may 2022 core drug list

Therapeutic Drug Classes Requirements & Limits

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Bold type = Brand-name drug[Plain type = Generic drug]E = May be excluded from coverage or subject to prior

authorization (sometimes referred to as precertification)1Coverage is provided for oral formulations

Pharmacy | PDL | Core Preventive

2022 Preventive Drug List for Consumer Driven Health Plans Core List

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 member ID card. This list may not be all-inclusive. Brand and generic drugs may not always be available due to market changes.

This list applies to UnitedHealthcare and Oxford medical plans. It is correct as of January 1, 2022 and is subject to change after this date. The next anticipated update will occur with the next PDL cycle.

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

Effective May 1, 2022

Therapeutic Drug Classes Requirements & Limits

Breast Cancer Prevention

Anastrozole

Arimidex

Aromasin

Exemestane

Fareston

Femara

Letrozole

Soltamox

Tamoxifen

Toremifene

E

E

E

E

E

Cardiovascular/Heart Disease: Blood Clot/Platelet Therapy

Aggrenox

Arixtra E

Aspirin-Dipyridamole

Bevyxxa

Brilinta

Cilostazol

Clopidogrel

Coumadin

Dipyridamole

Effient E

Eliquis

Therapeutic Drug Classes Requirements Therapeutic Drug Classes Requirements & Limits & Limits

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Bold type = Brand-name drug E = May be excluded from coverage or subject to prior [Plain type = Generic drug] authorization (sometimes referred to as precertification) 1Coverage is provided for oral formulations

Enoxaparin

Fragmin

Fondaparinux

Heparin

Jantoven

Lovenox E

Persantine

Plavix E

Pletal

Pradaxa

Prasugrel

Savaysa

Ticlopidine

Warfarin

Xarelto

Zontivity

g Cardiovascular/Heart Disease: High Blood Pressure

Accupril E

Accuretic

Acebutolol

Aceon

Adalat CC

Afeditab

Aldactazide

Aldactone E

Aliskiren

Altace E

Amiloride

Amiloride-Hydrochlorothiazide

Amlodipine

Amlodipine-Benazepril

Amlodipine-Olmesartan E

Amlodipine-Olmesartan-Hydrochlorothiazide

E

Amlodipine-Valsartan

Amlodipine-Valsartan-Hydrochlorothiazide E

Amturnide E

Atacand E

Atacand HCT E

Atenolol

Atenolol-Chlorthalidone

Avalide E

Avapro E

Azor E

Benazepril

Benazepril-Hydrochlorothiazide

Benicar E

Benicar HCT 1

E

Betaxolol

Bidil

Bisoprolol

Bisoprolol-Hydrochlorothiazide

Bumetanide

Bystolic E

Byvalson

Calan

Calan SR

Candesartan

Candesartan-Hydrochlorothiazide

Captopril

Captopril-Hydrochlorothiazide

Cardene SR

Cardizem E

Cardizem CD E

Cardizem LA E

Cardura

Carospir

Cartia XT

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Carvedilol

Carvedilol ER E

Catapres

Catapres TTS E

Chlorothiazide

Clonidine

Clonidine Patch

Clorpress

Conjupri E

Coreg E

Coreg CR E

Corgard

Corzide

Covera HS

Cozaar E

Demadex

Dilacor XR

Dilt CD

Dilt XR

Diltia XT

Diltiazem

Diltiazem ER

Diltzac ER

Diovan E

Diovan HCT E

Diuril

Doxazosin

Dutoprol E

Dyazide

Dynacirc CR

Dyrenium E

Edarbi

Edarbyclor

Edecrin E

Enalapril

Enalapril-Hydrochlorothiazide

Epaned

Eplerenone

Eprosartan

Ethacrynic Acid

Exforge E

Exforge HCT E

Felodipine ER

Fosinopril

Fosinopril-Hydrochlorothiazide

Furosemide

Guanfacine

Hydralazine

Hydrochlorothiazide

Hyzaar E

Indapamide

Inderal

Inderal LA E

Inderal XL E

Innopran XL E

Inspra E

Irbesartan

Irbesartan-Hydrochlorothiazide

Isoptin SR

Isradipine

Kapspargo

Katerzia

Labetalol

Lasix

Levatol

Lisinopril

Lisinopril-Hydrochlorothiazide

Lopressor

Lopressor HCT

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Losartan

Losartan-Hydrochlorothiazide

Lotensin

Lotensin HCT

Lotrel E

Matzim LA

Mavik

Maxzide

Methyclothiazide

Methyldopa

Methyldopa-Hydrochlorothiazide

Metolazone

Metoprolol 37.5, 75 mg E

Metoprolol-Hydrochlorothiazide

Metoprolol Succinate

Metoprolol Tartrate

Micardis E

Micardis HCT E

Microzide

Midamor

Minipress

Minoxidil

Moexipril

Moexipril-Hydrochlorothiazide

Nadolol

Nadolol-Bendroflumethazide

Nebivolol E

Nicardipine

Nifedipine

Nifedipine ER

Nimodipine

Nisoldipine

Norvasc E

Olmesartan

Olmesartan-Hydrochlorothiazide

Perindopril

Pindolol

Prazosin

Prestalia E

Prinivil

Procardia

Procardia XL E

Propranolol

Propranolol-Hydrochlorothiazide

Qbrelis

Quinapril

Quinapril-Hydrochlorothiazide

Ramipril

Reserpine

Sectral

Spironolactone

Spironolactone-Hydrochlorothiazide

Sular

Tarka E

Taztia XT

Tekturna

Tekturna HCT

Telmisartan

Telmisartan-Amlodipine E

Telmisartan-Hydrochlorothiazide

Tenex

Tenoretic E

Tenormin E

Terazosin

Teveten

Teveten HCT

Thalitone 15 mg E

Thalitone 25 mg

Tiazac 1Timolol

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Toprol XL E

Torsemide

Trandate

Trandolapril

Trandolapril-Verapamil

Triamterene

Triamterene-Hydrochlorothiazide

Tribenzor

Twynsta

Uniretic

Univasc

Valsartan

Valsartan-Hydrochlorothiazide

Vaseretic

Vasotec

Verapamil

Verapamil ER

Verelan

Verelan PM

Zaroxolyn

Zebeta

Zestoretic

Zestril

Ziac

Cardiovascular/Heart Disease: High Chol

Altoprev

Antara

Atorvastatin

Cholestyramine

Cholestyramine Light

Choline Fenofibrate

Colesevelam Tablets, Powder for Suspension

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E

E

E

E

E

esterol

E

E

E

E

CB

Colestid

Colestipol

Crestor E

Ezallor Sprinkle

Ezetimibe

Ezetimibe/Rosuvastain E

Fenofibrate 30, 43, 50, 67, 75, 90, 130, 134, 150, 200 mg Capsule

E

Fenofibrate 40, 48, 120 mg Tablet E

Fenofibrate 54, 145, 160 mg Tablet

Fenofibric Acid E

Fenoglide E

Fibricor E

Flolipid

Fluvastatin

Fluvastatin ER

Gemfibrozil

Icosapent E

Lescol

Lescol XL E

Lipitor E

Lipofen E

Livalo E

Lofibra E

Lopid

Lovastatin

Lovaza E

Mevacor

Nexletol

Nexlizet

Niacin Extended-Release

Niacor E

Niaspan E

Omega-3 Acid Ethyl Esters

Pravachol E

Pravastatin

Prevalite

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Questran

Questran Light

Rosuvastatin

Roszet E

Simvastatin

Simvastatin/Ezetimibe

Tricor E

Triglide E

Trilipix E

Vascepa E

Vytorin E

Welchol

Zetia E

Zocor E

Zypitamag E

B Immunosuppressant: Organ Rejection

Astagraf XL E

Azasan

Azathioprine

Cellcept E

Cyclosporine

Envarsus XR E

Everolimus

Gengraf

Imuran E

Mycophenolate

Mycophenolic Acid

Myfortic E

Neoral E

Prograf

Rapamune E

Sandimmune E

Sirolimus

Tacrolimus

Zortress E

Musculoskeletal: Osteoporosis

Vitamins

Actonel E

Alendronate

Atelvia E

Binosto E

Boniva E

Calcitonin (Salmon)

Didronel

Etidronate

Evista E

Forteo E

Fortical

Fosamax

Fosamax Plus D

Ibandronate

Miacalcin

Raloxifene

Risedronate

Teriparatide

Tymlos

Pediatric Fluoride Preparations (for example: Florvite, Poly-Vi-Flor, Tri-Vi-Flor) - Brand Name and Generic Products

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

6

IndexA

Accupril ................................................. 2Accuretic ............................................... 2Acebutolol ............................................. 2Aceon .................................................... 2Actonel .................................................. 6Adalat CC .............................................. 2Afeditab ................................................. 2Aggrenox ............................................... 1Aldactazide ........................................... 2Aldactone .............................................. 2Alendronate........................................... 6Aliskiren ................................................. 2Altace ..................................................... 2Altoprev ................................................. 5Amiloride ............................................... 2Amiloride-Hydrochlorothiazide ........... 2Amlodipine ............................................ 2Amlodipine-Benazepril ........................ 2Amlodipine-Olmesartan....................... 2Amlodipine-Olmesartan-

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

Hydrochlorothiazide ......................... 2Amturnide .............................................. 2Anastrozole ........................................... 1Antara .................................................... 5Arimidex ................................................ 1Arixtra .................................................... 1Aromasin ............................................... 1Aspirin-Dipyridamole............................ 1Astagraf XL ........................................... 6Atacand ................................................. 2Atacand HCT ........................................ 2Atelvia .................................................... 6Atenolol ................................................. 2Atenolol-Chlorthalidone ....................... 2Atorvastatin ........................................... 5Avalide ................................................... 2Avapro ................................................... 2Azasan ................................................... 6Azathioprine .......................................... 6Azor ........................................................ 2

B

Benazepril ............................................. 2

Benazepril-Hydrochlorothiazide ......... 2Benicar .................................................. 2Benicar HCT.......................................... 2Betaxolol ............................................... 2Bevyxxa ................................................. 1Bidil ........................................................ 2Binosto .................................................. 6Bisoprolol .............................................. 2Bisoprolol-Hydrochlorothiazide .......... 2Boniva .................................................... 6Brilinta.................................................... 1Bumetanide ........................................... 2Bystolic .................................................. 2Byvalson ................................................ 2

C

Calan ...................................................... 2Calan SR ............................................... 2Calcitonin (Salmon) .............................. 6Candesartan ......................................... 2Candesartan-Hydrochlorothiazide ..... 2Captopril ................................................ 2Captopril-Hydrochlorothiazide ............ 2Cardene SR ........................................... 2Cardizem ............................................... 2Cardizem CD ......................................... 2Cardizem LA ......................................... 2Cardura .................................................. 2Carospir ................................................. 2Cartia XT ............................................... 2Carvedilol .............................................. 3Carvedilol ER ........................................ 3Catapres ................................................ 3Catapres TTS ........................................ 3Cellcept ................................................. 6Chlorothiazide ....................................... 3Cholestyramine .................................... 5Cholestyramine Light ........................... 5Choline Fenofibrate .............................. 5Cilostazol ............................................... 1Clonidine ............................................... 3Clonidine Patch .................................... 3Clopidogrel ........................................... 1Clorpress ............................................... 3Colesevelam Tablets, Powder for

Suspension ........................................ 5Colestid ................................................. 5Colestipol .............................................. 5

Conjupri ................................................ 3Coreg ..................................................... 3Coreg CR .............................................. 3Corgard ................................................. 3Corzide .................................................. 3Coumadin .............................................. 1Covera HS ............................................. 3Cozaar ................................................... 3Crestor ................................................... 5Cyclosporine ......................................... 6

D

Demadex ............................................... 3Didronel ................................................. 6Dilacor XR ............................................. 3Dilt CD ................................................... 3Dilt XR .................................................... 3Diltia XT ................................................. 3Diltiazem ................................................ 3Diltiazem ER .......................................... 3Diltzac ER .............................................. 3Diovan .................................................... 3Diovan HCT ........................................... 3Dipyridamole ......................................... 1Diuril ....................................................... 3Doxazosin .............................................. 3Dutoprol ................................................. 3Dyazide .................................................. 3Dynacirc CR .......................................... 3Dyrenium ............................................... 3

E

Edarbi .................................................... 3Edarbyclor ............................................. 3Edecrin .................................................. 3Efment ..................................................... 1Eliquis .................................................... 1Enalapril ................................................. 3Enalapril-Hydrochlorothiazide ............. 3Enoxaparin ............................................ 2Envarsus XR .......................................... 6Epaned .................................................. 3Eplerenone ............................................ 3Eprosartan ............................................ 3Ethacrynic Acid ..................................... 3Etidronate .............................................. 6Everolimus ............................................. 6Evista ..................................................... 6

7

Exemestane .......................................... 1Exforge .................................................. 3Exforge HCT ......................................... 3Ezallor Sprinkle ..................................... 5Ezetimibe ........................................... 5, 6Ezetimibe/Rosuvastain ........................ 5

F

Fareston ................................................ 1Felodipine ER ........................................ 3Femara................................................... 1Fenofibrate 40, 48, 120 mg Tablet ...... 5Fenofibrate 30, 43, 50, 67, 75, 90, 130,

134, 150, 200 mg Capsule ....................... 5

Fenofibrate 54, 145, 160 mg Tablet .... 5Fenofibric Acid ...................................... 5Fenoglide ............................................... 5Fibricor .................................................. 5Flolipid ................................................... 5Fluvastatin ............................................. 5Fluvastatin ER ....................................... 5Fondaparinux ........................................ 2Forteo .................................................... 6Fortical ................................................... 6Fosamax ................................................ 6Fosamax Plus D .................................... 6Fosinopril ............................................... 3Fosinopril-Hydrochlorothiazide ........... 3Fragmin.................................................. 2Furosemide ........................................... 3

G

Gemfibrozil ............................................ 5Gengraf .................................................. 6Guanfacine ............................................ 3

H

Heparin .................................................. 2Hydralazine ........................................... 3Hydrochlorothiazide ............................. 3Hyzaar.................................................... 3

I

Ibandronate ........................................... 6Imuran.................................................... 6Indapamide ........................................... 3Inderal .................................................... 3Inderal LA .............................................. 3Inderal XL .............................................. 3

Innopran XL ........................................... 3Inspra ..................................................... 3Irbesartan .............................................. 3Irbesartan-Hydrochlorothiazide .......... 3Isoptin SR .............................................. 3Isradipine ............................................... 3

J

Jantoven ................................................ 2

K

Kapspargo ............................................. 3Katerzia .................................................. 3

L

Labetalol ................................................ 3Lasix....................................................... 3Lescol .................................................... 5Lescol XL ............................................... 5Letrozole ................................................ 1Levatol ................................................... 3Lipitor ..................................................... 5Lipofen ................................................... 5Lisinopril ................................................ 3Lisinopril-Hydrochlorothiazide ............ 3Livalo...................................................... 5Lofibra ................................................... 5Lopid ...................................................... 5Lopressor .............................................. 3Lopressor HCT ..................................... 3Losartan ................................................ 4Losartan-Hydrochlorothiazide ............ 4Lotensin ................................................. 4Lotensin HCT ........................................ 4Lotrel ...................................................... 4Lovastatin .............................................. 5Lovaza ................................................... 5Lovenox ................................................. 2

M

Matzim LA ............................................. 4Mavik ..................................................... 4Maxzide ................................................. 4Methyclothiazide .................................. 4Methyldopa ........................................... 4Methyldopa-Hydrochlorothiazide ....... 4Metolazone ........................................... 4Metoprolol 37.5, 75 mg ........................ 4Metoprolol Succinate ........................... 4Metoprolol Tartrate ............................... 4

Metoprolol-Hydrochlorothiazide ......... 4Mevacor ................................................. 5Miacalcin ............................................... 6Micardis ................................................. 4Micardis HCT ........................................ 4Microzide ............................................... 4Midamor ................................................ 4Minipress ............................................... 4Minoxidil ................................................ 4Moexipril ................................................ 4Moexipril-Hydrochlorothiazide ............ 4Mycophenolate ..................................... 6Mycophenolic Acid ............................... 6Myfortic ................................................. 6

N

Nadolol .................................................. 4Nadolol-Bendroflumethazide .............. 4Neoral .................................................... 6Nebivolol .............................................. 4Nexletol .................................................. 5Nexlizet .................................................. 5Niacin Extended-Release .................... 5Niacor .................................................... 5Niaspan ................................................. 5Nicardipine ............................................ 4Nifedipine .............................................. 4Nifedipine ER ........................................ 4Nimodipine ............................................ 4Nisoldipine ............................................ 4Norvasc ................................................. 4

O

Olmesartan ........................................... 4Olmesartan-Hydrochlorothiazide........ 4Omega-3 Acid Ethyl Esters .................. 5

P

Pediatric Fluoride Preparations .......... 6Perindopril ............................................. 4Persantine ............................................. 2Pindolol .................................................. 4Plavix ...................................................... 2Pletal ...................................................... 2Pradaxa ................................................. 2Prasugrel ............................................... 2Pravachol ............................................... 5Pravastatin ............................................ 5Prazosin ................................................. 4Prenatal Vitamins ................................. 6

8

Prestalia ................................................. 4Prevalite ................................................. 5Prinivil .................................................... 4Procardia ............................................... 4Procardia XL ......................................... 4Prograf ................................................... 6Propranolol ........................................... 4Propranolol-Hydrochlorothiazide ........ 4

Q

Qbrelis ................................................... 4Questran ................................................ 6Questran Light ...................................... 6Quinapril ................................................ 4Quinapril-Hydrochlorothiazide ............ 4

R

Raloxifene ............................................. 6Ramipril ................................................. 4Rapamune ............................................. 6Reserpine .............................................. 4Risedronate ........................................... 6Rosuvastatin ......................................... 6Roszet .................................................... 5

S

Sandimmune ......................................... 6Savaysa ................................................. 2Sectral ................................................... 4Simvastatin ............................................ 6Simvastatin/Ezetimibe ......................... 6Sirolimus ................................................ 6Soltamox ............................................... 1Spironolactone ..................................... 4Spironolactone-

Hydrochlorothiazide ......................... 4Sular ....................................................... 4

T

Tacrolimus ............................................. 6Tamoxifen .............................................. 1Tarka ...................................................... 4Taztia XT ................................................ 4Tekturna ................................................ 4Tekturna HCT ........................................ 4Telmisartan............................................ 4Telmisartan-Amlodipine ....................... 4Telmisartan-Hydrochlorothiazide ........ 4Tenex ..................................................... 4

Tenoretic ................................................ 4Tenormin ............................................... 4Terazosin ............................................... 4Teriparatide ........................................... 6Teveten .................................................. 4Teveten HCT ......................................... 4Thalitone 15 mg .................................... 4Thalitone 25 mg .................................... 4Tiazac .................................................... 4Ticlopidine ............................................. 2Timolol ................................................... 4Toprol XL ............................................... 5Toremifene ............................................ 1Torsemide ............................................. 5Trandate ................................................ 5Trandolapril ........................................... 5Trandolapril-Verapamil ......................... 5Triamterene ........................................... 5Triamterene-Hydrochlorothiazide ....... 5Tribenzor ............................................... 5Tricor ...................................................... 6Triglide ................................................... 6Trilipix..................................................... 6Twynsta ................................................. 5Tymlos ................................................... 6

U

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

V

Valsartan ............................................... 5Valsartan-Hydrochlorothiazide ............ 5Vascepa ................................................. 6Vaseretic ................................................ 5Vasotec .................................................. 5Verapamil .............................................. 5Verapamil ER ........................................ 5Verelan ................................................... 5Verelan PM ............................................ 5Vytorin ................................................... 6

W

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

X

Xarelto ................................................... 2

Y

Z

Zaroxolyn ............................................... 5Zebeta ................................................... 5Zestoretic .............................................. 5Zestril ..................................................... 5Zetia ....................................................... 6Ziac ........................................................ 5Zocor ..................................................... 6Zontivity ................................................. 2Zortress ................................................. 6Zypitamag ............................................. 6

9

Nondiscrimination notice and access to communication servicesUnitedHealthcare® and its subsidiaries do not discriminate on the basis of race, color, national origin, age, disability or sex in their 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: [email protected]

Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 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 member ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

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 member ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m., or at the times listed in your health plan documents.

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at

Learn more

Call the toll-free phone number on your member ID card to speak with customer service.

Visit the member website listed on your member ID card to look up the price of drugs covered by your plan, find lower-cost options and more.

This plan includes plan participants for a self-funded plan administered by Oxford. If you are not currently enrolled with UnitedHealthcare or Oxford for pharmacy benefit coverage, you may access your health plan’s member website 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. This document applies to commercial group members of UnitedHealthcare and Oxford New York plans.

Insurance coverage provided by or through UnitedHealthcare Insurance Company of New York or Oxford Health Insurance, Inc. Administrative services provided by UnitedHealthcare Service LLC, Oxford Health Plans LLC, or their affiliates.

12/21 ©2022 United HealthCare Services, Inc. WF5978676-A_2022 Preventive Core List

may 2022 core drug list

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