2021 Preventive Medications of the Medical Plan of the Presbyterian Church (U.S.A.)

This list of commonly prescribed preventive medications is the preventive drug list for the Medical Plan of the Presbyterian Church (U.S.A.). Note that not all strengths and dosages of the medications listed below will be covered as preventive.

Please check with Express Scripts at 800-344-3896 or the Board of Pensions at 800-773-7752 (800- PRESPLAN) if you have questions on coverage. You may also view benefit information materials at pensions.org/members or express-scripts.com. The amount you pay for medications will be determined by your medical option’s prescription coverage and formulary.

ANTIPSYCHOTICS IMIPRAMINE Anti-Anginal Agents ARIPIPRAZOLE MIRTAZAPINE ISOSORBIDE DINITRATE COMPRO NEFAZODONE ISOSORBIDE MONONITRATE FLUPHENAZINE DECANOATE NORTRIPTYLINE ISOSORBIDE MONONITRATE ER HALOPERIDOL PAROXETINE NITROGLYCERIN LOXAPINE PHENELZINE SULFATE MOLINDONE HCL SERTRALINE Anticoagulants OLANZAPINE TRANYLCYPROMINE SULFATE ASPIRIN-DIPYRIDAMOLE ER OLANZAPINE-FLUOXETINE HCL TRAZODONE CILOSTAZOL PALIPERIDONE ER TRIMIPRAMINE MALEATE CLOPIDOGREL PROCHLORPERAZINE DIPYRIDAMOLE QUETIAPINE FUMARATE ASTHMA AND COPD ENOXAPARIN SODIUM RISPERIDONE ADVAIR HFA FONDAPARINUX SODIUM ZIPRASIDONE HCL ALBUTEROL NEB/SYRUP/TA B HEPARIN ALBUTEROL SULFATE HFA JANTOVEN ANTIDEPRESANTS FLOVENT DISKUS PRASUGREL AMITRIPTYLINE HCL FLOVENT HFA WARFARIN SODIUM AMOXAPINE FLUTICASONE-SALMETEROL BUPROPION IPRATROPIUM BROMIDE Cardiac Glycosides BUPROPION HCL ER IPRATROPIUM-ALBUTEROL DIGITEK BUPROPION XL 150mg, 300mg MONTELUKAST SODIUM DIGOX CITALOPRAM PULMICORT FLEXHALER DIGOXIN CLOMIPRAMINE SYMBICORT DESIPRAMINE High blood pressure DOXEPIN CANCER ACEBUTOLOL HCL Duloxetine 20, 30, 60mg Letrozole AFEDITAB CR ESCITALOPRAM OXALATE AMILORIDE FLUOXETINE 10, 20, 40 mg Capsules CARDIOVASCULAR/ HEART AMILORIDE-HYDROCHLOROTHIAZIDE FLUVOXAMINE DISEASE AMLODIPINE

CRP2011_005927.1 AMLODIPINE BESYLATE-BENAZEPRIL ISRADIPINE TIMOLOL MALEATE AMLODIPINE-ATORVASTATIN LABETALOL HCL TORSEMIDE AMLODIPINE-OLMESA RTAN LISINOPRIL TRANDOLAPRIL AMLODIPINE-VALSARTAN LISINOPRIL-HYDROCHLOROTHIAZIDE TRANDOLAPRIL-VERAPAMIL ER AMLODIPINE-VALSARTAN-HCTZ LOSARTAN POTASSIUM TRIAMTERENE-HCTZ ATENOLOL LOSARTAN-HYDROCHLOROTHIAZIDE TRIAMTERENE-HYDROCHLOROTHIAZID ATENOLOL-CHLORTHA LIDONE MATZIM LA VALSARTAN BENAZEPRIL HCL METHYLDOPA VALSARTAN-HYDROCHLOROTHIAZIDE BENAZEPRIL-HYDROCHLOROTHIAZIDE METHYLDOPA-HYDROCHLOROTHIAZIDE VERAPAMIL ER BETAXOLOL HCL METOLAZONE VERAPAMIL HCL BISOPROLOL FUMARATE METOPROLOL SUCCINATE BISOPROLOL-HYDROCHLOROTHIAZIDE METOPROLOL TARTRATE High cholesterol BUMETANIDE METOPROLOL-HYDROCHLOROTHIAZIDE ATORVASTATIN CALCIUM CANDESARTAN CILEXETIL MINOXIDIL CHOLESTYRAMINE CANDESARTAN-HYDROCHLOROTHIAZID MOEXIPRIL HCL CHOLESTYRAMINE LIGHT CAPTOPRIL NADOLOL COLESTIPOL HCL CAPTOPRIL-HYDROCHLOROTHIAZIDE NADOLOL-BENDROFLUMETHIAZIDE EZETIMIBE CARTIA XT NICARDIPINE HCL EZETIMIBE-SIMVASTATIN CARVEDILOL NIFEDIPINE FENOFIBRATE CARVEDILOL ER NIFEDIPINE ER FENOFIBRIC ACID CHLOROTHIAZIDE NISOLDIPINE FLUVASTATIN ER CHLOROTHIAZIDE SODIUM OLMESARTAN MEDOXOMIL FLUVASTATIN SODIUM CHLORTHALIDONE OLMESARTAN-AMLODIPINE-HCTZ GEMFIBROZIL CLONIDINE HCL OLMESARTAN-HYDROCHLOROTHIAZIDE LOVASTATIN DILTIAZEM PERINDOPRIL ERBUMINE NIACIN ER DILT-XR PHENOXYBENZA MINE HCL OMEGA-3 ACID ETHYL ESTERS DOXAZOSIN MESYLATE PINDOLOL PRAVASTATIN SODIUM ENALAPRIL MALEATE PRAZOSIN HCL PREVALITE ENALAPRIL-HYDROCHLOROTHIAZIDE PROPRANOLOL HCL ROSUVASTATIN CALCIUM EPLERENONE PROPRANOLOL HCL ER SIMVASTATIN EPROSARTAN MESYLATE PROPRANOLOL-HYDROCHLOROTHIAZID TRIKLO ETHACRYNATE SODIUM QUINAPRIL HCL ETHACRYNIC ACID QUINAPRIL-HYDROCHLOROTHIAZIDE DIABETES FELODIPINE ER RAMIPRIL Insulin FOSINOPRIL SODIUM SPIRONOLACTONE HUMALOG FOSINOPRIL-HYDROCHLOROTHIAZIDE SPIRONOLACTONE-HCTZ HUMALOG KWIKPEN FUROSEMIDE SORINE HUMULIN KWIKPEN GUANFACINE HCL SOTALOL HUMULIN HYDRALAZINE HCL SOTALOL AF LANTUS HYDROCHLOROTHIAZIDE TELMISARTAN-AMLODIPINE LANTUS SOLOSTAR INDAPAMIDE TELMISARTAN-HYDROCHLOROTHIAZID IRBESARTAN TERAZOSIN HCL Non-insulin IRBESARTAN-HYDROCHLOROTHIAZIDE TIADYLT ER ACARBOSE

CRP2011_005927.1 GLIMEPIRIDE ESTRADIOL-NORETHINDRONE ACETAT OSTEOPOROSIS GLIPIZIDE FYAVOLV ALENDRONATE SODIUM GLIPIZIDE ER JEVANTIQUE LO CALCITONIN SP GLIPIZIDE XL JINTELI ETIDRONATE GLIPIZIDE-METFORMIN LOPREEZA IBANDRONATE SODIUM GLYBURIDE MIMVEY RISEDRONATE SODIUM GLYBURIDE-METFORMIN HCL MIMVEY LO METFORMIN HCL NORETHINDRON-ETHINYL ESTRADIOL TRANSPLANT MIGLITOL AZATHIOPRINE NATEGLINIDE GASTROINTESTINAL-ULCER CYCLOSPORINE PIOGLITAZONE HCL DRUGS CYCLOSPORINE MODIFIED PIOGLITAZONE-GLIMEPIRIDE CIMETIDINE GENGRAF PIOGLITAZONE-METFORMIN ESOMEPRAZOLE MYCOPHENOLATE MOFETIL REPAGLINIDE FAMOTIDINE MYCOPHENOLIC ACID REPAGLINIDE-METFORMIN HCL LANSOPRAZOLE SIROLIMUS LANSOPRAZOL-AMOXICIL-CLA RITHRO TACROLIMUS MISOPROSTOL ESTROGENS AMABELZ NIZATIDINE VITAMINS & HEMATINICS DOTTI OMEPRAZOLE Prenatal multivitamins with iron ESTRADIOL PANTOPRAZOLE and folic acid ESTRADIOL TRANSDERMAL PATCH SUCRALFATE Generic Products

CRP2011_005927.1