HSA Preventive Drug List

2024 EpiphanyRx Preventive Drug List (4/1/2024) Your employer is working to reduce your health care costs by giving you tools to help you stay healthy and productive. The preventive medications below 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. ASTHMA AND OTHER RESPIRATORY CONDITIONS Tier 1 Tier 2 Tier 3 albuterol HFA inhaler ADVAIR HFA INHALER ACCOLATE TAB albuterol neb soln ALVESCO INHALER ACCUNEB NEB SOLN albuterol sulfate tab ANORO ELLIPTA INHALER ADVAIR DISKUS INHALER albuterol sulfate syrup ATROVENT HFA INHALER BROVANA NEB SOLN albuterol/ipratropium neb soln BREO ELLIPTA INHALER DALIRESP TAB aminophylline tab BREZTRI AEROSPHERE INHALER DUONEB NEB SOLN arformoterol tartrate neb soln COMBIVENT INHALER FLOVENT DISKUS INHALER ARNUITY ELLIPTA INHALER COMBIVENT RESPIMAT INHALER FLOVENT HFA INHALER ASMANEX HFA INHALER DULERA INHALER LEVALBUTEROL INHALER, XOPENEX ASMANEX INHALER ELIXOPHYLLIN ELIXIR HFA budesonide inh susp INCRUSE ELLIPTA INHALER LUFYLLIN TAB budesonide/formoterol inhaler LONHALA MAGNAIR SOLN PERFOROMIST NEB SOLN FLUTICASONE PROPIONATE DISKUS INHALER QVAR REDIHALER PULMICORT INH SUSP FLUTICASONE HFA INHALER SEREVENT DISKUS INHALER SINGULAIR CHEW TAB FLUTICASONE/SALMETEROL INHALER SPIRIVA RESPIMAT INHALER 1.25MCG SINGULAIR GRANULE PACK fluticasone/salmeterol inhaler, wixela STIOLTO INHALER SINGULAIR TAB formoterol fumarate neb soln THEOPHYLLINE ER TAB STRIVERDI RESPIMAT INHALER ipratropium neb soln TRELEGY ELLIPTA INHALER SYMBICORT INHALER levalbuterol neb soln THEO-24 CAP montelukast chew tab VOSPIRE ER TAB montelukast granule pack XOPENEX NEB SOLN

montelukast tab peak flow meter roflumilast tab terbutaline sulfate tab theophylline ER tab theophylline soln VENTOLIN HFA INHALER zafirlukast tab CONDITIONS RELATED TO BLOOD CLOTS Tier 1 Tier 2 Tier 3 anagrelide cap BRILINTA TAB AGGRENOX CAP aspirin/dipyridamole cap CABLIVI INJ KIT AGRYLIN CAP cilostazol tab ELIQUIS TAB, ELIQUIS STARTER PACK ARIXTRA INJ clopidogrel tab 75mg XARELTO STARTER PACK COUMADIN TAB dipyridamole tab XARELTO SUSP EFFIENT TAB enoxaparin inj XARELTO TAB FRAGMIN INJ fondaparinux inj LOVENOX INJ prasugrel tab PERSANTINE TAB ticlopidine tab PLAVIX TAB 75mg warfarin tab PLETAL TAB PRADAXA CAP ZONTIVITY TAB DIABETES Tier 1 Tier 2 Tier 3 acarbose tab BAQSIMI NASAL POWDER ACTOS TAB diazoxide susp BYDUREON BCISE AUTO INJ AMARYL TAB glimepiride tab BYDUREON INJ / PEN BYETTA INJ glipizide ER tab FARXIGA TAB CYCLOSET TAB glipizide tab GLUCAGON HYPOKIT INJ DIABETA TAB glipizide/metformin tab GLUCAGON EMR INJ GLUCOPHAGE TAB glucagon (rdna) for inj kit GLUCAGON INJ KIT GLUCOPHAGE XR TAB Page 2 of 10

glyburide micronized tab GLYXAMBI TAB GLUCOTROL TAB glyburide tab GVOKE INJ / KIT / PFS INJ GLUCOTROL XL TAB glyburide/metformin tab HUMALOG KWIKPEN INJ GLUCOVANCE TAB INSULIN LISPRO INJ (VIAL) HUMALOG JR KWIKPEN INJ GLYNASE TAB metformin ER tab HUMALOG MIX INJ GLYSET TAB metformin soln HUMALOG MIX KWIKPEN INJ METAGLIP TAB metformin tab HUMALOG PEN INJ PRANDIN TAB miglitol tab HUMULIN MIX INJ / PEN PRECOSE TAB nateglinide tab HUMULIN N INJ / PEN PROGLYCEM SUSP pioglitazone tab HUMULIN R INJ / PEN RIOMET ER SUSP repaglinide tab HUMULIN R U-500 KWIKPEN / INJ RIOMET SOLN tolazamide tab INSULIN LISPRO KWIKPEN STARLIX TAB INSULIN LISPRO MIX KWIKPEN INSULIN LISPRO JR KWIKPEN JANUMET TAB JANUMET XR TAB JANUVIA TAB JARDIANCE TAB JENTADUETO TAB JENTADUETO XR TAB KORLYM TAB LEVEMIR FLEXTOUCH INJ LEVEMIR INJ LYUMJEV INJ LYUMJEV KWIKPEN INJ MOUNJARO INJ OZEMPIC INJ RYBELSUS TAB SEMGLEE INJ, insulin glargine inj (LANTUS equivalent) SEMGLEE PEN, insulin glargine inj (LANTUS equivalent) SOLIQUA INJ SYNJARDY TAB Page 3 of 10

SYNJARDY XR TAB 10-1000mg, 25- 1000mg SYNJARDY XR TAB 5-1000mg, 12.5- 1000mg TOLBUTAMIDE TAB TOUJEO MAX SOLOSTAR INJ TOUJEO SOLOSTAR INJ TRADJENTA TAB TRESIBA FLEXTOUCH INJ TRESIBA INJ TRIJARDY XR TAB 10-5-1000mg, 25-5- 1000mg TRIJARDY XR TAB 5-25-1000mg, 12.5-2.5- 1000mg TRULICITY INJ VICTOZA INJ XIGDUO XR TAB 2.5-1000mg, 5-1000mg XIGDUO XR TAB 5-500mg, 10-500mg, 10- 1000mg XULTOPHY INJ ZEGALOGUE INJ DIABETIC SUPPLIES Tier 1 Tier 2 Tier 3 B-D INSULIN SYRINGE ACCU-CHEK AVIVA PLUS TEST STRIP B-D PEN NEEDLE ACCU-CHEK GUIDE TEST STRIP CALIBRATION LIQUID ACCU-CHEK SMARTVIEW TEST STRIP CLINISTIX TEST STRIP ACCU-CHEK TEST STRIP KETO-DIASTIX TEST STRIP DEXCOM G7 RECEIVER KETOSTIX DEXCOM G7 SENSOR LANCET DEVICE DEXCOM G6 RECEIVER LANCET KIT DEXCOM G6 SENSOR LANCET DEXCOM G6 TRANSMITTER NOVOFINE PEN NEEDLE FREESTYLE LIBRE 2 RECEIVER Page 4 of 10

NOVOTWIST PEN NEEDLE FREESTYLE LIBRE 2 SENSOR NOVOTWIST/NOVOFINE PEN NEEDLE FREESTYLE LIBRE 3 SENSOR FREESTYLE LIBRE 3 RECEIVER FREESTYLE LIBRE RECEIVER FREESTYLE LIBRE SENSOR (14-DAY) OMNIPOD STARTER KIT OMNIPOD GO KIT OMNIPOD DASH INTRO KIT OMNIPOD 5 INTRO KIT OMNIPOD 5 PACK PODS OMNIPOD 5 G7 INTRO KIT OMNIPOD 5 G7 PODS ONETOUCH TEST STRIP ONETOUCH VERIO TEST STRIP V-GO INJ KIT EMOTIONAL HEALTH Tier 1 Tier 2 Tier 3 citalopram soln / tab CELEXA TAB escitalopram soln / tab LEXAPRO SOLN / TAB fluoxetine soln / cap / tab LUVOX CR CAP fluvoxamine ER cap PAXIL CR TAB fluvoxamine tab PAXIL SUSP / TAB paroxetine ER tab PROZAC SOLN / CAP / TAB paroxetine oral susp / tab ZOLOFT CONC / TAB sertraline conc / tab Page 5 of 10

HIGH BLOOD PRESSURE Tier 1 Tier 2 Tier 3 acebutolol cap DIURIL SUSP ACCUPRIL TAB aliskiren tab ENTRESTO TAB ACCURETIC TAB amiloride tab MULTAQ TAB ACEON TAB amiloride/hydrochlorothiazide tab NITRO-BID OINT ADALAT CC TAB amiodarone tab NORPACE CR CAP ALDACTAZIDE TAB amlodipine tab ALDACTAZIDE TAB 50-50mg amlodipine/benazepril cap ALDACTONE TAB amlodipine/olmesartan tab ALTACE CAP amlodipine/valsartan tab ALTACE TAB atenolol tab AMTURNIDE TAB atenolol/chlorthalidone tab ATACAND TAB benazepril tab AVALIDE TAB benazepril/hydrochlorothiazide tab AVAPRO TAB betaxolol tab AZOR TAB bisoprolol tab BENICAR HCT TAB bisoprolol/hydrochlorothiazide tab BETAPACE AF TAB bumetanide tab BETAPACE TAB candesartan tab CALAN SR TAB captopril tab CALAN TAB captopril/hydrochlorothiazide tab CARDENE SR CAP carvedilol tab CARDIZEM CD CAP chlorothiazide tab CARDIZEM LA TAB chlorthalidone tab CARDIZEM TAB clonidine patch CARDURA TAB clonidine tab CAROSPIR SUSP digoxin soln CATAPRES TAB digoxin tab CATAPRES-TTS PATCH diltiazem ER cap CORDARONE TAB diltiazem ER tab COREG TAB diltiazem tab CORGARD TAB disopyramide cap CORZIDE TAB Page 6 of 10

CORZIDE TAB 80-5mg dofetilide cap COVERA-HS TAB doxazosin tab COZAAR TAB enalapril maleate oral soln DEMADEX TAB enalapril tab DIBENZYLINE CAP enalapril/hydrochlorothiazide tab DILACOR XR CAP eplerenone tab DILATRATE SR CAP ethacrynic tab DIOVAN HCT TAB felodipine ER tab DIOVAN TAB flecainide tab DYAZIDE CAP fosinopril tab DYNACIRC CR TAB fosinopril/hydrochlorothiazide tab DYRENIUM CAP furosemide soln EDECRIN TAB furosemide tab EPANED SOLN guanfacine IR tab EXFORGE TAB hydralazine tab FIRST ATENOLOL SOLN hydrochlorothiazide cap FIRST METOPROLOL ORAL SOLN hydrochlorothiazide tab GUANABENZ TAB indapamide tab HYZAAR TAB irbesartan tab IMDUR TAB irbesartan/hydrochlorothiazide tab INDERAL LA CAP isosorbide dinitrate tab INSPRA TAB isosorbide dinitrate tab 40mg ISORDIL TITRADOSE TAB isosorbide mononitrate ER tab ISORDIL TITRADOSE TAB 40mg isosorbide mononitrate tab KATERZIA SUSP isoxsuprine tab LANOXIN TAB isradipine cap LASIX TAB labetalol tab LEVATOL TAB lisinopril tab LOPRESSOR HCT TAB lisinopril/hydrochlorothiazide tab LOPRESSOR TAB losartan tab LOTENSIN HCT TAB losartan/hydrochlorothiazide tab LOTENSIN TAB METHYCLOTHIAZIDE TAB LOTREL CAP methyldopa tab MAXZIDE TAB Page 7 of 10

MICARDIS TAB metolazone tab MICROZIDE CAP metoprolol ER tab MIDAMOR TAB metoprolol tab MINIPRESS CAP metoprolol/hydrochlorothiazide tab NEXICLON XR SUSP mexiletine hcl cap NIMOTOP CAP midodrine tab NISOLDIPINE ER TAB 25.5mg minoxidil tab NITRO-DUR PATCH moexipril tab NITRO-DUR PATCH 0.3mg/HR, nadolol tab 0.8mg/HR nadolol/bendroflumethiazide tab NITROLINGUAL PUMP SPRAY nebivolol hcl tab NITROMIST SPRAY nicardipine cap NITROSTAT SL TAB nifedipine cap NORPACE CAP nifedipine ER tab NORVASC TAB nimodipine cap PRINIVIL TAB, ZESTRIL TAB nisoldipine ER tab PROAMATINE TAB nisoldipine ER tab 20mg, 30mg, 40mg PROCARDIA CAP nitroglycerin ER cap QBRELIS SOLN nitroglycerin lingual spray QUINIDINE SULFATE ER TAB nitroglycerin patch RANEXA TAB nitroglycerin SL tab RESERPINE TAB olmesartan tab RYTHMOL SR CAP olmesartan/hydrochlorothiazide tab RYTHMOL TAB perindopril tab SECTRAL CAP phenoxybenzamine cap SOTYLIZE SOLN 5mg/ML pindolol tab SULAR TAB prazosin cap TAMBOCOR TAB propafenone ER cap TEKAMLO TAB propafenone tab TEKTURNA HCT TAB propranolol ER cap TEKTURNA TAB propranolol oral soln 20mg/5ml TENEX TAB propranolol soln TENORETIC TAB propranolol tab TENORMIN TAB Page 8 of 10

TIAZAC CAP quinapril tab TIKOSYN CAP quinapril/hydrochlorothiazide tab TOPROL XL TAB quinidine gluconate CR tab TRANDATE TAB quinidine sulfate tab UNIRETIC TAB ramipril cap VALTURNA TAB ranolazine tab VASERETIC TAB sotalol AF tab VASOTEC TAB sotalol tab VERELAN CAP spironolactone tab VERELAN PM CAP spironolactone/hydrochlorothiazide tab VERELAN PM ER CAP 100mg, telmisartan tab 300mg terazosin cap VERELAN SR CAP 360mg timolol maleate tab ZAROXOLYN TAB torsemide tab ZEBETA TAB trandolapril tab ZESTORETIC TAB triamterene cap ZIAC TAB triamterene/hydrochlorothiazide cap / tab valsartan tab valsartan/hydrochlorothiazide tab verapamil SR cap / tab verapamil SR cap 360mg verapamil tab HIGH CHOLESTEROL Tier 1 Tier 2 Tier 3 atorvastatin tab* COLESTID GRANULE cholestyramine lite powder COLESTID POWDER PACK cholestyramine lite powder pack COLESTID TAB cholestyramine powder CRESTOR TAB cholestyramine powder pack FENOFIBRIC TAB, FIBRICOR TAB colesevelam pack LESCOL CAP colesevelam tab LESCOL XL TAB colestipol granule / powder packet LIPITOR TAB Page 9 of 10

colestipol tab LIVALO TAB ezetimibe tab LOPID TAB ezetimibe/simvastatin tab LOVAZA CAP fenofibrate cap 67mg, 134mg, 200mg MEVACOR TAB fenofibrate tab 48mg, 54mg, 145mg, NIASPAN ER TAB 160mg PRAVACHOL TAB fenofibric acid DR cap QUESTRAN LITE POWDER / PACK fluvastatin cap QUESTRAN POWDER / PACK fluvastatin ER tab TRICOR TAB gemfibrozil tab VASCEPA CAP icosapent ethyl cap VYTORIN TAB lovastatin tab* WELCHOL PACK / TAB niacin ER tab ZOCOR TAB omega-3-acid ethyl esters cap pravastatin tab* rosuvastatin tab* simvastatin tab* OSTEOPOROSIS (BONE DISEASE) Tier 1 Tier 2 Tier 3 alendronate sodium oral soln ALENDRONATE TAB 40mg ACTONEL TAB alendronate tab FORTICAL NASAL SPRAY ATELVIA TAB calcitonin nasal spray NATPARA INJ BONIVA TAB 150mg ibandronate tab 150mg TERIPARATIDE INJ FOSAMAX TAB risedronate DR tab TYMLOS INJ SKELID TAB *This drug is also on the ACA List ($0 copay). Page 10 of 10