Coronary Artery Disease (CAD) and Congestive Heart Failure (CHF)

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1 06/2015 Express Scripts Preventive Care Drug Listing for J.C. Penney Associates Please note that this listing is to be used as a general reference and does not apply to all strengths or dosage forms of a drug. This list is subject to change based on formulary composition and/or marketplace conditions. For further details and specific drug coverage verification, please call Express Scripts at Asthma/Chronic Obstructive Pulmonary Disease (COPD) ALBUTEROL SULFATE DYLIX PULMICORT FLEXHALER ALBUTEROL SULFATE HFA ELIXOPHYLLIN QVAR ARCAPTA FORADIL SEREVENT DISKUS ASMANEX/ASMANEX HFA IPRATROPIUM BROMIDE SPIRIVA ATROVENT HFA IPRATROPIUM-ALBUTEROL SYMBICORT BUDESONIDE LEVALBUTEROL HCL TERBUTALINE SULFATE COMBIVENT METAPROTERENOL SULFATE THEOCHRON COMBIVENT RESPIMAT MONTELUKAST SODIUM THEOPHYLLINE ANHYDROUS CROMOLYN SODIUM PERFOROMIST VENTOLIN HFA DIFIL-G 400 PROAIR HFA ZAFIRLUKAST DULERA PULMICORT Coronary Artery Disease (CAD) and Congestive Heart Failure (CHF) ACEBUTOLOL HCL ENALAPRIL MALEATE/HCTZ NISOLDIPINE ACETAZOLAMIDE EPLERENONE NITRO-BID AFEDITAB CR EPROSARTAN MESYLATE NITROGLYCERIN AGGRENOX FELODIPINE ER NITROLINGUAL AMILORIDE HCL FENOFIBRATE NITROSTAT AMILORIDE HCL W/HCTZ FENOFIBRIC ACID NITRO-TIME AMIODARONE HCL FLECAINIDE ACETATE PACERONE AMLODIPINE BESYLATE FLUVASTATIN SODIUM PENTOXIFYLLINE AMLODIPINE BESYLATE-BENAZEPRIL FOSINOPRIL SODIUM PERINDOPRIL ERBUMINE AMLODIPINE-ATORVASTATIN FOSINOPRIL-HYDROCHLOROTHIAZIDE PINDOLOL AMLODIPINE-VALSARTAN / HCTZ FUROSEMIDE PRAVASTATIN SODIUM AMTURNIDE GEMFIBROZIL PRAZOSIN HCL ATENOLOL GUANFACINE HCL PREVALITE ATENOLOL W/CHLORTHALIDONE HYDRALAZINE HCL PROPAFENONE HCL ATORVASTATIN CALCIUM HYDROCHLOROTHIAZIDE PROPRANOLOL HCL BENAZEPRIL HCL INDAPAMIDE PROPRANOLOL HCL-HCTZ BENAZEPRIL HCL-HCTZ IRBESARTAN QUINAPRIL BETAXOLOL HCL IRBESARTAN-HYDROCHLOROTHIAZIDE QUINAPRIL-HYDROCHLOROTHIAZIDE BISOPROLOL FUMARATE ISOSORBIDE DINITRATE QUINIDINE GLUCONATE BISOPROLOL FUMARATE/HCTZ ISOSORBIDE MONONITRATE QUINIDINE SULFATE BUMETANIDE ISRADIPINE RAMIPRIL BYSTOLIC JANTOVEN RANEXA CANDESARTAN CILEXETIL LABETALOL HCL RESERPINE CANDESARTAN-HYDROCHLOROTHIAZID SIMCOR CAPTOPRIL LIPOFEN SIMVASTATIN CAPTOPRIL/HYDROCHLOROTHIAZIDE LIPTRUZET SORINE 1

2 06/2015 CARTIA XT LISINOPRIL SOTALOL CARVEDILOL LISINOPRIL-HCTZ SOTALOL AF CHLOROTHIAZIDE LOSARTAN POTASSIUM SPIRONOLACTONE CHLORTHALIDONE LOSARTAN-HYDROCHLOROTHIAZIDE SPIRONOLACTONE W/HCTZ CHOLESTYRAMINE LOVASTATIN TARKA CHOLESTYRAMINE LIGHT LOVAZA TAZTIA XT CILOSTAZOL MATZIM LA TEKAMLO CLONIDINE HCL METHAZOLAMIDE TEKTURNA CLOPIDOGREL METHYCLOTHIAZIDE TEKTURNA HCT CLORPRES METHYLDOPA TERAZOSIN HCL COLESTIPOL HCL METHYLDOPA/HYDROCHLOROTHIAZIDE TIKOSYN COREG CR METOLAZONE TIMOLOL MALEATE CRESTOR METOPROLOL SUCCINATE TORSEMIDE DIGOXIN METOPROLOL TARTRATE TRANDOLAPRIL DILATRATE-SR METOPROLOL-HYDROCHLOROTHIAZIDE TRANDOLAPRIL-VERAPAMIL DILT-CD MEXILETINE HCL TRIAMTERENE W/HCTZ DILTIA XT MINOXIDIL TRIBENZOR DILTIAZEM 24HR CD MOEXIPRIL HCL TRILIPIX DILTIAZEM ER MOEXIPRIL-HYDROCHLOROTHIAZIDE VALSARTAN-HYDROCHLOROTHIAZIDE DILTIAZEM HCL NADOLOL VASCEPA DILT-XR NADOLOL-BENDROFLUMETHIAZIDE VENTAVIS DILTZAC ER NIACIN ER VERAPAMIL ER DIPYRIDAMOLE NICARDIPINE HCL VERAPAMIL ER PM DOXAZOSIN MESYLATE NIFEDIAC CC VERAPAMIL HCL DUTOPROL NIFEDICAL XL VYTORIN EFFIENT NIFEDIPINE WARFARIN SODIUM ENALAPRIL MALEATE NIFEDIPINE ER WELCHOL NIMODIPINE ZETIA Diabetes 1ST TIER UNIFINE PENTIPS HUMULIN N PIOGLITAZONE HCL ACARBOSE HUMULIN R PIOGLITAZONE-GLIMEPIRIDE ACTOPLUS MET XR IN CONTROL PEN NEEDLE PIOGLITAZONE-METFORMIN ADVOCATE PEN NEEDLES INCONTROL NEEDLE PRANDIMET ADVOCATE SYRINGES INSULIN PEN NEEDLE PRODIGY INSULIN SYRINGE ASSURE ID INSULIN SAFETY SYRINGE INSUPEN NEEDLE PRODIGY PEN NEEDLE AUTOSHIELD DUO PEN NEEDLE JANUMET RELION PEN NEEDLES AUTOSHIELD PEN NEEDLE JANUMET XR RIOMET BD ULTRA FINE PEN NEEDLE JANUVIA SAFESNAP INSULIN SYRINGE BYDUREON JUVISYNC SURE COMFORT NEEDLE BYETTA KOMBIGLYZE XR SURE COMFORT SYRINGE CLICKFINE NEEDLE LANTUS SURE-FINE PEN NEEDLES COMFORT EZ NEEDLE LANTUS SOLOSTAR SURE-JECT INSULIN SYRINGE COMFORT EZ SYRINGE LEVEMIR SYMLINPEN 120 EASY COMFORT INSULIN SYRINGE LITE TOUCH SYMLINPEN 60 EASY TOUCH NEEDLE LITE TOUCH SYRINGE TERUMO INSULIN SYRINGE EASY TOUCH SYRINGE LUER-LOK SYRINGE THINPRO INSULIN SYRINGE EXEL INSULIN SYRINGE MAGELLAN INSULIN SAFETY SYRNG TOLAZAMIDE FREESTYLE PRECISION SYRINGE MAGELLAN INSULIN SYRINGE TOLBUTAMIDE GLIMEPIRIDE MAXI-COMFORT SYRINGE TOPCARE ULTRA COMFORT SYRINGE GLIPIZIDE METFORMIN HCL TRUEPLUS INSULIN SYRINGE GLIPIZIDE ER METFORMIN HCL ER ULTICARE NEEDLE GLIPIZIDE XL MINI ULTRA-THIN II NEEDLE ULTICARE SYRINGE GLIPIZIDE-METFORMIN MONOJECT SYRINGE ULTICARE INSULIN SYRINGE GLUCOPRO SYRINGE MONOJECT INSULIN SYRINGE ULTILET INSULIN SYRINGE GLYBURIDE NATEGLINIDE ULTILET PEN NEEDLE GLYBURIDE MICRONIZED NOVOFINE NEEDLE ULTRA COMFORT GLYBURIDE-METFORMIN HCL NOVOFINE AUTOCOVER NEEDLE ULTRA COMFORT NEEDLE HEALTHY ACCENTS UNIFINE PENTIP NEEDLE NOVOTWIST NEEDLE ULTRA COMFORT SYRINGE 2

3 06/2015 HUMALOG ONE TOUCH ULTRA TEST STRIPS ULTRA-THIN II NEEDLE HUMALOG MIX ONE TOUCH VERIO TEST STRIPS ULTRA-THIN II SYRINGE HUMALOG MIX ONGLYZA UNIFINE PENTIPS NEEDLE HUMULIN ORSINI INSULIN SYRINGE UNIFINE PENTIPS PLUS NEEDLE PEN- NEEDLE VANISHPOINT SYRINGE Prenatal Vitamins BAL-CARE DHA PR NATAL 430 TRIVEEN-U CAVAN-ALPHA KIT PR NATAL 430 EC TRUST NATAL DHA CAVAN-EC SOD DHA PRENA1 ULTIMATE OB DHA CHOICE-OB + DHA PRENA1 CHEW ULTIMATECARE ONE C-NATE DHA PRENA1 PLUS ULTIMATECARE ONE NF COMPLETE NATAL DHA PRENAISSANCE VEMAVITE-PRX 2 COMPLETENATE PRENAISSANCE 90 DHA VENA-BAL DHA ELITE OB PRENAISSANCE BALANCE VENATAL COMPLETE DHA ELITE-OB DHA PRENAISSANCE DHA VENATAL-FA ELITE-OB 400 PRENAISSANCE HARMONY DHA VINACAL FOLBECAL PRENAISSANCE NEXT FOLCAL DHA PRENAISSANCE PLUS VINATE AZ FOLCAPS OMEGA-3 PRENAISSANCE PROMISE VINATE CALCIUM FOLINATAL PLUS B PRENAPLUS VINATE DHA FOLIVANE-OB PRENATABS FA VINATE GT FOLIVANE-PRX DHA NF PRENATABS RX VINATE IC HEMENATAL OB PRENATAL VINATE II HEMENATAL OB + DHA PRENATAL 19 VINATE ONE INATAL ADVANCE PRENATAL AD VINATE ULTRA INATAL GT PRENATAL LOW IRON VINATE-M INATAL ULTRA PRENATAL PLUS VIRT-BAL DHA L-METHYLFOLATE PNV DHA PRENATAL-U VIRT-BAL DHA PLUS MACNATAL CN DHA RELNATE DHA VIRT-PN MYNATAL SE-NATAL 19 VIRT-PN DHA MYNATAL ADVANCE SE-TAN DHA VIRT-PN PLUS MYNATAL PLUS SETONET VIRT-SELECT MYNATAL-Z SETONET-EC VITAFOL-OB MYNATE 90 PLUS TARON-BC VITAFOL-PN NATAL-V RX TARON-C DHA VITASPIRE NATALVIRT 90 DHA TARON-DUO EC VOL-NATE NATALVIRT CA TL-CARE DHA VOL-PLUS OBSTETRIX DHA TL-SELECT VOL-TAB RX PNV OB+DHA TRIADVANCE VP-CH-PNV PNV-DHA TRINATAL GT VP-ERA OB PLUS PNV-DHA + DOCUSATE TRINATAL RX 1 VP-GGR-B6 PNV-FIRST TRINATAL ULTRA VP-HEME ONE PNV-OMEGA TRINATE VYNATAL-FA PNV-SELECT TRIVEEN-DUO DHA ZATEAN-CH PNV-TOTAL TRIVEEN-ONE ZATEAN-PN PR NATAL 400 TRIVEEN-PRX RNF ZATEAN-PN DHA PR NATAL 400 EC TRIVEEN-TEN ZATEAN-PN PLUS ZINGIBER 3

4 Patient Protection and Affordable Care Act Preventive Items and Services The Patient Protection and Affordable Care Act (PPACA) imposes a number of insurance reforms and mandates including a requirement to cover certain preventive items and services at 100 percent and ensure these items and services are not subject to deductibles or other cost-sharing limitations. The following list of preventive medications should be used as a guide. It cannot be considered a comprehensive listing of medications available or covered without cost-sharing. Coverage of any of the listed medications (including over-the-counter (OTC) medications) requires a prescription from a licensed health care provider. The availability or coverage of these medications without cost-sharing may be subject to criteria established by the terms of your health plan. This list is subject to change as ACA guidelines are updated or modified. Members: The terms of your health plan will ultimately determine coverage, the applicability of coverage criteria, and cost-sharing. For specific questions about your coverage, please call the phone number printed on your ID card. You can get more information and updates to this document at our website at This list provides examples of commonly prescribed preventative medications. ASPIRIN PRODUCTS ASPIRIN 81 MG and 325 MG IRON SUPPLEMENTS IRON (various strengths) DROPS, LIQUID, SUSPENSION MULTIVITAMIN W/IRON DROPS, LIQUID, SUSPENSION FOLIC ACID PRODUCTS FOLIC ACID TABLET 0.4 MG AND 0.8 MG PRENATAL AND MULTIVITAMINS W/FOLIC ACID (0.4 MG AND 0.8 MG) PRIMARY PREVENTION OF BREAST CANCER TAMOXIFEN RALOXIFENE SOLTAMOX (LIQUID TAMOXIFEN) SMOKING CESSATION PRODUCTS ZYBAN (Brand and Generic) CHANTIX ALL NICOTINE PRODUCTS (Rx and OTC; Brand and Generic) FLUORIDE PRODUCTS FLUORIDE CHEWABLE TABLET 0.25 MG AND 0.5 MG FLUORIDE DROPS 0.125, 0.25 MG AND 0.5 MG MULTIVITAMIN W/ FLUORIDE: CHEWABLE 0.25 MG AND 0.5 MG DROPS 0.25MG and 0.5 MG Suspension IMMUNIZATIONS Covered immunizations include those that are routine vaccines recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and that meet the US Food and Drug Administration approved indications for age and/or gender limitations. Coverage also includes immunizations used to prevent illnesses associated with travel such as typhoid, yellow fever, and Japanese encephalitis. BOWEL PREPS (LIMIT OF 2 PRESCRIPTIONS PER YEAR) BISACODYL MAGNESIUM CITRATE MILK OF MAGNESIA PEG 3350-ELECTROLYTE VITAMIN D SUPPLEMENTS VITAMIN D 1,000 UNITS OR LESS PER DOSE UNIT CALCIUM WITH VITAMIN D Please note: coverage of brand name medications is dependent on the terms of your health plan.

5 Preventive Items and Services Merged Offering Contraceptives Drug List "Following is a list of the female contraceptives that are currently included in the Express Scripts standard contraceptive offering for the Preventive Items and Services Program. These contraceptives are provided at a zero cost share to the member as mandated by the Affordable Care Act (ACA). Please note that Multi Source Brand contraceptives are available at a zero cost share only when processed as a DAW1 (substitution not allowed by the prescriber). The list is subject to change to remain compliant with ACA guidelines. Members: The terms of your health plan will ultimately determine coverage and cost-sharing. For specific questions about your coverage, please call the phone number printed on your ID card. You can get more information and updates to this document at our website at * Indicates Single Source Brand product **Indicates Multi Source Brand product as of 8/1/13, the drug list will contain Multi-Source Brand products that are processed as DAW1" BARRIER CONTRACEPTIVE METHODS FEMCAP* ORTHO-DIAPHRAGM* WIDE SEAL DIAPHRAGM* EMERGENCY CONTRACEPTIVE METHODS ELLA FALLBACK SOLO LEVONORGESTREL MY WAY NEXT CHOICE NEXT CHOICE ONE DOSE PLAN B ONE-STEP** (OTC FOR ALL AGES AS OF 8/1/13) OVER-THE-COUNTER CONTRACEPTIVE METHODS CONCEPTROL* GYNOL II TODAY CONTRACEPTIVE SPONGE* VCF* IMPLANT CONTRACEPTIVE METHODS IMPLANON* MIRENA* NEXPLANON* PARAGARD T 380-A* SKYLA* HORMONAL CONTRACEPTIVE METHODS ALTAVERA ESTARYLLA MARLISSA PREVIFEM ALYACEN ESTROSTEP FE** MEDROXYPROGESTERONE QUARTETTE ACETATE AMETHIA FALMINA MICROGESTIN QUASENSE AMETHIA LO FEMCON FE** MICROGESTIN FE RECLIPSEN AMETHYST GENERESS FE* MINASTRIN 24 FE* SAFYRAL* APRI GIANVI MIRCETTE** SEASONALE** ARANELLE GILDAGIA MODICON** SHAROBEL AVIANE GILDESS MONO-LINYAH SOLIA AZURETTE GILDESS FE MONONESSA SPRINTEC BALZIVA HEATHER MYZILRA SRONYX

6 HORMONAL CONTRACEPTIVE METHODS Con t BEYAZ* INTROVALE NATAZIA* SYEDA BREVICON** JENCYCLA NECON TARINA FE BRIELLYN JOLESSA NIKKI TILIA FE CAMILA JOLIVETTE NORETHINDRONE-ETHINYL TRI-ESTARYLLA CAMRESE JUNEL NORGESTIMATE-ETHINYL TRI-LEGEST FE CAMRESE LO JUNEL FE NORGESTREL-ETHINYL TRI-LINYAH CAZIANT KARIVA NORINYL** TRINESSA CHATEAL KELNOR NOR-Q-D** TRI-NORINYL** CRYSELLE KURVELO NORLYROC TRI-PREVIFEM CYCLAFEM LARIN NORTREL TRI-SPRINTEC CYCLESSA** LARIN FE NUVARING* TRIVORA-28 DASETTA LEENA OCELLA VELIVET DAYSEE LESSINA OGESTREL VESTURA DEBLITANE LEVONEST ORSYTHIA VIORELE DELYLA LEVONORGESTREL-ETH ORTHO EVRA** VYFEMLA DEMULEN** LEVONORG-ETH ESTRAD ORTHO MICRONOR** WERA ETH ESTRAD DEPO-PROVERA** LEVORA-28 ORTHO-NOVUM** WYMZYA FE DEPO-SUBQ PROVERA* LO LOESTRIN FE* ORTHO-CEPT** XULANE DESOGEN** LOESTRIN** ORTHO-CYCLEN** YASMIN** DESOGESTREL-ETHINYL LOESTRIN FE** ORTHO TRI-CYCLEN** YAZ** DROSPIRENONE-ETHINYL LOMEDIA 24 FE ORTHO TRI-CYCLEN LO* ZARAH ELINEST LORYNA OVCON** ZENCHENT EMOQUETTE LOSEASONIQUE** PHILITH ZENCHENT FE ENPRESSE LOW-OGESTREL PIMTREA ZEOSA ENSKYCE LUTERA PIRMELLA ZOVIA ERRIN LYZA PORTIA