Safe Harbor Preventative Drug List
This list includes medications identified as those most likely to qualify as “preventive” based on the U.S. Department of Treasury Department/IRS guidance. This list may not include all medications considered preventive or every health condition for which a preventive drug may be prescribed. At this time, neither MedImpact nor your health plan can guarantee which medications will satisfy U.S. Treasury Department definition for preventative safe harbor medications. Please also note: • Utilization management (ie. prior authorization, step therapy, and quantity limits) may apply to listed medications based on benefit design • Use of generics may be required depending on plan design • Some strengths or dosage forms may not be included • Certain products or therapeutic categories may not be covered • Brand and generic status may not be current due to the changes in the market • This list is subject to change without prior notice • Regardless of their appearance in this document, please contact member services at the number on your prescription benefits card should you have any questions regarding coverage Updated 3Q18
THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME
ANAPHYLAXIS THERAPY EPINEPHRINE EPINEPHRINE ADRENACLICK, EPI-PEN, EPI-PEN JR AUTOINJECTORS
ANTICOAGULANTS/ANTIP ANTICOAGULANTS APIXABAN ELIQUIS* LATELETS
BETRIXABAN BEVYXXA*
DABIGATRAN PRADAXA*
DALTEPARIN SODIUM FRAGMIN*
EDOXABAN TOSYLATE SAVAYSA*
ENOXAPARIN SODIUM LOVENOX
FONDAPARINUX SODIUM ARIXTRA
RIVAROXABAN XARELTO*
WARFARIN SODIUM COUMADIN, JANTOVEN
ANTIPLATELETS ASPIRIN/DIPYRIDAMOLE AGGRENOX*
CILOSTAZOL CILOSTAZOL
CLOPIDOGREL BISULFATE PLAVIX
DIPYRIDAMOLE PERSANTINE
PRASUGREL HCL EFFIENT
TICAGRELOR BRILINTA*
TICLOPIDINE TICLOPIDINE
VORAPAXAR SULFATE ZONTIVITY*
SICKLE CELL ANEMIA HYDROXYUREA DROXIA*, SIKLOS*
ASTHMA/COPD ASTHMA/COPD BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT* COMBINATIONS
FLUTICASONE/SALMETEROL ADVAIR DISKUS*, ADVAIR HFA*, AIRDUO RESPICLICK
FLUTICASONE/UMECLIDINIUM/VILANTEROL TRELEGY ELLIPTA*
FLUTICASONE/VILANTEROL BREO ELLIPTA*
GLYCOPYRROLATE/FORMOTEROL FUM BEVESPI AEROSPHERE*
INDACATEROL/GLYCOPYRROLATE UTIBRON NEOHALER*
Effective July 1, 2018 Page 1 of 8 * Available as Brand Only THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME
ASTHMA/COPD ASTHMA/COPD IPRATROPIUM/ALBUTEROL SULFATE DUONEB, COMBIVENT*, COMBIVENT COMBINATIONS RESPIMAT*
MOMETASONE/FORMOTEROL DULERA*
TIOTROPIUM BR/OLODATEROL HCL STIOLTO RESPIMAT*
UMECLIDINIUM BRM/VILANTEROL TR ANORO ELLIPTA*
INHALED BECLOMETHASONE DIPROPIONATE QVAR REDIHALER* CORTICOSTEROIDS
BUDESONIDE PULMICORT, PULMICORT FLEXHALER*
CICLESONIDE ALVESCO*
FLUNISOLIDE AEROSPAN*
FLUTICASONE FUROATE ARNUITY ELLIPTA*
FLUTICASONE PROPIONATE FLOVENT HFA*, FLOVENT DISKUS*, ARMONAIR RESPICLICK*
MOMETASONE FUROATE ASMANEX*, ASMANEX HFA*
LONG ACTING BETA- ARFORMOTEROL TARTRATE BROVANA* AGONIST
FORMOTEROL FUMARATE PERFOROMIST*
INDACATEROL MALEATE ARCAPTA NEOHALER*
OLODATEROL HCL STRIVERDI RESPIMAT*
SALMETEROL XINAFOATE SEREVENT DISKUS*
LONG ACTING MUSCARINIC ACLIDINIUM BROMIDE TUDORZA PRESSAIR* ANATGONIST
GLYCOPYRROLATE LONHALA MAGNAIR*
SEEBRI NEOHALER*
TIOTROPIUM BROMIDE SPIRIVA*, SPIRIVA RESPIMAT*
UMECLIDINIUM BROMIDE INCRUSE ELLIPTA*
MISC ASTHMA/COPD CROMOLYN SODIUM GASTROCROM
MONTELUKAST SODIUM SINGULAIR
PREDNISONE
ROFLUMILAST DALIRESP*
ZAFIRLUKAST ACCOLATE
SHORT ACTING BETA- ALBUTEROL SULFATE ACCUNEB, PROAIR HFA*, PROAIR AGONIST RESPICLICK*, PROVENTIL HFA* VENTOLIN HFA*
LEVALBUTEROL TARTRATE XOPENEX HFA*, XOPONEX
SHORT ACTING IPRATROPIUM BROMIDE ATROVENT, ATROVENT HFA* MUSCARINIC ANATGONIST
CANCER PREVENTION BREAST CANCER ANASTROZOLE ARIMIDEX PREVENTION
EXEMESTANE AROMASIN
CARDIOVASCULAR ALPHA AND BETA ACEBUTOLOL HCL SECTRAL ADRENERGIC BLOCKERS
ATENOLOL TENORMIN
Effective July 1, 2018 Page 2 of 8 * Available as Brand Only THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME
CARDIOVASCULAR ALPHA AND BETA BETAXOLOL HCL ADRENERGIC BLOCKERS
BISOPROLOL FUMARATE ZEBETA
CARVEDILOL COREG, COREG CR
LABETALOL HCL TRANDATE
METOPROLOL SUCCINATE TOPROL XL
METOPROLOL TARTRATE LOPRESSOR
NADOLOL CORGARD
NEBIVOLOL HCL BYSTOLIC*
PENBUTOLOL SULFATE LEVATOL*
PINDOLOL
PROPRANOLOL HCL HEMANGEOL*, INDERAL LA, INNOPRAN XL*, INDERAL XL*
TIMOLOL MALEATE
ANGIOTENSIN BENAZEPRIL HCL LOTENSIN CONVERTING ENZYME INHIBITORS
CAPTOPRIL
ENALAPRIL MALEATE EPANED*, VASOTEC
FOSINOPRIL SODIUM
LISINOPRIL PRINIVIL, QBRELIS*, ZESTRIL
MOEXIPRIL HCL UNIVASC
PERINDOPRIL ERBUMINE ACEON
QUINAPRIL HCL ACCUPRIL
RAMIPRIL ALTACE
TRANDOLAPRIL MAVIK
ANGIOTENSIN II RECEPTOR AZILSARTAN MEDOXOMIL EDARBI* ANTAGONISTS
CANDESARTAN CILEXETIL ATACAND
EPROSARTAN MESYLATE TEVETEN
IRBESARTAN AVAPRO
LOSARTAN POTASSIUM COZAAR
OLMESARTAN MEDOXOMIL BENICAR
TELMISARTAN MICARDIS
VALSARTAN DIOVAN
ANTI-ARRHYTHMICS AMIODARONE HCL CORDARONE, PACERONE
MULTAQ*
DOFETILIDE TIKOSYN
FLECAINIDE ACETATE TAMBOCOR
PROPAFENONE HCL PROPAFENONE HCL
Effective July 1, 2018 Page 3 of 8 * Available as Brand Only THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME
CARDIOVASCULAR ANTI-ARRHYTHMICS SOTALOL HCL BETAPACE, BETASPACE AF, SOTYLIZE*
CALCIUM CHANNEL AMLODIPINE BESYLATE NORVASC BLOCKER
DILTIAZEM HCL CARDIZEM, CD, LA, CARTIA XT, DILACOR XR*, DILT-CD, DILT-XR, MATZIM LA, TIAZAC
FELODIPINE FELODIPINE ER
ISRADIPINE
NICARDIPINE HCL CARDENE SR
NIFEDIPINE ADALAT CC, AFEDITAB CR, NIFEDICAL XL
NISOLDIPINE SULAR
VERAPAMIL HCL CALAN, CALAN SR, VERELAN, VERELAN PM
CARDIOVASCULAR AMILORIDE/HYDROCHLOROTHIAZIDE COMBINATIONS
AMLODIPINE BES/OLMESARTAN MED AZOR
AMLODIPINE BESYLATE/BENAZEPRIL LOTREL
AMLODIPINE/ATORVASTATIN CADUET
AMLODIPINE/VALSARTAN EXFORGE
AMLODIPINE/VALSARTAN/HCTHIAZID EXFORGE HCT
ATENOLOL/CHLORTHALIDONE TENORETIC 50, 100
AZILSARTAN MED/CHLORTHALIDONE EDARBYCLOR*
BENAZEPRIL/HYDROCHLOROTHIAZIDE LOTENSIN HCT
BISOPROL/HYDROCHLOROTHIAZIDE ZIAC
CANDESARTAN/HYDROCHLOROTHIAZID ATACAND HCT
CAPTOPRIL/HYDROCHLOROTHIAZIDE
ENALAPRIL/HYDROCHLOROTHIAZIDE VASERETIC
FOSINOPRIL/HYDROCHLOROTHIAZIDE
IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE
LISINOPRIL/HYDROCHLOROTHIAZIDE ZESTORETIC
LOSARTAN/HYDROCHLOROTHIAZIDE HYZAAR
METOPROLOL SU/HYDROCHLOROTHIAZ DUTOPROL
METOPROLOL/HYDROCHLOROTHIAZIDE LOPRESSOR HCT
MOEXIPRIL/HYDROCHLOROTHIAZIDE UNIRETIC
NADOLOL/BENDROFLUMETHIAZIDE CORZIDE
NEBIVOLOL HCL/VALSARTAN BYVALSON*
OLMESARTAN/AMLODIPIN/HCTHIAZID TRIBENZOR
OLMESARTAN/HYDROCHLOROTHIAZIDE BENICAR HCT
PERINDOPRIL ARG/AMLODIPINE BES PRESTALIA*
PROPRANOLOL/HYDROCHLOROTHIAZID
Effective July 1, 2018 Page 4 of 8 * Available as Brand Only THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME
CARDIOVASCULAR CARDIOVASCULAR QUINAPRIL/HYDROCHLOROTHIAZIDE ACCURETIC COMBINATIONS
SPIRONOLACT/HYDROCHLOROTHIAZID ALDACTAZIDE
TELMISARTAN/AMLODIPINE TWYNSTA
TELMISARTAN/HYDROCHLOROTHIAZID MICARDIS HCT
TRANDOLAPRIL/VERAPAMIL HCL TARKA
TRIAMTERENE/HYDROCHLOROTHIAZID DYAZIDE, MAXZIDE, MAXZIDE 25
VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT
DIURETICS AMILORIDE HCL
BUMETANIDE
CHLOROTHIAZIDE DIURIL*
CHLORTHALIDONE
EPLERENONE INSPRA
ETHACRYNIC ACID EDECRIN
FUROSEMIDE LASIX
HYDROCHLOROTHIAZIDE MICROZIDE
INDAPAMIDE
METHYCLOTHIAZIDE
METOLAZONE ZAROXOLYN
SPIRONOLACTONE ALDACTONE, CAROSPIR*
TORSEMIDE DEMADEX
TRIAMTERENE DYRENIUM
MISC CARDIOVASCULAR DIGOXIN
IVABRADINE HCL CORLANOR*
NITROGLYCERIN NITRO-TIME, NITRO-STAT
VALSARTAN/SACUBITRIL ENTRESTO*
DIABETES BIGUANIDES METFORMIN HCL FORTAMET, GLUCOPHAGE, GLUMETZA, RIOMET*
DIABETES COMBINATION ALOGLIPTIN BENZ/METFORMIN HCL KAZANO
ALOGLIPTIN BENZ/PIOGLITAZONE OSENI
CANAGLIFLOZIN/METFORMIN HCL INVOKAMET*, INVOKAMET XR*
DAPAGLIFLOZIN/METFORMIN HCL XIGDUO XR*
DAPAGLIFOZIN/SAXAGLIPTIN QTERN*
EMPAGLIFLOZIN/LINAGLIPTIN GLYXAMBI*
EMPAGLIFLOZIN/METFORMIN HCL SYNJARDY*, SYNJARDY XR*
ERTUGLIFLOZIN/METFORMIN SEGLUROMET*
ERTUGLIFLOZIN/SITAGLIPTIN STEGLUJAN*
GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN
GLYBURIDE/METFORMIN HCL GLUCOVANCE
Effective July 1, 2018 Page 5 of 8 * Available as Brand Only THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME
DIABETES DIABETES COMBINATION INSULIN DEGLUDEC/LIRAGLUTIDE XULTOPHY*
INSULIN GLARGINE/LIXISENATIDE SOLIQUA*
LINAGLIPTIN/METFORMIN HCL JENTADUETO, JENTADUETO XR
PIOGLITAZONE HCL/GLIMEPIRIDE DUETACT
PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET/ACTOPLUS MET XR*
REPAGLINIDE/METFORMIN HCL PRANDIMET
ROSIGLITAZONE/GLIMEPIRIDE AVANDARYL*
ROSIGLITAZONE/METFORMIN HCL AVANDAMET*
SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR
SITAGLIPTIN PHOS/METFORMIN HCL JANUMET, JANUMET XR
DPP-4 INHIBITORS ALOGLIPTIN BENZOATE NESINA
LINAGLIPTIN TRADJENTA*
SAXAGLIPTIN HCL ONGLYZA*
SITAGLIPTIN PHOSPHATE JANUVIA*
GLP-1 AGONISTS ALBIGLUTIDE TANZEUM*
DULAGLUTIDE TRULICITY*
EXENATIDE BYETTA*
EXENATIDE MICROSPHERES BYDUREON*, BYDUREON BCISE*
LIRAGLUTIDE VICTOZA*
LIXISENATIDE ADLYXIN*
SEMAGLUTIDE OZEMPIC*
INSULIN SECRETAGOGUES CHLORPROPAMIDE
GLIMEPIRIDE AMARYL
GLIPIZIDE GLUCOTROL, GLUCOTROL XL
GLYBURIDE DIABETA
GLYBURIDE,MICRONIZED GLYNASE
NATEGLINIDE STARLIX
REPAGLINIDE PRANDIN
TOLAZAMIDE
TOLBUTAMIDE
INSULINS INSULIN ASPART NOVOLOG*
INSULIN ASPART (NIACINAMIDE) FIASP*, FIASP FLEXTOUCH*
INSULIN ASPART PROT/INSULN ASP NOVOLOG MIX 70-30*, FLEXPEN*
INSULIN DEGLUDEC TRESIBA FLEXTOUCH U-100*, U-200*
INSULIN DETEMIR LEVEMIR FLEXPEN*/FLEXTOUCH*
INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO SOLOSTAR*, TOUJEO MAX SOLOSTAR*
BASAGLAR KWIKPEN*
LANTUS*, LANTUS SOLOSTAR*
Effective July 1, 2018 Page 6 of 8 * Available as Brand Only THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME
DIABETES INSULINS INSULIN GLULISINE APIDRA*, APIDRA SOLOSTAR*
INSULIN LISPRO HUMALOG*, HUMALOG JR*, KWIKPEN*, 200*, ADMELOG*, ADMELOG SOLOSTAR*
INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 75-25*, KWIKPEN*
HUMALOG MIX 50-50*, KWIKPEN*
INSULIN NPH HUM/REG INSULIN HM HUMULIN 70-30*, KWIKPEN*
NOVOLIN 70-30*
INSULIN NPH HUMAN ISOPHANE HUMULIN N*, KWIKPEN*
NOVOLIN N*
INSULIN REGULAR, HUMAN NOVOLIN R*
HUMULIN R*, AFREZZA*
HUMULIN R U-500*, U-500 KWIKPEN*
MISC DIABETES DEXTROSE ORAL GLUCOSE PRODUCTS
SGLT-2 INHIBITORS CANAGLIFLOZIN INVOKANA*
DAPAGLIFLOZIN FARXIGA*
EMPAGLIFLOZIN JARDIANCE*
ERTUGLIFLOZIN STEGLATRO*
THIAZOLINDINEDIONES PIOGLITAZONE HCL ACTOS
ROSIGLITAZONE MALEATE AVANDIA*
HIV PROPHYLAXIS HIV PROPHYLAXIS EMTRICITABINE/TENOFOVIR (TDF) TRUVADA*
HYPERLIPIDEMIA BILE ACID CHOLESTYRAMINE (WITH SUGAR) QUESTRAN SEQUESTRANTS/LIPOTROPI CS/NIACIN
CHOLESTYRAMINE/ASPARTAME PREVALITE
COLESEVELAM HCL WELCHOL
COLESTIPOL HCL COLESTID
EZETIMIBE ZETIA
FENOFIBRATE FENOGLIDE, LIPOFEN, LOFIBRA
FENOFIBRATE NANOCRYSTALLIZED TRICOR
FENOFIBRATE,MICRONIZED ANTARA*, LOFIBRA
FENOFIBRIC ACID FIBRICOR
FENOFIBRIC ACID (CHOLINE) TRILIPIX
GEMFIBROZIL LOPID
ICOSAPENT ETHYL VASCEPA*
NIACIN ENDUR-ACIN, SLO-NIACIN, NIACIN FLUSH FREE
NIACIN ER, NIASPAN
OMEGA-3 ACID ETHYL ESTERS LOVAZA
HYPERLIPIDEMIA COMBO EZETIMIBE/SIMVASTATIN VYTORIN
STATINS ATORVASTATIN CALCIUM LIPITOR
Effective July 1, 2018 Page 7 of 8 * Available as Brand Only THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME
HYPERLIPIDEMIA STATINS FLUVASTATIN SODIUM LESCOL, LESCOL XL
LOVASTATIN MEVACOR
PITAVASTATIN CALCIUM LIVALO*, ZYPITAMAG*
PRAVASTATIN SODIUM PRAVACHOL
ROSUVASTATIN CRESTOR
SIMVASTATIN ZOCOR, FLOLIPID*
OSTEOPOROSIS OSTEOPOROSIS ALENDRONATE SODIUM FOSAMAX, FOSAMAX + D*
CALCITONIN NASAL SPRAY MIACALCIN
ETIDRONATE DISODIUM
IBANDRONATE SODIUM BONIVA
RALOXIFENE HCL EVISTA
RISEDRONATE SODIUM ACTONEL
VITAMINS PEDIATRIC VITAMINS PEDIATRIC MULTIVITAMIN
PRENATAL VITAMINS PRENATAL VITAMINS W/ FOLIC ACID
Effective July 1, 2018 Page 8 of 8 * Available as Brand Only