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