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Indiana University High Deductible Health Plan (HDHP) - Health Savings Account (HSA)

Preventive Therapy List (04/01/2021) ANTI-INFECTIVES topiramate DILATRATE-SR ANTIRETROVIRAL AGENTS topiramate ext-rel ISORDIL emtricitabine/tenofovir valproic acid DESCOVY vigabatrin SL and chewable formulations are not included zonisamide on this list. TRUVADA 200/300 mg BANZEL CARBATROL TRANSDERMAL/TOPICAL ANTIANGINAL / CELONTIN AGENTS ANTIPLATELETS DEPAKOTE minitran ANTICOAGULANTS DEPAKOTE ER nitroglycerin transdermal aspirin DIACOMIT NITRO-BID enoxaparin DILANTIN NITRO-DUR fondaparinux FELBATOL jantoven FINTEPLA warfarin GABITRIL ANTIHYPERLIPIDEMICS ARIXTRA KEPPRA atorvastatin ELIQUIS KEPPRA XR cholestyramine FRAGMIN KLONOPIN colesevelam LOVENOX MYSOLINE colestipol SAVAYSA OXTELLAR XR ezetimibe XARELTO PHENYTEK fenofibric acid delayed-rel QUDEXY XR fluvastatin AGGREGATION INHIBITORS ROWEEPRA fluvastatin ext-rel aspirin/omeprazole delayed-rel TEGRETOL gemfibrozil clopidogrel TOPAMAX lovastatin dipyridamole TRILEPTAL niacin ext-rel dipyridamole ext-rel/aspirin TROKENDI XR niacor prasugrel VIMPAT pravastatin BRILINTA XCOPRI prevalite DURLAZA ZARONTIN rosuvastatin EFFIENT simvastatin YOSPRALA CARDIOVASCULAR CONDITIONS - ANTARA ZONTIVITY COLESTID OTHER EZALLOR SPRINKLE ANTIARRHYTHMIC AGENTS FENOFIBRIC ACID 105mg amiodarone carbamazepine FLOLIPID disopyramide LIPOFEN carbamazepine ext-rel dofetilide clobazam LOFIBRA flecainide LOPID clonazepam pacerone divalproex sodium delayed-rel NIASPAN PRAVACHOL divalproex sodium ext-rel propafenone ext-rel epitol PRALUENT QUESTRAN/QUESTRAN LIGHT ethosuximide sotalol AF felbamate REPATHA MULTAQ TRILIPIX lamotrigine NORPACE lamotrigine ext-rel VASCEPA NORPACE CR ZOCOR levetiracetam RYTHMOL SR levetiracetam ext-rel ZYPITAMAG SORINE oxcarbazepine SOTYLIZE phenobarbital COMBINATION ANTIHYPERLIPIDEMICS TIKOSYN /atorvastatin phenytoin phenytoin sodium extended ezetimibe/simvastatin ORAL ANTIANGINAL AGENTS CADUET primidone (not including 40mg) rufinamide VYTORIN tiagabine isosorbide mononitrate ext-rel

Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications.

This document contains content that is copyrighted by CVS Caremark® and reprinted with permission. CVS Caremark is a registered trademark of CVS Pharmacy, Inc. 106-45139A 041521

DIABETES GLYNASE losartan/hydrochlorothiazide DIAGNOSTIC AGENTS AND SUPPLIES GLYXAMBI moexipril GLUCOSE STRIPS –ONE JANUMET olmesartan TOUCH JANUMET XR olmesartan/hydrochlorothiazide CONTROL SOLUTIONS JANUVIA perindopril INSULIN SYRINGES, AND NEEDLES – METAGLIP quinapril BD ULTRAFINE PRECOSE quinapril/hydrochlorothiazide KETONE BLOOD TEST STRIPS - ALL RIOMET ramipril LANCETS, LANCET DEVICES RYBELSUS telmisartan URINE TESTING STRIPS - ALL SEGLUROMET telmisartan/hydrochlorothiazide STARLIX trandolapril INHALED DIABETES AGENTS STEGLATRO trandolapril/ ext-rel AFREZZA STEGLUJAN valsartan TRIJARDY XR valsartan/hydrochlorothiazide INJECTABLE DIABETES AGENTS XIGDUO XR ACCUPRIL ADMELOG ACCURETIC BASAGLAR KWIKPEN HEMATOLOGIC AGENTS ALTACE FIASP ADVATE AVALIDE HUMULIN R U-500 ADYNOVATE AVAPRO LEVEMIR AFSTYLA COZAAR LYUMJEV ALPHANATE EPANED MYXREDLIN ALPHANINE SD HYZAAR NOVOLIN BENEFIX LOTENSIN NOVOLOG COAGADEX LOTENSIN HCT OZEMPIC CORIFACT LOTREL SEMGLEE ESPEROCT MICARDIS SOLIQUA FEIBA MICARDIS HCT SYMLINPEN HEMOFIL M PRESTALIA TRESIBA HUMATE-P PRINIVIL TRULICITY IDELVION QBRELIS VICTOZA IXINITY TARKA XULTOPHY JIVI VASERETIC KOATE-DVI VASOTEC Over-the-Counter (OTC) products require a prescription. KOGENATE FS ZESTORETIC Coverage may vary by plan. KOVALTRY ZESTRIL MONONINE ORAL DIABETES AGENTS NOVOEIGHT BETA-BLOCKERS AND COMBINATION acarbose NUWIQ AGENTS alogliptin PROFILNINE alogliptin/metformin RECOMBINATE alogliptin/pioglitazone RIXUBIS atenolol/chlorthalidone glimepiride TRETTEN glipizide XYNTHA glipizide ext-rel bisoprolol/hydrochlorothiazide glipizide/metformin glyburide HYPERTENSION carvedilol ext-rel glyburide, micronized ACE INHIBITORS/ANGIOTENSIN II RECEPTOR glyburide/metformin ANTAGONISTS AND COMBINATION AGENTS metformin aliskiren metoprolol succinate ext-rel metformin ext-rel (generic Glucophage) amlodipine/benazepril metoprolol/hydrochlorothiazide miglitol benazepril nateglinide benazepril/hydrochlorothiazide pioglitazone candesartan pioglitazone/glimepiride candesartan/hydrochlorothiazide propranolol ext-rel pioglitazone/metformin captopril propranolol/hydrochlorothiazide repaglinide captopril/hydrochlorothiazide maleate ACTOPLUS MET enalapril BYSTOLIC ACTOPLUS MET XR enalapril/hydrochlorothiazide COREG AMARYL fosinopril COREG CR D-CARE DM2 KIT fosinopril/hydrochlorothiazide CORGARD DUETACT irbesartan INDERAL LA FARXIGA irbesartan/hydrochlorothiazide KAPSPARGO GLUCOTROL lisinopril LEVATOL GLUCOTROL XL lisinopril/hydrochlorothiazide LOPRESSOR losartan Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications.

This document contains content that is copyrighted by CVS Caremark® and reprinted with permission. CVS Caremark is a registered trademark of CVS Pharmacy, Inc. 106-45139A 041521

TENORETIC TWYNSTA TENORMIN aripiprazole TRANDATE IMMUNIZING AGENTS ZIAC ALLERGENIC EXTRACTS GRASTEK CHANNEL BLOCKERS AND ODACTRA fluphenazine decanoate COMBINATION AGENTS ORALAIR haloperidol amlodipine RAGWITEK cartia XT IMMUNIZATIONS olanzapine orally disintegrating tabs diltiazem ext-rel - ALL diltiazem XR perphenazine dilt XR felodipine ext-rel MENTAL HEALTH quetiapine ext-rel isradipine nicardipine thiothixene nifedipine ext-rel trifluoperazine nisoldipine ext-rel bupropion ziprasidone taztia XT bupropion ext-rel ABILIFY MAINTENA verapamil citalopram ARISTADA verapamil ext-rel desipramine CAPLYTA CALAN SR desvenlafaxine ext-rel CLOZARIL CONJUPRI EQUETRO ISOPTIN SR duloxetine delayed-rel GEODON KATERZIA escitalopram HALDOL PROCARDIA fluoxetine HALDOL DECANOATE PROCARDIA XL fluoxetine delayed-rel INVEGA SULAR HCl INVEGA TRINZA TIAZAC imipramine pamoate LATUDA VERELAN REXULTI VERELAN PM RISPERDAL nortriptyline RISPERDAL CONSTA paroxetine HCl SAPHRIS amiloride/hydrochlorothiazide paroxetine HCl ext-rel SECUADO chlorthalidone phenelzine SEROQUEL hydrochlorothiazide protriptyline VERSACLOZ indapamide sertraline VRAYLAR spironolactone/hydrochlorothiazide tranylcypromine ZYPREXA triamterene/hydrochlorothiazide ZYPREXA ZYDIS ALDACTAZIDE DIURIL venlafaxine OBSESSIVE COMPULSIVE DISORDER MAXZIDE venlafaxine ext-rel capsule venlafaxine ext-rel tablet 225 mg fluvoxamine OTHER ANTIHYPERTENSIVE AGENTS ANAFRANIL fluvoxamine ext-rel amlodipine/olmesartan APLENZIN amlodipine/telmisartan CELEXA DRIZALMA OSTEOPOROSIS amlodipine/valsartan/ alendronate hydrochlorothiazide EMSAM FETZIMA calcitonin calcitonin/salmon clonidine transdermal FLUOXETINE 60 mg FORFIVO XL ibandronate raloxifene MARPLAN NARDIL risedronate zoledronic acid 5 mg/100 mL methyldopa/hydrochlorothiazide NORPRAMIN PAMELOR ACTONEL ATELVIA olmesartan/amlodipine/ PARNATE REMERON BINOSTO hydrochlorothiazide BONIVA AZOR TRINTELLIX VENLAFAXINE ER BONIVA INJECTION CATAPRES EVENITY CATAPRES-TTS WELLBUTRIN SR WELLBUTRIN XL EVISTA TEKTURNA FORTEO TEKTURNA HCT ZOLOFT FOSAMAX TRIBENZOR FOSAMAX PLUS D

Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications.

This document contains content that is copyrighted by CVS Caremark® and reprinted with permission. CVS Caremark is a registered trademark of CVS Pharmacy, Inc. 106-45139A 041521

PROLIA zileuton ext-rel sirolimus RECLAST ACCOLATE tacrolimus TERIPARATIDE ADVAIR NEORAL TYMLOS ADVAIR HFA NULOJIX AIRDUO RESPICLICK SANDIMMUNE PREVENTIVE CARE SERVICES ARNUITY ELLIPTA AGENTS FOR CHEMICAL DEPENDENCY BREO ELLIPTA MULTIPLE SCLEROSIS AGENTS acamprosate calcium CINQAIR Dimethyl fumarate delayed-rel buprenorphine sublingual FASENRA glatiramer buprenorphine/naloxone sublingual FLOVENT DISKUS AUBAGIO disulfiram FLOVENT HFA BAFIERTAM naltrexone NUCALA BETASERON BUNAVAIL PULMICORT COPAXONE PROBUPHINE PULMICORT FLEXHALER GILENYA SUBLOCADE QVAR REDIHALER KESIMPTA VIVITROL SPIRIVA RESPIMAT 1.25 mcg LEMTRADA ZUBSOLV SYMBICORT MAVENCLAD SYNAGIS MAYZENT BOWEL PREPARATIONS TRELEGY ELLIPTA OCREVUS gavilyte XOLAIR PLEGRIDY peg 3350/electrolytes ZYFLO REBIF CLENPIQ TYSABRI NULYTELY SUPPLIES VUMERITY PLENVU SPACER DEVICES ZEPOSIA SUTAB SPACER SUPPLIES WOMEN'S HEALTH SMOKING DETERRENTS VARIOUS CONDITIONS ANTIESTROGENS bupropion ext-rel ANTI-MALARIAL AGENTS tamoxifen nicotine polacrilex atovaquone/proguanil SOLTAMOX nicotine transdermal chloroquine CHANTIX mefloquine AROMATASE INHIBITORS NICODERM CQ ARAKODA anastrozole NICORETTE GUM MALARONE exemestane NICORETTE LOZENGE PRIMAQUINE letrozole NICOTROL INHALER ARIMIDEX NICOTROL NS DENTAL CARIES PREVENTION AROMASIN sodium fluoride FEMARA Over-the-Counter (OTC) products require a prescription. PEDIATRIC MULTIVITAMINS WITH Coverage may vary by plan. FLUORIDE - ALL MARKETED CONTRACEPTIVES PRODUCTS CONTRACEPTIVES - ALL MISCELLANEOUS PRESCRIPTION FORMULATIONS cholecalciferol (D3) HEREDITARY ANGIOEDEMA AGENTS (Subject to formulary inclusion) CINRYZE Over-the-Counter (OTC) products require a prescription. HAEGARDA Over-the-Counter (OTC) emergency contraceptive Coverage may vary by plan. products require a prescription. Coverage may vary by ORLADEYO TAKHZYRO plan. RESPIRATORY DISORDERS PRENATAL RESPIRATORY AGENTS IMMUNOSUPPRESSIVE AGENTS folic acid budesonide suspension cyclosporine caps PRENATAL VITAMINS cromolyn sodium nebulizer solution everolimus

fluticasone/ gengraf montelukast mycophenolate mofetil zafirlukast mycophenolate sodium delayed-rel

Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications.

This document contains content that is copyrighted by CVS Caremark® and reprinted with permission. CVS Caremark is a registered trademark of CVS Pharmacy, Inc. 106-45139A 041521