Advantage Value for Diabetes Eligible Drug List for the ... - Caremark

January 2024

Advantage Value for Diabetes Eligible Drug List for the State of Minnesota

This list includes drugs that are covered by your pharmacy benefit plan managed by CVS Caremark? when filled at a network pharmacy (including retail, mail and specialty).

Eligible Drugs/Supplies

Diabetes drugs Hypertensive (blood pressure) drugs Cholesterol drugs Depression drugs Diabetes supplies (including test strips, syringes, lancets and more)

You pay

Copay**: $0 tier 1 / $20 tier 2 / $35 tier 3 Copay: $0 tier 1 / $20 tier 2 / $35 tier 3 Copay: $0 tier 1 / $20 tier 2 / $35 tier 3 Copay: $0 tier 1 / $20 tier 2 / $35 tier 3 0% coinsurance, deductible waived

Drug Class Antidiabetic Medications

* ALPHA-GLUCOSIDASE INHIBITORS

Drug Brand Name

ACARBOSE

Tier

1

* AMYLIN ANALOGS

SYMLINPEN

2

BIGUANIDES BIGUANIDES

METFORMIN HCL

1

METFORMIN HCL ER

1

* BIGUANIDE/SULONYLUREA COMBINATIONS

GLIPIZIDE/METFORMIN

1

* DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

JANUVIA

2

*

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS/BIGUANIDE COMBINATIONS

JANUMET

2

*

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS/BIGUANIDE COMBINATIONS

JANUMET XR

2

* INCRETIN MIMETIC AGENTS * INCRETIN MIMETIC AGENTS * INCRETIN MIMETIC AGENTS * INCRETIN MIMETIC AGENTS * INCRETIN MIMETIC AGENTS

MOUNJARO

2

OZEMPIC

2

RYBELSUS

2

TRULICITY

2

VICTOZA

2

* INCRETIN MIMETIC AGENT/INSULIN COMBINATIONS

SOLIQUA

2

* INCRETIN MIMETIC AGENT/INSULIN COMBINATIONS

XULTOPHY

2

* INSULIN * INSULIN * INSULIN * INSULIN * INSULIN * INSULIN * INSULIN * INSULIN

FIASP HUMULIN R U-500 LANTUS NOVOLIN 70/30 NOVOLIN NOVOLOG NOVOLOG MIX 70/30 TOUEJO

?2022 CVS Health and/or its affiliates. All rights reserved. 106-44166A 082522

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* INSULIN

TRESIBA

2

* INSULIN SENSITIZING AGENTS

* INSULIN SENSITIZING AGENTS/BIGUANIDE COMBINATIONS * INSULIN SENSITIZING AGENTS/BIGUANIDE COMBINATIONS

PIOGLITAZONE

1

PIOGLITAZONE/METFORMIN

1

ACTOPLUS MET

3

* INSULIN SENSITIZER/SULFONYLUREA COMBINATOINS * INSULIN SENSITIZER/SULFONYLUREA COMBINATOINS

PIOGLITAZONE/GLIMEPIRIDE

1

DUETAC

3

* MEGLITINIDE ANALOGUES * MEGLITINIDE ANALOGUES

NATEGLINIDE

1

REPAGLINIDE

1

* SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

FARXIGA

2

* SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

JARDIANCE

2

*

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS/ BIGUANIDE COMBINATIONS

SYNJARDY

2

*

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS/ BIGUANIDE COMBINATIONS

SYNJARDY XR

2

*

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS/ BIGUANIDE COMBINATIONS

XIGDUO XR

2

*

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS/ DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS COMBINATIONS

GLYXAMBI

2

ENDOCRINE AND METABOLIC/ ANTIDIABETICS/ SODIUM-GLUCOSE

* CO-TRANSPORTER 2 (SGLT2) INHIBITOR/DIPEPTIDYL PEPTIDASE-4

TRIJARDY XR

2

(DPP-4) INHIBITOR/BIGUANIDE COMBINATIONS

* SULFONYLUREAS * SULFONYLUREAS * SULFONYLUREAS * SULFONYLUREAS

GLIMEPIRIDE

1

GLIPIZIDE

1

GLIPIZIDE ER

1

AMARYL

3

Antihypertensive Medications

ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS ACE INHIBITORS

BENAZEPRIL

1

CAPTOPRIL

1

ENALAPRIL

1

FOSINOPRIL

1

LISINOPRIL

1

PERINDOPRIL

1

QUINAPRIL

1

RAMIPRIL

1

TRANDOLAPRIL

1

ACCUPRIL

3

ALTACE

3

LOTENSIN

3

ZESTRIL

3

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

AMLODIPINE/BENAZAPRIL

1

TRANDOLAPRIL/VERAPAMIL EXT-REL 1

?2022 CVS Health and/or its affiliates. All rights reserved. 106-44166A 082522

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ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

LOTREL

2

ACE INHIBITOR/DIURETIC COMBINATIONS ACE INHIBITOR/DIURETIC COMBINATIONS ACE INHIBITOR/DIURETIC COMBINATIONS ACE INHIBITOR/DIURETIC COMBINATIONS ACE INHIBITOR/DIURETIC COMBINATIONS ACE INHIBITOR/DIURETIC COMBINATIONS ACE INHIBITOR/DIURETIC COMBINATIONS ACE INHIBITOR/DIURETIC COMBINATIONS

BENAZEPRIL/HCTZ

1

ENALAPRIL/HCTZ

1

FOSINOPRIL/HCTZ

1

LISINOPRIL/HCTZ

1

QUINAPRIL/HCTZ

1

ACCURETIC

3

LOTENSIN HCT

3

VASERETIC

3

ADRENOLYTICS, CENTRAL ADRENOLYTICS, CENTRAL ADRENOLYTICS, CENTRAL ADRENOLYTICS, CENTRAL

CLONIDINE

1

CLONIDINE TRANSDERMAL

1

GUANFACINE

1

CATAPRES-TTS

2

ALDOSTERONE RECEPTOR ANTAGONISTS ALDOSTERONE RECEPTOR ANTAGONISTS

SPIRONOLACTONE

1

ALDACTONE

2

ALPHA BLOCKERS ALPHA BLOCKERS ALPHA BLOCKERS

DOXAZOSIN

1

TERAZOSIN

1

CARDURA

3

ANGIOTENSIN II RECEPTOR ANTAGONISTS ANGIOTENSIN II RECEPTOR ANTAGONISTS ANGIOTENSIN II RECEPTOR ANTAGONISTS ANGIOTENSIN II RECEPTOR ANTAGONISTS ANGIOTENSIN II RECEPTOR ANTAGONISTS ANGIOTENSIN II RECEPTOR ANTAGONISTS

CANDESARTAN

1

IRBESARTAN

1

LOSARTAN

1

OLMESARTAN

1

TELMISARTAN

1

VALSARTAN

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS CANDESARTAN/HCTZ

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS IRBESARTAN/HCTZ

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS LOSARTAN/HCTZ

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS OLMESARTAN/HCTZ

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS TELMISARTAN/HCTZ

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS DIURETIC COMBINATIONS VALSARTAN/HCTZ

1

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS

BETA-BLOCKERS

AMLODIPINE/OLMESARTAN

1

AMLODIPINE/TELMISARTAN

1

AMLODIPINE/VALSARTAN

1

AMLODIPINE/VALSARTAN/HCTZ

1

OLMESARTAN/AMLODIPINE/HCTZ

1

TRIBENZOR

3

ATENOLOL

1

?2022 CVS Health and/or its affiliates. All rights reserved. 106-44166A 082522

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BETA-BLOCKERS BETA_BLOCKERS BETA-BLOCKERS BETA-BLOCKERS BETA-BLOCKERS BETA-BLOCKERS BETA-BLOCKERS BETA-BLOCKERS BETA-BLOCKERS BETA-BLOCKERS BETA-BLOCKERS BETA-BLOCKERS BETA-BLOCKERS

BETA-BLOCKER/DIURETIC COMBINATIONS BETA-BLOCKER/DIURETIC COMBINATIONS BETA-BLOCKER/DIURETIC COMBINATIONS BETA-BLOCKER/DIURETIC COMBINATIONS

CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS

CARBONIC ANHYDRASE INHIBITORS CARBONIC ANHYDRASE INHIBITORS CARBONIC ANHYDRASE INHIBITORS

DIURETIC COMBINATIONS DIURETIC COMBINATIONS DIURETIC COMBINATIONS DIURETIC COMBINATIONS DIURETIC COMBINATIONS

LOOP DIURETICS LOOP DIURETICS LOOP DIURETICS LOOP DIURETICS LOOP DIURETICS

BISOPROLOL

1

CARVEDILOL

1

CARVEDILOL EXT-REL

1

LABETALOL

1

METOPROLOL SUCCINATE ER

1

METOPROLOL TARTRATE

1

NADOLOL

1

NEBIVOLOL

1

PINDOLOL

1

PROPRANOLOL HCL

1

PROPRANOLOL HCL ER

1

COREG

3

CORGARD

3

ATENOLOL/CHLORTHALIDONE

1

BISOPROLOL/HCTZ

1

METOPROLOL/HCTZ

1

ZIAC

2

AMLODIPINE

1

DILTIAZEM ER

1

FELODIPINE ER

1

NIFEDIPINE ER

1

VERAPAMIL HCL ER

1

CALAN SR

3

PROCARDIA XL

3

TIAZAC

3

AMLODIPINE/ATORVASTATIN

1

CADUET

3

ALISKIREN

1

TEKTURNA HCT

2

ACETAZOLAMIDE

1

ACETAZOLAMIDE ER

1

METHAZOLAMIDE

1

AMILORIDE/HCTZ

1

SPIRONOLACTONE/HCTZ

1

TRIAMTERENE/HCTZ

1

ALDACTAZIDE

3

MAXZIDE

3

BUMETANIDE

1

ETHACRYNIC ACID

1

FUROSEMIDE

1

TORSEMIDE

1

LASIX

3

?2022 CVS Health and/or its affiliates. All rights reserved. 106-44166A 082522

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POTASSIUM SPARING DIURETICS POTASSIUM SPARING DIURETICS

AMILORIDE TRIAMTERENE

THIAZIDES AND THIAZIDE-LIKE DIURETICS THIAZIDES AND THIAZIDE-LIKE DIURETICS THIAZIDES AND THIAZIDE-LIKE DIURETICS THIAZIDES AND THIAZIDE-LIKE DIURETICS

CHLORTHALIDONE HYDROCHLOROTHIAZIDE INDAPAMIDE METOLAZONE

MISCELLANEOUS

HYDRALAZINE

Cholesterol Lowering Medications

BILE ACID SEQUESTRANTS BILE ACID SEQUESTRANTS BILE ACID SEQUESTRANTS BILE ACID SEQUESTRANTS BILE ACID SEQUESTRANTS

COLESEVELAM CHOLESTYRAMINE COLESTIPOL HCL COLESTID QUESTRAN/QUESTRAN LIGHT

CHOLESTEROL OBSORPTION INHIBITORS

EZETIMIBE

FIBRIC ACID DERIVATIVES FIBRIC ACID DERIVATIVES FIBRIC ACID DERIVATIVES FIBRIC ACID DERIVATIVES FIBRIC ACID DERIVATIVES

FENOFIBRATE FENOFIBRIC ACID DELAYED-REL GEMFIBROZIL LOPID TRILIPIX

HMG COA REDUCTASE INHIBITORS HMG COA REDUCTASE INHIBITORS HMG COA REDUCTASE INHIBITORS HMG COA REDUCTASE INHIBITORS HMG COA REDUCTASE INHIBITORS HMG COA REDUCTASE INHIBITORS HMG COA REDUCTASE INHIBITORS

ATORVASTATIN FLUVASTATIN LOVASTATIN PRAVASTATIN ROSUVASTATIN SIMVASTATIN ZOCOR

HMG COA REDUCTASE INHIBITORS COMBINATIONS HMG COA REDUCTASE INHIBITORS COMBINATIONS

EZETIMIBE/SIMVASTATIN VYTORIN

NICOTINIC ACID DERIVATIVES

NIACIN EXT-REL

OMEGA-3 FATTY ACIDS OMEGA-3 FATTY ACIDS

OMEGA-3-ACID ETHYL ESTERS VASCEPA

PCSK9 INHIBITORS

REPATHA

Anti-Depressants

MONOAMINE OXIDASE INHIBITORS (MAOIS) MONOAMINE OXIDASE INHIBITORS (MAOIS) MONOAMINE OXIDASE INHIBITORS (MAOIS) MONOAMINE OXIDASE INHIBITORS (MAOIS)

PHENELZINE TRANYLCYPROMINE NARDIL PARNATE

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

CITALOPRAM

?2022 CVS Health and/or its affiliates. All rights reserved. 106-44166A 082522

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