Elkhart Community Schools HDHP Generic Preventive Therapy Drug List

Elkhart Community Schools High Deductible Health Plan (HDHP) - Health Savings Account (HSA) Generics Only Preventive Therapy Drug List (01/01/25) ANTI-INFECTIVES CARDIOVASCULAR CONDITIONS - ORAL DIABETES AGENTS ANTIRETROVIRAL AGENTS OTHER acarbose emtricitabine/tenofovir disoproxil ANTIARRHYTHMIC AGENTS glimepiride fumarate 200/300 mg amiodarone glipizide disopyramide glipizide ext-rel ANTICOAGULANTS/ dofetilide glipizide/metformin ANTIPLATELETS flecainide metformin propafenone metformin ext-rel ANTICOAGULANTS propafenone ext-rel miglitol dabigatran sotalol nateglinide enoxaparin sotalol AF pioglitazone fondaparinux Pacerone pioglitazone/glimepiride warfarin pioglitazone/metformin Jantoven ORAL ANTIANGINAL AGENTS repaglinide isosorbide dinitrate (except 40 mg) saxagliptin PLATELET AGGREGATION INHIBITORS isosorbide mononitrate saxagliptin/metformin ext-rel aspirin 81 mg clopidogrel Sublingual and chewable formulations are not included HYPERTENSION dipyridamole on this list. ACE INHIBITORS/ANGIOTENSIN II RECEPTOR dipyridamole ext-rel/aspirin ANTAGONISTS AND COMBINATION AGENTS prasugrel TRANSDERMAL/TOPICAL ANTIANGINAL amlodipine/benazepril AGENTS benazepril Over-the-Counter (OTC) products require a prescription. nitroglycerin transdermal benazepril/hydrochlorothiazide Coverage may vary by plan. candesartan CORONARY ARTERY DISEASE candesartan/hydrochlorothiazide ANTICONVULSANTS ANTIHYPERLIPIDEMICS captopril carbamazepine atorvastatin captopril/hydrochlorothiazide carbamazepine ext-rel cholestyramine enalapril clobazam colesevelam enalapril/hydrochlorothiazide clonazepam colestipol fosinopril divalproex sodium delayed-rel ezetimibe fosinopril/hydrochlorothiazide divalproex sodium ext-rel fenofibrate (except fenofibrate capsule irbesartan ethosuximide 30 mg, 50 mg, 90 mg, 130 mg; irbesartan/hydrochlorothiazide felbamate fenofibrate tablet 40 mg, 120 mg) lisinopril lacosamide fenofibric acid lisinopril/hydrochlorothiazide lamotrigine fenofibric acid delayed-rel losartan lamotrigine ext-rel fluvastatin losartan/hydrochlorothiazide levetiracetam fluvastatin ext-rel moexipril levetiracetam ext-rel gemfibrozil olmesartan methsuximide icosapent ethyl olmesartan/hydrochlorothiazide oxcarbazepine lovastatin perindopril phenobarbital niacin ext-rel quinapril phenytoin pitavastatin quinapril/hydrochlorothiazide phenytoin sodium extended pravastatin ramipril primidone rosuvastatin telmisartan rufinamide simvastatin telmisartan/hydrochlorothiazide tiagabine Prevalite trandolapril topiramate trandolapril/verapamil ext-rel topiramate ext-rel COMBINATION ANTIHYPERLIPIDEMICS valsartan (except valsartan solution) valproic acid amlodipine/atorvastatin valsartan/hydrochlorothiazide vigabatrin ezetimibe/simvastatin zonisamide BETA-BLOCKERS AND COMBINATION Epitol DIABETES AGENTS Phenytek acebutolol INJECTABLE DIABETES AGENTS atenolol liraglutide atenolol/chlorthalidone betaxolol 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 their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by 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 010125 VERSION 1500

bisoprolol desipramine PREVENTIVE CARE SERVICES bisoprolol/hydrochlorothiazide desvenlafaxine ext-rel AGENTS FOR CHEMICAL DEPENDENCY carvedilol doxepin acamprosate calcium carvedilol phosphate ext-rel duloxetine delayed-rel buprenorphine sublingual labetalol escitalopram buprenorphine/naloxone sublingual metoprolol fluoxetine (except 60 mg tablet and disulfiram metoprolol succinate ext-rel generics for SARAFEM) naltrexone metoprolol/hydrochlorothiazide fluoxetine delayed-rel nadolol imipramine HCl BOWEL PREPARATIONS nebivolol imipramine pamoate peg 3350/electrolytes (except generics pindolol mirtazapine for MOVIPREP) propranolol nortriptyline sodium sulfate/potassium propranolol ext-rel paroxetine HCl (except 7.5 mg capsule) sulfate/magnesium sulfate timolol maleate paroxetine HCl ext-rel Gavilyte phenelzine CALCIUM CHANNEL BLOCKERS AND protriptyline SMOKING DETERRENTS COMBINATION AGENTS sertraline bupropion ext-rel amlodipine tranylcypromine nicotine polacrilex diltiazem trazodone nicotine transdermal diltiazem ext-rel trimipramine varenicline diltiazem XR venlafaxine felodipine ext-rel venlafaxine ext-rel capsules Over-the-Counter (OTC) products require a prescription. isradipine vilazodone Coverage may vary by plan. levamlodipine nicardipine ANTIMANIC MISCELLANEOUS nifedipine lithium carbonate cholecalciferol (D3) nifedipine ext-rel lithium carbonate ext-rel nisoldipine ext-rel Over-the-Counter (OTC) products require a prescription. verapamil ANTIPSYCHOTICS Coverage may vary by plan. verapamil ext-rel aripiprazole Cartia XT asenapine RESPIRATORY DISORDERS Dilt-XR chlorpromazine RESPIRATORY AGENTS clozapine budesonide suspension DIURETICS fluphenazine budesonide/formoterol amiloride/hydrochlorothiazide fluphenazine decanoate cromolyn sodium nebulizer solution chlorthalidone haloperidol fluticasone/salmeterol hydrochlorothiazide loxapine montelukast indapamide lurasidone zafirlukast spironolactone/hydrochlorothiazide olanzapine Breyna triamterene/hydrochlorothiazide olanzapine orally disintegrating tabs Wixela Inhub paliperidone OTHER ANTIHYPERTENSIVE AGENTS perphenazine VARIOUS CONDITIONS aliskiren quetiapine ANTI-MALARIAL AGENTS amlodipine/olmesartan quetiapine ext-rel atovaquone/proguanil amlodipine/telmisartan risperidone chloroquine amlodipine/valsartan/ thioridazine mefloquine hydrochlorothiazide thiothixene primaquine clonidine trifluoperazine clonidine transdermal ziprasidone DENTAL CARIES PREVENTION guanfacine sodium fluoride hydralazine OBSESSIVE COMPULSIVE DISORDER Plan restrictions may apply methyldopa clomipramine minoxidil fluvoxamine IMMUNOSUPPRESSIVE AGENTS olmesartan/amlodipine/ fluvoxamine ext-rel cyclosporine caps hydrochlorothiazide everolimus OSTEOPOROSIS mycophenolate mofetil MENTAL HEALTH alendronate mycophenolate sodium delayed-rel ANTIDEPRESSANTS calcitonin-salmon sirolimus amitriptyline ibandronate tacrolimus amoxapine raloxifene Gengraf bupropion risedronate bupropion ext-rel (except 450 mg tablet) teriparatide MULTIPLE SCLEROSIS AGENTS citalopram zoledronic acid 5 mg/100 mL dimethyl fumarate delayed-rel 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 their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by 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 010125 VERSION 1500

fingolimod exemestane PRENATAL VITAMINS glatiramer letrozole folic acid teriflunomide PRENATAL VITAMINS – GENERIC CONTRACEPTIVES PRODUCTS WOMEN'S HEALTH CONTRACEPTIVES – ALL GENERIC ANTIESTROGENS PRESCRIPTION FORMULATIONS Over-the-Counter (OTC) products require a prescription. tamoxifen Coverage may vary by plan. Over-the-Counter (OTC) emergency contraceptive AROMATASE INHIBITORS products require a prescription. anastrozole 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 their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue Service (IRS) guidance. This list includes medications considered preventive by 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 010125 VERSION 1500