In addition to a healthy lifestyle, preventive medications can helppeople avoid many illnesses and conditions. A consumer-directedhealth (CDH) plan that includes preventive medications can helpsupport the goal of ongoing good health.

This list provides examples of commonly prescribed preventive medications. The medications are categorized based on the medicalconditions that they are used to prevent. This is not an all-inclusive list;only examples of medicines in each category are listed. Coverage priorto the deductible being met may not be provided for every dosageform of a listed medication.

This list does not indicate coverage. Please check with your planadministrator and/or benefit information materials if you have questions on coverage. Your cost share will be determined by yourplan’s drug coverage and formulary plan.

This list is periodically reviewed and updated to ensure that the drugslisted meet the criteria for inclusion.

Medications on this list that are not covered under yourplan are not eligible for the preventive medication program.

Preventive medications list

PDL9400C

ANEMIA IN CHILDRENFERROUS SULFATE LIQUID DROPS FOR INFANTS (SUCH AS FER-IN-SOL)

ASTHMASINGULAIRMONTELUKAST

ACCOLATEZAFIRLUKAST

ZYFLO CRZILEUTON

BONE DISEASE AND FRACTURESFOSAMAX, FOSAMAX PLUS DALENDRONATE

FORTICAL, MIACALCINCALCITONIN

XGEVADENOSUMAB

BONIVAIBANDRONATE

EVISTARALOXIFENE

ACTONELRISEDRONATE

RECLASTZOLEDRONIC ACID

BREAST CANCER RECURRENCETAMOXIFEN ARIMIDEXANASTROZOLE

AROMASINEXEMESTANE

FEMARALETROZOLE

CANCER TREATMENT, SIDEEFFECTS FROM ARANESPDARBEPOETIN ALFA

EPOGEN, PROCRITEPOETIN ALFA

NEUPOGENFILGRASTIM

MESNEXMESNA

NEULASTAPEGFILGRASTIM

LEUKINESARGRAMOSTIM

CAVITIESPREVIDENT SODIUM FLUORIDE

COLONOSCOPY PREPARATIONGOLYTELY, HALFLYTELY, NULYTELY,TRILYTE, MOVIPREP, SUCLEARPOLYETHYLENE GLYCOL

PREPOPIKSODIUM PICOSULFATE

VISICOL, OSMOPREP, SUPREPSODIUM PHOSPHATE SALTS

DIABETES, COMPLICATIONS OF

INSULINS: LEVEMIRDETEMIR

LANTUS, LANTUS SOLOSTARGLARGINE

HUMULININSULIN

Preventive Medications List

HUMALOG, 50/50, 75/25LISPRO, LISPRO PROTAMINE MIX

NON-INSULIN MEDICINES: BYETTAEXENATIDE

AMARYLGLIMEPIRIDE

GLUCOTROL, METAGLIPGLIPIZIDE AND COMBINATIONS

DIABETA, GLYNASE, GLUCOVANCEGLYBURIDE AND COMBINATIONSLIRAGLUTIDE

FORTAMET, GLUCOPHAGE,GLUMETZA, RIOMETMETFORMIN

STARLIXNATEGLINIDE

ACTOS, DUETACT, ACTOPLUS METPIOGLITAZONE AND COMBINATIONS

SYMLIN PRAMLINTIDE

PRANDINREPAGLINIDE

AVANDIA, AVANDAMET,AVANDARYLROSIGLITAZONE AND COMBINATIONS

ONGLYZA, KOMBIGLYZE XRSAXAGLIPTIN AND COMBINATIONS

JANUVIA, JANUMETSITAGLIPTIN AND COMBINATIONS

ESTROGEN REPLACEMENT ANDOTHER HORMONESPREMARIN CONJUGATED ESTROGEN TABLETS

PREMPRO, PREMPHASECONJUGATED ESTROGEN/MEDROXYPROGESTERONE

ESTRACEESTRADIOL TABLETS

CLIMARAESTRADIOL TRANSDERMAL

ESTRADERMESTRADIOL TRANSDERMAL

VIVELLE DOTESTRADIOL TRANSDERMAL

DIVIGELESTRADIOL, GEL

EVAMISTESTRADIOL, TRANSDERMAL SPRAY

COMBIPATCHESTRADIOL/NORETHINDRONE, TRANSDERMAL

MAKENAHYDROXYPROGESTERONE CAPROATE

PROVERAMEDROXYPROGESTERONE

CRINONE, PROMETRIUMPROGESTERONE

CENESTINSYNTHETIC CONJUGATED ESTROGENS, A

ENJUVIASYNTHETIC CONJUGATED ESTROGENS, B

GOUTZYLOPRIMALLOPURINOL

COLCRYSCOLCHICINE

GUM DISEASEARESTINMINOCYCLINE

Preventive Medications List

HEART DISEASE AND STROKE

BLOOD THINNER MEDICINES: ASPIRIN, 81 MG OR 325 MGHEPARINELIQUIS APIXIBAN

PRADAXA DIBIGATRAM ETEXILATE

AGGRENOX ASA/DIPYRIDAMOLE

PLAVIXCLOPIDOGREL

FRAGMIN DALTEPARIN

LOVENOXENOXAPARIN

ARIXTRAFONDAPARINUX

EFFIENT PRASUGREL

XARELTORIVAROXABAN

BRILINTATICAGRELOR

COUMADIN, JANTOVENWARFARIN

CHOLESTEROL LOWERING MEDICINES

HMG-COA REDUCTASEINHIBITORS: LIPITORATORVASTATIN

MEVACORLOVASTATIN

PRAVACHOLPRAVASTATIN

CRESTORROSUVASTATIN

ZOCORSIMVASTATIN

OTHER AGENTS: PREVALITE, QUESTRANCHOLESTYRAMINE

WELCHOLCOLESEVELAM

COLESTIDCOLESTIPOL

ZETIAEZETIMIBE

VYTORINEZETIMIBE/SIMVASTATIN

FENOGLIDE, LIPOFEN, TRICOR, ANTARA, TRIGLIDEFENOFIBRATE

TRILIPIXFENOFIBRIC ACID

LOPIDGEMFIBROZIL

NIACOR, NIASPAN ERNIACIN

ADVICORNIACIN/LOVASTATIN

SIMCORNIACIN ER/SIMVASTATIN

LOVAZAOMEGA-3-ACID ETHYL ESTERS

HIGH BLOOD PRESSURE MEDICINES

ACE INHIBITORS AND COMBINATIONS:

LOTENSIN, LOTENSIN HCTBENAZEPRIL

VASOTEC, VASERETICENALAPRIL

UNIVASC, UNIRETICMOEXIPRIL

Preventive Medications List

PRINIVIL, PRINZIDE, ZESTRIL, ZESTORETICLISINOPRIL

ACCUPRIL, ACCURETICQUINAPRIL

ACE RECEPTOR BLOCKERS AND COMBINATIONS:

ATACAND, ATACAND HCTCANDESARTAN

AVAPRO, AVALIDEIRBESARTAN

COZAAR, HYZAARLOSARTAN

BENICAR, BENICAR HCTOLMESARTAN

DIOVAN, DIOVAN HCTVALSARTAN

BETA BLOCKERS AND COMBINATIONS:

TENORMIN, TENORETICATENOLOL

ZEBETA, ZIACBISOPROLOL

LOPRESSOR, LOPRESSOR HCT,TOPROL XLMETOPROLOL

BYSTOLICNEBIVOLOL

INDERAL LA, INNOPRAN XLPROPRANOLOL

CALCIUM CHANNEL BLOCKERS:

NORVASCAMLODIPINE

CARDIZEM, CARDIZEM LA,

CARTIA XT, TIAZACDILTIAZEM

ADALAT CC, PROCARDIANIFEDIPINE

SULARNISOLDIPINE

CALAN, COVERA HS, ISOPTIN SR,VERELANVERAPAMIL

DIURETICS AND COMBINATIONS:HYDROCHLOROTHIAZIDEINDAPAMIDEMIDAMORAMILORIDE

ZAROXOLYNMETOLAZONE

ALDACTONESPIRONOLACTONE

DYAZIDE, MAXZIDETRIAMTERENE-HCTZ

HIGH BLOOD PRESSURE MEDICINES MISCELLANEOUS:HYDRALAZINE TEKTURNA, TEKTURNA HCT,TEKAMLO, AMTURNIDE, VALTURNAALISKIREN AND COMBINATIONS

LOTRELAMLODIPINE/BENAZEPRIL

AZORAMLODIPINE/OLMESARTAN

TRIBENZORAMLODIPINE/OLMESARTAN/ HYDROCHLOROTHIAZIDE

Preventive Medications List

TWYNSTAAMLODIPINE/TELMISARTAN

EXFORGEAMLODIPINE/VALSARTAN

EXFORGE HCT AMLODIPINE/VALSARTAN/ HYDROCHLOROTHIAZIDE

COREG, COREG CRCARVEDILOL

CATAPRES, CLORPRESCLONIDINE

CARDURADOXAZOSIN

HYTRINTERAZOSIN

INFECTION

FUNGALMEPRONATOVAQUONE

NEBUPENT, PENTAMPENTAMIDINE

NOXAFILPOSACONAZOLE

MALARIAPRIMAQUINECOARTEMARTEMETHER/LUMEFANTRINE

MALARONEATOVAQUONE/PROGUANIL

PLAQUENILHYDROXYCHLOROQUINE

DARAPRIMPYRIMETHAMINE

VIRUSAMANTADINEZOVIRAXACYCLOVIR

FAMVIRFAMCICLOVIR

FOSCAVIRFOSCARNET

CYTOVENEGANCICLOVIR

TAMIFLUOSELTAMIVIR

VALTREXVALACYCLOVIR

VALCYTEVALGANCICLOVIR

RELENZAZANAMIVIR

KIDNEY DISEASE, HIGH PHOSPHATE LEVELS PHOSLO, PHOSLYRACALCIUM ACETATE

FOSRENOLLANTHANUM

RENVELA, RENAGELSEVELAMER

NAUSEA AND DIZZINESSPROCHLORPERAZINE PROMETHAZINE EMENDAPREPITANT

ANZEMETDOLASETRON

MARINOLDRONABINOL

SANCUSOGRANISETRON

ANTIVERTMECLIZINE

ZOFRAN, ZOFRAN ODTONDANSETRON

TRANSDERM-SCOP, SCOPACESCOPOLAMINE

Preventive Medications List

OBESITYDIETHYLPROPIONBELVIQLORCASERIN

QYSMIAPHENTERMINE/TOPIRAMATE

XENICALORLISTAT

BONTRILPHENDIMETRAZINE

ADIPEX-P, IONAMINPHENTERMINE

PREGNANCYBIRTH CONTROL MEDICINES TAKEN BY MOUTHBIRTH CONTROL DEVICES: DIAPHRAGMS, SKIN PATCH SYSTEMS, INJECTABLE BIRTH CONTROL, INTRAUTERINE SYSTEMS, ANDIMPLANTS

SMOKING-CESSATION THERAPYZYBANBUPROPION

NICOTROLNICOTINE PRODUCTS

CHANTIXVARENICLINE

ULCER DISEASE

H2-ANTAGONISTS: CIMETIDINE PEPCIDFAMOTIDINE

AXIDNIZATADINE

ZANTACRANITIDINE

MISCELLANEOUS AGENTS:

PYLERABISMUTH/METRONIDAZOLE/TETRACYCLINE

CARAFATESUCRALFATE

PROTON PUMP INHIBITORS:

NEXIUMESOMEPRAZOLE

PREVACIDLANSOPRAZOLE

PROTONIXPANTOPRAZOLE

ACIPHEXRABEPRAZOLE

VACCINESVACCINES:JE-VAX, TYPHIM, DIPHTHERIA, PERTUSSIS, TETANUS, HAEMOPHILUSINFLUENZAE B, HEPATITIS A AND B,HUMAN PAPILLOMAVIRUS, INFLUENZA, MEASLES, MENINGOCOCCAL, MUMPS, PNEU-MOCOCCAL, POLIOVIRUS,ROTAVIRUS, RUBELLA, AND VARICELLA

VITAMINS OR MINERALS,LOW LEVELS OFCALCIUMFOLIC ACID, 0.4 TO 0.8 MGIRON MAGNESIUMMULTIVITAMIN PRODUCTSPOTASSIUM BICARBONATE/CITRIC ACID POTASSIUM CHLORIDEPRESCRIPTION PRENATAL VITAMINSVITAMINS: A, B, B1, B6, B12, D, KZINC

Preventive Medications List

*0000000PDL9400C**0000000PDL9400C*

Express Scripts manages your prescription benefit for youremployer, plan sponsor, or health plan. For specific questions oncoverage, please call the phone number on your ID card or visitour website www.express-scripts.com. Please note: Brand names are shown in italics in each category.

All rights in the product names of all third-party products appearinghere, whether or not appearing with the trademark symbol, belongexclusively to their respective owners.

PDL9400C List 1+2 - DIABETES 9.13

In addition to a healthy lifestyle, preventive medications can helppeople avoid many illnesses and conditions. A consumer-directedhealth (CDH) plan that includes preventive medications can helpsupport the goal of ongoing good health.

This list provides examples of commonly prescribed preventive medications. The medications are categorized based on the medicalconditions that they are used to prevent. This is not an all-inclusive list;only examples of medicines in each category are listed. Coverage priorto the deductible being met may not be provided for every dosageform of a listed medication.

This list does not indicate coverage. Please check with your planadministrator and/or benefit information materials if you have questions on coverage. Your cost share will be determined by yourplan’s drug coverage and formulary plan.

This list is periodically reviewed and updated to ensure that the drugslisted meet the criteria for inclusion.

Medications on this list that are not covered under yourplan are not eligible for the preventive medication program.

Preventive medications list

PDL9398C

ASTHMA, PROGRESSION OFQVARBECLOMETHASONE

PULMICORT, PULMICORT FLEXHALERBUDESONIDE

SYMBICORTBUDESONIDE/FORMOTEROL

INTALCROMOLYN SODIUM

ASMANEXMOMETASONE

DULERAMOMETASONE/FORMOTEROL

DEPRESSION, RECURRENCE OFAPLENZIN ER, WELLBUTRIN

BUPROPIONCELEXA

CITALOPRAMPRISTIQ

DESVENLAFAXINE ERCYMBALTA

DULOXETINELEXAPRO

ESCITALOPRAMPROZAC

FLUOXETINEPAXIL, PEXEVA

PAROXETINEZOLOFT

SERTRALINEEFFEXOR

VENLAFAXINEVIIBRYD

VILAZODONE

DIABETES, COMPLICATIONS OF

INSULINS: LEVEMIR

DETEMIRLANTUS, LANTUS SOLOSTARGLARGINE

HUMULININSULIN

HUMALOG, 50/50, 75/25LISPRO, LISPRO PROTAMINE MIX

NON-INSULIN MEDICINES: BYETTAEXENATIDE

AMARYLGLIMEPIRIDE

GLUCOTROL, METAGLIPGLIPIZIDE AND COMBINATIONS

DIABETA, GLYNASE, GLUCOVANCEGLYBURIDE AND COMBINATIONS

TRADJENTALINAGLIPTIN

FORTAMET, GLUCOPHAGE,GLUMETZA, RIOMET METFORMIN

STARLIXNATEGLINIDE

ACTOS, DUETACT, ACTOPLUS METPIOGLITAZONE AND COMBINATIONS

SYMLIN PRAMLINTIDE

PRANDINREPAGLINIDE

AVANDIA, AVANDAMET,AVANDARYLROSIGLITAZONE AND COMBINATIONS

ONGLYZA, KOMBIGLYZE XRSAXAGLIPTIN AND COMBINATIONS

Preventive Medications List

JANUVIA, JANUMETSITAGLIPTIN AND COMBINATIONS

MISCELLANEOUS MEDICINESCINRYZEC1 ESTERASE INHIBITOR

ORGAN TRANSPLANT REJECTIONIMURAN, AZASANAZATHIOPRINE

NULOJIXBELATACEPT

SANDIMMUNE, NEORALCYCLOSPORINE

CELLCEPTMYCOPHENOLATE MOFETIL

MYFORTICMYCOPHENOLIC ACID

RAPAMUNESIROLIMUS

PROGRAFTACROLIMUS

PROSTATE ENLARGEMENT

AVODARTDUTASTERIDE

PROSCARFINASTERIDE

RHEUMATOID ARTHRITIS,PROGRESSION OFORENCIAABATACEPT

HUMIRAADALIMUMAB

RIDAURAAURANOFIN

ENBRELETANERCEPT

REMICADEINFLIXIMAB

RHEUMATREX, TREXALLMETHOTREXATE

CUPRIMINEPENICILLAMINE

ACTEMRA TOCILIZUMAB

Preventive Medications List

*0000000PDL9398C**0000000PDL9398C*

Express Scripts manages your prescription benefit for youremployer, plan sponsor, or health plan. For specific questions oncoverage, please call the phone number on your ID card or visitour website www.express-scripts.com. Please note: Brand names are shown in italics in each category.

All rights in the product names of all third-party products appearinghere, whether or not appearing with the trademark symbol, belongexclusively to their respective owners.

PDL9398C List 3 9.13