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High Deductible Health Plan Preventive Drug List Updated July 2018 Your employer is making an effort to reduce your health care costs by giving you tools to help you stay healthy and productive. Below are the medications your employer has chosen to be included in the High Deductible Health Plan Preventive Drug list described in detail in your benefit plan. These medications help protect against or manage some high risk medical conditions. Taking these medications as directed by your prescriber can help avoid serious health problems. That may mean fewer doctor visits and hospitalizations, reducing your total health care costs.

In the drug list below, generic drugs are shown in lowercase type. Brand name drugs are shown in uppercase type. ANTIANGINAL AGENTS disopyramide cap DILATRATE SR CAP disopyramide ER cap ISOSORBIDE DINITRATE ER TAB dofetilide cap isosorbide dinitrate SL tab flecainide tab isosorbide dinitrate tab mexiletine cap ISOSORBIDE DINITRATE TAB 30MG, MULTAQ TAB 40MG NORPACE CR CAP isosorbide mononitrate ER tab propafenone ER cap isosorbide mononitrate tab propafenone tab NITRO-BID OINT quinidine gluconate CR tab NITRO-DUR PATCH 0.3MG/HR, 0.8MG/ QUINIDINE SULFATE ER TAB HR QUINIDINE SULFATE TAB nitroglycerin lingual spray ANTIDIABETICS nitroglycerin patch acarbose tab nitroglycerin SL tab ACTOPLUS MET XR TAB nitroglycerin SR cap AVANDAMET TAB NITROMIST SPRAY AVANDARYL TAB RANEXA TAB AVANDIA TAB ANTIARRHYTHMICS B-D INSULIN SYRINGE amiodarone tab B-D PEN NEEDLE

• Note: The list is subject to change and not all drugs listed may be covered on your formulary. Please refer to your Navitus formulary for a complete list of covered products.

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BYDUREON BCISE AUTO INJ miglitol tab BYDUREON INJ nateglinide tab BYDUREON PEN INJ NOVOFINE PEN NEEDLE BYETTA INJ NOVOLIN INJ CHLORPROPAMIDE TAB NOVOLOG FLEXPEN INJ, FIASP CYCLOSET TAB FLEXTOUCH INJ DIABETA TAB NOVOLOG INJ, FIASP INJ FARXIGA TAB NOVOLOG MIX FLEXPEN INJ FREESTYLE INSULIN SYRINGE NOVOLOG MIX INJ glimepiride tab NOVOLOG PENFILL INJ glipizide ER tab NOVOTWIST PEN NEEDLE glipizide tab NOVOTWIST/NOVOFINE PEN NEEDLE glipizide/metformin tab OZEMPIC INJ GLUCAGEN HYPOKIT INJ PEN NEEDLE GLUCAGON INJ KIT pioglitazone tab glyburide micronized tab pioglitazone/glimepiride tab glyburide tab pioglitazone/metformin tab glyburide/metformin tab PRECISION INSULIN SYRINGE GLYXAMBI TAB PROGLYCEM SUSP HUMULIN R INJ U-500 repaglinide tab HUMULIN R U-500 KWIKPEN INJ RIOMET SOLN INSULIN SYRINGE SYNJARDY TAB JANUMET TAB SYNJARDY XR TAB 10-1000MG, 25- JANUMET XR TAB 1000MG JANUVIA TAB SYNJARDY XR TAB 5-1000MG, 12.5- JARDIANCE TAB 1000MG JENTADUETO TAB tolazamide tab JENTADUETO XR TAB TOLBUTAMIDE TAB KORLYM TAB TOUJEO MAX SOLOSTAR INJ LANTUS INJ TOUJEO SOLOSTAR INJ LANTUS SOLOSTAR INJ TRADJENTA TAB LEVEMIR FLEXTOUCH INJ TRESIBA INJ LEVEMIR INJ TRULICITY INJ metformin ER tab VICTOZA INJ metformin tab

• Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products.

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XIGDUO XR TAB 2.5-1000MG, simvastatin tab 5-1000MG TRILIPIX CAP XIGDUO XR TAB 5-500MG, 10-500MG, WELCHOL PAK 10-1000MG WELCHOL TAB XULTOPHY INJ ANTIHYPERTENSIVES ANTIHYPERLIPIDEMICS ALTACE TAB atorvastatin tab 10mg amlodipine/benazepril cap atorvastatin tab 20mg amlodipine/olmesartan tab atorvastatin tab 40mg amlodipine/valsartan tab atorvastatin tab 80mg amlodipine/valsartan/ cholestyramine lite powder hydrochlorothiazide tab cholestyramine lite powder pack AMTURNIDE TAB cholestyramine powder atenolol/chlorthalidone tab cholestyramine powder pack benazepril tab colestipol granule benazepril/hydrochlorothiazide tab colestipol powder packet bisoprolol/hydrochlorothiazide tab colestipol tab captopril tab ezetimibe tab CAPTOPRIL/HYDROCHLOROTHIAZIDE ezetimibe/simvastatin tab TAB fenofibrate cap 67mg, 134mg, 200mg clonidine patch fenofibrate tab 48mg, 54mg, 145mg, clonidine tab 160mg doxazosin tab FENOFIBRIC TAB, FIBRICOR TAB enalapril tab fluvastatin cap enalapril/hydrochlorothiazide tab gemfibrozil tab EPANED PREMIXED SOLN LIVALO TAB EPANED SOLN lovastatin tab eplerenone tab NIASPAN ER TAB fosinopril tab omega-3- ethyl esters cap fosinopril/hydrochlorothiazide tab pravastatin tab GUANABENZ TAB rosuvastatin tab 10mg guanfacine IR tab rosuvastatin tab 20mg hydralazine tab rosuvastatin tab 40mg irbesartan tab rosuvastatin tab 5mg irbesartan/hydrochlorothiazide tab

• Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products.

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lisinopril tab ANTINEOPLASTICS AND ADJUNCTIVE lisinopril/hydrochlorothiazide tab THERAPIES losartan tab anastrozole tab losartan/hydrochlorothiazide tab bicalutamide tab methyldopa tab EMCYT CAP methyldopa/hydrochlorothiazide tab exemestane tab metoprolol/hydrochlorothiazide tab FARESTON TAB minoxidil tab flutamide cap moexipril tab letrozole tab moexipril/hydrochlorothiazide tab LYSODREN TAB nadolol/bendroflumethiazide tab megestrol susp NEXICLON XR SUSP megestrol tab NEXICLON XR TAB nilutamide tab olmesartan tab tamoxifen tab olmesartan/hydrochlorothiazide tab XTANDI CAP perindopril tab ZYTIGA TAB 250MG phenoxybenzamine cap ZYTIGA TAB 500MG prazosin cap BETA BLOCKERS propranolol/hydrochlorothiazide tab acebutolol cap QBRELIS SOLN atenolol tab quinapril tab betaxolol tab quinapril/hydrochlorothiazide tab bisoprolol tab ramipril cap BYSTOLIC TAB RESERPINE TAB carvedilol tab TARKA TAB labetalol tab TEKAMLO TAB LEVATOL TAB TEKTURNA HCT TAB metoprolol ER tab TEKTURNA TAB metoprolol tab telmisartan tab nadolol tab terazosin cap pindolol tab trandolapril tab propranolol ER cap trandolapril/verapamil ER tab PROPRANOLOL SOLN valsartan tab propranolol tab valsartan/hydrochlorothiazide tab sotalol AF tab VALTURNA TAB sotalol tab

• Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products.

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timolol maleate tab CERVICAL CAP CALCIUM CHANNEL BLOCKERS cesia tab amlodipine tab CONCEPTROL GEL CARDENE SR CAP CONTRACEPTIVE FILM CARDIZEM LA TAB CONTRACEPTIVE FOAM COVERA-HS TAB CONTRACEPTIVE GEL diltiazem ER cap CONTRACEPTIVE SUPP diltiazem ER tab cryselle tab diltiazem tab DEPO-PROVERA SC INJ 104MG DYNACIRC CR TAB DIAPHRAGM felodipine ER tab ELLA TAB isradipine cap enpresse tab nicardipine cap FEMALE CONDOMS nifedipine cap IMPLANON IMPLANT, NEXPLANON nifedipine ER tab IMPLANT nimodipine cap jolessa tab, amethia tab nisoldipine ER tab junel FE tab NISOLDIPINE ER TAB 25.5MG junel tab verapamil SR cap kariva tab VERAPAMIL SR CAP 360mg kelnor tab verapamil SR tab levonorgestrel tab verapamil tab LEVONORGESTREL TAB 0.75MG VERELAN SR CAP 360mg LO LOESTRIN TAB CARDIAC GLYCOSIDES LO MINASTRIN 24 FE CHEW TAB digoxin soln LOESTRIN 24 FE TAB digoxin tab medroxyprogesterone inj CARDIOVASCULAR AGENTS - MISC. mibelas chew tab amlodipine/atorvastatin tab MIRENA IUD ENTRESTO TAB mononessa tab CONTRACEPTIVES NATAZIA TAB amethyst tab necon tab apri tab necon tab 1-50 aranelle tab norethindrone tab aviane tab NORINYL TAB 1-50 BEYAZ TAB nortrel tab

• Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products.

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NUVARING LANCETS OGESTREL TAB PRECISION XTRA METER PARAGARD IUD PRECISION XTRA TEST STRIP PLAN B TAB V-GO INJ KIT TODAY SPONGE DIURETICS tri-legest tab acetazolamide ER cap tri-nessa (LO) tab acetazolamide tab ALDACTAZIDE TAB 50-50MG vcf vaginal gel amiloride tab wymzya FE tab amiloride/hydrochlorothiazide tab XULANE PATCH bumetanide tab YASMIN TAB chlorothiazide tab YAZ TAB CHLOROTHIAZIDE TAB 250MG DIAGNOSTIC PRODUCTS CHLORTHALIDONE TAB ACCU-CHECK GUIDE CARE METER DIURIL SUSP ACCU-CHEK AVIVA PLUS METER DYRENIUM CAP ACCU-CHEK AVIVA PLUS TEST STRIP ethacrynic tab ACCU-CHEK GUIDE TEST STRIP FUROSEMIDE SOLN ACCU-CHEK NANO METER furosemide tab ACCU-CHEK SMARTVIEW TEST STRIP hydrochlorothiazide cap ACCU-CHEK TEST STRIP hydrochlorothiazide tab CALIBRATION LIQUID indapamide tab CLINISTIX TEST STRIP methazolamide tab FREESTYLE FREEDOM LITE METER METHYCLOTHIAZIDE TAB FREESTYLE INSULINX METER metolazone tab FREESTYLE INSULINX TEST STRIP spironolactone tab FREESTYLE LITE METER spironolactone/hydrochlorothiazide tab FREESTYLE LITE TEST STRIP torsemide tab FREESTYLE PRECISION NEO METER triamterene/hydrochlorothiazide cap FREESTYLE PRECISION NEO TEST STRIP TRIAMTERENE/ FREESTYLE TEST STRIP KETO-DIASTIX TEST STRIP HYDROCHLOROTHIAZIDE CAP 50-25mg KETOSTIX triamterene/hydrochlorothiazide tab LANCET DEVICE ENDOCRINE AND METABOLIC AGENTS - LANCET KIT MISC. ALENDRONATE SOLN

• Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products.

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alendronate tab KLOR-CON M15 TAB ALENDRONATE TAB 40MG KLOR-CON POWDER PACKET 25MEQ calcitonin nasal spray K-PHOS TAB etidronate disodium tab 200mg LURIDE CHEW TAB ETIDRONATE DISODIUM TAB 400MG LURIDE SOLN FORTEO INJ phospha 250 neutral tab FORTICAL NASAL SPRAY potassium bicarbonate effer tab FOSAMAX+D TAB effer tab ibandronate tab 150mg potassium chloride ER cap MIACALCIN INJ POTASSIUM CHLORIDE ER TAB NATPARA INJ potassium chloride micro tab risedronate DR tab potassium chloride powder packet risedronate tab POTASSIUM CHLORIDE SOLN SKELID TAB chew tab TYMLOS INJ SODIUM FLUORIDE LOZENGE HEMATOLOGICAL AGENTS - MISC. sodium fluoride soln anagrelide cap SODIUM FLUORIDE TAB /dipyridamole cap zinc sulfate cap BRILINTA TAB MOUTH/THROAT/DENTAL AGENTS cilostazol tab gluconate soln clopidogrel tab 75mg PREVIDENT 5000 PLUS CREAM dipyridamole tab PREVIDENT GEL pentoxifylline ER tab PREVIDENT PASTE prasugrel tab PREVIDENT RINSE TICLOPIDINE TAB sodium fluoride cream ZONTIVITY TAB sodium fluoride gel LAXATIVES sodium fluoride paste CLENPIQ SOLN sodium fluoride rinse KRISTALOSE PACKET sodium fluoride/potassium nitrate lactulose soln paste peg 3350/electrolytes soln in orabase paste trilyte soln SMOKING CESSATION & ELECTROLYTES bupropion SR tab FLUORABON SOLN CHANTIX PAK FLUOR-A-DAY CHEW TAB CHANTIX TAB GALZIN CAP NICODERM PATCH • Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products.

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NICORETTE GUM MENACTRA INJ NICORETTE LOZENGE MENHIBRIX INJ nicotine gum MENOMUNE INJ NICOTINE KIT MENVEO INJ nicotine lozenge M-M-R II INJ nicotine patch PNEUMOVAX INJ NICOTROL INHALER PREVNAR 13 INJ NICOTROL NASAL SPRAY SHINGRIX INJ ZYBAN TAB TETANUS/DIPHTHERIA TOXOID INJ VACCINES TRUMENBA INJ ADACEL/BOOSTRIX INJ TWINRIX INJ AFLURIA INJ VARIVAX INJ AFLURIA INJ, FLUZONE INJ VIVOTIF CAP BEXSERO INJ ZOSTAVAX INJ CERVARIX INJ VITAMINS ENGERIX-B INJ PRENATAL VITAMINS (NON-PREFERRED) ENGERIX-B INJ, RECOMBIVAX-HB INJ PRENATAL VITAMINS (PRENATAL PLUS, FLUAD INJ PREPLUS, PRENAPLUS) FLUBLOK INJ FLUBLOK QUAD PF INJ FLUCELVAX INJ FLUCELVAX QUAD INJ FLULAVAL QUAD INJ, FLUZONE QUAD INJ FLUVIRIN INJ FLUVIRIN PF INJ FLUZONE HIGH DOSE PF INJ FLUZONE INTRADERMAL INJ FLUZONE QUAD INJ FLUZONE/FLUARIX QUAD INJ GARDASIL 9 INJ GARDASIL INJ HAVRIX INJ, VAQTA INJ

• Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products.

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