Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans

Transcription

1 Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans This document is a searchable PDF. On your keyboard press Ctrl+F (Command+F for Mac) and a search field will open. Type in the name of the drug you are looking for in the search field, press enter and it will locate the name of the drug in the document. 205 Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association

2 Things to know about Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary The Blue Cross of Idaho formulary is a list of drugs approved by Blue Cross of Idaho s Pharmacy and Therapeutics Committee for coverage under your pharmacy benefit. The formulary includes brand name as well as generic drugs that have undergone rigorous testing and are approved by the Food and Drug Administration (FDA). Not all drugs approved by the FDA are covered under the Blue Cross of Idaho formulary. The Multi-Tier Formulary In most cases you will be responsible for a portion of the cost of each prescription you have filled and depending on the drug prescribed, your cost can vary. The Blue Cross of Idaho formulary for qualified health plans has four tiers, with the first tier costing you the least and the third and fourth tier costing you the most. Asking your doctor to prescribe drugs listed in the first or second tier of the formulary can save you money. Tier Description Cost* Generic Drugs are equivalent to brand-name drugs in dosage, safety, strength, $ method of administration, performance characteristics and intended use. 2 Preferred Brand-Name Drugs are drugs that Blue Cross of Idaho has rated as preferred due to their quality and cost-effectiveness. $$ Non-Preferred Brand-Name Drugs are clinically effective medications, but come $$$ with an excessive cost compared to other alternatives within the same drug class. 4 Specialty Drugs are medications used to treat complex conditions. $$$$ ACA Affordable Care Act Drugs are drugs prescribed for covered preventive services No Cost that are available at no cost to members of Qualified Health Plans. *Cost Definitions $ = lowest cost, $$$$ = highest cost

3 Reading the Formulary On the following pages, you ll find a list of prescription drugs and columns that list the tier they each belong to and any specific requirements or limitations. Column Name Drug Reference Tier Notes What you will find in each column: Name of covered prescription drugs Brand Name Drugs are UPPER CASE Generic Drugs are lower case Brand name of the covered generic drug listed in the Drug column. *Please see information below regarding Mandatory Generic Substitution The tier assignment for the prescription drug listed in the Drug column Requirements and limitations, as well as indicating if drugs are part of the Preventive Drug List for HSA Plans. See Abbreviation Dictionary on the next page for definitions and more information about the abbreviations. Mandatory Generic Substitution Your plan includes a mandatory generic substitution requirement. When a drug has both brand and generic forms available, the generic drug is listed under the Drug column as the covered option with the brand or trademark name listed under the Reference column. When you or your physician choose the brand name drug, in addition to any applicable cost share (deductible/coinsurance/copayments) for the brand name medication, you will pay the cost difference between the contracted cost of the generic drug and brand name drug. These cost difference amounts do not apply to your annual out of pocket maximum. Reference Specialty Drugs designated by an SP- or SP-2 in the Notes column will apply a Tier 4 cost share prior to the cost difference calculation All other Reference brand name drugs will apply a Tier cost share prior to the cost difference calculation Drugs noted as Narrow Therapeutic Index (NTI) are not subject to the cost difference calculation This formulary is subject to change as new products and information become available. Please refer to your contract for more information about the terms and conditions of your prescription drug benefit. If you have questions about any of your medications, please discuss them with your doctor or pharmacist.

4 Abbreviation Dictionary NTI Narrow Therapeutic Index Some drugs have a narrow range between a drug s effective dose, and the dose where it may cause harm. These drugs are considered by the Food and Drug Administration to be Narrow Therapeutic Index (NTI), and their administration should be carefully monitored by a physician. Due to the need for careful and uninterrupted control of these medications, the mandatory generic substitution requirement is waived for NTI drugs. PA - Prior authorization Medications that list PA need prior authorization from Blue Cross of Idaho before we will cover the drug. Your provider must provide documentation showing that the prescription is medically necessary. If prior authorization is not obtained, you may be held responsible for the entire cost of the drug. Please refer to your policy (also called a member contract) for more information about prior authorization. You can find a copy of your policy and detailed information on the prior authorization process online by logging into members.bcidaho.com. PR - Preventive Drugs for HSA Plans Some preventive drugs may be available at no cost to members of High Deductible Health Plans, also known as HSA plans. Preventive medications are prescribed for the prevention of conditions or illnesses when individuals may be at high risk. QL - Quantity Limits Some formulary drugs can only be filled in limited quantities. These prescriptions have been found to be less effective or even dangerous when taken at higher than normal doses. The limits on QL drugs are in line with manufacturer s recommendations regarding safety and effectiveness. SP Specialty Drug Program Specialty medications are generally prescribed for treatment of complex, on -going medical conditions. These medications are generally high cost, and have specific handling requirements. All specialty drugs are limited to a 0 day supply per fill. SP-: Some drugs must be obtained by mail order through CVS Caremark Specialty Pharmacy in order to be covered. Blue Cross of Idaho participates in the CVS Specialty Drug Program to allow member s access to high cost medications at carefully controlled rates. SP-2: Some specialty drugs can be obtained through retail channels and do not have to be purchased through CVS Caremark Specialty Pharmacy. ST - Step Therapy You may need to use one or more alternative medications before Blue Cross of Idaho can authorize benefits for the use of another medication. Blue Cross of Idaho wants to ensure providers are trying equally or more effective, low-cost options before recommending effective, but higher cost treatments. AL - Age Limitation Some drugs may be only be safe or recommended for certain age groups. Blue Cross of Idaho places age limitations to ensure drugs are not prescribed to individuals who are not of the recommended age.

5 *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet Intuniv extended release 24 hour *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** STRATTERA ORAL CAPSULE 0 MG, 00 MG, 8 MG, 25 MG, 40 MG, 60 MG, 80 MG *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 0 mg, 5 mg, 20 mg, 25 mg, 0 mg, 5 mg amphetamine-dextroamphetamine oral tablet *Amphetamines*** 2 QL Adderall XR QL Adderall QL ADZENYS XR-ODT ORAL QL dextroamphetamine sulfate er oral capsule extended release 24 hour 0 mg, 5 mg, 5 mg dextroamphetamine sulfate oral tablet Dexedrine QL Zenzedi QL DYANAVEL XR ORAL QL methamphetamine hcl oral tablet Desoxyn QL VYVANSE ORAL CAPSULE 0 MG, 20 MG, 0 MG, 40 MG, 50 MG, 60 MG, 70 MG 2 QL PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 5

6 *Stimulants - Misc.*** armodafinil oral tablet Nuvigil PA DAYTRANA TRANSDERMAL PATCH QL dexmethylphenidate hcl er oral capsule extended release 24 hour 0 mg, 5 mg, 20 mg, 0 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 0 mg, 2.5 mg, 5 mg FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 5 MG METHYLIN ORAL TABLET CHEWABLE methylphenidate hcl er (cd) oral capsule extended release methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 0 mg, 40 mg methylphenidate hcl er oral tablet extended release methylphenidate hcl oral solution 0 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 0 mg, 20 mg, 5 mg Focalin XR QL Focalin QL QL QL Metadate CD QL Ritalin LA QL Metadate ER QL Methylin QL Ritalin QL modafinil oral tablet Provigil PA QUILLICHEW ER ORAL 20 MG, 0 MG, 40 MG QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED *Amebicides* *Amebicides*** YODOXIN ORAL TABLET 2 QL QL PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 6

7 *Aminoglycosides* *Aminoglycosides*** neomycin sulfate oral tablet paromomycin sulfate oral capsule TOBI PODHALER INHALATION CAPSULE 4 PA; SP- tobramycin inhalation nebulization Tobi 4 PA; SP- solution *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** XELJANZ ORAL TABLET 4 PA; SP- XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR *Antirheumatic Antimetabolites*** RHEUMATREX ORAL TABLET 2.5 MG *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; SP- 4 PA; SP- 4 PA; SP- 4 PA; SP- 4 PA; SP- 4 PA; SP- 4 PA; SP- 4 PA; SP- PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 7

8 *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg *Gold Compounds*** CeleBREX ST; QL RIDAURA ORAL CAPSULE 2 *Interleukin- Receptor Antagonist (Il-Ra)*** KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Interleukin-Beta Blockers*** ILARIS SUBCUTANEOUS SOLUTION RECONSTITUTED *Interleukin-6 Receptor Inhibitors*** ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Nonsteroidal Anti-Inflammatory Agent Combinations*** diclofenac-misoprostol oral tablet Arthrotec delayed release *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hour diclofenac sodium oral tablet delayed release etodolac er oral tablet extended release 24 hour etodolac oral capsule etodolac oral tablet Lodine fenoprofen calcium oral capsule 400 mg Fenortho fenoprofen calcium oral tablet flurbiprofen oral tablet ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION 4 PA; SP- 4 PA; SP- 4 PA; SP- PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 8

9 indomethacin er oral capsule extended release indomethacin oral capsule ketoprofen er oral capsule extended release 24 hour ketoprofen oral capsule ketorolac tromethamine oral tablet QL meclofenamate sodium oral capsule mefenamic acid oral capsule Ponstel meloxicam oral suspension meloxicam oral tablet Mobic nabumetone oral tablet naproxen dr oral tablet delayed release EC-Naprosyn naproxen oral suspension Naprosyn naproxen oral tablet Naprosyn naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg Anaprox DS oxaprozin oral tablet Daypro piroxicam oral capsule Feldene sulindac oral tablet tolmetin sodium oral capsule tolmetin sodium oral tablet *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet Arava QL *Selective Costimulation Modulators*** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- INJECTOR ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Soluble Tumor Necrosis Factor Receptor Agents*** 4 PA; SP- 4 PA; SP- ENBREL SUBCUTANEOUS KIT 4 PA; SP- PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 9

10 ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR *Analgesics - Nonnarcotic* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet mg butalbital-aspirin-caffeine oral capsule *Salicylate Combinations*** choline & mag trisalicylate oral tablet 000 mg choline-mag trisalicylate oral liquid *Salicylates*** aspirin adult low strength oral tablet delayed release aspirin low dose oral tablet chewable aspirin oral tablet aspirin oral tablet delayed release 25 mg Tencon Esgic Esgic Fiorinal Bayer Aspirin EC Low Dose 4 PA; SP- 4 PA; SP- $0 AL Bayer Low Dose $0 AL Bayer Advanced Aspirin Reg St $0 AL EcPirin $0 AL diflunisal oral tablet salsalate oral tablet Disalcid ST JOSEPH ADULT ORAL TABLET CHEWABLE $0 AL PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 0

11 *Analgesics - Opioid* *Codeine Combinations*** acetaminophen-codeine oral solution acetaminophen-codeine oral tablet 00-5 mg acetaminophen-codeine oral tablet 00-0 mg acetaminophen-codeine oral tablet mg butalbital-apap-caff-cod oral capsule mg Tylenol with Codeine # Tylenol with Codeine #4 butalbital-asa-caff-codeine oral capsule Fiorinal/Codeine # *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution mg/5ml hydrocodone-acetaminophen oral tablet 0-00 mg hydrocodone-acetaminophen oral tablet 0-25 mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet 5-00 mg hydrocodone-acetaminophen oral tablet 5-25 mg, mg hydrocodone-acetaminophen oral tablet mg hydrocodone-ibuprofen oral tablet mg hydrocodone-ibuprofen oral tablet mg hydrocodone-ibuprofen oral tablet mg Hycet QL QL QL Vicodin HP QL Norco QL Verdrocet QL Vicodin QL Lortab QL Vicodin ES QL Xylon QL Ibudone QL Vicoprofen PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206

12 *Opioid Agonists*** ABSTRAL SUBLINGUAL TABLET SUBLINGUAL PA codeine sulfate oral tablet QL EMBEDA ORAL CAPSULE EXTENDED RELEASE PA fentanyl citrate buccal lollipop Actiq PA fentanyl transdermal patch 72 hr 00 mcg/hr fentanyl transdermal patch 72 hr 2 mcg/hr fentanyl transdermal patch 72 hr 25 mcg/hr fentanyl transdermal patch 72 hr 50 mcg/hr fentanyl transdermal patch 72 hr 75 mcg/hr FENTORA BUCCAL TABLET 00 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Duragesic-00 QL Duragesic-2 QL Duragesic-25 QL Duragesic-50 QL Duragesic-75 QL PA hydromorphone hcl er oral Exalgo PA; QL hydromorphone hcl oral liquid Dilaudid hydromorphone hcl oral tablet Dilaudid QL KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG, 40 MG levorphanol tartrate oral tablet QL meperidine hcl oral solution QL meperidine hcl oral tablet Demerol QL methadone hcl oral concentrate Methadose methadone hcl oral solution methadone hcl oral tablet Dolophine QL methadone hcl oral tablet soluble Methadose QL morphine sulfate (concentrate) oral solution 20 mg/ml QL PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 2

13 morphine sulfate er beads oral capsule extended release 24 hour morphine sulfate er oral capsule extended release 24 hour morphine sulfate er oral tablet extended release PA; QL Kadian QL MS Contin morphine sulfate oral solution QL morphine sulfate oral tablet QL NUCYNTA ER ORAL TABLET EXTENDED RELEASE 2 HOUR NUCYNTA ORAL TABLET 00 MG, 50 MG, 75 MG QL QL OPANA ER ORAL PA; QL oxycodone hcl er oral 0 mg, 20 mg, 40 mg, 80 mg OxyCONTIN QL oxycodone hcl oral capsule QL oxycodone hcl oral concentrate 00 mg/5ml oxycodone hcl oral solution oxycodone hcl oral tablet QL OXYCONTIN ORAL 0 MG, 5 MG, 20 MG, 0 MG, 40 MG, 60 MG oxymorphone hcl er oral tablet extended release 2 hour oxymorphone hcl oral tablet Opana tramadol hcl er oral tablet extended release 24 hour 2 QL QL QL tramadol hcl oral tablet Ultram QL *Opioid Combinations*** oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet 0-25 mg, 5-25 mg, mg oxycodone-acetaminophen oral tablet mg Endocet QL Percocet QL PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206

14 oxycodone-aspirin oral tablet mg oxycodone-ibuprofen oral tablet *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg QL butorphanol tartrate nasal solution QL BUTRANS TRANSDERMAL PATCH WEEKLY pentazocine-naloxone hcl oral tablet SUBOXONE SUBLINGUAL FILM 2- MG, MG, 4- MG, 8-2 MG *Tramadol Combinations*** PA; QL PA; QL tramadol-acetaminophen oral tablet Ultracet QL *Androgens-Anabolic* *Anabolic Steroids*** ANADROL-50 ORAL TABLET PA oxandrolone oral tablet Oxandrin PA *Androgens*** ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR ANDROGEL PUMP TRANSDERMAL GEL 2.5 MG/ACT (%) ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (.62%) ANDROGEL TRANSDERMAL GEL MG/.25GM (.62%), 40.5 MG/2.5GM (.62%) 2 PA 2 PA 2 PA 2 PA PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 4

15 ANDROGEL TRANSDERMAL GEL 50 MG/5GM (%) ANDROID ORAL CAPSULE ANDROXY ORAL TABLET 2 2 PA AXIRON TRANSDERMAL SOLUTION 2 PA danazol oral capsule METHITEST ORAL TABLET testosterone cypionate intramuscular solution testosterone enanthate intramuscular solution testosterone transdermal gel 0 mg/act (2%) testosterone transdermal gel 2.5 mg/act (%) testosterone transdermal gel 25 mg/2.5gm (%), 50 mg/5gm (%) *Anorectal Agents* *Intrarectal Steroids*** Depo-Testosterone Fortesta PA Vogelxo Pump PA AndroGel PA CORTIFOAM FOAM 2 hydrocortisone enema Cortenema *Nitrate Vasodilating Agents*** RECTIV OINTMENT *Rectal Anesthetic/Steroids*** ANALPRAM-HC LOTION -2.5 % hydrocortisone ace-pramoxine cream Analpram-HC hydrocortisone ace-pramoxine kit PROCTOFOAM HC FOAM 2 *Rectal Steroids*** hydrocortisone acetate suppository Hemmorex-HC hydrocortisone cream 2.5 % ProctoCare-HC PROCTO-PAK CREAM PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 5

16 *Anthelmintics* *Anthelmintics*** ALBENZA ORAL TABLET BILTRICIDE ORAL TABLET ivermectin oral tablet Stromectol *Antianginal Agents* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 2 HOUR *Nitrates*** DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE ISORDIL TITRADOSE ORAL TABLET 40 MG isosorbide dinitrate er oral tablet extended release isosorbide dinitrate oral tablet isosorbide mononitrate er oral tablet extended release 24 hour isosorbide mononitrate oral tablet NITRO-BID TRANSDERMAL OINTMENT NITRO-DUR TRANSDERMAL PATCH 24 HR 0. MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended release nitroglycerin sublingual tablet sublingual nitroglycerin transdermal patch 24 hr nitroglycerin translingual aerosol, solution Nitro-Time Nitrostat Nitro-Dur NitroMist nitroglycerin translingual solution Nitrolingual 2 PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 6

17 *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule meprobamate oral tablet *Benzodiazepines*** ALPRAZOLAM INTENSOL ORAL CONCENTRATE alprazolam oral tablet 0.25 mg, 0.5 mg, mg, 2 mg 2 QL Xanax QL alprazolam oral tablet dispersible chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet QL diazepam oral concentrate Diazepam Intensol QL diazepam oral solution mg/ml QL diazepam oral tablet Valium QL lorazepam oral concentrate LORazepam Intensol QL lorazepam oral tablet Ativan QL oxazepam oral capsule QL *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule NORPACE CR ORAL CAPSULE EXTENDED RELEASE 2 HOUR quinidine gluconate er oral tablet extended release quinidine sulfate er oral tablet extended release Norpace quinidine sulfate oral tablet PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 7

18 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule *Antiarrhythmics Type I-C*** flecainide acetate oral tablet propafenone hcl er oral capsule extended release 2 hour Rythmol SR propafenone hcl oral tablet *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet Pacerone NTI dofetilide oral capsule Tikosyn MULTAQ ORAL TABLET *Antiasthmatic And Bronchodilator Agents* *5-Lipoxygenase Inhibitors*** ZYFLO CR ORAL TABLET EXTENDED RELEASE 2 HOUR *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED ADVAIR HFA INHALATION AEROSOL COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION DULERA INHALATION AEROSOL ipratropium-albuterol inhalation solution STIOLTO RESPIMAT INHALATION AEROSOL, SOLUTION SYMBICORT INHALATION AEROSOL *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 2 PR 2 PR 2 PR PR 2 PR 4 PA; SP- PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 8

19 *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 2 hour albuterol sulfate inhalation nebulization solution VoSpire ER albuterol sulfate oral syrup albuterol sulfate oral tablet ARCAPTA NEOHALER INHALATION CAPSULE BROVANA INHALATION NEBULIZATION SOLUTION FORADIL AEROLIZER INHALATION CAPSULE levalbuterol hcl inhalation nebulization solution Xopenex PR 2 PR metaproterenol sulfate oral syrup PR metaproterenol sulfate oral tablet PR PERFOROMIST INHALATION NEBULIZATION SOLUTION PROAIR HFA INHALATION AEROSOL, SOLUTION PROAIR RESPICLICK INHALATION AEROSOL POWDER, BREATH ACTIVATED PROVENTIL HFA INHALATION AEROSOL, SOLUTION SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED PR terbutaline sulfate oral tablet PR VENTOLIN HFA INHALATION AEROSOL, SOLUTION 2 PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 9

20 XOPENEX HFA INHALATION AEROSOL *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION ipratropium bromide inhalation solution SPIRIVA HANDIHALER INHALATION CAPSULE SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Receptor Antagonists*** 2 PR 2 PR 2 PR montelukast sodium oral packet Singulair PR montelukast sodium oral tablet Singulair PR montelukast sodium oral tablet chewable Singulair PR zafirlukast oral tablet Accolate PR *Selective Phosphodiesterase 4 (Pde4) Inhibitors*** DALIRESP ORAL TABLET PA *Steroid Inhalants*** ALVESCO INHALATION AEROSOL, SOLUTION ASMANEX 20 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX 4 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX 0 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 0 MCG/INH, 220 MCG/INH QL 2 PR; QL 2 PR; QL 2 PR; QL PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 20

21 ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED FLOVENT HFA INHALATION AEROSOL 0 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED PULMICORT INHALATION SUSPENSION MG/2ML QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthine-Expectorants*** 2 PR; QL 2 PR; QL Pulmicort PR; QL DIFIL-G FORTE ORAL LIQUID *Xanthines*** ELIXOPHYLLIN ORAL ELIXIR 2 LUFYLLIN ORAL TABLET 400 MG THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR theophylline er oral tablet extended release 2 hour theophylline er oral tablet extended release 24 hour 2 PR; QL 2 PR; QL 2 PR; QL 2 PR; QL 2 PR; QL 2 NTI; PR NTI; PR theophylline oral solution NTI; PR PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 2

22 *Anticoagulants* *Coumarin Anticoagulants*** warfarin sodium oral tablet Jantoven NTI; PR *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2 XARELTO ORAL TABLET 0 MG, 5 MG XARELTO ORAL TABLET 20 MG 2 XARELTO STARTER PACK ORAL 2 *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 000 unit/ml, 0000 unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution *Low Molecular Weight Heparins*** enoxaparin sodium injection solution enoxaparin sodium subcutaneous solution FRAGMIN SUBCUTANEOUS SOLUTION *Synthetic Heparinoid-Like Agents*** 2 QL Lovenox 4 SP-; QL Lovenox 4 SP-; QL 4 PA; SP-; QL fondaparinux sodium Arixtra 4 SP-; QL subcutaneous solution *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE 50 MG, 75 MG *Anticonvulsants* *Ampa Glutamate Receptor Antagonists*** 2 QL FYCOMPA ORAL TABLET PA *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet KlonoPIN PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 22

23 diazepam gel Diastat Pediatric ONFI ORAL SUSPENSION ONFI ORAL TABLET 0 MG, 20 MG *Anticonvulsants - Misc.*** BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine er oral capsule extended release 2 hour carbamazepine er oral tablet extended release 2 hour Carbatrol NTI TEGretol-XR NTI carbamazepine oral suspension TEGretol NTI carbamazepine oral tablet Epitol NTI carbamazepine oral tablet chewable NTI gabapentin oral capsule Neurontin gabapentin oral solution 250 mg/5ml Neurontin gabapentin oral tablet Neurontin LAMICTAL ODT ORAL KIT 2 LAMICTAL STARTER ORAL KIT 2 LAMICTAL XR ORAL KIT 2 lamotrigine er oral tablet extended release 24 hour LaMICtal XR NTI lamotrigine oral tablet LaMICtal NTI lamotrigine oral tablet chewable LaMICtal NTI lamotrigine oral tablet dispersible LaMICtal ODT NTI levetiracetam er oral tablet extended release 24 hour Keppra XR levetiracetam oral solution Keppra levetiracetam oral tablet Keppra LYRICA ORAL CAPSULE 2 LYRICA ORAL SOLUTION 2 oxcarbazepine oral suspension Trileptal NTI oxcarbazepine oral tablet Trileptal NTI POTIGA ORAL TABLET PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 2

24 primidone oral tablet Mysoline topiramate oral capsule sprinkle Topamax Sprinkle NTI topiramate oral tablet Topamax NTI VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET zonisamide oral capsule Zonegran NTI *Carbamates*** felbamate oral suspension Felbatol felbamate oral tablet Felbatol *Gaba Modulators*** GABITRIL ORAL TABLET 2 MG, 6 MG SABRIL ORAL PACKET 4 PA; SP- SABRIL ORAL TABLET 4 PA; SP- tiagabine hcl oral tablet Gabitril *Hydantoins*** DILANTIN ORAL CAPSULE 0 MG 2 PEGANONE ORAL TABLET phenytoin oral suspension 25 mg/5ml Dilantin NTI phenytoin oral tablet chewable Phenytoin Infatabs NTI phenytoin sodium extended oral capsule 00 mg *Succinimides*** Dilantin NTI CELONTIN ORAL CAPSULE ethosuximide oral capsule Zarontin NTI ethosuximide oral solution Zarontin NTI *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral capsule sprinkle Depakote ER NTI 2 NTI PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 24

25 divalproex sodium oral tablet delayed release STAVZOR ORAL CAPSULE DELAYED RELEASE Depakote NTI valproic acid oral capsule Depakene NTI valproic acid oral syrup Depakene NTI *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet Remeron mirtazapine oral tablet dispersible Remeron SolTab *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 2 hour bupropion hcl er (xl) oral tablet extended release 24 hour Wellbutrin SR Wellbutrin XL bupropion hcl oral tablet FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR maprotiline hcl oral tablet *Modified Cyclics*** nefazodone hcl oral tablet OLEPTRO ORAL TABLET EXTENDED RELEASE 24 HOUR trazodone hcl oral tablet TRINTELLIX ORAL TABLET PA; ST VIIBRYD ORAL TABLET PA; QL VIIBRYD STARTER PACK ORAL KIT PA *Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL PATCH 24 HR MARPLAN ORAL TABLET phenelzine sulfate oral tablet Nardil tranylcypromine sulfate oral tablet Parnate 2 PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 25

26 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution citalopram hydrobromide oral tablet CeleXA escitalopram oxalate oral solution Lexapro escitalopram oxalate oral tablet Lexapro fluoxetine hcl oral capsule PROzac fluoxetine hcl oral capsule delayed release PROzac Weekly fluoxetine hcl oral solution fluoxetine hcl oral tablet 0 mg, 20 mg FLUOXETINE HCL ORAL TABLET 60 MG fluvoxamine maleate er oral capsule extended release 24 hour fluvoxamine maleate oral tablet paroxetine hcl er oral tablet extended release 24 hour Paxil CR paroxetine hcl oral tablet Paxil PAXIL ORAL SUSPENSION sertraline hcl oral concentrate Zoloft sertraline hcl oral tablet Zoloft *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20 mg, 0 mg, 60 mg PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR venlafaxine hcl er oral capsule extended release 24 hour venlafaxine hcl er oral tablet extended release 24 hour Cymbalta Effexor XR venlafaxine hcl oral tablet PA; ST PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 26

27 *Tricyclic Agents*** amitriptyline hcl oral tablet 0 mg, 50 mg amitriptyline hcl oral tablet 00 mg, 50 mg, 75 mg QL amitriptyline hcl oral tablet 25 mg Elavil QL amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 0 mg, 25 mg desipramine hcl oral tablet 00 mg, 50 mg, 50 mg, 75 mg doxepin hcl oral capsule 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg QL Anafranil QL Norpramin QL QL QL doxepin hcl oral concentrate QL imipramine hcl oral tablet Tofranil QL imipramine pamoate oral capsule QL nortriptyline hcl oral capsule 0 mg, 25 mg, 50 mg, 75 mg Pamelor QL nortriptyline hcl oral solution QL protriptyline hcl oral tablet QL *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet Precose PR miglitol oral tablet Glyset *Antidiabetic - Amylin Analogs*** SYMLINPEN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR ST; PR ST; PR PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 27

28 *Biguanides*** metformin hcl er (osm) oral tablet extended release 24 hour metformin hcl er oral tablet extended release 24 hour Fortamet PR Glucophage XR PR metformin hcl oral tablet Glucophage PR RIOMET ORAL SOLUTION *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION 2 *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 2 TRADJENTA ORAL TABLET *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 2 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR JENTADUETO ORAL TABLET JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR *Dopamine Receptor Agonists - Ergot Derivatives*** CYCLOSET ORAL TABLET *Human Insulin*** APIDRA INJECTION SOLUTION 2 PR APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR PR 2 PR PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 28

29 HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION HUMALOG SUBCUTANEOUS SOLUTION HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE HUMULIN 70/0 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR HUMULIN 70/0 SUBCUTANEOUS SUSPENSION HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR HUMULIN N SUBCUTANEOUS SUSPENSION 2 PR 2 PR 2 PR 2 PR 2 PR 2 PR 2 PR 2 PR 2 PR 2 PR HUMULIN R INJECTION SOLUTION 2 PR HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR LANTUS SUBCUTANEOUS SOLUTION LEVEMIR SUBCUTANEOUS SOLUTION NOVOLIN 70/0 RELION SUBCUTANEOUS SUSPENSION 2 PR 2 PR 2 PR 2 PR 2 PR PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 29

30 NOVOLIN N SUBCUTANEOUS SUSPENSION 2 PR NOVOLIN R INJECTION SOLUTION 2 PR NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR NOVOLOG MIX 70/0 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR NOVOLOG MIX 70/0 SUBCUTANEOUS SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE NOVOLOG SUBCUTANEOUS SOLUTION TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR *Incretin Mimetic Agents (Glp- Receptor Agonists)*** BYDUREON SUBCUTANEOUS PEN- INJECTOR BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED BYETTA 0 MCG PEN SUBCUTANEOUS SOLUTION BYETTA 0 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 2 PR 2 PR 2 PR 2 PR 2 PR 2 2 PA; ST; PR PA; ST; PR PA; ST PA; ST PA; ST PA; ST PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 0

31 TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR VICTOZA SUBCUTANEOUS SOLUTION VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR *Meglitinide Analogues*** 2 PA; ST; PR; QL 2 PR 2 PA; ST; PR nateglinide oral tablet Starlix PR repaglinide oral tablet Prandin PR *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA ORAL TABLET 2 PA JARDIANCE ORAL TABLET 2 PA *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet PR glyburide-metformin oral tablet PR *Sulfonylureas*** chlorpropamide oral tablet PR glimepiride oral tablet Amaryl PR glipizide er oral tablet extended release 24 hour Glucotrol XL PR glipizide oral tablet Glucotrol PR glyburide micronized oral tablet Glynase PR glyburide oral tablet PR tolazamide oral tablet PR tolbutamide oral tablet *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral Duetact PR tablet *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet *Thiazolidinediones*** Actoplus Met PR AVANDIA ORAL TABLET PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206

32 pioglitazone hcl oral tablet Actos PR *Antidiarrheals* *Antidiarrheal - Chloride Channel Antagonists*** FULYZAQ ORAL TABLET DELAYED RELEASE *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule Imodium A-D loperamide hcl oral tablet Loperamide A-D MOTOFEN ORAL TABLET opium oral tincture opium tincture (paregoric) oral tincture *Antidotes* *Antidotes - Chelating Agents*** 4 PA; SP- CHEMET ORAL CAPSULE PA EXJADE ORAL TABLET SOLUBLE 4 PA; SP- FERRIPROX ORAL SOLUTION 4 PA; SP-2 FERRIPROX ORAL TABLET 4 PA; SP-2 JADENU ORAL TABLET 4 PA; SP- *Antidotes*** VISTOGARD ORAL PACKET 4 SP- *Opioid Antagonists*** naloxone hcl injection solution 0.4 mg/ml naltrexone hcl oral tablet QL NARCAN NASAL LIQUID 2 QL VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 4 PA; SP- PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 2

33 *Antiemetics* *5-Ht Receptor Antagonists*** ANZEMET ORAL TABLET granisetron hcl oral tablet QL ondansetron hcl oral solution Zofran ondansetron hcl oral tablet Zofran QL ondansetron oral tablet dispersible Zofran ODT QL SANCUSO TRANSDERMAL PATCH QL ZUPLENZ ORAL FILM PA; QL *Antiemetics - Anticholinergic*** meclizine hcl oral tablet meclizine hcl oral tablet chewable trimethobenzamide hcl oral capsule Tigan *Antiemetics - Miscellaneous*** CESAMET ORAL CAPSULE dronabinol oral capsule Marinol QL *Substance P/Neurokinin (Nk) Receptor Antagonists*** EMEND ORAL CAPSULE 25 MG, 40 MG, 80 & 25 MG, 80 MG 2 QL VARUBI ORAL TABLET PA; ST; QL *Antifungals* *Antifungals*** BIO-STATIN ORAL CAPSULE 2 flucytosine oral capsule Ancobon griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet Gris-PEG LAMISIL ORAL PACKET nystatin oral powder nystatin oral tablet PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206

34 terbinafine hcl oral tablet LamISIL *Imidazoles*** ketoconazole oral tablet *Triazoles*** CRESEMBA ORAL CAPSULE PA fluconazole oral suspension reconstituted Diflucan fluconazole oral tablet Diflucan itraconazole oral capsule Sporanox NOXAFIL ORAL SUSPENSION PA NOXAFIL ORAL TABLET DELAYED RELEASE SPORANOX ORAL SOLUTION 2 voriconazole oral suspension reconstituted PA Vfend PA voriconazole oral tablet Vfend *Antihistamines* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable *Antihistamines - Ethanolamines*** carbinoxamine maleate oral solution Arbinoxa carbinoxamine maleate oral tablet Arbinoxa clemastine fumarate oral tablet 2.68 mg *Antihistamines - Non-Sedating*** CLARINEX ORAL SYRUP 2 desloratadine oral tablet Clarinex desloratadine oral tablet dispersible levocetirizine dihydrochloride oral solution levocetirizine dihydrochloride oral tablet Xyzal Xyzal PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 4

35 *Antihistamines - Phenothiazines*** promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl suppository Promethegan *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup cyproheptadine hcl oral tablet *Antihyperlipidemics* *Antihyperlipidemics - Misc.*** omega--acid ethyl esters oral capsule Lovaza VASCEPA ORAL CAPSULE GM *Bile Acid Sequestrants*** cholestyramine light oral packet Prevalite cholestyramine light oral powder Prevalite cholestyramine oral packet Questran PR cholestyramine oral powder Questran PR colestipol hcl oral granules Colestid Flavored PR colestipol hcl oral packet Colestid PR colestipol hcl oral tablet Colestid PR WELCHOL ORAL PACKET WELCHOL ORAL TABLET *Fibric Acid Derivatives*** fenofibrate micronized oral capsule Lofibra PR fenofibrate oral capsule Lipofen PR fenofibrate oral tablet 20 mg Fenoglide fenofibrate oral tablet 45 mg, 48 mg fenofibrate oral tablet 60 mg, 54 mg fenofibric acid oral capsule delayed release Tricor PR Lofibra PR Trilipix fenofibric acid oral tablet Fibricor PR PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 5

36 FENOGLIDE ORAL TABLET 40 MG gemfibrozil oral tablet Lopid PR *Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet Lipitor PR fluvastatin sodium oral capsule Lescol PR LIVALO ORAL TABLET PA; ST lovastatin oral tablet PR pravastatin sodium oral tablet PR rosuvastatin calcium oral tablet Crestor simvastatin oral tablet Zocor PR *Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 2 *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release *Antihypertensives* Niaspan PR *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule PR trandolapril-verapamil hcl er oral Tarka PR tablet extended release *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet PR PR Vaseretic PR fosinopril sodium-hctz oral tablet PR lisinopril-hydrochlorothiazide oral tablet moexipril-hydrochlorothiazide oral tablet Zestoretic PR PR PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 6

37 quinapril-hydrochlorothiazide oral tablet *Ace Inhibitors*** Accuretic PR benazepril hcl oral tablet Lotensin PR captopril oral tablet PR enalapril maleate oral tablet Vasotec PR fosinopril sodium oral tablet PR lisinopril oral tablet Prinivil PR moexipril hcl oral tablet PR perindopril erbumine oral tablet PR quinapril hcl oral tablet Accupril PR ramipril oral capsule Altace PR trandolapril oral tablet Mavik PR *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** CLORPRES ORAL TABLET PR methyldopa-hydrochlorothiazide oral tablet *Agents For Pheochromocytoma*** PR phenoxybenzamine hcl oral capsule Dibenzyline PA *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet Exforge PR amlodipine-olmesartan oral tablet Azor telmisartan-amlodipine oral tablet Twynsta PR *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** BENICAR HCT ORAL TABLET 2 PR candesartan cilexetil-hctz oral tablet Atacand HCT PR EDARBYCLOR ORAL TABLET irbesartan-hydrochlorothiazide oral tablet Avalide PR losartan potassium-hctz oral tablet Hyzaar PR PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 7

38 olmesartan medoxomil-hctz oral tablet Benicar HCT telmisartan-hctz oral tablet Micardis HCT PR valsartan-hydrochlorothiazide oral Diovan HCT PR tablet *Angiotensin Ii Receptor Antagonists*** BENICAR ORAL TABLET 2 PR candesartan cilexetil oral tablet Atacand PR EDARBI ORAL TABLET eprosartan mesylate oral tablet PR irbesartan oral tablet Avapro PR losartan potassium oral tablet Cozaar PR olmesartan medoxomil oral tablet Benicar telmisartan oral tablet Micardis PR valsartan oral tablet Diovan PR *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet olmesartan-amlodipine-hctz oral tablet Exforge HCT PR Tribenzor TRIBENZOR ORAL TABLET 2 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet Catapres PR clonidine hcl transdermal patch weekly Catapres-TTS- PR guanfacine hcl oral tablet Tenex PR methyldopa oral tablet PR *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet Cardura prazosin hcl oral capsule Minipress terazosin hcl oral capsule *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 00 PR PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 8

39 bisoprolol-hydrochlorothiazide oral tablet DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR metoprolol-hydrochlorothiazide oral tablet nadolol-bendroflumethiazide oral tablet Ziac PR PR Corzide PR propranolol-hctz oral tablet PR *Direct Renin Inhibitors*** TEKTURNA ORAL TABLET *Reserpine*** reserpine oral tablet PR *Selective Aldosterone Receptor Antagonists (Saras)*** eplerenone oral tablet Inspra PR *Vasodilators*** hydralazine hcl oral tablet PR minoxidil oral tablet PR *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** CAYSTON INHALATION SOLUTION RECONSTITUTED FIRST-VANCOMYCIN 50 ORAL SOLUTION FLAGYL ER ORAL TABLET EXTENDED RELEASE 24 HOUR metronidazole oral capsule Flagyl metronidazole oral tablet Flagyl NEBUPENT INHALATION SOLUTION RECONSTITUTED PENTAM INJECTION SOLUTION RECONSTITUTED PRIMSOL ORAL SOLUTION 2 tinidazole oral tablet Tindamax 4 PA; SP- 2 PA; ST PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 9

40 trimethoprim oral tablet vancomycin hcl oral capsule Vancocin HCl PA; ST XIFAXAN ORAL TABLET 2 PA *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral tablet mg *Antiprotozoal Agents*** ALINIA ORAL SUSPENSION RECONSTITUTED Bactrim ALINIA ORAL TABLET atovaquone oral suspension Mepron *Ketolides*** KETEK ORAL TABLET PA *Leprostatics*** dapsone oral tablet *Lincosamides*** clindamycin hcl oral capsule Cleocin clindamycin palmitate hcl oral solution reconstituted *Oxazolidinones*** Cleocin linezolid oral tablet Zyvox PA ZYVOX ORAL SUSPENSION RECONSTITUTED *Antimalarials* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet Malarone COARTEM ORAL TABLET *Antimalarials*** chloroquine phosphate oral tablet DARAPRIM ORAL TABLET 2 hydroxychloroquine sulfate oral tablet Plaquenil PA PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 40

41 mefloquine hcl oral tablet PRIMAQUINE PHOSPHATE ORAL TABLET quinine sulfate oral capsule Qualaquin *Antimyasthenic Agents* *Antimyasthenic Agents*** GUANIDINE HCL ORAL TABLET MESTINON ORAL SYRUP 2 MESTINON ORAL TABLET EXTENDED RELEASE pyridostigmine bromide oral tablet Mestinon *Antimycobacterial Agents* *Anti Tb Combinations*** RIFAMATE ORAL CAPSULE RIFATER ORAL TABLET 2 *Antimycobacterial Agents*** cycloserine oral capsule Seromycin ethambutol hcl oral tablet Myambutol isoniazid oral syrup isoniazid oral tablet PASER ORAL PACKET PRIFTIN ORAL TABLET pyrazinamide oral tablet rifabutin oral capsule Mycobutin rifampin oral capsule Rifadin TRECATOR ORAL TABLET 2 *Antineoplastic - Bcl-2 Inhibitors*** *Antineoplastic - Bcl-2 Inhibitors*** VENCLEXTA ORAL TABLET 4 PA VENCLEXTA STARTING PACK ORAL PA PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 4

42 *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** HEXALEN ORAL CAPSULE 2 MYLERAN ORAL TABLET 2 *Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 4 PA; SP- *Antiadrenals*** LYSODREN ORAL TABLET 2 *Antiandrogens*** bicalutamide oral tablet Casodex flutamide oral capsule nilutamide oral tablet Nilandron XTANDI ORAL CAPSULE 4 PA; SP- *Antiestrogens*** FARESTON ORAL TABLET 2 tamoxifen citrate oral tablet $0 PR; AL *Antimetabolites*** capecitabine oral tablet Xeloda 4 PA; SP- mercaptopurine oral tablet methotrexate oral tablet methotrexate sodium (pf) injection solution 50 mg/2ml methotrexate sodium injection solution 25 mg/ml TABLOID ORAL TABLET TREXALL ORAL TABLET *Antineoplastic - Braf Kinase Inhibitors*** TAFINLAR ORAL CAPSULE 4 PA; SP- ZELBORAF ORAL TABLET 4 PA; SP- *Antineoplastic - Hedgehog Pathway Inhibitors*** ERIVEDGE ORAL CAPSULE 4 PA; SP- ODOMZO ORAL CAPSULE 4 PA; SP- PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 42

43 *Antineoplastic - Histone Deacetylase Inhibitors*** FARYDAK ORAL CAPSULE 4 PA; SP- ZOLINZA ORAL CAPSULE 4 PA; SP- *Antineoplastic - Immunomodulators*** POMALYST ORAL CAPSULE 4 PA; SP- *Antineoplastic - Mek Inhibitors*** COTELLIC ORAL TABLET 4 PA; SP- MEKINIST ORAL TABLET 4 PA; SP- *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR DISPERZ ORAL TABLET SOLUBLE 4 PA; SP- AFINITOR ORAL TABLET 4 PA; SP- *Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 4 PA; SP- STIVARGA ORAL TABLET 4 PA; SP- SUTENT ORAL CAPSULE 4 PA; SP- *Antineoplastic - Proteasome Inhibitors*** NINLARO ORAL CAPSULE 4 PA; SP- *Antineoplastic - Tyrosine Kinase Inhibitors*** ALECENSA ORAL CAPSULE 4 PA; SP- BOSULIF ORAL TABLET 4 PA; SP- CABOMETYX ORAL TABLET 4 PA; SP- CAPRELSA ORAL TABLET 4 PA; SP- COMETRIQ (00 MG DAILY DOSE) ORAL KIT COMETRIQ (40 MG DAILY DOSE) ORAL KIT COMETRIQ (60 MG DAILY DOSE) ORAL KIT 4 PA; SP- 4 PA; SP- 4 PA; SP- GILOTRIF ORAL TABLET 4 PA; SP-2 GLEEVEC ORAL TABLET 4 PA; SP- ICLUSIG ORAL TABLET 4 PA; SP- imatinib mesylate oral tablet Gleevec 4 PA; SP- PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 4

44 IMBRUVICA ORAL CAPSULE 4 PA; SP- INLYTA ORAL TABLET 4 PA; SP- IRESSA ORAL TABLET 4 PA; SP-2 LENVIMA 0 MG DAILY DOSE ORAL 4 PA; SP- LENVIMA 4 MG DAILY DOSE ORAL 4 PA; SP- LENVIMA 8 MG DAILY DOSE ORAL 4 PA; SP- LENVIMA 20 MG DAILY DOSE ORAL 4 PA; SP- LENVIMA 24 MG DAILY DOSE ORAL 4 PA; SP- LENVIMA 8 MG DAILY DOSE ORAL 4 PA; SP- SPRYCEL ORAL TABLET 4 PA; SP- TAGRISSO ORAL TABLET 4 PA TARCEVA ORAL TABLET 4 PA; SP- TASIGNA ORAL CAPSULE 4 PA; SP- TYKERB ORAL TABLET 4 PA; SP- VOTRIENT ORAL TABLET 4 PA; SP- XALKORI ORAL CAPSULE 4 PA; SP- ZYKADIA ORAL CAPSULE 4 PA; SP- *Antineoplastic Combinations*** LONSURF ORAL TABLET 4 PA; SP- *Antineoplastics Misc.*** ACTIMMUNE SUBCUTANEOUS SOLUTION hydroxyurea oral capsule Hydrea MATULANE ORAL CAPSULE 2 *Aromatase Inhibitors*** anastrozole oral tablet Arimidex exemestane oral tablet Aromasin letrozole oral tablet Femara *Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE 2 *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 4 PA; SP- PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 44

45 *Imidazotetrazines*** temozolomide oral capsule Temodar 4 PA; SP- *Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 4 PA; SP- *Lhrh Analogs*** ELIGARD SUBCUTANEOUS KIT 4 PA; SP- LUPRON DEPOT INTRAMUSCULAR KIT *Mitotic Inhibitors*** etoposide oral capsule *Nitrogen Mustards*** ALKERAN ORAL TABLET 2 CYCLOPHOSPHAMIDE ORAL CAPSULE LEUKERAN ORAL TABLET 2 *Nitrosoureas*** lomustine oral capsule Gleostine *Progestins-Antineoplastic*** DEPO-PROVERA INTRAMUSCULAR SUSPENSION megestrol acetate oral suspension 40 mg/ml Megace Oral megestrol acetate oral tablet *Retinoids*** tretinoin oral capsule *Selective Retinoid X Receptor Agonists*** 4 PA; SP- TARGRETIN ORAL CAPSULE 4 PA; SP- *Topoisomerase I Inhibitors*** HYCAMTIN ORAL CAPSULE 4 PA; SP- *Urinary Tract Protective Agents*** MESNEX ORAL TABLET PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 45

46 *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet trihexyphenidyl hcl oral elixir trihexyphenidyl hcl oral tablet *Antiparkinson Dopaminergics*** amantadine hcl oral capsule amantadine hcl oral syrup amantadine hcl oral tablet bromocriptine mesylate oral capsule bromocriptine mesylate oral tablet Parlodel *Antiparkinson Monoamine Oxidase Inhibitors*** AZILECT ORAL TABLET selegiline hcl oral capsule Eldepryl selegiline hcl oral tablet *Central/Peripheral Comt Inhibitors*** tolcapone oral tablet Tasmar *Decarboxylase Inhibitors*** carbidopa oral tablet Lodosyn *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release Sinemet CR carbidopa-levodopa oral tablet Sinemet carbidopa-levodopa oral tablet dispersible carbidopa-levodopa-entacapone Stalevo 50 oral tablet *Nonergoline Dopamine Receptor Agonists*** APOKYN SUBCUTANEOUS SOLUTION NEUPRO TRANSDERMAL PATCH 24 HR 4 PA; SP- 2 PA PR=Preventive Drugs for HSA Plans SP-=MUST be Purchased at CVS Specialty Pharmacy Last Updated //206 46