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 EPINEPHRINE, AUVI-Q*, EPIPEN*, THERAPY AGENTS EPIPEN JR*, SYMJEPI* ANTICOAGULANTS ANTICOAGULANTS,COU WARFARIN SODIUM COUMADIN, WARFARIN SODIUM, ANTIPLATELET MARIN TYPE JANTOVEN DIRECT FACTOR XA APIXABAN ELIQUIS* INHIBITORS RIVAROXABAN XARELTO* BETRIXABAN MALEATE BEVYXXA* EDOXABAN TOSYLATE SAVAYSA* HEPARIN AND RELATED DALTEPARIN FRAGMIN* PREPARATIONS SODIUM,PORCINE

ENOXAPARIN SODIUM LOVENOX, ENOXAPARIN SODIUM

FONDAPARINUX SODIUM ARIXTRA, FONDAPARINUX SODIUM

PLATELET AGGREGATION ASPIRIN DIPYRIDAMOLE AGGRENOX, ASPIRIN- INHIBITORS DIPYRIDAMOLE ER

CILOSTAZOL CILOSTAZOL CLOPIDOGREL BISULFATE PLAVIX, CLOPIDOGREL

DIPYRIDAMOLE DIPYRIDAMOLE PRASUGREL HCL EFFIENT, PRASUGREL HCL TICAGRELOR BRILINTA*

Effective July 1, 2020 *Available as Brand Only 1 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

VORAPAXAR SULFATE ZONTIVITY* SICKLE CELL ANEMIA HYDROXYUREA DROXIA*, SIKLOS* AGENTS GLUTAMINE ENDARI* THROMBIN DABIGATRAN ETEXILATE PRADAXA* INHIBITORS,SELECTIVE,DI MESYLATE RECT, & REVERSIBLE

ASTHMA AND COPD ANTICHOLINERGICS, TIOTROPIUM BROMIDE SPIRIVA*, SPIRIVA RESPIMAT* ORALLY INHALED LONG ACTING UMECLIDINIUM BROMIDE INCRUSE ELLIPTA*

GLYCOPYRROLATE LONHALA MAGNAIR REFILL* NEB.ACCESSORIES GLYCOPYRROL NEBULIZER LONHALA MAGNAIR STARTER* ACCESSOR GLYCOPYRROLATE SEEBRI NEOHALER* ACLIDINIUM BROMIDE TUDORZA PRESSAIR* REVEFENACIN YUPELRI* BETA-ADRENERGIC ALBUTEROL SULFATE ALBUTEROL SULFATE, PROAIR AGENTS, INHALED, HFA*, PROAIR RESPICLICK*, SHORT ACTING VENTOLIN HFA*, ALBUTEROL SULFATE HFA, PROAIR DIGIHALER*, PROVENTIL HFA LEVALBUTEROL HCL XOPENEX, XOPENEX CONCENTRATE, LEVALBUTEROL CONCENTRATE, LEVALBUTEROL HCL LEVALBUTEROL TARTRATE LEVALBUTEROL TARTRATE HFA, XOPENEX HFA BETA-ADRENERGIC FORMOTEROL FUMARATE PERFOROMIST* AGENTS, ORALLY INHALED,LONG ACTING

SALMETEROL XINAFOATE SEREVENT DISKUS*

ARFORMOTEROL BROVANA* TARTRATE

Effective July 1, 2020 *Available as Brand Only 2 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

BETA-ADRENERGIC AND BUDESONIDE SYMBICORT*, BUDESONIDE- GLUCOCORTICOID FORMOTEROL FUMARATE FORMOTEROL FUMARATE COMBINATIONS

FLUTICASONE VILANTEROL BREO ELLIPTA*

MOMETASONE DULERA* FORMOTEROL FLUTICASONE PROPION ADVAIR HFA*, ADVAIR DISKUS, SALMETEROL AIRDUO RESPICLICK, FLUTICASONE- SALMETEROL, WIXELA INHUB

GLUCOCORTICOIDS, BECLOMETHASONE QVAR REDIHALER* ORALLY INHALED DIPROPIONATE BUDESONIDE BUDESONIDE, PULMICORT, PULMICORT FLEXHALER* FLUTICASONE FUROATE ARNUITY ELLIPTA* FLUTICASONE ARMONAIR RESPICLICK*, FLOVENT PROPIONATE DISKUS*, FLOVENT HFA*

CICLESONIDE ALVESCO* MOMETASONE FUROATE ASMANEX*, ASMANEX HFA*

LEUKOTRIENE RECEPTOR MONTELUKAST SODIUM SINGULAIR, MONTELUKAST ANTAGONISTS SODIUM

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 UMECLIDINIUM BRM ANORO ELLIPTA* ANTICHOLINERGIC VILANTEROL TR COMBINATIONS

Effective July 1, 2020 *Available as Brand Only 3 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

GLYCOPYRROLATE BEVESPI AEROSPHERE* FORMOTEROL FUM IPRATROPIUM ALBUTEROL COMBIVENT RESPIMAT*, SULFATE IPRATROPIUM-ALBUTEROL ACLIDINIUM BROM DUAKLIR PRESSAIR* FORMOTEROL FUM

TIOTROPIUM BR STIOLTO RESPIMAT* OLODATEROL HCL INDACATEROL UTIBRON NEOHALER* GLYCOPYRROLATE BETA-ADRENERGIC- FLUTICASONE UMECLIDIN TRELEGY ELLIPTA* ANTICHOLINERGIC- VILANTER GLUCOCORT, INHALED 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 LEXAPRO, ESCITALOPRAM OXALATE

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

Effective July 1, 2020 *Available as Brand Only 4 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

CANCER ANTINEOPLASTIC ANASTROZOLE ARIMIDEX, ANASTROZOLE PREVENTION AROMATASE INHIBITORS

EXEMESTANE AROMASIN, EXEMESTANE CARDIOVASCULAR ACE INHIBITOR CALCIUM AMLODIPINE BESYLATE LOTREL, AMLODIPINE BESYLATE- CHANNEL BLOCKER BENAZEPRIL BENAZEPRIL COMBINATION

TRANDOLAPRIL TARKA, TRANDOLAPRIL-VERAPAMIL VERAPAMIL HCL ER PERINDOPRIL ARG PRESTALIA* AMLODIPINE BES ACE INHIBITOR THIAZIDE BENAZEPRIL LOTENSIN HCT, BENAZEPRIL- & THIAZIDE-LIKE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE DIURETIC

CAPTOPRIL CAPTOPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

ENALAPRIL VASERETIC, ENALAPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

FOSINOPRIL FOSINOPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

LISINOPRIL ZESTORETIC, LISINOPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

QUINAPRIL ACCURETIC, QUINAPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

ALPHA BETA- CARVEDILOL COREG, CARVEDILOL ADRENERGIC BLOCKING AGENTS CARVEDILOL PHOSPHATE COREG CR, CARVEDILOL ER

LABETALOL HCL LABETALOL HCL ANGIOTEN.RECEPTR AMLODIPINE VALSARTAN EXFORGE HCT, AMLODIPINE- ANTAG. CAL.CHANL BLKR HCTHIAZID VALSARTAN-HCTZ THIAZIDE CB

Effective July 1, 2020 *Available as Brand Only 5 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

OLMESARTAN TRIBENZOR, OLMESARTAN- AMLODIPIN HCTHIAZID AMLODIPINE-HCTZ

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

ANGIOTENSIN RECEPTOR AMLODIPINE BES AZOR, AMLODIPINE-OLMESARTAN ANTGNST & OLMESARTAN MED CALC.CHANNEL BLOCKR

AMLODIPINE BESYLATE EXFORGE, AMLODIPINE- VALSARTAN VALSARTAN TELMISARTAN TWYNSTA, TELMISARTAN- AMLODIPINE AMLODIPINE ANTIHYPERTENSIVES, BENAZEPRIL HCL LOTENSIN, BENAZEPRIL HCL ACE INHIBITORS CAPTOPRIL CAPTOPRIL ENALAPRIL MALEATE VASOTEC, ENALAPRIL MALEATE, EPANED* FOSINOPRIL SODIUM FOSINOPRIL SODIUM LISINOPRIL PRINIVIL, ZESTRIL, LISINOPRIL, QBRELIS* MOEXIPRIL HCL MOEXIPRIL HCL PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE

Effective July 1, 2020 *Available as Brand Only 6 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

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 TENORMIN, ATENOLOL BETAXOLOL HCL BETAXOLOL HCL BISOPROLOL FUMARATE BISOPROLOL FUMARATE

METOPROLOL SUCCINATE TOPROL XL, KAPSPARGO SPRINKLE*, METOPROLOL SUCCINATE METOPROLOL TARTRATE LOPRESSOR, METOPROLOL TARTRATE NADOLOL CORGARD, NADOLOL NEBIVOLOL HCL BYSTOLIC* PINDOLOL PINDOLOL PROPRANOLOL HCL INDERAL LA, HEMANGEOL*, 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*

Effective July 1, 2020 *Available as Brand Only 7 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

BETA-ADRENERGIC ATENOLOL TENORETIC 100, TENORETIC 50, BLOCKING AGENTS CHLORTHALIDONE ATENOLOL-CHLORTHALIDONE THIAZIDE & RELATED

BISOPROLOL ZIAC, BISOPROLOL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

METOPROLOL SU DUTOPROL* HYDROCHLOROTHIAZ METOPROLOL LOPRESSOR HCT, METOPROLOL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

NADOLOL NADOLOL-BENDROFLUMETHIAZIDE BENDROFLUMETHIAZIDE

PROPRANOLOL PROPRANOLOL- HYDROCHLOROTHIAZID HYDROCHLOROTHIAZID CALCIUM CHANNEL AMLODIPINE BESYLATE NORVASC, AMLODIPINE BESYLATE BLOCKING AGENTS DILTIAZEM HCL CARDIZEM CD, TIAZAC, CARDIZEM, CARDIZEM LA*, CARDIZEM LA, CARTIA XT, DILTIAZEM 12HR ER, DILTIAZEM 24HR ER, DILTIAZEM 24HR ER (CD), DILTIAZEM 24HR ER (LA), DILTIAZEM HCL, DILT-XR, MATZIM LA, TAZTIA XT, TIADYLT ER

FELODIPINE FELODIPINE ER ISRADIPINE ISRADIPINE NICARDIPINE HCL NICARDIPINE HCL NIFEDIPINE ADALAT CC, PROCARDIA, PROCARDIA XL, NIFEDIPINE, NIFEDIPINE ER NISOLDIPINE SULAR, NISOLDIPINE VERAPAMIL HCL CALAN SR, VERELAN, VERELAN PM, VERAPAMIL ER, VERAPAMIL ER PM, VERAPAMIL HCL, VERAPAMIL SR

AMLODIPINE BENZOATE KATERZIA*

Effective July 1, 2020 *Available as Brand Only 8 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

DIGITALIS GLYCOSIDES DIGOXIN DIGOXIN, DIGOXIN*, DIGITEK, DIGOX, LANOXIN*, LANOXIN PEDIATRIC* LOOP DIURETICS BUMETANIDE BUMETANIDE ETHACRYNIC ACID EDECRIN, ETHACRYNIC ACID FUROSEMIDE LASIX, FUROSEMIDE TORSEMIDE TORSEMIDE POTASSIUM SPARING AMILORIDE HCL AMILORIDE HCL DIURETICS EPLERENONE INSPRA, EPLERENONE SPIRONOLACTONE ALDACTONE, CAROSPIR*, SPIRONOLACTONE TRIAMTERENE DYRENIUM, TRIAMTERENE POTASSIUM SPARING AMILORIDE AMILORIDE- DIURETICS IN HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE COMBINATION SPIRONOLACT ALDACTAZIDE, ALDACTAZIDE*, HYDROCHLOROTHIAZID SPIRONOLACTONE-HCTZ TRIAMTERENE DYAZIDE, MAXZIDE, MAXZIDE-25 HYDROCHLOROTHIAZID MG, TRIAMTERENE- HYDROCHLOROTHIAZID THIAZIDE AND RELATED CHLOROTHIAZIDE CHLOROTHIAZIDE, DIURIL* DIURETICS CHLORTHALIDONE CHLORTHALIDONE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE

INDAPAMIDE INDAPAMIDE METOLAZONE METOLAZONE VASODILATORS,CORONA NITROGLYCERIN NITROGLYCERIN, NITROLINGUAL, RY NITROSTAT, NITRO-TIME, GONITRO*, NITROMIST*

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 DOFETILIDE DOFETILIDE, TIKOSYN FLECAINIDE ACETATE FLECAINIDE ACETATE

Effective July 1, 2020 *Available as Brand Only 9 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

DRONEDARONE HCL MULTAQ* PROPAFENONE HCL PROPAFENONE HCL, PROPAFENONE HCL ER, RYTHMOL SR BRETYLIUM TOSYLATE BRETYLIUM TOSYLATE ANTIHYPERLIPIDEMIC - BEMPEDOIC ACID NEXLETOL* ATP CITRATE LYASE INHIBITOR DIABETES ANTIHYPERGLY, (DPP-4) LINAGLIPTIN METFORMIN JENTADUETO*, JENTADUETO XR* INHIBITOR & BIGUANIDE HCL COMB. SITAGLIPTIN PHOS JANUMET*, JANUMET XR* METFORMIN HCL ALOGLIPTIN BENZ ALOGLIPTIN-METFORMIN, METFORMIN HCL KAZANO* SAXAGLIPTIN HCL KOMBIGLYZE XR* METFORMIN HCL ANTIHYPERGLY,INCRETIN DULAGLUTIDE TRULICITY* MIMETIC(GLP-1 RECEP.AGONIST) LIRAGLUTIDE VICTOZA 2-PAK*, VICTOZA 3-PAK*

LIXISENATIDE ADLYXIN* EXENATIDE BYDUREON BCISE*, BYDUREON MICROSPHERES PEN* 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*

Effective July 1, 2020 *Available as Brand Only 10 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

ANTIHYPERGLYCEMIC, GLIMEPIRIDE AMARYL, GLIMEPIRIDE INSULIN-RELEASE STIMULANT TYPE GLIPIZIDE GLUCOTROL, GLUCOTROL XL, GLIPIZIDE, GLIPIZIDE ER, GLIPIZIDE XL GLYBURIDE GLYBURIDE GLYBURIDE,MICRONIZED GLYNASE, GLYBURIDE MICRONIZED

NATEGLINIDE STARLIX, NATEGLINIDE 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, RIOMET*, SULFONYLUREA) GLUMETZA, METFORMIN ER GASTRIC, METFORMIN ER OSMOTIC, METFORMIN HCL, METFORMIN HCL ER, 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*, SYNJARDY XR* METFORMIN HCL ERTUGLIFLOZIN SEGLUROMET* METFORMIN DAPAGLIFLOZIN XIGDUO XR* METFORMIN HCL

Effective July 1, 2020 *Available as Brand Only 11 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

ANTIHYPERGLYCM,INSUL-PIOGLITAZONE HCL ACTOPLUS MET, ACTOPLUS MET RESP.ENHANCER & METFORMIN HCL XR*, PIOGLITAZONE-METFORMIN BIGUANIDE CMB INSULINS INSULIN LANTUS SOLOSTAR*, LANTUS*, GLARGINE,HUM.REC.ANL TOUJEO SOLOSTAR*, BASAGLAR OG KWIKPEN U-100*, TOUJEO MAX SOLOSTAR* INSULIN LISPRO HUMALOG JUNIOR KWIKPEN*, HUMALOG KWIKPEN U-200*, HUMALOG*, ADMELOG SOLOSTAR*, HUMALOG KWIKPEN U- 100, INSULIN LISPRO KWIKPEN U- 100, ADMELOG*, HUMALOG, INSULIN LISPRO, INSULIN LISPRO JUNIOR KWIKPEN

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*, NOVOLIN N FLEXPEN* INSULIN REGULAR, HUMULIN R U-500*, HUMULIN R*, HUMAN HUMULIN R U-500 KWIKPEN*, AFREZZA*, NOVOLIN R*, NOVOLIN R FLEXPEN*

INSULIN GLULISINE APIDRA SOLOSTAR*, APIDRA* INSULIN ASPART FIASP FLEXTOUCH*, FIASP (NIACINAMIDE) PENFILL*, FIASP* INSULIN DETEMIR LEVEMIR FLEXTOUCH*, LEVEMIR*

INSULIN ASPART NOVOLOG FLEXPEN*, INSULIN ASPART, INSULIN ASPART FLEXPEN, INSULIN ASPART PENFILL, NOVOLOG

Effective July 1, 2020 *Available as Brand Only 12 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

INSULIN ASPART PROT NOVOLOG MIX 70-30 FLEXPEN*, INSULN ASP INSULIN ASPART PROT-INSULN ASP, NOVOLOG MIX 70-30* INSULIN DEGLUDEC TRESIBA FLEXTOUCH U-100*, TRESIBA FLEXTOUCH U-200*, TRESIBA* ANTIHYPERGLYCEMIC,IN INSULIN DEGLUDEC XULTOPHY 100-3.6* SULIN & GLP-1 LIRAGLUTIDE RECEPTOR AGONIST INSULIN GLARGINE SOLIQUA 100-33* LIXISENATIDE

ANTIHYPERGLY,DPP-4 ALOGLIPTIN BENZ ALOGLIPTIN-PIOGLITAZONE, OSENI ENZYME INHIB PIOGLITAZONE &THIAZOLIDINEDIONE ANTIHYPERGLYCEMIC, EMPAGLIFLOZIN GLYXAMBI* SGLT-2 & DPP-4 LINAGLIPTIN INHIBITOR COMB. DAPAGLIFLOZIN QTERN* SAXAGLIPTIN HCL ERTUGLIFLOZIN STEGLUJAN* SITAGLIPTIN HYPERGLYCEMICS DEXTROSE DEX4 GLUCOSE, DEX4 GLUCOSE BITS, GLUCO BURST, GLUCO SHOT, GLUCOSE, GLUCOSE BITS, GLUCOSE GEL, GLUTOSE-15, GLUTOSE-45, GLUTOSE-5, MICRODOT GLUCOSE GEL, SUGARUP*, TRUEPLUS GLUCOSE DEXTROSE DEXTRIN INSTA-GLUCOSE*, INSTA-GLUCOSE MALTOSE DIABETIC SUPPLIES BLOOD-GLUCOSE METER 0

ANTIHYPERGLY-SGLT-2 EMPAGLIFLOZ LINAGLIP TRIJARDY XR* INHIB,DPP-4 METFORMIN INHIB,BIGUANIDE CB HIV PROPHYLAXIS ANTIVIRALS, HIV-SPEC, EMTRICITABINE TRUVADA* NUCLEOSIDE- TENOFOVIR (TDF) NUCLEOTIDE ANALOG HYPERLIPIDEMIA ANTIHYPERLIPIDEMIC - ATORVASTATIN CALCIUM LIPITOR, ATORVASTATIN CALCIUM HMG COA REDUCTASE INHIBITORS

Effective July 1, 2020 *Available as Brand Only 13 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

FLUVASTATIN SODIUM LESCOL, LESCOL XL, FLUVASTATIN ER, FLUVASTATIN SODIUM

LOVASTATIN ALTOPREV*, LOVASTATIN PITAVASTATIN CALCIUM LIVALO*

PRAVASTATIN SODIUM PRAVACHOL, PRAVASTATIN SODIUM ROSUVASTATIN CALCIUM CRESTOR, EZALLOR SPRINKLE*, ROSUVASTATIN CALCIUM SIMVASTATIN ZOCOR, FLOLIPID*, SIMVASTATIN

PITAVASTATIN ZYPITAMAG* MAGNESIUM BILE SALT CHOLESTYRAMINE (WITH QUESTRAN, CHOLESTYRAMINE SEQUESTRANTS SUGAR) CHOLESTYRAMINE QUESTRAN LIGHT, ASPARTAME CHOLESTYRAMINE LIGHT, PREVALITE COLESEVELAM HCL COLESEVELAM HCL, WELCHOL COLESTIPOL HCL COLESTID, COLESTID*, COLESTIPOL HCL LIPOTROPICS EZETIMIBE ZETIA, EZETIMIBE FENOFIBRATE FENOGLIDE, LIPOFEN, FENOFIBRATE FENOFIBRATE TRICOR, TRIGLIDE*, FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE,MICRONIZE ANTARA*, FENOFIBRATE D FENOFIBRIC ACID FIBRICOR, FENOFIBRIC ACID FENOFIBRIC ACID TRILIPIX, FENOFIBRIC ACID (CHOLINE) GEMFIBROZIL LOPID, GEMFIBROZIL ICOSAPENT ETHYL VASCEPA* NIACIN NIACOR, NIASPAN, NIACIN, NIACIN ER OMEGA-3 ACID ETHYL LOVAZA, OMEGA-3 ACID ETHYL ESTERS ESTERS ANTIHYPERLIP.HMG COA EZETIMIBE SIMVASTATIN VYTORIN, EZETIMIBE-SIMVASTATIN REDUCT INHIB&CHOLEST.AB.INHI B

Effective July 1, 2020 *Available as Brand Only 14 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME

NIACIN PREPARATIONS NIACIN NIACIN, ENDUR-ACIN, PLAIN NIACIN, SLO-NIACIN NIACINAMIDE NIACIN, ENDUR-AMIDE, ENDUR- AMIDE*, NIACINAMIDE NIACIN PANTETHINE ENDUR-THINE* NIACIN (INOSITOL NIACIN, NIACIN*, NIACIN FLUSH NIACINATE) FREE, NIACIN FLUSH FREE*, NIACIN FLUSH-FREE, NIACIN INOSITOL, NO FLUSH NIACIN

OSTEOPOROSIS BONE RESORPTION ALENDRONATE SODIUM FOSAMAX PLUS D* INHIBITOR & VITAMIN D VITAMIN D3 COMBINATIONS BONE RESORPTION ALENDRONATE SODIUM FOSAMAX, ALENDRONATE INHIBITORS SODIUM, BINOSTO* IBANDRONATE SODIUM BONIVA, IBANDRONATE SODIUM

RALOXIFENE HCL EVISTA, RALOXIFENE HCL RISEDRONATE SODIUM ACTONEL, ATELVIA, RISEDRONATE SODIUM, RISEDRONATE SODIUM DR DENOSUMAB PROLIA* VITAMIN AND OR PEDIATRIC VITAMIN VARIOUS PRENATAL MINERAL DEFICIENCY PREPARATIONS VITAMINS

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