Tier Zero Prescription Drug List (HSA & POS Plans)
• Fosinopril/Hydrochlorothiazide • Propranolol/Hydrochlorothiazide ANTIRETROVIRAL THERAPY * • Furosemide • Quinapril HCL CONTRACEPTIVES • Guanabenz Acetate • Quinapril/Hydrochlorothiazide • Emtricitabine/tenofovir disoproxil • Guanfacine HCL • Ramipril • Oral Contraceptives: Monophasic/ fumarate 200 mg – 300 mg • Hydralazine HCL • Reserpine Biphasic/Triphasic Generic Agents • Hydralazine/Hydrochlorothiazid • Sotalol • Non-Oral Contraceptive: NuvaRing BLOOD PRESSURE & • Hydralazine/Reserpin/Hctz • Spironolact/Hydrochlorothiazide • Non-Oral Contraceptive: Ortho Evra HEART FAILURE • Hydrochlorothiazide • Telmisartan • Irbesartan • Telmisartan/Hydrochlorothiazide • Acebutolol HCL • Irbesartan/Hydrochlorothiazide • Terazosin HCL DIABETES • Amiodarone HCL • Isosorbide Dinitrate • Timolol Maleate • Amlodipine Besylate • Isosorbide Mononitrate • Torsemide • Acarbose • Amlodipine/Olmesartan • Isradipine • Trandolapril • Acetohexamide • Amlodipine/Olmesartan/HCT • Labetalol HCL • Trandolapril/Verapamil • Alogliptin • Amlodipine/Valsartan • Lisinopril • Triamterene/Hydrochlorothiazide • Alogliptin/Metformin • Amlodipine/Telmisartan • Lisinopril/Hydrochlorothiazide • Valsartan • Alogliptin/Pioglitazone • Atenolol • Losartan Potassium • Valsartan/Hydrochlorothiazide • Chlorpropamide • Atenolol/Chlorthalidone • Losartan Potassium/ • Verapamil HCL • Glimepiride • Benazepril HCL Hydrochlorothiazide • Glipizide • Benazepril/Hydrochlorothiazide • Methyldopa • Glyburide, ext-rel • Betaxolol HCL • Metolazone CHOLESTEROL LOWERING • Glyburide/Metformin HCL • Bisoprol/Hydrochlorothiazide • Metoprol/Hydrochlorothiazide • Metformin HCL • Bisoprolol Fumarate • Metoprolol Succinate • Metformin ext-rel • Captopril • Metoprolol Tartrate • Amlodipine Besylate/Atorvastatin • Metformin/Repaglinide • Captopril/Hydrochlorothiazide • Minoxidil Calcium • Miglitol • Candesartan Cilexetil • Moexipril HCL • Atorvastatin Calcium • Nateglinide • Candesartan Cilexetil/ • Moexipril/Hydrochlorothiazide • Cholestyramine • Pioglitazone Hydrochlorothiazide • Nadolol • Colestipol HCL • Pioglitazone HCl/Metformin HCl • Carvedilol • Nicardipine HCL • Ezetimbe • Repaglinide • Clonidine HCL • Nifedipine • Fenofibrate • Tolazamide • Digoxin • Nimodipine • Fenofibric acid • Tolbutamide • Diltiazem HCL • Nisoldipine • Fluvastatin • Doxazosin Mesylate • Nitroglycerin • Gemfibrozil • Enalapril Maleate • Olmesartan • Lovastatin SMOKING CESSATION • Enalapril/Hydrochlorothiazide • Olmesartan/Hydrochlorothiazide • Niacin • Eplerenone • Papaverine HCLl • Omega-3 Polyunsaturated FA • Nicotrol NS • Esmolol HCL • Pindolol • Pravastatin Sodium • Nicotrol Inhaler • Felodipine • Prazosin HCL • Simvastatin • Bupripion HCI (smoking deterrent) • Fosinopril Sodium • Propranolol HCL • Rosuvastatin SR 12 hr 150 mg *Generic antiretroviral therapy for preexposure prevention of human immunodeficiency virus (HIV) infection in people who are at an increased risk. • Zyban As prescription drugs come off patent protection (lose brand status), become available as generics, or over-the-counter, this list will change. • Chantix For the most up-to-date list, contact CVS Caremark at 866-601-6935; www.caremark.com.