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Generics Only Preventive Therapy Drug List

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Generics Only Preventive Therapy Drug List High Deductible Health Plan (HDHP) - Health Savings Account (HSA) Generics Only Preventive Therapy Drug List (09/01/20) ANTICOAGULANTS/ sotalol AF pioglitazone/glimepiride Pacerone pioglitazone/metformin ANTIPLATELETS repaglinide ANTICOAGULANTS ORAL ANTIANGINAL AGENTS tolbutamide enoxaparin isosorbide dinitrate fondaparinux isosorbide mononitrate HYPERTENSION warfarin isosorbide mononitrate ext-rel Jantoven ACE INHIBITORS/ANGIOTENSIN II RECEPTOR ANTAGONISTS AND COMBINATION AGENTS SL and chewable formulations are not included amlodipine/benazepril PLATELET AGGREGATION INHIBITORS on this list. aspirin 81 mg benazepril clopidogrel TRANSDERMAL/TOPICAL ANTIANGINAL benazepril/hydrochlorothiazide dipyridamole AGENTS candesartan dipyridamole ext-rel/aspirin nitroglycerin transdermal candesartan/hydrochlorothiazide prasugrel Minitran captopril captopril/hydrochlorothiazide Over-the-Counter (OTC) products require a prescription. CORONARY ARTERY DISEASE enalapril Coverage may vary by plan. enalapril/hydrochlorothiazide ANTIHYPERLIPIDEMICS fosinopril atorvastatin fosinopril/hydrochlorothiazide ANTICONVULSANTS cholestyramine carbamazepine irbesartan colesevelam irbesartan/hydrochlorothiazide carbamazepine ext-rel colestipol clobazam lisinopril ezetimibe lisinopril/hydrochlorothiazide clonazepam fenofibrate divalproex sodium delayed-rel losartan fenofibric acid delayed-rel losartan/hydrochlorothiazide divalproex sodium ext-rel fluvastatin ethosuximide moexipril fluvastatin ext-rel olmesartan felbamate gemfibrozil lamotrigine olmesartan/hydrochlorothiazide lovastatin perindopril lamotrigine ext-rel niacin ext-rel levetiracetam quinapril pravastatin quinapril/hydrochlorothiazide levetiracetam ext-rel rosuvastatin oxcarbazepine ramipril simvastatin telmisartan phenobarbital Niacor phenytoin telmisartan/hydrochlorothiazide Prevalite trandolapril phenytoin sodium extended primidone trandolapril/verapamil ext-rel COMBINATION ANTIHYPERLIPIDEMICS valsartan tiagabine amlodipine/atorvastatin topiramate valsartan/hydrochlorothiazide ezetimibe/simvastatin topiramate ext-rel valproic acid BETA-BLOCKERS AND COMBINATION vigabatrin DIABETES AGENTS zonisamide ORAL DIABETES AGENTS acebutolol Epitol acarbose atenolol alogliptin atenolol/chlorthalidone alogliptin/metformin betaxolol CARDIOVASCULAR CONDITIONS - alogliptin/pioglitazone bisoprolol OTHER glimepiride bisoprolol/hydrochlorothiazide ANTIARRHYTHMIC AGENTS glipizide carvedilol amiodarone glipizide ext-rel carvedilol phosphate ext-rel disopyramide glipizide/metformin labetalol dofetilide metformin metoprolol flecainide metformin ext-rel metoprolol succinate ext-rel propafenone miglitol metoprolol/hydrochlorothiazide propafenone ext-rel nateglinide nadolol sotalol pioglitazone pindolol Please note: This list represents 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 Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-29793A 090120 propranolol doxepin naltrexone propranolol ext-rel duloxetine delayed-rel Depade propranolol/hydrochlorothiazide escitalopram timolol maleate fluoxetine ANTI-OBESITY AGENTS fluoxetine delayed-rel benzphetamine CALCIUM CHANNEL BLOCKERS AND fluvoxamine diethylpropion COMBINATION AGENTS imipramine HCl diethylpropion ext-rel amlodipine imipramine pamoate phendimetrazine diltiazem maprotiline phendimetrazine ext-rel diltiazem ext-rel mirtazapine phentermine diltiazem XR nortriptyline felodipine ext-rel paroxetine HCl BOWEL PREPARATIONS isradipine paroxetine HCl ext-rel peg 3350/electrolytes nicardipine phenelzine Gavilyte nifedipine protriptyline nifedipine ext-rel sertraline SMOKING DETERRENTS nisoldipine ext-rel tranylcypromine bupropion ext-rel verapamil trazodone nicotine polacrilex verapamil ext-rel trimipramine nicotine transdermal Cartia XT venlafaxine Dilt-XR venlafaxine ext-rel Over-the-Counter (OTC) products require a prescription. Matzim LA Irenka Coverage may vary by plan. Nifediac CC Taztia XT ANTIPSYCHOTICS MISCELLANEOUS aripiprazole cholecalciferol (D3) DIURETICS chlorpromazine Over-the-Counter (OTC) products require a prescription. amiloride/hydrochlorothiazide clozapine Coverage may vary by plan. chlorothiazide fluphenazine chlorthalidone fluphenazine decanoate hydrochlorothiazide haloperidol RESPIRATORY DISORDERS indapamide loxapine RESPIRATORY AGENTS spironolactone/hydrochlorothiazide olanzapine budesonide suspension triamterene/hydrochlorothiazide olanzapine orally disintegrating tabs budesonide/formoterol paliperidone cromolyn sodium nebulizer solution OTHER ANTIHYPERTENSIVE AGENTS perphenazine fluticasone/salmeterol aliskiren quetiapine montelukast amlodipine/olmesartan quetiapine ext-rel zafirlukast amlodipine/telmisartan risperidone zileuton ext-rel amlodipine/valsartan/ thioridazine Wixela Inhub hydrochlorothiazide thiothixene clonidine trifluoperazine VARIOUS CONDITIONS clonidine transdermal ziprasidone ANTI-MALARIAL AGENTS guanabenz atovaquone/proguanil guanfacine OBSESSIVE COMPULSIVE DISORDER chloroquine hydralazine fluvoxamine ext-rel mefloquine methyldopa primaquine methyldopa/hydrochlorothiazide OSTEOPOROSIS minoxidil alendronate DENTAL CARIES PREVENTION olmesartan/amlodipine/ calcitonin sodium fluoride hydrochlorothiazide calcitonin/salmon ibandronate IMMUNOSUPPRESSIVE AGENTS MENTAL HEALTH raloxifene cyclosporine caps ANTIDEPRESSANTS risedronate everolimus amitriptyline zoledronic acid 5 mg/100 mL mycophenolate mofetil amoxapine mycophenolate sodium delayed-rel bupropion PREVENTIVE CARE SERVICES sirolimus bupropion ext-rel tacrolimus AGENTS FOR CHEMICAL DEPENDENCY Gengraf citalopram acamprosate calcium clomipramine buprenorphine sublingual MULTIPLE SCLEROSIS AGENTS desipramine buprenorphine/naloxone sublingual desvenlafaxine ext-rel glatiramer disulfiram Please note: This list represents 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 Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-29793A 090120 WOMEN'S HEALTH CONTRACEPTIVES PRENATAL VITAMINS ANTIESTROGENS CONTRACEPTIVES - ALL GENERIC folic acid tamoxifen PRESCRIPTION FORMULATIONS PRENATAL VITAMINS - GENERIC PRESCRIPTION PRODUCTS AROMATASE INHIBITORS Over-the-Counter (OTC) emergency contraceptive products require a prescription. Coverage may vary by Over-the-Counter (OTC) products require a prescription. anastrozole plan. Coverage may vary by plan. exemestane letrozole Please note: This list represents 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 Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-29793A 090120 .
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