Download Therapeutic Category Drug Class Clinical Edits

General Motors 2017 Preventive Services & Medications List
Updated September 2016
The plan covers the following preventive medications, both prescription and over-the-counter (OTC) with no ($0)
copayment, before meeting the plan’s annual deductible and out of pocket maximum.
To receive these medications with no copayment, you must have an authorized prescription for the product and
it must be dispensed by a participating mail or retail pharmacy. In other words, for OTC medications to be
covered by the plan with no copayment, enrollees are not able to purchase the product (e.g., bottle of aspirin)
without presenting a pharmacist with a prescription. In addition, the below mentioned "Clinical
Edits/Comments" are the only situations in which no copayment will apply. This list will be reviewed
periodically. For more information on medications, please contact Express Scripts at 800-464-4679.
Preventive Medications List with No Copayment
Therapeutic Category Drug Class
Clinical Edits/Comments
Drug Name Examples
CARDIOVASCULAR
ASPIRIN
ASPIRIN
FLUORIDE SUPPLEMENT
FLUORIDE PREPARATIONS
Aspirin – an OTC product for males and
females age <60.
Fluoride – a prescription product for children
to prevent dental cavities through Age 5.
FLUORIDE Tabs
FLUORIDE Drops
FLUORITAB
LUDENT FLUORIDE
MULTIVITAMIN AND FLUORIDE
SODIUM FLUORIDE
CONTRACEPTIVES
ORAL CONTRACEPTIVES
Generic Oral Contraceptives (brand name
TRI-SPRINTEC
drug will be covered if no generic equivalent is SPRINTEC
available.)
APRI
JUNEL FE
AVIANE
TRINESSA
CYRSELLE
NORGESTIMATE-ETHINYL
LORYNA
GIANVI
CONTRACEPTIVES
TOBACCO DETERRENTS
OTHER CONTRACEPTIVES
Tobacco Deterrent Agents
Non-Oral Contraceptives (Brand name item
will be covered if no Generic equivalent is
available.)
Tobacco cessation products - some OTC and
some prescription products, age 18 or older.
DIAPHRAGMS
XULANE
NUVARING
BUPROPION HCL ER, BUPRIOPION SR
CHANTIX
COMMIT
NICODERM CQ
NICORETTE
NICOTINE, NICOTINE GUM
NICOTROL, NICOTROL NS
STOP SMOKING AID
THRIVE NICOTINE
VITAMINS
FOLIC ACID PREPARATIONS
Folic acid – OTC doses of 400 to 800 mcg/day FOLIC ACID
for women, through Age 50, who are
pregnant or who are planning to become
pregnant.
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VITAMINS
BREAST CANCER PRIMARY
PREVENTION
VITAMIN D SUPPLEMENTATION Vitamin D - OTC product for communityVITAMIN D2 OR D3
dwelling adults aged 65 years or older.Vitamin
D2 or D3 1,000IU or less
ANTIESTROGENS
For use in primary prevention of invasive
TAMOXIFEN, RALOXIFENE
breast cancer in women at high risk; must be
35 years or older who do not have a prior
history of a diagnosis of breast cancer.
Medications used to prepare for BOWEL EVACUANTS
Colonoscopy
Adults ≥ 50 and ≤ 75 years of age
GoLytely
Limit of 2 prescriptions per year
MoviPrep
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General Motors 2017 Preventive Services & Medications List
Updated September 2016
To promote good health and help prevent the need for costly care, certain eligible generic only preventive medications,
listed below, are available for a $10 Retail / $20 Mail copayment before meeting the plan’s annual deductible and out-ofpocket maximum. This list will be reviewed periodically as new generics become available in these therapeutic categories.
For more information, please contact Express Scripts at 800-464-4679.
Preventive Medications List with Copayment
Therapeutic Category
BONE STRENGTH
Drug Class
OSTEOPOROSIS THERAPY
HIGH BLOOD PRESSURE
ACE INHIBITORS
Drug Name Examples
ANGIOTENSIN RECEPTOR ANTAGONIST
BETA BLOCKERS
CALCIUM CHANNEL BLOCKERS
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ALENDRONATE
CALCITONIN-SALMON
FORTICAL
IBANDRONATE
RISEDRONATE/DR
BENAZEPRIL HCL
CAPTOPRIL
ENALAPRIL MALEATE
FOSINOPRIL SODIUM
LISINOPRIL
MOEXIPRIL HCL
PERINDOPRIL ERBUMINE
QUINAPRIL
RAMIPRIL
TRANDOLAPRIL
CANDESARTAN
EPROSARTAN
IRBESARTAN
LOSARTAN
TELMISARTAN
VALSARTAN
ACEBUTOLOL HCL
ATENOLOL
BETAXOLOL HCL
BISOPROLOL FUMARATE
METOPROLOL SUCCINATE
METOPROLOL TARTRATE
NADOLOL
PINDOLOL
PROPRANOLOL/ER
TIMOLOL MALEATE
AFEDITAB CR
AMLODIPINE BESYLATE
CARTIA XT
DILT-CD
DILTIA XT
DILTIAZEM 24HR CD
DILTIAZEM ER
DILTIAZEM HCL
DILT-XR
DILTZAC ER
FELODIPINE ER
ISRADIPINE
General Motors 2017 Preventive Services & Medications List
Updated September 2016
MATZIM LA
NICARDIPINE HCL
NIFEDIAC CC
NIFEDICAL XL
NIFEDIPINE
NIFEDIPINE ER
NISOLDIPINE
TAZTIA XT
Therapeutic Category
Drug Class
Drug Name Examples
HIGH BLOOD PRESSURE
(Continued)
COMBINATION PRODUCTS
AMLODIPINE BESYLATE/BENAZEPRIL
AMLODIPINE/ ATORVASTATIN
AMLODIPINE/VALSARTAN
AMLODIPINE/ VALSARTAN/ HCTZ
ATENOLOL W/CHLORTHALIDONE
BENAZEPRIL/HYDROCHLOROTHIAZIDE
BISOPROLOL FUMARATE/HCTZ
CANDESARTAN/ HYDROCHLOROTHIAZIDE
CAPTOPRIL/HYDROCHLOROTHIAZIDE
ENALAPRIL/HYDROCHLOROTHIAZIDE
FOSINOPRIL/HYDROCHLOROTHIAZIDE
IRBESARTAN/ HYDROCHLOROTHIAZIDE
LISINOPRIL/HYDROCHLOROTHIAZIDE
LOSARTAN/HYDROCHLOROTHIAZIDE
METOPROLOL-HYDROCHLOROTHIAZIDE
MOEXIPRIL/HYDROCHLOROTHIAZIDE
NADOLOL-BENDROFLUMETHIAZIDE
PROPRANOLOL HCL-HCTZ
QUINAPRIL/HYDROCHLOROTHIAZIDE
TELMISARTAN-AMLODIPINE
TELMISARTAN-HYDROCHLOROTHIAZIDE
TRANDOLAPRIL/VERAPAMIL HCL
VALSARTAN / HYDROCHLOROTHIAZIDE
AMILORIDE HCL
AMILORIDE HCL W/HCTZ
BUMETANIDE
CHLOROTHIAZIDE
CHLORTHALIDONE
EPLERENONE
FUROSEMIDE
HYDROCHLOROTHIAZIDE
INDAPAMIDE
METHYCLOTHIAZIDE
METOLAZONE
SPIRONOLACTONE
SPIRONOLACTONE W/HCTZ
TORSEMIDE
TRIAMTERENE W/HCTZ
ATORVASTATIN
CHOLESTYRAMINE
CHOLESTYRAMINE LIGHT
COLESTIPOL HCL
FENOFIBRIC ACID
DIURETICS
HIGH CHOLESTEROL
CHOLESTEROL LOWERING THERAPY
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HIGH CHOLESTEROL
CHOLESTEROL LOWERING THERAPY
General Motors 2017 Preventive Services & Medications List
Updated September 2016
FLUVASTATIN
LOVASTATIN
NIACIN ER
OMEGA-3 ACID ETHYL ESTERS
PRAVASTATIN SODIUM
PREVALITE
ROSUVASTATIN
SIMVASTATIN
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