Preventative Medication List

MedImpact Safe Harbor Preventative Drug List This list includes medications 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 and drug availability 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 ANAPHYLAXIS THERAPY EPINEPHRINE AUVI-Q*, EPINEPHRINE, EPIPEN, THERAPY AGENTS EPIPEN 2-PAK, EPIPEN JR, EPIPEN JR 2-PAK, SYMJEPI* ANTICOAGULANTS / ANTICOAGULANTS,COU WARFARIN SODIUM JANTOVEN, WARFARIN SODIUM ANTIPLATELET MARIN TYPE DIRECT FACTOR XA APIXABAN ELIQUIS* INHIBITORS RIVAROXABAN XARELTO* EDOXABAN TOSYLATE SAVAYSA* HEPARIN AND RELATED DALTEPARIN FRAGMIN* PREPARATIONS SODIUM,PORCINE ENOXAPARIN SODIUM ENOXAPARIN SODIUM, LOVENOX FONDAPARINUX SODIUM ARIXTRA, FONDAPARINUX SODIUM

PLATELET ASPIRIN/ DIPYRIDAMOLE ASPIRIN-DIPYRIDAMOLE ER AGGREGATION INHIBITORS CILOSTAZOL CILOSTAZOL CLOPIDOGREL BISULFATE CLOPIDOGREL, PLAVIX DIPYRIDAMOLE DIPYRIDAMOLE PRASUGREL HCL EFFIENT, PRASUGREL HCL TICAGRELOR BRILINTA* VORAPAXAR SULFATE ZONTIVITY* SICKLE CELL ANEMIA HYDROXYUREA DROXIA*, SIKLOS* AGENTS GLUTAMINE ENDARI*

Effective July 1, 2021 *Available as Brand Only 1 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME THROMBIN DABIGATRAN ETEXILATE PRADAXA* INHIBITORS,SELECTIVE,D MESYLATE IRECT, & REVERSIBLE ASTHMA AND COPD ANTICHOLINERGICS, TIOTROPIUM BROMIDE SPIRIVA RESPIMAT*, SPIRIVA* ORALLY INHALED LONG ACTING UMECLIDINIUM BROMIDE INCRUSE ELLIPTA*

GLYCOPYRROLATE SEEBRI NEOHALER* ACLIDINIUM BROMIDE TUDORZA PRESSAIR* REVEFENACIN YUPELRI* GLYCOPYRROL/ LONHALA MAGNAIR STARTER* NEBULIZER/ ACCESSOR GLYCOPYRROLATE/ LONHALA MAGNAIR REFILL* NEB.ACCESSORIES BETA-ADRENERGIC ALBUTEROL SULFATE ALBUTEROL SULFATE, ALBUTEROL AGENTS, INHALED, SULFATE HFA, PROAIR DIGIHALER*, SHORT ACTING PROAIR HFA, PROAIR RESPICLICK*, PROVENTIL HFA, VENTOLIN HFA

LEVALBUTEROL HCL LEVALBUTEROL CONCENTRATE, LEVALBUTEROL HCL, XOPENEX, XOPENEX CONCENTRATE LEVALBUTEROL TARTRATE LEVALBUTEROL TARTRATE HFA, XOPENEX HFA BETA-ADRENERGIC FORMOTEROL FUMARATE PERFOROMIST* AGENTS, ORALLY INHALED,LONG ACTING SALMETEROL XINAFOATE SEREVENT DISKUS* ARFORMOTEROL ARFORMOTEROL TARTRATE, TARTRATE BROVANA BETA-ADRENERGIC AND BUDESONIDE/ BUDESONIDE-FORMOTEROL GLUCOCORTICOID FORMOTEROL FUMARATE FUMARATE, SYMBICORT* COMBINATIONS FLUTICASONE PROPION/ ADVAIR DISKUS, ADVAIR HFA*, SALMETEROL AIRDUO DIGIHALER*, AIRDUO RESPICLICK, FLUTICASONE- SALMETEROL, WIXELA INHUB FLUTICASONE/ BREO ELLIPTA* VILANTEROL MOMETASONE/ DULERA* FORMOTEROL

Effective July 1, 2021 *Available as Brand Only 2 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME GLUCOCORTICOIDS, BECLOMETHASONE QVAR REDIHALER* ORALLY INHALED DIPROPIONATE BUDESONIDE BUDESONIDE, PULMICORT, PULMICORT FLEXHALER* FLUTICASONE FUROATE ARNUITY ELLIPTA* FLUTICASONE ARMONAIR DIGIHALER*, FLOVENT PROPIONATE DISKUS*, FLOVENT HFA* CICLESONIDE ALVESCO* MOMETASONE FUROATE ASMANEX HFA*, ASMANEX* LEUKOTRIENE RECEPTOR MONTELUKAST SODIUM MONTELUKAST SODIUM, ANTAGONISTS SINGULAIR

ZAFIRLUKAST ACCOLATE, ZAFIRLUKAST MAST CELL STABILIZERS, CROMOLYN SODIUM CROMOLYN SODIUM, ORALLY INHALED GASTROCROM, CROMOLYN SODIUM ANTICHOLINERGIC, IPRATROPIUM BROMIDE ATROVENT HFA*, IPRATROPIUM ORALLY INHALED SHORT BROMIDE ACTING BETA-ADRENERGIC INDACATEROL MALEATE ARCAPTA NEOHALER* AGENTS, INHALED, ULTRA-LONG ACTING OLODATEROL HCL STRIVERDI RESPIMAT* BETA-ADRENERGIC AND ACLIDINIUM BROM/ DUAKLIR PRESSAIR* ANTICHOLINERGIC FORMOTEROL FUM COMBINATIONS GLYCOPYRROLATE/ BEVESPI AEROSPHERE* FORMOTEROL FUM INDACATEROL/ UTIBRON NEOHALER* GLYCOPYRROLATE IPRATROPIUM/ COMBIVENT RESPIMAT*, ALBUTEROL SULFATE IPRATROPIUM-ALBUTEROL TIOTROPIUM BR/ STIOLTO RESPIMAT* OLODATEROL HCL UMECLIDINIUM BRM/ ANORO ELLIPTA* VILANTEROL TR BETA-ADRENERGIC- FLUTICASONE/ TRELEGY ELLIPTA* ANTICHOLINERGIC- UMECLIDIN/ VILANTER GLUCOCORT, INHALED BUDESONIDE/ GLYCOPYR/ BREZTRI AEROSPHERE* FORMOTEROL

Effective July 1, 2021 *Available as Brand Only 3 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME PHOSPHODIESTERASE-4 ROFLUMILAST DALIRESP* (PDE4) INHIBITORS GLUCOCORTICOIDS PREDNISONE PREDNISONE, PREDNISONE INTENSOL*, RAYOS* BEHAVIORAL HEALTH SELECTIVE SEROTONIN CITALOPRAM CELEXA, CITALOPRAM HBR - ANTIDEPRESSANTS REUPTAKE INHIBITOR HYDROBROMIDE (SSRIS) ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE, LEXAPRO

FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE, FLUVOXAMINE MALEATE ER PAROXETINE HCL PAROXETINE CR, PAROXETINE ER, PAROXETINE HCL, PAXIL, PAXIL CR, PAXIL* SERTRALINE HCL SERTRALINE HCL, ZOLOFT FLUOXETINE HCL FLUOXETINE DR, FLUOXETINE HCL, PROZAC PAROXETINE MESYLATE PEXEVA* SSRI & 5HT1A PARTIAL VILAZODONE HCL VIIBRYD* AGONIST ANTIDEPRESSANT SSRI & SEROTONIN VORTIOXETINE TRINTELLIX* RECEPTOR MODULATOR HYDROBROMIDE ANTIDEPRESSANT

CANCER PREVENTION SELECTIVE ESTROGEN TAMOXIFEN CITRATE TAMOXIFEN CITRATE RECEPTOR MODULATORS (SERM) ANTINEOPLASTIC ANASTROZOLE ANASTROZOLE, ARIMIDEX AROMATASE INHIBITORS

EXEMESTANE AROMASIN, EXEMESTANE BONE RESORPTION RALOXIFENE HCL EVISTA, RALOXIFENE HCL INHIBITORS CARDIOVASCULAR ACE AMLODIPINE BESYLATE/ AMLODIPINE BESYLATE- INHIBITOR/CALCIUM BENAZEPRIL BENAZEPRIL, LOTREL CHANNEL BLOCKER COMBINATION TRANDOLAPRIL/ TARKA, TRANDOLAPRIL-VERAPAMIL VERAPAMIL HCL ER PERINDOPRIL ARG/ PRESTALIA* AMLODIPINE BES

Effective July 1, 2021 *Available as Brand Only 4 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME ACE INHIBITOR/THIAZIDE BENAZEPRIL/ BENAZEPRIL- & THIAZIDE-LIKE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE, LOTENSIN DIURETIC HCT

CAPTOPRIL/ CAPTOPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE ENALAPRIL/ ENALAPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE, VASERETIC FOSINOPRIL/ FOSINOPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE LISINOPRIL/ LISINOPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE, ZESTORETIC QUINAPRIL/ ACCURETIC, QUINAPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE ALPHA/BETA- CARVEDILOL CARVEDILOL, COREG ADRENERGIC BLOCKING AGENTS CARVEDILOL PHOSPHATE CARVEDILOL ER, COREG CR LABETALOL HCL LABETALOL HCL ANGIOTEN.RECEPTR AMLODIPINE/ AMLODIPINE-VALSARTAN-HCTZ, ANTAG./CAL.CHANL VALSARTAN/ HCTHIAZID EXFORGE HCT BLKR/THIAZIDE CB OLMESARTAN/ OLMESARTAN-AMLODIPINE-HCTZ, AMLODIPIN/ HCTHIAZID TRIBENZOR ANGIOTENSIN RECEPTOR AZILSARTAN MED/ EDARBYCLOR* ANTAG./THIAZIDE CHLORTHALIDONE DIURETIC COMB

CANDESARTAN/ ATACAND HCT, CANDESARTAN- HYDROCHLOROTHIAZID HYDROCHLOROTHIAZID IRBESARTAN/ AVALIDE, IRBESARTAN- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE LOSARTAN/ HYZAAR, LOSARTAN- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE OLMESARTAN/ BENICAR HCT, OLMESARTAN- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE TELMISARTAN/ MICARDIS HCT, TELMISARTAN- HYDROCHLOROTHIAZID HYDROCHLOROTHIAZID VALSARTAN/ DIOVAN HCT, VALSARTAN- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

Effective July 1, 2021 *Available as Brand Only 5 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME ANGIOTENSIN RECEPTOR AMLODIPINE BES/ AMLODIPINE-OLMESARTAN, AZOR ANTGNST & OLMESARTAN MED CALC.CHANNEL BLOCKR AMLODIPINE BESYLATE/ AMLODIPINE-VALSARTAN, VALSARTAN EXFORGE TELMISARTAN/ TELMISARTAN-AMLODIPINE, AMLODIPINE TWYNSTA ANTIHYPERTENSIVES, BENAZEPRIL HCL BENAZEPRIL HCL, LOTENSIN ACE INHIBITORS CAPTOPRIL CAPTOPRIL ENALAPRIL MALEATE ENALAPRIL MALEATE, EPANED*, VASOTEC FOSINOPRIL SODIUM FOSINOPRIL SODIUM LISINOPRIL LISINOPRIL, PRINIVIL, QBRELIS*, ZESTRIL MOEXIPRIL HCL MOEXIPRIL HCL PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE QUINAPRIL HCL ACCUPRIL, QUINAPRIL HCL RAMIPRIL ALTACE, RAMIPRIL TRANDOLAPRIL TRANDOLAPRIL ANTIHYPERTENSIVES, AZILSARTAN MEDOXOMIL EDARBI* ANGIOTENSIN RECEPTOR ANTAGONIST

CANDESARTAN CILEXETIL ATACAND, CANDESARTAN CILEXETIL EPROSARTAN MESYLATE EPROSARTAN MESYLATE IRBESARTAN AVAPRO, IRBESARTAN LOSARTAN POTASSIUM COZAAR, LOSARTAN POTASSIUM OLMESARTAN BENICAR, OLMESARTAN MEDOXOMIL MEDOXOMIL TELMISARTAN MICARDIS, TELMISARTAN VALSARTAN DIOVAN, VALSARTAN BETA-ADRENERGIC ACEBUTOLOL HCL ACEBUTOLOL HCL BLOCKING AGENTS ATENOLOL ATENOLOL, TENORMIN BETAXOLOL HCL BETAXOLOL HCL BISOPROLOL FUMARATE BISOPROLOL FUMARATE METOPROLOL SUCCINATE KAPSPARGO SPRINKLE*, METOPROLOL SUCCINATE, TOPROL XL METOPROLOL TARTRATE LOPRESSOR, METOPROLOL TARTRATE

Effective July 1, 2021 *Available as Brand Only 6 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME NADOLOL CORGARD, NADOLOL NEBIVOLOL HCL BYSTOLIC* PINDOLOL PINDOLOL PROPRANOLOL HCL HEMANGEOL*, INDERAL LA, INDERAL XL*, INNOPRAN XL*, PROPRANOLOL HCL, PROPRANOLOL HCL ER SOTALOL HCL BETAPACE, BETAPACE AF, SORINE, SOTALOL, SOTALOL AF, SOTYLIZE* TIMOLOL MALEATE TIMOLOL MALEATE PENBUTOLOL SULFATE LEVATOL* BETA-ADRENERGIC ATENOLOL/ ATENOLOL-CHLORTHALIDONE, BLOCKING CHLORTHALIDONE TENORETIC 100, TENORETIC 50 AGENTS/THIAZIDE & RELATED BISOPROLOL/ BISOPROLOL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE, ZIAC METOPROLOL SU/ DUTOPROL* HYDROCHLOROTHIAZ METOPROLOL/ LOPRESSOR HCT, METOPROLOL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE NADOLOL/ NADOLOL-BENDROFLUMETHIAZIDE BENDROFLUMETHIAZIDE PROPRANOLOL/ PROPRANOLOL- HYDROCHLOROTHIAZID HYDROCHLOROTHIAZID CALCIUM CHANNEL AMLODIPINE BESYLATE AMLODIPINE BESYLATE, NORVASC BLOCKING AGENTS DILTIAZEM HCL CARDIZEM, CARDIZEM CD, CARDIZEM LA, CARDIZEM LA*, CARTIA XT, DILTIAZEM 12HR ER, DILTIAZEM 24HR ER, DILTIAZEM 24HR ER (CD), DILTIAZEM 24HR ER (LA), DILTIAZEM 24HR ER (XR), DILTIAZEM HCL, DILT-XR, MATZIM LA, TAZTIA XT, TIADYLT ER, TIAZAC

FELODIPINE FELODIPINE ER ISRADIPINE ISRADIPINE NICARDIPINE HCL NICARDIPINE HCL NIFEDIPINE ADALAT CC, NIFEDIPINE, NIFEDIPINE ER, PROCARDIA, PROCARDIA XL NISOLDIPINE NISOLDIPINE, SULAR

Effective July 1, 2021 *Available as Brand Only 7 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME VERAPAMIL HCL CALAN SR, VERAPAMIL ER, VERAPAMIL ER PM, VERAPAMIL HCL, VERAPAMIL SR, VERELAN, VERELAN PM AMLODIPINE BENZOATE KATERZIA* LEVAMLODIPINE MALEATE CONJUPRI*

DIGITALIS GLYCOSIDES DIGOXIN DIGITEK, DIGOX, DIGOXIN, DIGOXIN*, LANOXIN* LOOP DIURETICS BUMETANIDE BUMETANIDE ETHACRYNIC ACID EDECRIN, ETHACRYNIC ACID FUROSEMIDE FUROSEMIDE, LASIX TORSEMIDE TORSEMIDE POTASSIUM SPARING AMILORIDE HCL AMILORIDE HCL DIURETICS EPLERENONE EPLERENONE, INSPRA SPIRONOLACTONE ALDACTONE, CAROSPIR*, SPIRONOLACTONE TRIAMTERENE DYRENIUM, TRIAMTERENE POTASSIUM SPARING AMILORIDE/ AMILORIDE- DIURETICS IN HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE COMBINATION SPIRONOLACT/ ALDACTAZIDE, ALDACTAZIDE*, HYDROCHLOROTHIAZID SPIRONOLACTONE-HCTZ TRIAMTERENE/ MAXZIDE, MAXZIDE-25 MG, HYDROCHLOROTHIAZID TRIAMTERENE- HYDROCHLOROTHIAZID THIAZIDE AND RELATED CHLOROTHIAZIDE DIURIL* DIURETICS CHLORTHALIDONE CHLORTHALIDONE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE INDAPAMIDE INDAPAMIDE METOLAZONE METOLAZONE VASODILATORS,CORONA NITROGLYCERIN GONITRO*, NITROGLYCERIN, RY NITROLINGUAL, NITROMIST*, NITROSTAT, NITRO-TIME ANGIOTENSIN RECEPT- SACUBITRIL/ VALSARTAN ENTRESTO* NEPRILYSIN INHIBITOR COMB(ARNI) ANTIANGINAL, HEART IVABRADINE HCL CORLANOR* RATE REDUCING, I(F) INHIBITOR ANTIARRHYTHMICS AMIODARONE HCL AMIODARONE HCL, PACERONE

Effective July 1, 2021 *Available as Brand Only 8 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME DOFETILIDE DOFETILIDE, TIKOSYN FLECAINIDE ACETATE FLECAINIDE ACETATE DRONEDARONE HCL MULTAQ* PROPAFENONE HCL PROPAFENONE HCL, PROPAFENONE HCL ER, RYTHMOL SR

DIABETES ANTIHYPERGLY, (DPP-4) LINAGLIPTIN/ JENTADUETO XR*, JENTADUETO* INHIBITOR & BIGUANIDE METFORMIN HCL COMB. SITAGLIPTIN PHOS/ JANUMET XR*, JANUMET* METFORMIN HCL ALOGLIPTIN BENZ/ ALOGLIPTIN-METFORMIN, KAZANO METFORMIN HCL SAXAGLIPTIN HCL/ KOMBIGLYZE XR* METFORMIN HCL ANTIHYPERGLY,INCRETI DULAGLUTIDE TRULICITY* N MIMETIC(GLP-1 RECEP.AGONIST) LIRAGLUTIDE VICTOZA 2-PAK*, VICTOZA 3-PAK* LIXISENATIDE ADLYXIN* EXENATIDE BYDUREON BCISE* MICROSPHERES EXENATIDE BYETTA* SEMAGLUTIDE OZEMPIC*, RYBELSUS* ANTIHYPERGLYCEMC- CANAGLIFLOZIN INVOKANA* SOD/GLUC COTRANSPORT2(SGLT2)I NHIB EMPAGLIFLOZIN JARDIANCE* DAPAGLIFLOZIN FARXIGA* PROPANEDIOL ERTUGLIFLOZIN PIDOLATE STEGLATRO*

ANTIHYPERGLYCEMIC, LINAGLIPTIN TRADJENTA* DPP-4 INHIBITORS SITAGLIPTIN PHOSPHATE JANUVIA* ALOGLIPTIN BENZOATE ALOGLIPTIN, NESINA SAXAGLIPTIN HCL ONGLYZA* ANTIHYPERGLYCEMIC, GLIMEPIRIDE AMARYL, GLIMEPIRIDE INSULIN-RELEASE STIMULANT TYPE GLIPIZIDE GLIPIZIDE, GLIPIZIDE ER, GLIPIZIDE XL, GLUCOTROL, GLUCOTROL XL

Effective July 1, 2021 *Available as Brand Only 9 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME GLYBURIDE GLYBURIDE GLYBURIDE,MICRONIZED GLYBURIDE MICRONIZED, GLYNASE

NATEGLINIDE NATEGLINIDE, STARLIX REPAGLINIDE PRANDIN, REPAGLINIDE ANTIHYPERGLYCEMIC, PIOGLITAZONE HCL ACTOS, PIOGLITAZONE HCL INSULIN-RESPONSE ENHANCER (N-S) ROSIGLITAZONE MALEATE AVANDIA*

ANTIHYPERGLYCEMIC,BI METFORMIN HCL FORTAMET, GLUCOPHAGE, GUANIDE TYPE(NON- GLUCOPHAGE XR, GLUMETZA, SULFONYLUREA) METFORMIN ER GASTRIC, METFORMIN ER OSMOTIC, METFORMIN HCL, METFORMIN HCL ER, RIOMET, RIOMET ER* ANTIHYPERGLYCEMIC,IN GLIPIZIDE/ METFORMIN GLIPIZIDE-METFORMIN SULIN-REL STIM.& HCL BIGUANIDE CMB GLYBURIDE/ METFORMIN GLYBURIDE-METFORMIN HCL HCL REPAGLINIDE/ REPAGLINIDE-METFORMIN HCL METFORMIN HCL ANTIHYPERGLYCEMIC,IN PIOGLITAZONE HCL/ DUETACT, PIOGLITAZONE- SULIN-RESPONSE & GLIMEPIRIDE GLIMEPIRIDE RELEASE COMB. ANTIHYPERGLYCEMIC- CANAGLIFLOZIN/ INVOKAMET XR*, INVOKAMET* SGLT2 INHIBITOR & METFORMIN HCL BIGUANIDE COMB EMPAGLIFLOZIN/ SYNJARDY XR*, SYNJARDY* METFORMIN HCL DAPAGLIFLOZIN/ XIGDUO XR* METFORMIN HCL ERTUGLIFLOZIN/ SEGLUROMET* METFORMIN ANTIHYPERGLYCM,INSUL-PIOGLITAZONE HCL/ ACTOPLUS MET, PIOGLITAZONE- RESP.ENHANCER & METFORMIN HCL METFORMIN BIGUANIDE CMB INSULINS INSULIN BASAGLAR KWIKPEN U-100*, GLARGINE,HUM.REC.ANLO LANTUS SOLOSTAR*, LANTUS*, G SEMGLEE PEN*, SEMGLEE*, TOUJEO MAX SOLOSTAR*, TOUJEO SOLOSTAR*

Effective July 1, 2021 *Available as Brand Only 10 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME INSULIN LISPRO ADMELOG SOLOSTAR*, ADMELOG*, HUMALOG, HUMALOG JUNIOR KWIKPEN*, HUMALOG KWIKPEN U-100, HUMALOG KWIKPEN U-200*, HUMALOG*, INSULIN LISPRO, INSULIN LISPRO JUNIOR KWIKPEN, INSULIN LISPRO KWIKPEN U-100 INSULIN LISPRO HUMALOG MIX 50-50 KWIKPEN*, PROTAMIN/ LISPRO HUMALOG MIX 50-50*, HUMALOG MIX 75-25 KWIKPEN*, HUMALOG MIX 75-25*, INSULIN LISPRO PROTAMINE MIX INSULIN NPH HUM/ REG HUMULIN 70/30 KWIKPEN*, INSULIN HM HUMULIN 70-30*, NOVOLIN 70-30 FLEXPEN*, NOVOLIN 70-30* INSULIN NPH HUMAN HUMULIN N KWIKPEN*, HUMULIN ISOPHANE N*, NOVOLIN N FLEXPEN*, NOVOLIN N* INSULIN REGULAR, AFREZZA*, HUMULIN R U-500 HUMAN KWIKPEN*, HUMULIN R U-500*, HUMULIN R*, NOVOLIN R FLEXPEN*, NOVOLIN R* INSULIN GLULISINE APIDRA SOLOSTAR*, APIDRA* INSULIN ASPART FIASP FLEXTOUCH*, FIASP (NIACINAMIDE) PENFILL*, FIASP* INSULIN DETEMIR LEVEMIR FLEXTOUCH*, LEVEMIR* INSULIN ASPART INSULIN ASPART, INSULIN ASPART FLEXPEN, INSULIN ASPART PENFILL, NOVOLOG, NOVOLOG FLEXPEN*

INSULIN DEGLUDEC TRESIBA FLEXTOUCH U-100*, TRESIBA FLEXTOUCH U-200*, TRESIBA* INSULIN ASPART PROT/ INSULIN ASPART PROT-INSULN ASP, INSULN ASP NOVOLOG MIX 70-30 FLEXPEN*, NOVOLOG MIX 70-30* INSULIN LISPRO-AABC LYUMJEV KWIKPEN U-100*, LYUMJEV KWIKPEN U-200*, LYUMJEV* ANTIHYPERGLYCEMIC,IN INSULIN DEGLUDEC/ XULTOPHY 100-3.6* SULIN & GLP-1 LIRAGLUTIDE RECEPTOR AGONIST

Effective July 1, 2021 *Available as Brand Only 11 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME INSULIN GLARGINE/ SOLIQUA 100-33* LIXISENATIDE ANTIHYPERGLY,DPP-4 ALOGLIPTIN BENZ/ ALOGLIPTIN-PIOGLITAZONE, OSENI ENZYME INHIB PIOGLITAZONE &THIAZOLIDINEDIONE ANTIHYPERGLYCEMIC, DAPAGLIFLOZIN/ QTERN* SGLT-2 & DPP-4 SAXAGLIPTIN HCL INHIBITOR COMB. EMPAGLIFLOZIN/ GLYXAMBI* LINAGLIPTIN ERTUGLIFLOZIN/ STEGLUJAN* SITAGLIPTIN DIABETIC SUPPLIES BLOOD-GLUCOSE METER BLOOD-GLUCOSE METER* ANTIHYPERGLY-SGLT-2 EMPAGLIFLOZ/ LINAGLIP/ TRIJARDY XR* INHIB,DPP-4 METFORMIN INHIB,BIGUANIDE CB HIV PROPHYLAXIS ANTIVIRALS, HIV-SPEC, EMTRICITABINE/ EMTRICITABINE-TENOFOVIR DISOP, NUCLEOSIDE- TENOFOVIR (TDF) TRUVADA NUCLEOTIDE ANALOG EMTRICITABINE/ DESCOVY* TENOFOV ALAFENAM HYPERLIPIDEMIA ANTIHYPERLIPIDEMIC - ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM, LIPITOR HMG COA REDUCTASE INHIBITORS FLUVASTATIN SODIUM FLUVASTATIN ER, FLUVASTATIN SODIUM, LESCOL XL LOVASTATIN ALTOPREV*, LOVASTATIN PITAVASTATIN CALCIUM LIVALO* PRAVASTATIN SODIUM PRAVASTATIN SODIUM ROSUVASTATIN CALCIUM CRESTOR, EZALLOR SPRINKLE*, ROSUVASTATIN CALCIUM SIMVASTATIN FLOLIPID*, SIMVASTATIN, ZOCOR PITAVASTATIN ZYPITAMAG* MAGNESIUM BILE SALT CHOLESTYRAMINE (WITH CHOLESTYRAMINE, QUESTRAN SEQUESTRANTS SUGAR) CHOLESTYRAMINE/ CHOLESTYRAMINE LIGHT, ASPARTAME PREVALITE, QUESTRAN LIGHT COLESEVELAM HCL COLESEVELAM HCL, WELCHOL COLESTIPOL HCL COLESTID, COLESTID*, COLESTIPOL HCL LIPOTROPICS EZETIMIBE EZETIMIBE, ZETIA

Effective July 1, 2021 *Available as Brand Only 12 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME FENOFIBRATE FENOFIBRATE, FENOGLIDE, LIPOFEN

FENOFIBRATE FENOFIBRATE, TRICOR NANOCRYSTALLIZED FENOFIBRATE,MICRONIZE ANTARA*, FENOFIBRATE D FENOFIBRIC ACID FENOFIBRIC ACID, FIBRICOR FENOFIBRIC ACID FENOFIBRIC ACID, TRILIPIX (CHOLINE) GEMFIBROZIL GEMFIBROZIL, LOPID ICOSAPENT ETHYL ICOSAPENT ETHYL, VASCEPA* NIACIN NIACIN, NIACIN ER, NIACOR, NIASPAN OMEGA-3 ACID ETHYL LOVAZA, OMEGA-3 ACID ETHYL ESTERS ESTERS ANTIHYPERLIP.HMG COA EZETIMIBE/ SIMVASTATIN EZETIMIBE-SIMVASTATIN, VYTORIN REDUCT INHIB&CHOLEST.AB.INHI B EZETIMIBE/ ROSZET* ROSUVASTATIN CALCIUM

ANTIHYPERLIPIDEMIC - BEMPEDOIC ACID NEXLETOL* ATP CITRATE LYASE INHIBITOR ANTIHYPERLIPIDEMIC - ALIROCUMAB PRALUENT PEN* PCSK9 INHIBITORS EVOLOCUMAB REPATHA PUSHTRONEX*, REPATHA SURECLICK*, REPATHA SYRINGE*

ANTIHYPERLIPIDEMIC- BEMPEDOIC ACID/ NEXLIZET* ACLY AND CHOLES EZETIMIBE ABSORP INHIB OSTEOPOROSIS BONE RESORPTION ALENDRONATE SODIUM/ FOSAMAX PLUS D* INHIBITOR & VITAMIN D VITAMIN D3 COMBINATIONS BONE RESORPTION ALENDRONATE SODIUM ALENDRONATE SODIUM, INHIBITORS BINOSTO*, FOSAMAX IBANDRONATE SODIUM BONIVA, IBANDRONATE SODIUM RALOXIFENE HCL EVISTA, RALOXIFENE HCL RISEDRONATE SODIUM ACTONEL, ATELVIA, RISEDRONATE SODIUM, RISEDRONATE SODIUM DR

Effective July 1, 2021 *Available as Brand Only 13 of 14 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME DENOSUMAB PROLIA* VITAMIN AND OR PEDIATRIC VITAMIN VARIOUS PRENATAL MINERAL DEFICIENCY PREPARATIONS VITAMINS

Effective July 1, 2021 *Available as Brand Only 14 of 14