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Preventive List Effective: July 1, 2013

In addition to a healthy lifestyle, preventive medications can help people avoid many illnesses and conditions. A consumer-directed health (CDH) plan that includes preventive medications can help support the goal of ongoing good health. This list provides examples of your plan’s preventive medications. The medications are categorized based on the medical conditions that they are used to prevent. Coverage prior to the deductible being met may not be provided for every dosage form of a listed . Please call Member Services at 877.223.4721. This list is periodically reviewed and updated to ensure that the drugs listed meet the criteria for inclusion.

This list includes medications sometimes used for prevention and sometimes for treatment.

PDL8745C Preventive Medications List

ANEMIA IN CHILDREN CANCER TREATMENT, SIDE FERROUS SULFATE LIQUID DROPS FOR EFFECTS FROM INFANTS (SUCH AS FER-IN-SOL) ARANESP DARBEPOETIN ALFA EPOGEN, PROCRIT SINGULAIR EPOETIN ALFA NEUPOGEN ACCOLATE FILGRASTIM DEPO-PROVERA ZYFLO CR MEDROXYPROGESTERONE MESNEX BONE DISEASE AND FRACTURES MESNA NEULASTA FOSAMAX, FOSAMAX PLUS D PEGFILGRASTIM ALENDRONATE LEUKINE FORTICAL, MIACALCIN SARGRAMOSTIM CALCITONIN XGEVA CAVITIES DENOSUMAB PEDIATRIC FLUORIDE BONIVA DROPS IBANDRONATE PREVIDENT EVISTA SODIUM FLUORIDE ACTONEL COLONOSCOPY PREPARATION RISEDRONATE RECLAST COLYTE, GOLYTELY, HALFLYTELY, ZOLEDRONIC ACID NULYTELY, TRILYTE, MOVIPREP POLYETHYLENE GLYCOL BREAST CANCER RECURRENCE VISICOL, OSMOPREP, SUPREP SODIUM PHOSPHATE SALTS ARIMIDEX , COMPLICATIONS OF AROMASIN : EXEMESTANE NOVOLOG, NOVOLOG 70/30 FEMARA ASPART, ASPART PROTAMINE MIX LETROZOLE LEVEMIR DETEMIR LANTUS, LANTUS SOLOSTAR GLARGINE Preventive Medications List

APIDRA, APIDRA SOLOSTAR REPLACEMENT AND GLULISINE OTHER HORMONES HUMULIN, NOVOLIN PREMARIN HUMALOG, 50/50, 75/25 CONJUGATED ESTROGEN TABLETS PREMPRO, PREMPHASE LISPRO, LISPRO PROTAMINE MIX CONJUGATED ESTROGEN/ NON-INSULIN MEDICINES: MEDROXYPROGESTERONE BYETTA ESTRACE TABLETS AMARYL CLIMARA ESTRADIOL TRANSDERMAL GLIMEPIRIDE GLUCOTROL, METAGLIP ESTRADERM ESTRADIOL TRANSDERMAL GLIPIZIDE AND COMBINATIONS DIABETA, GLYNASE, GLUCOVANCE VIVELLE DOT ESTRADIOL TRANSDERMAL GLYBURIDE AND COMBINATIONS TRADJENTA DIVIGEL ESTRADIOL, GEL LINAGLIPTIN VICTOZA EVAMIST ESTRADIOL, TRANSDERMAL SPRAY LIRAGLUTIDE FORTAMET, GLUCOPHAGE, COMBIPATCH GLUMETZA, RIOMET ESTRADIOL/NORETHINDRONE, TRANSDERMAL METFORMIN MAKENA STARLIX HYDROXYPROGESTERONE CAPROATE NATEGLINIDE PROVERA ACTOS, DUETACT, ACTOPLUS MET MEDROXYPROGESTERONE AND COMBINATIONS CRINONE, PROMETRIUM SYMLIN PRAMLINTIDE CENESTIN PRANDIN SYNTHETIC CONJUGATED , A REPAGLINIDE ENJUVIA AVANDIA, AVANDAMET, SYNTHETIC , B AVANDARYL AND COMBINATIONS ONGLYZA, KOMBIGLYZE XR ZYLOPRIM SAXAGLIPTIN AND COMBINATIONS ALLOPURINOL JANUVIA, JANUMET COLCRYS AND COMBINATIONS COLCHICINE Preventive Medications List

GUM DISEASE ZOCOR ARESTIN OTHER AGENTS: HEART DISEASE AND PREVALITE, QUESTRAN BLOOD THINNER MEDICINES: CHOLESTYRAMINE WELCHOL , 81 MG OR 325 MG HEPARIN COLESTID AGGRENOX ASA/DIPYRIDAMOLE ZETIA PLAVIX CLOPIDOGREL VYTORIN FRAGMIN EZETIMIBE/SIMVASTATIN DALTEPARIN FENOGLIDE, LIPOFEN, TRICOR, LOVENOX ANTARA, TRIGLIDE ENOXAPARIN ARIXTRA TRILIPIX FONDAPARINUX FENOFIBRIC ACID EFFIENT LOPID PRASUGREL XARELTO NIACOR, NIASPAN ER RIVAROXABAN ` BRILINTA ADVICOR NIACIN/ COUMADIN, JANTOVEN SIMCOR NIACIN ER/SIMVASTATIN LOWERING LOVAZA MEDICINES OMEGA-3-ACID ETHYL HIGH BLOOD PRESSURE HMG-COA REDUCTASE MEDICINES INHIBITORS: ACE INHIBITORS AND LIPITOR COMBINATIONS: MEVACOR, ALTOPREV LOTENSIN, LOTENSIN HCT LOVASTATIN PRAVACHOL VASOTEC, VASERETIC CRESTOR MONOPRIL, MONOPRIL HCT Preventive Medications List

PRINIVIL, PRINZIDE, ZESTRIL, CALCIUM CHANNEL BLOCKERS: ZESTORETIC NORVASC ACCUPRIL, ACCURETIC CARDIZEM, CARDIZEM LA, CARTIA XT, TIAZAC ER ACE BLOCKERS AND COMBINATIONS: ADALAT CC, PROCARDIA EDARBI SULAR ATACAND, ATACAND HCT CALAN, COVERA HS, ISOPTIN SR, TEVETEN, TEVETEN HCT VERELAN AVAPRO, AVALIDE DIURETICS AND COMBINATIONS: COZAAR, HYZAAR HYDROCHLOROTHIAZIDE INDAPAMIDE BENICAR, BENICAR HCT MIDAMOR AMILORIDE MICARDIS, MICARDIS HCT ZAROXOLYN METOLAZONE DIOVAN, DIOVAN HCT ALDACTONE DYAZIDE, MAXZIDE BETA BLOCKERS AND TRIAMTERENE-HCTZ COMBINATIONS: HIGH BLOOD PRESSURE TENORMIN, TENORETIC MEDICINES, MISCELLANEOUS: HYDRALAZINE ZEBETA, ZIAC TEKTURNA, TEKTURNA HCT, BISOPROLOL LOPRESSOR, TOPROL XL TEKAMLO, AMTURNIDE, METOPROLOL VALTURNA BYSTOLIC AND COMBINATIONS NEBIVOLOL LOTREL INDERAL LA, INNOPRAN XL AMLODIPINE/BENAZEPRIL PROPRANOLOL AZOR AMLODIPINE/OLMESARTAN TRIBENZOR AMLODIPINE/OLMESARTAN/ HYDROCHLOROTHIAZIDE Preventive Medications List

TWYNSTA VIRUS AMLODIPINE/TELMISARTAN AMANTADINE EXFORGE ZOVIRAX AMLODIPINE/VALSARTAN ACYCLOVIR EXFORGE HCT FAMVIR AMLODIPINE/VALSARTAN/ FAMCICLOVIR HYDROCHLOROTHIAZIDE FOSCAVIR COREG, COREG CR FOSCARNET CATAPRES, CLORPRES CYTOVENE GANCICLOVIR CLONIDINE CARDURA TAMIFLU OSELTAMIVIR HYTRIN VALTREX VALACYCLOVIR VALCYTE INFECTION VALGANCICLOVIR RELENZA FUNGAL ZANAMIVIR MEPRON DISEASE, HIGH ATOVAQUONE NEBUPENT, PENTAM PHOSPHATE LEVELS PHOSLO, PHOSLYRA NOXAFIL CALCIUM ACETATE FOSRENOL MALARIA RENVELA, RENAGEL PRIMAQUINE SEVELAMER COARTEM ARTEMETHER/LUMEFANTRINE NAUSEA AND DIZZINESS MALARONE ATOVAQUONE/PROGUANIL PROMETHAZINE PLAQUENIL EMEND HYDROXYCHLOROQUINE DARAPRIM ANZEMET PYRIMETHAMINE DOLASETRON MARINOL DRONABINOL SANCUSO GRANISETRON Preventive Medications List

ANTIVERT MISCELLANEOUS AGENTS: ZOFRAN, ZOFRAN ODT PYLERA BISMUTH/METRONIDAZOLE/ ONDANSETRON TRANSDERM-SCOP, SCOPACE CARAFATE SCOPOLAMINE SUCRALFATE OBESITY* PROTON PUMP INHIBITORS: DIETHYLPROPION XENICAL NEXIUM BONTRIL PREVACID PHENDIMETRAZINE LANSOPRAZOLE ADIPEX-P, IONAMIN PROTONIX PHENTERMINE PANTOPRAZOLE ACIPHEX RABEPRAZOLE BIRTH CONTROL MEDICINES OR MINERALS, LOW TAKEN BY MOUTH BIRTH CONTROL DEVICES: LEVELS OF DIAPHRAGMS, SKIN PATCH SYSTEMS, PRESCRIPTION PRENATAL VITAMINS INJECTABLE BIRTH CONTROL VITAMINS: B12, K SMOKING-CESSATION THERAPY ZYBAN BUPROPION NICOTROL PRODUCTS CHANTIX VARENICLINE ULCER DISEASE H2-ANTAGONISTS: CIMETIDINE PEPCID FAMOTIDINE AXID NIZATIDINE ZANTAC RANITIDINE

*Prior authorization is required. Express Scripts manages your prescription benefit for your employer, plan sponsor, or health plan. Please note: Brand names are shown in italics in each category. All rights in the product names of all third-party products appearing here, whether or not appearing with the trademark symbol, belong exclusively to their respective owners.

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