Preventive Drug List

Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details or ask Member Services if you have this benefit.

How to use this list: • Brand medicines are in ALL CAPS (e.g., DALIRESP ORAL ) • Generic medicines are in lower italics (e.g., furosemide oral tablet)

PA – Prior authorization ST – Step therapy QL – Quantity limit AE – Age Edit

Please note: If your drug requires PA, ST, QL or AE, you must meet the coverage criteria for the drug to be covered at your preventive benefit.

Drug More Details Alcohol Dependency Alcohol Dependency acamprosate oral tablet,delayed release (dr/ec) disulfiram oral tablet & COPD Asthma & COPD, Other ATROVENT HFA INHALATION HFA AEROSOL INHALER cromolyn inhalation for nebulization DALIRESP ORAL TABLET PA ipratropium bromide inhalation solution montelukast oral granules in packet montelukast oral tablet montelukast oral tablet,chewable SPIRIVA RESPIMAT INHALATION MIST

SPIRIVA WITH HANDIHALER INHALATION , W/INHALATION DEVICE

Bronchodilators, Inhaled SEREVENT DISKUS INHALATION BLISTER WITH DEVICE STRIVERDI RESPIMAT INHALATION MIST Bronchodilators, Oral theophylline oral tablet extended release

1 April 1, 2017 theophylline oral tablet extended release 12 hr Combination Agents, Inhaled ADVAIR DISKUS INHALATION BLISTER WITH DEVICE ADVAIR HFA INHALATION HFA AEROSOL INHALER ANORO ELLIPTA INHALATION BLISTER WITH DEVICE PA BREO ELLIPTA INHALATION BLISTER WITH DEVICE COMBIVENT RESPIMAT INHALATION MIST DULERA INHALATION HFA AEROSOL INHALER PA ipratropium-albuterol inhalation solution for nebulization STIOLTO RESPIMAT INHALATION MIST Corticosteroids, Inhaled ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE ASMANEX HFA INHALATION HFA AEROSOL INHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) budesonide inhalation for nebulization AE FLOVENT DISKUS INHALATION BLISTER WITH DEVICE FLOVENT HFA INHALATION HFA AEROSOL INHALER PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH

ACTIVATED QVAR INHALATION AEROSOL Behavioral Health Antipsychotic aripiprazole oral solution AE aripiprazole oral tablet AE aripiprazole oral tablet,disintegrating PA; AE chlorpromazine oral tablet AE clozapine oral tablet AE clozapine oral tablet,disintegrating PA; AE fluphenazine hcl oral concentrate AE fluphenazine hcl oral AE fluphenazine hcl oral tablet AE haloperidol lactate oral concentrate AE haloperidol oral tablet AE loxapine succinate oral capsule AE olanzapine oral tablet AE olanzapine oral tablet,disintegrating PA; AE perphenazine oral tablet AE quetiapine oral tablet AE quetiapine oral tablet extended release 24 hr PA; AE risperidone oral solution AE

2 April 1, 2017 risperidone oral tablet AE risperidone oral tablet,disintegrating PA; AE thioridazine oral tablet AE thiothixene oral capsule AE trifluoperazine oral tablet AE VERSACLOZ ORAL SUSPENSION PA; AE ziprasidone hcl oral capsule AE Bipolar Disorder lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution 8 meq/5 ml Depression, Atypical Antidepressants bupropion hcl oral tablet bupropion hcl oral tablet extended release bupropion hcl oral tablet extended release 24 hr mirtazapine oral tablet Depression, Maois phenelzine oral tablet tranylcypromine oral tablet Depression, Serotonin Modulators nefazodone oral tablet trazodone oral tablet Depression, Snris duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet Depression, Ssris citalopram oral solution citalopram oral tablet escitalopram oxalate oral solution escitalopram oxalate oral tablet fluoxetine oral capsule fluoxetine oral solution fluvoxamine oral tablet paroxetine hcl oral tablet PAXIL ORAL SUSPENSION sertraline oral concentrate sertraline oral tablet Depression, Tricyclic & Tetracyclic Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 25 mg, 50 mg, 75 mg AE amitriptyline oral tablet 150 mg AE 3 April 1, 2017 clomipramine oral capsule AE desipramine oral tablet doxepin oral capsule AE imipramine hcl oral tablet AE nortriptyline oral capsule nortriptyline oral solution Blood Thinner Anticoagulants ELIQUIS ORAL TABLET jantoven oral tablet PRADAXA ORAL CAPSULE warfarin oral tablet XARELTO ORAL TABLET XARELTO ORAL TABLETS,DOSE PACK Platelet Inhibitors anagrelide oral capsule aspirin-dipyridamole oral capsule, er multiphase 12 hr BRILINTA ORAL TABLET cilostazol oral tablet clopidogrel oral tablet 75 mg dipyridamole oral tablet EFFIENT ORAL TABLET ZONTIVITY ORAL TABLET PA Cancer Cancer, Serms tamoxifen oral tablet Diabetes Diabetes, Alpha-Glucosidase Inhibitors acarbose oral tablet miglitol oral tablet Diabetes, Biguanides metformin oral tablet metformin oral tablet extended release 24 hr Diabetes, Dpp-4 Inhibitor / Biguanide Combinations JENTADUETO ORAL TABLET

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG

Diabetes, Dpp-4 Inhibitors TRADJENTA ORAL TABLET Diabetes, Glp-1 Agonists BYDUREON SUBCUTANEOUS PEN INJECTOR QL

4 April 1, 2017 BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON QL

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, QL 5 MCG/DOSE (250 MCG/ML) 1.2 ML TRULICITY SUBCUTANEOUS PEN INJECTOR PA; QL VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR QL VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR QL Diabetes, Intermediate-Acting Insulins HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN N SUBCUTANEOUS SUSPENSION Diabetes, Long-Acting Insulins BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN ST LEVEMIR SUBCUTANEOUS SOLUTION ST Diabetes, Meglitinides nateglinide oral tablet repaglinide oral tablet Diabetes, Other Oral Agents CYCLOSET ORAL TABLET PA Diabetes, Pre-Mixed Insulins HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN 70/30 SUBCUTANEOUS SUSPENSION Diabetes, Rapid-Acting Insulins HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG SUBCUTANEOUS CARTRIDGE HUMALOG SUBCUTANEOUS SOLUTION Diabetes, Rescue Agents GLUCAGEN HYPOKIT RECON SOLN GLUCAGEN INJECTION RECON SOLN GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT Diabetes, Sglt2 Inhibitor / Biguanide Combinations INVOKAMET ORAL TABLET ST INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR ST SYNJARDY ORAL TABLET ST Diabetes, Sglt2 Inhibitors INVOKANA ORAL TABLET ST JARDIANCE ORAL TABLET ST Diabetes, Short-Acting Insulins 5 April 1, 2017 HUMULIN R U-100 INJECTION SOLUTION

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

Diabetes, Sulfonylurea / Biguanide Combination glipizide-metformin oral tablet Diabetes, Sulfonylureas glimepiride oral tablet glipizide oral tablet glipizide oral tablet extended release 24hr Diabetes, Thiazolidinedione / Biguanide Combinations pioglitazone-metformin oral tablet Diabetes, Thiazolidinedione / Sulfonylurea Combinations pioglitazone-glimepiride oral tablet Diabetes, Thiazolidinediones pioglitazone oral tablet Heart Health Blood Pressure, ACEI & ARB amlodipine-benazepril oral capsule amlodipine-valsartan oral tablet ST amlodipine-valsartan-hcthiazid oral tablet ST benazepril oral tablet benazepril-hydrochlorothiazide oral tablet captopril oral tablet captopril-hydrochlorothiazide oral tablet enalapril maleate oral tablet enalapril-hydrochlorothiazide oral tablet fosinopril oral tablet fosinopril-hydrochlorothiazide oral tablet irbesartan oral tablet irbesartan-hydrochlorothiazide oral tablet lisinopril oral tablet lisinopril-hydrochlorothiazide oral tablet losartan oral tablet losartan-hydrochlorothiazide oral tablet moexipril oral tablet moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 7.5-12.5 mg moexipril-hydrochlorothiazide oral tablet 15-25 mg perindopril erbumine oral tablet quinapril oral tablet quinapril-hydrochlorothiazide oral tablet 6 April 1, 2017 ramipril oral capsule trandolapril oral tablet valsartan oral tablet valsartan-hydrochlorothiazide oral tablet Blood Pressure, Beta Blockers atenolol oral tablet atenolol-chlorthalidone oral tablet bisoprolol fumarate oral tablet bisoprolol-hydrochlorothiazide oral tablet carvedilol oral tablet COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR ST labetalol oral tablet metoprolol succinate oral tablet extended release 24 hr metoprolol ta-hydrochlorothiaz oral tablet metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol oral tablet propranolol oral capsule,extended release 24 hr propranolol oral tablet propranolol-hydrochlorothiazid oral tablet Blood Pressure, Calcium Channel Blockers amlodipine oral tablet amlodipine-benazepril oral capsule amlodipine-valsartan oral tablet ST amlodipine-valsartan-hcthiazid oral tablet ST cartia xt oral capsule,extended release 24hr diltiazem hcl oral capsule, extended release diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet dilt-xr oral capsule,ext release degradable 120 mg, 180 mg nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr taztia xt oral capsule, extended release 120 mg, 180 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release Blood Pressure, Other clonidine hcl oral tablet clonidine weekly doxazosin oral tablet guanfacine oral tablet

7 April 1, 2017 hydralazine oral tablet methyldopa oral tablet minoxidil oral tablet prazosin oral capsule reserpine oral tablet terazosin oral capsule Cholesterol Lowering, Bile Acid Resins cholestyramine (with sugar) oral cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder cholestyramine light oral powder in packet colestipol oral tablet Cholesterol Lowering, Other ezetimibe oral tablet Cholesterol Lowering, Statins atorvastatin oral tablet lovastatin oral tablet pravastatin oral tablet rosuvastatin oral tablet simvastatin oral tablet 10 mg, 20 mg, 5 mg simvastatin oral tablet 40 mg QL simvastatin oral tablet 80 mg PA Diuretics amiloride oral tablet amiloride-hydrochlorothiazide oral tablet bumetanide oral tablet chlorothiazide oral tablet chlorthalidone oral tablet 25 mg, 50 mg eplerenone oral tablet furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet indapamide oral tablet metolazone oral tablet spironolactone oral tablet spironolacton-hydrochlorothiaz oral tablet torsemide oral tablet triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet Heart Health, Other ENTRESTO ORAL TABLET 8 April 1, 2017 Triglyceride Lowering fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized oral tablet fenofibrate oral tablet 160 mg, 54 mg gemfibrozil oral tablet omega-3 acid ethyl esters oral capsule ST VASCEPA ORAL CAPSULE ST Smoking Cessation Nicotine Replacement nicotine (polacrilex) buccal gum nicotine (polacrilex) buccal lozenge nicotine transdermal patch 24 hour NICOTROL INHALATION CARTRIDGE NICOTROL NS ,NON-AEROSOL Smoking Cessation, Other buproban oral tablet extended release CHANTIX ORAL TABLET QL CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK QL Vitamins And Minerals Vitamins And Minerals completenate oral tablet,chewable inatal ultra oral tablet mynatal plus oral tablet mynate 90 plus oral tablet extended release o-cal prenatal oral tablet prenaplus oral tablet prenatabs fa oral tablet prenatabs rx oral tablet prenatal low iron oral tablet prenatal plus (calcium carb) oral tablet prenatal plus oral tablet trinate oral tablet vinate care oral tablet,chewable vinate one oral tablet Weight Loss Weight Loss ALLI ORAL CAPSULE PA phentermine oral capsule 15 mg, 30 mg, 37.5 mg QL phentermine oral tablet QL XENICAL ORAL CAPSULE PA

9 April 1, 2017