Preventive Drug List2022

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 prevented 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

• Quantity limits, step therapy, prior authorizations and other coverage limitations may apply on select products. Please refer to the formulary for the most current limitations.

• 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 the preventive 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. 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: Please refer to your plan documents for specific information on the coverage of preventive medications.

You can view your Summary of Benefits and Certificate of Coverage or Policy online when you log in to 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

Advair® HFA inhaler Levalbuterol nebules

Albuterol HFA inhaler Metaproterenol syrup

Albuterol nebules Montelukast granules

Albuterol Sulfate ER tablet Montelukast tablet 

Albuterol Sulfate tablet Montelukast chewable tablet

Albuterol syrup QVAR® RediHaler

Anoro® Ellipta inhaler Serevent® Diskus

Arnuity® Ellipta inhaler Spiriva® Handihaler

Breo® Ellipta Inhaler Spiriva® Respimat inhaler

Breztri® HFA Inhaler Stiolto® Respimat inhaler

Budesonide suspension Striverdi® Inhaler

Combivent® Respimat inhaler Symbicort® HFA inhaler

Cromolyn nebules Terbutaline tablet

Flovent® Diskus Theophylline elixir

Flovent® HFA inhaler Theophylline ER tablet

Fluticasone‐Salmeterol inhaler (generic Airduo®) Theophylline tablet

Ipratroprium‐Albuterol nebules Trelegy® Ellipta inhaler

Zafirlukast tablet

Aspirin‐Dipyridamole ER capsule  Eliquis® tablet

Brilinta® tablet  Jantoven® tablet

Cilostazol tablet Prasugrel tablet

Clopidogrel tablet Warfarin tablet

Dipyridamole tablet Xarelto® tablet

Diabetic List:

Acarbose tablet Metformin tablet

Bydureon® injection Metformin ER tablet

Byetta® injection Nateglinide tablet

Farxiga® tablet Ozempic® injection

Glimepiride tablet Pioglitazone‐Glimepiride tablet

Glipizide tablet Pioglitazone tablet

Glipizide ER tablet Repaglinide tablet

Glipizide XL tablet Repaglinide‐Metformin tablet

Glipizide‐Metformin 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 

Jentadueto® XR tablet Xigduo® XR tablet

Diabetes drugs and supplies

Prevention of complications related to high blood sugar

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

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 Medisense Glucose & Ketone Control Solution

FreeStyle® Libre reader  Novopen® Echo

FreeStyle® Libre sensors  Novolog® Inpen

Freestyle® Libre 2 reader Pen Needles

Freestyle® Libre 2 sensors Precision® Neo meter

FreeStyle® Lite Meter Precision® Neo test strips 

FreeStyle® Lite test strips Precision® Xtra beta ketone test strips

FreeStyle® Optium ketone strips Precision® Xtra meter

FreeStyle® test strips  Precision® Xtra test strips

Trueplus® Ketone test strips 

Insulin List

Fiasp® Novolin® N Flexpen

Fiasp® Flextouch Novolin® R

Fiasp® Penfill Novolin® R Flexpen

Humulin® R U‐500 Novolog®

Humulin® R U‐500 Kwikpen Novolog® Flexpen

Lantus® Novolog® Mix 70‐30

Lantus® Solostar Novolog® Mix 70‐30 Flexpen

Novolin® 70‐30 Toujeo® Max Solostar

Novolin® 70‐30 Flexpen Toujeo® Solostar

Novolin® N

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  Atenolol‐Chlorthalidone tablet

Acebutolol capsule Benazepril tablet

Amiloride tablet Benazepril‐HCTZ tablet

Amiloride‐HCTZ tablet Betaxolol tablet

Amlodipine tablet Bisoprolol tablet

Amlodipine ‐Valsartan tablet Bisoprolol‐HCTZ tablet

Amlodipine ‐Valsartan‐HCTZ tablet Bumetanide tablet

Amlodipine‐Benazepril tablet Candesartan tablet

Atenolol tablet Candesartan‐HCTZ 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

Captopril tablet Losartan‐HCTZ tablet

Captopril‐HCTZ tablet Methyclothiazide tablet

Cartia® XT capsule Methyldopa tablet

Carvedilol tablet Metolazone tablet

Chlorothiazide tablet Metoprolol Succinate ER tablet

Chlorthalidone tablet Metoprolol Tartrate tablet

Clonidine  tablet Metoprolol‐HCTZ tablet

Clonidine Transderm Patch Minoxidil tablet

Dilt® XR capsule Moexipril tablet

Diltiazem 12Hr ER capsule Nadolol tablet

Diltiazem 24Hr CD capsule Nifedipine ER tablet

Diltiazem 24Hr ER capsule Olmesartan tablet

Diltiazem ER capsule  Olmesartan/HCTZ tablet

Diltiazem tablet Perindopril tablet

Doxazosin capsule Pindolol tablet

Enalapril tablet Prazosin capsule

Enalapril‐HCTZ tablet Propranolol tablet

Epaned oral solution Irbesartan tablet

Eplerenone tablet Propranolol ER capsule

Eprosartan tablet Propranolol‐HCTZ tablet

Ethacrynic Acid tablet Quinapril tablet

Felodipine ER tablet Quinapril‐HCTZ tablet

Fosinopril tablet Ramipril capsule

Fosinopril‐HCTZ tablet Spironolactone tablet

Furosemide solution Spironolactone‐HCTZ tablet

Furosemide tablet Telmisartan tablet

Guanfacine tablet Telmisartan‐HCTZ tablet

Hydralazine tablet Terazosin capsule

Hydrochlorothiazide capsule Timolol tablet

Hydrochlorothiazide tablet Torsemide tablet

Indapamide tablet Trandolapril tablet

Irbesartan‐HCTZ tablet Trandolapril ‐Verapamil ER tablet

Isradipine capsule Triamterene‐HCTZ capsule

Katerzia® suspension Triamterene‐HCTZ tablet

Labetalol tablet Valsartan tablet

Lisinopril tablet Valsartan‐HCTZ tablet

Lisinopril‐HCTZ tablet Verapamil tablet

Losartan tablet Verapamil ER tablet

Atorvastatin tablet Fenofibric Acid DR capsule

Cholestyramine for oral suspension Fluvastatin capsule

Cholestyramine Light for oral suspension Gemfibrozil tablet

Colestipol tablet Lovastatin tablet

Colestipol packet Niacin ER tablet

Colestipol granules Pravastatin tablet

Colestipol tablet Praluent® injection

Ezetimibe tablet Repatha® injection

Fenofibrate (54mg, 160mg) tablet Rosuvastatin tablet

Fenofibric Acid tablet Simvastatin tablet

Vascepa® capsule

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 vitamin capsules (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

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