HEALTHY VALUES LIST that offer the best value.

The medications that are on this list are maintenance and preventive medications that can help prevent many illnesses and conditions for people who have certain risk factors. These medications are: (1) included in the Standard Plan Medications List, which can be found at www.prescryptive.com/member, and (2) are different from the list of preventive medications mandated by the Affordable Care Act to be covered by health plans at no cost to members.

Some benefit plans may provide different coverage for the medications on the Healthy Values Medication List. Under some plans you may not need to pay a copay, coinsurance and/or deductible for the medications on this list. Check your plan documents to determine your benefit coverage. If your prescription benefit plan provides coverage of maintenance or preventive medications prior to meeting your deductible, you may pay less or perhaps nothing for the medications on this list, which may help you save money and stay on your treatment plan.

Be sure to follow your doctor’s treatment plan by taking prescribed medications as directed to help you live a healthier life today and possibly avoid serious illness and high health care costs down the road.

Note: Pharmacy products and services covered by your benefit plan may change from time to time. Some products and services may not be covered under a specific member’s plan design. The information provided here is for general information purposes only and does not guarantee coverage. To confirm your coverage, reference your specific plan documents within your member portal account at www.prescryptive.com or contact Prescryptive Member Services at the phone number on your Member ID card.

Class/Group Name Class/Group Drug Name Agents Isosorbide Dinitrate Antiasthmatic and Bronchodilator Isosorbide Mononitrate, ER Agents Ipratropium-Albuterol Nitroglycerin (cont.) Ranolazine ER Pulmicort Antiarrhythmics Amiodarone Spiriva, Handihaler Disopyramide Stiolto Dofetilide Striverdi Flecainide Symbicort Mexiletine , ER Propafenone Warfarin Sodium Quinidine Gluconate ER Carbamazepine, ER Quinidine Sulfate Clonazepam Antiasthmatic and Albuterol Sulfate, HFA Divalproex, ER Bronchodilator Bevespi Ethosuximide Agents Gabapentin

pg. 1 www.prescryptive.com © 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.02 Class/Group Drug Name Class/Group Drug Name Anticonvulsants Lamotrigine Antidiabetics Glucagon Emergency (cont.) (cont.) Levetiracetam, ER Glyburide Oxcarbazepine Glyburide Micronized Phenytoin Glyburide-Metformin Pregabalin Humulin 70/30 Primidone Humulin N Topiramate Humulin R Valproic Acid Humalog Zonisamide Humalog Mix 75/25 Amitriptyline Metformin, ER Bupropion ER (Non-Mod,Non-Osm) Citalopram Nateglinide Desvenlafaxine Succinate ER Pioglitazone Doxepin Pioglitazone-Metformin Duloxetine Repaglinide Escitalopram Antihyperlipidemics Atorvastatin Calcium Fluoxetine Ezetimibe Fluvoxamine Lovastatin Imipramine Pravastatin Sodium Mirtazapine Rosuvastatin Calcium Nortriptyline Simvastatin Paroxetine Antihypertensives Amlodipine-Benazepril Sertraline Amlodipine-Olmesartan Trazodone Amlodipine-Valsartan Venlafaxine, ER Atenolol-Chlorthalidone Antidiabetics Acarbose Benazepril Baqsimi Benazepril- Hydrochlorothiazide Basaglar Bisoprolol- Glimepiride Hydrochlorothiazide Glipizide, ER Candesartan Glipizide-Metformin Captopril

pg. 2 www.prescryptive.com © 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.02 Class/Group Drug Name Class/Group Drug Name Antihypertensives Clonidine Antihypertensives Telmisartan (cont.) (cont.) Enalapril Telmisartan- Hydrochlorothiazide Enalapril- Hydrochlorothiazide Trandolapril Eplerenone Valsartan Fosinopril Valsartan- Hydrochlorothiazide Fosinopril- Hydrochlorothiazide Antineoplastics and Anastrozole Guanfacine Adjunctive Therapies Letrozole Hydralazine Tamoxifen Irbesartan Antiparkinson and Carbidopa-Levodopa, ER Related Therapy Pramipexole Dihydrochloride Irbesartan- Agents Hydrochlorothiazide Ropinirole Lisinopril / Aripiprazole Antimanic Agents Lisinopril- Clozapine Hydrochlorothiazide Haloperidol Losartan Lithium Carbonate, ER Losartan- Loxapine Succinate Hydrochlorothiazide Olanzapine Methyldopa Perphenazine Metoprolol- Quetiapine, ER Hydrochlorothiazide Risperidone Moexipril Thioridazine Olmesartan Trifluoperazine Olmesartan- Ziprasidone Hydrochlorothiazide Beta Blockers Acebutolol Perindopril Atenolol Quinapril Betaxolol Quinapril- Bisoprolol Hydrochlorothiazide Carvedilol Ramipril Labetalol

pg. 3 www.prescryptive.com © 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.02 Class/Group Drug Name Class/Group Drug Name Beta Blockers Metoprolol, ER Gout Agents Allopurinol (cont.) Nadolol Hematological Cilostazol Agents - Misc. Propranolol, ER Clopidogrel Sotalol Dipyridamole Calcium Afeditab Cr Prasugrel Channel Blockers Amlodipine / Phenobarbital Diltiazem, ER Sleep Disorder Agents Felodipine ER Medical Devices Insulin Pen Needle Isradipine and Supplies Insulin Syringe Nifedipine OneTouch Verio Verapamil, ER Ophthalmic Agents Dorzolamide Cardiotonics Digoxin Dorzolamide -Timolol Mal Acetazolamide Latanoprost Acetazolamide, ER Timolol Maleate Amiloride Ulcer / Dicyclomine Amiloride- Anti-spasmodics/ Hydrochlorothiazide Hyoscyamine, SL Bumetanide Chlorthalidone Furosemide Hydrochlorothiazide Indapamide Metolazone Spironolactone Spironolactone- Hydrochlorothiazide Torsemide Triamterene- Hydrochlorothiazide Endocrine and Alendronate Sodium Metabolic Agents - Misc. Ibandronate

pg. 4 www.prescryptive.com © 2021 PRESCRYPTIVE. ALL RIGHTS RESERVED. 2021.02