Advantage Value for Diabetes Eligible Drug List for the State of Minnesota This list includes drugs that are covered by your pharmacy benefit plan managed by CVS Caremark® when filled at a network pharmacy (including retail, mail and specialty). Eligible Drugs/Supplies You pay Diabetes drugs Copay**: $0 tier 1 / $20 tier 2 / $35 tier 3 Hypertensive (blood pressure) drugs Copay: $0 tier 1 / $20 tier 2 / $35 tier 3 Cholesterol drugs Copay: $0 tier 1 / $20 tier 2 / $35 tier 3 Depression drugs Copay: $0 tier 1 / $20 tier 2 / $35 tier 3 Diabetes supplies 0% coinsurance, deductible waived (including test strips, syringes, lancets and more) Drug Class Drug Brand Name Tier Antidiabetic Medications * ALPHA-GLUCOSIDASE INHIBITORS ACARBOSE 1 * ALPHA-GLUCOSIDASE INHIBITORS PRECOSE 2 * AMYLIN ANALOGS SYMLINPEN 2 BIGUANIDES METFORMIN HCL 1 BIGUANIDES METFORMIN HCL ER 1 * BIGUANIDE/SULONYLUREA COMBINATIONS GLIPIZIDE/METFORMIN 1 * DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA 2 DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS/BIGUANIDE * JANUMET 2 COMBINATIONS DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS/BIGUANIDE * JANUMET XR 2 COMBINATIONS * INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) OZEMPIC 2 * INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) RYBELSUS 2 * INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) TRULICITY 2 * INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) VICTOZA 2 * INCRETIN MIMETIC AGENT/INSULIN COMBINATIONS SOLIQUA 2 * INCRETIN MIMETIC AGENT/INSULIN COMBINATIONS XULTOPHY 2 * INSULIN BASAGLAR 2 * INSULIN FIASP 2 * INSULIN HUMULIN R U-500 2 * INSULIN LEVEMIR 2 * INSULIN NOVOLIN 70/30 2 * INSULIN NOVOLIN N 2 * INSULIN NOVOLIN R 2 * INSULIN NOVOLOG 2 ©2021 CVS Caremark. All rights reserved. 106-44166A 090121 October 2021 Page 1 of 7 * INSULIN NOVOLOG MIX 70/30 2 * INSULIN TOUEJO 2 * INSULIN TRESIBA 2 * INSULIN SENSITIZING AGENTS PIOGLITAZONE 1 * INSULIN SENSITIZING AGENTS/BIGUANIDE COMBINATIONS PIOGLITAZONE/METFORMIN 1 * INSULIN SENSITIZING AGENTS/BIGUANIDE COMBINATIONS ACTOPLUS MET 3 * INSULIN SENSITIZER/SULFONYLUREA COMBINATOINS PIOGLITAZONE/GLIMEPIRIDE 1 * INSULIN SENSITIZER/SULFONYLUREA COMBINATOINS DUETAC 3 * MEGLITINIDE ANALOGUES NATEGLINIDE 1 * MEGLITINIDE ANALOGUES REPAGLINIDE 1 * SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA 2 * SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS JARDIANCE 2 SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS/ * SYNJARDY 2 BIGUANIDE COMBINATIONS SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS/ * SYNJARDY XR 2 BIGUANIDE COMBINATIONS SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS/ * XIGDUO XR 2 BIGUANIDE COMBINATIONS SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS/ * GLYXAMBI 2 DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS COMBINATIONS ENDOCRINE AND METABOLIC/ ANTIDIABETICS/ SODIUM-GLUCOSE * CO-TRANSPORTER 2 (SGLT2) INHIBITOR/DIPEPTIDYL PEPTIDASE-4 TRIJARDY XR 2 (DPP-4) INHIBITOR/BIGUANIDE COMBINATIONS * SULFONYLUREAS GLIMEPIRIDE 1 * SULFONYLUREAS GLIPIZIDE 1 * SULFONYLUREAS GLIPIZIDE ER 1 * SULFONYLUREAS AMARYL 3 * SULFONYLUREAS GLUCOTROL 3 * SULFONYLUREAS GLUCOTROL XL 3 Antihypertensive Medications ACE INHIBITORS BENAZEPRIL 1 ACE INHIBITORS CAPTOPRIL 1 ACE INHIBITORS ENALAPRIL 1 ACE INHIBITORS FOSINOPRIL 1 ACE INHIBITORS LISINOPRIL 1 ACE INHIBITORS PERINDOPRIL 1 ACE INHIBITORS QUINAPRIL 1 ACE INHIBITORS RAMIPRIL 1 ACE INHIBITORS TRANDOLAPRIL 1 ACE INHIBITORS ACCUPRIL 3 ACE INHIBITORS ALTACE 3 ACE INHIBITORS LOTENSIN 3 ©2021 CVS Caremark. All rights reserved. 106-44166A 090121 October 2021 Page 2 of 7 ACE INHIBITORS VASOTEC 3 ACE INHIBITORS ZESTRIL 3 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS AMLODIPINE/BENAZAPRIL 1 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS TRANDOLAPRIL/VERAPAMIL EXT-REL 1 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS LOTREL 2 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS TARKA 2 ACE INHIBITOR/DIURETIC COMBINATIONS CAPTOPRIL/HCTZ 1 ACE INHIBITOR/DIURETIC COMBINATIONS BENAZEPRIL/HCTZ 1 ACE INHIBITOR/DIURETIC COMBINATIONS ENALAPRIL/HCTZ 1 ACE INHIBITOR/DIURETIC COMBINATIONS FOSINOPRIL/HCTZ 1 ACE INHIBITOR/DIURETIC COMBINATIONS LISINOPRIL/HCTZ 1 ACE INHIBITOR/DIURETIC COMBINATIONS QUINAPRIL/HCTZ 1 ACE INHIBITOR/DIURETIC COMBINATIONS ACCURETIC 3 ACE INHIBITOR/DIURETIC COMBINATIONS LOTENSIN HCT 3 ACE INHIBITOR/DIURETIC COMBINATIONS VASERETIC 3 ADRENOLYTICS, CENTRAL CLONIDINE 1 ADRENOLYTICS, CENTRAL CLONIDINE TRANSDERMAL 1 ADRENOLYTICS, CENTRAL GUANFACINE 1 ADRENOLYTICS, CENTRAL CATAPRES 2 ADRENOLYTICS, CENTRAL CATAPRES-TTS 2 ALDOSTERONE RECEPTOR ANTAGONISTS SPIRONOLACTONE 1 ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE 2 ALPHA BLOCKERS DOXAZOSIN 1 ALPHA BLOCKERS TERAZOSIN 1 ALPHA BLOCKERS CARDURA 3 ANGIOTENSIN II RECEPTOR ANTAGONISTS CANDESARTAN 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS IRBESARTAN 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS LOSARTAN 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS OLMESARTAN 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS TELMISARTAN 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS VALSARTAN 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS CANDESARTAN/HCTZ 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS IRBESARTAN/HCTZ 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS LOSARTAN/HCTZ 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS OLMESARTAN/HCTZ 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS TELMISARTAN/HCTZ 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS VALSARTAN/HCTZ 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL AMLODIPINE/OLMESARTAN 1 BLOCKER COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL AMLODIPINE/TELMISARTAN 1 BLOCKER COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL AMLODIPINE/VALSARTAN 1 BLOCKER COMBINATIONS ©2021 CVS Caremark. All rights reserved. 106-44166A 090121 October 2021 Page 3 of 7 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL AMLODIPINE/VALSARTAN/HCTZ 1 BLOCKER/DIURETIC COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL OLMESARTAN/AMLODIPINE/HCTZ 1 BLOCKER/DIURETIC COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL TRIBENZOR 3 BLOCKER/DIURETIC COMBINATIONS BETA-BLOCKERS ATENOLOL 1 BETA-BLOCKERS BISOPROLOL 1 BETA_BLOCKERS CARVEDILOL 1 BETA-BLOCKERS CARVEDILOL EXT-REL 1 BETA-BLOCKERS LABETALOL 1 BETA-BLOCKERS METOPROLOL SUCCINATE ER 1 BETA-BLOCKERS METOPROLOL TARTRATE 1 BETA-BLOCKERS NADOLOL 1 BETA-BLOCKERS PINDOLOL 1 BETA-BLOCKERS PROPRANOLOL HCL 1 BETA-BLOCKERS PROPRANOLOL HCL ER 1 BETA-BLOCKERS BYSTOLIC 2 BETA-BLOCKERS COREG 3 BETA-BLOCKERS CORGARD 3 BETA-BLOCKER/DIURETIC COMBINATIONS ATENOLOL/CHLORTHALIDONE 1 BETA-BLOCKER/DIURETIC COMBINATIONS BISOPROLOL/HCTZ 1 BETA-BLOCKER/DIURETIC COMBINATIONS METOPROLOL/HCTZ 1 BETA-BLOCKER/DIURETIC COMBINATIONS ZIAC 2 CALCIUM CHANNEL BLOCKERS AMLODIPINE 1 CALCIUM CHANNEL BLOCKERS DILTIAZEM ER 1 CALCIUM CHANNEL BLOCKERS FELODIPINE ER 1 CALCIUM CHANNEL BLOCKERS NIFEDIPINE ER 1 CALCIUM CHANNEL BLOCKERS VERAPAMIL HCL ER 1 CALCIUM CHANNEL BLOCKERS CALAN SR 3 CALCIUM CHANNEL BLOCKERS PROCARDIA XL 3 CALCIUM CHANNEL BLOCKERS TIAZAC 3 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS AMLODIPINE/ATORVASTATIN 1 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS CADUET 3 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ALISKIREN 1 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT 2 CARBONIC ANHYDRASE INHIBITORS ACETAZOLAMIDE 1 CARBONIC ANHYDRASE INHIBITORS ACETAZOLAMIDE ER 1 CARBONIC ANHYDRASE INHIBITORS METHAZOLAMIDE 1 DIURETIC COMBINATIONS AMILORIDE/HCTZ 1 DIURETIC COMBINATIONS SPIRONOLACTONE/HCTZ 1 DIURETIC COMBINATIONS TRIAMTERENE/HCTZ 1 DIURETIC COMBINATIONS ALDACTAZIDE 3 DIURETIC COMBINATIONS MAXZIDE 3 ©2021 CVS Caremark. All rights reserved. 106-44166A 090121 October 2021 Page 4 of 7 LOOP DIURETICS BUMETANIDE 1 LOOP DIURETICS FUROSEMIDE 1 LOOP DIURETICS TORSEMIDE 1 LOOP DIURETICS LASIX 3 POTASSIUM SPARING DIURETICS AMILORIDE 1 POTASSIUM SPARING DIURETICS TRIAMTERENE 1 THIAZIDES AND THIAZIDE-LIKE DIURETICS CHLORTHALIDONE 1 THIAZIDES AND THIAZIDE-LIKE DIURETICS HYDROCHLOROTHIAZIDE 1 THIAZIDES AND THIAZIDE-LIKE DIURETICS INDAPAMIDE 1 THIAZIDES AND THIAZIDE-LIKE DIURETICS METOLAZONE 1 MISCELLANEOUS HYDRALAZINE 1 MISCELLANEOUS METHYLDOPA 1 Cholesterol Lowering Medications BILE ACID SEQUESTRANTS COLESEVELAM 1 BILE ACID SEQUESTRANTS CHOLESTYRAMINE 1 BILE ACID SEQUESTRANTS COLESTIPOL HCL 1 BILE ACID SEQUESTRANTS COLESTID 3 BILE ACID SEQUESTRANTS QUESTRAN 3 CHOLESTEROL OBSORPTION INHIBITORS EZETIMIBE 1 FIBRIC ACID DERIVATIVES FENOFIBRATE 1 FIBRIC ACID DERIVATIVES FENOFIBRIC ACID DELAYED-REL 1 FIBRIC ACID DERIVATIVES GEMFIBROZIL 1 FIBRIC ACID DERIVATIVES ANTARA 3 FIBRIC ACID DERIVATIVES LOPID 3 FIBRIC ACID DERIVATIVES TRILIPIX 3 HMG COA REDUCTASE INHIBITORS ATORVASTATIN 1 HMG COA REDUCTASE INHIBITORS FLUVASTATIN 1 HMG COA REDUCTASE INHIBITORS LOVASTATIN 1 HMG COA REDUCTASE INHIBITORS PRAVASTATIN 1 HMG COA REDUCTASE INHIBITORS ROSUVASTATIN 1 HMG COA REDUCTASE INHIBITORS SIMVASTATIN 1 HMG COA REDUCTASE INHIBITORS PRAVACHOL 3 HMG COA REDUCTASE INHIBITORS ZOCOR 3 HMG COA REDUCTASE INHIBITORS COMBINATIONS EZETIMIBE/SIMVASTATIN 1 HMG COA REDUCTASE INHIBITORS COMBINATIONS VYTORIN 3 NICOTINIC ACID DERIVATIVES NIACIN EXT-REL 1 NICOTINIC ACID DERIVATIVES NIASPAN 3 OMEGA-3 FATTY ACIDS OMEGA-3-ACID ETHYL ESTERS 1 OMEGA-3 FATTY ACIDS VASCEPA 2 ©2021 CVS Caremark. All rights reserved. 106-44166A 090121 October 2021 Page 5 of 7 OMEGA-3 FATTY ACIDS LOVAZA 3 PCSK9 INHIBITORS PRALUENT 2 Anti-Depressants ANTIDEPRESSANTS - MISC. BUPROPION 1 ANTIDEPRESSANTS - MISC. BUPROPION EXT-REL 1 ANTIDEPRESSANTS - MISC MIRTAZAPINE 1 ANTIDEPRESSANTS - MISC TRAZODONE 1 ANTIDEPRESSANTS