ASTHMA/COPD (CONTINUED) Please note: When feasible, brand names are shown in capitals in each category. If generic is available, it is listed in lowercase next to the brand name. If only generics are available (for example, brands are no longer available), they will only be listed in lowercase. ASTHMA/COPD ACCOLATE (zafirlukast) ADVAIR HFA AIRSUPRA albuterol HFA albuterol nebulizer solution albuterol oral 2026 Consumer Directed Healthcare (CDH) Preventive Medications - Standard Plus This list provides examples of commonly prescribed preventive medications. It is not an all-inclusive list; however, many examples of the medications are listed in each category. This list does not indicate coverage. Please check with your plan administrator and/or benefit information materials if you have questions on coverage. Your cost share will be determined by your plan’s drug coverage and formulary plan. Coverage prior to the deductible being met may not be provided for every strength or dosage form of a listed medication. BONE DISEASE AND FRACTURES ACTONEL (risedronate) ATELVIA DR (risedronate DR)
levabuterol nebulizer solution and concentrate montelukast NUCALA Peak flow meters QVAR REDIHALER roflumilast Spirometers SPIRIVA HANDIHALER (tiotropium cap-inhaler)
BINOSTO DUAVEE EVISTA (raloxifene) FOSAMAX (alendronate) FOSAMAX D ibandronate oral RECLAST (zoledronic acid)
ANORO ELLIPTA ASMANEX HFA ASMANEX TWISTHALER ATROVENT HFA BREO ELLIPTA breyna BREZTRI AEROSPHERE BROVANA (arformoterol) budesonide oral inhalation
CAVITIES CLINPRO FRAICHE GEL-KAM periomed PREVIDENT sodium fluoride rinse, gel, cream, paste, tabs and drops COLONOSCOPY PREPARATION* gavilyte-c gavilyte-n GOLYTELY solution (PEG-3350/
SPIRIVA RESPIMAT STIOLTO RESPIMAT STRIVERDI RESPIMAT terbutaline oral
TEZSPIRE THEO-24 theophylline theophylline ER TRELEGY ELLIPTA wixela inhub
budesonide/formoterol COMBIVENT RESPIMAT cromolyn nebulizer solution DULERA FASENRA fluticasone/salmeterol inhalation powder formoterol INCRUSE ELLIPTA Inhaler and nebulizer assistive devices ipratropium/albuterol nebulizer solution ipratropium nebulizer solution
XOLAIR YUPELRI
electrolytes, gavilyte-g) sodium, potassium and magnesium sulfates
(over, please)
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DEPRESSION citalopram escitalopram fluoxetine fluoxetine DR fluvoxamine fluvoxamine ER PAXIL (paroxetine) PAXIL CR (paroxetine ER) INSULINS HUMALOG HUMULIN INSULIN GLARGINE-YFGN INSULIN LISPRO LYUMJEV SEMGLEE-YFGN TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR TRESIBA TRESIBA FLEXTOUCH sertraline DIABETES INSULIN/GLP-1 RECEPTOR AGONIST COMBINATIONS SOLIQUA NON-INSULINS acarbose ACTOS (pioglitazone) ACTOPLUS MET (pioglitazone/metformin) BYDUREON BCISE CYCLOSET DUETACT (pioglitazone/glimepiride)
NON-INSULINS (CONTINUED) JANUMET XR JANUVIA JARDIANCE Lancets and lancing devices liraglutide metformin metformin ER miglitol Misc. diabetic supplies (e.g., control solution, sensors, transmitters, insulin pumps and accessories, readers, pods) MOUNJARO nateglinide Needles OZEMPIC repaglinide RIOMET (metformin solution) SYMLINPEN SYNJARDY SYNJARDY XR Syringes Test strips TRIJARDY XR TRULICITY XIGDUO XR HEART DISEASE AND STROKE RYBELSUS saxagliptin saxagliptin/metformin ER
CHOLESTEROL LOWERING
HMG-COA REDUCTASE INHIBITORS* atorvastatin FLOLIPID suspension fluvastatin LESCOL XL (fluvastatin ER) lovastatin
pitavastatin pravastatin rosuvastatin simvastatin ZYPITAMAG OTHER CHOLESTEROL LOWERING AGENTS CADUET (amlodipine/atorvastatin) colesevelam COLESTID (colestipol) ezetimibe ezetimibe/simvastatin fenofibrate fenofibric acid DR FIBRICOR (fenofibric acid) LOPID (gemfibrozil) NEXLETOL NEXLIZET NIACOR niacin niacin ER QUESTRAN (cholestyramine) QUESTRAN LIGHT (cholestyramine light, prevalite) REPATHA VASCEPA (icosapent ethyl)
BLOOD THINNERS aspirin, 81mg* & 325mg aspirin/dipyridamole ER
clopidogrel dabigatran
dipyridamole DURLAZA ER EFFIENT (prasugrel) ELIQUIS jantoven ticagrelor warfarin XARELTO (rivaroxaban) ZONTIVITY
exenatide FARXIGA glimepiride glipizide
glipizide ER and XL glipizide/metformin Glucometers glyburide glyburide/metformin glyburide micronized
GLYXAMBI JANUMET
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HIGH BLOOD PRESSURE (HBP)
BETA BLOCKERS acebutolol
DIURETICS chlorthalidone DIURIL suspension hydrochlorothiazide
ACE INHIBITORS ACCUPRIL (quinapril) ALTACE (ramipril) captopril fosinopril LOTENSIN (benazepril) moexipril
betaxolol bisoprolol LOPRESSOR (metoprolol tartrate) metoprolol succinate ER nadolol nebivolol pindolol propranolol propranolol ER TENORMIN (atenolol) timolol BETA BLOCKER/ DIURETIC
indapamide metolazone OTHER HBP & COMBINATIONS amlodipine/benazepril amlodipine/olmesartan amlodipine/olmesartan/HCTZ amlodipine/valsartan amlodipine/valsartan/HCTZ Blood pressure monitors CADUET (amlodipine/atorvastatin) PRESTALIA trandolapril/verapamil ER MALARIA ARAKODA
perindopril trandolapril VASOTEC (enalapril) ZESTRIL (lisinopril) ACE INHIBITORS/DIURETIC COMBINATIONS ACCURETIC (quinapril/HCTZ)
COMBINATIONS bisoprolol/HCTZ metoprolol/HCTZ propranolol/HCTZ TENORETIC (atenolol/chlorthalidone) CALCIUM CHANNEL BLOCKERS amlodipine CARDIZEM (diltiazem) CARDIZEM CD (cartia XT, diltiazem CD) CARDIZEM LA (diltiazem ER, matzim LA) felodipine ER isradipine nicardipine nifedipine PROCARDIA XL (nifedipine ER) SULAR ER (nisoldipine ER) TIAZAC ER (diltiazem ER, tiadylt ER) verapamil verapamil ER verapamil ER PM verapamil SR
captopril/HCTZ fosinopril/HCTZ LOTENSIN HCT (benazepril/HCTZ)
chloroquine mefloquine MALARONE (atovaquone/proguanil) primaquine MIGRAINE PREVENTION AIMOVIG AJOVY EMGALITY 120mg QULIPTA MISC ANTIVIRALS
VASERETIC (enalapril/HCTZ) ZESTORETIC (lisinopril/HCTZ) ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan
eprosartan irbesartan losartan
olmesartan telmisartan valsartan ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS candesartan/HCTZ irbesartan/HCTZ losartan/HCTZ
APRETUDE* BEYFORTUS DESCOVY*
emtricitabine/ tenofovir disoproxil fumarate (TDF) 200mg/300mg* ENFLONSIA PREVYMIS SYNAGIS YEZTUGO
olmesartan/HCTZ telmisartan/HCTZ valsartan/HCTZ
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OBESITY ADIPEX-P (phentermine) benzphetamine CONTRAVE diethylpropion diethylpropion ER IMCIVREE LOMAIRA phendimetrazine phendimetrazine ER PLENITY QSYMIA (phentermine/ topiramate ER) WEGOVY XENICAL ZEPBOUND pens SMOKING-CESSATION* bupropion SR 150mg CHANTIX (varenicline)
VACCINATION* Anthrax, BCG, Chikungunya, Cholera, COVID-19, Diphtheria, Haemophilus Influenza B, Hepatitis A and B, Human Papillomavirus, Influenza, Japanese Encephalitis, Measles, Meningococcal, Monkey/Smallpox, Mumps, Pertussis, Pneumococcal, Poliovirus, Rabies, Respiratory syncytial virus, Rotavirus, Rubella,
Shingles, Tetanus, Tick-borne encephalitis, Typhoid, Varicella, Yellow Fever, Zoster VITAMINS OR MINERALS Folic acid* Prenatal vitamins Pediatric multivitamins with fluoride*
NICODERM CQ (nicotine patches) NICORETTE (nicotine gum and lozenges) NICOTROL NS
*Please note that some of these medications are also subject to the Affordable Care Act (ACA) and may be covered by your plan at 100%.
® Express Scripts Pharmacy Benefit Services manages your prescription benefit for your employer, plan sponsor, or health plan. For specific questions on coverage, please call the phone number on your member ID card or visit our website express-scripts.com. © 2025 Evernorth Health Services. All Rights Reserved. All trademarks are the property of their respective owners.
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