Preventive Drug List2021

COMMERCIAL

In addition to a healthy lifestyle, preventive prescription drugs are important in helping people avoid many types of illnesses and complications from illnesses. This book contains a list of the most commonly prescribed preventive prescription drugs. It does not include all conditions that may be pre-vented with prescription drugs. The prescription drugs listed here serve to maintain a person’s health status and help them avoid acute complications. This list is not all-inclusive and is subject to change.

Important facts about this benefit

• Please refer to your plan documents for coverage on the selected products. Quantity limits, steptherapy, prior authorizations and other coverage limitations may apply.

• Quantities are limited to a maximum 3-month supply per fill.

• Tier 3 medications listed in the Security Health Plan Formulary are not routinely placed on thepreventive list.

• If a generic equivalent product is available, the originator brand medication will not be covered(Example: simvastatin is covered, ZOCOR is not).

• This list is updated annually on a calendar year basis.

The covered preventive drugs are divided into medication categories. The Diabetic Drugs and Supplies category is further divided into three subcategories labeled “Diabetic List,” “Diabetic Supply List” and “Insulin List.” Drugs are considered preventive by Security Health Plan when taken by a person who has developed risk factors for a disease that has not yet become clinically apparent (e.g., blood pressure or cholesterol drugs to prevent heart attack or stroke). Taking these medications as directed by your prescriber can help avoid serious health problems.

Note: Some plans do not include this preventive drug list and some plans cover the entire preventive drug list, while other plans will only cover select categories within the list. Please refer to your plan documents for information specific to your preventive coverage.

You can view your Summary of Benefits and Certificate of Coverage or Policy online when you log into your My Security Health Plan account. If you don’t have an account go to

www.securityhealth.org/registration.

Advair® Diskus Ipratropium 0.02% solution

Albuterol HFA inhaler Levalbuterol nebules

Albuterol nebules Metaproterenol syrup

Albuterol Sulfate ER tablet Montelukast granules

Albuterol Sulfate tablet Montelukast tablet

Albuterol syrup Montelukast tablet chew

Anoro® Ellipta inhaler QVAR® RediHaler

Arnuity® Ellipta inhaler Serevent® Diskus

Budesonide suspension Spiriva® Handihaler

Budesonide/Salmeterol HFA inhaler Spiriva® Respimat inhaler

Combivent® Respimat inhaler Stiolto® Respimat inhaler

Cromolyn nebules Terbutaline tablet

Flovent® Diskus Theophylline elixir

Flovent® HFA inhaler Theophylline ER tablet

Fluticasone-Salmeterol inhaler (generic Airduo®) Theophylline tablet

Incruse® Ellipta Trelegy® Ellipta inhaler

Ipratroprium-Albuterol nebules Zafirlukast tablet

Aspirin-Dipyridamole ER capsule Eliquis® tablet

Brilinta® tablet Jantoven® tablet

Clopidogrel tablet Prasugrel tablet

Dipyridamole tablet Warfarin tablet

Xarelto® tablet

Diabetic List:

Acarbose tablet Jentadueto® XR tablet

Glimepiride tablet Metformin tablet

Glipizide tablet Metformin ER tablet

Glipizide ER tablet Nateglinide tablet

Glipizide XL tablet Ozempic® injection

Glipizide-Metformin tablet Pioglitazone-Glimepiride tablet

Glyxambi® Pioglitazone tablet

Invokamet® tablet Repaglinide tablet

Invokamet® XR tablet Repaglinide-Metformin tablet

Invokana® tablet Synjardy® tablet

Janumet® tablet Synjardy® XR tablet

Janumet® XR tablet Tolbutamide tablet

Januvia® tablet Tradjenta® tablet

Jardiance® tablet Trulicity® injection

Jentadueto® tablet Victoza® injection

Preventive Drug ListAsthma and chronic obstructive pulmonary disease (COPD) drugs

Prevention of an asthma or COPD episode

Blood thinners

Prevention of stroke, blood clot or repeat heart attack

Diabetes drugs and supplies

Prevention of complications related to high blood sugar

Diabetic Supply List

Alcohol prep pads Glucagon® emergency kit

Batteries Gvoke® Hypopen

Baqsimi Nasal Spray Gvoke® Syringe

Chemstrips Insulin needles

Dexcom® G6 Insulin syringes

Diastix® (urine glucose test strips) Keto-Diastix® (urine glucose-acet test strip)

FreeStyle® control solution Lancets

FreeStyle® Freedom Lite meter Novopen® Echo

FreeStyle® Libre reader Pen Needles

FreeStyle® Libre sensors Precision® Neo meter

Freestyle® Libre 2 reader Precision® Neo test strips

Freestyle® Libre 2 sensors Precision® Xtra beta ketone test strips

FreeStyle® Lite Meter Precision® Xtra meter

FreeStyle® Lite test strips Precision® Xtra test strips

FreeStyle® Optium ketone strips Medisense Glucose & Ketone Control Solution

FreeStyle® test strips Trueplus® Ketone test strips

FreeStyle® lancets

Insulin List

Fiasp® Novolin® R

Lantus® Novolin® R Flexpen

Lantus® Solostar Novolog®

Novolin® 70-30 Novolog® Flexpen

Novolin® 70-30 Flexpen Novolog® Mix 70-30

Novolin® N Novolog® Mix 70-30 Flexpen

Novolin® N Flexpen Toujeo®

Amiodarone tablet Isosorbide mononitrate tablet

Digoxin tablet Mexilitine capsule

Digoxin oral solution Nitroglycerin sublingual tablet

Disopyramide capsule Propafenone tablet

Dofetilide capsule Quinidine tablet

Flecainide tablet Sotalol AF tablet

Isosorbide Dinitrate tablet Sotalol tablet

Acetazolamide tablet Hydrochlorothiazide capsule

Acebutolol capsule Hydrochlorothiazide tablet

Amiloride tablet Indapamide tablet

Amiloride-HCTZ tablet Irbesartan-HCTZ tablet

Amlodipine tablet Isradipine capsule

Amlodipine -Valsartan tablet Labetalol tablet

Amlodipine -Valsartan-HCTZ tablet Lisinopril tablet

Amlodipine-Benazepril tablet Lisinopril-HCTZ tablet

Atenolol tablet Losartan tablet

Atenolol-Chlorthalidone tablet Losartan-HCTZ tablet

Benazepril tablet Methyclothiazide tablet

High blood pressure drugs

Prevention of stroke, complications due to high blood pressure and reoccurrence of heart attack

Heart disease drugs

Prevention of heart disease

Diabetes drugs and supplies (continued)

Prevention of complications related to high blood sugar

Benazepril-HCTZ tablet Methyldopa tablet

Betaxolol tablet Metolazone tablet

Bisoprolol tablet Metoprolol Succinate ER tablet

Bisoprolol-HCTZ tablet Metoprolol Tartrate tablet

Bumetanide tablet Metoprolol-HCTZ tablet

Candesartan tablet Minoxidil tablet

Candesartan-HCTZ tablet Moexipril tablet

Captopril tablet Nadolol tablet

Captopril-HCTZ tablet Nifedipine ER tablet

Cartia® XT capsule Olmesartan tablet

Carvedilol tablet Olmesartan/HCTZ tablet

Chlorothiazide tablet Perindopril tablet

Chlorthalidone tablet Pindolol tablet

Clonidine tablet Prazosin capsule

Clonidine Transderm Patch Propranolol tablet

Dilt® XR capsule Irbesartan tablet

Diltiazem 12Hr ER capsule Propranolol ER capsule

Diltiazem 24Hr CD capsule Propranolol-HCTZ tablet

Diltiazem 24Hr ER capsule Quinapril tablet

Diltiazem ER capsule Quinapril-HCTZ tablet

Diltiazem tablet Ramipril capsule

Doxazosin capsule Spironolactone tablet

Enalapril tablet Spironolactone-HCTZ tablet

Enalapril-HCTZ tablet Telmisartan tablet

Epaned oral solution Telmisartan-HCTZ tablet

Eplerenone tablet Terazosin capsule

Eprosartan tablet Timolol tablet

Ethacrynic Acid tablet Torsemide tablet

Felodipine ER tablet Trandolapril tablet

Fosinopril tablet Trandolapril -Verapamil ER tablet

Fosinopril-HCTZ tablet Triamterene-HCTZ capsule

Furosemide solution Triamterene-HCTZ tablet

Furosemide tablet Valsartan tablet

Guanfacine tablet Valsartan-HCTZ tablet

Hydralazine tablet Verapamil tablet

Verapamil ER tablet

Atorvastatin tablet Fenofibric Acid tablet

Cholestyramine for oral suspension Fenofibric Acid DR capsule

Cholestyramine Light for oral suspension Fluvastatin capsule

Colestipol tablet Gemfibrozil tablet

Colestipol packet Lovastatin tablet

Colestipol granules Niacin ER tablet

Colestipol tablet Pravastatin tablet

Ezetimibe tablet Rosuvastatin tablet

Fenofibrate (54mg, 160mg) tablet Simvastatin tablet

High cholesterol drugs

High cholesterol drugs (prevention of heart disease)

High blood pressure drugs (continued)

Prevention of stroke, complications due to high blood pressure and reoccurrence of heart attack

Citalopram tablet Fluoxetine solution

Citalopram solution Paroxetine tablet (10, 20, 30 40 mg)

Escitalopram tablet Sertraline tablet

Escitalopram solution Sertraline solution

Fluoxetine capsule (10, 20, 40 mg)

Alendronate tablet Raloxifene tablet

Calcitonin (Salmon) Nasal spray Risedronate tablet

Ibandronate tablet

Prenatal vitamin tablets (generic versions only)

Prenatal vitamins

Prevention of birth defects

Osteoporosis (bone disease) drugs

Prevention of bone fractures

Mental health drugs

Prevention of symptoms of anxiety, depression or other mood disorders

Advair® Diskus Ipratropium 0.02% solutionAlbuterol HFA inhaler Levalbuterol nebulesAlbuterol nebules Metaproterenol syrupAlbuterol Sulfate ER tablet Montelukast granulesAlbuterol Sulfate tablet Montelukast tablet Albuterol syrup Montelukast tablet chewAnoro® Ellipta inhaler QVAR® RediHalerArnuity® Ellipta inhaler Serevent® DiskusBudesonide suspension Spiriva® HandihalerBudesonide/Salmeterol HFA inhaler Spiriva® Respimat inhalerCombivent® Respimat inhaler Stiolto® Respimat inhalerCromolyn nebules Terbutaline tabletFlovent® Diskus Theophylline elixirFlovent® HFA inhaler Theophylline ER tabletFluticasone-Salmeterol inhaler (generic Airduo®) Theophylline tabletIncruse® Ellipta Trelegy® Ellipta inhalerIpratroprium-Albuterol nebules Zafirlukast tablet

Aspirin-Dipyridamole ER capsule Eliquis® tabletBrilinta® tablet Jantoven® tabletClopidogrel tablet Prasugrel tabletDipyridamole tablet Warfarin tablet

Xarelto® tablet

Diabetic List:Acarbose tablet Jentadueto® XR tabletGlimepiride tablet Metformin tabletGlipizide tablet Metformin ER tabletGlipizide ER tablet Nateglinide tabletGlipizide XL tablet Ozempic® injectionGlipizide-Metformin tablet Pioglitazone-Glimepiride tabletGlyxambi® Pioglitazone tabletInvokamet® tablet Repaglinide tabletInvokamet® XR tablet Repaglinide-Metformin tabletInvokana® tablet Synjardy® tabletJanumet® tablet Synjardy® XR tabletJanumet® XR tablet Tolbutamide tablet Januvia® tablet Tradjenta® tablet Jardiance® tablet Trulicity® injection Jentadueto® tablet Victoza® injection

Diabetes drugs and suppliesPrevention of complications related to high blood sugar

Preventive Drug ListAsthma and chronic obstructive pulmonary disease (COPD) drugsPrevention of an asthma or COPD episode

Blood thinnersPrevention of stroke, blood clot or repeat heart attack