2021 Preventive Medications For Group HSA Qualified Plans

Your pharmacy benefit plan includes special coverage for preventive medications. These drugs help protect against or manage a medical condition, such as:

• Preventing blood clots and reducing the risk of a stroke

• Preventing heart disease and reducing high blood pressure

• Preventing osteoporosis (a disease that leads to an increased risk of bone fracture)

Your health is important. Taking preventive medications as directed by yourhealth care provider can help you avoid serious illness and high health care costs.

Managing your health with preventive medications

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2021 Preventive medications and your plan

Special coverage for preventive medications

Drugs on your plan’s list of preventive medications are not subject to a deductible. You’ll pay your copayment/coinsurance or nothing at all, depending on your plan. So you can save money and get the medications you need to help you live a healthier life.

Preventive medications are a subset of products included within your plan’s formulary, or list of prescription drugs, which tells you what medications your plan covers.

Please note that most medications on the Formulary are subject to a deductible. Preventive medications are an exception. To check the cost of any medication, refer to your benefit handbook or contact customer service at the toll-free member phone number on your benefit plan ID card.

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.

Quality drives our decisions

Our committee of independent doctors and pharmacists meets regularly to review medications and consider how they should be covered by your pharmacy benefit plan. They also recommend which medications should be on your plan’s list of preventive medications.

A list of covered preventive medications begins on the next page. Medications are listed by therapeutic category. To help you tell generic and brand drugs apart, all generics start with a lowercase letter. For questions on injectable dose forms of preventive medications administered by your healthcare provider, please call the number on the back of your membership card for more information.

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Expanded listing by therapeutic categoryANTIDEPRESSANTSCELEXAcitalopramescitalopramfluoxetinefluoxetine drfluvoxaminefluvoxamine erLEXAPROparoxetinePAXILPAXIL CRparoxetine ERPEXEVAPROZACsertralineZOLOFT

ANTIPSYCHOTICSABILIFYABILIFY MAINTENA‡

ABILIFY MYCITE‡

ADASUVEaripiprazolearipiprazole odtARISTADA‡

ARISTADA INITIO‡

CAPLYTA chlorpromazineclozapineclozapine odtCLOZARILcomproEQUETROFANAPTFAZACLOfluphenazineGEODONhaloperidolINVEGAINVEGA SUSTENNA‡

INVEGA TRINZA‡

LATUDAloxapinemolindoneNUPLAZIDolanzapineolanzapine odtolanzapine/fluoxetinepaliperidone er

perphenazinePERSERIS‡

prochlorperazinequetiapinequetiapine erREXULTIRISPERDALRISPERDAL CONSTA‡

risperidonerisperidone odtSAPHRISSEROQUELSEROQUEL XRSYMBYAXthioridazinethiothixenetrifluoperazineVERSACLOZVRAYLARziprasidoneZYPREXAZYPREXA RELPREVV‡

ZYPREXA ZYDIS

ASTHMA AND COPDACCOLATEADVAIR DISKUSADVAIR HFAAIRDUO DIGIHALER AIRDUO RESPICLICKalbuterol sulfatealbuterol sulfate erALBUTEROL SULFATE HFAalbuterol sulfate hfaALVESCOANORO ELLIPTAARCAPTA NEOHALERARMONAIR DIGIHALERARNUITY ELLIPTAASMANEX HFAASMANEX TWISTHALERATROVENT HFABEVESPI AEROSPHEREBREO ELLIPTABREZTRI AEROSPHEREBROVANAbudesonideBUDESONIDE/FORMOTEROL AERCOMBIVENT RESPIMATcromolyn

DALIRESPdifil-g forteDULERAELIXOPHYLLINFLOVENT DISKUSFLOVENT HFAfluticasone/salmeterol diskusFLUTICASONE PROPIONATE? SALMETEROL INHINCRUSE ELLIPTAipratropiumipratropium/albuterolisoproterenol aerlevalbuterolLEVALBUTEROL HFALONHALA MAGNAIRmetaproterenolmontelukastPEAK FLOW METERS‡

PERFOROMISTPROAIR HFAPROAIR DIGIHALERPROAIR RESPICLICKPROVENTIL HFAPULMICORTPULMICORT FLEXHALERQVARQVAR REDIHALERSEEBRI NEOHALERSEREVENT DISKUSSINGULAIRSPIRIVA HANDIHALERSPIRIVA RESPIMATSTIOLTO RESPIMATSTRIVERDI RESPIMATSYMBICORTterbutalineTHEO-24theophyllinetheophylline crtheophylline erTRELEGY ELLIPTATUDORZA PRESSAIRUTIBRON NEOHALERVENTOLIN HFAwixela inhubXOPENEXXOPENEX CONCENTRATEXOPENEX HFAYUPELRIzafirlukast

2021 Preventive medication list

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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2021 Preventive medication list (cont.)

zileuton erZYFLOZYFLO CR

CANCERanastrozoleARIMIDEXAROMASINEVISTA exemestaneFARESTONFEMARAletrozoleraloxifeneSOLTAMOXtamoxifen

toremifene

CARDIOVASCULAR/HEART DISEASEAnti-Anginal Agents

DILATRATE SRGONITROISORDIL TITRADOSEisosorbide dinitrateisosorbide dinitrate erisosorbide mononitrateisosorbide mononitrate erminitranNITRO-BIDNITRO-DURnitroglycerinnitroglycerin ernitroglycerin lingualnitroglycerin transdermalNITROLINGUAL PUMPSPRAYNITROMISTnitro-timepetnranolazine erRANEXA

Anticoagulants

AGGRENOXARIXTRA SP

aspirin/dipyridamoleASPIRIN/OMEPRAZOLEBEVYXXABRILINTAcilostazolclopidogrelCOUMADIN

dipyridamoleDURLAZAEFFIENTELIQUISenoxaparin SP

fondaparinux SP

FRAGMIN SP

heparinjantovenLOVENOX SP

PLAVIXPLETALPRADAXAprasugrelSAVAYSAwarfarinXARELTOYOSPRALAZONTIVITY

Cardiac Glycosides

digitekdigoxdigoxinLANOXIN

High Blood Pressure

ACCUPRILACCURETICacebutololADALAT CCALDACTAZIDEALDACTONEaliskirenALTACEamilorideamiloride/hctzamlodipineamlodipine/benazeprilamlodipine/olmesartanamlodipine/valsartanamlodipine/valsartan/hctzATACANDATACAND HCTatenololatenolol/chlorthalidoneAVALIDEAVAPROAZORbenazeprilbenazepril /hctzBENICARBENICAR HCT

BETAPACEbetaxolol tabletBIDILbisoprololbisoprolol/hctzBLOOD PRESSUREMONITORS ‡

bumetanideBUMEXBYSTOLICBYVALSONCALANCALAN SRcandesartancandesartan /hctzcaptoprilcaptopril/hctzCARDIZEMCARDIZEM CDCARDIZEM LACARDURACAROSPIRcartia xtcarvedilolcarvedilol erCATAPRESCATAPRES-TTSchlorothiazidechlorthalidoneclonidineCONSENSICOREGCOREG CRCORGARDCOZAARDEMADEXDEMSERDIBENZYLINEdiltiazemdiltiazem erdiltiazem cddilt-xrDIOVANDIOVAN HCTDIURILdoxazosinDUTOPROLDYAZIDEDYRENIUMEDARBIEDARBYCLOREDECRINenalapril

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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enalapril/hctzEPANEDeplerenoneeprosartanethacrynic acidEXFORGEEXFORGE HCTezidefelodipine erFIRST - ATENOLOL ‡

FIRST - METOPROLOL ‡

fosinoprilfosinopril /hctzfurosemideguanfacinehydralazinehydrochlorothiazideHYZAARindapamideINDERAL LAINDERAL XLINNOPRAN XLINSPRAirbesartanirbesartan/hctzisradipineKAPSPARGO SPRINKLEKATERZIAlabetalolLASIXlisinoprillisinopril/hctzLOPRESSORLOPRESSOR HCTlosartan potassiumlosartan potassium/hctzLOTENSINLOTENSIN HCTLOTRELmatzim laMAXZIDEMAXZIDE-25methyclothiazidemethyldopamethyldopa/hctzmetolazonemetoprololmetoprolol erMETOPROLOL ER/HCTZmetoprolol/hctzMICARDISMICARDIS HCTMINIPRESS

minoxidil tabletmoexiprilnadololnadolol/bendroflumethiazidenicardipinenifedipinenifedipine ernimodipinenisoldipinenisoldipine erNORVASCNYMALIZEolmesartanolmesartan /hctzolmesartan/amlodipine/hctzperindoprilphenoxybenzaminepindololprazosinPRESTALIAPRINIVILPROCARDIAPROCARDIA XLpropranololpropranolol erpropranolol/hctzQBRELISquinaprilquinapril/hctzramiprilsotalolSOTYLIZEspironolactonespironolactone/hctzSULARTARKAtaztia xtTEKTURNATEKTURNA HCTtelmisartantelmisartan/amlodipinetelmisartan/hctzTENORETICTENORMINterazosinTIAZACtimolol tabTOPROL XLtorsemidetrandolapriltrandolapril/verapamil ertriamterenetriamterene/hctz

TRIBENZORTWYNSTAvalsartanvalsartan/hctzVASERETICVASOTECVECAMYLverapamilverapamil erverapamil srVERELANVERELAN PMZESTORETICZESTRILZIAC

High cholesterol

ALTOPREVamlodipine/atorvastatinANTARAatorvastatinCADUETcholestyraminecholestyramine lightcolesevelamCOLESTIDCOLESTID FLAVOREDcolestipolCRESTOREZALLOR SPRINKLEezetimibeezetimibe/simvastatinfenofibratefenofibrate micronizedfenofibric acidfenofibric acid drFENOGLIDEFIBRICORFLOLIPIDfluvastatinfluvastatin ergemfibrozilJUXTAPID SP

LESCOL XLLIPITORLIPOFENLIVALOLOPIDlovastatinLOVAZANEXLETOLNEXLIZETniacin (Rx only)

2021 Preventive medication list (cont.)

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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2021 Preventive medication list (cont.)

niacin erniacorNIASPANomega-3-acid ethyl estersPRALUENTPRAVACHOLpravastatinprevaliteQUESTRANQUESTRAN LIGHTREPATHAREPATHA SURECLICKrosuvastatinsimvastatinTRICORTRIGLIDETRILIPIXVASCEPAVYTORINWELCHOLZETIAZOCORZYPITAMAG

CONTRACEPTIVES ‡

This section lists contraceptive categories. Please note thatbrands and generics are eligible.CONTRACEPTIVE PATCHCONTRACEPTIVE RING (VAGINAL)EMERGENCY CONTRACEPTIVESIMPLANT CONTRACEPTIVEINJECTABLE CONTRACEPTIVEIUDsORAL CONTRACEPTIVES

DIABETESInsulin

ADMELOGADMELOG SOLOSTARAFREZZAAPIDRAAPIDRA SOLOSTARBASAGLAR KWIKPENFIASPFIASP FLEXTOUCHFIASP PENFILLHUMALOGHUMALOG JUNIOR KWIKPENHUMALOG KWIKPEN

HUMALOG MIX 50/50HUMALOG MIX 50/50 KWIKPENHUMALOG MIX 75/25HUMALOG MIX 75/25 KWIKPENHUMULIN 70/30HUMULIN 70/30 KWIKPENHUMULIN NHUMULIN N KWIKPENHUMULIN RHUMULIN R U-500INSULIN ASPARTINSULIN ASPART PROTAMINE/ INSULIN ASPARTINSULIN LISPROINSULIN LISPRO JUNIOR KWIKPENINSULIN LISPRO PROTAMINE/ INSULIN LISPRO KWIKPENLANTUSLANTUS SOLOSTARLEVEMIRLEVEMIR FLEXTOUCHLYUMJEVLYUMJEV KWIKPENNOVOLIN 70/30NOVOLIN 70/30 FLEXPENNOVOLIN 70/30 RELIONNOVOLIN NNOVOLIN N FLEXPENNOVOLIN N RELIONNOVOLIN RNOVOLIN R RELIONNOVOLOGNOVOLOG FLEXPENNOVOLOG MIX 70/30NOVOLOG MIX 70/30 PREFILLED FLEXPENNOVOLOG PENFILLTOUJEO MAX SOLOSTARTOUJEO SOLOSTARTRESIBATRESIBA FLEXTOUCH

Non-insulin

acarboseACTOPLUS METACTOPLUS MET XRACTOSADLYXINALOGLIPTINALOGLIPTIN / METFORMINALOGLIPTIN / PIOGLITAZONEAMARYL

AVANDIABYDUREONBYDUREON BCISEBYDUREON PENBYETTAchlorpropamideCYCLOSETDUETACTFARXIGAFORTAMETglimepirideglipizideglipizide erglipizide xlglipizide/metforminGLUCOMETERS ‡

GLUCOTROLGLUCOTROL XLGLUCOVANCEGLUMETZAglyburideglyburide micronizedglyburide/metforminGLYNASEGLYSETGLYXAMBIINVOKAMETINVOKAMET XRINVOKANAJANUMETJANUMET XRJANUVIAJARDIANCEJENTADUETOJENTADUETO XRKAZANOKOMBIGLYZE XRmetforminmetformin ermetformin er (mod)metformin er (osm)metformin solmiglitolnateglinideNESINAONGLYZAOSENIOZEMPICpioglitazonepioglitazone /metforminpioglitazone-glimepiridePRANDIN

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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PRECOSEQTERNrepagliniderepaglinide/metforminRIOMETRYBELSUSSEGLUROMETSOLIQUA 100/33STARLIXSTEGLATROSTEGLUJANSYMLINPENSYNJARDYSYNJARDY XRtolazamidetolbutamideTRADJENTATRIJARDY XRTRULICITYVICTOZAXIGDUO XRXULTOPHY

ESTROGENSACTIVELLAALORAamabelzANGELIQCLIMARACLIMARA PROCOMBIPATCHcovaryxcovaryx HSDIVIGELdottiDUAVEEeemteemt HSELESTRINesterified estrogens/ methltestosteroneesterified estrogens/ methltestosterone dsesterified estrogens/ methltestosterone hsESTRACEestradiolestradiol/norethindrone acetateESTROGELEVAMISTFEMHRT LOW DOSE

fyavolvjintelilopreezaMENESTMENOSTARmimveymimvey loMINIVELLEnorethindrone acetate/ethinyl estradiolPREFESTPREMARINPREMPHASEPREMPROVIVELLE-DOT

GASTROINTESTINAL-ULCER DRUGS‡

ACIPHEXACIPHEX SPRINKLEAXIDCARAFATEcimetidineCYTOTECDEXILANTesomeprazole magnesiumESOMEPRAZOLE STRONTIUMfamotidineFIRST-LANSOPRAZOLE ‡

FIRST-OMEPRAZOLE ‡

lansoprazolelansoprazole/amoxicillin/ clarithromycinmisoprostolNEXIUMnizatidineOMECLAMOX-PAKomeppiomeprazoleomeprazole /sodium bicarbonatepantoprazolepantoprazole drPEPCIDPREVACIDPREVACID SOLUTABPRILOSECPROTONIXPYLERArabeprazole tabRABEPRAZOLE DR SPRINKLEsucralfate

TALICIAZEGERID

HIV/AIDSabacavirabacavir / lamivudineabacavir / lamivudine / zidovudinAPTIVUSatazanavirATRIPLABIKTARVYCIMDUOCOMBIVIRCOMPLERACRIXIVANDELSTRIGODESCOVYdidanosineDOVATOEDURANTefavirenzefavirenz/lamivudine/tenofovir EMTRIVAEPIVIREPZICOMEVOTAZfosamprenavirFUZEONGENVOYAINTELENCEINVIRASEISENTRESSISENTRESS HDJULUCAKALETRAlamivudinelamivudine / zidovudineLEXIVAlopinavir / ritonavirnevirapinenevirapine erNORVIRODEFSEYPIFELTRO PREZCOBIX PREZISTA RESCRIPTOR RETROVIR REYATAZ ritonavir RUKOBIA

2021 Preventive medication list (cont.)

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule

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SELZENTRY stavudineSTRIBILDSUSTIVA SYMFI SYMFI LO SYMTUZATEMIXYS tenofovir TIVICAY TIVICAY PDTRIUMEQ TRIZIVIR TROGARZO TRUVADA TYBOST VIDEX PEDIATRIC VIDEX EC VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD ZERIT ZIAGEN zidovudine

OSTEOPOROSISACTONELalendronateATELVIABINOSTOBONIVAcalcitonin-salmonetidronate diEVENITY SP

EVISTAFORTEO SP

FOSAMAXFOSAMAX + DibandronateNATPARA SP

raloxifenerisedronaterisedronate drTYMLOS SP

SMOKING DETERRENTS ‡bupropion erCHANTIXNICODERM CQNICORETTEnicotine gum / lozenge / patchNICOTROL INH / NSZYBAN

TRANSPLANT ‡ASTAGRAF XL SP

AZASANazathioprineCELLCEPT SP

cyclosporine SP

cyclosporine modified SP

ENVARSUS XR SP

gengraf SP

IMURANmycophenolate SP

mycophenolic DR SP

MYFORTIC SP

NEORAL SP

PROGRAF SP

RAPAMUNE SP

SANDIMMUNE SP

sirolimus SP

tacrolimus cap SP

ZORTRESS SP

VITAMINS & ELECTROLYTES ‡

Pediatric vitamins with fluoride

(for example; POLY-VI-FLOR, tri-vit / fl)generic productsBRAND NAME PRODUCTS

Prenatal multivitamins with iron and folic acid

(for example; OB COMPLETE, prenatabs RX)generic productsBRAND NAME PRODUCTS

2021 Preventive medication list (cont.)

SVHP-3262 Rev. 10/20

This list refers to High Deductible Health Plan medications only. It 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. Use of generics may be required depending upon plan design.OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

All Optum trademarks and logos are owned by Optum, Inc. in the U.S. and other jurisdictions. All other trademarks are the property of their respective owners.

©2020 Optum, Inc. All rights reserved. WF3429992-D_ORX_HDHP preventive select _09242020 68551F-092020

SP Oral and self-injectable Specialty medications may have limitations based on your plan benefit‡ Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will ruleIf you continue to use the brand medication, you will pay your cost share and potentially the cost difference between the brand and generic.