High Deductible Health Plan Expanded Preventive Drug ListNITROGLYCERIN ER CAP nitroglycerin lingual spray nitroglycerin patch nitroglycerin SL tab NITROMIST SPRAY ... B-D INSULIN SYRINGE

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ANTIANGINAL AGENTSDILATRATE SR CAPISOSORBIDE DINITRATE ER TABisosorbide dinitrate SL tabisosorbide dinitrate tab

isosorbide dinitrate tab 40mgisosorbide mononitrate ER tabisosorbide mononitrate tabNITRO-BID OINTNITRO-DUR PATCH 0.3MG/HR, 0.8MG/HRNITROGLYCERIN ER CAPnitroglycerin lingual spraynitroglycerin patchnitroglycerin SL tabNITROMIST SPRAYranolazine tabANTIARRHYTHMICSamiodarone tab

disopyramide capdisopyramide ER capdofetilide capflecainide tabMEXILETINE CAPMULTAQ TABNORPACE CR CAPpropafenone ER cappropafenone tabquinidine gluconate CR tabQUINIDINE SULFATE ER TABQUINIDINE SULFATE TABANTIASTHMATIC AND BRONCHODILATOR AGENTSADVAIR DISKUS INHALERADVAIR HFA INHALERALBUTEROL HFA INHALERalbuterol neb solnalbuterol sulfate ER tab

• Note: The list is subject to change and not all drugs listed may be covered on your formulary. Please refer to your Navitus formulary for a complete list of covered products.

Your employer is making an effort to reduce your health care costs by giving you tools to help you stay healthy and productive. Below are the medications that are currently included in the High Deductible Health Plans offered through your employer. These medications help protect against or manage some high risk medical conditions. Taking these medications as directed by your prescriber can help avoid serious health problems. That may mean fewer doctor visits and hospitalizations, reducing your total health care costs.

In the drug list below, generic drugs are shown in lowercase type. Brand name drugs are shown in uppercase type.

High Deductible Health Plan Expanded Preventive Drug ListUpdated July 2020



albuterol sulfate syrupalbuterol sulfate tabALBUTEROL TAB ERalbuterol/ipratropium neb solnaminophylline tabANORO ELLIPTA INHALERARNUITY ELLIPTA INHALERASMANEX HFA INHALERASMANEX INHALERATROVENT HFA INHALERBREO ELLIPTA INHALERBROVANA NEB SOLNbudesonide inh suspCOMBIVENT INHALERCOMBIVENT RESPIMAT INHALERDULERA INHALERELIXOPHYLLIN ELIXIRFLOVENT DISKUS INHALERFLOVENT HFA INHALERFLUTICASONE/SALMETEROL INHALERINCRUSE ELLIPTA INHALERipratropium neb solnLEVALBUTEROL INHALER, XOPENEX HFA INHALERlevalbuterol neb solnLONHALA MAGNAIR SOLNLUFYLLIN TABMETAPROTERENOL SYRUPMETAPROTERENOL TABmontelukast chew tabmontelukast granule packmontelukast tabPERFOROMIST NEB SOLNPROAIR HFA INHALERPROVENTIL HFA INHALER

SEREVENT DISKUS INHALERSPIRIVA RESPIMAT INHALER 1.25MCG/ACTSTIOLTO INHALERSTRIVERDI RESPIMAT INHALERterbutaline sulfate tabTHEO-24 CAPTHEOCHRON TABtheophylline CR tabtheophylline ER tabtheophylline solnTRELEGY ELLIPTA INHALERVENTOLIN HFA INHALERzafirlukast tabANTICOAGULANTSELIQUIS TAB, ELIQUIS STARTER PACKenoxaparin injfondaparinux injFRAGMIN INJPRADAXA CAPwarfarin tabXARELTO STARTER PACKXARELTO TABANTICONVULSANTSBANZEL SUSPBANZEL TABcarbamazepine chew tabcarbamazepine ER capcarbamazepine ER tabcarbamazepine suspcarbamazepine tabCELONTIN CAPclobazam tabclonazepam ODTclonazepam tab

• Note: The list is subject to change. Please always refer to your Navitus formulary for a complete list of covered products.



DIACOMIT CAPDIACOMIT POWDER PACKDIASTAT RECTAL GEL, DIAZEPAM RECTAL GELDILANTIN CAP 30MGdivalproex ER tabdivalproex sodium DR tabdivalproex sprinkle capEPIDIOLEX SOLNethosuximide capethosuximide solnfelbamate suspfelbamate tabgabapentin capgabapentin solngabapentin tabLAMICTAL CHEW TAB 2MGLAMICTAL ODT KIT, LAMICTAL XR KITlamotrigine chew tablamotrigine ER tablamotrigine ODTlamotrigine ODT kitlamotrigine tablevetiracetam ER tablevetiracetam solnlevetiracetam taboxcarbazepine suspoxcarbazepine tabPEGANONE TABphenytoin capphenytoin chew tabphenytoin suspPOTIGA TABPOTIGA TAB 50MGpregabalin cap

pregabalin solnprimidone tabtiagabine tabtopiramate sprinkle captopiramate tabvalproic acid capvalproic acid syrupvigabatrin powder packvigabatrin tabVIMPAT SOLNVIMPAT TABzonisamide capANTIDEPRESSANTSamitriptyline tabAMOXAPINE TABbupropion ER tabbupropion tabbupropion XL tabcitalopram solncitalopram tabclomipramine capdesipramine tabdesvenlafaxine ER tabDOXEPIN CAPdoxepin concduloxetine EC capEMSAM PATCHescitalopram solnescitalopram tabfluoxetine capfluoxetine solnfluoxetine tabfluvoxamine ER capfluvoxamine tabimipramine pamoate cap




imipramine tabMAPROTILINE TABMARPLAN TABmirtazapine ODTmirtazapine tabNEFAZODONE TABnefazodone tab 50mg, 250mgnortriptyline capnortriptyline oral solnNORTRIPTYLINE SOLNOLEPTRO TABparoxetine ER tabparoxetine tabPAXIL SUSPphenelzine tabprotriptyline tabsertraline concsertraline tabtranylcypromine tabtrazodone tabtrimipramine capTRINTELLIX TABvenlafaxine ER capvenlafaxine tabANTIDIABETICSacarbose tabACTOPLUS MET XR TABAVANDAMET TABAVANDARYL TABAVANDIA TABBAQSIMI NASAL POWDERB-D INSULIN SYRINGEB-D PEN NEEDLEBYDUREON BCISE AUTO INJBYDUREON INJ

BYDUREON PEN INJBYETTA INJCHLORPROPAMIDE TABCYCLOSET TABDIABETA TABdiazoxide suspFARXIGA TABFIASP FLEXTOUCH INJFIASP INJFIASP PENFILL INJglimepiride tabglipizide ER tabglipizide tabglipizide/metformin tabGLUCAGEN HYPOKIT INJGLUCAGON INJ KITglyburide micronized tabglyburide tabglyburide/metformin tabGLYXAMBI TABGVOKE INJGVOKE PFS INJHUMULIN R INJ U-500HUMULIN R U-500 KWIKPEN INJINSULIN ASPART FLEXPEN INJINSULIN ASPART INJINSULIN ASPART MIX FLEXPEN INJINSULIN ASPART MIX INJINSULIN ASPART PENFILL INJJANUMET TABJANUMET XR TABJANUVIA TABJARDIANCE TABJENTADUETO TABJENTADUETO XR TAB




KORLYM TABLANTUS INJLANTUS SOLOSTAR INJLEVEMIR FLEXTOUCH INJLEVEMIR INJmetformin ER tabmetformin solnmetformin tabmiglitol tabnateglinide tabNOVOFINE PEN NEEDLENOVOLIN 70/30 FLEXPEN INJNOVOLIN INJNOVOLIN N FLEXPEN INJNOVOLIN R FLEXPEN INJNOVOLOG FLEXPEN INJNOVOLOG INJNOVOLOG MIX FLEXPEN INJNOVOLOG MIX INJNOVOLOG PENFILL INJNOVOTWIST PEN NEEDLENOVOTWIST/NOVOFINE PEN NEEDLEOZEMPIC INJpioglitazone tabPUMP SUPPLIESrepaglinide tabRIOMET ER SUSPRYBELSUS TABSYNJARDY TABSYNJARDY XR TAB 10-1000MG, 25-1000MGSYNJARDY XR TAB 5-1000MG, 12.5-1000MGTOLAZAMIDE TABTOLBUTAMIDE TAB

TOUJEO MAX SOLOSTAR INJTOUJEO SOLOSTAR INJTRADJENTA TABTRESIBA FLEXTOUCH INJTRESIBA INJTRIJARDY XR TAB 10-5-1000MG, 25-5-1000MGTRIJARDY XR TAB 5-25-1000MG, 12.5-2.5-1000MGTRULICITY INJVICTOZA INJXIGDUO XR TAB 2.5-1000MG, 5-1000MGXIGDUO XR TAB 5-500MG, 10-500MG, 10-1000MGXULTOPHY INJANTIHYPERLIPIDEMICSatorvastatin tab 10mgatorvastatin tab 20mgatorvastatin tab 40mgatorvastatin tab 80mgcholestyramine lite powdercholestyramine lite powder packcholestyramine powdercholestyramine powder packcolesevelam packcolesevelam tabcolestipol granulecolestipol powder packetcolestipol tabezetimibe tabezetimibe/simvastatin tabfenofibrate cap 67mg, 134mg, 200mgfenofibrate tab 48mg, 54mg, 145mg, 160mg




fenofibric acid DR capFENOFIBRIC TAB, FIBRICOR TABfluvastatin capfluvastatin ER tabgemfibrozil tabLIVALO TABlovastatin tabniacin ER tabomega-3-acid ethyl esters cappravastatin tabrosuvastatin tab 10mgrosuvastatin tab 20mgrosuvastatin tab 40mgrosuvastatin tab 5mgsimvastatin tabVASCEPA CAPANTIHYPERTENSIVESaliskiren tabALTACE TABamlodipine/benazepril capamlodipine/olmesartan tabamlodipine/valsartan tabamlodipine/valsartan/hydrochlorothiazide tabAMTURNIDE TABatenolol/chlorthalidone tabbenazepril tabbenazepril/hydrochlorothiazide tabbisoprolol/hydrochlorothiazide tabcaptopril tabCAPTOPRIL/HYDROCHLOROTHIAZIDE TABclonidine patchclonidine tabCORZIDE TAB 80-5MG

doxazosin tabenalapril tabenalapril/hydrochlorothiazide tabEPANED PREMIXED SOLNEPANED SOLNeplerenone tabfosinopril tabfosinopril/hydrochlorothiazide tabGUANABENZ TABguanfacine IR tabhydralazine tabirbesartan tabirbesartan/hydrochlorothiazide tablisinopril tablisinopril/hydrochlorothiazide tablosartan tablosartan/hydrochlorothiazide tabmethyldopa tabMETHYLDOPA/HYDROCHLOROTHIAZIDE TABMETOPROLOL/HYDROCHLOROTHIAZIDE TABminoxidil tabmoexipril tabMOEXIPRIL/HYDROCHLOROTHIAZIDE TABnadolol/bendroflumethiazide tabNEXICLON XR SUSPNEXICLON XR TABolmesartan tabolmesartan/hydrochlorothiazide tabperindopril tabphenoxybenzamine capprazosin cap




PROPRANOLOL/HYDROCHLOROTHIAZIDE TABQBRELIS SOLNquinapril tabquinapril/hydrochlorothiazide tabramipril capRESERPINE TABTARKA TABTEKAMLO TABTEKTURNA HCT TABtelmisartan tabterazosin captrandolapril tabtrandolapril/verapamil ER tabvalsartan tabvalsartan/hydrochlorothiazide tabVALTURNA TABANTINEOPLASTICS AND ADJUNCTIVE THERAPIESabiraterone tab 250mganastrozole tabbicalutamide tabEMCYT CAPERLEADA TABexemestane tabflutamide capletrozole tableuprolide injLYSODREN TABmegestrol suspmegestrol tabnilutamide tabNUBEQA TABtamoxifen tabtoremifene tabTRELSTAR INJ

ANTIOBESITYADIPEX-P CAPADIPEX-P TABCONTRAVE TABLOMAIRA TABphentermine capphentermine tabQSYMIA CAPBETA BLOCKERSacebutolol capatenolol tabbetaxolol tabbisoprolol tabBYSTOLIC TABcarvedilol tabFIRST ATENOLOL SOLNFIRST METOPROLOL ORAL SOLNlabetalol tabLEVATOL TABmetoprolol ER tabmetoprolol tabnadolol tabpindolol tabpropranolol ER capPROPRANOLOL SOLNpropranolol tabsotalol AF tabsotalol tabtimolol maleate tabCALCIUM CHANNEL BLOCKERSamlodipine tabCARDENE SR CAPCARDIZEM LA TABCOVERA-HS TABDILTIAZEM CAPdiltiazem ER cap





diltiazem ER tabdiltiazem tabDYNACIRC CR TABfelodipine ER tabisradipine capnicardipine capnifedipine capnifedipine ER tabnimodipine capnisoldipine ER tabNISOLDIPINE ER TAB 20MG, 30MG, 40MGNISOLDIPINE ER TAB 25.5MGVERAPAMIL CAP 100MGVERAPAMIL ER CAP 200MGVERAPAMIL ER CAP 300MGverapamil SR capVERAPAMIL SR CAP 360mgverapamil SR tabverapamil tabVERELAN PM ER CAP 100MG, 300MGVERELAN SR CAP 360mgCARDIAC GLYCOSIDESDIGOXIN SOLNdigoxin tabCARDIOVASCULAR AGENTS - MISC.amlodipine/atorvastatin tabENTRESTO TABCONTRACEPTIVESamethyst tabashlyna tab, daysee tabCERVICAL CAPCONCEPTROL GELCONTRACEPTIVE FILMCONTRACEPTIVE FOAM

CONTRACEPTIVE GELCONTRACEPTIVE SUPPcryselle tabDEPO-PROVERA SC INJ 104MGDIAPHRAGMELLA TABenpresse tabFEMALE CONDOMSgianvi tab, ocella tabIMPLANON IMPLANT, NEXPLANON IMPLANTisibloom tab, enskyce tab, apri tabjunel FE tabjunel tabkelnor tablayolis FE tab, wymzya FE tablevonorgestrel tabLEVONORGESTREL TAB 0.75MGLO LOESTRIN TABLOESTRIN 24 FE TABmedroxyprogesterone injmibelas chew tabMIRENA IUDNATAZIA TABNECON TABnorethindrone tabnortrel 7/7/7 tab, pirmella 7/7/7 tabnortrel tabNUVARINGOGESTREL TABPARAGARD IUDPLAN B TABSLYND TABsprintec 28 tabTODAY SPONGE




tri-legest tabtri-sprintec tabvcf vaginal gelvelivet tabvienva tab, lessina tab, kurvelo tabviorele tab, kariva tabXULANE PATCHDIAGNOSTIC PRODUCTSACCU-CHEK AVIVA PLUS METERACCU-CHEK AVIVA PLUS TEST STRIPACCU-CHEK GUIDE CARE METERACCU-CHEK GUIDE ME KITACCU-CHEK GUIDE TEST STRIPACCU-CHEK NANO METERACCU-CHEK SMARTVIEW TEST STRIPACCU-CHEK TEST STRIPCALIBRATION LIQUIDCLINISTIX TEST STRIPDEXCOM G6 RECEIVERDEXCOM G6 SENSORDEXCOM G6 TRANSMITTERDIABETIC PUMPFREESTYLE FREEDOM LITE METERFREESTYLE INSULINX METERFREESTYLE INSULINX TEST STRIPFREESTYLE LIBRE RECEIVERFREESTYLE LIBRE SENSOR (10-DAY)FREESTYLE LIBRE SENSOR (14-DAY)FREESTYLE LITE METERFREESTYLE LITE TEST STRIPFREESTYLE PRECISION NEO METERFREESTYLE PRECISION NEO TEST STRIPFREESTYLE TEST STRIPKETO-DIASTIX TEST STRIPKETOSTIXLANCET DEVICE

LANCET KITLANCETSOMNIPOD 5 PACK PODSOMNIPOD DASH PODSOMNIPOD STARTER KITPRECISION XTRA KETONE TEST STRIPPRECISION XTRA METERPRECISION XTRA TEST STRIPPUMP SUPPLIESV-GO INJ KITDIURETICSacetazolamide ER capacetazolamide tabALDACTAZIDE TAB 50-50MGamiloride tabamiloride/hydrochlorothiazide tabbumetanide tabCHLOROTHIAZIDE TABCHLORTHALIDONE TABDIURIL SUSPethacrynic tabFUROSEMIDE SOLNfurosemide tabhydrochlorothiazide caphydrochlorothiazide tabindapamide tabmethazolamide tabMETHYCLOTHIAZIDE TABmetolazone tabspironolactone tabspironolactone/hydrochlorothiazide tabtorsemide tabtriamterene captriamterene/hydrochlorothiazide capTRIAMTERENE/HYDROCHLOROTHIAZIDE CAP 50-25mg




triamterene/hydrochlorothiazide tabENDOCRINE AND METABOLIC AGENTS - MISC.ALENDRONATE SOLNalendronate tabALENDRONATE TAB 40MGcalcitonin nasal sprayETIDRONATE DISODIUM TAB 400MGFORTEO INJFORTICAL NASAL SPRAYFOSAMAX+D TABibandronate tab 150mgMIACALCIN INJNATPARA INJrisedronate DR tabrisedronate tabSKELID TABTYMLOS INJGOUT AGENTSallopurinol tabcolchicine/probenecid tabfebuxostat tabMITIGARE CAPprobenecid tabHEMATOLOGICAL AGENTS - MISC.anagrelide capaspirin/dipyridamole capBRILINTA TABCABLIVI INJ KITcilostazol tabclopidogrel tab 75mgdipyridamole tabpentoxifylline ER tabprasugrel tabTICLOPIDINE TAB

ZONTIVITY TABLAXATIVESCLENPIQ SOLNGAVILYTE-C SOLNKRISTALOSE PACKKRISTALOSE PACKETlactulose solnpeg 3350/electrolytes solntrilyte solnMINERALS & ELECTROLYTESFLUORABON SOLNFLUOR-A-DAY CHEW TABGALZIN CAPKLOR-CON M15 TABKLOR-CON POWDER PACKET 25MEQK-PHOS TABK-TABLURIDE CHEW TABLURIDE SOLNphospha 250 neutral tabPOT/CHLORIDE EFFER TABpotassium bicarbonate effer tabpotassium chloride effer tabpotassium chloride ER cappotassium chloride ER tabpotassium chloride micro tabpotassium chloride powder packetpotassium chloride solnsodium fluoride chew tabSODIUM FLUORIDE LOZENGEsodium fluoride solnSODIUM FLUORIDE TABzinc sulfate capMOUTH/THROAT/DENTAL AGENTSchlorhexidine gluconate solnPREVIDENT 5000 PLUS CREAM




PREVIDENT GELPREVIDENT PASTEPREVIDENT RINSEsodium fluoride creamsodium fluoride gelsodium fluoride pastesodium fluoride rinsesodium fluoride/potassium nitrate pastetriamcinolone in orabase pastePSYCHOTHERAPEUTIC COMBINATION AGENTSCHLORDIAZEPOXIDE/AMITRIPTYLINE TABolanzapine/fluoxetine capPERPHENAZINE/ AMITRIPTYLINE TABSMOKING CESSATIONbupropion SR tabCHANTIX PAKCHANTIX TABNICODERM PATCHNICORETTE GUMNICORETTE LOZENGEnicotine gumNICOTINE KITnicotine lozengenicotine patchNICOTROL INHALERNICOTROL NASAL SPRAYZYBAN TABTHYROID AGENTSARMOUR THYROID TAB, NATURE THROID TABliothyronine tabmethimazole tabnp thyroid tab

propylthiouracil tabSYNTHROID TABTHYROLAR TABVACCINESADACEL/BOOSTRIX INJAFLURIA INJAFLURIA INJ, FLUZONE INJBEXSERO INJCERVARIX INJENGERIX-B INJENGERIX-B INJ, RECOMBIVAX-HB INJFLUAD INJFLUAD QUAD INJFLUBLOK INJFLUBLOK QUAD PF INJFLUCELVAX INJFLUCELVAX QUAD INJFLULAVAL QUAD INJ, FLUZONE QUAD INJFLUMIST QUADRIVALENT NASAL SUSPFLUVIRIN INJFLUVIRIN PF INJFLUZONE HD PF INJFLUZONE HIGH DOSE PF INJFLUZONE INTRADERMAL INJFLUZONE QUAD INJFLUZONE/FLUARIX QUAD INJGARDASIL 9 INJGARDASIL INJHAVRIX INJ, VAQTA INJHEPLISAV-B INJMENACTRA INJMENHIBRIX INJMENOMUNE INJMENVEO INJM-M-R II INJ




PNEUMOVAX INJPREVNAR 13 INJSHINGRIX INJTETANUS/DIPHTHERIA TOXOID INJTRUMENBA INJTWINRIX INJVARIVAX INJVAXCHORA SUSPVIVOTIF CAPZOSTAVAX INJVITAMINSCONCEPT DHA CAPMYNATAL-Z TABPRENATABS RX TABPRENATAL 19 CHEW TABPRENATAL 19 TABPRENATAL VITAMINS (NON-PREFERRED)PRENATAL VITAMINS (PRENATAL PLUS, PREPLUS, PRENAPLUS)VITAFOL STRIPSVP-PNV-DHA CAP

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High Deductible Health Plan Expanded Preventive Drug ListNITROGLYCERIN ER CAP nitroglycerin lingual spray nitroglycerin patch nitroglycerin SL tab NITROMIST SPRAY ... B-D INSULIN SYRINGE