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Preventive Therapy Drug List for PPO and PPO Savings Plan(08/01/22)ANTI-INFECTIVESANTIRETROVIRAL AGENTSemtricitabine/tenofovir disoproxilfumarate 200/300 mgAPRETUDEDESCOVYTRUVADA 200/300 MINLOVENOXPRADAXASAVAYSAXARELTOPLATELET AGGREGATION INHIBITORSaspirin 81 mgclopidogreldipyridamoledipyridamole ext-rel/aspirinprasugrelASPIRIN/OMEPRAZOLE TIVITYOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.ANTICONVULSANTScarbamazepinecarbamazepine ext-relclobazamclonazepamdivalproex sodium delayed-reldivalproex sodium amotrigine ext-rellevetiracetamlevetiracetam n sodium ramate ext-relvalproic CARBATROLCELONTINDEPAKOTEDEPAKOTE ERDIACOMITDILANTINELEPSIA KEPPRAKEPPRA XRKLONOPINLAMICTALLAMICTAL XRMYSOLINEONFIOXTELLAR XRPHENYTEKQUDEXY LTROKENDI XRVIMPATXCOPRIZARONTINZONEGRANZTALMYCARDIOVASCULAR CONDITIONS OTHERANTIARRHYTHMIC opafenonepropafenone ext-relsotalolsotalol AFPaceroneBETAPACEBETAPACE AFMULTAQNORPACENORPACE CRRYTHMOL SRSORINESOTYLIZETIKOSYNORAL ANTIANGINAL AGENTSisosorbide dinitrateisosorbide mononitrateisosorbide mononitrate ext-relISORDILSublingual and chewable formulations are not includedon this list.TRANSDERMAL/TOPICAL ANTIANGINALAGENTSnitroglycerin transdermalNITRO-BIDNITRO-DURCORONARY ARTERY ric acidfenofibric acid delayed-relfluvastatinfluvastatin ext-relgemfibrozilicosapent ethyllovastatinniacin valiteALTOPREVANTARACOLESTIDCRESTOREZALLOR SPRINKLEFENOFIBRIC ACIDFENOGLIDEFIBRICORFLOLIPIDLESCOL XLLIPITORLIPOFENPlease 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 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 document contains content that is copyrighted by CVS Caremark and reprinted with permission. CVS Caremark is a registered trademark of CVS Pharmacy, Inc.106-1038894B 080122
LIVALOLOPIDNIASPANPRALUENTQUESTRAN/QUESTRAN ZYPITAMAGCOMBINATION ORINDIABETESDIAGNOSTIC AGENTS AND SUPPLIESBLOOD GLUCOSE MONITORS - ALLBLOOD GLUCOSE STRIPS - ALLCONTROL SOLUTIONSINSULIN DELIVERY DEVICESINSULIN SYRINGES, INFUSION SETS,AND NEEDLES - ALLKETONE BLOOD TEST STRIPS - ALLLANCETS, LANCET DEVICESURINE TESTING STRIPS - ALLOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.INHALED DIABETES AGENTSAFREZZAINJECTABLE DIABETES AGENTSADLYXINADMELOGAPIDRABASAGLAR KWIKPENBYDUREON BCISEBYETTAFIASPHUMALOGHUMULININSULIN ASPARTINSULIN GLARGINEINSULIN TRULICITYVICTOZAXULTOPHYOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.ORAL DIABETES ptin/pioglitazoneglimepirideglipizideglipizide ext-relglipizide/metforminmetforminmetformin LUS METACTOPLUS MET XRACTOSAMARYLDUETACTFARXIGAGLUCOTROL XLGLUMETZAGLYXAMBIINVOKAMETINVOKAMET XRINVOKANAJANUMETJANUMET XRJANUVIAJARDIANCEJENTADUETOJENTADUETO XRKAZANOKOMBIGLYZE YNJARDY XRTRADJENTATRIJARDY XRXIGDUO XRHEMATOLOGIC AGENTSADVATEADYNOVATEAFSTYLAALPHANATEALPHANINE EIBAHEMOFIL MHUMATE-PIDELVIONIXINITYJIVIKOATEKOGENATE ISTRETTENXYNTHAHYPERTENSIONACE INHIBITORS/ANGIOTENSIN II RECEPTORANTAGONISTS AND COMBINATION rothiazidetrandolapriltrandolapril/verapamil ext-relvalsartanPlease 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 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 document contains content that is copyrighted by CVS Caremark and reprinted with permission. CVS Caremark is a registered trademark of CVS Pharmacy, Inc.106-1038894B 080122
CEATACANDATACAND HCTAVALIDEAVAPROBENICARBENICAR HCTCOZAARDIOVANDIOVAN HCTEDARBIEDARBYCLOREPANEDHYZAARLOTENSINLOTENSIN HCTLOTRELMICARDISMICARDIS ETICZESTRILBETA-BLOCKERS AND hiazidecarvedilolcarvedilol phosphate ext-rellabetalolmetoprololmetoprolol succinate lolpindololpropranololpropranolol ext-reltimolol maleateBYSTOLICCOREGCOREG CRCORGARDDUTOPROLINDERAL -XLTRANDATEZIACCALCIUM CHANNEL BLOCKERS ANDCOMBINATION AGENTSamlodipinediltiazemdiltiazem ext-reldiltiazem XRfelodipine ext-relisradipinenicardipinenifedipinenifedipine ext-relnisoldipine ext-relverapamilverapamil ext-relCartia XTDilt-XRMatzim LANifediac CCTaztia XTCALAN SRCARDIZEMCARDIZEM CDCARDIZEM LACONJUPRIISOPTIN SRKATERZIANORLIQVANORVASCPROCARDIA XLSULARTIAZACVERELANVERELAN DACTAZIDEDIURILMAXZIDETHALITONEOTHER ANTIHYPERTENSIVE misartanclonidineclonidine PRES-TTSEXFORGEEXFORGE HCTTEKTURNATEKTURNA HCTTRIBENZORIMMUNIZING AGENTSALLERGENIC EXTRACTSALLERGENIC EXTRACTS - ALLIMMUNIZATIONSVACCINES - ALLMENTAL onbupropion ext-relcitalopramdesipraminedesvenlafaxine ext-reldoxepinduloxetine delayed-relescitalopramfluoxetinefluoxetine delayed-relimipramine HClimipramine pamoatemirtazapinenortriptylineparoxetine HClparoxetine HCl ominetrazodonetrimipraminevenlafaxinevenlafaxine ALTADESVENLAFAXINE ERDRIZALMA SPRINKLEEFFEXOR XREMSAMFETZIMAFLUOXETINE 60 mgFORFIVO TEPAXILPAXIL CRPlease 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 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 document contains content that is copyrighted by CVS Caremark and reprinted with permission. CVS Caremark is a registered trademark of CVS Pharmacy, Inc.106-1038894B 080122
RYDWELLBUTRIN SRWELLBUTRIN omazineclozapinefluphenazinefluphenazine decanoatehaloperidolloxapineolanzapineolanzapine orally disintegrating tabspaliperidoneperphenazinequetiapinequetiapine razineziprasidoneABILIFYABILIFY MAINTENAABILIFY LDOL DECANOATEINVEGAINVEGA SUSTENNAINVEGA TRINZALATUDALYBALVIREXULTIRISPERDALRISPERDAL CONSTASAPHRISSECUADOSEROQUELSEROQUEL XRVERSACLOZVRAYLARZYPREXAZYPREXA ZYDISOBSESSIVE COMPULSIVE DISORDERclomipraminefluvoxaminefluvoxamine /salmonibandronateraloxifenerisedronatezoledronic acid 5 mg/100 mLACTONELATELVIABINOSTOBONIVABONIVA INJECTIONEVENITYEVISTAFORTEOFOSAMAXFOSAMAX PLUS DMIACALCIN NASAL SPRAYPROLIARECLASTTERIPARATIDETYMLOSPREVENTIVE CARE SERVICESAGENTS FOR CHEMICAL DEPENDENCYacamprosate calciumbuprenorphine sublingualbuprenorphine/naloxone ONE FILMVIVITROLZUBSOLVANTI-OBESITY AGENTSbenzphetaminediethylpropiondiethylpropion OMAIRAPHENDIMETRAZINE ERQSYMIASAXENDAWEGOVYXENICALBOWEL PREPARATIONSpeg MOPREPPLENVUSUPREPSUTABSMOKING DETERRENTSbupropion ext-relnicotine polacrilexnicotine transdermalvareniclineCHANTIXNICODERM CQNICORETTE GUMNICORETTE LOZENGENICOTROL INHALERNICOTROL NSOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.MISCELLANEOUScholecalciferol (D3)Over-the-Counter (OTC) products require a prescription.Coverage may vary by plan.RESPIRATORY DISORDERSRESPIRATORY AGENTSbudesonide suspensionbudesonide/formoterolcromolyn sodium nebulizer stzileuton ext-relWixela InhubACCOLATEADVAIRADVAIR HFAAIRDUO RESPICLICKALVESCOARNUITY ELLIPTAASMANEXASMANEX HFABREO ELLIPTACINQAIRDULERAFASENRAFLOVENT DISKUSFLOVENT HFAFLUTICASONE FUROATE/VILANTEROL ELLIPTAFLUTICASONE PROPIONATE HFANUCALAPULMICORTPULMICORT FLEXHALERQVAR REDIHALERPlease 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 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 document contains content that is copyrighted by CVS Caremark and reprinted with permission. CVS Caremark is a registered trademark of CVS Pharmacy, Inc.106-1038894B 080122
SINGULAIRSPIRIVA RESPIMAT 1.25 mcgSYMBICORTSYNAGISTEZSPIRETRELEGY ELLIPTAXOLAIRZYFLOSUPPLIESPEAK FLOW METERSSPACER DEVICESSPACER SUPPLIESVARIOUS CONDITIONSANTI-MALARIAL maquineARAKODAMALARONEPRIMAQUINEDENTAL CARIES PREVENTIONsodium fluoridePEDIATRIC MULTIVITAMINS WITHFLUORIDE - ALL MARKETEDPRODUCTSHEREDITARY ANGIOEDEMA SIVE AGENTScyclosporine capseverolimusmycophenolate mofetilmycophenolate sodium delayed-relsirolimustacrolimusGengrafASTAGRAF XLCELLCEPTENVARSUS RTRESSMULTIPLE SCLEROSIS AGENTSdimethyl fumarate UMERITYZEPOSIAWOMEN'S HEALTHANTIESTROGENStamoxifenSOLTAMOXAROMATASE OMASINFEMARACONTRACEPTIVESCONTRACEPTIVES - ALLPRESCRIPTION FORMULATIONSOver-the-Counter (OTC) emergency contraceptiveproducts require a prescription. Coverage may vary byplan.PRENATAL VITAMINSfolic acidPRENATAL VITAMINSOver-the-Counter (OTC) products require a prescription.Coverage may vary by plan.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 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 document contains content that is copyrighted by CVS Caremark and reprinted with permission. CVS Caremark is a registered trademark of CVS Pharmacy, Inc.106-1038894B 080122
fumarate 200/300 mg apretude descovy truvada 200/300 mg anticoagulants/ antiplatelets anticoagulants . dulera fasenra flovent diskus flovent hfa fluticasone furoate/ vilanterol ellipta fluticasone propionate hfa . spiriva respimat 1.25 mcg symbicort synagis tezspire trelegy ellipta xolair zyflo women's health supplies
