2026 ESI No Cost Share Preventive Drug List HDHP

2026 CDH Preventive Medications - Standard Plus

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

DL_0017456B 303862

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