$0 Preferred Generics List

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1 2017 HMO/POS/Select $0 Preferred Generics List Members enrolled in one of the listed HMO/POS/Select plans beginning on or after January 1, 2016 will have a zero-dollar copayment for the following Preferred Generic drugs. This list includes preferred generic drugs used in the treatment of the following conditions: diabetes, hypertension, congestive heart failure, bipolar disorder, asthma, COPD, and coronary artery disease. Please note this list does not guarantee coverage and is subject to change. If you have questions about your prescription drug plan, please visit and log into your member portal Small Group Plans: Evergreen Health Small Group Open-Access Platinum 500 Evergreen Health Small Group Open-Access Gold Plus 1500 Evergreen Health Small Group Open-Access Silver Plus 3000 Evergreen Health Small Group POS Platinum 500 Evergreen Health Small Group POS Gold 1000 Evergreen Health Small Group POS Gold Plus 1500 Evergreen Health Small Group POS Silver 1900 Evergreen Health Small Group POS Silver Plus 3000 Evergreen Health Small Group Select Platinum 500 Evergreen Health Small Group Select Gold 1500 Evergreen Health Small Group Select Silver 3500 Effective January 1,

2 Diabetic Medications GLIMEPIRIDE TAB 1MG GLIMEPIRIDE TAB 2MG GLIMEPIRIDE TAB 4MG GLIPIZIDE TAB 10MG GLIPIZIDE TAB 5MG GLIPIZIDE ER TAB 10MG GLIPIZIDE ER TAB 2.5MG GLIPIZIDE ER TAB 5MG GLIPIZIDE XL TAB 10MG GLIPIZIDE XL TAB 2.5MG GLIPIZIDE XL TAB 5MG GLYBURID MCR TAB 3MG GLYBURID MCR TAB 6MG GLYBURIDE TAB 1.25MG GLYBURIDE TAB 2.5MG GLYBURIDE TAB 5MG METFORMIN TAB 1000MG METFORMIN TAB 500MG Biguanides METFORMIN TAB 500MG ER Biguanides METFORMIN TAB 850MG Biguanides GLIMEPIRIDE TAB 1MG Biguanides Asthma/Congestive Obstructive Pulmonary Disease (COPD) Medications ALBUTEROL NEB 0.5% DEXAMETH PHO INJ 10MG/ML DEXAMETH PHO INJ 120MG/30 DEXAMETH PHO INJ 20MG/5ML DEXAMETH PHO INJ 4MG/ML DEXAMETHASON ELX 0.5/5ML DEXAMETHASON SOL 0.5/5ML DEXAMETHASON TAB 0.5MG DEXAMETHASON TAB 0.75MG DEXAMETHASON TAB 1MG DEXAMETHASON TAB 2MG DEXAMETHASON TAB 4MG DEXAMETHASON TAB 6MG HYDROCORT TAB 10MG HYDROCORT TAB 20MG HYDROCORT TAB 5MG IPRATROPIUM SOL 0.02%INH METHYLPR ACE INJ 40MG/ML METHYLPR SS INJ 1000MG 2 Effective January 1, 2017

3 Asthma/Congestive Obstructive Pulmonary Disease (COPD) Medications METHYLPRED PAK 4MG METHYLPRED TAB 16MG METHYLPRED TAB 32MG METHYLPRED TAB 4MG METHYLPRED TAB 8MG MONTELUKAST CHW 4MG MONTELUKAST CHW 5MG MONTELUKAST GRA 4MG MONTELUKAST TAB 10MG PRED SOD PHO SOL 5MG/5ML PREDNISOLONE SOL 15MG/5ML PREDNISOLONE SYP 15MG/5ML PREDNISONE PAK 10MG PREDNISONE PAK 5MG PREDNISONE SOL 5MG/5ML PREDNISONE TAB 10MG PREDNISONE TAB 1MG PREDNISONE TAB 2.5MG PREDNISONE TAB 20MG PREDNISONE TAB 50MG PREDNISONE TAB 5MG Antiasthmatics - Anticholinergics Beta Adrenergics Congestive Heart Failure (CHF) Medications AMILOR/HCTZ TAB 5-50 BUMETANIDE TAB 0.5MG BUMETANIDE TAB 1MG BUMETANIDE TAB 2MG CHLOROTHIAZ TAB 250MG CHLORTHALID TAB 25MG CHLORTHALID TAB 50MG DIGITEK TAB 0.25MG DIGOX TAB 0.125MG DIGOX TAB 0.25MG DIGOXIN TAB 0.125MG DIGOXIN TAB 0.25MG FUROSEMIDE TAB 20MG FUROSEMIDE TAB 40MG FUROSEMIDE TAB 80MG HYDROCHLOROT CAP 12.5MG HYDROCHLOROT TAB 12.5MG HYDROCHLOROT TAB 25MG Effective January 1,

4 Congestive Heart Failure (CHF) Medications (continued) HYDROCHLOROT TAB 50MG INDAPAMIDE TAB 1.25MG INDAPAMIDE TAB 2.5MG JANTOVEN TAB 1MG JANTOVEN TAB 2.5MG JANTOVEN TAB 2MG JANTOVEN TAB 3MG Potassium Sparing Diuretics JANTOVEN TAB 5MG Potassium Sparing Diuretics JANTOVEN TAB 6MG Potassium Sparing Diuretics JANTOVEN TAB 7.5MG Thiazides and Thiazide-Like Diuretics SPIRONO/HCTZ TAB 25/25 SPIRONOLACT TAB 100MG SPIRONOLACT TAB 25MG SPIRONOLACT TAB 50MG Thiazides and Thiazide-Like Diuretics Thiazides and Thiazide-Like Diuretics Thiazides and Thiazide-Like Diuretics Thiazides and Thiazide-Like Diuretics TORSEMIDE TAB 100MG Thiazides and Thiazide-Like Diuretics TORSEMIDE TAB 10MG Thiazides and Thiazide-Like Diuretics TORSEMIDE TAB 20MG Combination Diuretics TORSEMIDE TAB 5MG Combination Diuretics TRIAMT/HCTZ CAP TRIAMT/HCTZ CAP 50-25MG TRIAMT/HCTZ TAB TRIAMT/HCTZ TAB 75-50MG Combination Diuretics Combination Diuretics Combination Diuretics Coumarin Anticoagulants WARFARIN TAB 10MG Coumarin Anticoagulants WARFARIN TAB 1MG Coumarin Anticoagulants WARFARIN TAB 2.5MG Coumarin Anticoagulants WARFARIN TAB 2MG Coumarin Anticoagulants WARFARIN TAB 3MG Coumarin Anticoagulants WARFARIN TAB 4MG Coumarin Anticoagulants WARFARIN TAB 5MG Coumarin Anticoagulants WARFARIN TAB 7.5MG Coumarin Anticoagulants WARFARIN SOD TAB 10MG Coumarin Anticoagulants 4 Effective January 1, 2017

5 Hypertensive (High Blood Pressure) Medications AMLODIPINE TAB 10MG AMLODIPINE TAB 2.5MG AMLODIPINE TAB 5MG ATENOL/CHLOR TAB MG ATENOL/CHLOR TAB 50-25MG ATENOLOL TAB 100MG ATENOLOL TAB 25MG ATENOLOL TAB 50MG BENAZEPRIL TAB 10MG BENAZEPRIL TAB 20MG BENAZEPRIL TAB 40MG BENAZEPRIL TAB 5MG BISOPRL/HCTZ TAB 10/6.25 BISOPRL/HCTZ TAB 2.5/6.25 BISOPRL/HCTZ TAB MG BISOPROL FUM TAB 10MG BISOPROL FUM TAB 5MG CARVEDILOL TAB 12.5MG CARVEDILOL TAB 25MG CARVEDILOL TAB 3.125MG CARVEDILOL TAB 6.25MG Alpha-Beta Blockers Alpha-Beta Blockers Alpha-Beta Blockers Alpha-Beta Blockers Calcium Blockers Calcium Blockers Calcium Blockers CLONIDINE TAB 0.1MG Calcium Blockers CLONIDINE TAB 0.2MG Calcium Blockers DOXAZOSIN TAB 1MG DOXAZOSIN TAB 2MG DOXAZOSIN TAB 4MG DOXAZOSIN TAB 8MG ENALAPR/HCTZ TAB MG ENALAPRIL TAB 10MG ENALAPRIL TAB 2.5MG ENALAPRIL TAB 20MG ENALAPRIL TAB 5MG FOSINOPRIL TAB 10MG FOSINOPRIL TAB 20MG FOSINOPRIL TAB 40MG GUANFACINE TAB 1MG HYDRALAZINE TAB 100MG HYDRALAZINE TAB 10MG HYDRALAZINE TAB 25MG HYDRALAZINE TAB 50MG Effective January 1,

6 Hypertensive (High Blood Pressure) Medications (continued) LISINOP/HCTZ TAB LISINOP/HCTZ TAB LISINOP/HCTZ TAB 20-25MG LISINOPRIL TAB 10MG LISINOPRIL TAB 2.5MG LISINOPRIL TAB 20MG LISINOPRIL TAB 30MG LISINOPRIL TAB 40MG LISINOPRIL TAB 5MG LOSARTAN POT TAB 100MG LOSARTAN POT TAB 25MG LOSARTAN POT TAB 50MG LOSARTAN/HCT TAB LOSARTAN/HCT TAB LOSARTAN/HCT TAB METHYLDOPA TAB 250MG METHYLDOPA TAB 500MG METOPROL TAR TAB 100MG METOPROL TAR TAB 25MG METOPROL TAR TAB 50MG Angiotensin II Receptor Antagonist Angiotensin II Receptor Antagonist Angiotensin II Receptor Antagonist MOEXIPRIL TAB 15MG PRAZOSIN HCL CAP 1MG PRAZOSIN HCL CAP 2MG PRAZOSIN HCL CAP 5MG PROPRANOLOL TAB 10MG PROPRANOLOL TAB 20MG PROPRANOLOL TAB 40MG PROPRANOLOL TAB 80MG QUINAPRIL TAB 10MG QUINAPRIL TAB 20MG QUINAPRIL TAB 40MG RAMIPRIL CAP 10MG RAMIPRIL CAP 2.5MG RAMIPRIL CAP 5MG Vasodilators SOTALOL HCL TAB 80MG Vasodilators TERAZOSIN CAP 10MG Vasodilators TERAZOSIN CAP 1MG Vasodilators TERAZOSIN CAP 2MG & Thiazide/Thiazide-Like TERAZOSIN CAP 5MG & Thiazide/Thiazide-Like TRANDOLAPRIL TAB 4MG VERAPAMIL TAB 120MG VERAPAMIL TAB 80MG 6 Effective January 1, 2017

7 Coronary Artery Disease (CAD) SIMVASTATIN TAB 40MG ATORVASTATIN TAB 20MG ATORVASTATIN TAB 10MG GEMFIBROZIL TAB 600MG SIMVASTATIN TAB 10MG SIMVASTATIN TAB 80MG SIMVASTATIN TAB 20MG ATORVASTATIN TAB 40MG SIMVASTATIN TAB 5MG ATORVASTATIN TAB 80MG Fibric Acid Derivatives Psychiatric Medications AMITRIPTYLIN TAB 100MG AMITRIPTYLIN TAB 10MG AMITRIPTYLIN TAB 150MG AMITRIPTYLIN TAB 25MG AMITRIPTYLIN TAB 50MG AMITRIPTYLIN TAB 75MG CARBAMAZEPIN TAB 200MG CITALOPRAM TAB 10MG CITALOPRAM TAB 20MG CITALOPRAM TAB 40MG DOXEPIN HCL CAP 100MG DOXEPIN HCL CAP 10MG Misc. Anticonvulsants Effective January 1,

8 Psychiatric Medications (continued) DOXEPIN HCL CAP 150MG DOXEPIN HCL CAP 25MG DOXEPIN HCL CAP 50MG DOXEPIN HCL CON 10MG/ML EPITOL TAB 200MG Misc. Anticonvulsants FLUOXETINE CAP 10MG FLUOXETINE CAP 20MG FLUOXETINE CAP 40MG FLUOXETINE TAB 10MG FLUPHENAZINE TAB 1MG Antipsychotics Phenothiazines HALOPERIDOL TAB 0.5MG Antipsychotics Butyrophenones HALOPERIDOL TAB 1MG Antipsychotics Butyrophenones HALOPERIDOL TAB 2MG Antipsychotics Butyrophenones HALOPERIDOL TAB 5MG Antipsychotics Butyrophenones LITHIUM CARB CAP 150MG LITHIUM CARB CAP 300MG LITHIUM CARB CAP 600MG LITHIUM CARB TAB 300MG LITHIUM CARB TAB 300MG ER LITHIUM CARB TAB 450MG ER MIRTAZAPINE TAB 15MG MIRTAZAPINE TAB 15MG ODT MIRTAZAPINE TAB 30MG MIRTAZAPINE TAB 45MG MIRTAZAPINE TAB 7.5MG NORTRIPTYLIN CAP 10MG NORTRIPTYLIN CAP 25MG NORTRIPTYLIN CAP 50MG NORTRIPTYLIN CAP 75MG PAROXETINE TAB 10MG PAROXETINE TAB 20MG PAROXETINE TAB 30MG PAROXETINE TAB 40MG PRIMIDONE TAB 250MG Misc. Anticonvulsants PRIMIDONE TAB 50MG Misc. Anticonvulsants PROCHLORPER TAB 10MG Antipsychotics Phenothiazines TRAZODONE TAB 100MG Antidepressant - Modified Cyclics TRAZODONE TAB 150MG Antidepressant - Modified Cyclics TRAZODONE TAB 50MG Antidepressant - Modified Cyclics VALPROIC ACD CAP 250MG Valproic Acid VALPROIC ACD SOL 250/5ML Valproic Acid VALPROIC ACD SYP 250/5ML Valproic Acid 8 Effective January 1, 2017

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