Preventive medications list - mymohawkbenefits.com PANTOPRAZOLE ACIPHEX RABEPRAZOLE ... please call...
Transcript of Preventive medications list - mymohawkbenefits.com PANTOPRAZOLE ACIPHEX RABEPRAZOLE ... please call...
In addition to a healthy lifestyle, preventive medications can helppeople avoid many illnesses and conditions. A consumer-directedhealth (CDH) plan that includes preventive medications can helpsupport the goal of ongoing good health.
This list provides examples of commonly prescribed preventive medications. The medications are categorized based on the medicalconditions that they are used to prevent. This is not an all-inclusive list;only examples of medicines in each category are listed. Coverage priorto the deductible being met may not be provided for every dosageform of a listed medication.
This list does not indicate coverage. Please check with your planadministrator and/or benefit information materials if you have questions on coverage. Your cost share will be determined by yourplan’s drug coverage and formulary plan.
This list is periodically reviewed and updated to ensure that the drugslisted meet the criteria for inclusion.
Medications on this list that are not covered under yourplan are not eligible for the preventive medication program.
Preventive medications list
PDL9400C
ANEMIA IN CHILDRENFERROUS SULFATE LIQUID DROPS FOR INFANTS (SUCH AS FER-IN-SOL)
ASTHMASINGULAIRMONTELUKAST
ACCOLATEZAFIRLUKAST
ZYFLO CRZILEUTON
BONE DISEASE AND FRACTURESFOSAMAX, FOSAMAX PLUS DALENDRONATE
FORTICAL, MIACALCINCALCITONIN
XGEVADENOSUMAB
BONIVAIBANDRONATE
EVISTARALOXIFENE
ACTONELRISEDRONATE
RECLASTZOLEDRONIC ACID
BREAST CANCER RECURRENCETAMOXIFEN ARIMIDEXANASTROZOLE
AROMASINEXEMESTANE
FEMARALETROZOLE
CANCER TREATMENT, SIDEEFFECTS FROM ARANESPDARBEPOETIN ALFA
EPOGEN, PROCRITEPOETIN ALFA
NEUPOGENFILGRASTIM
MESNEXMESNA
NEULASTAPEGFILGRASTIM
LEUKINESARGRAMOSTIM
CAVITIESPREVIDENT SODIUM FLUORIDE
COLONOSCOPY PREPARATIONGOLYTELY, HALFLYTELY, NULYTELY,TRILYTE, MOVIPREP, SUCLEARPOLYETHYLENE GLYCOL
PREPOPIKSODIUM PICOSULFATE
VISICOL, OSMOPREP, SUPREPSODIUM PHOSPHATE SALTS
DIABETES, COMPLICATIONS OF
INSULINS: LEVEMIRDETEMIR
LANTUS, LANTUS SOLOSTARGLARGINE
HUMULININSULIN
Preventive Medications List
HUMALOG, 50/50, 75/25LISPRO, LISPRO PROTAMINE MIX
NON-INSULIN MEDICINES: BYETTAEXENATIDE
AMARYLGLIMEPIRIDE
GLUCOTROL, METAGLIPGLIPIZIDE AND COMBINATIONS
DIABETA, GLYNASE, GLUCOVANCEGLYBURIDE AND COMBINATIONSLIRAGLUTIDE
FORTAMET, GLUCOPHAGE,GLUMETZA, RIOMETMETFORMIN
STARLIXNATEGLINIDE
ACTOS, DUETACT, ACTOPLUS METPIOGLITAZONE AND COMBINATIONS
SYMLIN PRAMLINTIDE
PRANDINREPAGLINIDE
AVANDIA, AVANDAMET,AVANDARYLROSIGLITAZONE AND COMBINATIONS
ONGLYZA, KOMBIGLYZE XRSAXAGLIPTIN AND COMBINATIONS
JANUVIA, JANUMETSITAGLIPTIN AND COMBINATIONS
ESTROGEN REPLACEMENT ANDOTHER HORMONESPREMARIN CONJUGATED ESTROGEN TABLETS
PREMPRO, PREMPHASECONJUGATED ESTROGEN/MEDROXYPROGESTERONE
ESTRACEESTRADIOL TABLETS
CLIMARAESTRADIOL TRANSDERMAL
ESTRADERMESTRADIOL TRANSDERMAL
VIVELLE DOTESTRADIOL TRANSDERMAL
DIVIGELESTRADIOL, GEL
EVAMISTESTRADIOL, TRANSDERMAL SPRAY
COMBIPATCHESTRADIOL/NORETHINDRONE, TRANSDERMAL
MAKENAHYDROXYPROGESTERONE CAPROATE
PROVERAMEDROXYPROGESTERONE
CRINONE, PROMETRIUMPROGESTERONE
CENESTINSYNTHETIC CONJUGATED ESTROGENS, A
ENJUVIASYNTHETIC CONJUGATED ESTROGENS, B
GOUTZYLOPRIMALLOPURINOL
COLCRYSCOLCHICINE
GUM DISEASEARESTINMINOCYCLINE
Preventive Medications List
HEART DISEASE AND STROKE
BLOOD THINNER MEDICINES: ASPIRIN, 81 MG OR 325 MGHEPARINELIQUIS APIXIBAN
PRADAXA DIBIGATRAM ETEXILATE
AGGRENOX ASA/DIPYRIDAMOLE
PLAVIXCLOPIDOGREL
FRAGMIN DALTEPARIN
LOVENOXENOXAPARIN
ARIXTRAFONDAPARINUX
EFFIENT PRASUGREL
XARELTORIVAROXABAN
BRILINTATICAGRELOR
COUMADIN, JANTOVENWARFARIN
CHOLESTEROL LOWERING MEDICINES
HMG-COA REDUCTASEINHIBITORS: LIPITORATORVASTATIN
MEVACORLOVASTATIN
PRAVACHOLPRAVASTATIN
CRESTORROSUVASTATIN
ZOCORSIMVASTATIN
OTHER AGENTS: PREVALITE, QUESTRANCHOLESTYRAMINE
WELCHOLCOLESEVELAM
COLESTIDCOLESTIPOL
ZETIAEZETIMIBE
VYTORINEZETIMIBE/SIMVASTATIN
FENOGLIDE, LIPOFEN, TRICOR, ANTARA, TRIGLIDEFENOFIBRATE
TRILIPIXFENOFIBRIC ACID
LOPIDGEMFIBROZIL
NIACOR, NIASPAN ERNIACIN
ADVICORNIACIN/LOVASTATIN
SIMCORNIACIN ER/SIMVASTATIN
LOVAZAOMEGA-3-ACID ETHYL ESTERS
HIGH BLOOD PRESSURE MEDICINES
ACE INHIBITORS AND COMBINATIONS:
LOTENSIN, LOTENSIN HCTBENAZEPRIL
VASOTEC, VASERETICENALAPRIL
UNIVASC, UNIRETICMOEXIPRIL
Preventive Medications List
PRINIVIL, PRINZIDE, ZESTRIL, ZESTORETICLISINOPRIL
ACCUPRIL, ACCURETICQUINAPRIL
ACE RECEPTOR BLOCKERS AND COMBINATIONS:
ATACAND, ATACAND HCTCANDESARTAN
AVAPRO, AVALIDEIRBESARTAN
COZAAR, HYZAARLOSARTAN
BENICAR, BENICAR HCTOLMESARTAN
DIOVAN, DIOVAN HCTVALSARTAN
BETA BLOCKERS AND COMBINATIONS:
TENORMIN, TENORETICATENOLOL
ZEBETA, ZIACBISOPROLOL
LOPRESSOR, LOPRESSOR HCT,TOPROL XLMETOPROLOL
BYSTOLICNEBIVOLOL
INDERAL LA, INNOPRAN XLPROPRANOLOL
CALCIUM CHANNEL BLOCKERS:
NORVASCAMLODIPINE
CARDIZEM, CARDIZEM LA,
CARTIA XT, TIAZACDILTIAZEM
ADALAT CC, PROCARDIANIFEDIPINE
SULARNISOLDIPINE
CALAN, COVERA HS, ISOPTIN SR,VERELANVERAPAMIL
DIURETICS AND COMBINATIONS:HYDROCHLOROTHIAZIDEINDAPAMIDEMIDAMORAMILORIDE
ZAROXOLYNMETOLAZONE
ALDACTONESPIRONOLACTONE
DYAZIDE, MAXZIDETRIAMTERENE-HCTZ
HIGH BLOOD PRESSURE MEDICINES MISCELLANEOUS:HYDRALAZINE TEKTURNA, TEKTURNA HCT,TEKAMLO, AMTURNIDE, VALTURNAALISKIREN AND COMBINATIONS
LOTRELAMLODIPINE/BENAZEPRIL
AZORAMLODIPINE/OLMESARTAN
TRIBENZORAMLODIPINE/OLMESARTAN/ HYDROCHLOROTHIAZIDE
Preventive Medications List
TWYNSTAAMLODIPINE/TELMISARTAN
EXFORGEAMLODIPINE/VALSARTAN
EXFORGE HCT AMLODIPINE/VALSARTAN/ HYDROCHLOROTHIAZIDE
COREG, COREG CRCARVEDILOL
CATAPRES, CLORPRESCLONIDINE
CARDURADOXAZOSIN
HYTRINTERAZOSIN
INFECTION
FUNGALMEPRONATOVAQUONE
NEBUPENT, PENTAMPENTAMIDINE
NOXAFILPOSACONAZOLE
MALARIAPRIMAQUINECOARTEMARTEMETHER/LUMEFANTRINE
MALARONEATOVAQUONE/PROGUANIL
PLAQUENILHYDROXYCHLOROQUINE
DARAPRIMPYRIMETHAMINE
VIRUSAMANTADINEZOVIRAXACYCLOVIR
FAMVIRFAMCICLOVIR
FOSCAVIRFOSCARNET
CYTOVENEGANCICLOVIR
TAMIFLUOSELTAMIVIR
VALTREXVALACYCLOVIR
VALCYTEVALGANCICLOVIR
RELENZAZANAMIVIR
KIDNEY DISEASE, HIGH PHOSPHATE LEVELS PHOSLO, PHOSLYRACALCIUM ACETATE
FOSRENOLLANTHANUM
RENVELA, RENAGELSEVELAMER
NAUSEA AND DIZZINESSPROCHLORPERAZINE PROMETHAZINE EMENDAPREPITANT
ANZEMETDOLASETRON
MARINOLDRONABINOL
SANCUSOGRANISETRON
ANTIVERTMECLIZINE
ZOFRAN, ZOFRAN ODTONDANSETRON
TRANSDERM-SCOP, SCOPACESCOPOLAMINE
Preventive Medications List
OBESITYDIETHYLPROPIONBELVIQLORCASERIN
QYSMIAPHENTERMINE/TOPIRAMATE
XENICALORLISTAT
BONTRILPHENDIMETRAZINE
ADIPEX-P, IONAMINPHENTERMINE
PREGNANCYBIRTH CONTROL MEDICINES TAKEN BY MOUTHBIRTH CONTROL DEVICES: DIAPHRAGMS, SKIN PATCH SYSTEMS, INJECTABLE BIRTH CONTROL, INTRAUTERINE SYSTEMS, ANDIMPLANTS
SMOKING-CESSATION THERAPYZYBANBUPROPION
NICOTROLNICOTINE PRODUCTS
CHANTIXVARENICLINE
ULCER DISEASE
H2-ANTAGONISTS: CIMETIDINE PEPCIDFAMOTIDINE
AXIDNIZATADINE
ZANTACRANITIDINE
MISCELLANEOUS AGENTS:
PYLERABISMUTH/METRONIDAZOLE/TETRACYCLINE
CARAFATESUCRALFATE
PROTON PUMP INHIBITORS:
NEXIUMESOMEPRAZOLE
PREVACIDLANSOPRAZOLE
PROTONIXPANTOPRAZOLE
ACIPHEXRABEPRAZOLE
VACCINESVACCINES:JE-VAX, TYPHIM, DIPHTHERIA, PERTUSSIS, TETANUS, HAEMOPHILUSINFLUENZAE B, HEPATITIS A AND B,HUMAN PAPILLOMAVIRUS, INFLUENZA, MEASLES, MENINGOCOCCAL, MUMPS, PNEU-MOCOCCAL, POLIOVIRUS,ROTAVIRUS, RUBELLA, AND VARICELLA
VITAMINS OR MINERALS,LOW LEVELS OFCALCIUMFOLIC ACID, 0.4 TO 0.8 MGIRON MAGNESIUMMULTIVITAMIN PRODUCTSPOTASSIUM BICARBONATE/CITRIC ACID POTASSIUM CHLORIDEPRESCRIPTION PRENATAL VITAMINSVITAMINS: A, B, B1, B6, B12, D, KZINC
Preventive Medications List
*0000000PDL9400C**0000000PDL9400C*
Express Scripts manages your prescription benefit for youremployer, plan sponsor, or health plan. For specific questions oncoverage, please call the phone number on your ID card or visitour website www.express-scripts.com. Please note: Brand names are shown in italics in each category.
All rights in the product names of all third-party products appearinghere, whether or not appearing with the trademark symbol, belongexclusively to their respective owners.
PDL9400C List 1+2 - DIABETES 9.13
In addition to a healthy lifestyle, preventive medications can helppeople avoid many illnesses and conditions. A consumer-directedhealth (CDH) plan that includes preventive medications can helpsupport the goal of ongoing good health.
This list provides examples of commonly prescribed preventive medications. The medications are categorized based on the medicalconditions that they are used to prevent. This is not an all-inclusive list;only examples of medicines in each category are listed. Coverage priorto the deductible being met may not be provided for every dosageform of a listed medication.
This list does not indicate coverage. Please check with your planadministrator and/or benefit information materials if you have questions on coverage. Your cost share will be determined by yourplan’s drug coverage and formulary plan.
This list is periodically reviewed and updated to ensure that the drugslisted meet the criteria for inclusion.
Medications on this list that are not covered under yourplan are not eligible for the preventive medication program.
Preventive medications list
PDL9398C
ASTHMA, PROGRESSION OFQVARBECLOMETHASONE
PULMICORT, PULMICORT FLEXHALERBUDESONIDE
SYMBICORTBUDESONIDE/FORMOTEROL
INTALCROMOLYN SODIUM
ASMANEXMOMETASONE
DULERAMOMETASONE/FORMOTEROL
DEPRESSION, RECURRENCE OFAPLENZIN ER, WELLBUTRIN
BUPROPIONCELEXA
CITALOPRAMPRISTIQ
DESVENLAFAXINE ERCYMBALTA
DULOXETINELEXAPRO
ESCITALOPRAMPROZAC
FLUOXETINEPAXIL, PEXEVA
PAROXETINEZOLOFT
SERTRALINEEFFEXOR
VENLAFAXINEVIIBRYD
VILAZODONE
DIABETES, COMPLICATIONS OF
INSULINS: LEVEMIR
DETEMIRLANTUS, LANTUS SOLOSTARGLARGINE
HUMULININSULIN
HUMALOG, 50/50, 75/25LISPRO, LISPRO PROTAMINE MIX
NON-INSULIN MEDICINES: BYETTAEXENATIDE
AMARYLGLIMEPIRIDE
GLUCOTROL, METAGLIPGLIPIZIDE AND COMBINATIONS
DIABETA, GLYNASE, GLUCOVANCEGLYBURIDE AND COMBINATIONS
TRADJENTALINAGLIPTIN
FORTAMET, GLUCOPHAGE,GLUMETZA, RIOMET METFORMIN
STARLIXNATEGLINIDE
ACTOS, DUETACT, ACTOPLUS METPIOGLITAZONE AND COMBINATIONS
SYMLIN PRAMLINTIDE
PRANDINREPAGLINIDE
AVANDIA, AVANDAMET,AVANDARYLROSIGLITAZONE AND COMBINATIONS
ONGLYZA, KOMBIGLYZE XRSAXAGLIPTIN AND COMBINATIONS
Preventive Medications List
JANUVIA, JANUMETSITAGLIPTIN AND COMBINATIONS
MISCELLANEOUS MEDICINESCINRYZEC1 ESTERASE INHIBITOR
ORGAN TRANSPLANT REJECTIONIMURAN, AZASANAZATHIOPRINE
NULOJIXBELATACEPT
SANDIMMUNE, NEORALCYCLOSPORINE
CELLCEPTMYCOPHENOLATE MOFETIL
MYFORTICMYCOPHENOLIC ACID
RAPAMUNESIROLIMUS
PROGRAFTACROLIMUS
PROSTATE ENLARGEMENT
AVODARTDUTASTERIDE
PROSCARFINASTERIDE
RHEUMATOID ARTHRITIS,PROGRESSION OFORENCIAABATACEPT
HUMIRAADALIMUMAB
RIDAURAAURANOFIN
ENBRELETANERCEPT
REMICADEINFLIXIMAB
RHEUMATREX, TREXALLMETHOTREXATE
CUPRIMINEPENICILLAMINE
ACTEMRA TOCILIZUMAB
Preventive Medications List
*0000000PDL9398C**0000000PDL9398C*
Express Scripts manages your prescription benefit for youremployer, plan sponsor, or health plan. For specific questions oncoverage, please call the phone number on your ID card or visitour website www.express-scripts.com. Please note: Brand names are shown in italics in each category.
All rights in the product names of all third-party products appearinghere, whether or not appearing with the trademark symbol, belongexclusively to their respective owners.
PDL9398C List 3 9.13