium oral tablet VRAYLAR ORAL CAPSULE THERAPY PACK ziprasidone hcl oral capsule FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED ziprasidone mesylate intramuscular solution reconstituted GENVOYA ORAL TABLET INTELENCE ORAL TABLET 100 MG, 200 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED INTELENCE ORAL TABLET 25 MG ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE ISENTRESS HD ORAL TABLET INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL PACKET ANTIVIRALS ISENTRESS ORAL TABLET abacavir sulfate oral solution ISENTRESS ORAL TABLET CHEWABLE abacavir sulfate oral tablet JULUCA ORAL TABLET abacavir sulfate-lamivudine oral tablet KALETRA ORAL SOLUTION abacavir-lamivudine-zidovudine oral tablet KALETRA ORAL TABLET APRETUDE INTRAMUSCULAR SUSPENSION EXTENDED RELEASE lamivudine oral solution lamivudine oral tablet 150 mg, 300 mg APTIVUS ORAL CAPSULE 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 5
Drug Name Drug Name lamivudine-zidovudine oral tablet TRIUMEQ ORAL TABLET LEXIVA ORAL SUSPENSION TRIZIVIR ORAL TABLET LEXIVA ORAL TABLET TYBOST ORAL TABLET lopinavir-ritonavir oral solution VIRACEPT ORAL TABLET lopinavir-ritonavir oral tablet VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR maraviroc oral tablet VIREAD ORAL POWDER nevirapine er oral tablet extended release 24 hour VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG nevirapine oral suspension VIREAD ORAL TABLET 300 MG nevirapine oral tablet ZIAGEN ORAL SOLUTION NORVIR ORAL PACKET ZIAGEN ORAL TABLET NORVIR ORAL SOLUTION zidovudine oral capsule NORVIR ORAL TABLET zidovudine oral syrup ODEFSEY ORAL TABLET zidovudine oral tablet PIFELTRO ORAL TABLET BIPOLAR AGENTS - DRUGS FOR MOOD DISORDERS PREZCOBIX ORAL TABLET PREZISTA ORAL SUSPENSION EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR PREZISTA ORAL TABLET RETROVIR ORAL CAPSULE RETROVIR ORAL SYRUP CARDIOVASCULAR AGENTS - DRUGS FOR HEART AND CIRCULATION CONDITIONS REYATAZ ORAL CAPSULE ACCUPRIL ORAL TABLET REYATAZ ORAL PACKET ACCURETIC ORAL TABLET ritonavir oral tablet acebutolol hcl oral capsule RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR ALDACTAZIDE ORAL TABLET SELZENTRY ORAL SOLUTION aliskiren fumarate oral tablet ALDACTONE ORAL TABLET SELZENTRY ORAL TABLET stavudine oral capsule ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR STRIBILD ORAL TABLET amiloride hcl oral tablet SUSTIVA ORAL CAPSULE amiloride-hydrochlorothiazide oral tablet SUSTIVA ORAL TABLET AMLODIPINE BES SYRSPEND SF ORAL SUSPENSION SYMFI LO ORAL TABLET amlodipine besylate oral tablet SYMFI ORAL TABLET amlodipine besylate-benazepril hcl oral capsule SYMTUZA ORAL TABLET tenofovir disoproxil fumarate oral tablet amlodipine besylate-valsartan oral tablet TIVICAY ORAL TABLET amlodipine-atorvastatin oral tablet TIVICAY PD ORAL TABLET SOLUBLE amlodipine-olmesartan 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 6
Drug Name Drug Name ANTARA ORAL CAPSULE cholestyramine oral packet ATACAND HCT ORAL TABLET cholestyramine oral powder atenolol oral tablet clonidine hcl oral tablet ATENOLOL SYRSPEND SF ORAL SUSPENSION clonidine transdermal patch weekly atenolol-chlorthalidone oral tablet colesevelam hcl oral tablet colesevelam hcl oral packet atorvastatin calcium oral tablet colestipol hcl oral granules AVALIDE ORAL TABLET colestipol hcl oral packet benazepril hcl oral tablet colestipol hcl oral tablet benazepril-hydrochlorothiazide oral tablet CORGARD ORAL TABLET BETAPACE AF ORAL TABLET DEMSER ORAL CAPSULE BETAPACE ORAL TABLET DIBENZYLINE ORAL CAPSULE betaxolol hcl oral tablet digitek oral tablet BIDIL ORAL TABLET digox oral tablet bisoprolol fumarate oral tablet digoxin oral solution bisoprolol-hydrochlorothiazide oral tablet digoxin oral tablet 125 mcg, 250 mcg bumetanide oral tablet diltiazem hcl er beads oral capsule extended release 24 hour BUMEX ORAL TABLET CADUET ORAL TABLET diltiazem hcl er coated beads oral capsule extended release 24 hour CALAN SR ORAL TABLET EXTENDED RELEASE diltiazem hcl er coated beads oral tablet extended release 24 hour candesartan cilexetil oral tablet diltiazem hcl er oral capsule extended release 12 hour candesartan cilexetil-hctz oral tablet captopril oral tablet diltiazem hcl er oral capsule extended release 24 hour CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR diltiazem hcl oral tablet CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG dilt-xr oral capsule extended release 24 hour DIURIL ORAL SUSPENSION CARDIZEM ORAL TABLET doxazosin mesylate oral tablet CARDURA ORAL TABLET DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR CAROSPIR ORAL SUSPENSION cartia xt oral capsule extended release 24 hour DYRENIUM ORAL CAPSULE carvedilol oral tablet EDARBI ORAL TABLET carvedilol phosphate er oral capsule extended release 24 hour EDARBYCLOR ORAL TABLET EDECRIN ORAL TABLET chlorthalidone oral tablet enalapril maleate oral solution cholestyramine light oral packet enalapril maleate oral tablet cholestyramine light oral powder 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 7
Drug Name Drug Name enalapril-hydrochlorothiazide oral tablet irbesartan oral tablet EPANED ORAL SOLUTION irbesartan-hydrochlorothiazide oral tablet eplerenone oral tablet ISORDIL TITRADOSE ORAL TABLET ethacrynic acid oral tablet isosorbide dinitrate oral tablet EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE isosorbide mononitrate er oral tablet extended release 24 hour ezetimibe oral tablet isosorbide mononitrate oral tablet ezetimibe-simvastatin oral tablet isradipine oral capsule felodipine er oral tablet extended release 24 hour JUXTAPID ORAL CAPSULE fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg LANOXIN ORAL TABLET labetalol hcl oral tablet LEQVIO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE FENOFIBRATE MICRONIZED ORAL CAPSULE 30 MG, 90 MG LIPOFEN ORAL CAPSULE fenofibrate oral capsule lisinopril oral tablet fenofibrate oral tablet lisinopril-hydrochlorothiazide oral tablet fenofibric acid oral capsule delayed release LOPID ORAL TABLET fenofibric acid oral tablet LOPRESSOR ORAL TABLET FENOGLIDE ORAL TABLET losartan potassium oral tablet FIBRICOR ORAL TABLET losartan potassium-hctz oral tablet FLOLIPID ORAL SUSPENSION LOTENSIN HCT ORAL TABLET fluvastatin sodium er oral tablet extended release 24 hour LOTENSIN ORAL TABLET lovastatin oral tablet fluvastatin sodium oral capsule matzim la oral tablet extended release 24 hour fosinopril sodium oral tablet fosinopril sodium-hctz oral tablet MAXZIDE ORAL TABLET furosemide oral solution MAXZIDE-25 ORAL TABLET furosemide oral tablet methyldopa oral tablet gemfibrozil oral tablet metolazone oral tablet GONITRO SUBLINGUAL PACKET metoprolol succinate er oral tablet extended release 24 hour guanfacine hcl oral tablet HEMANGEOL ORAL SOLUTION metoprolol tartrate oral tablet hydralazine hcl oral tablet metoprolol-hydrochlorothiazide oral tablet hydrochlorothiazide oral capsule metyrosine oral capsule hydrochlorothiazide oral tablet MINIPRESS ORAL CAPSULE icosapent ethyl oral capsule minoxidil oral tablet indapamide oral tablet moexipril hcl oral tablet INSPRA ORAL TABLET nadolol 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 8
Drug Name Drug Name nebivolol hcl oral tablet PRESTALIA ORAL TABLET NEXLETOL ORAL TABLET prevalite oral packet NEXLIZET ORAL TABLET prevalite oral powder niacin (antihyperlipidemic) oral tablet PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 HOUR niacin er (antihyperlipidemic) oral tablet extended release propranolol hcl er oral capsule extended release 24 hour niacor oral tablet nicardipine hcl oral capsule propranolol hcl oral solution nifedipine er oral tablet extended release 24 hour propranolol hcl oral tablet QBRELIS ORAL SOLUTION nifedipine er osmotic release oral tablet extended release 24 hour quinapril hcl oral tablet nifedipine oral capsule ramipril oral capsule quinapril-hydrochlorothiazide oral tablet nimodipine oral capsule ranolazine er oral tablet extended release 12 hour nisoldipine er oral tablet extended release 24 hour NITRO-BID TRANSDERMAL OINTMENT REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE NITRO-DUR TRANSDERMAL PATCH 24 HOUR REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE nitroglycerin sublingual tablet sublingual REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR nitroglycerin transdermal patch 24 hour rosuvastatin calcium oral tablet nitroglycerin translingual solution NITROLINGUAL TRANSLINGUAL SOLUTION simvastatin oral tablet NITROMIST TRANSLINGUAL AEROSOL SOLUTION sorine oral tablet sotalol hcl (af) oral tablet NITRO-TIME ORAL CAPSULE EXTENDED RELEASE sotalol hcl oral tablet NYMALIZE ORAL SOLUTION spironolactone oral tablet SOTYLIZE ORAL SOLUTION olmesartan medoxomil oral tablet spironolactone-hctz oral tablet olmesartan medoxomil-hctz oral tablet SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR olmesartan-amlodipine-hctz oral tablet OMEGA-3 RX COMPLETE ORAL THERAPY PACK SURE RESULT O3D3 SYSTEM ORAL KIT omega-3-acid ethyl esters oral capsule TEKTURNA HCT ORAL TABLET taztia xt oral capsule extended release 24 hour perindopril erbumine oral tablet TEKTURNA ORAL TABLET phenoxybenzamine hcl oral capsule telmisartan oral tablet pindolol oral tablet telmisartan-amlodipine oral tablet pravastatin sodium oral tablet telmisartan-hctz oral tablet prazosin hcl oral capsule TENORETIC 100 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 9
Drug Name Drug Name TENORETIC 50 ORAL TABLET BYETTA 10 MCG PEN THALITONE ORAL TABLET BYETTA 5 MCG PEN tiadylt er oral capsule extended release 24 hour CYCLOSET ORAL TABLET TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR FARXIGA ORAL TABLET DUETACT ORAL TABLET glimepiride oral tablet timolol maleate oral tablet glipizide er oral tablet extended release 24 hour torsemide oral tablet trandolapril oral tablet glipizide oral tablet trandolapril-verapamil hcl er oral tablet extended release glipizide xl oral tablet extended release 24 hour glipizide-metformin hcl oral tablet triamterene oral capsule GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR triamterene-hctz oral capsule triamterene-hctz oral tablet glyburide micronized oral tablet TRILIPIX ORAL CAPSULE DELAYED RELEASE glyburide oral tablet glyburide-metformin oral tablet valsartan oral tablet GLYNASE ORAL TABLET valsartan-hydrochlorothiazide oral tablet GLYXAMBI ORAL TABLET VASCEPA ORAL CAPSULE JANUMET ORAL TABLET VASERETIC ORAL TABLET JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR VASOTEC ORAL TABLET VECAMYL ORAL TABLET JANUVIA ORAL TABLET verapamil hcl er oral capsule extended release 24 hour JARDIANCE ORAL TABLET JENTADUETO ORAL TABLET verapamil hcl er oral tablet extended release JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR verapamil hcl oral tablet VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR metformin hcl er oral tablet extended release 24 hour VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR metformin hcl oral solution metformin hcl oral tablet ZESTORETIC ORAL TABLET miglitol oral tablet ZIAC ORAL TABLET nateglinide oral tablet DIABETES - ANTIDIABETIC AGENTS OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR acarbose oral tablet ACTOPLUS MET ORAL TABLET pioglitazone hcl oral tablet ACTOS ORAL TABLET pioglitazone hcl-glimepiride oral tablet AMARYL ORAL TABLET pioglitazone hcl-metformin hcl oral tablet BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR PRECOSE 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 10
Drug Name Drug Name repaglinide oral tablet HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION RIOMET ORAL SOLUTION HUMALOG SUBCUTANEOUS SOLUTION RYBELSUS ORAL TABLET HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PENINJECTOR SYMLINPEN 120 SYMLINPEN 60 SYNJARDY ORAL TABLET HUMULIN 70/30 KWIKPEN SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION TRADJENTA ORAL TABLET HUMULIN N KWIKPEN TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR HUMULIN N VIAL SUBCUTANEOUS SUSPENSION TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR HUMULIN R U-500 KWIKPEN HUMULIN R U-500 VIAL SUBCUTANEOUS SOLUTION VICTOZA XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR HUMULIN R VIAL INJECTION SOLUTION LANTUS U-100 SOLOSTAR XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION DIABETES - GLUCOSE MONITORING LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR CONTOUR MONITOR DEVICE DEVICE CONTOUR MONITOR KIT W/DEVICE KIT LYUMJEV VIAL INJECTION SOLUTION CONTOUR NEXT EZ KIT TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR CONTOUR NEXT LINK KIT CONTOUR NEXT MONITOR KIT TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR CONTOUR NEXT ONE DEVICE ELECTROLYTES / MINERALS / METALS / VITAMINS CONTOUR NEXT ONE KIT CONTOUR NEXT TEST IN VITRO STRIP adc/f (0.5mg/ml) oral solution CONTOUR TEST IN VITRO STRIP ATABEX OB ORAL TABLET LANCETS CITRANATAL MEDLEY ORAL CAPSULE DIABETES - INSULINS ELITE-OB ORAL TABLET AFREZZA INHALATION POWDER FLORIVA ORAL LIQUID HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR FLORIVA ORAL TABLET CHEWABLE HUMALOG MIX 50/50 KWIKPEN FLORIVA PLUS ORAL SOLUTION HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION M-NATAL PLUS ORAL TABLET MULTI-MAC ORAL TABLET HUMALOG MIX 75/25 KWIKPEN multi-vitamin/fluoride oral solution 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 11
Drug Name Drug Name multivitamin/fluoride tablet chewable 0.25 mg oral (rx) SELECT-OB ORAL TABLET CHEWABLE 29-1 MG MULTIVITAMIN/FLUORIDE TABLET CHEWABLE 0.25 MG ORAL (RX) TRINATE ORAL TABLET multivitamin/fluoride tablet chewable 0.5 mg oral TRI-VI-FLORO ORAL SUSPENSION TRI-VI-FLOR ORAL SUSPENSION tri-vite/fluoride oral solution MULTIVITAMIN/FLUORIDE TABLET CHEWABLE 0.5 MG ORAL UDAMIN SP ORAL TABLET multivitamin/fluoride tablet chewable 1 mg oral VINATE ONE ORAL TABLET MULTIVITAMIN/FLUORIDE TABLET CHEWABLE 1 MG ORAL VITAFOL STRIPS ORAL FILM vitamins acd-fluoride oral solution multi-vitamin/fluoride/iron oral solution vp-pnv-dha oral capsule NEONATAL 19 ORAL TABLET WESCAP-C DHA ORAL CAPSULE NEONATAL COMPLETE ORAL TABLET 27-1 MG WESCAP-PN DHA ORAL CAPSULE NEONATAL PLUS ORAL TABLET WESTAB PLUS ORAL TABLET WESNATE DHA ORAL CAPSULE NESTABS ORAL TABLET ONE VITE WOMENS PLUS ORAL TABLET GASTROINTESTINAL AGENTS - DRUGS FOR ACID REFLUX AND ULCER ONEVITE ORAL TABLET CARAFATE ORAL SUSPENSION POLY-VI-FLOR ORAL SUSPENSION cimetidine hcl oral solution POLY-VI-FLOR ORAL TABLET CHEWABLE cimetidine oral tablet POLY-VI-FLOR/IRON ORAL SUSPENSION CYTOTEC ORAL TABLET POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE DEXLANSOPRAZOLE ORAL CAPSULE DELAYED RELEASE PREMESISRX ORAL TABLET esomeprazole magnesium oral capsule delayed release PRENAISSANCE ORAL CAPSULE esomeprazole magnesium oral packet prenatal oral tablet 27-1 mg ESOMEPRAZOLE STRONTIUM ORAL CAPSULE DELAYED RELEASE prenatal vitamin plus low iron oral tablet PRENATVITE PLUS ORAL TABLET famotidine oral suspension reconstituted PRENATVITE RX ORAL TABLET famotidine oral tablet 20 mg, 40 mg preplus oral tablet FIRST-LANSOPRAZOLE ORAL SUSPENSION PRETAB ORAL TABLET QUFLORA FE PEDIATRIC ORAL LIQUID FIRST-OMEPRAZOLE ORAL SUSPENSION QUFLORA GUMMIES ORAL TABLET CHEWABLE lansoprazole oral capsule delayed release lansoprazole oral tablet delayed release dispersible QUFLORA PEDIATRIC ORAL SOLUTION QUFLORA PEDIATRIC ORAL TABLET CHEWABLE misoprostol oral tablet NEXIUM ORAL PACKET RELNATE DHA ORAL CAPSULE nizatidine oral capsule 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 12
Drug Name Drug Name nizatidine oral solution trilyte oral solution reconstituted 420 gm omeprazole oral capsule delayed release HORMONAL AGENTS - SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS OMEPRAZOLE SYRSPEND SF ALKA ORAL SUSPENSION pantoprazole sodium oral packet EVISTA ORAL TABLET pantoprazole sodium oral tablet delayed release OSPHENA ORAL TABLET raloxifene hcl oral tablet PEPCID ORAL TABLET HORMONAL AGENTS - SEX HORMONES AND BIRTH CONTROL PRILOSEC ORAL PACKET ACTIVELLA ORAL TABLET PROTONIX ORAL PACKET afirmelle oral tablet rabeprazole sodium oral tablet delayed release ALORA TRANSDERMAL PATCH TWICE WEEKLY sucralfate oral suspension sucralfate oral tablet altavera oral tablet GASTROINTESTINAL AGENTS - DRUGS FOR BOWEL, INTESTINE AND STOMACH CONDITIONS alyacen 1/35 oral tablet alyacen 7/7/7 oral tablet amoxicill-clarithro-lansopraz oral amabelz oral tablet CLENPIQ ORAL SOLUTION amethia oral tablet gavilyte-c oral solution reconstituted amethyst oral tablet gavilyte-g oral solution reconstituted ANGELIQ ORAL TABLET gavilyte-n with flavor pack oral solution reconstituted ANNOVERA VAGINAL RING HELIDAC THERAPY ORAL aranelle oral tablet apri oral tablet OMECLAMOX-PAK ORAL ashlyna oral tablet PCP 100 COMBINATION KIT aubra eq oral tablet peg 3350-kcl-na bicarb-nacl oral solution reconstituted aubra oral tablet aurovela 1.5/30 oral tablet peg-3350/electrolytes oral solution reconstituted aurovela 1/20 oral tablet peg-3350/electrolytes/ascorbat oral solution reconstituted aurovela 24 fe oral tablet peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted aurovela fe 1/20 oral tablet peg-prep oral kit ayuna oral tablet aurovela fe 1.5/30 oral tablet aviane oral tablet PYLERA ORAL CAPSULE azurette oral tablet SUPREP BOWEL PREP KIT ORAL SOLUTION BALCOLTRA ORAL TABLET balziva oral tablet SUTAB ORAL TABLET BIJUVA ORAL CAPSULE TALICIA ORAL CAPSULE DELAYED RELEASE blisovi 24 fe 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. Oral and self-injectable specialty medications may have limitations based on your plan benefit. 13
Drug Name Drug Name blisovi fe 1.5/30 oral tablet dotti transdermal patch twice weekly blisovi fe 1/20 oral tablet drospiren-eth estrad-levomefol oral tablet briellyn oral tablet drospirenone-ethinyl estradiol oral tablet camila oral tablet DUAVEE ORAL TABLET camrese lo oral tablet EC-RX ESTRADIOL TRANSDERMAL CREAM camrese oral tablet EEMT HS ORAL TABLET caziant oral tablet EEMT ORAL TABLET charlotte 24 fe oral tablet chewable ELESTRIN TRANSDERMAL GEL chateal eq oral tablet elinest oral tablet chateal oral tablet ELLA ORAL TABLET CLIMARA PRO TRANSDERMAL PATCH WEEKLY eluryng vaginal ring COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY enpresse-28 oral tablet emoquette oral tablet enskyce oral tablet COVARYX HS ORAL TABLET errin oral tablet COVARYX ORAL TABLET est estrogens-methyltest ds oral tablet cryselle-28 oral tablet est estrogens-methyltest hs oral tablet cyclafem 1/35 oral tablet est estrogens-methyltest oral tablet cyclafem 7/7/7 oral tablet estarylla oral tablet cyred eq oral tablet estra
bupropion hcl er (sr) oral tablet extended release 12 hour. Drug Name. bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg bupropion hcl oral tablet citalopram hydrobromide oral solution citalopram hydrobromide oral tablet DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR desvenlafaxine succinate er oral tablet
Get a prescription for these products from your doctor, even if the products are sold over-the-counter (OTC) Fill the prescription at a Walmart or Sam’s Club pharmacy. Or, ifyour work location is more than five miles, you may also purchase at any OptumRx network pharmacy. Up t
Preventive Medicine and Public Health Preventive Medicine and Pediatrics Healthcare and Primary Care Preventive Medicines and Vaccinations Occupational Health and Safety Preventive Medicine and Pathology Preventive Medicine and Diabetes Preventive Medicine and Geriatrics 13:10-13:15 GROUP PHOTO 13:15-14:00 LUNCH BREAK MEETING HALL 01 MEETING .
Feb 19, 2022 · Miami-Dade County Daily Covid-19 Hospital Report Category 02/05/2022 02/06/2022 02/07/2022 02/08/2022 02/09/2022 02/10/2022 02/11/2022 02/12/2022 02/13/2022 02/14/2022 02/15/2022 02/16/2022 02/17/2022 02/18/2022 Beds Acute Care Beds Beds that may be converted to Acute Care Beds IC
Jul 01, 2021 · Call the number on your member ID card Visit your plan’s website on your member ID card or log on to the OptumRx app to: . You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This
For most BCBSAZ members, specialty copay tiers (A, B, C, or D) apply. Tier Description A Specialty Medications, Low Cost Share B Specialty Medications, Moderate Cost Share C Specialty Medications, Moderately High Cost Share D Specialty Medications, Highest Cost Share Plans may include specialty medications at varying cost share tiers. Questions?
forms of preventive medications administered by your healthcare provider, please call the number on the back of your membership card for more information. 2018 Preventive medication list . Forteo SP Fosamax Fosamax
Prescription Drugs OptumRx 800-797-9791 www.optumrx.com Telemedicine AmWell Doctor on Demand 855-818-3627 800-997-6196 . CAT, PET scan, etc. . Provides most primary care and emergency services at a much lower price than an Emergency Room, and comparable to your Primary Care Physician. Some examples of things they can
Source: Data shown in the figure above are based on a compilation of CVS Caremark's, Express Scripts', and OptumRx's formulary exclusion listings from 2014–2020. a In 2014, medicines were either excluded from CVS Caremark, Express Scripts, or both. OptumRx did not begin excluding medicines from their formulary until 2016.
