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Download OGB Pelican HSA 775 CDHP Maintenance/ Preventive Care Drug List
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OGB Pelican HSA 775 CDHP Maintenance/ Preventive Care Drug List Preventive care medications are drugs that can help you prevent health problems or problems caused by a health condition. The OGB Pelican HSA 775 CDHP (consumer-driven health plan) Maintenance/Preventive Care Drug List shows certain brand and generic preventive drugs covered by your plan. Drugs on this list are covered with no deductible, when you fill them at a network pharmacy, though they may require you or your doctor to follow some rules based on your plan. Please see your benefit plan for a full list of these rules, which are listed as benefits, limitations and exclusions. DRUG NAME ACCUPRIL ACCURETIC ACEBUTOLOL HCL ACEON ACTIVE OB ACTONEL ADACEL ADALAT CC ADVICOR AFEDITAB CR AFLURIA AGGRENOX ALENDRONATE SODIUM ALTACE ALTOPREV AMLODIPINE BESYLATE AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE-ATORVASTATIN AMLODIPINE-VALSARTAN AMLODIPINE-VALSARTAN-HCTZ ANTARA ASPIR 81 ASPIRIN ASPIRIN E.C. ASPIRIN-DIPYRIDAMOLE ER ASPIR-LOW ASPIR-TRIN ATABEX EC ATACAND ATACAND HCT ATELVIA 04HQ1393 R09/15 DRUG CLASSIFICATION Cardiovascular Cardiovascular Cardiovascular Cardiovascular Prenatal Osteoporosis Infection Cardiovascular Cardiovascular Cardiovascular Infection Cardiovascular Osteoporosis Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Prenatal Cardiovascular Cardiovascular Osteoporosis Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company ATENOLOL ATENOLOL W/CHLORTHALIDONE ATORVASTATIN CALCIUM ATOVAQUONE-PROGUANIL HCL AVALIDE AVAPRO AZOR BAL-CARE DHA BAL-CARE DHA ESSENTIAL BENAZEPRIL HCL BENAZEPRIL HCL-HCTZ BENICAR BENICAR HCT BETAXOLOL HCL BINOSTO BISOPROLOL FUMARATE BISOPROLOL FUMARATE/HCTZ BONIVA BOOSTRIX BRILINTA BYSTOLIC CADUET CALAN CALAN SR CALCIUM PNV CANDESARTAN CILEXETIL CANDESARTANHYDROCHLOROTHIAZID CAPTOPRIL CAPTOPRIL/HYDROCHLOROTHIAZIDE CARDENE SR CARDIZEM CARDIZEM CD CARDIZEM LA CARTIA XT CERVARIX CHILDREN'S ASPIRIN CHLOROQUINE PHOSPHATE CHLOROTHIAZIDE CHLORTHALIDONE CHOICE-OB + DHA CHOLESTYRAMINE CHOLESTYRAMINE LIGHT CITRANATAL 90 DHA CITRANATAL ASSURE 04HQ1393 R09/15 Cardiovascular Cardiovascular Cardiovascular Malaria Cardiovascular Cardiovascular Cardiovascular Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Osteoporosis Cardiovascular Cardiovascular Osteoporosis Infection Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Prenatal Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Infection Cardiovascular Malaria Cardiovascular Cardiovascular Prenatal Cardiovascular Cardiovascular Prenatal Prenatal Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 2 of 12 CITRANATAL B-CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX CLOPIDOGREL C-NATE DHA COLESTID COLESTIPOL HCL COMPLETE NATAL DHA COMPLETENATE COMVAX CONCEPT DHA CONCEPT OB CORGARD CORZIDE COUMADIN COZAAR CRESTOR DAILY PRENATAL DAPTACEL DILTIAZEM 24HR CD DILTIAZEM ER DILTIAZEM HCL DILT-XR DIOVAN DIOVAN HCT DIPHTHERIA-TETANUS TOXOIDS-PED DIPYRIDAMOLE DIURIL DOTHELLE DHA DUET DHA DUET DHA BALANCED DUTOPROL ECOTRIN ECPIRIN EDARBI EDARBYCLOR EFFIENT ELIQUIS ELITE OB ELITE-OB ELITE-OB 400 ENALAPRIL MALEATE ENALAPRIL MALEATE/HCTZ 04HQ1393 R09/15 Prenatal Prenatal Prenatal Prenatal Cardiovascular Prenatal Cardiovascular Cardiovascular Prenatal Prenatal Infection Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Prenatal Infection Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Infection Cardiovascular Cardiovascular Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 3 of 12 ENBRACE HR ENGERIX-B ENTERIC COATED ASPIRIN EPANED EPROSARTAN MESYLATE EVISTA EXFORGE EXFORGE HCT EXPECTA PRENATAL EXTRA-VIRT PLUS DHA FELODIPINE ER FENOFIBRATE FENOFIBRIC ACID FENOGLIDE FIBRICOR FLUARIX FLUBLOK 2015-2016 FLUCELVAX FLULAVAL FLUMIST FLUORIDE FLUORITAB FLUVASTATIN SODIUM FLUVIRIN FLUZONE FLUZONE HIGH-DOSE FLUZONE INTRADERM QUAD 2015-16 FLUZONE QUAD 2015-2016 FLUZONE QUAD PEDI 2015-2016 FOCALGIN 90 DHA FOCALGIN CA FOLBECAL FOLET DHA FOLET ONE FOLIC ACID FOLINATAL PLUS B FOLIVANE-OB FOSAMAX FOSAMAX PLUS D FOSINOPRIL SODIUM FOSINOPRIL-HYDROCHLOROTHIAZIDE GARDASIL GEMFIBROZIL HAVRIX 04HQ1393 R09/15 Prenatal Infection Cardiovascular Cardiovascular Cardiovascular Osteoporosis Cardiovascular Cardiovascular Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Infection Infection Infection Infection Infection Childhood nutrition Childhood nutrition Cardiovascular Infection Infection Infection Infection Infection Infection Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Osteoporosis Osteoporosis Cardiovascular Cardiovascular Infection Cardiovascular Infection Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 4 of 12 HEMANGEOL HEMENATAL OB HEMENATAL OB + DHA HYDROCHLOROTHIAZIDE HYZAAR IBANDRONATE SODIUM INATAL ADVANCE INATAL GT INATAL ULTRA INDAPAMIDE INDERAL LA INDERAL XL INFANATE BALANCE INFANRIX INNOPRAN XL IPOL IRBESARTAN IRBESARTANHYDROCHLOROTHIAZIDE ISRADIPINE JANTOVEN KINRIX KPN LESCOL LESCOL XL LEVATOL LIPITOR LIPOFEN LISINOPRIL LISINOPRIL-HCTZ LITE COAT ASPIRIN LIVALO LOFIBRA LOPID LOPRESSOR LOPRESSOR HCT LOSARTAN POTASSIUM LOSARTAN-HYDROCHLOROTHIAZIDE LOTENSIN LOTENSIN HCT LOTREL LOVASTATIN LOW DOSE ASPIRIN LUDENT FLUORIDE MACNATAL CN DHA 04HQ1393 R09/15 Cardiovascular Prenatal Prenatal Cardiovascular Cardiovascular Osteoporosis Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Prenatal Infection Cardiovascular Infection Cardiovascular Cardiovascular Cardiovascular Cardiovascular Infection Prenatal Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Childhood nutrition Prenatal Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 5 of 12 MALARONE MARNATAL-F MATZIM LA MAVIK MAXINATE MEFLOQUINE HCL MENACTRA MENOMUNE-A-C-Y-W-135 MENVEO A-C-Y-W-135-DIP METHYCLOTHIAZIDE METOLAZONE METOPROLOL SUCCINATE METOPROLOL TARTRATE METOPROLOLHYDROCHLOROTHIAZIDE MICARDIS MICARDIS HCT MICROZIDE M-M-R II VACCINE W/DILUENT MOEXIPRIL HCL MOEXIPRIL-HYDROCHLOROTHIAZIDE MULTIVITAMIN WITH FLUORIDE MVC-FLUORIDE M-VIT MYNATAL MYNATAL ADVANCE MYNATAL PLUS MYNATAL-Z MYNATE 90 PLUS NADOLOL NADOLOL-BENDROFLUMETHIAZIDE NATACHEW NATALVIT NATELLE ONE NESTABS NESTABS ABC NESTABS DHA NEWGEN NEXA PLUS NIACIN ER NIACOR NIASPAN NICARDIPINE HCL NIFEDICAL XL NIFEDIPINE 04HQ1393 R09/15 Malaria Prenatal Cardiovascular Cardiovascular Prenatal Malaria Infection Infection Infection Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Infection Cardiovascular Cardiovascular Childhood nutrition Childhood nutrition Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 6 of 12 NIFEDIPINE ER NISOLDIPINE NIVA-PLUS NORVASC OB COMPLETE OB COMPLETE DHA OB COMPLETE ONE OB COMPLETE PETITE OB COMPLETE PREMIER OBSTETRIX DHA OBSTETRIX EC OBTREX DHA O-CAL FA O-CAL PRENATAL ONE DAILY PRENATAL ONE-A-DAY WOMEN'S PRENATAL DHA PAIRE OB PLUS DHA PEDIARIX PEDVAXHIB PENTACEL PERINDOPRIL ERBUMINE PERRY PRENATAL TABLET PERSANTINE PINDOLOL PLAVIX PNEUMOVAX 23 PNV 29-1 PNV OB+DHA PNV-DHA PNV-DHA + DOCUSATE PNV-FERROUS FUMARATE-DOCU-FA PNV-FIRST PNV-OMEGA PNV-SELECT PNV-TOTAL PNV-VP-U PR NATAL 400 PR NATAL 400 EC PR NATAL 430 PR NATAL 430 EC PRADAXA PRAVACHOL PRAVASTATIN SODIUM PREFERA-OB 04HQ1393 R09/15 Cardiovascular Cardiovascular Prenatal Cardiovascular Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Infection Infection Infection Cardiovascular Prenatal Cardiovascular Cardiovascular Cardiovascular Infection Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Prenatal Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 7 of 12 PREFERA-OB ONE PREFERA-OB PLUS DHA PRENA1 CHEW PRENA1 PEARL PRENAISSANCE PRENAISSANCE BALANCE PRENAISSANCE NEXT PRENAISSANCE NEXT-B PRENAISSANCE PLUS PRENATA PRENATABS FA PRENATABS RX PRENATAL PRENATAL 19 PRENATAL COMPLETE PRENATAL FORMULA PRENATAL LOW IRON PRENATAL PLUS PRENATAL PLUS DHA PRENATAL VITAMIN PRENATAL-U PRENATE PRENATE AM PRENATE DHA PRENATE ELITE PRENATE ENHANCE PRENATE ESSENTIAL PRENATE MINI PRENATE PIXIE PRENATE RESTORE PRENATE STAR PRENAVITE PREPLUS PREQUE 10 PRESTALIA PRETAB PREVALITE PREVNAR 13 PRIMAQUINE PRINIVIL PROCARDIA PROCARDIA XL PROPRANOLOL HCL PROPRANOLOL HCL ER 04HQ1393 R09/15 Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Cardiovascular Prenatal Cardiovascular Infection Malaria Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 8 of 12 PROPRANOLOL HCL-HCTZ PROQUAD PROTECT NATAL PROVIDA DHA PROVIDA OB PUREFE OB PLUS PUREFE PLUS QUADRACEL DTAP-IPV QUESTRAN QUESTRAN LIGHT QUINAPRIL QUINAPRIL-HYDROCHLOROTHIAZIDE RALOXIFENE HCL RAMIPRIL RECOMBIVAX HB RELNATE DHA RIGHT STEP PRENATAL VITAMINS RISEDRONATE SODIUM RISEDRONATE SODIUM DR R-NATAL OB ROTARIX ROTATEQ RULAVITE DHA SAVAYSA SECTRAL SELECT-OB SELECT-OB + DHA SE-NATAL 19 SE-TAN DHA SIMCOR SIMVASTATIN SODIUM FLUORIDE SULAR TARKA TARON PRENATAL TARON-BC TARON-C DHA TAZTIA XT TELMISARTAN TELMISARTAN-AMLODIPINE TELMISARTANHYDROCHLOROTHIAZID TENIVAC TENORETIC TENORMIN 04HQ1393 R09/15 Cardiovascular Infection Prenatal Prenatal Prenatal Prenatal Prenatal Infection Cardiovascular Cardiovascular Cardiovascular Cardiovascular Osteoporosis Cardiovascular Infection Prenatal Prenatal Osteoporosis Osteoporosis Prenatal Infection Infection Prenatal Cardiovascular Cardiovascular Prenatal Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Childhood nutrition Cardiovascular Cardiovascular Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Cardiovascular Infection Cardiovascular Cardiovascular Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 9 of 12 TETANUS DIPHTHERIA TOXOIDS THRIVITE 19 TIAZAC TICLOPIDINE HCL TIMOLOL MALEATE TL FOLATE TL-SELECT TOPROL XL TRANDOLAPRIL TRANDOLAPRIL-VERAPAMIL TRIADVANCE TRIBENZOR TRICARE TRICARE PRENATAL DHA ONE TRICOR TRIGLIDE TRILIPIX TRINATAL GT TRINATAL RX 1 TRINATE TRIPLE-VITAMIN W-FLUORIDE TRISTART DHA TRI-TABS DHA TRIVEEN-DUO DHA TRIVEEN-ONE TRIVEEN-PRX RNF TRIVEEN-U TRI-VITAMIN WITH FLUORIDE TRUST NATAL DHA TWINRIX TWYNSTA ULTIMATECARE ONE ULTIMATECARE ONE NF VALSARTAN VALSARTAN-HYDROCHLOROTHIAZIDE VAQTA VARIVAX VACCINE VARIZIG VASERETIC VASOTEC VEMAVITE-PRX 2 VENA-BAL DHA VENATAL COMPLETE DHA VERAPAMIL ER 04HQ1393 R09/15 Infection Prenatal Cardiovascular Cardiovascular Cardiovascular Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Prenatal Cardiovascular Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Prenatal Prenatal Prenatal Childhood nutrition Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Childhood nutrition Prenatal Infection Cardiovascular Prenatal Prenatal Cardiovascular Cardiovascular Infection Infection Infection Cardiovascular Cardiovascular Prenatal Prenatal Prenatal Cardiovascular Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 10 of 12 VERAPAMIL ER PM VERAPAMIL HCL VERELAN VERELAN PM VINACAL VINATE VINATE GT VINATE II VINATE ONE VINATE ULTRA VINATE-M VIRT NATE VIRT-ADVANCE VIRT-C DHA VIRT-CARE ONE VIRT-PN VIRT-PN DHA VIRT-PN PLUS VIRTPREX VIRT-SELECT VIRT-VITE GT VITAFOL NANO VITAFOL ULTRA VITAFOL-OB VITAFOL-OB+DHA VITAFOL-ONE VITAMED MD ONE RX VITAMED MD PLUS RX VITAMEDMD REDICHEW RX VITAMINS A,C,D & FLUORIDE VITAPEARL VITASPIRE VIVA DHA VOL-NATE VOL-PLUS VOL-TAB RX VP-CH PLUS VP-CH-PNV VP-GGR-B6 VP-HEME OB VP-HEME ONE VP-PNV-DHA VYTORIN WARFARIN SODIUM 04HQ1393 R09/15 Cardiovascular Cardiovascular Cardiovascular Cardiovascular Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Childhood nutrition Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 11 of 12 WELCHOL XARELTO ZATEAN-CH ZATEAN-PN DHA ZATEAN-PN PLUS ZEBETA ZESTORETIC ZESTRIL ZETIA ZIAC ZINGIBER ZOCOR ZONTIVITY ZOSTAVAX 04HQ1393 R09/15 Cardiovascular Cardiovascular Prenatal Prenatal Prenatal Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Prenatal Cardiovascular Cardiovascular Infection Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company Page 12 of 12
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