Preventive Therapy Drug List (Brand name in CAPS and generic in lower case) (08/01/18) ANTI-INFECTIVES phenytoin sotalol AF ANTIRETROVIRAL AGENTS phenytoin sodium extended Pacerone TRUVADA 200/300 mg primidone BETAPACE tiagabine BETAPACE AF topiramate MULTAQ ANTICOAGULANTS/ topiramate ext-rel NORPACE ANTIPLATELETS valproic acid NORPACE CR ANTICOAGULANTS vigabatrin RYTHMOL SR enoxaparin zonisamide SORINE fondaparinux Epitol SOTYLIZE warfarin APTIOM TIKOSYN Jantoven BANZEL ARIXTRA BRIVIACT ORAL ANTIANGINAL AGENTS BEVYXXA CARBATROL isosorbide dinitrate COUMADIN CELONTIN isosorbide dinitrate ext-rel COUMADIN INJECTION DEPAKENE isosorbide mononitrate ELIQUIS DEPAKOTE isosorbide mononitrate ext-rel FRAGMIN DEPAKOTE ER DILATRATE-SR IPRIVASK DILANTIN ISORDIL LOVENOX FELBATOL PRADAXA FYCOMPA SL and chewable formulations are not included SAVAYSA GABITRIL on this list. XARELTO KEPPRA KEPPRA XR TRANSDERMAL/TOPICAL ANTIANGINAL PLATELET AGGREGATION INHIBITORS KLONOPIN AGENTS aspirin 81 mg LAMICTAL nitroglycerin transdermal clopidogrel LAMICTAL XR Minitran dipyridamole MYSOLINE NITRO-BID dipyridamole ext-rel/aspirin ONFI NITRO-DUR prasugrel OXTELLAR XR AGGRENOX PEGANONE CORONARY ARTERY DISEASE BRILINTA PHENYTEK ANTIHYPERLIPIDEMICS CLOPIDOGREL KIT QUDEXY XR atorvastatin DURLAZA ROWEEPRA cholestyramine EFFIENT SABRIL colesevelam PLAVIX SPRITAM colestipol YOSPRALA TEGRETOL ezetimibe ZONTIVITY TEGRETOL-XR fenofibrate TOPAMAX fenofibric acid Over-the-Counter (OTC) products require a prescription. TRILEPTAL fenofibric acid delayed-rel Coverage may vary by plan. TROKENDI XR fluvastatin VIMPAT fluvastatin ext-rel ANTICONVULSANTS ZARONTIN gemfibrozil carbamazepine ZONEGRAN lovastatin carbamazepine ext-rel niacin ext-rel clonazepam CARDIOVASCULAR CONDITIONS - pravastatin divalproex sodium delayed-rel rosuvastatin divalproex sodium ext-rel OTHER simvastatin ethosuximide ANTIARRHYTHMIC AGENTS Niacor felbamate amiodarone Prevalite lamotrigine disopyramide ALTOPREV lamotrigine ext-rel dofetilide ANTARA levetiracetam flecainide COLESTID levetiracetam ext-rel propafenone CRESTOR oxcarbazepine propafenone ext-rel FENOGLIDE phenobarbital sotalol FIBRICOR Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications. This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894B 080118 FLOLIPID TRESIBA PRANDIN KYNAMRO TRULICITY PRECOSE LESCOL XL VICTOZA QTERN LIPITOR XULTOPHY RIOMET LIPOFEN SEGLUROMET LIVALO Over-the-Counter (OTC) products require a prescription. STARLIX LOPID Coverage may vary by plan. STEGLATRO NIASPAN STEGLUJAN ORAL DIABETES AGENTS PRAVACHOL SYNJARDY acarbose QUESTRAN/QUESTRAN LIGHT SYNJARDY XR alogliptin TRICOR TRADJENTA alogliptin/metformin TRIGLIDE XIGDUO XR alogliptin/pioglitazone TRILIPIX chlorpropamide WELCHOL glimepiride HEMATOLOGIC AGENTS ZETIA glipizide ADVATE ZOCOR glipizide ext-rel ADYNOVATE ZYPITAMAG glipizide/metformin AFSTYLA glyburide ALPHANATE COMBINATION ANTIHYPERLIPIDEMICS glyburide, micronized ALPHANINE SD amlodipine/atorvastatin glyburide/metformin ALPROLIX ezetimibe/simvastatin metformin BEBULIN CADUET metformin ext-rel BENEFIX VYTORIN miglitol CORIFACT nateglinide ELOCTATE DIABETES pioglitazone FEIBA DIAGNOSTIC AGENTS AND SUPPLIES pioglitazone/glimepiride HELIXATE FS BLOOD GLUCOSE MONITORS - ALL pioglitazone/metformin HEMOFIL M BLOOD GLUCOSE STRIPS - ALL repaglinide HUMATE-P CONTROL SOLUTIONS repaglinide/metformin IDELVION INSULIN SYRINGES, INFUSION SETS, tolbutamide IXINITY AND NEEDLES - ALL ACTOPLUS MET KOATE-DVI KETONE BLOOD TEST STRIPS - ALL ACTOPLUS MET XR KOGENATE FS LANCETS, LANCET DEVICES ACTOS KOVALTRY OMNIPOD INSULIN INFUSION PUMP AMARYL MONOCLATE-P URINE TESTING STRIPS - ALL D-CARE DM2 KIT MONONINE V-GO INSULIN DELIVERY DEVICE DUETACT NOVOEIGHT FARXIGA NUWIQ Over-the-Counter (OTC) products require a prescription. FORTAMET PROFILNINE SD Coverage may vary by plan GLUCOPHAGE RECOMBINATE GLUCOPHAGE XR RIXUBIS INHALED DIABETES AGENTS GLUCOTROL TRETTEN AFREZZA GLUCOTROL XL XYNTHA GLUCOVANCE INJECTABLE DIABETES AGENTS ADLYXIN GLUMETZA HYPERTENSION ADMELOG GLYNASE ACE INHIBITORS/ANGIOTENSIN II RECEPTOR GLYSET APIDRA ANTAGONISTS AND COMBINATION AGENTS GLYXAMBI BASAGLAR KWIKPEN amlodipine/benazepril BYDUREON INVOKAMET benazepril BYETTA INVOKAMET XR benazepril/hydrochlorothiazide INVOKANA FIASP candesartan JANUMET HUMALOG candesartan/hydrochlorothiazide JANUMET XR HUMULIN captopril LANTUS JANUVIA captopril/hydrochlorothiazide JARDIANCE LEVEMIR enalapril JENTADUETO NOVOLIN enalapril/hydrochlorothiazide JENTADUETO XR NOVOLOG eprosartan OZEMPIC KAZANO fosinopril KOMBIGLYZE XR SOLIQUA fosinopril/hydrochlorothiazide METAGLIP SYMLINPEN irbesartan NESINA TANZEUM irbesartan/hydrochlorothiazide TOUJEO ONGLYZA lisinopril OSENI Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications. This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894B 080118 lisinopril/hydrochlorothiazide nadolol/bendroflumethiazide hydrochlorothiazide losartan pindolol indapamide losartan/hydrochlorothiazide propranolol methyclothiazide moexipril propranolol ext-rel spironolactone/hydrochlorothiazide moexipril/hydrochlorothiazide propranolol/hydrochlorothiazide triamterene/hydrochlorothiazide olmesartan timolol maleate ALDACTAZIDE olmesartan/hydrochlorothiazide BYSTOLIC DIURIL perindopril BYVALSON DYAZIDE quinapril COREG MAXZIDE quinapril/hydrochlorothiazide COREG CR MICROZIDE ramipril CORGARD telmisartan CORZIDE OTHER ANTIHYPERTENSIVE AGENTS telmisartan/hydrochlorothiazide DUTOPROL amlodipine/olmesartan trandolapril INDERAL LA amlodipine/telmisartan trandolapril/verapamil ext-rel LEVATOL amlodipine/valsartan/ valsartan LOPRESSOR hydrochlorothiazide valsartan/hydrochlorothiazide LOPRESSOR HCT clonidine ACCUPRIL TENORETIC clonidine transdermal ACCURETIC TENORMIN guanabenz ALTACE TOPROL-XL guanfacine ATACAND TRANDATE hydralazine ATACAND HCT ZIAC methyldopa AVALIDE methyldopa/hydrochlorothiazide AVAPRO CALCIUM CHANNEL BLOCKERS AND minoxidil BENICAR COMBINATION AGENTS olmesartan/amlodipine/ BENICAR HCT amlodipine hydrochlorothiazide COZAAR diltiazem AZOR DIOVAN diltiazem ext-rel CATAPRES DIOVAN HCT diltiazem XR CATAPRES-TTS EDARBI felodipine ext-rel EXFORGE EDARBYCLOR isradipine EXFORGE HCT EPANED nicardipine TEKTURNA HYZAAR nifedipine TEKTURNA HCT LOTENSIN nifedipine ext-rel TRIBENZOR LOTENSIN HCT nisoldipine ext-rel TWYNSTA LOTREL verapamil MICARDIS verapamil ext-rel IMMUNIZING AGENTS MICARDIS HCT Afeditab CR ALLERGENIC EXTRACTS PRESTALIA Cartia XT ALLERGENIC EXTRACTS - ALL PRINIVIL Dilt-XR QBRELIS Matzim LA IMMUNIZATIONS TARKA Nifediac CC VACCINES - ALL VASERETIC Taztia XT VASOTEC ADALAT CC ZESTORETIC CALAN MENTAL HEALTH ZESTRIL CALAN SR ANTIDEPRESSANTS CARDIZEM amitriptyline BETA-BLOCKERS AND COMBINATION CARDIZEM CD amoxapine AGENTS CARDIZEM LA bupropion acebutolol ISOPTIN SR bupropion ext-rel atenolol NORVASC citalopram atenolol/chlorthalidone PROCARDIA clomipramine betaxolol PROCARDIA XL desipramine bisoprolol SULAR desvenlafaxine ext-rel bisoprolol/hydrochlorothiazide TIAZAC doxepin carvedilol VERELAN duloxetine delayed-rel carvedilol phosphate ext-rel VERELAN PM escitalopram labetalol fluoxetine metoprolol DIURETICS fluoxetine delayed-rel metoprolol succinate ext-rel amiloride/hydrochlorothiazide fluvoxamine metoprolol/hydrochlorothiazide chlorothiazide imipramine HCl imipramine pamoate nadolol chlorthalidone Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about