2021 Preventive Medications - For Group HSA Qualified Plans - Sanford Health Plan
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2021
Preventive
Medications
For Group HSA
Qualified Plans
Managing your health with preventive medications
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 your
health care provider can help you avoid serious illness and high health care costs.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.
12021 Preventive medication list
Expanded listing by therapeutic category
ANTIDEPRESSANTS perphenazine DALIRESP
PERSERIS‡ difil-g forte
CELEXA
prochlorperazine DULERA
citalopram
quetiapine ELIXOPHYLLIN
escitalopram
quetiapine er FLOVENT DISKUS
fluoxetine
REXULTI FLOVENT HFA
fluoxetine dr
RISPERDAL fluticasone/salmeterol diskus
fluvoxamine
RISPERDAL CONSTA‡ FLUTICASONE PROPIONATE?
fluvoxamine er
risperidone SALMETEROL INH
LEXAPRO
risperidone odt INCRUSE ELLIPTA
paroxetine
SAPHRIS ipratropium
PAXIL
SEROQUEL ipratropium/albuterol
PAXIL CR
SEROQUEL XR isoproterenol aer
paroxetine ER
SYMBYAX levalbuterol
PEXEVA
thioridazine LEVALBUTEROL HFA
PROZAC
thiothixene LONHALA MAGNAIR
sertraline
trifluoperazine metaproterenol
ZOLOFT
VERSACLOZ montelukast
VRAYLAR PEAK FLOW METERS‡
ANTIPSYCHOTICS ziprasidone PERFOROMIST
ABILIFY ZYPREXA PROAIR HFA
ABILIFY MAINTENA‡ ZYPREXA RELPREVV‡ PROAIR DIGIHALER
ABILIFY MYCITE‡ ZYPREXA ZYDIS PROAIR RESPICLICK
ADASUVE PROVENTIL HFA
aripiprazole ASTHMA AND COPD PULMICORT
aripiprazole odt PULMICORT FLEXHALER
ACCOLATE
ARISTADA‡ QVAR
ADVAIR DISKUS
ARISTADA INITIO‡ QVAR REDIHALER
ADVAIR HFA
CAPLYTA SEEBRI NEOHALER
AIRDUO DIGIHALER
chlorpromazine SEREVENT DISKUS
AIRDUO RESPICLICK
clozapine SINGULAIR
albuterol sulfate
clozapine odt SPIRIVA HANDIHALER
albuterol sulfate er
CLOZARIL SPIRIVA RESPIMAT
ALBUTEROL SULFATE HFA
compro STIOLTO RESPIMAT
albuterol sulfate hfa
EQUETRO STRIVERDI RESPIMAT
ALVESCO
FANAPT SYMBICORT
ANORO ELLIPTA
FAZACLO terbutaline
ARCAPTA NEOHALER
fluphenazine THEO-24
ARMONAIR DIGIHALER
GEODON theophylline
ARNUITY ELLIPTA
haloperidol theophylline cr
ASMANEX HFA
INVEGA theophylline er
ASMANEX TWISTHALER
INVEGA SUSTENNA‡ TRELEGY ELLIPTA
ATROVENT HFA
INVEGA TRINZA‡ TUDORZA PRESSAIR
BEVESPI AEROSPHERE
LATUDA UTIBRON NEOHALER
BREO ELLIPTA
loxapine VENTOLIN HFA
BREZTRI AEROSPHERE
molindone wixela inhub
BROVANA
NUPLAZID XOPENEX
budesonide
olanzapine XOPENEX CONCENTRATE
BUDESONIDE/FORMOTEROL AER
olanzapine odt XOPENEX HFA
COMBIVENT RESPIMAT
olanzapine/fluoxetine YUPELRI
cromolyn
paliperidone er zafirlukast
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 22021 Preventive medication list (cont.)
zileuton er dipyridamole BETAPACE
ZYFLO DURLAZA betaxolol tablet
ZYFLO CR EFFIENT BIDIL
ELIQUIS bisoprolol
CANCER enoxaparin SP bisoprolol/hctz
anastrozole fondaparinux SP BLOOD PRESSURE
ARIMIDEX FRAGMIN SP MONITORS ‡
AROMASIN heparin bumetanide
EVISTA jantoven BUMEX
exemestane LOVENOX SP BYSTOLIC
FARESTON PLAVIX BYVALSON
FEMARA PLETAL CALAN
letrozole PRADAXA CALAN SR
raloxifene prasugrel candesartan
SOLTAMOX SAVAYSA candesartan /hctz
tamoxifen warfarin captopril
toremifene XARELTO captopril/hctz
YOSPRALA CARDIZEM
CARDIOVASCULAR/ ZONTIVITY CARDIZEM CD
CARDIZEM LA
HEART DISEASE Cardiac Glycosides
CARDURA
Anti-Anginal Agents digitek CAROSPIR
DILATRATE SR digox cartia xt
GONITRO digoxin carvedilol
ISORDIL TITRADOSE LANOXIN carvedilol er
isosorbide dinitrate High Blood Pressure CATAPRES
isosorbide dinitrate er CATAPRES-TTS
ACCUPRIL
isosorbide mononitrate chlorothiazide
ACCURETIC
isosorbide mononitrate er chlorthalidone
acebutolol
minitran clonidine
ADALAT CC
NITRO-BID CONSENSI
ALDACTAZIDE
NITRO-DUR COREG
ALDACTONE
nitroglycerin COREG CR
aliskiren
nitroglycerin er CORGARD
ALTACE
nitroglycerin lingual COZAAR
amiloride
nitroglycerin transdermal DEMADEX
amiloride/hctz
NITROLINGUAL PUMPSPRAY DEMSER
amlodipine
NITROMIST DIBENZYLINE
amlodipine/benazepril
nitro-time diltiazem
amlodipine/olmesartan
petn diltiazem er
amlodipine/valsartan
ranolazine er diltiazem cd
amlodipine/valsartan/hctz
RANEXA dilt-xr
ATACAND
DIOVAN
Anticoagulants ATACAND HCT
DIOVAN HCT
AGGRENOX atenolol
DIURIL
ARIXTRA SP atenolol/chlorthalidone
doxazosin
aspirin/dipyridamole AVALIDE
DUTOPROL
ASPIRIN/OMEPRAZOLE AVAPRO
DYAZIDE
BEVYXXA AZOR
DYRENIUM
BRILINTA benazepril
EDARBI
cilostazol benazepril /hctz
EDARBYCLOR
clopidogrel BENICAR
EDECRIN
COUMADIN BENICAR HCT
enalapril
SP
Oral and self-injectable Specialty medications may have limitations based on your plan benefit
3 ‡
Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule2021 Preventive medication list (cont.)
enalapril/hctz minoxidil tablet TRIBENZOR
EPANED moexipril TWYNSTA
eplerenone nadolol valsartan
eprosartan nadolol/bendroflumethiazide valsartan/hctz
ethacrynic acid nicardipine VASERETIC
EXFORGE nifedipine VASOTEC
EXFORGE HCT nifedipine er VECAMYL
ezide nimodipine verapamil
felodipine er nisoldipine verapamil er
FIRST - ATENOLOL ‡ nisoldipine er verapamil sr
FIRST - METOPROLOL ‡ NORVASC VERELAN
fosinopril NYMALIZE VERELAN PM
fosinopril /hctz olmesartan ZESTORETIC
furosemide olmesartan /hctz ZESTRIL
guanfacine olmesartan/amlodipine/hctz ZIAC
hydralazine perindopril High cholesterol
hydrochlorothiazide phenoxybenzamine
HYZAAR pindolol ALTOPREV
indapamide prazosin amlodipine/atorvastatin
INDERAL LA PRESTALIA ANTARA
INDERAL XL PRINIVIL atorvastatin
INNOPRAN XL PROCARDIA CADUET
INSPRA PROCARDIA XL cholestyramine
irbesartan propranolol cholestyramine light
irbesartan/hctz propranolol er colesevelam
isradipine propranolol/hctz COLESTID
KAPSPARGO SPRINKLE QBRELIS COLESTID FLAVORED
KATERZIA quinapril colestipol
labetalol quinapril/hctz CRESTOR
LASIX ramipril EZALLOR SPRINKLE
lisinopril sotalol ezetimibe
lisinopril/hctz SOTYLIZE ezetimibe/simvastatin
LOPRESSOR spironolactone fenofibrate
LOPRESSOR HCT spironolactone/hctz fenofibrate micronized
losartan potassium SULAR fenofibric acid
losartan potassium/hctz TARKA fenofibric acid dr
LOTENSIN taztia xt FENOGLIDE
LOTENSIN HCT TEKTURNA FIBRICOR
LOTREL TEKTURNA HCT FLOLIPID
matzim la telmisartan fluvastatin
MAXZIDE telmisartan/amlodipine fluvastatin er
MAXZIDE-25 telmisartan/hctz gemfibrozil
methyclothiazide TENORETIC JUXTAPID SP
methyldopa TENORMIN LESCOL XL
methyldopa/hctz terazosin LIPITOR
metolazone TIAZAC LIPOFEN
metoprolol timolol tab LIVALO
metoprolol er TOPROL XL LOPID
METOPROLOL ER/HCTZ torsemide lovastatin
metoprolol/hctz trandolapril LOVAZA
MICARDIS trandolapril/verapamil er NEXLETOL
MICARDIS HCT triamterene NEXLIZET
MINIPRESS triamterene/hctz niacin (Rx only)
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
42021 Preventive medication list (cont.)
niacin er HUMALOG MIX 50/50 AVANDIA
niacor HUMALOG MIX 50/50 KWIKPEN BYDUREON
NIASPAN HUMALOG MIX 75/25 BYDUREON BCISE
omega-3-acid ethyl esters HUMALOG MIX 75/25 KWIKPEN BYDUREON PEN
PRALUENT HUMULIN 70/30 BYETTA
PRAVACHOL HUMULIN 70/30 KWIKPEN chlorpropamide
pravastatin HUMULIN N CYCLOSET
prevalite HUMULIN N KWIKPEN DUETACT
QUESTRAN HUMULIN R FARXIGA
QUESTRAN LIGHT HUMULIN R U-500 FORTAMET
REPATHA INSULIN ASPART glimepiride
REPATHA SURECLICK INSULIN ASPART PROTAMINE/ glipizide
rosuvastatin INSULIN ASPART glipizide er
simvastatin INSULIN LISPRO glipizide xl
TRICOR INSULIN LISPRO JUNIOR glipizide/metformin
TRIGLIDE KWIKPEN GLUCOMETERS ‡
TRILIPIX INSULIN LISPRO PROTAMINE/ GLUCOTROL
VASCEPA INSULIN LISPRO KWIKPEN GLUCOTROL XL
VYTORIN LANTUS GLUCOVANCE
WELCHOL LANTUS SOLOSTAR GLUMETZA
ZETIA LEVEMIR glyburide
ZOCOR LEVEMIR FLEXTOUCH glyburide micronized
ZYPITAMAG LYUMJEV glyburide/metformin
LYUMJEV KWIKPEN GLYNASE
NOVOLIN 70/30 GLYSET
CONTRACEPTIVES ‡
NOVOLIN 70/30 FLEXPEN GLYXAMBI
This section lists contraceptive NOVOLIN 70/30 RELION INVOKAMET
categories. Please note that NOVOLIN N INVOKAMET XR
brands and generics are eligible. NOVOLIN N FLEXPEN INVOKANA
CONTRACEPTIVE PATCH NOVOLIN N RELION JANUMET
CONTRACEPTIVE RING NOVOLIN R JANUMET XR
(VAGINAL) NOVOLIN R RELION JANUVIA
EMERGENCY CONTRACEPTIVES NOVOLOG JARDIANCE
IMPLANT CONTRACEPTIVE NOVOLOG FLEXPEN JENTADUETO
INJECTABLE CONTRACEPTIVE NOVOLOG MIX 70/30 JENTADUETO XR
IUDs NOVOLOG MIX 70/30 KAZANO
ORAL CONTRACEPTIVES PREFILLED FLEXPEN KOMBIGLYZE XR
NOVOLOG PENFILL metformin
DIABETES TOUJEO MAX SOLOSTAR metformin er
Insulin TOUJEO SOLOSTAR metformin er (mod)
TRESIBA metformin er (osm)
ADMELOG
TRESIBA FLEXTOUCH metformin sol
ADMELOG SOLOSTAR
Non-insulin miglitol
AFREZZA
nateglinide
APIDRA acarbose NESINA
APIDRA SOLOSTAR ACTOPLUS MET ONGLYZA
BASAGLAR KWIKPEN ACTOPLUS MET XR OSENI
FIASP ACTOS OZEMPIC
FIASP FLEXTOUCH ADLYXIN pioglitazone
FIASP PENFILL ALOGLIPTIN pioglitazone /metformin
HUMALOG ALOGLIPTIN / METFORMIN pioglitazone-glimepiride
HUMALOG JUNIOR KWIKPEN ALOGLIPTIN / PIOGLITAZONE PRANDIN
HUMALOG KWIKPEN AMARYL
SP
Oral and self-injectable Specialty medications may have limitations based on your plan benefit
5 ‡
Where differences are noted between this formulary and your benefit plan documents, the benefit plan documents will rule2021 Preventive medication list (cont.)
PRECOSE fyavolv TALICIA
QTERN jinteli ZEGERID
repaglinide lopreeza
repaglinide/metformin MENEST
HIV/AIDS
RIOMET MENOSTAR
RYBELSUS mimvey abacavir
SEGLUROMET mimvey lo abacavir / lamivudine
SOLIQUA 100/33 MINIVELLE abacavir / lamivudine / zidovudin
STARLIX norethindrone acetate/ethinyl APTIVUS
STEGLATRO estradiol atazanavir
STEGLUJAN PREFEST ATRIPLA
SYMLINPEN PREMARIN BIKTARVY
SYNJARDY PREMPHASE CIMDUO
SYNJARDY XR PREMPRO COMBIVIR
tolazamide VIVELLE-DOT COMPLERA
tolbutamide CRIXIVAN
TRADJENTA DELSTRIGO
GASTROINTESTINAL- DESCOVY
TRIJARDY XR
TRULICITY ULCER DRUGS‡ didanosine
VICTOZA ACIPHEX DOVATO
XIGDUO XR ACIPHEX SPRINKLE EDURANT
XULTOPHY AXID efavirenz
CARAFATE efavirenz/lamivudine/tenofovir
cimetidine EMTRIVA
ESTROGENS CYTOTEC EPIVIR
ACTIVELLA DEXILANT EPZICOM
ALORA esomeprazole magnesium EVOTAZ
amabelz ESOMEPRAZOLE STRONTIUM fosamprenavir
ANGELIQ famotidine FUZEON
CLIMARA FIRST-LANSOPRAZOLE ‡ GENVOYA
CLIMARA PRO FIRST-OMEPRAZOLE ‡ INTELENCE
COMBIPATCH lansoprazole INVIRASE
covaryx lansoprazole/amoxicillin/ ISENTRESS
covaryx HS clarithromycin ISENTRESS HD
DIVIGEL misoprostol JULUCA
dotti NEXIUM KALETRA
DUAVEE nizatidine lamivudine
eemt OMECLAMOX-PAK lamivudine / zidovudine
eemt HS omeppi LEXIVA
ELESTRIN omeprazole lopinavir / ritonavir
esterified estrogens/ omeprazole /sodium bicarbonate nevirapine
methltestosterone pantoprazole nevirapine er
esterified estrogens/ pantoprazole dr NORVIR
methltestosterone ds PEPCID ODEFSEY
esterified estrogens/ PREVACID PIFELTRO
methltestosterone hs PREVACID SOLUTAB PREZCOBIX
ESTRACE PRILOSEC PREZISTA
estradiol PROTONIX RESCRIPTOR
estradiol/norethindrone acetate PYLERA RETROVIR
ESTROGEL rabeprazole tab REYATAZ
EVAMIST RABEPRAZOLE DR SPRINKLE ritonavir
FEMHRT LOW DOSE sucralfate RUKOBIA
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 62021 Preventive medication list (cont.)
SELZENTRY EVISTA PROGRAF SP
stavudine FORTEO SP RAPAMUNE SP
STRIBILD FOSAMAX SANDIMMUNE SP
SUSTIVA FOSAMAX + D sirolimus SP
SYMFI ibandronate tacrolimus cap SP
SYMFI LO NATPARA SP ZORTRESS SP
SYMTUZA raloxifene
TEMIXYS risedronate
VITAMINS &
tenofovir risedronate dr
TIVICAY TYMLOS SP ELECTROLYTES ‡
TIVICAY PD Pediatric vitamins
TRIUMEQ with fluoride
SMOKING DETERRENTS ‡
TRIZIVIR
bupropion er (for example; POLY-VI-FLOR,
TROGARZO
CHANTIX tri-vit / fl)
TRUVADA
NICODERM CQ generic products
TYBOST
NICORETTE BRAND NAME PRODUCTS
VIDEX PEDIATRIC
VIDEX EC nicotine gum / lozenge / patch
NICOTROL INH / NS Prenatal multivitamins
VIRACEPT with iron and folic acid
VIRAMUNE ZYBAN
VIRAMUNE XR (for example; OB COMPLETE,
prenatabs RX)
VIREAD TRANSPLANT ‡
ZERIT generic products
ASTAGRAF XL SP BRAND NAME PRODUCTS
ZIAGEN AZASAN
zidovudine azathioprine
CELLCEPT SP
OSTEOPOROSIS cyclosporine SP
ACTONEL cyclosporine modified SP
alendronate ENVARSUS XR SP
ATELVIA gengraf SP
BINOSTO IMURAN
BONIVA mycophenolate SP
calcitonin-salmon mycophenolic DR SP
etidronate di MYFORTIC SP
EVENITY SP NEORAL SP
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
If you continue to use the brand medication, you will pay your cost share and potentially the cost difference between the brand and generic.
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
SVHP-3262 Rev. 10/20
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