UnitedHealthcare Medication List Maintenance Medication …

1 Drug NameADHDGUANFACINE ERINTUNIV+Agents used for Dry MouthCAPHOSOLCEVIMELINEEVOXACGELCLAIRNEU TRASALNUMOISYNORAFATEPILOCARPINESALAGENA lzheimer s DiseaseARICEPTARICEPT 23 MG*ARICEPT ODTDONEPEZIL HCL EXELON+GALANTAMINE HBRMEMANTINENAMENDANAMENDA XR*NAMZARIC*RAZADYNERAZADYNE ERRIVASTIGMINE Asthma/Chronic Obstructive Pulmonary Disease (COPD)ACCOLATE ADVAIR DISKUS ADVAIR HFA AIRDUO RESPICLICK*ALVESCO ANORO ELLIPTADrug NameARCAPTA NEOHALER ARNUITY ELLIPTAASMANEX TWISTHALERASMANEX HFAATROVENT HFA BEVESPI AEROSPHEREBREO ELLIPTABROVANA BUDESONIDE NEBCOMBIVENT RESPIMAT DALIRESP DULERA* DUONEB DYLIX ELIXOPHYLLINFLOVENT DISKUSFLOVENT HFAFLUTICASONE/SALMETEROL (GENERIC AIRDUO RESPICLICK)

2 INCRUSE ELLIPTAIPRATROPIUM BROMIDE IPRATROPIUM-ALBUTEROLLUFYLLIN MONTELUKAST SODIUM PERFOROMIST PULMICORT PULMICORT FLEXHALER QVAR SEEBRI NEOHALER*SEREVENT DISKUS SINGULAIR+SPIRIVA HANDIHALER SPIRIVA RESPIMATSTIOLTO RESPIMAT*STRIVERDI RESPIMATDrug NameSYMBICORTTHEO-24 THEOCHRON THEOPHYLLINE ANHYDROUS TUDORZA PRESSAIR UTIBRON NEOHALER*ZILEUTON ERZAFIRLUKAST ZYFLO ZYFLO CR Blood Clots/PreventionELIQUIS PRADAXA SAVAYSAXARELTO Benign Prostatic Hyperplasia (BPH)ALFUZOSIN HCL AVODART+ CARDURA XL DOXAZOSINDUTASTERIDEDUTASTERIDE/TAMSULOS IN*FINASTERIDE FLOMAX+JALYN*PROSCAR RAPAFLO TAMSULOSIN HCL TERAZOSINUROXATRAL Breast Cancer PreventionANASTROZOLE ARIMIDEX+AROMASIN Page 1 of 7 Below is a list of all the therapeutic classes of medications included in home delivery programs.

3 The most commonly prescribed medications are included under each therapeutic class. It is not inclusive of all Maintenance medications that may be included in home delivery programs. The Maintenance Medication list was determined by taking into consideration chronic, long-term use of a Medication , frequency of dose changes and other clinical factors. If you have questions or are not sure if your Medication needs to be filled with OptumRx home delivery, call Customer Service at the phone number listed on your plan ID card. Maintenance Medication January 1, 2018 UnitedHealthcareMedication List Drug NameBreast Cancer Prevention FEMARA+LETROZOLE SOLTAMOX*TAMOXIFEN CITRATE Chest PainIMDUR ISORDIL ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE MINITRAN NITROGLYCERINNITROGLYCERIN PATCH NITRO-DURRANEXA Cholesterol/Lipid LoweringALTOPREV*ANTARA*ATORVASTATIN CALCIUM CHOLESTYRAMINE CHOLESTYRAMINE LIGHTCOLESTID COLESTIPOL HCL CRESTOR+EZETIMIBEEZETIMIBE/SIMVASTATINFE NOFIBRATE 43, 50, 67, 130,134, 150, 200 MG CAPSULE* FENOFIBRATE 40 MG, 45 MG, 120MG, 145 MG TABLET*FENOFIBRATE 54.

4 160 MG TABLETFENOFIBRIC ACID*FENOGLIDE FLOLIPIDFLUVASTATIN ERFLUVASTATIN SODIUM GEMFIBROZIL LESCOL LESCOL XL+LIPITOR+LIPOFEN* LIVALO LOPID LOVA STAT I N LOVA Z A+ MEVACOR NIACOR NIASPAN OMEGA-3-ACID ETHYL ESTERSPRAVACHOL PRAVASTATIN SODIUM PREVALITEDrug NameROSUVASTAINQUESTRAN QUESTRAN LIGHT RO S U VA STAT I NSIMVASTATIN TRICOR*TRIGLIDE* TRILIPIX*VASCEPA VYTORIN*WELCHOLZETIA+ ZOCOR ConstipationAMITIZALINZESSMOVANTIKRELIST OR TABLET*TRULANCEC ontraceptiveALTAVERA ALYACEN AMETHIA AMETHIA LOAPRI ARANELLE AVIANE AZURETTE BALZIVA BEKYREEBEYAZ*BLISOVI 24 FEBLISOVI FEBREVICON BRIELLYN CAMILA CAMRESE CAMRESE LO CAZIANT CHATEAL CRYSELLE CYCLAFEM CYCLESSA CYREDDASETTA DAYSEE DESOGEN DROSPIRENONE-ETHINYL ESTRADIOL-FOLIC ACID*DROSPIRENONE-ETHINYL ESTRADIOLELINEST EMOQUETTE ENPRESSE Drug NameENSKYCE ERRIN ESTARYLLA ESTRADIOL-FOLIC ACID*ESTROSTEP FE FALESSA KIT*FALMINA FAYOSIM*FEMYNORGENERESS FE*GIANVI GILDAGIA HEATHER INTROVALE ISIBLOOMJENCYCLA JOLESSAJOLIVETTE JULEBERJUNEL 24 FEJUNEL JUNEL FE KARIVA KELNOR 1-35 KIMIDESSKURVELOLARISSIALEENA LESSINA LEVONESTLEVONORGESTREL-ETHINYL ESTRADIOLLEVONORGESTREL-ETHINYL ESTRADIOL 150-30 (84)

5 LEVORA-28 LILLOWLO LOESTRIN FE LO MEDIA 24 FELOESTRIN LOESTRIN FE LORYNA LOSEASONIQUELOW-OGESTREL LUTERA MARLISSA MIBELAS 24 FE*MICROGESTIN MICROGESTIN FE MICRONOR MIRCETTE MONO-LINYAH MONONESSA MYZILRA N ATA Z I A Page 2 of 7 Drug NameContraceptive NORA-BE NORETHINDRONE NORETHINDRONE-ETHINYL ESTRADIOL-FERROUS FUMARATENORGESTIMATE-ETHINYL ESTADIOLNORGESTIMATE ETHINYL ESTRADIOL LONORGESTREL-ETHINY ESTRADIOLNORINYL NORLYDANORTREL NUVARING OCELLA OGESTREL ORSYTHIA ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO+ ORTHO-CEPT ORTHO-CYCLEN ORTHO-NOVUM OVCON-35 PHILITH PORTIA PREVIFEM QUARTETTE*QUASENSERANJANI*RECLIPSENRIVEL SA*SAFYRAL*SEASONIQUE SETLAKINSPRINTEC SRONYX SYEDA TAYTULLA*TILIA FE TRI-ESTARYLLA TRI-FEMYNORTRI-LEGEST FE TRI-LINYAH TRINESSA TRI-LO-ESTARYLLATRI-LO-MARZIATRI-LO SPRINTECTRI-NORINYL TRI-PREVIFEM TRI-SPRINTEC TRINESSA LOTRIVORA-28 VELIVET VESTURA Drug NameVIENVAVIORELE WERA WYMZYA FE XULANEYASMINYA Z ZARAH ZENCHENT ZENCHENT FE ZEOSA ZOVIA 1-35 EZOVIA 1-50E DepressionAPLENZIN* BUDEPRION BUDEPRION XL BUPROPION CELEXA+ CITALOPRAM CYMBALTA+ DESVENLAFAXINE (GENERIC PRISTIQ)

6 DULOXETINE EFFEXOR EFFEXOR XR+ ESCITALOPRAM FETZIMA FLUVOXAMINE FORFIVO XL* KHEDEZLA* LEXAPRO+ LUVOX CR MAPROTILINE MIRTAZAPINE NEFAZODONE OLEPTRO* PAROXETINE PAROXETINE ER PAXIL PAXIL CR PEXEVA PRISTIQ PROZAC+ REMERON REMERON SOLUTAB SERTRALINE TRAZODONE TRINTELLIX*VENLAFAXINE VENLAFAXINE ER CAPSULEVIIBRYD WELLBUTRIN+Drug NameWELLBUTRIN SR+WELLBUTRIN XL+ZOLOFT+DiabetesACARBOSEACTOPLUS MET XR ACTOS+ADLYXINAFREZZA*ALOGLIPTIN*ALOGLIPT IN-METFORMIN*ALOGLIPTIN-PIOGLITAZONE*AMA RYL APIDRA APIDRA SOLOSTAR BASAGLARBYDUREON BYETTA CYCLOSET DIABETA DUETACT FARXIGAFORTAMET* GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER GLIPIZIDE-METFORMINGLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVANCE GLUMETZA*GLYBURIDE GLYBURIDE MICRONIZED GLYBURIDE-METFORMIN GLYNASE GLYSET GLYXAMBI*HUMALOG HUMALOG MIX 50-50 HUMALOG MIX 75-25 HUMULIN 70-30 HUMULIN N HUMULIN R INVOKAMETINVOKAMET XRINVOKANA JANUMET JANUMET XR JANUVIA JARDIANCEPage 3 of 7 Drug NameDiabetes XR*KAZANO KOMBIGLYZE XR LANTUS*LANTUS SOLOSTAR*LEVEMIR LEVEMIR FLEXPEN METFORMIN HCLMETFORMIN HCL ERMETFORMIN SR MODIFIED-RELEASE*MIGLITOLNATEGLINIDE NESINA NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70-30 NOVOLOG MIX 70-30 FLEXPEN ONGLYZA OSENI PIOGLITAZONE HCL PIOGLITAZONE-GLIMEPIRIDEPIOGLITAZONE-MET FORMIN PRANDIMET PRANDIN PRECOSE

7 REPAGLINIDE-METFORMINRIOMET SOLIQUASTARLIX SYNJARDYSYNJARDY XRTANZEUMTOUJEO*TRADJENTA TRESIBA*TRULICITYVICTOZA XIGDUO XR*XULTOPHY*Diabetic SuppliesINSULIN SYRINGELANCETSPEN NEEDLETEST STRIPSD iarrheaALOSETRONLOTRONEXVIBERZIE levated Thyroid HormoneMETHIMAZOLE PROPYLTHIOURACIL Drug NameTAPAZOLE FibromyalgiaSAVELLAG laucomaALPHAGAN P APRACLONIDINE HCL AZOPT BETAGAN BETAXOLOL HCL BETIMOL BETOPTIC S % BIMATOPROST *BRIMONIDINE TARTRATE OPHTHALMIC SOLUTIONCARTEOLOL HCL 1% COMBIGAN 2% PF 2% *DORZOLAMIDE HCL 2 % DORZOLAMIDE-TIMOLOL 2% ISOPTO CARBACHOL OPHTHALMICISOPTO CARPINE LATANOPROST LEVOBUNOLOL HCL OPHTHALMIC SOLUTIONLUMIGAN METIPRANOLOL MIOSTAT PHOSPHOLINE IODIDEPILOCARPINE HCL PILOPINE HS SIMBRINZA*TIMOLOL MALEATE OPHTHALMIC SOLUTIONTIMOPTIC TIMOPTIC OCUDOSE TIMOPTIC-XE TRAVATAN Z TRAVOPROST TRUSOPT 2% XALATAN ZIOPTAN GoutALLOPURINOL COLCHICINE CAPSULE*COLCHICINE TABLET*COLCRYS*DUZALLO*MITIGAREPROBENECI DPROBENECID-COLCHICINEULORIC ZURAMPICZYLOPRIM Drug NameHeart FailureCORLANORENTRESTOH eart RhythmAMIODARONE HCL BETAPACE+ BETAPACE AFCORDARONE DIGOXIN DISOPYRAMIDE PHOSPHATEDOFETILIDEFLECAINIDE ACETATE LANOXIN MEXILETINE HCL MULTAQ NORPACE NORPACE CR PACERONE PROPAFENONE HCL QUINIDINE GLUCONATE QUINIDINE SULFATE RYTHMOL RYTHMOL SR SOTALOL AF

8 TAMBOCORTIKOSYN High Blood PressureACCUPRIL ACCURETIC ACEBUTOLOL HCLACEON ADALAT CC ALDACTAZIDE ALDACTONE ALTACE AMILORIDE HCL AMILORIDE-HYDROCHLOROTHIAZIDEAMLODIPINE BESYLATE AMLODIPINE BESYLATE-BENAZAPRILAMLODIPINE BESYLATE-VALARTANAMLODIPINE BESYLATE-VALARTAN-HYDROCHLOROTHIAZIDE*AM LODIPINE-OLMESARTAN*AMLODIPINE-OLMESARTA N-HYDROCHLOROHTHIZIE*AMTURNIDE*ATACAND ATACAND HCT ATENOLOL ATENOLOL-CHLORTHALIDONEAVALIDE AVAPRO AZOR*Page 4 of 7 Drug NameHigh Blood Pressure HCL BENAZEPRIL-HYDROCHLOROTHIAZIDEBENICAR+ BENICAR HCT+ BETAXOLOL HCL bisoprolol FUMARATEBISOPROLOL-HYDROCHLOROTHIAZIDEBU METANIDE BYVALSON*CALAN CALAN SR CANDESARTAN CILEXETILCANDESARTAN-HYDROCHLOROTHIZIDEC APTOPRIL CAPTOPRIL-HYDROCHLOROTHIAZIDECARDENE SR CARDIZEM+ CARDIZEM CD+ CARDIZEM LA+ CARDURA CARTIA XT CARVEDILOL CATA P R ESCATA P R ES -T T S CHLOROTHIAZIDECHLORTHALIDONE CLONIDINE PATCHCLONIDINE HCLCLORPRESCOREG COREG CR*CORGARD CORZIDE COZAAR DEMADEX DIAMOX SEQUELSDIBENZYLINE DILACOR XR DILT-CDDILTIA XT DILTIAZEM 24HR CDDILTIAZEM 24HR ERDILTIAZEM HCL DILT-XR DILTZAC ER DIOVAN+ DIOVAN HCT+DOXAZOSIN MESYLATEDUTOPROL* DYAZIDE DYRENIUM Drug NameEDARBI EDARBYCLOR EDECRINENALAPRIL MALEATE ENALAPRIL-HYDROCHLOROTHIAZIDEEPLERENONE EPROSARTANETHACRYNIC ACIDEXFORGE+ EXFORGE HCT*FELODIPINE ER

9 FOSINOPRIL SODIUM FOSINOPRIL-HYDROCHLOROTHIAZIDEFUROSEMIDE GUANFACINE HCL HYDRALAZINE HCL HYDROCHLOROTHIAZIDE HYZAARINDAPAMIDE INDERAL LA* INNOPRAN XL INSPRA IRBESARTAN IRBESARTAN-HYDROCHLOROTHIAZIDEISRADIPINE KERLONE LABETALOL HCL LASIX LEVATOLLISINOPRIL LISINOPRIL-HYDROCHLOROTHIAZIDELOPRESSOR LOPRESSOR HCT LOSARTAN POTASSIUMLOSARTAN-HYDROCHLOROTHIAZIDELOT ENSIN LOTENSIN HCT LOTREL MATZIM LA MAVIK MAXZIDE METHYCLOTHIAZIDE METHYLDOPAMETHYLDOPA-HYDROCHLOROTHIAZIDE METOLAZONE METOPROLOL EXTENDED-RELEASE/HYDROCHLOROTHIAZIDE*MET OPROLOL SUCCINATE METOPROLOL TARTRATE METOPROLOL-HYDROCHLOROTIAZIDEMICARDIS+ MICARDIS HCT+ MICROZIDE Drug NameMINIPRESS MINOXIDIL MOEXIPRIL HCL MOEXIPRIL-HYDROCHLOROTHIAZIDENADOLOL NADOLOL-BENDROFLUMETHIAZIDENEPTAZANE NICARDIPINE HCL NIFEDIPINE NIFEDIPINE ER NIMODIPINE NISOLDIPINE NORVASC OLMESARTANOLMESARTAN-HYDROCHLOROTHIAZIDE PERINDOPRIL ERBUMINE PINDOLOL PRAZOSIN HCL PRINIVIL PROCARDIA PROCARDIA XL PROPRANOLOL HCL PROPRANOLOL-HYDROCHLOROTHIAZIDEQBRELIS*Q UINAPRIL HCL QUINAPRIL-HYDROCHL