Appendix A: Medications Included in RX Outcomes The drugs included in the following list are included in the RX Outcomes Benefit value tier. These medications have been shown to improve the overall health outcomes of people with health problems like high blood pressure, high blood sugars (diabetes mellitus), and breathing difficulties (asthma) when taken on a daily schedule. For members whose plan includes the RX Outcomes Benefit, these drugs will process with a lower cost share. These medications have been designated with a “RXO” within the formulary document. Only applies to plans with the value tier benefit. See the Plan Summary of Benefits documents for details.

Drug Category: Drug Name - generic (Brand)* *Only generic formulations included when available

Bone Health: • Nifedical XL • Alendronate • Nifedipine ER • Calcitonin, Salmon Nasal • Verapamil • Etidronate • Verapamil ER • Ibandronate • Verapamil SR • Risedronate Cardiovascular (Heart Health) - Diuretics: Cardiovascular (Heart Health) - ACE • Bumetanide Inhibitors: • Chlorothiazide • Benazepril • Chlorthalidone • Benazepril/HCTZ • Furosemide • Enalapril • Hydrochlorothiazide (HCTZ) • Enalapril/HCTZ • Indapamide • Fosinopril • Metolazone • Fosinopril/HCTZ • Spironolactone • Lisinopril • Spironolactone/HCTZ • Lisinopril/HCTZ • Triamterene/HCTZ • Perindopril • Quinapril Cardiovascular (Heart Health) - Other: • Quinapril/HCTZ • Clopidogrel • Ramipril • Isosorbide Dinitrate • Isosorbide Dinitrate ER Cardiovascular (Heart Health) - ARBs: • Isosorbide Dinitrate Sublingual • Candesartan • Warfarin • Candesartan/HCTZ • Irbesartan Cholesterol Drugs: • Irbesartan/HCTZ • Atorvastatin • Losartan Potassium • Gemfibrozil • Losartan/HCTZ • Lovastatin • Valsartan • Pravastatin • Valsartan/HCTZ • Rosuvastatin • Simvastatin Cardiovascular (Heart Health) - Beta Blockers: Diabetes Medications - Insulins: • Atenolol • Insulin Aspart (Novolog) • Atenolol/Chlorthalidone • Insulin Aspart Protamine/Insulin Aspart • Bisoprolol/HCTZ (Novolog Mix 70-30) • Carvedilol • Insulin Glargine (Basaglar U-100) • Metoprolol Succinate 24hr • Insulin NPH Isophane (Novolin N) • Metoprolol Tartrate • Insulin NPH Isophane/Insulin Regular (Novolin • Metoprolol/HCTZ 70-30) • Nadolol/Bendroflumethiazide • Insulin Regular (Novolin R) • Propranolol/HCTZ Diabetes Medications - Other: Cardiovascular (Heart Health) - Calcium • Acarbose Channel Blockers: • Dapagliflozin (Farxiga) • Amlodipine • Dapagliflozin/Metformin (Xigduo XR) • Diltiazem 24hr • Dulaglutide (Trulicity) Injection

08/21 Appendix A: Medications Included in RX Outcomes • Ertugliflozin (Steglatro) Respiratory Aids: • Ertugliflozin Pidolate/Metformin (Segluromet) • Spacers And Masks (various brands) • Ertugliflozin/Sitagliptin (Steglujan) • Peak Flow Meters (various brands) • Exenatide (Byetta, Bydureon) Injection • Spirometers (various brands) • Glimepiride • Glipizide Women's Health: • Glipizide ER • Prenatal Vitamins (preferred only) • Glipizide XL • Glipizide/Metformin • Glyburide • Glyburide Micronized • Glyburide/Metformin • Metformin • Metformin ER • Nateglinide • Pioglitazone • Repaglinide • Sitagliptin (Januvia) • Sitagliptin/Metformin (Janumet, Janumet XR)

Diabetic Supplies: • Blood Sugar Test Strips (Abbott & Bayer Brands) • Preferred Glucose Meters (Abbott & Bayer Brands) • Control Solutions (various brands) • Insulin Syringes (various brands) • Lancets (various brands) • Needles (various brands)

Mental Health - Depression: • Bupropion • Bupropion SR • Bupropion XL • Citalopram • Escitalopram • Fluoxetine capsules, solution • Mirtazapine • Paroxetine • Sertraline • Trazodone • Venlafaxine ER capsules

Respiratory (Asthma) Medications: • Budesonide Nebs Inhalation • Fluticasone (Arnuity Ellipta) Inhalation • Fluticasone (Flovent Diskus) Inhalation • Fluticasone (Flovent HFA) Inhalation • Mometasone (Asmanex HFA) Inhalation • Mometasone (Asmanex) Inhalation • Fluticasone/Salmeterol (Advair Diskus, HFA) Inhalation • Mometasone/Formoterol (Dulera) Inhalation • Fluticasone/Vilanterol (Breo Ellipta) Inhalation • Montelukast

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