Download preventive drug

PREVENTIVE DRUG
BENEFIT PROGRAM
FOR GROUPS USING THE BASIC OR
ENHANCED DRUG LIST
Employee Guide
Effective January 1, 2017
732660.1016
Blue Cross and Blue Shield of Texas, 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 FOR
A.H. BELO CORPORATION
INTRODUCTION
Blue 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). Coverage of some medications or drug products may be covered under your
medical benefit.
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 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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2017 STANDARD HSA COMMON PREVENTIVE DRUG
LIST FOR A.H. BELO CORPORATION
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). Coverage of some medications or drug products may be covered under your
medical benefit.
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
• Fluoride supplements
• Anti-arrhythmics
• Heparins/low molecular weight heparin
• Anti-coagulants/anti-platelets
• High blood pressure
• Breast cancer primary and secondary
prevention
• High cholesterol
• Contraceptives
• Osteoporosis
• Diabetes medications
• Prenatal vitamins
• Diabetic supplies
• Respiratory
• Infant eye ointment (for newborns)
The drugs in each category are listed alphabetically on the following pages.
Generic drugs are listed in bold.
Brand drugs are listed in all CAPITAL letters.
Asterisk (*) denotes 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.
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2017 STANDARD HSA COMMON PREVENTIVE DRUG
LIST FOR A.H. BELO CORPORATION
ANTI-ANGINA
DILATRATE SR
ISORDIL TITRADOSE 5 MG*
ISORDIL TITRADOSE 40 MG
isosorbide dinitrate 5 mg, 10 mg,
20 mg
ISOSORBIDE DINITRATE 30 MG
ISOSORBIDE DINITRATE ER
isosorbide mononitrate
isosorbide mononitrate ext-release
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
nitroglycerin lingual spray
nitroglycerin patches
NITROLINGUAL PUMPSPRAY*
NITROMIST
NITROSTAT
RANEXA
ANTI-ARRHYTHMICS
amiodarone
BETAPACE*
BETAPACE AF*
CORDARONE*
DIGOXIN SOLN
digoxin tabs
disopyramide
dofetilide
flecainide
LANOXIN 0.0625 MG, 0.1875 MG
LANOXIN 0.125 MG, 0.25 MG*
mexiletine
MULTAQ
NORPACE*
NORPACE CR
propafenone
propafenone ext-release
quinidine gluconate ext-release
QUINIDINE SULFATE
QUINIDINE SULFATE EXT-RELEASE
RYTHMOL*
RYTHMOL SR*
sotalol
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sotalol AF
SOTYLIZE
TIKOSYN*
ANTI-COAGULANTS/
ANTI-PLATELETS
AGGRENOX
AGRYLIN*
anagrelide
ASPIRIN/DIPYRIDAMOLE
BRILINTA
cilostazol
clopidogrel
COUMADIN*
dipyridamole
EFFIENT
ELIQUIS
PERSANTINE*
PLAVIX*
PLETAL*
PRADAXA
SAVAYSA
warfarin
XARELTO
ZONTIVITY
BREAST CANCER
PRIMARY AND
SECONDARY
PREVENTION
anastrozole
ARIMIDEX*
AROMASIN*
EVISTA*
exemestane
raloxifene
SOLTAMOX
tamoxifen
CONTRACEPTIVES
Cervical Caps
FEMCAP
PRENTIF CAVITY-RIM CERVICAL
CAP
PRENTIF FITTING SET
Diaphragms
CAYA
OMNIFLEX DIAPHRAGM
ORTHO DIAPHRAGM COIL SPRING
KIT
ORTHO DIAPHRAGM FLAT SPRING
KIT
WIDE-SEAL SILICONE DIAPHRAGM
KIT
Emergency Ella
ELLA
Emergency Progestin
Aftera
Econtera EZ
Fallback Solo
LEVONORGESTREL 0.75 MG
levonorgestrel 1.5 mg
My Way
Next Choice One Dose
Opcicon One-Step
PLAN B ONE-STEP*
Take Action
Injectable Progestin
DEPO-PROVERA CONTRACEPTIVE*
DEPO-SUBQ-PROVERA 104
medroxyprogesterone acetate
IUD Progestin
LILETTA
MIRENA
SKYLA
Oral Combined
Altavera
Alyacen
Apri
Aranelle
Aubra
Aviane
Azurette
Balziva
Bekyree
BEYAZ
Blisovi Fe
Blisovi 24 Fe
BREVICON*
Briellyn
Caziant
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2017 STANDARD HSA COMMON PREVENTIVE DRUG
LIST FOR A.H. BELO CORPORATION
Chateal
Cryselle
Cyclafem
CYCLESSA*
Cyred
Dasetta
Delyla
DESOGEN*
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
Elinest
Emoquette
Enpresse
Enskyce
Estarylla
ESTROSTEP FE*
FALESSA
Falmina
FEMCON FE*
GENERESS FE*
Gianvi
Gildagia
Gildess
Gildess Fe
Gildess 24 Fe
Juleber
Junel
Junel Fe
Junel Fe 24
Kaitlib Fe
Kariva
Kelnor
Kimidess
Kurvelo
Larin
Larin Fe
Larin 24 Fe
Layolis Fe
Leena
Lessina
Levonest
levonorgestrel/ethinyl estradiol
Levora
LOESTRIN*
LOESTRIN FE*
LO LOESTRIN FE
Lomedia 24 Fe
Loryna
Low-Ogestrel
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Lutera
Marlissa
Microgestin
Microgestin Fe
Microgestin 24 Fe
MINASTRIN 24 FE
MIRCETTE*
MODICON*
Mono-Linyah
Mononessa
Myzilra
NATAZIA
Necon 0.5/35, 1/35, 7/7/7
NECON 1/50, 10/11
Nikki
norethindrone/ethinyl estradiol
norethindrone/ethinyl estradiol fe
norgestimate/ethinyl estradiol
NORINYL 1+35*
NORINYL 1+50
Nortrel
Ocella
OGESTREL
Orsythia
ORTHO TRI-CYCLEN*
ORTHO TRI-CYCLEN LO*
ORTHO-CEPT*
ORTHO-CYCLEN*
ORTHO-NOVUM*
OVCON-35*
Philith
Pimtrea
Pirmella
Portia
Previfem
Reclipsen
SAFYRAL
Sprintec
Sronyx
Syeda
Tarina Fe
Tilia Fe
Tri-Estarylla
Tri-Legest Fe
Tri-Linyah
Tri-Lo-Estarylla
Tri-Lo-Marzia
Tri-Lo-Sprintec
TRI-NORINYL*
Tri-Previfem
Tri-Sprintec
Trinessa
Trinessa Lo
Trivora
Velivet
Vestura
Vienva
Viorele
Vyfemla
Wera
Wymzya Fe
YASMIN*
YAZ*
Zarah
Zenchent
Zenchent Fe
Zovia 1/35E
ZOVIA 1/50E
Oral Extended Continuous
Amethia
Amethia Lo
Amethyst
Ashlyna
Camrese
Camrese Lo
Daysee
Introvale
Jolessa
levonorgestrel/ethinyl estradiol
LOSEASONIQUE*
QUARTETTE
Quasense
SEASONIQUE*
Setlakin
Oral Progestin
Camila
Deblitane
Errin
Heather
Jencycla
Jolivette
Lyza
NOR-QD*
Nora-Be
norethindrone
Norlyroc
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2017 STANDARD HSA COMMON PREVENTIVE DRUG
LIST FOR A.H. BELO CORPORATION
ORTHO MICRONOR*
Sharobel
Transdermal Combined
ORTHO EVRA
Xulane
Vaginal Combined
NUVARING
DIABETES MEDICATIONS
Hypoglycemic Agents
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
Insulin Only
AFREZZA
APIDRA
HUMALOG
HUMULIN
LANTUS
LEVEMIR
NOVOLIN RELION
NOVOLOG
RELION R
TOUJEO SOLOSTAR
Orals Only
acarbose
ACTOPLUS MET*
ACTOPLUS MET XR
ACTOS*
ALOGLIPTIN
ALOGLIPTIN/METFORMIN
ALOGLIPTIN/PIOGLITAZONE
AMARYL*
CHLORPROPAMIDE
CYCLOSET
DIABETA
DUETACT*
FARXIGA
FORTAMET*
glimepiride
glipizide
glipizide ext-release
glipizide/metformin
GLUCOPHAGE*
GLUCOPHAGE XR*
GLUCOTROL*
GLUCOTROL XL*
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GLUCOVANCE*
GLUMETZA*
GLYBURIDE, distributor of Diabeta
glyburide, generics of Micronase
glyburide/metformin
glyburide micronized
GLYNASE*
GLYSET*
GLYXAMBI
INVOKAMET
INVOKANA
JANUMET
JANUMET XR
JANUVIA
JARDIANCE
JENTADUETO
JENTADUETO XR
KAZANO
KOMBIGLYZE XR
metformin
metformin ext-release
miglitol
nateglinide
NESINA
NOVOLIN
ONGLYZA
OSENI
pioglitazone
pioglitazone/glimepiride
pioglitazone/metformin
PRANDIMET
PRANDIN*
PRECOSE*
repaglinide
REPAGLINIDE/METFORMIN
RIOMET
STARLIX*
SYMLINPEN
SYNJARDY
TOLAZAMIDE
TOLBUTAMIDE
TRADJENTA
TRESIBA
XIGDUO XR
Other Diabetic Injectables
BYDUREON
BYETTA
TANZEUM
TRULICITY
VICTOZA
DIABETIC SUPPLIES
Alcohol prep pads, swabs
Calibration liquid
Insulin Infusion Pump Tubing, IV
sets, reservoirs, and adapters
Insulin syringes
Lancets
Lancet devices
Pen needles
Test strips (acetone, blood and
urine glucose, blood and urine
ketone)
FLUORIDE SUPPLEMENTS
ACT TOTAL CARE DRY MOUTH
COLGATE DRY MOUTH RELIEF
CREST COMPLETE
FLORICAL
FLORIVA
FLUOR-A-DAY CHEW TABS
FLUORABON
FLUORIDEX DAILY DEFENSE
SENSITIVITY RELIEF GEL
FLURA-DROPS
GEL-KAM*
LISTERINE ESSENTIAL CARE
LISTERINE RESTORING*
LISTERINE SMART RINSE*
LISTERINE TOTAL CARE*
LISTERINE WHITENING/RESTORING*
LOZI-FLUR
LURIDE*
MONOCAL
NAFRINSE
OMNI GEL*
PHOS FLUR
PHOS-FLUR ORTHO DEFENSE
PREVIDENT*
REMBRANDT
SENSODYNE REPAIR & PROTECT
WHITENING
sodium fluoride chew tabs; crm;
drops; gel; oral rinse; paste; soln
SODIUM FLUORIDE TABS
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2017 STANDARD HSA COMMON PREVENTIVE DRUG
LIST FOR A.H. BELO CORPORATION
sodium fluoride/potassium nitrate
stannous fluoride gel, oral rinse
STANNOUS FLUORIDE RINSE
THERA-FLUR-N*
HEPARINS/LOW
MOLECULAR
WEIGHT HEPARIN
ARIXTRA*
enoxaparin
fondaparinux
FRAGMIN
heparin sodium inj, 5,000 unit/
0.5 mL, 5,000 unit mL
IPRIVASK
LOVENOX*
HIGH BLOOD PRESSURE
ACCUPRIL*
ACCURETIC*
acebutolol
ACEON*
ADALAT CC*
ALDACTAZIDE 25-25 MG*
ALDACTAZIDE 50-50 MG
ALDACTONE*
ALTACE*
amiloride
amiloride/hydrochlorothiazide
amlodipine
amlodipine/atorvastatin
amlodipine/benazepril
amlodipine/valsartan
amlodipine/valsartan/
hydrochlorothiazide
AMTURNIDE
ATACAND*
ATACAND HCT*
atenolol
atenolol/chlorthalidone
AVALIDE*
AVAPRO*
AZOR
benazepril
benazepril/hydrochlorothiazide
BENICAR
BENICAR HCT
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betaxolol
BIDIL
bisoprolol
bisoprolol/hydrochlorothiazide
bumetanide
BUMEX*
BYSTOLIC
CADUET*
CALAN*
CALAN SR*
candesartan
candesartan/hydrochlorothiazide
captopril
CAPTOPRIL/HYDROCHLOROTHIAZIDE
CARDIZEM*
CARDIZEM CD*
CARDIZEM LA 120 MG
CARDIZEM LA 180 MG, 240 MG,
300 MG, 360 MG, 420 MG*
CARDURA*
carvedilol
CATAPRES*
CATAPRES-TTS*
CHLOROTHIAZIDE 250 MG
chlorothiazide 500 mg
CHLORTHALIDONE
clonidine
CLORPRES
COREG*
COREG CR
CORGARD*
CORZIDE*
COZAAR*
DEMADEX*
DEMSER
DIBENZYLINE*
diltiazem
diltiazem ext-release
DIOVAN*
DIOVAN HCT*
DIURIL
doxazosin
DUTOPROL
DYAZIDE*
DYRENIUM
EDARBI
EDARBYCLOR
enalapril
enalapril/hydrochlorothiazide
EPANED
eplerenone
EPROSARTAN
EXFORGE*
EXFORGE HCT*
felodipine ext-release
fosinopril
fosinopril/hydrochlorothiazide
FUROSEMIDE SOLN 8 MG/ML
furosemide soln 10 mg/mL; tabs
guanfacine
hydralazine
hydrochlorothiazide
HYZAAR*
indapamide
INDERAL LA*
INDERAL XL
INNOPRAN XL
INSPRA*
irbesartan
irbesartan/hydrochlorothiazide
isradipine
KERLONE*
labetalol
LASIX*
LEVATOL
lisinopril
lisinopril/hydrochlorothiazide
LOPRESSOR*
LOPRESSOR HCT*
losartan
losartan/hydrochlorothiazide
LOTENSIN*
LOTENSIN HCT*
LOTREL*
MAVIK*
MAXZIDE*
MAXZIDE-25*
METHYCLOTHIAZIDE
methyldopa
METHYLDOPA/
HYDROCHLOROTHIAZIDE
metolazone
metoprolol succinate ext-release
metoprolol tartrate 25 mg, 50 mg,
100 mg
METOPROLOL TARTRATE 37.5 MG,
75 MG
metoprolol/hydrochlorothiazide
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2017 STANDARD HSA COMMON PREVENTIVE DRUG
LIST FOR A.H. BELO CORPORATION
MICARDIS*
MICARDIS HCT*
MICROZIDE*
MINIPRESS*
minoxidil
moexipril
moexipril/hydrochlorothiazide
nadolol
nadolol/bendroflumethiazide
nicardipine
nifedipine
nifedipine ext-release
nisoldipine ext-release 8.5 mg,
17 mg, 34 mg
NISOLDIPINE EXT-RELEASE 20 MG,
25.5 MG, 30 MG, 40 MG
NORVASC*
perindopril
phenoxybenzamine
pindolol
prazosin
PRESTALIA
PRINIVIL*
PROCARDIA*
PROCARDIA XL*
PROPRANOLOL SOLN
propranolol tabs
propranolol ext-release
PROPRANOLOL/
HYDROCHLOROTHIAZIDE
quinapril
quinapril/hydrochlorothiazide
ramipril
SECTRAL*
spironolactone
spironolactone/hydrochlorothiazide
SULAR*
TARKA*
TEKAMLO
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan/amlodipine
telmisartan/hydrochlorothiazide
TENEX*
TENORETIC*
TENORMIN*
terazosin
TEVETEN 600 MG
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TEVETEN HCT
TIAZAC*
TIMOLOL TABS
TOPROL XL*
torsemide
trandolapril
trandolapril/verapamil ext-release
triamterene/hydrochlorothiazide
caps, 37.5-25 mg; tabs
TRIAMTERENE/
HYDROCHLOROTHIAZIDE CAPS,
50-25 MG
TRIBENZOR
TWYNSTA*
valsartan
valsartan/hydrochlorothiazide
VASERETIC*
VASOTEC*
verapamil
verapamil ext-release
VERELAN*
VERELAN PM*
ZEBETA*
ZESTORETIC*
ZESTRIL*
ZIAC*
HIGH CHOLESTEROL
ALTOPREV
amlodipine/atorvastatin
ANTARA
atorvastatin
CADUET*
cholestyramine
cholestyramine light
COLESTID*
colestipol
CRESTOR*
EQUAPAX/ATORVASTATIN/COQ10
FENOFIBRATE CAPS
fenofibrate micronized
fenofibrate tabs
FENOFIBRIC ACID
fenofibric acid delayed-release
FENOGLIDE*
FIBRICOR
fluvastatin
fluvastatin ext-release
gemfibrozil
LESCOL*
LESCOL XL*
LIPITOR*
LIPOFEN
LIVALO
LOFIBRA*
LOPID*
lovastatin
LOVAZA*
MEVACOR*
niacin ext-release
NIACOR
NIASPAN*
omega-3-acid ethyl esters
PRAVACHOL*
pravastatin
QUESTRAN*
QUESTRAN LIGHT*
rosuvastatin
simvastatin
TRICOR*
TRIGLIDE
TRILIPIX*
VASCEPA
VYTORIN
WELCHOL
ZETIA
ZOCOR*
INFANT EYE OINTMENT
(for newborns)
erythromycin eye ointment
OSTEOPOROSIS
ACTONEL*
alendronate 5 mg, 10 mg, 35 mg, 70 mg
ALENDRONATE 40 MG
ALENDRONATE SOLN
ATELVIA*
BINOSTO
BONIVA*
calcitonin-salmon
EVISTA*
FORTICAL
FOSAMAX*
FOSAMAX PLUS D
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2017 STANDARD HSA COMMON PREVENTIVE DRUG
LIST FOR A.H. BELO CORPORATION
ibandronate
MIACALCIN NASAL*
raloxifene
risedronate
risedronate delayed-release
PRENATAL VITAMINS
ALL PRESCRIPTION PRENATAL
VITAMINS
RESPIRATORY
ACCOLATE*
acetylcysteine
ADVAIR DISKUS
ADVAIR HFA
AEROSPAN
albuterol
albuterol ext-release
ALVESCO
ANORO ELLIPTA
ARCAPTA NEOHALER
ARNUITY ELLIPTA
ASMANEX HFA
ASMANEX TWISTHALER
ATROVENT HFA
BEVESPI AEROSPHERE
BREO ELLIPTA
BROVANA
budesonide inhal susp
COMBIVENT RESPIMAT
CROMOLYN SODIUM INHAL SOLN
DALIRESP
DULERA
dyphylline/guaifenesin
ELIXOPHYLLIN
FLOVENT DISKUS
FLOVENT HFA
FORADIL AEROLIZER
INCRUSE ELLIPTA
ipratropium inhal soln
ipratropium/albuterol inhal soln
levalbuterol inhal soln
LUFYLLIN
METAPROTERENOL
montelukast
PERFOROMIST
PROAIR HFA
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PROAIR RESPICLICK
PROVENTIL HFA
PULMICORT FLEXHALER
PULMICORT RESPULES
QVAR
SEREVENT DISKUS
SINGULAIR*
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
STIOLTO RESPIMAT
STRIVERDI RESPIMAT
SYMBICORT
terbutaline
THEO-24
theophylline
theophylline ext-release
TUDORZA PRESSAIR
UTIBRON NEOHALER
VENTOLIN HFA
VOSPIRE ER*
XOPENEX*
XOPENEX CONCENTRATE*
XOPENEX HFA
zafirlukast
Third-party brand names are the property of their respective owners.
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