Safe Harbor Preventative Drug List

This list includes identified as those most likely to qualify as “preventive” based on the U.S. Department of Treasury Department/IRS guidance. This list may not include all medications considered preventive or every health condition for which a preventive drug may be prescribed. At this time, neither MedImpact nor your health plan can guarantee which medications will satisfy U.S. Treasury Department definition for preventative safe harbor medications. Please also note: • Utilization management (ie. prior authorization, step therapy, and quantity limits) may apply to listed medications based on benefit design • Use of generics may be required depending on plan design • Some strengths or dosage forms may not be included • Certain products or therapeutic categories may not be covered • Brand and generic status may not be current due to the changes in the market • This list is subject to change without prior notice • Regardless of their appearance in this document, please contact member services at the number on your prescription benefits card should you have any questions regarding coverage

THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

ANAPHYLAXIS THERAPY EPINEPHRINE EPINEPHRINE ADRENACLICK, EPI-PEN, EPI-PEN JR AUTOINJECTORS

ANTICOAGULANTS/ANTIP ANTICOAGULANTS APIXABAN ELIQUIS* LATELETS

DABIGATRAN PRADAXA*

DALTEPARIN SODIUM FRAGMIN*

EDOXABAN TOSYLATE SAVAYSA*

ENOXAPARIN SODIUM LOVENOX

FONDAPARINUX SODIUM ARIXTRA

RIVAROXABAN XARELTO*

WARFARIN SODIUM COUMADIN, JANTOVEN

ANTIPLATELETS ASPIRIN/DIPYRIDAMOLE AGGRENOX*

CILOSTAZOL CILOSTAZOL

CLOPIDOGREL BISULFATE PLAVIX

DIPYRIDAMOLE PERSANTINE

PRASUGREL HCL EFFIENT*

TICAGRELOR BRILINTA*

VORAPAXAR SULFATE ZONTIVITY*

SICKLE CELL ANEMIA HYDROXYUREA DROXIA*

ASTHMA/COPD ASTHMA/COPD BUDESONIDE/FORMOTEROL FUMARATE SYMBICORT* COMBINATIONS

FLUTICASONE/SALMETEROL ADVAIR DISKUS*, ADVAIR HFA

FLUTICASONE/VILANTEROL BREO ELLIPTA*

GLYCOPYRROLATE/FORMOTEROL FUM BEVESPI AEROSPHERE*

INDACATEROL/GLYCOPYRROLATE UTIBRON NEOHALER*

IPRATROPIUM/ALBUTEROL SULFATE DUONEB, COMBIVENT*, COMBIVENT RESPIMAT*

MOMETASONE/FORMOTEROL DULERA*

TIOTROPIUM BR/OLODATEROL HCL STIOLTO RESPIMAT*

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ASTHMA/COPD ASTHMA/COPD UMECLIDINIUM BRM/VILANTEROL TR ANORO ELLIPTA* COMBINATIONS

INHALED BECLOMETHASONE DIPROPIONATE QVAR* CORTICOSTEROIDS

BUDESONIDE PULMICORT*, PULMICORT FLEXHALER*

CICLESONIDE ALVESCO*

FLUNISOLIDE AEROSPAN*

FLUTICASONE FUROATE ARNUITY ELLIPTA*

FLUTICASONE PROPIONATE FLOVENT HFA*, FLOVENT DISKUS*

MOMETASONE FUROATE ASMANEX*, ASTHMANEX HFA

LONG ACTING BETA- ARFORMOTEROL TARTRATE BROVANA* AGONIST

FORMOTEROL FUMARATE FORADIL*, PERFOROMIST*

INDACATEROL MALEATE ARCAPTA NEOHALER*

OLODATEROL HCL STRIVERDI RESPIMAT*

SALMETEROL XINAFOATE SEREVENT DISKUS*

LONG ACTING MUSCARINIC ACLIDINIUM BROMIDE TUDORZA PRESSAIR* ANATGONIST

GLYCOPYRROLATE SEEBRI NEOHALER*

TIOTROPIUM BROMIDE SPIRIVA*, SPIRIVA RESPIMAT*

UMECLIDINIUM BROMIDE INCRUSE ELLIPTA*

MISC ASTHMA/COPD AMINOPHYLLINE AMINOPHYLLINE

CROMOLYN SODIUM GASTROCROM

MONTELUKAST SODIUM SINGULAIR

OMALIZUMAB XOLAIR*

PREDNISONE PREDNISONE

ROFLUMILAST DALIRESP*

ZAFIRLUKAST ACCOLATE

SHORT ACTING BETA- ALBUTEROL SULFATE ACCUNEB, PROAIR HFA*, PROAIR AGONIST RESPICLICK*, PROVENTIL HFA* VENTOLIN HFA*

LEVALBUTEROL TARTRATE XOPENEX HFA*

PIRBUTEROL ACETATE MAXAIR AUTOHALER*

SHORT ACTING IPRATROPIUM BROMIDE ATROVENT, ATROVENT HFA* MUSCARINIC ANATGONIST

CANCER PREVENTION BREAST CANCER ANASTROZOLE ARIMIDEX PREVENTION

EXEMESTANE AROMASIN

CARDIOVASCULAR ALPHA AND BETA ACEBUTOLOL HCL SECTRAL ADRENERGIC BLOCKERS

ATENOLOL TENORMIN

BETAXOLOL HCL

BISOPROLOL FUMARATE ZEBETA

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CARDIOVASCULAR ALPHA AND BETA CARVEDILOL COREG, COREG CR* ADRENERGIC BLOCKERS

LABETALOL HCL TRANDATE

METOPROLOL SUCCINATE TOPROL XL

METOPROLOL TARTRATE LOPRESSOR

NADOLOL CORGARD

NEBIVOLOL HCL BYSTOLIC*

PENBUTOLOL SULFATE LEVATOL*

PROPRANOLOL HCL HEMANGEOL*, INDERAL LA, INNOPRAN XL

TIMOLOL MALEATE

ANGIOTENSIN HCL LOTENSIN CONVERTING ENZYME INHIBITORS

CAPTOPRIL

ENALAPRIL MALEATE EPANED*, VASOTEC

FOSINOPRIL SODIUM

LISINOPRIL PRINIVIL, QBRELIS*, ZESTRIL

MOEXIPRIL HCL UNIVASC

PERINDOPRIL ERBUMINE ACEON

QUINAPRIL HCL ACCUPRIL

RAMIPRIL ALTACE

TRANDOLAPRIL MAVIK

ANGIOTENSIN II RECEPTOR MEDOXOMIL EDARBI* ANTAGONISTS

CANDESARTAN CILEXETIL ATACAND

EPROSARTAN MESYLATE TEVETEN

IRBESARTAN AVAPRO

LOSARTAN POTASSIUM COZAAR

OLMESARTAN MEDOXOMIL BENICAR

TELMISARTAN MICARDIS

VALSARTAN DIOVAN

ANTI-ARRHYTHMICS AMIODARONE HCL CORDARONE, PACERONE

DOFETILIDE TIKOSYN

FLECAINIDE ACETATE TAMBOCOR

PROPAFENONE HCL PROPAFENONE HCL

SOTALOL HCL BETAPACE, BETASPACE AF, SOTYLIZE*

CALCIUM CHANNEL AMLODIPINE BESYLATE NORVASC BLOCKER

DILTIAZEM HCL CARDIZEM, CD, LA, CARTIA XT, DILACOR XR*, DILT-CD, DILT-XR, MATZIM LA, TIAZAC

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CARDIOVASCULAR CALCIUM CHANNEL ISRADIPINE BLOCKER

NICARDIPINE HCL CARDENE SR

NIFEDIPINE ADALAT CC, AFEDITAB CR, NIFEDICAL XL

NISOLDIPINE SULAR

VERAPAMIL HCL CALAN, CALAN SR, VERELAN, VERELAN PM

CARDIOVASCULAR AMILORIDE/HYDROCHLOROTHIAZIDE COMBINATIONS

AMLODIPINE BES/ MED AZOR

AMLODIPINE BESYLATE/BENAZEPRIL LOTREL

AMLODIPINE/ATORVASTATIN CADUET

AMLODIPINE/ EXFORGE

AMLODIPINE/VALSARTAN/HCTHIAZID EXFORGE HCT

ATENOLOL/CHLORTHALIDONE TENORETIC 50, 100

AZILSARTAN MED/CHLORTHALIDONE EDARBYCLOR

BENAZEPRIL/HYDROCHLOROTHIAZIDE LOTENSIN HCT

BISOPROL/HYDROCHLOROTHIAZIDE ZIAC

CANDESARTAN/HYDROCHLOROTHIAZID ATACAND HCT

CAPTOPRIL/HYDROCHLOROTHIAZIDE

ENALAPRIL/HYDROCHLOROTHIAZIDE VASERETIC

EPROSARTAN/HYDROCHLOROTHIAZIDE TEVETEN HCT

IRBESARTAN/HYDROCHLOROTHIAZIDE AVALIDE

ISOSORBIBE DINIT/HYDRALAZINE BIDIL*

LISINOPRIL/HYDROCHLOROTHIAZIDE ZESTORETIC

LOSARTAN/HYDROCHLOROTHIAZIDE HYZAAR

METOPROLOL SU/HYDROCHLOROTHIAZ DUTOPROL

METOPROLOL/HYDROCHLOROTHIAZIDE

MOEXIPRIL/HYDROCHLOROTHIAZIDE UNIRETIC

NADOLOL/BENDROFLUMETHIAZIDE CORZIDE

NEBIVOLOL HCL/VALSARTAN BYVALSON*

OLMESARTAN/AMLODIPIN/HCTHIAZID TRIBENZOR

OLMESARTAN/HYDROCHLOROTHIAZIDE BENICAR HCT

PERINDOPRIL ARG/AMLODIPINE BES PRESTALIA*

PROPRANOLOL/HYDROCHLOROTHIAZID

QUINAPRIL/HYDROCHLOROTHIAZIDE ACCURETIC

SACUBITRIL/VALSARTAN ENTRESTO*

SPIRONOLACT/HYDROCHLOROTHIAZID ALDACTAZIDE

TELMISARTAN/AMLODIPINE TWYNSTA

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CARDIOVASCULAR CARDIOVASCULAR TELMISARTAN/HYDROCHLOROTHIAZID MICARDIS HCT COMBINATIONS

TRANDOLAPRIL/VERAPAMIL HCL TARKA

TRIAMTERENE/HYDROCHLOROTHIAZID DYAZIDE, MAXZIDE, MAXZIDE 25

VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT

DIURETICS AMILORIDE HCL AMILORIDE HCL

BUMETANIDE

CHLOROTHIAZIDE DIURIL*

CHLORTHALIDONE

EPLERENONE INSPRA

ETHACRYNIC ACID EDECRIN

FUROSEMIDE LASIX

HYDROCHLOROTHIAZIDE MICROZIDE

INDAPAMIDE

METHYCLOTHIAZIDE

METOLAZONE ZAROXOLYN

SPIRONOLACTONE ALDACTONE

TORSEMIDE DEMADEX

TRIAMTERENE DYRENIUM

MISC CARDIOVASCULAR DIGOXIN DIGOXIN

IVABRADINE HCL CORLANOR*

NITROGLYCERIN NITRO-TIME

SACUBITRIL/VALSARTAN ENTRESTO*

VALSARTAN/SACUBITRIL ENTRESTO*

DIABETES BIGUANIDES METFORMIN HCL FORTAMET*, GLUCOPHAGE, GLUMETZA, RIOMET*

DIABETES COMBINATION ALOGLIPTIN BENZ/METFORMIN HCL KAZANO

ALOGLIPTIN BENZ/PIOGLITAZONE OSENI

CANAGLIFLOZIN/METFORMIN HCL INVOKAMET*, INVOKAMET XR*

DAPAGLIFLOZIN/METFORMIN HCL XIGDUO XR*

EMPAGLIFLOZIN/LINAGLIPTIN GLYXAMBI*

EMPAGLIFLOZIN/METFORMIN HCL SYNJARDY*

GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN

GLYBURIDE/METFORMIN HCL GLUCOVANCE

INSULIN DEGLUDEC/ XULTOPHY 100-3.6

INSULIN GLARGINE/ SOLIQUA 100-33

LINAGLIPTIN/METFORMIN HCL JENTADUETO, JENTADUETO XR

PIOGLITAZONE HCL/GLIMEPIRIDE DUETACT

PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET/ACTOPLUS MET XR*

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DIABETES DIABETES COMBINATION REPAGLINIDE/METFORMIN HCL PRANDIMET

ROSIGLITAZONE/GLIMEPIRIDE AVANDARYL*

ROSIGLITAZONE/METFORMIN HCL AVANDAMET*

SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR

SITAGLIPTIN PHOS/METFORMIN HCL JANUMET, JANUMET XR

DPP-4 INHIBITORS ALOGLIPTIN BENZOATE NESINA

LINAGLIPTIN TRADJENTA*

SAXAGLIPTIN HCL ONGLYZA*

SITAGLIPTIN PHOSPHATE JANUVIA*

GLP-1 AGONISTS TANZEUM*

DULAGLUTIDE TRULICITY*

EXENATIDE BYETTA*

EXENATIDE MICROSPHERES BYDUREON*

LIRAGLUTIDE VICTOZA*

LIXISENATIDE ADLYXIN*

INSULIN SECRETAGOGUES CHLORPROPAMIDE

GLIMEPIRIDE AMARYL

GLIPIZIDE GLUCOTROL, GLUCOTROL XL

GLYBURIDE DIABETA

GLYBURIDE,MICRONIZED GLYNASE

NATEGLINIDE STARLIX

REPAGLINIDE PRANDIN

TOLAZAMIDE

TOLBUTAMIDE

INSULINS NOVOLOG*

INSULIN ASPART PROT/INSULN ASP NOVOLOG MIX 70-30*, FLEXPEN*

INSULIN DEGLUDEC TRESIBA FLEXTOUCH U-100*, U-200*

INSULIN DETEMIR LEVEMIR*, FLEXPEN*, FLEXTOUCH*

INSULIN GLARGINE,HUM.REC.ANLOG BASAGLAR KWIKPEN U-100*

LANTUS*, SOLOSTAR*

TOUJEO SOLOSTAR

INSULIN GLULISINE APIDRA*, APIDRA SOLOSTAR*

INSULIN LISPRO HUMALOG*, KWIKPEN U-100*, 200*

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 50-50*, KWIKPEN*

HUMALOG MIX 75-25*, KWIKPEN*

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70-30*, KWIKPEN*

NOVOLIN 70-30*

INSULIN NPH HUMAN ISOPHANE NOVOLIN N*

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DIABETES INSULIN NPH HUMAN ISOPHANE HUMULIN N*, KWIKPEN*

INSULIN REGULAR, HUMAN NOVOLIN R*

HUMULIN R*

HUMULIN R U-500*, KWIKPEN*

MISC DIABETES DEXTROSE

SGLT-2 INHIBITORS CANAGLIFLOZIN INVOKANA*

DAPAGLIFLOZIN PROPANEDIOL FARXIGA*

EMPAGLIFLOZIN JARDIANCE*

THIAZOLINDINEDIONES PIOGLITAZONE HCL ACTOS

ROSIGLITAZONE MALEATE AVANDIA*

HIV PROPHYLAXIS HIV PROPHYLAXIS EMTRICITABINE/TENOFOVIR (TDF) TRUVADA*

HYPERLIPIDEMIA BILE ACID CHOLESTYRAMINE (WITH SUGAR) QUESTRAN SEQUESTRANTS/LIPOTROPI CS/NIACIN

CHOLESTYRAMINE/ASPARTAME PREVALITE

COLESEVELAM HCL WELCHOL*

COLESTIPOL HCL COLESTID

EZETIMIBE ZETIA

FENOFIBRATE FENOGLIDE, LIPOFEN, LOFIBRA

FENOFIBRATE NANOCRYSTALLIZED TRICOR

FENOFIBRATE,MICRONIZED ANTARA, LOFIBRA

FENOFIBRIC ACID FIBRICOR

FENOFIBRIC ACID (CHOLINE) TRILIPIX

GEMFIBROZIL LOPID

ICOSAPENT ETHYL VASCEPA*

NIACIN ENDUR-ACIN, SLO-NIACIN, NIACIN FLUSH FREE

NIACIN ER, NIASPAN

OMEGA-3 ACID ETHYL ESTERS LOVAZA

HYPERLIPIDEMIA COMBO EZETIMIBE/ATORVASTATIN CALCIUM LIPTRUZET*

EZETIMIBE/SIMVASTATIN VYTORIN*

VYTORIN*

NIACIN/LOVASTATIN ADVICOR*

NIACIN/SIMVASTATIN SIMCOR*

STATINS ATORVASTATIN CALCIUM LIPITOR

FLUVASTATIN SODIUM LESCOL, LESCOL XL

PITAVASTATIN CALCIUM LIVALO*

PRAVASTATIN SODIUM PRAVACHOL

SIMVASTATIN ZOCOR

OSTEOPOROSIS OSTEOPOROSIS ALENDRONATE SODIUM FOSAMAX

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OSTEOPOROSIS OSTEOPOROSIS ,SALMON,SYNTHETIC FORTICAL

ETIDRONATE DISODIUM

IBANDRONATE SODIUM BONIVA

RALOXIFENE HCL EVISTA

RISEDRONATE SODIUM ACTONEL

VITAMINS PEDIATRIC VITAMINS PEDIATRIC MULTIVITAMIN

PRENATAL VITAMINS PRENATAL VITAMINS W/ FOLIC ACID

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