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