Tier 1 CO-PAY MEDICATION LIST 2021

Arthritis & Pain Diabetes (cont.)

Aspirin buffered tablet Metformin HCL 24hr (SA) tablet Aspirin chewable tablet Pioglitazone HCL tablet Aspirin enteric coated tablet Allopurinol tablet Celecoxib capsule Electrolyte Supplement Diclofenac tablet Ibuprofen tablet Potassium SA tablet Meloxicam tablet Potassium SA dispersible tablet Naproxen tablet Gastrointestinal Health Blood Thinners & Platelet Inhibitors

Clopidogrel Bisulfate tablet Famotidine tablet Warfarin Sodium tablet Omeprazole EC capsule Pantoprazole Sodium EC capsule Bone Health Glaucoma & Eye Care Alendronate tablet Diclofenac solution Cholesterol Dorzolamide 2%/Timolol 0.5%

solution Atorvastatin tablet Ezetimibe tablet Latanoprost 0.005% solution Pravastatin tablet Polyethylene Glycol 400/ Poly- Rosuvastatin CA tablet ethylene Glycol 4000 solution Carboxymethylcellulose Sodium Simvastatin tablet solution

Dementia Heart Health & Blood Pressure

Donepezil tablet Amlodipine tablet Diabetes Amiodarone HCL tablet

Aspirin (see Arthritis & Pain) Atenolol tablet Glimepiride tablet Carvedilol tablet Glipizide tablet Metformin HCL tablet Chlorthalidone tablet Clonidine tablet Tier 1 CO-PAY MEDICATION LIST 2021

Heart Health & Blood Pressure (cont.) Mental Health (cont.)

Diltiazem 24HR capsule Paroxetine tablet Diltiazem HCL tablet Sertraline HCL tablet Enalapril Maleate tablet Trazodone tablet Furosemide tablet Venlafaxine HCL IR tablet Hydralazine HCL tablet Venlafaxine HCL SA capsule Hydrochlorothiazide tablet/capsule Hydrochlorothiazide/Lisinopril tablet Hydrochlorothiazide/Losartan tablet Respiratory Condition Hydrochlorothiazide/Triamterene tab/cap Isosorbide Mononitrate SA tablet Lisinopril tablet Montelukast NA tablet Losartan tablet Metoprolol Succinate SA tablet Seizures Metoprolol Tartrate tablet Nifedipine SA capsule Gabapentin capsule Nitroglycerin sublingual tablet Lamotrigine tablet Prazosin HCL capsule Topiramate tablet Propranolol HCL tablet Spironolactone tablet Thyroid Conditions

Levothyroxine Sodium tablet Mental Health

Urologic (Bladder & Prostate) Health Amitriptyline HCL tablet Buspirone HCL tablet Bupropion HCL tablet Alfuzosin HCL SA tablet Bupropion HCL SA (12HR-SR) tablet Doxazosin Mesylate tablet Bupropion HCL SA (24HR-XL) tablet Finasteride tablet Citalopram Hydrobromide tablet Oxybutynin Chloride IR tablet Duloxetine HCL EC capsule Oxybutynin Chloride SA tablet Escitalopram Oxalate tablet Sildenafil tablet Fluoxetine tablet/capsule Tamsulosin HCL capsule Mirtazapine tablet Terazosin HCL capsule