726589.0114 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
PREVENTIVE DRUG BENEFIT PROGRAM
Employee GuideEffective January 1, 2014
PREVENTIVE DRUG BENEFIT PROGRAM
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INTRODUCTIONBlue Cross and Blue Shield of Texas (“BCBSTX”) administers the preventive drug benefit for your group’s high deductible health plan (“HDHP”), which has been designed for use with Health Savings Accounts (“HSAs”). The preventive drug benefit program includes categories of prescription drugs that are frequently used for preventive purposes. If your doctor has prescribed any of them to you for preventive purposes, then you and your HSA-eligible dependents may have coverage before satisfying your HDHP deductible.
Below and on the following pages is a Guide listing some examples of drugs that are commonly prescribed for preventive purposes. Coverage of all medications is still subject to your HDHP limitations, exclusions and out-of-pocket requirements (for example, your prescription drug payment levels).
IMPORTANT REMINDER: These drugs could also at times be prescribed for treatment purposes. As a result, the listing of a drug in the Guide does not mean that it will be covered by your particular benefit plan before your HDHP deductible is satisfied. If your doctor has prescribed a listed drug for treatment purposes (and not preventive purposes) then your plan does not provide coverage for that drug before your HDHP deductible is satisfied.
As each individual’s medical circumstances are different, and because proper classification is necessary for you to ensure you are complying with your HDHP tax obligations, it is important for you to confirm the purpose of the prescription with your doctor. Please call the number on the back of your member ID card when your doctor confirms to you that he or she prescribed one of the listed drugs for treatment purposes so your claims can be processed correctly. Unless you provide us with this information, claims for the drugs listed in the Guide will be processed as “preventive,” and you or your doctor may be asked by us to provide medical records showing that the drug you’re taking is being used for prevention. Remember, if you improperly classify the drug, it may result in adverse tax consequences so please be sure to take the confirming step to properly classify your claim.
REMEMBER: Just because a drug is on the list, doesn’t always mean it is covered.
FOLLOW THESE STEPS:1. Find your drug in the Guide.
2. Talk to your doctor about whether your drug is in fact being prescribed for you for preventive purposes (and not treatment purposes).
3. If prescribed for treatment purposes, call the number on the back of your ID card to let us know.
4. If prescribed for preventive purposes, there is no need to call.
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This Guide lists some, but not all, examples of drugs that are commonly prescribed for preventive purposes. It is being provided to you at your employer’s request as a resource to help you in managing your prescription drug benefits under your employer’s HDHP.
This list does not include all drugs that may be prescribed as preventive. It will be reviewed periodically and is subject to change. Coverage of all medications is still subject to your HDHP limitations, exclusions and out-of pocket requirements (for example, your prescription drug payment levels).
It is important to note, for the reasons described in the Introduction to this Guide, that the listing of a drug in the Guide does not mean that it will be covered by your particular benefit plan before your HDHP deductible is satisfied. Please follow the steps outlined in the Introduction to ensure you are properly directing the processing of your claims.
The preventive drug program currently includes prescription drugs in the following categories:
• Anti-angina• Anti-arrhythmics• Anti-coagulants/anti-platelets• Breast cancer prevention• Contraceptives• Diabetes Rx – hypoglycemic agents• Diabetes Rx – insulin and oral• Fluoride supplements
• Heparins/low molecular weight heparin• High blood pressure• High cholesterol• Infant eye ointment (for newborns)• Osteoporosis• Prenatal vitamins• Respiratory• Tobacco cessation
The drugs in each category are listed alphabetically below.
• Generic drugs are listed in bold.• Brand drugs are listed in all CAPITAL letters.* Generic equivalent available
Please be reminded that Health Savings Accounts (HSAs) have tax and legal ramifications. Blue Cross and Blue Shield of Texas does not provide legal or tax advice, and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on, for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products.
ANTI-ANGINA DILATRATE SR IMDUR * ISORDIL TITRADOSE 5 MG * ISORDIL TITRADOSE 40 MG isosorbide dinitrate tabs isosorbide dinitrate ext-release ISOSORBIDE DINITRATE SUBLINGUAL isosorbide mononitrate isosorbide mononitrate ext-release MONOKET * NITRO-BID NITRO-DUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR * NITRO-DUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin ext-release NITROGLYCERIN LINGUAL PUMPSPRAY nitroglycerin patches NITROLINGUAL PUMPSPRAY NITROMIST NITROSTAT RANEXA
ANTI-ARRHYTHMICS amiodarone CORDARONE * DIGOXIN SOLN digoxin tabs disopyramide flecainide LANOXIN * MEXILETINE MULTAQ NORPACE * NORPACE CR PACERONE 100 MG PACERONE 400 MG * propafenone propafenone ext-release quinidine gluconate ext-release quinidine sulfate QUINIDINE SULFATE EXT-RELEASE RYTHMOL * RYTHMOL SR * TAMBOCOR * TIKOSYN
ANTI-COAGULANTS/ ANTI-PLATELETS AGGRENOX AGRYLIN * anagrelide BRILINTA cilostazol clopidogrel COUMADIN * dipyridamole EFFIENT ELIQUIS PERSANTINE * PLAVIX * PLETAL * PRADAXA warfarin XARELTO
BREAST CANCER PREVENTION EVISTA SOLTAMOX tamoxifen
CONTRACEPTIVESCervical CapsFEMCAPPRENTIF CAVITY-RIM CERVICAL CAPPRENTIF FITTING SET
DiaphragmsOMNIFLEX DIAPHRAGMORTHO DIAPHRAGM ALL-FLEXORTHO DIAPHRAGM COIL SPRING KITORTHO DIAPHRAGM FLAT SPRING KITWIDE-SEAL SILICONE DIAPHRAGM KIT
Emergency Progestinlevonorgestrel My WayNext Choice/One DosePLAN B/ONE-STEP *
Emergency EllaELLA
Implants ProgestinIMPLANONNEXPLANON
Injectable ProgestinDEPO-PROVERA CONTRACEPTIVE *DEPO-SUBQ PROVERA 104medroxyprogesterone acetate
IUD ProgestinMIRENA SKYLA
Oral CombinedAltaveraAlyacenApriAranelleAvianeAzuretteBalzivaBEYAZBREVICON *BriellynCaziantCesia ChatealCryselleCyclafemCYCLESSA *DasettaDESOGEN * drospirenone/ethinyl estradiol ElinestEmoquetteEnpresse EnskyceEstaryllaESTROSTEP FE * FalminaFEMCON FE *GENERESS FEGianvi GildagiaGildessGildess FeJunelJunel FeKarivaKelnor KurveloLeenaLessina Levonest
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levonorgestrel/ethinyl estradiolLevoraLO LOESTRIN FELO/OVRAL *LOESTRIN *LOESTRIN 24 FELOESTRIN FE *LorynaLow-OgestrelLuteraMarlissaMicrogestinMicrogestin Fe MINASTRIN 24 FEMIRCETTE *MODICON * Mono-LinyahMononessa MyzilraNATAZIANecon 0.5/35, 1/35, 7/7/7NECON 1/50, 10/11NORDETTE *norgestimate/ethinyl estradiolnorgestrel/ethinyl estradiolNORINYL 1+35 *NORINYL 1+50NortrelOcellaOGESTRELOrsythiaORTHO TRI-CYCLEN * ORTHO TRI-CYCLEN LOORTHO-CEPT *ORTHO-CYCLEN *ORTHO-NOVUMOVCON-35 *OVCON-50 Philith PirmellaPortiaPrevifemReclipsenSAFYRALSoliaSprintecSronyxSyedaTilia Fe Tri-Estarylla
Tri-Legest Fe Tri-LinyahTRI-NORINYL *Tri-PrevifemTri-SprintecTrinessaTrivoraVelivetVesturaViorele WeraWymzya FeYASMIN *YAZ *ZarahZenchentZenchent FeZeosaZovia 1/35EZOVIA 1/50E
Oral Extended ContinuousAmethiaAmethia LoAMETHYSTCamreseCamrese Lo DayseeIntrovaleJolessalevonorgestrel/ethinyl estradiolLOSEASONIQUE *LYBREL *QUARTETTEQuasenseSEASONALE *SEASONIQUE *
Oral ProgestinCamilaErrinHeather JencyclaJolivette LyzaNOR-QD *Nora-BEnorethindroneORTHO MICRONOR *
Transdermal CombinedORTHO EVRA
Vaginal CombinedNUVARING
DIABETES Rx – HYPOGLYCEMIC AGENTSGLUCAGENGLUCAGEN HYPOKITGLUCAGON EMERGENCY KITPROGLYCEM
DIABETES Rx – INSULIN AND ORAL acarboseACTOPLUS MET *ACTOPLUS MET XRACTOS *AMARYL *APIDRA BYDUREONBYETTA CHLORPROPAMIDECYCLOSET DIABETA DUETACTFORTAMET *glimepirideglipizideglipizide ext-releaseglipizide/metformin GLUCOPHAGE *GLUCOPHAGE XR *GLUCOTROL *GLUCOTROL XL *GLUCOVANCE *GLUMETZAglyburide, generics of Micronase GLYBURIDE, distributor of DIABETAglyburide micronizedglyburide/metforminGLYNASE *GLYSETHUMALOGHUMULININVOKANAJANUMET JANUMET XRJANUVIA
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JENTADUETO JUVISYNC KAZANO KOMBIGLYZE XRLANTUSLEVEMIRMETAGLIP *metformin metformin ext-releasenateglinideNESINANOVOLINNOVOLIN RELIONNOVOLOGONGLYZA OSENI pioglitazonepioglitazone/glimepiridepioglitazone/metforminPRANDIMETPRANDINPRECOSE *RELION RRIOMETSTARLIX *SYMLINPEN tolazamide 250 mgTOLAZAMIDE 500 mgTOLBUTAMIDE TRADJENTAVICTOZA
FLUORIDE SUPPLEMENTSFLUOR-A-DAY CHEW TABSFLUORABONFLUORIDEX DAILY DEFENSE SENSITIVITY RELIEF GELFLURA-DROPS 0.25 MG GEL-KAM *LOZI-FLURLURIDE *NAFRINSENAFRINSE DAILY/ACIDULATEDPREVIDENT *sodium fluoride chew tabs; crm; drops; gel; oral rinse; paste; soln SODIUM FLUORIDE TABS sodium fluoride/potassium nitrate stannous fluorideTHERA-FLUR-N *
HEPARINS/LOW MOLECULAR WEIGHT HEPARIN ARIXTRA * enoxaparin fondaparinux FRAGMIN heparin sodium inj, 5,000 unit/mL IPRIVASK LOVENOX *
HIGH BLOOD PRESSUREACCUPRIL *ACCURETIC *acebutolol ACEON *ACETAZOLAMIDE 125 mgacetazolamide 250 mg acetazolamide ext-releaseADALAT CC *ALDACTAZIDE 25/25 MG *ALDACTAZIDE 50/50 MGALDACTONE *ALTACE *amilorideamiloride/hydrochlorothiazideamlodipine AMLODIPINE/ATORVASTATINamlodipine/benazeprilAMTURNIDE ATACANDATACAND HCT *atenololatenolol/chlorthalidoneAVALIDE *AVAPRO *AZORbenazeprilbenazepril/hydrochlorothiazideBENICARBENICAR HCTBETAPACE *BETAPACE AF *betaxolol BIDILbisoprololbisoprolol/hydrochlorothiazide bumetanideBYSTOLICCADUET
CALAN *CALAN SR * candesartan candesartan/hydrochlorothiazidecaptopril CAPTOPRIL/HYDROCHLOROTHIAZIDECARDENE SRCARDIZEM *CARDIZEM CD * CARDIZEM LA 120 MGCARDIZEM LA 180 MG, 240 MG, 300 MG, 360 MG, 420 MG *CARDURA *carvedilolCATAPRES *CATAPRES-TTS *chlorothiazideCHLORTHALIDONEclonidine CLORPRESCOREG *COREG CRCORGARD *CORZIDE *COVERA-HSCOZAAR *DEMADEX *DEMSER DIAMOX *DIBENZYLINEDILACOR XR *diltiazemdiltiazem ext-releaseDIOVANDIOVAN HCT *DIURILdoxazosin DUTOPROLDYAZIDE *DYNACIRC CRDYRENIUM EDARBI EDARBYCLOREDECRINenalaprilenalapril/hydrochlorothiazideeplerenone eprosartanEXFORGEEXFORGE HCT
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felodipine ext-releasefosinoprilfosinopril/hydrochlorothiazide FUROSEMIDE SOLN 8 MG/MLfurosemide soln 10 mg/mL; tabs guanfacine hydralazine hydrochlorothiazideHYZAAR *indapamideINDERAL LA *INNOPRAN XLINSPRA *irbesartanirbesartan/hydrochlorothiazideISOPTIN SR *ISRADIPINEKERLONE *labetalol LASIX *LEVATOLlisinopril lisinopril/hydrochlorothiazideLOPRESSOR *LOPRESSOR HCT *losartanlosartan/hydrochlorothiazideLOTENSIN *LOTENSIN HCT *LOTREL *MAVIK *MAXZIDE *MAXZIDE-25 *methazolamide METHYCLOTHIAZIDEmethyldopaMETHYLDOPA/ HYDROCHLOROTHIAZIDEmetolazonemetoprolol succinate ext-releasemetoprolol tartratemetoprolol/hydrochlorothiazide MICARDISMICARDIS HCTMICROZIDE *MINIPRESS *minoxidilmoexiprilmoexipril/hydrochlorothiazidenadolol
nadolol/bendroflumethiazideNEPTAZANE * NEXICLON XR nicardipine nifedipine 10 mgNIFEDIPINE 20 mg nifedipine ext-releasenimodipineNIMOTOP * nisoldipine ext-release 8.5 mg, 17 mg, 34 mg NISOLDIPINE EXT-RELEASE 20 MG, 25.5 MG, 30 MG, 40 MGNORVASC * NYMALIZEperindoprilPINDOLOLprazosinPRINIVIL *PRINZIDE * PROCARDIA *PROCARDIA XL *PROPRANOLOL SOLNpropranolol tabspropranolol ext-release PROPRANOLOL/ HYDROCHLOROTHIAZIDEquinapril quinapril/hydrochlorothiazideramiprilSECTRAL *sotalol sotalol AFspironolactonespironolactone/hydrochlorothiazide SULAR *TARKATEKAMLOTEKTURNATEKTURNA HCTTENEX *TENORETIC *TENORMIN *terazosin TEVETEN 400 MG TEVETEN 600 MG *TEVETEN HCTTHALITONETIAZAC *TIMOLOL TABS
TOPROL XL *torsemideTRANDATE *trandolapriltriamterene/hydrochlorothiazideTRIBENZORTWYNSTAUNIRETIC *UNIVASC * valsartan/hydrochlorothiazideVALTURNA VASERETIC *VASOTEC * VERAPAMIL 40 mgverapamil 80 mg, 120 mg verapamil ext-releaseVERELAN *VERELAN PM *ZAROXOLYN * ZEBETA *ZESTORETIC *ZESTRIL *ZIAC *
HIGH CHOLESTEROLADVICORALTOPREV AMLODIPINE/ATORVASTATINANTARA atorvastatinCADUETcholestyraminecholestyramine lightCOLESTID *colestipol CRESTORfenofibratefenofibrate micronizedFENOFIBRIC ACIDFENOGLIDEFIBRICOR fluvastatingemfibrozilLESCOL *LESCOL XLLIPITOR *LIPOFEN LIPTRUZETLIVALOLOFIBRA *
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LOPID *lovastatinLOVAZAMEVACOR * NIACORNIASPANPRAVACHOL *pravastatin QUESTRAN *QUESTRAN LIGHT *SIMCORsimvastatinTRICORTRIGLIDETRILIPIX VASCEPA VYTORINWELCHOLZETIAZOCOR *
INFANT EYE OINTMENT (for newborns)erythromycin eye oint
OSTEOPOROSISACTONELalendronate 5 mg, 10 mg, 35 mg, 70 mgALENDRONATE 40 mgALENDRONATE SOLNATELVIA BINOSTO BONIVA *calcitonin-salmonDIDRONEL * ETIDRONATEEVISTA FORTICAL FOSAMAX *FOSAMAX PLUS D ibandronateMIACALCIN NASAL *SKELID
PRENATAL VITAMINSALL PRESCRIPTION PRENATAL VITAMINS
RESPIRATORYACCOLATE *ACCUNEB * acetylcysteine ADVAIR DISKUSADVAIR HFAalbuterolalbuterol ext-releaseALVESCOARCAPTA NEOHALER ASMANEXATROVENT HFA BREO ELLIPTABRONCOMAR-1BRONDILBROVANA budesonide inhal susp 0.25 mg/2 mL, 0.5 mg/2 mLCOMBIVENT COMBIVENT RESPIMATcromolyn sodium inhal soln DALIRESP DULERA DUONEB *ELIXOPHYLLIN FLOVENT DISKUSFLOVENT HFAFORADIL AEROLIZERipratropium inhal solnipratropium/albuterol inhal soln levalbuterol inhal solnLUFYLLINMAXAIR AUTOHALER METAPROTERENOL montelukastPERFOROMISTPROAIR HFAPROVENTIL HFAPULMICORT FLEXHALERPULMICORT RESPULES 0.25 MG/2 ML, 0.5 MG/2 ML *PULMICORT RESPULES 1 MG/2 ML QVARSEREVENT DISKUSSINGULAIR *SPIRIVA HANDIHALERSYMBICORTterbutaline THEO-24
theophyllinetheophylline ext-release TUDORZA PRESSAIR VENTOLIN HFAVOSPIRE ER *XOPENEXXOPENEX CONCENTRATE *XOPENEX HFAzafirlukast
TOBACCO CESSATIONALL BRAND/GENERIC OTC NICOTINE GUM, LOZENGES, PATCHES bupropion ext-release (smoking cessation)CHANTIXCOMMIT * (OTC)NICODERM CQ * (OTC)NICORETTE * (OTC)nicotine gum, lozenges, patches NICOTINE TRANSDERMAL KIT (OTC) NICOTROL INHALERNICOTROL NSZYBAN *
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