Trinity Health High Deductible Health Plan 2021
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Trinity Health High Deductible
Health Plan 2021
Preventive Medication List
Managing your health with preventive medications
Your pharmacy benefit plan includes special coverage for preventive
medications. These medications 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 told by
your healthcare provider can help you avoid serious illness and high
healthcare costs.
In this drug list, brand-name
medications are shown in
UPPERCASE (for example,
LANOXIN) and generic
medications in lowercase
(for example, digoxin).Special coverage for preventive medications The drugs on your plan’s preventive medications list do not have a deductible. This means you’ll pay your copayment/coinsurance or nothing at all, depending on your plan. It can save you money and get the medications you need to help you live a healthier life. Preventive medications are a group of products in your plan’s formulary which tells you what medications your plan covers. Please note that most medications on the formulary have a deductible, but preventive medications do not. To check the cost of any medication, see your benefit handbook or contact customer service at the member phone number on your 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 A group of doctors and pharmacists meets often to review medications and coverage under pharmacy benefit plans. They also suggest which medications should be on your plan’s preventive medications list. A list of covered preventive medications begins on the next page. Medications are listed by therapeutic category. For questions on injectable preventive medications administered by your doctor or healthcare provider, please call the number on your ID card.
2021 Preventive medication list
Expanded listing by therapeutic category
ANTIARRHYTHMIC AGENTS ANTIDEPRESSANTS ABILIFY MYCITE ‡
Adasuve
amiodarone amitriptyline aripiprazole
disopyramide amoxapine aripiprazole odt
dofetilide bupropion er Aristada ‡
flecainide bupropion xl ARISTADA INITIO ‡
propafenone citalopram CAPLYTA
propafenone er clomipramine chlorpromazine
sotalol af desipramine clozapine
sotalol desvenlafaxine er clozapine odt
ANTICONVULSANTS doxepin CLOZARIL
duloxetine dr compro
carbamazepine escitalopram
carbamazepine er EQUETRO
fluoxetine FANAPT
clobazam fluoxetine 60mg
clonazepam FAZACLO
fluoxetine dr fluphenazine
divalproex sodium dr fluvoxamine
divalproex sodium er GEODON
fluvoxamine er haloperidol
ethosuximide imipramine HCl
felbamate INVEGA
imipramine pamoate INVEGA SUSTENNA ‡
lamotrigine maprotiline
lamotrigine er INVEGA TRINZA ‡
mirtazapine LATUDA
levetiracetam nortriptyline
levetiracetam er loxapine
paroxetine molindone
oxcarbazepine paroxetine er
phenobarbital NUPLAZID
phenelzine olanzapine
phenytoin protriptyline
phenytoin er olanzapine odt
sertraline olanzapine / fluoxetine
primidone tranylcypromine
tiagabine paliperidone er
trazodone perphenazine
topiramate trimipramine
topiramate er PERSERIS ‡
venlafaxine prochlorperazine
valproic acid venlafaxine er
vigabatrin quetiapine
zonisamide ANTIPSYCHOTICS quetiapine er
ABILIFY MAINTENA ‡ REXULTI
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 ruleRISPERDAL CONSTA ‡ PERFOROMIST minitran
risperidone PULMICORT FLEXHALER NITRO-BID
risperidone odt SEREVENT DISKUS NITRO-DUR
SAPHRIS SPIRIVA HANDIHALER nitroglycerin
SYMBYAX SPIRIVA RESPIMAT nitroglycerin er
thioridazine STIOLTO RESPIMAT nitroglycerin lingual
thiothixene STRIVERDI RESPIMAT nitroglycerin transdermal
trifluoperazine SYMBICORT NITROLINGUAL PUMPSPRAY
VERSACLOZ terbutaline NITROMIST
VRAYLAR THEO-24 nitro-time
ziprasidone theophylline petn
ZYPREXA RELPREVV ‡ theophylline CR ranolazine er
ZYPREXA ZYDIS theophylline ER Anticoagulants
ASTHMA AND COPD TRELEGY ELLIPTA
wixela inhub AGGRENOX
ACCOLATE XOPENEX NEB ARIXTRA SP
ADVAIR DISKUS XOPENEX CONCENTRATE aspirin/dipyridamole
ADVAIR HFA YUPELRI BEVYXXA
albuterol sulfate zafirlukast BRILINTA
albuterol sulfate er zileuton ER cilostazol
albuterol sulfate hfa ZYFLO clopidogrel
ANORO ELLIPTA ZYFLO CR COUMADIN
ARCAPTA NEOHALER dipyridamole
ARNUITY ELLIPTA CANCER DURLAZA
ATROVENT HFA anastrozole EFFIENT
BREO ELLIPTA AROMASIN ELIQUIS
BROVANA EVISTA enoxaparin SP
budesonide sus exemestane fondaparinux SP
COMBIVENT RESPIMAT FARESTON FRAGMIN SP
cromolyn FEMARA heparin
DALIRESP letrozole jantoven
difil-g forte raloxifene LOVENOX SP
ELIXOPHYLLIN SOLTAMOX PLETAL
FLOVENT DISKUS tamoxifen PRADAXA
FLOVENT HFA toremifene prasugrel
FLUTICASONE PROPIONATE/ CARDIOVASCULAR/ SAVAYSA
SALMETEROL INH warfarin
HEART DISEASE
fluticasone/salmeterol diskus XARELTO
ipratropium Anti-Anginal Agents
ZONTIVITY
ipratropium / albuterol DILATRATE SR Cardiac Glycosides
isoproterenol aer GONITRO
levalbuterol neb ISORDIL TITRADOSE digitek
LONHALA MAGNAIR isosorbide dinitrate digox
metaproterenol isosorbide dinitrate ER digoxin
montelukast isosorbide mononitrate LANOXIN
PEAKFLOW METERS‡ isosorbide mononitrate ER
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 ruleHigh Blood Pressure CATAPRES losartan potassium
chlorothiazide losartan potassium / hctz
ACCUPRIL chlorthalidone LOTENSIN
ACCURETIC clonidine LOTENSIN HCT
acebutolol CORGARD matzim LA
ADALAT CC DEMADEX MAXZIDE
afeditab CR DEMSER MAXZIDE-25
ALDACTAZIDE DIBENZYLINE methyclothiazide
ALDACTONE dilt-xr methyldopa
aliskiren diltiazem CD methyldopa / hctz
amiloride diltiazem metolazone
amiloride / hctz diltiazem ER metoprolol er
amlodipine DIURIL METOPROLOL ER / HCTZ
amlodipine / benazepril doxazosin metoprolol
amlodipine / valsartan DUTOPROL metoprolol / hctz
amlodipine / olmesartan DYRENIUM MINIPRESS
amlodipine / valsartan / hctz EDARBI minoxidil tablet
ATACAND HCT EDARBYCLOR moexipril
atenolol EDECRIN nadolol
atenolol/chlorthalidone enalapril nadolol / bendroflumethiazide
AVALIDE enalapril / hctz nicardipine
benazepril EPANED nifedipine
benazepril / hctz eplerenone nifedipine ER
BETAPACE eprosartan nimodipine
betaxolol tablet ethacrynic acid nisoldipine ER
BIDIL ezide NYMALIZE
bisoprolol felodipine ER olmesartan
bisoprolol / hctz FIRST - ATENOLOL ‡ olmesartan / amlodipine / hctz
BLOOD PRESSURE MONITORS ‡ FIRST - METOPROLOL ‡ olmesartan / hctz
bumetanide fosinopril perindopril
BUMEX fosinopril / hctz phenoxybenzamine
BYSTOLIC furosemide pindolol
BYVALSON guanfacine prazosin
CALAN HEMANGEOL PRESTALIA
CALAN SR hydralazine PROCARDIA
candesartan hydrochlorothiazide PROCARDIA XL
candesartan / hctz indapamide propranolol
captopril INSPRA propranolol ER
captopril / hctz irbesartan propranolol / hctz
CARDIZEM irbesartan / hctz QBRELIS
CARDIZEM CD isradipine quinapril
CARDURA labetalol quinapril / hctz
CAROSPIR lisinopril ramipril
cartia XT lisinopril / hctz sotalol
carvedilol LOPRESSOR SOTYLIZE
carvedilol er LOPRESSOR HCT spironolactone
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 rulespironolactone / hctz fenofibrate HUMULIN R
SULAR fenofibrate micronized HUMULIN R U-500
TARKA fenofibric acid LANTUS
taztia XT fenofibric acid dr LANTUS SOLOSTAR
TEKTURNA FENOGLIDE TOUJEO MAX SOLOSTAR
TEKTURNA HCT FIBRICOR TOUJEO SOLOSTAR
telmisartan FLOLIPID Non-insulin
telmisartan / amlodipine fluvastatin
telmisartan / hctz fluvastatin er acarbose
TENORETIC gemfibrozil ACTOPLUS MET
terazosin JUXTAPID SP ACTOPLUS MET XR
tiadylt er LIPOFEN ACTOS
TIAZAC LOPID AMARYL
timolol (tablet) lovastatin AVANDIA
torsemide NEXLETOL BYDUREON
trandolapril NEXLIZET BYDUREON BCISE
trandolapril / verapamil er niacin (Rx only) BYDUREON PEN
triamterene niacin ER BYETTA
triamterene / hctz niacor chlorpropamide
TWYNSTA omega-3-acid ethyl esters CYCLOSET
valsartan PRALUENT DUETACT
valsartan / hctz pravastatin FARXIGA
VASERETIC prevalite glimepiride
VASOTEC REPATHA glipizide
VECAMYL REPATHA SURECLICK glipizide ER
verapamil rosuvastatin glipizide XL
verapamil ER simvastatin glipizide/metformin
verapamil SR TRILIPIX GLUCOTROL
VERELAN VASCEPA GLUCOTROL XL
VERELAN PM GLUCOVANCE
DIABETES glyburide
ZESTORETIC
Insulin glyburide / metformin
ZIAC
AFREZZA glyburide micronized
High cholesterol GLYNASE
HUMALOG
ALTOPREV HUMALOG JUNIOR KWIKPEN GLYSET
amlodipine / atorvastatin HUMALOG KWIKPEN GLYXAMBI
ANTARA HUMALOG MIX 50 / 50 JANUMET
atorvastatin HUMALOG MIX 50 / 50 JANUMET XR
CADUET KWIKPEN JANUVIA
cholestyramine HUMALOG MIX 75 / 25 JARDIANCE
cholestyramine lite HUMALOG MIX 75 / 25 JENTADUETO
colesevelam KWIKPEN JENTADUETO XR
colestipol HUMULIN 70 / 30 metformin
EZALLOR SPRINKLE HUMULIN 70 / 30 KWIKPEN metformin ER (not mod or
ezetimibe osm)
HUMULIN N
ezetimibe / simvastatin miglitol
HUMULIN N KWIKPEN
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 rulenateglinide estradiol PRILOSEC
OZEMPIC estradiol/norethindrone acetate PROTONIX PAK
pioglitazone ESTROGEL PYLERA
pioglitazone / metformin EVAMIST rabeprazole tab
pioglitazone / glimepride FEMHRT LOW DOSE sucralfate
PRANDIN fyavolv TALICIA
PRECOSE jinteli HIV/AIDS
repaglinide lopreeza
repaglinide / metformin MENEST abacavir
RIOMET MENOSTAR abacavir / lamivudine
RYBELSUS mimvey abacavir / lamivudine /
SOLIQUA 100 / 33 mimvey lo zidovudine
STARLIX MINIVELLE APTIVUS
SYMLINPEN norethindrone acetate/ethinyl atazanavir
SYNJARDY estradiol BIKTARVY
SYNJARDY XR PREFEST CIMDUO
tolazamide PREMARIN COMBIVIR
tolbutamide PREMPHASE COMPLERA
TRADJENTA PREMPRO CRIXIVAN
TRULICITY DELSTRIGO
GASTROINTESTINAL-ULCER
VICTOZA didanosine
DRUGS‡
XIGDUO XR DOVATO
XULTOPHY ACIPHEX SPRINKLE EDURANT
AXID efavirenz
ESTROGENS CARAFATE SUS efavirenz/lamivudine/tenofovir
ACTIVELLA cimetidine EMTRIVA
ALORA CYTOTEC EPIVIR
amabelz DEXILANT EPZICOM
ANGELIQ esomeprazole magnesium EVOTAZ
CLIMARA PRO ESOMEPRAZOLE STRONTIUM fosamprenavir
COMBIPATCH famotidine FUZEON
covaryx FIRST-LANSOPRAZOLE ‡ GENVOYA
covaryx HS FIRST-OMEPRAZOLE ‡ INTELENCE
DIVIGEL lansoprazole INVIRASE
dotti lansoprazole odt ISENTRESS
DUAVEE lansoprazole/amoxicillin/ ISENTRESS HD
eemt clarithromycin JULUCA
eemt HS misoprostol KALETRA
ELESTRIN NEXIUM GRA lamivudine
esterified estrogens/ nizatidine lamivudine / zidovudine
methltestosterone OMECLAMOX -PAK LEXIVA
esterified estrogens/ omeprazole lopinavir / ritonavir
methltestosterone ds pantoprazole nevirapine
esterified estrogens/ pantoprazole dr nevirapine ER
methltestosterone hs PEPCID NORVIR
ODEFSEY
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 rulePIFELTRO BINOSTO everolimus
PREZCOBIX BONIVA gengraf
PREZISTA calcitonin -salmon IMURAN
RESCRIPTOR etidronate di mycophenolate
RETROVIR EVENITY SP mycophenolic acid DR
REYATAZ EVISTA MYFORTIC
ritonavir FORTEO SP NEORAL
SELZENTRY FOSAMAX PROGRAF
stavudine FOSAMAX + D RAPAMUNE
STRIBILD ibandronate SANDIMMUNE
SUSTIVA NATPARA SP sirolimus
SYMFI PROLIA SP tacrolimus
SYMFI LO raloxifene ZORTRESS
SYMTUZA risedronate VITAMINS & ELECTROLYTETS‡
tenofovir risedronate dr
Pediatric vitamins
TIVICAY TYMLOS SP
with fluoride
TRIUMEQ SMOKING DETERRENTS ‡
TRIZIVIR (for example; POLY-VI-FLOR,
TROGARZO bupropion er tri-vit / fl)
TYBOST CHANTIX generic products
VIDEX PEDIATRIC NICODERM CQ BRAND NAME PRODUCTS
VIDEX EC NICORETTE
nicotine gum / lozenge / patch Prenatal multivitamins
VIRACEPT with iron and folic acid
VIRAMUNE NICOTROL INH / NS
VIRAMUNE XR ZYBAN Brands and generics are eligible
VIREAD TRANSPLANT ‡ dependent upon your
benefit plan formulary.
ZERIT ASTAGRAF XL
ZIAGEN AZASAN
zidovudine azathioprine
OSTEOPOROSIS CELLCEPT
ACTONEL cyclosporine
alendronate cyclosporine modified
ATELVIA ENVARSUS XR
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
This list is should be used as a reference and may not include all medications.
Brand or generic availability may not be current because of market changes.
Using generics may be required based on your plan benefit.
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