2021 Enhanced High Deductible Health Plan (HDHP) Preventive Therapy Drug List

This enhanced list includes both brand and generic products used to manage additional disease states. The enhanced offering includes both insulin and oral therapy for diabetes, inhalers for asthma and COPD, and additional preventative supplies supported by the 2019 IRS publication.

ANAPHYLAXIS PREVENTION Sympazan clonidine HCl Adrenalin tiagabine HCl digoxin epinephrine autoinjector topiramate diltiazem HCl EpiPen Trokendi XR diltiazem HCl CD EpiPen Jr valproic acid diltiazem HCl ER Symjepi Vigabatrin doxazosin mesylate vigadrone enalapril maleate ANTICOAGULANTS Vimpat enalapril maleate/HCTZ Bevyxxa zonisamide eplerenone dalteparin sodium felodipine ER Eliquis BLOOD PRESSURE MONITORING fosinopril sodium enoxaparin sodium Blood Pressure Monitor fosinopril sodium/HCTZ fondaparinux sodium guanfacine HCl Fragmin CARDIOVASCULAR - ANTI-ANGINAL hydralazine HCl Pradaxa isosorbide dinitrate irbesartan Savaysa Isosorbide Dinitrate ER irbesartan/HCTZ warfarin sodium isosorbide mononitrate isradipine Xarelto isosorbide mononitrate ER labetalol HCl nitroglycerin lisinopril ANTI-CONVULSANTS nitroglycerin ER lisinopril/HCTZ Aptiom nitroglyerin lingual losartan potassium Banzel nitroglycerin transdermal losartan potassium/HCTZ Briviact ranolazine ER methyldopa carbamazepine methyldopa/HCTZ carbamazepine ER CARDIOVASCUALR - ANTI-ARRHYTHMIC metoprolol succinate ER Celontin amiodarone HCl metoprolol tartrate clobazam disopyramide phosphate Metoprolol/HCTZ clonazepam dofetilide minoxidil clonazepam odt flecainide acetate moexipril HCl Diacomit Mexiletine HCl moexipril/HCTZ Diastat Acudial Multaq nadolol divalproex sodium propafenone HCl nadolol/bendroflumethiazide divalproex sodium DR quinidine gluconate CR nicardipine HCl divalproex sodium ER Quinidine Sulfate nifedipine epitol nifedipine ER ethosuximide CARDIOVASCULAR - nimodipine felbamate ANTI-HYPERTENSIVES nisoldipine ER Fycompa acebutolol HCl olmesartan gabapentin aliskiren olmesartan/amlodipine lamotrigine amlodipine besylate olmesartan/HCTZ lamotrigine ER amlodipine besylate/benazpril perindopril erbumine lamotrigine ODT amlodipine besylate/valsartan phenoxybenzamine HCl levetiracetam amlodipine/olmesartan med pindolol Nayzilam amlodipine/valsartan/HCTZ prazosin HCl oxcarbazepine atenolol propranolol HCl Oxtellar XR atenolol/chlorthalidone propranolol/HCTZ Peganone benazepril HCl quinapril HCl phenobarbital benazepril HCl/HCTZ quinapril/HCTZ phenytoin betaxolol HCl ramipril phenytoin sodium extended bisoprolol fumarate sotalol HCl pregabalin bisoprolol fumarate/HCTZ sotalol HCl (AF) primidone candesartan cilexetil telmisartan Qudexy XR candesartan cilexetil/HCTZ telmisartan/amlodipine roweepra captopril telmisartan/HCTZ roweepra XR captopril/HCTZ terazosin HCl Spritam carvedilol tiadylt ER

KEY: CR = controlled release | DR = delayed release | ER = extended release HCl = hydrochloride | HCTZ = hydrochlorothiazide | HFA = hydrofluoroalkane LA = long acting | ODT = oral disintegrating tablet | XR = extended release timolol maleate diazoxide Insulin syringes trandolapril Farxiga Lancets trandolapril/verapamil HCl Fiasp Lancing devices valsartan glimepiride valsartan/HCTZ glipizide GOUT PREVENTION verapamil HCl ER glipizide ER allopurinol Verapamil HCl SR glipizide/metformin HCl verapamil HCl Glucagen Hypokit MENTAL HEALTH Glucagon Emergency Kit Abilify Maintena CARDIOVASCULAR - CHOLESTEROL glyburide acamprosate calcium DR MEDICATION glyburide micronized amitriptyline HCl Antara glyburide/metformin HCl Amoxapine atorvastatin calcium Glyxambi Aplenzin cholestyramine Gvoke aripiprazole cholestyramine light Humalog aripiprazole injection colesevelam HCl Humalog Mix 50/50 aripiprazole ODT colestipol HCl Humalog Mix 75/25 Aristada ezetimibe Humulin 70/30 Belbuca ezetimibe/simvastatin Humulin N Bunavail fenofibrate Humulin R buprenorphine HCl Fibricor Humulin R U-500 buprenorphine HCl/naloxone fluvastatin Insulin Aspart bupropion HCl fluvastatin sodium ER Insulin Aspart Protamine bupropion HCl SR gemfibrozil Insulin Lispro Caplyta Livalo Insulin Lispro Protamine chlorpromazine HCl lovastatin Invokana citalopram hydrobromide niacin ER Januvia clomipramine HCl pravastatin sodium Jardiance clozapine rosuvastatin calcium Lantus clozapine ODT simvastatin Levemir desipramine HCl Vascepa metformin extended release desipramine HCl Zypitamag metformin HCl desvenlafaxine ER miglitol disulfiram CARDIOVASCULAR - DIURETICS nateglinide duloxetine HCl acetazolamide Novolin 70/30 Emsam acetazolamide ER Novolin N escitalopram oxalate amiloride HCl Novolin R Fanapt amiloride/HCTZ Novolog Fazaclo bumetanide Novolog Mix 70/30 Fetzima chlorothiazide Onglyza Fluoxetine DR chlorthalidone Ozempic fluoxetine HCl ethacrynic acid pioglitazone HCl/metformin fluphenazine decanoate furosemide pioglitazone HCl/glimepiride fluphenazine HCl hydrochlorothiazide (HCTZ) pioglitazone HCl fluvoxamine maleate indapamide Qtern fluvoxamine maleate ER methazolamide repaglinide haloperidol metolazone Repaglinide/Metformin HCl haloperidol decanoate spironolactone Rybelsus imipramine HCl spironolactone/HCTZ Segluromet imipramine pamoate torsemide Soliqua Invega Trinza triamterene Steglatro Latuda triamterene/HCTZ Steglujan Lithium Symlinpen lithium carbonate DIABETES Tanzeum lithium carbonate ER acarbose Tolazamide loxapine succinate Adlyxin Tolbutamide Maprotiline HCl Admelog Toujeo Marplan Afrezza Tradjenta mirtazapine Alogliptin Tresiba mirtazapine ODT Alogliptin/Metformin HCl Trijardy XR Molindone HCl Alogliptin/Pioglitazone Trulicity nefazodone HCl Apidra Victoza nortriptyline HCl Avandia Xultophy olanzapine Baqsimi olanzapine ODT Basaglar Kwikpen DIABETES SUPPLIES paliperidone ER Bydureon Blood glucose test strips paroxetine HCl Byetta Glucometer perphenazine Chlorpropamide Insulin pen needles Perseris

KEY: CR = controlled release | DR = delayed release | ER = extended release HCl = hydrochloride | HCTZ = hydrochlorothiazide | HFA = hydrofluoroalkane LA = long acting | ODT = oral disintegrating tablet | XR = extended release ELIXIR • 2021 ENHANCED HDHP LIST | 2 phenelzine sulfate Alvesco TRANSPLANT ANTI-REJECTION Probuphine Implant Kit Anoro Ellipta Astagraf XL prochlorperazine Arcapta Neohaler Azasan prochlorperazine maleate Armonair Respiclick azathioprine protriptyline HCl Arnuity Ellipta basiliximab quetiapine fumarate Asmanex HFA belatacept injection quetiapine fumarate ER Asmanex Twisthaler cyclosporine Rexulti Atrovent HFA cyclosporine modified Risperdal Consta Bevespi Aerosphere Envarsus XR risperidone Breo Ellipta everolimus risperidone ODT Brovana mycophenolate mofetil Saphris budesonide mycophenolic acid DR Secuado Budesonide/Formoterol Fumurate Nulojix sertraline HCl Combivent Respimat Prograf Sublocade Duaklir Pressair Sandimmune thioridazine HCl Dulera sirolimus thiothixene Elixophyllin tacrolimus tranylcypromine sulfate Flovent Diskus Zortress trazodone HCl Flovent HFA trifluoperazine HCl fluticasone propionate/salmeterol WEIGHT LOSS AGENTS trimipramine maleate Incruse Ellipta benzphetamine HCl Trintellix ipratropium bromide Contrave venlafaxine HCl ipratropium bromide/albuterol diethylpropion HCl ER venlafaxine HCl ER levalbuterol phendimetrazine tartrate Viibryd Levalbuterol Tartrate HFA phentermine HCl Vraylar Lonhala Magnair Qsymia ziprasidone HCl Metaproterenol Sulfate Saxenda ziprasidone mesylate montelukast sodium Xenical Zyprexa Relprevv Perforomist Proair Digihaler OSTEOPOROSIS Proair Respiclick alendronate sodium Pulmicort Flexhaler calcitonin salmon Qvar Fosamax Plus D Qvar Redihaler Ibrandonate sodium Seebri Neohaler raloxifene HCl Serevent Diskus risedronate sodium Spiriva Handihaler risedronate sodium DR Spiriva Respimat Stiolto Respimat OTHER PREVENTIVE PRODUCTS Striverdi Respimat aspirin Symbicort bowel preparations Theo-24 cromolyn Theochron fluoride dental products theophylline folic acid theophylline CR hormonal contraceptives theophylline ER smoking deterrents Trelegy Ellipta vaccines Tudorza Pressair vitamins Utibron Neohaler Ventolin HFA PEAK FLOW METER wixela inhub Peak Flow Meter Xopenex HFA Yupelri PRENATAL VITAMINS zafirlukast Prenatal Vitamins zileuton ER Zyflo PULMONARY - ASTHMA/CHRONIC OBSTRUCTIVE PULMONARY DISEASE THROMBOTIC STROKE PREVENTION Advair HFA aspirin/dipyridamole ER Aerospan Brilinta Airduo Respiclick cilostazol albuterol sulfate clopidogrel albuterol sulfate ER dipyridamole albuterol sulfate HFA prasugrel

KEY: CR = controlled release | DR = delayed release | ER = extended release HCl = hydrochloride | HCTZ = hydrochlorothiazide | HFA = hydrofluoroalkane LA = long acting | ODT = oral disintegrating tablet | XR = extended release ELIXIR • 2021 ENHANCED HDHP LIST | 3 Medications are categorized by common therapeutic conditions in this Preventive Therapy Drug List for ease of reference only. These categories do not determine coverage for the medication for your condition. Your benefit plan determines how these medications may be covered for you and at what cost. Therefore, certain products, categories, strengths, dosage forms, or formulations may not be covered. Please note that over-the-counter products require a prescription. The ability to obtain medications listed on this Preventive Therapy Drug may be limited by federal, state, or local laws or regulations such as expiration dates or limits on the number of refills.

If there are differences between your plan design and this Preventive Therapy Drug List, your plan design will dictate final coverage status.

If you have any questions regarding the coverage of any particular drug under your benefit program, you may:

1. Call the Member Services number located on the back of your prescription drug identification card; 2. Refer to your plan-specific documents; or 3. Contact your plan administrator for further information.

This list is periodically reviewed and updated. 10/5/2020

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