2018 City of AustinPreventive Drug List forConsumer Driven Health PlansExpanded List80% Plan paid, no Deductible

2www.myuhc.com

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

2018 City of Austin Preventive Drug List for Consumer Driven Health Plans

Alphabetical Listing – Expanded List

A

Abacavir Abacavir-Lamivudine Abacavir-Lamivudine-

Zidovudine AcarboseAccolateAccunebAccuprilAccureticAcebutololAceonActonelACTOplus MetACTOplus Met XRAdalat CCAdlyxinAdvair DiskusAdvair HFAAerospan AfeditabAggrenoxAlbuterol Nebulized

SolutionAlbuterol Oral TabletAldactazideAldactoneAlendronateAltaceAlvescoAmarylAmilorideAmiloride-

HydrochlorothiazideAminophyllineAmlodipine Amlodipine-BenazeprilAmlodipine-ValsartanAnastrozoleAnoro Ellipta ApidraAptivusArcapta NeohalerAripiprazole ArixtraArnuity ElliptaAromasinAsmanex HFA Asmanex TwisthalerAspirin-Dipyridamole AtacandAtacand HCTAtenololAtenolol-ChlorthalidoneAtriplaAtorvastatin Atrovent HFAAubagioAvalideAvandiaAvaproAvonexAzasanAzathioprine

B

Basaglar Benazepril Benazepril-

HydrochlorothiazideBetaseronBetaxolol*Bevespi Aerosphere BidilBisoprololBisoprolol-

HydrochlorothiazideBonivaBreo Ellipta BrilintaBrovanaBudesonideBumetanideBydureon ByettaBystolic

C

CalanCalan SRCalcitonin (Salmon)Candesartan Candesartan-

HydrochlorothiazideCaptopril Captopril-

HydrochlorothiazideCardene SRCardura Cartia XTCarvedilolCatapres Catapres TTSChlorothiazideChlorpromazineCholestyramineCholestyramine LightCilostazolClonidine Clonidine PatchClopidogrel ClorpressClozapineClozarilColestidColestipolCombivent RespimatCombivirCompleraCopaxoneCoregCorgardCorzideCoumadinCovera HSCozaarCrixivanCromolynCycloset Cyclosporine

D

Daliresp DemadexDescovy DiabetaDiabetic Testing - Lancets DidanosineDidronelDilacor XRDilt CDDilt XRDiltia XTDiltiazemDiltiazem ERDiltzac ERDipyridamoleDiurilDoxazosinDuetactDuonebDyazideDynacirc CRDyrenium

E

EdarbiEdarbyclor EdecrinEdurant EffientEliquisElixophyllinEmtrivaEnalaprilEnalapril-

HydrochlorothiazideEnoxaparinEpaned EpivirEplerenoneEprosartan Ethacrynic Acid EtidronateEvotaz ExemestaneEzetimibe

F

FanaptFarestonFarxiga FazaCloFelodipine ERFenofibrate 54, 160 mg

Tablet Flovent DiskusFlovent HFAFluphenazineFluticasone/Salmeterol

Respiclick Fluvastatin Fluvastatin ER FondaparinuxForadilForteoForticalFosamax

Fosamax Plus DFosinopril Fosinopril-

HydrochlorothiazideFragminFurosemideFuzeon

G

GastrocromGemfibrozilGengrafGenvoya GilenyaGlimepirideGlipizideGlipizide ERGlipizide-MetforminGlucophageGlucophage XRGlucotrol Glucotrol XLGlucovanceGlyburideGlyburide MicronizedGlyburide-MetforminGlynaseGlysetGuanfacine

H

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

I

Ibandronate Incruse ElliptaIndapamideInderalInnopran XLInspraInsulin Needles/SyringesIntelenceInviraseInvokamet Invokamet XRInvokana IpratropiumIpratropium/AlbuterolIrbesartanIrbesartan -

Hydrochlorothiazide IsentressIsentress HD Isoptin SRIsradipine

J

JantovenJanumetJanumet XR JanuviaJardiance JentaduetoJentadueto XR

K

KaletraKazanoKombiglyze XR

L

LabetalolLamivudineLamivudine-ZidovudineLasixLatuda LescolLetrozoleLevalbuterol HFA Levatol LevemirLexivaLisinoprilLisinopril-

HydrochlorothiazideLopidLopinavir-Ritanavir LopressorLopressor HCTLosartanLosartan-

HydrochlorothiazideLotensin Lotensin HCTLotrelLovastatinLovenoxLoxapineLufyllin

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

2018 City of Austin Preventive Drug List for Consumer Driven Health Plans

Alphabetical Listing – Expanded List

3www.myuhc.com

M

Matzim LA MavikMaxzideMetaproterenolMetformin Metformin ER (generic

Glucophage XR)MethyclothiazideMethyldopaMethyldopa-

HydrochlorothiazideMetolazoneMetoprolol SuccinateMetoprolol TartrateMetoprolol-

HydrochlorothiazideMevacorMiacalcinMicrozideMidamorMiglitol MinipressMinoxidilMoexipril Moexipril-

HydrochlorothiazideMolindone Montelukast MycophenolateMycophenolic Acid

N

NadololNadolol-

BendroflumethazideNateglinideNesinaNevirapine Niacin

Extended-Release NiacorNiaspanNicardipineNifedipineNifedipine ERNimodipineNisoldipineNorvascNorvirNovolin 70/30Novolin N Novolin RNovologNovolog Mix 70/30

O

Odefsey Olanzapine Olmesartan Olmesartan-

Hydrochlorothiazide Omega-3 Acid Ethyl

Esters OneTouch Diabetic

MetersOneTouch Diabetic

Test StripsOnglyzaOseni

P

Paliperidone ER Pediatric Flouride

PreparationsPerforomistPerindoprilPerphenazinePersantinePioglitazonePioglitazone-GlimepiridePioglitazone-MetforminPindololPlegridy PletalPradaxaPrandiMetPrandinPravacholPravastatinPrazosinPrecosePrenatal VitaminsPrevalitePrezcobix PrezistaPrinivilProair HFAProair Respiclick ProcardiaProcardia XLPropranololPropranolol-

HydrochlorothiazideProventil HFAPulmicortPulmicort Flexhaler

Q

QuestranQuestran LightQuetiapine Quetiapine ER QuinaprilQuinapril-

HydrochlorothiazideQVAR

R

Raloxifene RamiprilRebifRepaglinide Repaglinide-Metformin RescriptorReserpineRetrovirRexulti ReyatazRiometRisedronate RisperidoneRosuvastatin

S

SaphrisSavaysaSectralSeebri NeoHaler SelzentrySerevent DiskusSimvastatinSimvastatin/Ezetimibe Sirolimus Soliqua Spiriva HandiHalerSpiriva Respimat Spironolactone Spironolactone-

HydrochlorothiazideStarlixStavudineStribildStriverdi Respimat SularSustivaSymbicortSymlinPenSynjardySynjardy XR

T

TacrolimusTamoxifenTanzeum TarkaTaztia XTTecfidera TekturnaTekturna HCTTelmisartanTelmisartan-

Hydrochlorothiazide TenexTerazosinTerbutalineTeveten Teveten HCTThalitoneTheo-24TheochronTheophyllineTheophylline/GuaifenesinThioridazineThiothixeneTiazacTiclopidineTimolol*Tivicay TolbutamideToprol XLTorsemideTradjenta TrandateTrandolaprilTrandolapril-Verapamil Triamterene-

HydrochlorothiazideTrifluoperazineTriumeq TrizivirTrulicity TruvadaTudorza PressairTymlos

U

UnireticUnivasc

V

Valsartan Valsartan-

Hydrochlorothiazide VascepaVentolin HFAVerapamilVerapamil ERVerelanVerelan PMVictozaVidexVidex ECViraceptVireadViteka VoSpire ERVraylar

W

WarfarinWelchol

X

Xarelto

Z

ZafirlukastZaroxolynZebetaZeritZiacZiagenZidovudineZinbryta Ziprasidone ZocorZontivity Zortress ZyfloZyflo CR

4www.myuhc.com

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

2018 City of Austin Preventive Drug List for Consumer Driven Health Plans

Listing by Therapeutic Category – Expanded List

Breast Cancer Prevention AnastrozoleAromasinExemestaneFarestonLetrozoleTamoxifen

Cardiovascular/Heart Disease - Blood Clot/Platelet Therapy AggrenoxArixtraAspirin-Dipyridamole BrilintaCilostazolClopidogrel CoumadinDipyridamoleEffientEliquisEnoxaparinFondaparinuxFragminHeparinJantovenLovenoxPersantinePletalPradaxaSavaysaTiclopidineWarfarinXareltoZontivity

Cardiovascular/Heart Disease - High Blood Pressure AccuprilAccureticAcebutololAceonAdalat CCAfeditabAldactazideAldactoneAltaceAmilorideAmiloride-HydrochlorothiazideAmlodipine Amlodipine-BenazeprilAmlodipine-ValsartanAtacandAtacand HCTAtenololAtenolol-ChlorthalidoneAvalideAvaproBenazepril Benazepril-HydrochlorothiazideBetaxolol*BidilBisoprololBisoprolol-HydrochlorothiazideBumetanideBystolicCalanCalan SRCandesartan Candesartan-Hydrochlorothiazide

Captopril Captopril-HydrochlorothiazideCardene SRCardura Cartia XTCarvedilolCatapres Catapres TTSChlorothiazideClonidine Clonidine PatchClorpressCoregCorgardCorzideCovera HSCozaarDemadexDilacor XRDilt CDDilt XRDiltia XTDiltiazemDiltiazem ERDiltzac ERDiurilDoxazosinDyazideDynacirc CRDyreniumEdarbiEdarbyclor EdecrinEnalapril Enalapril-HydrochlorothiazideEpaned EplerenoneEprosartan Ethacrynic Acid Felodipine ERFosinopril Fosinopril-HydrochlorothiazideFurosemideGuanfacineHydralazineHydrochlorothiazideHyzaarIndapamideInderalInnopran XLInspraIrbesartanIrbesartan - Hydrochlorothiazide Isoptin SRIsradipineLabetalolLasixLevatol LisinoprilLisinopril-HydrochlorothiazideLopressorLopressor HCTLosartanLosartan-HydrochlorothiazideLotensin Lotensin HCTLotrelMatzim LA MavikMaxzide

5www.myuhc.com

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

2018 City of Austin Preventive Drug List for Consumer Driven Health Plans

Listing by Therapeutic Category – Expanded List

MethyclothiazideMethyldopaMethyldopa-HydrochlorothiazideMetolazoneMetoprolol SuccinateMetoprolol TartrateMetoprolol-HydrochlorothiazideMicrozideMidamorMinipressMinoxidilMoexipril Moexipril-HydrochlorothiazideNadololNadolol-BendroflumethazideNicardipineNifedipineNifedipine ERNimodipineNisoldipineNorvascOlmesartan Olmesartan-Hydrochlorothiazide PerindoprilPindololPrazosinPrinivilProcardiaProcardia XLPropranololPropranolol-HydrochlorothiazideQuinaprilQuinapril-HydrochlorothiazideRamiprilReserpineSectralSpironolactone Spironolactone-HydrochlorothiazideSularTarkaTaztia XTTekturnaTekturna HCTTelmisartanTelmisartan-Hydrochlorothiazide TenexTerazosinTeveten Teveten HCTThalitoneTiazacTimolol*Toprol XLTorsemideTrandateTrandolaprilTrandolapril-VerapamilTriamterene-HydrochlorothiazideUnireticUnivascValsartan Valsartan-Hydrochlorothiazide VerapamilVerapamil ERVerelanVerelan PMZaroxolynZebetaZiac

Cardiovascular/Heart Disease - High Cholesterol Atorvastatin CholestyramineCholestyramine LightColestidColestipolEzetimibeFenofibrate 54, 160 mg Tablet Fluvastatin Fluvastatin ER GemfibrozilLescolLopidLovastatinMevacorNiacin Extended-Release NiacorNiaspanOmega-3 Acid Ethyl Esters PravacholPravastatinPrevaliteQuestranQuestran LightRosuvastatinSimvastatinSimvastatin/Ezetimibe VascepaWelcholZocor

Central Nervous System - Mental Health Aripiprazole ChlorpromazineClozapineClozarilFanaptFazaCloFluphenazineHaloperidolLatuda LoxapineMolindone Olanzapine Paliperidone ER PerphenazineQuetiapine Quetiapine ERRexulti RisperidoneSaphrisThioridazineThiothixeneTrifluoperazineVraylar Ziprasidone

Central Nervous System - Multiple Sclerosis AubagioAvonexBetaseronCopaxoneGilenyaRebifTecfideraZinbryta

6www.myuhc.com

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

2018 City of Austin Preventive Drug List for Consumer Driven Health Plans

Listing by Therapeutic Category – Expanded List

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

Diabetes - Insulin ApidraBasaglar HumalogHumalog Mix 50/50Humalog Mix 75/25Humulin 50/50Humulin 70/30Humulin NHumulin RLevemirNovolin 70/30Novolin N Novolin RNovologNovolog Mix 70/30Soliqua

Diabetes - Non-Insulin AcarboseACTOplus MetACTOplus Met XRAdlyxinAmarylAvandiaBydureon ByettaCycloset DiabetaDuetactFarxiga GlimepirideGlipizideGlipizide ERGlipizide-MetforminGlucophageGlucophage XRGlucotrol Glucotrol XLGlucovanceGlyburideGlyburide MicronizedGlyburide-MetforminGlynaseGlysetInvokamet Invokamet XRInvokana JanumetJanumet XR JanuviaJardiance Jentadueto Jentadueto XRKazanoKombiglyze XRMetformin Metformin ER (generic Glucophage XR)Miglitol NateglinideNesinaOnglyzaOseni

PioglitazonePioglitazone-GlimepiridePioglitazone-MetforminPrandiMetPrandinPrecoseRepaglinide Repaglinide-Metformin RiometStarlixSymlinPenSynjardy Synjardy XR Tanzeum TolbutamideTrulicity Tradjenta Victoza

HIV Abacavir Abacavir-Lamivudine Abacavir-Lamivudine-Zidovudine AptivusAtriplaCombivirCompleraCrixivanDescovy DidanosineEdurant EmtrivaEpivirEvotaz FuzeonGenvoya IntelenceInviraseIsentressIsentress HD KaletraLamivudineLamivudine-ZidovudineLexivaLopinavir-Ritanavir Nevirapine NorvirOdefsey Prezcobix PrezistaRescriptorRetrovirReyatazSelzentryStavudineStribildSustivaTivicay Triumeq TrizivirTruvadaVidexVidex ECViraceptVireadViteka ZeritZiagenZidovudine

7www.myuhc.com

2018 City of Austin Preventive Drug List for Consumer Driven Health Plans

Listing by Therapeutic Category – Expanded List

Immunosuppressant - Organ Rejection AzasanAzathioprineCyclosporineGengrafMycophenolateMycophenolic Acid Sirolimus TacrolimusZortress

Musculoskeletal - Osteoporosis ActonelAlendronateBonivaCalcitonin (salmon)DidronelEtidronateForteoForticalFosamaxFosamax Plus DIbandronate MiacalcinPlegridyRaloxifeneRisedronateTymlos

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

Combivent RespimatCromolynDaliresp DuonebElixophyllinFlovent DiskusFlovent HFAFluticasone/Salmeterol Respiclick ForadilGastrocromIncruse ElliptaIpratropiumIpratropium/AlbuterolLevalbuterol HFA LufyllinMetaproterenolMontelukast PerforomistProair HFAProair Respiclick Proventil HFAPulmicortPulmicort FlexhalerQVARSeebri NeoHaler Serevent DiskusSpiriva HandiHalerSpiriva Respimat Striverdi Respimat SymbicortTerbutalineTheo-24TheochronTheophyllineTheophylline/GuaifenesinTudorza PressairVentolin HFAVoSpire ERXopenex HFAZafirlukastZyfloZyflo 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 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.

*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.

©2018 United HealthCare Services, Inc.

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

2018 City of Austin Preventive Drug List for Consumer Driven Health Plans 1/18

69222-102017

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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