WIXLIB

BNY Mellon High Deductible Health Plan (HDHP) - Health Savings Account (HSA)Preventive Therapy Drug List(11/01/18)ANTI-INFECTIVESANTIRETROVIRAL ASEISENTRESSISENTRESS DSUSTIVASYMFISYMFI STVIDEXVIDEX ECVIRACEPTVIRAMUNEVIRAMUNE ntovenARIXTRABEVYXXACOUMADINCOUMADIN SAXARELTOPLATELET AGGREGATION INHIBITORSaspirin 81 mgclopidogreldipyridamoledipyridamole L ounter (OTC) products require a prescription.Coverage may vary by plan.ANTICONVULSANTScarbamazepinecarbamazepine ext-relclonazepamdivalproex sodium delayed-reldivalproex sodium ext-relethosuximidefelbamatelamotriginelamotrigine ext-rellevetiracetamlevetiracetam n sodium extendedprimidonetiagabinetopiramatetopiramate ext-relvalproic CARBATROLCELONTINDEPAKENEDEPAKOTEDEPAKOTE ERDILANTINFELBATOLFYCOMPAGABITRILKEPPRAKEPPRA XRKLONOPINLAMICTALLAMICTAL XRMYSOLINEONFIOXTELLAR XRPEGANONEPHENYTEKQUDEXY RILEPTALTROKENDI XRVIMPATZARONTINZONEGRANPlease note: Human immunodeficiency virus (HIV) drugs are being added as of January 1, 2019. This list represents brand products in CAPS, branded generics in upperand 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 theirappearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list fromtime to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventiveby 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 legalrequirements. 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.106-32255A 113018

CARDIOVASCULAR CONDITIONS OTHERANTIARRHYTHMIC opafenonepropafenone ext-relsotalolsotalol AFPaceroneBETAPACEBETAPACE AFMULTAQNORPACENORPACE CRRYTHMOL IDEFIBRICORFLOLIPIDKYNAMROLESCOL N/QUESTRAN MAGORAL ANTIANGINAL AGENTSisosorbide dinitrateisosorbide dinitrate ext-relisosorbide mononitrateisosorbide mononitrate ext-relDILATRATE-SRISORDILCOMBINATION e/simvastatinCADUETVYTORINSL and chewable formulations are not includedon this list.DIAGNOSTIC AGENTS AND SUPPLIESBLOOD GLUCOSE MONITORS - ALLBLOOD GLUCOSE STRIPS - ALLCONTROL SOLUTIONSINSULIN SYRINGES, INFUSION SETS,AND NEEDLES - ALLKETONE BLOOD TEST STRIPS - ALLLANCETS, LANCET DEVICESOMNIPOD INSULIN INFUSION PUMPURINE TESTING STRIPS - ALLV-GO INSULIN DELIVERY DEVICETRANSDERMAL/TOPICAL ANTIANGINALAGENTSnitroglycerin transdermalMinitranNITRO-BIDNITRO-DURCORONARY ARTERY ric acidfenofibric acid delayed-relfluvastatinfluvastatin ext-relgemfibrozillovastatinniacin valiteALTOPREVDIABETESOver-the-Counter (OTC) products require a prescription.Coverage may vary by planINHALED DIABETES AGENTSAFREZZAINJECTABLE DIABETES AGENTSADLYXINADMELOGAPIDRABASAGLAR IBATRULICITYVICTOZAXULTOPHYOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.ORAL DIABETES eglipizide ext-relglipizide/metforminglyburideglyburide, micronizedglyburide/metforminmetforminmetformin linide/metformintolbutamideACTOPLUS METACTOPLUS MET XRACTOSAMARYLD-CARE DM2 KITDUETACTFARXIGAFORTAMETGLUCOPHAGEGLUCOPHAGE XRGLUCOTROLGLUCOTROL XLGLUMETZAGLYNASEGLYSETGLYXAMBIINVOKAMETINVOKAMET XRINVOKANAJANUMETJANUMET XRJANUVIAJARDIANCEJENTADUETOJENTADUETO XRKAZANOKOMBIGLYZE XRPlease note: Human immunodeficiency virus (HIV) drugs are being added as of January 1, 2019. This list represents brand products in CAPS, branded generics in upperand 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 theirappearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list fromtime to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventiveby 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 legalrequirements. 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.106-32255A 113018

DY XRTRADJENTAXIGDUO XRHEMATOLOGIC AGENTSADVATEADYNOVATEAFSTYLAALPHANATEALPHANINE ATE FSHEMOFIL MHUMATE-PIDELVIONIXINITYJIVIKOATE-DVIKOGENATE INE SDRECOMBINATERIXUBISTRETTENXYNTHAHYPERTENSIONACE INHIBITORS/ANGIOTENSIN II RECEPTORANTAGONISTS AND COMBINATION il/verapamil RILACCURETICALTACEATACANDATACAND HCTAVALIDEAVAPROBENICARBENICAR HCTCOZAARDIOVANDIOVAN HCTEDARBIEDARBYCLOREPANEDHYZAARLOTENSINLOTENSIN HCTLOTRELMICARDISMICARDIS STORETICZESTRILBETA-BLOCKERS AND hiazidecarvedilolcarvedilol phosphate ext-rellabetalolmetoprololmetoprolol succinate l ext-relpropranolol/hydrochlorothiazidetimolol maleateBYSTOLICBYVALSONCOREGCOREG CRCORGARDCORZIDEDUTOPROLINDERAL LAKAPSPARGOLEVATOLLOPRESSORLOPRESSOR HCTTENORETICTENORMINTOPROL-XLTRANDATEZIACCALCIUM CHANNEL BLOCKERS ANDCOMBINATION AGENTSamlodipinediltiazemdiltiazem ext-reldiltiazem XRfelodipine ext-relisradipinenicardipinenifedipinenifedipine ext-relnisoldipine ext-relverapamilverapamil ext-relAfeditab CRCartia XTDilt-XRMatzim LANifediac CCTaztia XTADALAT CCCALANCALAN SRCARDIZEMCARDIZEM CDCARDIZEM LAISOPTIN SRNORVASCPROCARDIAPROCARDIA XLSULARTIAZACVERELANPlease note: Human immunodeficiency virus (HIV) drugs are being added as of January 1, 2019. This list represents brand products in CAPS, branded generics in upperand 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 theirappearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list fromtime to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventiveby 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 legalrequirements. 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.106-32255A 113018

VERELAN DEMAXZIDEMICROZIDEOTHER ANTIHYPERTENSIVE onidine S-TTSEXFORGEEXFORGE HCTTEKTURNATEKTURNA HCTTRIBENZORTWYNSTAIMMUNIZING AGENTSALLERGENIC EXTRACTSALLERGENIC EXTRACTS - ALLIMMUNIZATIONSVACCINES - ALLMENTAL onbupropion xine ext-reldoxepinduloxetine delayed-relescitalopramfluoxetinefluoxetine delayed-relfluvoxamineimipramine HClimipramine ne HClparoxetine HCl ominetrazodonetrimipraminevenlafaxinevenlafaxine LAFAXINE EREFFEXOR XREMSAMFETZIMAFLUOXETINE 60 mgFORFIVO LORPARNATEPAXILPAXIL ELLIXVENLAFAXINE ERVIIBRYDWELLBUTRIN SRWELLBUTRIN ozapinefluphenazinefluphenazine decanoatehaloperidolloxapineolanzapineolanzapine orally disintegrating tabspaliperidoneperphenazinequetiapinequetiapine razineziprasidoneABILIFYABILIFY HALDOLHALDOL DECANOATEINVEGAINVEGA SUSTENNAINVEGA TRINZALATUDAREXULTIRISPERDALRISPERDAL CONSTASAPHRISSEROQUELSEROQUEL XRVERSACLOZVRAYLARZYPREXAZYPREXA ZYDISOBSESSIVE COMPULSIVE DISORDERfluvoxamine /salmonibandronateraloxifenerisedronatezoledronic acid 5 mg/100 mLACTONELATELVIABINOSTOBONIVABONIVA INJECTIONEVISTAFOSAMAXFOSAMAX PLUS DMIACALCIN NASAL SPRAYPROLIARECLASTPREVENTIVE CARE SERVICESAGENTS FOR CHEMICAL DEPENDENCYacamprosate calciumPlease note: Human immunodeficiency virus (HIV) drugs are being added as of January 1, 2019. This list represents brand products in CAPS, branded generics in upperand 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 theirappearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list fromtime to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventiveby 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 legalrequirements. 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.106-32255A 113018