Internal CVS/caremark use only.

Highlighted drugs are covered at 100% including all insulin and generic drugs represented by products on this list

• BRAND DRUGS ARE IN ALL UPPERCASE • generic products are in lowercase italics. • Branded Generics in Upper and lower case italics • At CVS pharmacies, specific diabetic supplies are covered at 100%. This includes some CVS brand products and UltiCare/UltiGuard syringes and needles. Check specific drug costs on Caremark.com.

October 2015Health Savings Plan (HSP) Preventive Therapy Drug List

Keeping in good health depends on taking and finishing your preventive medications just as your doctor prescribed. Your benefit plan wants to make this as easy and affordable for you as possible. That’s why you are not required to meet a deductible for preventive prescriptions. Instead, your prescription benefits are paid right away for all medications on the CVS/caremark preventive drug list. You’ll pay 20% of the cost of most preventive medications and there will be no cost to you for generic medicines on this list. This no-deductible preventive drug list not only saves you money but is an important step in preventing more serious health issues in the future.

ANTICOAGULANTS/ANTIPLATELETSANTICOAGULANTSenoxaparin fondaparinux warfarin Jantoven ARIXTRA COUMADIN COUMADIN INJECTION ELIQUIS FRAGMIN IPRIVASK LOVENOX PRADAXA SAVAYSA XARELTO PLATELET AGGREGATION INHIBITORSclopidogrel dipyridamole dipyridamole ext-rel/aspirin ticlopidine AGGRENOX BRILINTA EFFIENT PERSANTINE PLAVIX ZONTIVITY ANTICONVULSANTS carbamazepine carbamazepine ext-relclonazepamdivalproex sodium delayed-rel divalproex sodium ext-rel ethosuximide felbamate lamotrigine lamotrigine ext-rel levetiracetam levetiracetam ext-reloxcarbazepine phenobarbital phenytoin phenytoin sodium extendedprimidonetiagabine topiramate topiramate ext-rel valproic acid zonisamide EpitolAPTIOMBANZEL CARBATROL CELONTIN DEPAKENE DEPAKOTE DEPAKOTE ER DILANTIN FELBATOL FYCOMPA GABITRIL KEPPRA KEPPRA XR KLONOPIN

LAMICTAL LAMICTAL XR LAMICTAL XR KIT MYSOLINE ONFIOXTELLAR XRPEGANONE PHENYTEK POTIGAQUDEXY XR SABRIL† STAVZOR TEGRETOL TEGRETOL-XR TOPAMAX TRILEPTALTROKENDI XR VIMPAT ZARONTIN ZONEGRAN

BOWEL PREPARATIONSpeg 3350/electrolytesGavilyteBOWEL PREPARATIONS (continued)COLYTEGOLYTELYMOVIPREP §NULYTELYOSMOPREPPREPOPIK §SUPREP §

CARDIOVASCULAR CONDITIONS–OTHER ANTIARRHYTHMIC AGENTS amiodarone disopyramide flecainide propafenone propafenone ext-relsotalol sotalol AF PaceroneBETAPACE BETAPACE AF CORDARONE NORPACE NORPACE CR RYTHMOL RYTHMOL SRSOTYLIZENEPRILYSIN/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONSENTRESTO ORAL ANTIANGINAL AGENTSisosorbide dinitrateisosorbide mononitrate isosorbide mononitrate ext-relnitroglycerinnitroglycerin lingual spray nitroglycerin sublingual aerosolDILATRATE-SRIMDUR

ISORDIL NITROLINGUAL NITROMISTSL and chewable formulations are not included on this list.

TRANSDERMAL/TOPICAL ANTIANGINAL AGENTS nitroglycerin transdermal MinitranNITRO-BID NITRO-DUR CORONARY ARTERY DISEASEANTIHYPERLIPIDEMICS atorvastatin cholestyramine colestipol fenofibrate fenofibric acid fenofibric acid delayed-relfluvastatin gemfibrozil lovastatinniacin ext-rel omega-3 acid ethyl esterspravastatin simvastatin NiacorPrevalite ALTOPREVANTARA COLESTID CRESTOR FENOGLIDE FIBRICOR JUXTAPID† LESCOL LESCOL XLLIPITOR LIPOFEN LIVALOLOCHOLEST/LOCHOLEST LIGHT LOFIBRA LOPID LOVAZA MEVACOR NIASPAN PRAVACHOL QUESTRAN/QUESTRAN LIGHT TRICOR TRIGLIDE TRILIPIX VASCEPA WELCHOL ZETIA ZOCOR

COMBINATION ANTIHYPERLIPIDEMICSamlodipine/atorvastatinADVICORCADUET LIPTRUZET SIMCOR VYTORIN

continued > *At CVS pharmacies, specific diabetic supplies are covered at 100%. This includes specific CVS brand products, UltiCare/UltiGuard syringes and needles, OneTouch Ultra, and OneTouch Verio brand diabetic supplies. Check specific drug costs on Caremark.com; formulary exclusions for other brands apply. † Specialty copayment applies§ No-Cost Preventive Service for recommended ages Some strengths or dosage forms may not be included in the HSP Preventative Therapy Drug List. Certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider. This is a representation of the covered drugs and not a complete list. To view the most current drug coverage, please visit Caremark.com. Internal CVS/caremark use only. 1

DIABETES DIAGNOSTIC AGENTS AND SUPPLIES* BLOOD GLUCOSE MONITORS ONETOUCH ULTRA KITS ONETOUCH VERIO KITSBLOOD GLUCOSE STRIPS ONETOUCH ULTRA STRIPS* ONETOUCH VERIO STRIPS*CONTROL SOLUTIONSINSULIN SYRINGES AND NEEDLES*KETONE BLOOD TEST STRIPS* LANCETS, LANCET DEVICES* URINE TESTING STRIPS*

INHALED DIABETES AGENTSAFREZZA

INJECTABLE DIABETES AGENTS BYDUREON LANTUS** LEVEMIR** NOVOLIN** NOVOLOG** SYMLINPEN TANZEUM TOUJEO SOLOSTAR**TRULICITYVICTOZA

ORAL DIABETES AGENTS acarbose chlorpropamide glimepiride glipizide glipizide ext-rel glipizide/metforminglyburide glyburide, micronized glyburide/metformin metformin metformin ext-rel nateglinide pioglitazone pioglitazone/glimepiridepioglitazone/metforminrepaglinide tolbutamideACTOPLUS MET ACTOPLUS MET XR ACTOS AMARYL DIABETA DUETACT GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVANCE GLYNASE GLYSET GLYXAMBIINVOKAMETINVOKANA JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO KAZANO METAGLIP NESSINA OSENI PRANDIMET

DUTOPROLEPANED HYZAAR LOTENSIN LOTENSIN HCT LOTRELMAVIK MICARDIS MICARDIS HCT PRESTALIAPRINIVIL TARKAUNIRETIC VASERETIC VASOTEC ZESTORETIC ZESTRIL

BETA-BLOCKERS AND COMBINATION AGENTSacebutolol atenolol atenolol/chlorthalidone betaxolol bisoprololbisoprolol/hydrochlorothiazide carvedilol labetalol metoprolol metoprolol succinate ext-rel metoprolol/hydrochlorothiazide nadolol nadolol/bendroflumethiazide pindolol propranolol propranolol ext-rel propranolol/hydrochlorothiazide timolol maleateBYSTOLIC COREG COREG CR CORGARD CORZIDE INDERAL LA KERLONE LEVATOL LOPRESSOR LOPRESSOR HCT SECTRAL TENORETIC TENORMIN TOPROL-XL TRANDATE ZEBETA ZIAC

CALCIUM CHANNEL BLOCKERS AND COMBINATION AGENTSamlodipine diltiazem diltiazem ext-rel diltiazem XR felodipine ext-rel isradipine nicardipine nifedipine nifedipine ext-rel nisoldipine ext-rel verapamil verapamil ext-rel Afeditab CR Cartia XT Dilt-XR Matzim LANifediac CCNifedical XLTaztia XT

continued > ** Insulin product; covered at 100%.† Specialty copayment applies.Some strengths or dosage forms may not be included in the HSP Preventative Therapy Drug List. Certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider. This is a representation of the covered drugs and not a complete list. To view the most current drug coverage, please visit Caremark.com. Internal CVS/caremark use only. 2

Over-the-Counter (OTC) products do not require a prescription. Coverage may vary by plan.

PRANDIN PRECOSE STARLIX TRADJENTAXIGDUO XR

HEMATOLOGIC AGENTS ADVATE† ALPHANATE† ALPHANINE SD† BEBULIN† BENEFIX† CORIFACT†

ELOCTATE† FEIBA† HELIXATE FS† HEMOFIL M† HUMATE-P† IXINITY†

KOATE-DVI†KOGENATE† KOGENATE FS† MONOCLATE-P† MONONINE†

NOVOEIGHT†

OBIZUR† PROFILNINE SD† RECOMBINATE† RIXUBIS† STIMATE†

TRETTEN† WILATE† XYNTHA†

HYPERTENSION ACE INHIBITORS/ANGIOTENSIN II RECEPTOR ANTAGONISTS AND COMBINATION AGENTS amlodipine/benazeprilbenazepril benazepril/hydrochlorothiazidecandesartan candesartan/hydrochlorothiazidecaptopril captopril/hydrochlorothiazideenalapril enalapril/hydrochlorothiazide eprosartan fosinopril fosinopril/hydrochlorothiazideirbesartan irbesartan/hydrochlorothiazidelisinopril lisinopril/hydrochlorothiazide losartan losartan/hydrochlorothiazide moexipril moexipril/hydrochlorothiazideperindopril quinapril quinapril/hydrochlorothiazideramipril telmisartan trandolapril valsartan valsartan/hydrochlorothiazide ACCUPRIL ACCURETIC ACEON ALTACE AVALIDEAVAPRO BENICAR BENICAR HCT COZAAR DIOVAN DIOVAN HCT

ADALAT CC CALAN CALAN SR CARDIZEM CARDIZEM CD CARDIZEM LAISOPTIN SR PROCARDIA PROCARDIA XL SULAR TIAZAC VERELAN VERELAN PMDIURETICSamiloride/hydrochlorothiazidechlorothiazide chlorthalidone hydrochlorothiazide indapamide methyclothiazide spironolactone/hydrochlorothiazide triamterene/hydrochlorothiazideALDACTAZIDE DIURIL DYAZIDE MAXZIDE MICROZIDE

OTHER ANTIHYPERTENSIVE AGENTS amlodipine/telmisartan clonidine clonidine transdermal guanabenz guanfacine hydralazine methyldopa methyldopa/hydrochlorothiazide minoxidil reserpine Clorpres AZOR CATAPRES CATAPRES-TTS EXFORGE EXFORGE HCT TEKTURNA TEKTURNA HCT TENEX TRIBENZOR TWYNSTA

IMMUNIZING AGENTS ALLERGENIC EXTRACTSCERVARIX CHOLERA VACCINECOMBINATION VACCINES CYTOMEGALOVIRUS IMMUNE GLOBULIN***†

DPT VACCINE DT VACCINE DTaP VACCINEGARDASILGARDASIL 9 GRASTEKHEPATITIS A VACCINE HEPATITIS B IMMUNE GLOBULIN***†

HEPATITIS B VACCINE HIB VACCINE INFLUENZA VACCINE JAPANESE ENCEPHALITIS VACCINE MEASLES VACCINE MENINGOCOCCAL VACCINE MUMPS VACCINEORALAIR†

ALLERGENIC EXTRACTS (continued)

PNEUMOCOCCAL VACCINEPOLIO VACCINE PREVNAR 13RABIES IMMUNE GLOBULIN RABIES VACCINE RAGWITEKRHO(D) IMMUNE GLOBULIN***†

ROTARIXROTATEQ RSV VACCINE*** RUBELLA VACCINE TETANUS IMMUNE GLOBULIN TETANUS TOXOID TYPHOID VACCINE VARICELLA VACCINE VARICELLA-ZOSTER IMMUNE GLOBULIN YELLOW FEVER VACCINE ZOSTAVAX

MENTAL HEALTH ANTIDEPRESSANTSamitriptyline amoxapine bupropion bupropion ext-relcitalopram clomipramine desipramine doxepin duloxetine delayed-rel escitalopram fluoxetine fluoxetine delayed-rel fluvoxamine imipramine HCl imipramine pamoate maprotiline mirtazapine nortriptyline paroxetine HCl paroxetine HCl ext-rel phenelzine protriptyline sertraline tranylcypromine trazodone venlafaxine venlafaxine ext-relANAFRANIL APLENZINBRINTELLIX CELEXA CYMBALTA EFFEXOR XR EMSAMFETZIMA FORFIVO XL IRENKAKHEDEZLA LEXAPRO MARPLAN NARDIL NORPRAMIN OLEPTROPAMELOR PARNATE PAXIL PAXIL CR PEXEVA PRISTIQ PROZAC PROZAC WEEKLY REMERON SURMONTIL

TOFRANIL TOFRANIL-PM VIIBRYD VIVACTIL WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL ZOLOFT

ANTIPSYCHOTICSchlorpromazineclozapine fluphenazine fluphenazine decanoate haloperidol loxapine olanzapine olanzapine orally disintegrating tabs perphenazine quetiapine risperidone thioridazine thiothixene trifluoperazine ziprasidoneABILIFY ABILIFY MAINTENACLOZARIL EQUETRO FAZACLO GEODON HALDOL INVEGA INVEGA SUSTENNA INVEGA TRINZ LATUDA REXULTIRISPERDAL RISPERDAL CONSTA SAPHRIS SEROQUEL SEROQUEL XR ZYPREXA

OBSESSIVE COMPULSIVE DISORDER fluvoxamine ext-rel

OSTEOPOROSISalendronate calcitonincalcitonin-salmonibandronaterisedronateACTONEL ATELVIA BINOSTO BONIVA EVISTA FORTICAL FOSAMAX FOSAMAX PLUS D MIACALCIN NASAL SPRAYRECLAST†

PREVENTIVE CARE SERVICES AGENTS FOR CHEMICAL DEPENDENCY acamprosate calcium buprenorphine/naloxone sublingual buprenorphine sublingual disulfiram naltrexoneDepadeANTABUSEBUNAVAIL CAMPRAL REVIA ZUBSOLV

continued >

3

***Covered through pharmacy benefit only.† Specialty copayment appliesSome strengths or dosage forms may not be included in the HSP Preventative Therapy Drug List. Certain products or categories may not be covered, regardless of their appearancein this document. Please check with your plan provider. This is a representation of the covered drugs and not a complete list. To view the most current drug coverage, please visit Caremark.com. Internal CVS/caremark use only.

ANTI-OBESITY AGENTS benzphetamine diethylpropion diethylpropion ext-relphendimetrazine phendimetrazine ext-relphentermineADIPEX-PBELVIQBONTRILCONTRAVE QSYMIAREGIMEXSAXENDASUPRENZAXENICAL

SMOKING DETERRENTS bupropion ext-rel nicotine polacrilex nicotine transdermalBuproban CHANTIXNICODERM CQ NICORETTE GUM NICORETTE LOZENGE NICOTROL INHALER NICOTROL NSOver-the-Counter (OTC) products do not require a prescription. Coverage may vary by plan.

RESPIRATORY DISORDERSRESPIRATORY AGENTSbudesonide suspension cromolyn sodium montelukast zafirlukast ACCOLATE ADVAIR ADVAIR HFA ALVESCO ARNUITY ELLIPTA ASMANEX BREO ELLIPTADULERA FLOVENT DISKUS FLOVENT HFA PULMICORT QVAR SINGULAIR SYNAGIS† XOLAIR† ZYFLO ZYFLO CR

SUPPLIESSPACER DEVICES SPACER SUPPLIES VARIOUS CONDITIONS ANTI-MALARIAL AGENTS atovaquone/proguanil chloroquine mefloquinemycophenolate sodium delayed-rel ARALEN MALARONE PRIMAQUINE

DENTAL CARIES PREVENTION sodium fluoride PEDIATRIC MULTIVITAMINS WITH FLUORIDE – ALL MARKETED PRODUCTS HEREDITARY ANGIOEDEMA AGENTS CINRYZE†

IMMUNOSUPPRESSIVE AGENTScyclosporine caps mycophenolate mofetil tacrolimus GengrafASTAGRAF XL†

CELLCEPT†

MYFORTIC† NEORAL† NULOJIX† RAPAMUNE†

SANDIMMUNE† ZORTRESS†

MULTIPLE SCLEROSIS AGENTS glatiramer

AVONEX†

COPAXONE† EXTAVIA† GILENYA†

LEMTRADA†

PLEGRIDY† TECFIDERA† TYSABRI†

WOMEN’S HEALTH ANTIESTROGENS tamoxifen

AROMATASE INHIBITORS anastrozole exemestane letrozole ARIMIDEX AROMASIN FEMARA

CONTRACEPTIVES EE = ethinyl estradiol ME = mestranol

LOW-DOSE MONOPHASIC PILLSdesogestrel/EE 0.15/30 drospirenone/EE 3/30 ethynodiol diacetate/EE 1/35 levonorgestrel/EE 0.1/20 and EE 10 levonorgestrel/EE 0.15/30 norethindrone acetate/EE 1/20 norethindrone acetate/EE 1/20 and iron norethindrone acetate/EE 1.5/30 LOW-DOSE MONOPHASIC PILLS (continued)

norethindrone acetate/EE 1.5/30 and iron norethindrone/EE 0.4/35 norethindrone/EE 0.5/35norethindrone/EE 0.8/25 chewable norethindrone/EE 1/35norethindrone/EE 1/50 norethindrone/ME 1/50 norgestimate/EE 0.25/35 norgestrel/EE 0.3/30 MINASTRIN 24 FE

HIGH-DOSE MONOPHASIC PILLSethynodiol diacetate/EE 1/50 norgestrel/EE 0.5/50

BIPHASIC PILLSdesogestrel/EE 0.15/20

TRIPHASIC PILLS desogestrel/EE 0.1-0.025/0.125-0.025/0.15-0.025 mg-mg levonorgestrel/EE 0.05-30/0.075-40/0.125- 30 mg-mcg norethindrone/EE 0.5-35/ 0.75-35/1-35 mg-mcg norethindrone/EE 0.5-35/1-35/0.5-35 mg-mcg norethindrone/EE 1-20/1-30/1-35 mg-mcg norgestimate/EE 0.18-35/0.215-35/0.25-35 mg-mcgORTHO TRI-CYCLEN LO

FOUR-PHASICNATAZIA

EXTENDED-CYCLE PILLS drospirenone/EE 3/20drospirenone/EE 3/30 levonorgestrel/EE 0.1/20 levonorgestrel/EE 0.15/30 levonorgestrel/EE 0.15/30 and EE 10BEYAZ LO LOESTRIN FE QUARTETTE TAB SAFYRAL

CONTINUOUS-CYCLE PILLS levonorgestrel/EE 0.09/20

PROGESTIN-ONLY PILLS norethindrone 0.35 mg

EMERGENCY CONTRACEPTION levonorgestrel levonorgestrel – Next Choice One DoseELLA

TRANSDERMAL PATCH norelgestromin/EE

MISCELLANEOUS CONTRACEPTIVES medroxyprogesterone acetate 150 mg/mLDEPO-SUBQ PROVERA 104 DIAPHRAGM FEMCAP IMPLANON MIRENA NEXPLANON NUVARING PARAGARD T380ASKYLA

PRENATAL VITAMINS PRENATAL VITAMINS – ALL PRESCRIPTION

4

***Covered through pharmacy benefit only.† Specialty copayment appliesSome strengths or dosage forms may not be included in the HSP Preventative Therapy Drug List. Certain products or categories may not be covered, regardless of their appearancein this document. Please check with your plan provider. This is a representation of the covered drugs and not a complete list. To view the most current drug coverage, please visit Caremark.com. Internal CVS/caremark use only.Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.

©2015 CVS/caremark. All rights reserved. This document contains confidential and proprietary information of CVS/caremark and cannot be reproduced, distributed or printed without written permission from CVS/caremark. 106-1047278 100115