September 2021 Expanded Drug List - Citgo

Pharmacy | PDL | Expanded Drug List

Therapeutic Drug Classes Requirements & Limits

Breast Cancer Preventiong Anastrozole

B Arimidex E

B Aromasin E

g Exemestane

B Fareston E

B Femara E

g Letrozole

B Soltamox E

g Tamoxifen

g Toremifene

Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy

B Aggrenox

B Arixtra E


g Aspirin-Dipyridamole

B Bevyxxa

B Brilinta

g Cilostazol

g Clopidogrel

B Coumadin

g Dipyridamole

B Effient E

B Eliquis

g Enoxaparin

g Fondaparinux

B Fragmin

g Heparin

g Jantoven

This is a list of Preventive Medications that may be covered under your plan. If your plan covers these Preventive Medications, your insurance benefit is applied before you meet your deductible.

Some medications may have other requirements or limits depending on your benefit plan and are noted below. To find out if a drug is covered, please check your plan benefits on the health plan’s member website. Or, call the toll-free phone number on your health plan ID card. This list may not be all-inclusive. Brand and generic drugs may not always be available due to market changes.

2021 Preventive Medication List for Consumer Driven Health Plans Expanded List

CDH preventive drug lists may also be used with non-CDH plans

Effective September 1, 2021

Bold type = Brand-name drug[Plain type = Generic drug]E = May be excluded from coverage1Coverage is provided for oral formulations.2SSRIs are included only for employer groups who have specifically requested coverage.

Bold type = Brand-name drug[Plain type = Generic drug]1Coverage is provided for oral formulations

E = May be excluded from coverage or subject to prior authorization (sometimes referred to as precertification)

2 SSRIs are included only for employer groups who have specifically requested coverage.

2


B Lovenox E

B Persantine

B Plavix E

B Pletal

B Pradaxa

g Prasugrel

B Savaysa

g Ticlopidine

g Warfarin

B Xarelto

B Zontivity

Cardiovascular/Heart Disease: High Blood PressureB Accupril

B Accuretic

g Acebutolol

B Aceon

B Adalat CC

g Afeditab

B Aldactazide

B Aldactone E

g Aliskiren

B Altace E

g Amiloride

g Amiloride-Hydrochlorothiazide

g Amlodipine

g Amlodipine-Benazepril

g Amlodipine-Olmesartan E

g Amlodipine-Olmesartan-Hydrochlorothiazide

E

g Amlodipine-Valsartan

g Amlodipine-Valsartan-Hydrochlorothiazide E

B Amturnide E

B Atacand E


B Atacand HCT E

g Atenolol

g Atenolol-Chlorthalidone

B Avalide E

B Avapro E

B Azor E

g Benazepril

g Benazepril-Hydrochlorothiazide

B Benicar E

B Benicar HCT E

g Betaxolol1

B Bidil

g Bisoprolol

g Bisoprolol-Hydrochlorothiazide

g Bumetanide

B Bystolic E

B Byvalson

B Calan

B Calan SR

g Candesartan

g Candesartan-Hydrochlorothiazide

g Captopril

g Captopril-Hydrochlorothiazide

B Cardene SR

B Cardizem E

B Cardizem CD E

B Cardizem LA E

B Cardura

B Carospir

g Cartia XT

g Carvedilol

g Carvedilol ER E




3


B Catapres

B Catapres TTS E

g Chlorothiazide

g Clonidine

g Clonidine Patch

B Clorpress

B Conjupri E

B Coreg E

B Coreg CR E

B Corgard

B Corzide

B Covera HS

B Cozaar E

B Demadex

B Dilacor XR

g Dilt CD

g Dilt XR

g Diltia XT

g Diltiazem

g Diltiazem ER

g Diltzac ER

B Diovan E

B Diovan HCT E

B Diuril

g Doxazosin

B Dutoprol E

B Dyazide

B Dynacirc CR

B Dyrenium

B Edarbi

B Edarbyclor

B Edecrin

g Enalapril


g Enalapril-Hydrochlorothiazide

B Epaned

g Eplerenone

g Eprosartan

g Ethacrynic Acid

B Exforge E

B Exforge HCT E

g Felodipine ER

g Fosinopril

g Fosinopril-Hydrochlorothiazide

g Furosemide

g Guanfacine

g Hydralazine

g Hydrochlorothiazide

B Hyzaar E

g Indapamide

B Inderal

B Inderal LA E

B Inderal XL E

B Innopran XL E

B Inspra E

g Irbesartan

g Irbesartan - Hydrochlorothiazide

B Isoptin SR

g Isradipine

B Kapspargo

B Katerzia

g Labetalol

B Lasix

B Levatol

g Lisinopril

g Lisinopril-Hydrochlorothiazide

B Lopressor




4


B Lopressor HCT

g Losartan

g Losartan-Hydrochlorothiazide

B Lotensin

B Lotensin HCT

B Lotrel E

g Matzim LA

B Mavik

B Maxzide

g Methyclothiazide

g Methyldopa

g Methyldopa-Hydrochlorothiazide

g Metolazone

g Metoprolol 37.5, 75 mg E

g Metoprolol Succinate

g Metoprolol Tartrate

g Metoprolol-Hydrochlorothiazide

B Micardis E

B Micardis HCT E

B Microzide

B Midamor

B Minipress

g Minoxidil

g Moexipril

g Moexipril-Hydrochlorothiazide

g Nadolol

g Nadolol-Bendroflumethazide

g Nicardipine

g Nifedipine

g Nifedipine ER

g Nimodipine

g Nisoldipine

B Norvasc E


g Olmesartan

g Olmesartan-Hydrochlorothiazide

g Perindopril

g Pindolol

g Prazosin

B Prestalia E

B Prinivil

B Procardia

B Procardia XL E

g Propranolol

g Propranolol-Hydrochlorothiazide

B Qbrelis E

g Quinapril

g Quinapril-Hydrochlorothiazide

g Ramipril

g Reserpine

B Sectral

g Spironolactone

g Spironolactone-Hydrochlorothiazide

B Sular

B Tarka

g Taztia XT

B Tekturna

B Tekturna HCT

g Telmisartan

g Telmisartan-Amlodipine E

g Telmisartan-Hydrochlorothiazide

B Tenex

B Tenoretic E

B Tenormin E

g Terazosin

B Teveten

B Teveten HCT




5


B Thalitone

B Tiazac

g Timolol1

B Toprol XL

g Torsemide

B Trandate

g Trandolapril

g Trandolapril-Verapamil

g Triamterene

g Triamterene-Hydrochlorothiazide

B Tribenzor E

B Twynsta E

B Uniretic

B Univasc

g Valsartan

g Valsartan-Hydrochlorothiazide

B Vaseretic E

B Vasotec E

g Verapamil

g Verapamil ER

g Verelan

B Verelan PM

B Zaroxolyn

B Zebeta

B Zestoretic E

B Zestril E

B Ziac

Cardiovascular/Heart Disease: High CholesterolB Altoprev E

B Antara E

g Atorvastatin

g Cholestyramine

g Cholestyramine Light


g Choline Fenofibrate E

B Colesevelam Tablets, Powder for Suspension

E

B Colestid

g Colestipol

B Crestor E

B Ezallor Sprinkle

g Ezetimibe

g Fenofibrate 43, 50 , 67, 130, 134, 150, 200 mg Capsule

E

g Fenofibrate 40, 48, 120 mg Tablet E

g Fenofibrate 54, 145, 160 mg Tablet

g Fenofibric Acid E

B Fenoglide E

B Fibricor E

B Flolipid

g Fluvastatin

g Fluvastatin ER

g Gemfibrozil

g Icosapent E

B Lescol

B Lescol XL E

B Lipitor E

B Lipofen E

B Livalo E

B Lofibra E

B Lopid

g Lovastatin

B Lovaza E

B Mevacor

B Nexletol

B Nexlizet

g Niacin Extended-Release




6


B Niacor E

B Niaspan

g Omega-3 Acid Ethyl Esters

B Pravachol

g Pravastatin

g Prevalite

B Questran

B Questran Light

g Rosuvastatin

g Simvastatin

g Simvastatin/Ezetimibe

B Tricor E

B Triglide E

B Trilipix E

B Vascepa E

B Vytorin E

B Welchol

B Zetia E

B Zocor E

B Zypitamag E

Central Nervous System: Mental HealthB Abilify, Abilify Mycite E

g Aripiprazole

g Asenapine E

B Caplyta

g Chlorpromazine

g Clozapine

B Clozaril

B Fanapt

B FazaClo

g Fluphenazine

B Geodon E

g Haloperidol


B Invega E

B Latuda

g Loxapine

g Molindone

g Olanzapine

g Paliperidone ER

g Perphenazine

g Quetiapine

g Quetiapine ER

B Rexulti

B Risperdal E

g Risperidone

B Saphris

B Secuado E

B Seroquel E

B Seroquel XR E

g Thioridazine

g Thiothixene

g Trifluoperazine

B Vraylar

B Versacloz E

g Ziprasidone

g Zyprexa E

Central Nervous System: Multiple SclerosisB Aubagio

B Avonex

B Bafiertam

B Betaseron

g Copaxone E

g Dimethyl Fumarate (generic Tecfidera)

g Extavia E

B Gilenya

g Glatiramer Acetate (generic Copaxone)




7


g Glatopa

B Kesimpta

B Mavenclad

B Mayzent

B Plegridy

B Rebif

B Tecfidera E

B Vumerity E

B Zeposia

Depression: Selective Serotonin Reuptake Inhibitors (SSRIs)2

B Celexa E

g Citalopram

g Escitalopram

g Fluoxetine Capsules

g Fluoxetine 10 mg, 20 mg Tablets

g Fluoxetine 60 mg Tablets E

g Fluvoxamine

g Fluvoxamine Extended-Release

B Lexapro E

g Paroxetine

g Paroxetine Extended-Release

B Paxil E

B Paxil CR E

B Pexeva E

B Prozac E

g Sertraline

B Zoloft E

Diabetes: Diabetic SuppliesB Accu-Chek Guide Meters

B Accu-Chek Guide Test Strips

B Contour Next EZ Meters

B Contour Next Meters


B Contour Next One Meters

B Contour Next Test Strips

g Diabetic Testing - Lancets

g Insulin Needles/Syringes

B OneTouch Diabetic Meters

B OneTouch Diabetic Test Strips

Diabetes: InsulinB Admelog, Admelog SoloStar E

B Afrezza E

B Apidra, Apidra SoloStar E

B Basaglar E

B Fiasp, Fiasp FlexTouch E

B Humalog

B Humalog Junior

B Humalog Mix 50/50

B Humalog Mix 75/25

B Humulin 50/50

B Humulin 70/30

B Humulin N

B Humulin R

B Insulin Aspart E

B Insulin Aspart Protamine/Insulin Aspart E

B Insulin Lispro E

B Insulin Lispro Jr. E

B Insulin Lispro Protamine/Insulin Lispro 75/25

E

B Lantus

B Levemir E

B Lyumjev

B Novolin 70/30 E

B Novolin N E

B Novolin R E

B Novolog E




8


B Novolog Mix 70/30 E

B Semglee E

B Soliqua

B Toujeo

B Tresiba E

Diabetes: Non-Insuling Acarbose

B ACTOplus Met

B ACTOplus Met XR

B Actos E

B Adlyxin

B Alogliptin E

B Alogliptin-Metformin E

B Alogliptin-Pioglitazone E

B Amaryl

B Avandia

B Bydureon

B Bydureon BCise

B Byetta

B Cycloset

B Diabeta

B Duetact

B Farxiga E

B Fortamet E

g Glimepiride

g Glipizide

g Glipizide ER

g Glipizide-Metformin

B Glucophage

B Glucophage XR

B Glucotrol

B Glucotrol XL

B Glucovance


B Glumetza E

g Glyburide

g Glyburide Micronized

g Glyburide-Metformin

B Glynase

B Glyset

B Glyxambi

B Invokamet E

B Invokamet XR E

B Invokana E

B Janumet E

B Janumet XR E

B Januvia E

B Jardiance

B Jentadueto

B Jentadueto XR

B Kazano

B Kombiglyze XR

g Metformin

g Metformin ER (generic Fortamet) E

g Metformin ER (generic Glucophage XR)

g Metformin ER (generic Glumetza) E

g Metformin Solution (generic Riomet)

g Miglitol

g Nateglinide

B Nesina

B Onglyza

B Oseni

B Ozempic

g Pioglitazone

g Pioglitazone-Glimepiride

g Pioglitazone-Metformin

B PrandiMet




9


B Prandin

B Precose

B Qtern E

g Repaglinide

g Repaglinide-Metformin

B Riomet E

B Riomet ER

B Rybelsus

B Segluromet E

B Starlix

B Steglatro E

B Steglujan E

B SymlinPen

B Synjardy

B Synjardy XR

g Tolbutamide

B Tradjenta

B Trijardy XR

B Trulicity

B Victoza

B Xigduo XR E

B Xultophy E

HIVg Abacavir

g Abacavir-Lamivudine

g Abacavir-Lamivudine-Zidovudine

B Aptivus

g Atazanavir

B Atripla E

B Biktarvy

B Cimduo

B Combivir

B Complera


B Crixivan

B Delstrigo

B Descovy E

g Didanosine

B Dovato

B Edurant

g Efavirenz

g Efavirenz-Emtricitabine-Tenofovir Disoproxil Fumarate (generic Atripla)

E

g Efavirenz-Lamivudine (generic Symfi, Symfi Lo)

g Emtricitabine

g Emtricitabine-Tenofovir Disoproxil Fumarate (generic Truvada)

B Emtriva

B Epivir

B Epzicom E

B Evotaz

g Fosamprenavir

B Fuzeon

B Genvoya

B Intelence

B Invirase

B Isentress

B Isentress HD

B Juluca

B Kaletra

g Lamivudine

g Lamivudine-Zidovudine

B Lexiva E

g Lopinavir-Ritonavir

g Nevirapine

g Nevirapine Extended-Release E

B Norvir Tablet E




10


B Odefsey

B Pifeltro

B Prezcobix

B Prezista

B Rescriptor

B Retrovir

B Reyataz E

B Ritonavir

B Rukobia

B Selzentry

g Stavudine

B Stribild

B Sustiva E

B Symfi

B Symfi Lo

B Symtuza E

B Temixys E

g Tenofovir

B Tivicay

B Tivicay PD

B Triumeq

B Trizivir E

B Truvada E

B Videx

B Videx EC

B Viracept

B Viramune E

B Viramune XR E

B Viread E

B Viteka

B Vocabria E

B Zerit

B Ziagen

g Zidovudine


Immunosuppressant: Organ RejectionB Astagraf XL E

B Azasan

g Azathioprine

B Cellcept E

g Cyclosporine

B Envarsus XR E

g Everolimus

g Gengraf

B Imuran E

g Mycophenolate

g Mycophenolic Acid

B Myfortic E

B Neoral E

B Prograf

B Rapamune E

B Sandimmune E

g Sirolimus

g Tacrolimus

B Zortress E

Musculoskeletal: OsteoporosisB Actonel E

g Alendronate

B Atelvia E

B Binosto E

B Boniva

g Calcitonin (salmon)

B Didronel

g Etidronate

B Evista E

B Forteo E

B Fortical

B Fosamax




11


B Fosamax Plus D

g Ibandronate

B Miacalcin

g Raloxifene

g Risedronate

B Teriparatide

B Tymlos

Respiratory: Asthma/COPDB Accolate

B Accuneb

B Advair Diskus

B Advair HFA

B AirDuo Digihaler E

B AirDuo RespiClick E

B Albuterol HFA (generic ProAir HFA, Proventil HFA)

B Albuterol HFA (Ventolin HFA authorized generic)

E

g Albuterol Nebulized Solution

g Albuterol Oral Tablet

B Alvesco E

g Aminophylline

B Anoro Ellipta

B ArmonAir Digihaler E

B ArmonAir RespiClick E

B Arnuity Ellipta

B Asmanex HFA E

B Asmanex Twisthaler E

B Atrovent HFA

B Bevespi Aerosphere

B Breo Ellipta

B Breztri Aerosphere

B Brovana


B Budesonide/Formoterol (Symbicort Authorized Generic)

E

g Budesonide Nebulized Solution

B Combivent Respimat

g Cromolyn

B Daliresp

B Duaklir Pressair E

B Dulera E

B Duoneb

B Elixophyllin

B Flovent Diskus

B Flovent HFA

g Fluticasone/Salmeterol Diskus E

g Fluticasone/Salmeterol RespiClick

B Foradil

B Gastrocrom E

B Incruse Ellipta E

g Ipratropium

g Ipratropium/Albuterol

B Levalbuterol HFA

g Levalbuterol Nebulized Solution

B Lonhala Magnair E

B Lufyllin

g Metaproterenol

g Montelukast

B Perforomist

B ProAir Digihaler E

B Proair HFA E

B Proair RespiClick E

B Proventil HFA E

B Pulmicort Flexhaler

B Pulmicort Nebulized Solution E

B QVAR Redihaler E




12


B Serevent Diskus

B Singulair E

B Spiriva HandiHaler

B Spiriva Respimat

B Stiolto Respimat E

B Striverdi Respimat

B Symbicort

g Terbutaline

B Theo-24

g Theophylline

g Theophylline/Guaifenesin

B Trelegy Ellipta

B Tudorza Pressair E

B Ventolin HFA E

B VoSpire ER

B Yupelri

B Xopenex HFA

B Xopenex Nebulized Solution E

g Zafirlukast

B Zyflo

B Zyflo CR

Vitaminsg Pediatric Flouride Preparations (for

example: Florvite, Poly-Vi-Flor, Tri-Vi-Flor) - Brand Name and Generic Products

g Prenatal Vitamins (for example: Citranatal Assure, Prenate DHA, Stuartnatal) - Brand Name and Generic Products

Index

13

A

Abacavir ................................................ 9Abacavir-Lamivudine............................ 9Abacavir-Lamivudine-Zidovudine ....... 9Abilify, Abilify Mycite ............................ 6Acarbose ............................................... 8Accolate .............................................. 11Accu-Chek Guide Meters .................... 7Accu-Chek Guide Test Strips .............. 7Accuneb .............................................. 11Accupril ................................................. 2Accuretic ............................................... 2Acebutolol ............................................. 2Aceon .................................................... 2Actonel ................................................ 10ACTOplus Met ...................................... 8ACTOplus Met XR ................................ 8Actos ...................................................... 8Adalat CC .............................................. 2Adlyxin ................................................... 8Admelog, Admelog SoloStar ............... 7Advair Diskus ...................................... 11Advair HFA .......................................... 11Afeditab ................................................. 2Afrezza ................................................... 7Aggrenox ............................................... 1AirDuo Digihaler ................................. 11AirDuo RespiClick .............................. 11Albuterol HFA ...................................... 11Albuterol Nebulized Solution ............ 11Albuterol Oral Tablet .......................... 11Aldactazide ........................................... 2Aldactone .............................................. 2Alendronate......................................... 10Aliskiren ................................................. 2Alogliptin ............................................... 8Alogliptin-Metformin............................. 8Alogliptin-Pioglitazone ......................... 8Altace ..................................................... 2Altoprev ................................................. 5Alvesco ................................................ 11Amaryl ................................................... 8Amiloride ............................................... 2Amiloride-Hydrochlorothiazide ........... 2Aminophylline ..................................... 11Amlodipine ............................................ 2Amlodipine-Benazepril ........................ 2Amlodipine-Olmesartan....................... 2

Amlodipine-Olmesartan-Hydrochlorothiazide ......................... 2

Amlodipine-Valsartan ........................... 2Amlodipine-Valsartan-

Hydrochlorothiazide ......................... 2Amturnide .............................................. 2Anastrozole ........................................... 1Anoro Ellipta ........................................ 11Antara .................................................... 5Apidra, Apidra SoloStar ....................... 7Aptivus ................................................... 9Arimidex ................................................ 1Aripiprazole ........................................... 6Arixtra .................................................... 1ArmonAir Digihaler ............................. 11ArmonAir RespiClick .......................... 11Arnuity Ellipta ...................................... 11Aromasin ............................................... 1Asenapine ............................................ 6Asmanex HFA ..................................... 11Asmanex Twisthaler ........................... 11Aspirin-Dipyridamole............................ 1Astagraf XL ......................................... 10Atacand ................................................. 2Atacand HCT ........................................ 2Atazanavir .............................................. 9Atelvia .................................................. 10Atenolol ................................................. 2Atenolol-Chlorthalidone ....................... 2Atorvastatin ........................................... 5Atripla .................................................... 9Atrovent HFA ....................................... 11Aubagio ................................................. 6Avalide ................................................... 2Avandia .................................................. 8Avapro ................................................... 2Avonex ................................................... 6Azasan ................................................. 10Azathioprine ........................................ 10Azor ........................................................ 2

B

Bafiertam ............................................... 6Basaglar ................................................ 7Benazepril ............................................. 2Benazepril-Hydrochlorothiazide ......... 2Benicar .................................................. 2Benicar HCT.......................................... 2Betaseron .............................................. 6

Betaxolol ............................................... 2Bevespi Aerosphere ........................... 11Bevyxxa ................................................. 1Bidil ........................................................ 2Biktarvy ................................................. 9Binosto ................................................ 10Bisoprolol .............................................. 2Bisoprolol-Hydrochlorothiazide .......... 2Boniva .................................................. 10Breo Ellipta .......................................... 11Breztri Aerosphere ............................. 11Brilinta.................................................... 1Brovana ............................................... 11Budesonide Nebulized Solution ....... 11Budesonide/Formoterol .................... 11Bumetanide ........................................... 2Bydureon ............................................... 8Bydureon BCise .................................... 8Byetta .................................................... 8Bystolic .................................................. 2Byvalson ................................................ 2

C

Calan ...................................................... 2Calan SR ............................................... 2Calcitonin (salmon) ............................. 10Candesartan ......................................... 2Candesartan-Hydrochlorothiazide ..... 2Caplyta .................................................. 6Captopril ................................................ 2Captopril-Hydrochlorothiazide ............ 2Cardene SR ........................................... 2Cardizem ............................................... 2Cardizem CD ......................................... 2Cardizem LA ......................................... 2Cardura .................................................. 2Carospir ................................................. 2Cartia XT ............................................... 2Carvedilol .............................................. 2Carvedilol ER ........................................ 2Catapres ................................................ 3Catapres TTS ........................................ 3Celexa .................................................... 7Cellcept E ............................................ 10Chlorothiazide ....................................... 3Chlorpromazine .................................... 6Cholestyramine .................................... 5Cholestyramine Light ........................... 5Choline Fenofibrate .............................. 5

14

Cilostazol ............................................... 1Cimduo .................................................. 9Citalopram ............................................. 7Clonidine ............................................... 3Clonidine Patch .................................... 3Clopidogrel ........................................... 1Clorpress ............................................... 3Clozapine .............................................. 6Clozaril ................................................... 6Colesevelam Tablets, Powder for

Suspension ........................................ 5Colestid ................................................. 5Colestipol .............................................. 5Combivent Respimat.......................... 11Combivir ................................................ 9Complera ............................................... 9Conjupri ................................................. 3Contour Next EZ Meters ...................... 7Contour Next Meters ............................ 7Contour Next One Meters ................... 7Contour Next Test Strips ..................... 7Copaxone .............................................. 6Coreg ..................................................... 3Coreg CR .............................................. 3Corgard ................................................. 3Corzide .................................................. 3Coumadin .............................................. 1Covera HS ............................................. 3Cozaar ................................................... 3Crestor ................................................... 5Crixivan .................................................. 9Cromolyn ............................................. 11Cycloset ................................................. 8Cyclosporine ....................................... 10

D

Daliresp ............................................... 11Delstrigo ................................................ 9Demadex ............................................... 3Descovy ................................................. 9Diabeta .................................................. 8Diabetic Testing - Lancets ................... 7Didanosine ............................................ 9Didronel ............................................... 10Dilacor XR ............................................. 3Dilt CD ................................................... 3Dilt XR .................................................... 3Diltia XT ................................................. 3Diltiazem ................................................ 3Diltiazem ER .......................................... 3Diltzac ER .............................................. 3

Dimethyl Fumarate ............................... 6Diovan .................................................... 3Diovan HCT ........................................... 3Dipyridamole ......................................... 1Diuril ....................................................... 3Dovato ................................................... 9Doxazosin .............................................. 3Duaklir Pressair .................................. 11Duetact .................................................. 8Dulera .................................................. 11Duoneb ................................................ 11Dutoprol ................................................. 3Dyazide .................................................. 3Dynacirc CR .......................................... 3Dyrenium ............................................... 3

E

Edarbi .................................................... 3Edarbyclor ............................................. 3Edecrin .................................................. 3Edurant .................................................. 9Efavirenz ................................................ 9Efavirenz-Emtricitabine-Tenofovir

Disoproxil Fumarate ......................... 9Efavirenz-Lamivudine ........................... 9Effient ..................................................... 1Eliquis .................................................... 1Elixophyllin .......................................... 11Emtricitabine ......................................... 9Emtricitabine-Tenofovir Disoproxil

Fumarate ............................................ 9Emtriva ................................................... 9Enalapril ................................................. 3Enalapril-Hydrochlorothiazide ............. 3Enoxaparin ............................................ 1Envarsus XR ........................................ 10Epaned .................................................. 3Epivir ...................................................... 9Eplerenone ............................................ 3Eprosartan ............................................ 3Epzicom ................................................. 9Escitalopram ......................................... 7Ethacrynic Acid ..................................... 3Etidronate ............................................ 10Everolimus ........................................... 10Evista ................................................... 10Evotaz .................................................... 9Exemestane .......................................... 1Exforge .................................................. 3Exforge HCT ......................................... 3Extavia ................................................... 6

Ezallor Sprinkle ..................................... 5Ezetimibe ...........................................5, 6

F

Fanapt .................................................... 6Fareston ................................................ 1Farxiga ................................................... 8FazaClo.................................................. 6Felodipine ER ........................................ 3Femara................................................... 1Fenofibrate 40, 48, 120 mg Tablet ...... 5Fenofibrate 43, 50 , 67, 130, 134,

150, 200 mg Capsule ....................... 5Fenofibrate 54, 145, 160 mg Tablet .... 5Fenofibric Acid ...................................... 5Fenoglide ............................................... 5Fiasp, Fiasp FlexTouch ......................... 7Fibricor .................................................. 5Flolipid ................................................... 5Flovent Diskus .................................... 11Flovent HFA ......................................... 11Fluoxetine 10 mg, 20 mg Tablets ........ 7Fluoxetine 60 mg Tablets ..................... 7Fluoxetine Capsules ............................. 7Fluphenazine ........................................ 6Fluticasone/Salmeterol Diskus ......... 11Fluticasone/Salmeterol RespiClick .. 11Fluvastatin ............................................. 5Fluvastatin ER ....................................... 5Fluvoxamine .......................................... 7Fluvoxamine Extended-Release ......... 7Fondaparinux ........................................ 1Foradil .................................................. 11Fortamet ................................................ 8Forteo .................................................. 10Fortical ................................................. 10Fosamax ........................................ 10, 11Fosamax Plus D .................................. 11Fosamprenavir ...................................... 9Fosinopril ............................................... 3Fosinopril-Hydrochlorothiazide ........... 3Fragmin.................................................. 1Furosemide ........................................... 3Fuzeon ................................................... 9

G

Gastrocrom ......................................... 11Gemfibrozil ............................................ 5Gengraf ................................................ 10Genvoya................................................. 9Geodon .................................................. 6

15

Gilenya ................................................... 6Glatiramer Acetate ............................... 6Glatopa .................................................. 7Glimepiride ............................................ 8Glipizide ................................................. 8Glipizide ER ........................................... 8Glipizide-Metformin .............................. 8Glucophage .......................................... 8Glucophage XR .................................... 8Glucotrol ................................................ 8Glucotrol XL .......................................... 8Glucovance ........................................... 8Glumetza ............................................... 8Glyburide ............................................... 8Glyburide Micronized ........................... 8Glyburide-Metformin ............................ 8Glynase .................................................. 8Glyset ..................................................... 8Glyxambi ............................................... 8Guanfacine ............................................ 3

H

Haloperidol ............................................ 6Heparin .................................................. 1Humalog ................................................ 7Humalog Junior .................................... 7Humalog Mix 50/50 .............................. 7Humalog Mix 75/25 .............................. 7Humulin 50/50 ...................................... 7Humulin 70/30 ...................................... 7Humulin N ............................................. 7Humulin R .............................................. 7Hydralazine ........................................... 3Hydrochlorothiazide ............................. 3Hyzaar.................................................... 3

I

Ibandronate ......................................... 11Icosapent .............................................. 5Imuran.................................................. 10Incruse Ellipta ..................................... 11Indapamide ........................................... 3Inderal .................................................... 3Inderal LA .............................................. 3Inderal XL .............................................. 3Innopran XL ........................................... 3Inspra ..................................................... 3Insulin Aspart ........................................ 7Insulin Aspart Protamine/Insulin

Aspart ................................................ 7Insulin Lispro ......................................... 7

Insulin Lispro Jr. .................................... 7Insulin Lispro Protamine/Insulin

Lispro 75/25 ...................................... 7Insulin Needles/Syringes ..................... 7Intelence ................................................ 9Invega .................................................... 6Invirase .................................................. 9Invokamet .............................................. 8Invokamet XR ........................................ 8Invokana ................................................ 8Ipratropium .......................................... 11Ipratropium/Albuterol ......................... 11Irbesartan .............................................. 3Irbesartan - Hydrochlorothiazide ........ 3Isentress ................................................ 9Isentress HD ......................................... 9Isoptin SR .............................................. 3Isradipine ............................................... 3

J

Jantoven ................................................ 1Janumet ................................................. 8Janumet XR ........................................... 8Januvia .................................................. 8Jardiance ............................................... 8Jentadueto ............................................ 8Jentadueto XR ...................................... 8Juluca .................................................... 9

K

Kaletra ................................................... 9Kapspargo ............................................. 3Katerzia .................................................. 3Kazano ................................................... 8Kesimpta ............................................... 7Kombiglyze XR ..................................... 8

L

Labetalol ................................................ 3Lamivudine ............................................ 9Lamivudine-Zidovudine ....................... 9Lantus .................................................... 7Lasix....................................................... 3Latuda .................................................... 6Lescol .................................................... 5Lescol XL ............................................... 5Letrozole ................................................ 1Levalbuterol HFA ................................ 11Levalbuterol Nebulized Solution ....... 11Levatol ................................................... 3Levemir .................................................. 7

Lexapro.................................................. 7Lexiva ..................................................... 9Lipitor ..................................................... 5Lipofen ................................................... 5Lisinopril ................................................ 3Lisinopril-Hydrochlorothiazide ............ 3Livalo...................................................... 5Lofibra ................................................... 5Lonhala Magnair ................................. 11Lopid ...................................................... 5Lopinavir-Ritonavir ................................ 9Lopressor ..........................................3, 4Lopressor HCT ..................................... 4Losartan ................................................ 4Losartan-Hydrochlorothiazide ............ 4Lotensin ................................................. 4Lotensin HCT ........................................ 4Lotrel ...................................................... 4Lovastatin .............................................. 5Lovaza ................................................... 5Lovenox ................................................. 2Loxapine ................................................ 6Lufyllin ................................................. 11Lyumjev ................................................. 7

M

Matzim LA ............................................. 4Mavenclad ............................................. 7Mavik ..................................................... 4Maxzide ................................................. 4Mayzent ................................................. 7Metaproterenol ................................... 11Metformin .............................................. 8Metformin ER ........................................ 8Metformin Solution ............................... 8Methyclothiazide .................................. 4Methyldopa ........................................... 4Methyldopa-Hydrochlorothiazide ....... 4Metolazone ........................................... 4Metoprolol 37.5, 75 mg ........................ 4Metoprolol Succinate ........................... 4Metoprolol Tartrate ............................... 4Metoprolol-Hydrochlorothiazide ......... 4Mevacor ................................................. 5Miacalcin ............................................. 11Micardis ................................................. 4Micardis HCT ........................................ 4Microzide ............................................... 4Midamor ................................................ 4Miglitol ................................................... 8Minipress ............................................... 4

16

Minoxidil ................................................ 4Moexipril ................................................ 4Moexipril-Hydrochlorothiazide ............ 4Molindone ............................................. 6Montelukast ........................................ 11Mycophenolate ................................... 10Mycophenolic Acid ............................. 10Myfortic ............................................... 10

N

Nadolol .................................................. 4Nadolol-Bendroflumethazide .............. 4Nateglinide ............................................ 8Neoral .................................................. 10Nesina .................................................... 8Nevirapine ............................................. 9Nevirapine Extended-Release ............ 9Nexletol .................................................. 5Nexlizet .................................................. 5Niacin Extended-Release .................... 5Niacor .................................................... 6Niaspan ................................................. 6Nicardipine ............................................ 4Nifedipine .............................................. 4Nifedipine ER ........................................ 4Nimodipine ............................................ 4Nisoldipine ............................................ 4Norvasc ................................................. 4Norvir Tablet .......................................... 9Novolin 70/30 ........................................ 7Novolin N ............................................... 7Novolin R ............................................... 7Novolog ............................................. 7, 8Novolog Mix 70/30 ............................... 8

O

Odefsey ............................................... 10Olanzapine ............................................ 6Olmesartan ........................................... 4Olmesartan-Hydrochlorothiazide........ 4Omega-3 Acid Ethyl Esters .................. 6OneTouch Diabetic Meters .................. 7OneTouch Diabetic Test Strips ............ 7Onglyza ................................................. 8Oseni...................................................... 8Ozempic ................................................ 8

P

Paliperidone ER .................................... 6Paroxetine ............................................. 7Paroxetine Extended-Release ............. 7

Paxil ....................................................... 7Paxil CR ................................................. 7Pediatric Flouride Preparations ........ 12Perforomist ......................................... 11Perindopril ............................................. 4Perphenazine ........................................ 6Persantine ............................................. 2Pexeva ................................................... 7Pifeltro ................................................. 10Pindolol .................................................. 4Pioglitazone .......................................... 8Pioglitazone-Glimepiride ..................... 8Pioglitazone-Metformin ....................... 8Plavix ...................................................... 2Plegridy.................................................. 7Pletal ...................................................... 2Pradaxa ................................................. 2PrandiMet .............................................. 8Prandin .................................................. 9Prasugrel ............................................... 2Pravachol ............................................... 6Pravastatin ............................................ 6Prazosin ................................................. 4Precose ................................................. 9Prenatal Vitamins ............................... 12Prestalia ................................................. 4Prevalite ................................................. 6Prezcobix ............................................. 10Prezista ................................................ 10Prinivil .................................................... 4ProAir Digihaler ................................... 11Proair HFA ........................................... 11ProAir HFA, Proventil HFA ................. 11Proair RespiClick ................................ 11Procardia ............................................... 4Procardia XL ......................................... 4Prograf ................................................. 10Propranolol ........................................... 4Propranolol-Hydrochlorothiazide ........ 4Proventil HFA ...................................... 11Prozac .................................................... 7Pulmicort Flexhaler ............................ 11Pulmicort Nebulized Solution ............ 11

Q

Qbrelis ................................................... 4Qtern ...................................................... 9Questran ................................................ 6Questran Light ...................................... 6Quetiapine ............................................. 6Quetiapine ER ....................................... 6

Quinapril ................................................ 4Quinapril-Hydrochlorothiazide ............ 4QVAR Redihaler .................................. 11

R

Raloxifene ........................................... 11Ramipril ................................................. 4Rapamune ........................................... 10Rebif ...................................................... 7Repaglinide ........................................... 9Repaglinide-Metformin ........................ 9Rescriptor ............................................ 10Reserpine .............................................. 4Retrovir ................................................ 10Rexulti .................................................... 6Reyataz ................................................ 10Riomet ...............................................8, 9Riomet ER ............................................. 9Risedronate ......................................... 11Risperdal ............................................... 6Risperidone ........................................... 6Ritonavir .............................................. 10Rosuvastatin ......................................... 6Rukobia ............................................... 10Rybelsus ................................................ 9

S

Sandimmune ....................................... 10Saphris .................................................. 6Savaysa ................................................. 2Sectral ................................................... 4Secuado ................................................ 6Segluromet ............................................ 9Selzentry .............................................. 10Semglee ................................................ 8Serevent Diskus .................................. 12Seroquel ................................................ 6Seroquel XR .......................................... 6Sertraline ............................................... 7Simvastatin ............................................ 6Simvastatin/Ezetimibe ......................... 6Singulair............................................... 12Sirolimus .............................................. 10Soliqua ................................................... 8Soltamox ............................................... 1Spiriva HandiHaler.............................. 12Spiriva Respimat ................................ 12Spironolactone ..................................... 4Spironolactone-Hydrochlorothiazide . 4Starlix ..................................................... 9Stavudine ............................................ 10

17

Steglatro ................................................ 9Steglujan ............................................... 9Stiolto Respimat ................................. 12Stribild ................................................. 10Striverdi Respimat .............................. 12Sular ....................................................... 4Sustiva ................................................. 10Symbicort ...................................... 11, 12Symfi ................................................9, 10Symfi Lo...........................................9, 10Symfi, Symfi Lo ..................................... 9SymlinPen ............................................. 9Symtuza ............................................... 10Synjardy ................................................. 9Synjardy XR ........................................... 9

T

Tacrolimus ........................................... 10Tamoxifen .............................................. 1Tarka ...................................................... 4Taztia XT ................................................ 4Tecfidera............................................6, 7Tekturna ................................................ 4Tekturna HCT ........................................ 4Telmisartan............................................ 4Telmisartan-Amlodipine ....................... 4Telmisartan-Hydrochlorothiazide ........ 4Temixys................................................ 10Tenex ..................................................... 4Tenofovir .............................................. 10Tenoretic ................................................ 4Tenormin ............................................... 4Terazosin ............................................... 4Terbutaline .......................................... 12Teriparatide ......................................... 11Teveten .................................................. 4Teveten HCT ......................................... 4Thalitone ................................................ 5Theo-24 ............................................... 12Theophylline........................................ 12Theophylline/Guaifenesin .................. 12Thioridazine .......................................... 6Thiothixene ............................................ 6Tiazac .................................................... 5Ticlopidine ............................................. 2Timolol ................................................... 5Tivicay .................................................. 10Tivicay PD............................................ 10Tolbutamide .......................................... 9Toprol XL ............................................... 5Toremifene ............................................ 1

Torsemide ............................................. 5Toujeo .................................................... 8Tradjenta ............................................... 9Trandate ................................................ 5Trandolapril ........................................... 5Trandolapril-Verapamil ......................... 5Trelegy Ellipta ...................................... 12Tresiba ................................................... 8Triamterene ........................................... 5Triamterene-Hydrochlorothiazide ....... 5Tribenzor ............................................... 5Tricor ...................................................... 6Trifluoperazine ...................................... 6Triglide ................................................... 6Trijardy XR ............................................. 9Trilipix..................................................... 6Triumeq ............................................... 10Trizivir ................................................... 10Trulicity .................................................. 9Truvada ............................................9, 10Tudorza Pressair ................................. 12Twynsta ................................................. 5Tymlos ................................................. 11

U

Uniretic .................................................. 5Univasc .................................................. 5

V

Valsartan ............................................... 5Valsartan-Hydrochlorothiazide ............ 5Vascepa ................................................. 6Vaseretic ................................................ 5Vasotec .................................................. 5Ventolin HFA ................................. 11, 12Verapamil .............................................. 5Verapamil ER ........................................ 5Verelan ................................................... 5Verelan PM ............................................ 5Versacloz ............................................... 6Victoza ................................................... 9Videx .................................................... 10Videx EC .............................................. 10Viracept ............................................... 10Viramune ............................................. 10Viramune XR ....................................... 10Viread .................................................. 10Viteka ................................................... 10Vocabria ............................................. 10VoSpire ER .......................................... 12Vraylar .................................................... 6

Vumerity ................................................ 7Vytorin ................................................... 6

W

Warfarin ................................................. 2Welchol .................................................. 6

X

Xarelto ................................................... 2Xigduo XR ............................................. 9Xopenex HFA ...................................... 12Xopenex Nebulized Solution ............. 12Xultophy ................................................. 9

Y

Yupelri .................................................. 12

Z

Zafirlukast ........................................... 12Zaroxolyn ............................................... 5Zebeta ................................................... 5Zeposia .................................................. 7Zerit ...................................................... 10Zestoretic .............................................. 5Zestril ..................................................... 5Zetia ....................................................... 6Ziac ........................................................ 5Ziagen .................................................. 10Zidovudine .......................................... 10Ziprasidone ........................................... 6Zocor ..................................................... 6Zoloft ..................................................... 7Zontivity ................................................. 2Zortress ............................................... 10Zyflo ..................................................... 12Zyflo CR ............................................... 12Zypitamag ............................................. 6Zyprexa .................................................. 6

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04/21 ©2021 United HealthCare Services, Inc. WF4331474-E_2021 Preventive Expanded List

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Learn more

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September 2021 Expanded Drug List - Citgo

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