2017 Preventive Drug List for Consumer Driven Health PlansCore Plus List

2www.myuhc.com

E May be excluded from coverage. *Coverage is provided for oral formulations. Bold type = Brand name drug [Plain type = Generic drug]

2017 Preventive Drug List for Consumer Driven Health Plans - Core Plus

Alphabetical Listing – Core Plus List

A

AcarboseAccolateAccunebAccuprilAccureticAcebutololAceonActonelACTOplus MetACTOplus Met XRActos EAdalat CCAdlyxinAdvair DiskusAdvair HFAAerospan AfeditabAfrezza E AggrenoxAlbuterol Nebulized

SolutionAlbuterol Oral TabletAldactazideAldactoneAlendronateAlogliptin EAlogliptin-

Metformin E Alogliptin-Pioglitazone E

AltaceAltoprev EAlvescoAmarylAmilorideAmiloride-

HydrochlorothiazideAminophyllineAmlodipine Amlodipine-BenazeprilAmlodipine-Olmesartan E Amlodipine-Olmesartan-

Hydrochlorothiazide EAmlodipine-ValsartanAmlodipine-Valsartan-

Hydrochlorothiazide EAmturnide EAnastrozoleAnoro Ellipta Antara EArnuity ElliptaApidraArcapta NeohalerArimidex EArixtraAromasinAsmanex HFA Asmanex TwisthalerAspirin-Dipyridamole Astagraf XL E AtacandAtacand HCTAtelvia E Atenolol

Atenolol-ChlorthalidoneAtorvastatinAtrovent HFAAvalideAvandiaAvaproAzasanAzathioprineAzor E

B

Basaglar Benazepril Benazepril-

HydrochlorothiazideBenicar EBenicar HCT EBetaxolol*Bevespi Aerosphere BidilBinosto EBisoprololBisoprolol-

HydrochlorothiazideBonivaBreo Ellipta BrilintaBrovanaBudesonideBumetanideBydureon ByettaBystolicByvalson E

C

CalanCalan SRCandesartan Candesartan-

HydrochlorothiazideCalcitonin (Salmon)Captopril Captopril-

HydrochlorothiazideCardene SRCardizem ECardizem CD ECardizem LA ECardura Cartia XTCarvedilolCatapres Catapres TTSCellcept EChlorothiazideCholestyramineCholestyramine LightCholine Fenofibrate E CilostazolClonidine Clonidine PatchClopidogrel Clorpress

ColestidColestipolCombivent RespimatCoregCoreg CR ECorgardCorzideCoumadinCovera HSCozaarCrestor ECromolynCycloset Cyclosporine

D

Daliresp DemadexDiabetaDiabetic Testing - Lancets DidronelDilacor XRDilt CDDilt XRDiltia XTDiltiazemDiltiazem ERDiltzac ERDiovan EDiovan HCT EDipyridamoleDiurilDoxazosinDuetactDulera DuonebDutoprol DyazideDynacirc CRDyrenium

E

EdarbiEdarbyclor EdecrinEffientEliquisElixophyllinEnalapril Enalapril-

HydrochlorothiazideEnoxaparinEnvarsus XR E Epaned EplerenoneEprosartan Ethacrynic Acid EtidronateEvista EExemestaneExforge EExforge HCT EEzetimibe

F

FarestonFarxiga Felodipine ERFemara EFenofibrate 43, 50, 67,

130, 134, 150, 200 mg Capsule E

Fenofibrate 40, 48, 120, 145 mg Tablet E

Fenofibrate 54, 160 mg Tablet

Fenofibric Acid EFenoglide EFibricor EFlovent DiskusFlovent HFAFluvastatin Fluvastatin ER FondaparinuxForadilFortamet EForteoForticalFosinopril Fosinopril-

HydrochlorothiazideFragminFurosemide

G

GastrocromGemfibrozilGengrafGlimepirideGlipizideGlipizide ERGlipizide-MetforminGlucophageGlucophage XRGlucotrol Glucotrol XLGlucovanceGlumetza EGlyburideGlyburide MicronizedGlyburide-MetforminGlynaseGlysetGlyxambi EGuanfacine

H

HeparinHumalogHumalog Mix 50/50Humalog Mix 75/25Humulin 50/50Humulin 70/30Humulin NHumulin RHydralazineHydrochlorothiazideHyzaar

I

Ibandronate Imuran EIncruse ElliptaIndapamideInderalInderal LAInnopran XLInspraInsulin Needles/SyringesInvokamet Invokamet XRInvokana IpratropiumIpratropium/AlbuterolIrbesartanIrbesartan-

Hydrochlorothiazide Isoptin SRIsradipine

J

JantovenJanumetJanumet XR JanuviaJardiance Jentadueto Jentadueto XR

K

KazanoKombiglyze XR

E May be excluded from coverage. *Coverage is provided for oral formulations. Bold type = Brand name drug [Plain type = Generic drug]

2017 Preventive Drug List for Consumer Driven Health Plans - Core Plus

Alphabetical Listing – Core Plus List

3www.myuhc.com

L

LabetalolLantus ELasixLescolLescol XL ELetrozoleLevalbuterol HFA Levalbuterol Nebulized

Solution ELevatol LevemirLipitor ELipofen ELisinoprilLisinopril-

HydrochlorothiazideLivalo Lofibra ELopidLopressorLopressor HCTLosartanLosartan-

HydrochlorothiazideLotensin Lotensin HCTLotrelLovastatinLovaza ELovenoxLufyllin

M

Matzim LA MavikMaxzideMetaproterenolMetformin Metformin ER (generic

Fortamet) E Metformin ER (generic

Glucophage XR)Metformin ER (generic

Glumetza) E MethyclothiazideMethyldopaMethyldopa-

HydrochlorothiazideMetolazoneMetoprolol 37.5, 75 mg E Metoprolol SuccinateMetoprolol TartrateMetoprolol-

HydrochlorothiazideMevacorMiacalcinMicardis EMicardis HCT EMicrozideMidamorMiglitol Minipress

MinoxidilMoexipril Moexipril-

HydrochlorothiazideMontelukast MycophenolateMycophenolic Acid Myfortic E

N

NadololNadolol-

BendroflumethazideNateglinideNeoral ENesinaNiacin Extended-Release NiacorNiaspanNicardipineNifedipineNifedipine ERNimodipineNisoldipineNorvascNovolin 70/30Novolin N Novolin RNovologNovolog Mix 70/30

O

Olmesartan Olmesartan-

Hydrochlorothiazide Omega-3 Acid Ethyl

Esters OneTouch Diabetic

MetersOneTouch Diabetic Test

StripsOnglyzaOseni

P

Pediatric Flouride Preparations

PerforomistPerindoprilPersantinePindololPioglitazonePioglitazone-GlimepiridePioglitazone-MetforminPlavix EPletalPradaxaPrandiMetPrandinPravacholPravastatinPrazosinPrecose

Prenatal VitaminsPrestalia EPrevalitePrinivilProair HFAProair Respiclick ProcardiaProcardia XLPrograf EPropranololPropranolol-

HydrochlorothiazideProventil HFAPulmicortPulmicort Flexhaler

Q

Qbrelis E QuestranQuestran LightQuinaprilQuinapril-

HydrochlorothiazideQVAR

R

Raloxifene RamiprilRapamune ERepaglinide Repaglinide-Metformin ReserpineRiometRisedronateRosuvastatin

S

Sandimmune ESavaysaSectralSeebri NeoHaler Serevent DiskusSimvastatinSingulair ESirolimus Soliqua Soltamox ESpiriva HandiHalerSpiriva Respimat Spironolactone Spironolactone-

HydrochlorothiazideStarlixStiolto Respimat E Striverdi Respimat SularSymbicortSymlinPenSynjardy

T

TacrolimusTamoxifenTanzeum TarkaTaztia XTTekturnaTekturna HCTTelmisartanTelmisartan-Amlodipine ETelmisartan-

Hydrochlorothiazide TenexTenoretic ETenormin ETerazosinTerbutalineTeveten Teveten HCTThalitoneTheo-24TheochronTheophyllineTheophylline/GuaifenesinTiazacTiclopidineTimolol*TolbutamideToprol XLTorsemideToujeo E Tradjenta TrandateTrandolaprilTrandolapril-Verapamil Tresiba ETriamterene-

HydrochlorothiazideTribenzor ETricor ETriglide ETrilipix ETrulicity Tudorza PressairTwynsta E

U

UnireticUnivascUtibron NeoHaler

V

Valsartan Valsartan-

Hydrochlorothiazide VascepaVaseretic EVasotec EVentolin HFAVerapamilVerapamil ERVerelanVerelan PMVictozaVoSpire ERVytorin

W

WarfarinWelchol

X

XareltoXigduo XR EXopenex HFAXopenex Nebulized

Solution E

Z

ZafirlukastZaroxolynZebetaZestoretic EZestril EZetia EZiacZocorZontivity ZortressZyfloZyflo CR

4www.myuhc.com

E May be excluded from coverage. *Coverage is provided for oral formulations. Bold type = Brand name drug [Plain type = Generic drug]

2017 Preventive Drug List for Consumer Driven Health Plans - Core Plus

Listing by Therapeutic Category – Core Plus List

Breast Cancer Prevention AnastrozoleArimidex EAromasinExemestaneLetrozoleFarestonFemara ESoltamox ETamoxifen

Cardiovascular/Heart Disease - Blood Clot/Platelet Therapy AggrenoxArixtraAspirin-Dipyridamole BrilintaCilostazolClopidogrel CoumadinDipyridamoleEffientEliquisEnoxaparinFragminFondaparinux HeparinJantovenLovenoxPersantinePlavix EPletalPradaxaSavaysaTiclopidineWarfarinXareltoZontivity

Cardiovascular/Heart Disease - High Blood Pressure AccuprilAccureticAcebutololAceonAdalat CCAfeditabAldactazideAldactoneAltaceAmilorideAmiloride-HydrochlorothiazideAmlodipine Amlodipine-BenazeprilAmlodipine-Olmesartan E Amlodipine-Olmesartan-Hydrochlorothiazide EAmlodipine-Valsartan Amlodipine-Valsartan-Hydrochlorothiazide E Amturnide EAtacandAtacand HCTAtenololAtenolol-ChlorthalidoneAvalideAvaproAzor EBenazepril

Benazepril-HydrochlorothiazideBenicar EBenicar HCT EBetaxolol*BidilBisoprololBisoprolol-HydrochlorothiazideBumetanideBystolicByvalson ECalanCalan SRCandesartan Candesartan-HydrochlorothiazideCaptopril Captopril-HydrochlorothiazideCardene SRCardizem ECardizem CD ECardizem LA ECardura Cartia XTCarvedilolCatapres Catapres TTSChlorothiazideClonidine Clonidine PatchClorpressCoregCoreg CR ECorgardCorzideCovera HSCozaarDemadexDilacor XRDilt CDDilt XRDiltia XTDiltiazemDiltiazem ERDiltzac ERDiovan EDiovan HCT EDiurilDoxazosinDutoprol DyazideDynacirc CRDyreniumEdarbiEdarbyclor EdecrinEnalapril Enalapril-HydrochlorothiazideEpaned EplerenoneEprosartan Ethacrynic Acid Exforge EExforge HCT EFelodipine ERFosinopril Fosinopril-HydrochlorothiazideFurosemideGuanfacineHydralazine

5www.myuhc.com

E May be excluded from coverage. *Coverage is provided for oral formulations. Bold type = Brand name drug [Plain type = Generic drug]

2017 Preventive Drug List for Consumer Driven Health Plans - Core Plus

Listing by Therapeutic Category – Core Plus List

HydrochlorothiazideHyzaarIndapamideInderalInderal LAInnopran XLInspraIrbesartanIrbesartan-Hydrochlorothiazide Isoptin SRIsradipineLabetalolLasixLevatol LisinoprilLisinopril-HydrochlorothiazideLopressorLopressor HCTLosartanLosartan-HydrochlorothiazideLotensin Lotensin HCTLotrelMatzim LA MavikMaxzideMethyclothiazideMethyldopaMethyldopa-HydrochlorothiazideMetolazoneMetoprolol 37.5, 75 mg E Metoprolol SuccinateMetoprolol TartrateMetoprolol-HydrochlorothiazideMicardis EMicardis HCT EMicrozideMidamorMinipressMinoxidilMoexipril Moexipril-HydrochlorothiazideNadololNadolol-BendroflumethazideNicardipineNifedipineNifedipine ERNimodipineNisoldipineNorvascOlmesartan Olmesartan-Hydrochlorothiazide PerindoprilPindololPrazosinPrestalia EPrinivilProcardiaProcardia XLPropranololPropranolol-HydrochlorothiazideQbrelis E QuinaprilQuinapril-HydrochlorothiazideRamiprilReserpineSectralSpironolactone

Spironolactone-HydrochlorothiazideSularTarkaTaztia XTTekturnaTekturna HCTTelmisartanTelmisartan-Amlodipine ETelmisartan-Hydrochlorothiazide TenexTenoretic ETenormin ETerazosinTeveten Teveten HCTThalitoneTiazacTimolol* Toprol XLTorsemideTrandateTrandolaprilTrandolapril-Verapamil Triamterene-HydrochlorothiazideTribenzor ETwynsta E UnireticUnivascValsartan Valsartan-Hydrochlorothiazide Vaseretic EVasotec EVerapamilVerapamil ERVerelanVerelan PMZaroxolynZebetaZestoretic EZestril EZiac

Cardiovascular/Heart Disease - High Cholesterol Altoprev EAntara EAtorvastatinCholestyramineCholestyramine LightCholine Fenofibrate E ColestidColestipolCrestor EEzetimibeFenofibrate 43, 50, 67, 130, 134, 150, 200 mg Capsule E Fenofibrate 40, 48, 120, 145 mg Tablet E Fenofibrate 54, 160 mg Tablet Fenofibric Acid EFenoglide EFibricor EFluvastatin Fluvastatin ER GemfibrozilLescolLescol XL ELipitor ELipofen ELivalo Lofibra E

6www.myuhc.com

2017 Preventive Drug List for Consumer Driven Health Plans - Core Plus

Listing by Therapeutic Category – Core Plus List

LopidLovastatinLovaza EMevacorNiacin Extended-Release NiacorNiaspanOmega-3 Acid Ethyl Esters PravacholPravastatinPrevaliteQuestranQuestran LightRosuvastatin SimvastatinTricor ETriglide ETrilipix EVascepaVytorinWelcholZetia EZocor

Diabetes - Diabetic Supplies Diabetic Testing - Lancets Insulin Needles/SyringesOneTouch Diabetic MetersOneTouch Diabetic Test Strips

Diabetes - Insulin Afrezza E ApidraBasaglar HumalogHumalog Mix 50/50Humalog Mix 75/25Humulin 50/50Humulin 70/30Humulin NHumulin RLantus ELevemirNovolin 70/30Novolin N Novolin RNovologNovolog Mix 70/30Soliqua Toujeo E Tresiba E

Diabetes - Non-Insulin AcarboseACTOplus MetACTOplus Met XRActos EAdlyxinAlogliptin EAlogliptin-Metformin E Alogliptin-Pioglitazone E AmarylAvandiaBydureon ByettaCycloset DiabetaDuetactFarxiga

Fortamet EGlimepirideGlipizideGlipizide ERGlipizide-MetforminGlucophageGlucophage XRGlucotrol Glucotrol XLGlucovanceGlumetza EGlyburideGlyburide MicronizedGlyburide-MetforminGlynaseGlysetGlyxambi EInvokamet Invokamet XRInvokana JanumetJanumet XR JanuviaJardiance Jentadueto Jentadueto XRKazanoKombiglyze XRMetformin Metformin ER (generic Fortamet) E Metformin ER (generic Glucophage XR)Metformin ER (generic Glumetza) E Miglitol NateglinideNesinaOnglyzaOseniPioglitazonePioglitazone-GlimepiridePioglitazone-MetforminPrandiMetPrandinPrecoseRepaglinide Repaglinide-Metformin RiometStarlixSymlinPenSynjardy Tanzeum Trulicity TolbutamideTradjenta VictozaXigduo XR E

Immunosuppressant - Organ Rejection Astagraf XL E AzasanAzathioprineCellcept ECyclosporineEnvarsus XR E GengrafImuran EMycophenolateMycophenolic Acid Myfortic ENeoral E

7www.myuhc.com

2017 Preventive Drug List for Consumer Driven Health Plans - Core Plus

Listing by Therapeutic Category – Core Plus List

Prograf ERapamune ESandimmune ESirolimus TacrolimusZortress

Musculoskeletal - Osteoporosis ActonelAlendronateAtelvia E Binosto EBonivaCalcitonin (Salmon)DidronelEtidronateEvista EForteoForticalIbandronate MiacalcinRaloxifeneRisedronate

Respiratory - Asthma/COPD AccolateAccunebAdvair DiskusAdvair HFAAerospan Albuterol Nebulized SolutionAlbuterol Oral TabletAlvescoAminophyllineAnoro Ellipta Arcapta NeohalerArnuity ElliptaAsmanex HFA Asmanex TwisthalerAtrovent HFABevespi Aerosphere Breo Ellipta BrovanaBudesonideCombivent RespimatCromolynDaliresp Dulera Duoneb

ElixophyllinFlovent DiskusFlovent HFAForadilGastrocromIncruse ElliptaIpratropiumIpratropium/AlbuterolLevalbuterol HFA Levalbuterol Nebulized Solution ELufyllinMetaproterenolMontelukast PerforomistProair HFAProair Respiclick Proventil HFAPulmicortPulmicort FlexhalerQVARSeebri NeoHaler Serevent DiskusSingulair ESpiriva HandiHalerSpiriva Respimat Stiolto Respimat E Striverdi Respimat SymbicortTerbutalineTheo-24TheochronTheophyllineTheophylline/GuaifenesinTudorza PressairUtibron NeoHaler Ventolin HFAVoSpire ERXopenex HFAXopenex Nebulized Solution E ZafirlukastZyfloZyflo CR

Vitamins Pediatric Flouride Preparations (for example: Florvite, Poly-Vi-Flor,

Tri-Vi-Flor) - Brand Name and Generic ProductsPrenatal Vitamins (for example: Citranatal Assure, Prenate DHA,

Stuartnatal) - Brand Name and Generic Products

If you have pharmacy benefit coverage with UnitedHealthcare, you may learn more about your benefit by visiting myuhc.com® or by calling the toll-free member phone number on the back of your ID card. If you are not currently enrolled with UnitedHealthcare for pharmacy benefit coverage, you may access myuhc.com for additional information during your open enrollment period or you may contact your employer or health plan for additional information.

Medications are categorized by common therapeutic conditions in this reference guide for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines how these medications may be covered for you.

Where differences are noted between this reference guide and your benefit plan documents, the benefit plan documents will govern.

E May be excluded from coverage.*Coverage is provided for oral formulations. Bold type = Brand name drug [Plain type = Generic drug]

Clinical programs such as Notification/Prior Authorization, Step Therapy and Supply Limits may apply to listed medications based off your benefit plan. This list 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. The list will be updated annually.

©2017 United HealthCare Services, Inc.

Created February, 2017. For the most current PDL updates, visit myuhc.com or call toll-free member phone number on the back of your health plan ID card.

Preventive Core Plus List 7/17

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Nondiscrimination notice and access to communication servicesUnitedHealthcare® does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.

Online: UHC_Civil_Rights@uhc.com

Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, Utah 84130

You must send the complaint within 60 days of your experience. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us, including letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

9