OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List

Transcription

1 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) 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. 1ST TIER UNIFINE PENTIPS 1ST TIER UNIFINE PENTIPS PLUS 1ST TIER UNILET COMFORTOUCH acarbose ACCOLATE ACCU CHEK ACCU CHEK AVIVA PLUS ACCU CHEK COMPACT PLUS STRIPS ACCU CHEK FASTCLIX LANCET DRUM ACCU CHEK GUIDE TEST STRIP ACCU CHEK SAFE T PRO ACCU CHEK SAFE T PRO PLUS ACCU CHEK SMARTVIEW ACCU CHEK SOFTCLIX ACCUPRIL ACCURETIC ACCUTREND GLUCOSE acebutolol hcl acetylcysteine ACTI LANCE acti lance ACTONEL ACTOPLUS MET ACTOPLUS MET XR ACTOS ADALAT CC ADLYXIN ADMELOG ADMELOG SOLOSTAR ADVAIR DISKUS ADVAIR HFA ADVANCED GLUCOSE TEST STRIP Prevention of Osteoporosis

2 ADVANCED GLUCOSE TEST STRIPS ADVANCED TRAVEL LANCETS ADVOCATE LANCET ADVOCATE LANCETS ADVOCATE PEN NEEDLE ADVOCATE PEN NEEDLES ADVOCATE REDI CODE ADVOCATE REDI CODE+ ADVOCATE SYRINGES ADVOCATE TEST STRIP AEROSPAN afeditab cr AFREZZA AGAMATRIX AMP AGGRENOX AIRDUO RESPICLICK albuterol sulfate alendronate sodium ALOGLIPTIN ALOGLIPTIN METFORMIN ALOGLIPTIN PIOGLITAZONE ALTACE ALTERNATE SITE LANCETS ALTOPREV ALVESCO AMARYL amlodipine besylate amlodipine besylate benazepril amlodipine atorvastatin amlodipine olmesartan amlodipine valsartan amlodipine valsartan hctz ANORO ELLIPTA ANTARA APIDRA APIDRA SOLOSTAR ARCAPTA NEOHALER ARMONAIR RESPICLICK ARNUITY ELLIPTA Prevention of Osteoporosis

3 ASMANEX ASMANEX HFA aspirin dipyridamole er ASSURE 4 ASSURE HAEMOLANCE PLUS ASSURE ID INSULIN SAFETY ASSURE ID PEN NEEDLE ASSURE LANCE ASSURE LANCE PLUS ASSURE PLATINUM ASSURE PRISM MULTI ATABEX EC ATACAND ATACAND HCT ATELVIA atenolol atenolol chlorthalidone atorvastatin calcium atovaquone proguanil hcl ATROVENT HFA AUTOSHIELD DUO PEN NEEDLE AVALIDE AVANDIA AVAPRO AZOR bal care dha BAL CARE DHA ESSENTIAL BASAGLAR KWIKPEN U 100 BD MICROTAINER LANCETS BD ULTRA FINE BD ULTRA FINE II benazepril hcl benazepril hydrochlorothiazide BENICAR BENICAR HCT betaxolol hcl BEVESPI AEROSPHERE BEVYXXA BINOSTO bisoprolol fumarate Prevention of Osteoporosis Prevention of Malaria Prevention of Osteoporosis

4 bisoprolol hydrochlorothiazide BLOOD GLUCOSE TEST STRIP BLOOD LANCETS BONIVA BOOSTRIX BREEZE 2 BREO ELLIPTA BRILINTA BROVANA budesonide BULLSEYE MINI SAFETY LANCETS BYDUREON BYDUREON BCISE BYDUREON PEN BYETTA BYSTOLIC BYVALSON CADUET CALAN CALAN SR calcium pnv candesartan cilexetil candesartan hydrochlorothiazid captopril captopril hydrochlorothiazide CARDIZEM CARDIZEM CD CARDIZEM LA CARDIZEM LA CAREFINE PEN NEEDLE CAREONE CARESENS N CARETOUCH PEN NEEDLE CARETOUCH TEST STRIP CARETOUCH TWIST LANCET cartia xt chloroquine phosphate chlorothiazide chlorpropamide chlorthalidone Prevention of Osteoporosis Prevention of Infections Prevention of Malaria

5 cholestyramine cholestyramine light CITRANATAL 90 DHA CITRANATAL ASSURE CITRANATAL B CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX CLEVER CHEK LANCETS CLEVER CHOICE MICRO TEST STRIP CLEVER CHOICE PRO CLEVER CHOICE TALK CLEVER CHOICE TEST STRIPS CLEVER CHOICE VOICE+ TST STRIP CLICKFINE clopidogrel c nate dha COAGUCHEK colesevelam hcl COLESTID COLESTID colestipol hcl COLOR LANCETS COMBIVENT RESPIMAT COMFORT EZ COMFORT LANCETS complete natal dha completenate CONCEPT DHA CONCEPT OB CONTOUR NEXT TEST STRIP CONTOUR TEST STRIP COOL GLUCOSE TEST STRIP CORGARD CORZIDE COUMADIN COZAAR CRESTOR cromolyn sodium CYCLOSET

6 DALIRESP DIASTIX REAGENT DIATRUE PLUS diltiazem 12hr er diltiazem 24hr cd diltiazem 24hr er diltiazem er diltiazem hcl dilt xr DIOVAN DIOVAN HCT dipyridamole DIURIL dothelle dha DROPLET LANCETS DROPLET PEN NEEDLE DROPSAFE PEN NEEDLE DUET DHA 400 DUET DHA BALANCED DUETACT DULERA DUTOPROL EASY COMFORT EASY COMFORT INSULIN SYRINGE EASY COMFORT PEN NEEDLES EASY GLIDE PEN NEEDLE EASY PLUS II EASY STEP EASY TALK EASY TOUCH EASY TOUCH FLIPLOCK INSULIN EASY TOUCH INSULIN SAFETY EASY TOUCH INSULIN SYRINGE EASY TOUCH LANCETS EASY TOUCH LUER LOCK INSULIN EASY TOUCH PEN NEEDLE EASY TOUCH SHEATHLOCK INSULIN EASY TOUCH TEST STRIP EASY TOUCH UNI SLIP EASY TRAK

7 EASY TWIST & CAP LANCETS EASYGLUCO PLUS EASYGLUCO TEST STRIPS EASYMAX EASYMAX 15 EASY TOUCH INSULIN SYRINGE ECLIPSE SYRINGE EDARBI EDARBYCLOR EFFIENT ELEMENT COMPACT ELEMENT TEST STRIPS ELIQUIS elite ob 400 ELIXOPHYLLIN EMBRACE EMBRACE EVO EMBRACE PRO enalapril maleate enalapril hydrochlorothiazide ENBRACE HR EPANED eprosartan mesylate EVENCARE G2 EVENCARE G3 EVENCARE MINI GLUCOSE TEST STR EVOLUTION TEST STRIPS EXFORGE EXFORGE HCT EXTRA VIRT PLUS DHA e z ject lancets EZ SMART EZ SMART LANCETS EZ SMART PLUS ezetimibe ezetimibe simvastatin e zject lancets FARXIGA felodipine er FENOFIBRATE

8 fenofibrate fenofibric acid FENOGLIDE FIASP FIASP FLEXTOUCH FIBRICOR FIFTY50 SAFETY SEAL LANCETS FIFTY50 TEST STRIP FINE 30 UNIVERSAL LANCETS FINGERSTIX FLOLIPID FLOVENT DISKUS FLOVENT HFA FLUMIST QUAD FLUTICASONE SALMETEROL FOLET ONE folic acid folivane ob FORA D15G FORA D20 FORA D40 G31 TEST STRIPS FORA G20 FORA G30 PREMIUM V10 TEST STRP FORA GD50 TEST STRIPS FORA LANCETS FORA TEST STRIP FORA TN'G VOICE TEST STRIPS FORA V10 FORA V10 V12 D10 D20 FORA V12 FORA V20 FORA V30A FORACARE GD20 FORACARE GD40 FORACARE LANCETS FORTAMET FORTISCARE GLUCOSE TEST STRIPS FOSAMAX FOSAMAX PLUS D fosinopril sodium Prevention of Infections Prevention of Osteoporosis Prevention of Osteoporosis

9 fosinopril hydrochlorothiazide FREESTYLE INSULINX FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE LITE TEST STRIPS FREESTYLE PRECISION FREESTYLE PRECISION NEO FREESTYLE TEST STRIPS FREESTYLE UNISTIK 2 GE100 BLOOD GLUCOSE TEST STRIP gemfibrozil GENSTRIP glimepiride glipizide glipizide er glipizide xl glipizide metformin GLUCAGEN GLUCAGON EMERGENCY KIT GLUCO NAVII GLUCOCARD 01 SENSOR PLUS GLUCOCARD EXPRESSION GLUCOCARD SHINE GLUCOCARD VITAL GLUCOCARD VITAL SENSOR GLUCOCOM GLUCOCOM GLUCOSE GLUCOCOM LANCETS GLUCOPHAGE GLUCOPHAGE XR GLUCOSE TEST STRIP GLUCOTROL GLUCOTROL XL GLUMETZA glyburide glyburide micronized glyburide metformin hcl GLYNASE GLYSET

10 GLYXAMBI HEALTHPRO TEST STRIPS HEALTHY ACCENTS UNIFINE PENTIP HEALTHY ACCENTS UNILET LANCET hemenatal ob hemenatal ob + dha HUMALOG HUMALOG JUNIOR KWIKPEN HUMALOG KWIKPEN U 100 HUMALOG KWIKPEN U 200 HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMULIN 70/30 KWIKPEN HUMULIN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U 500 HUMULIN R U 500 KWIKPEN hydrochlorothiazide HYZAAR ibandronate sodium IGLUCOSE TEST STRIP INCONTROL PEN NEEDLE INCONTROL SUPER THIN LANCETS INCONTROL ULTRA THIN LANCETS INCRUSE ELLIPTA indapamide INDERAL LA INDERAL XL INFINITY TEST STRIPS INFINITY VOICE TEST STRIP INJECT EASE LANCETS INNOPRAN XL INSULIN PEN NEEDLE INSULIN SYRINGE INSULIN SYRINGE U 500 INSUPEN Prevention of Osteoporosis

11 INVACARE LANCETS INVOKAMET INVOKAMET XR INVOKANA ipratropium bromide ipratropium albuterol irbesartan irbesartan hydrochlorothiazide isradipine jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR KAPSPARGO SPRINKLE KAZANO KETO DIASTIX REAGENT KETONE CARE TEST STRIP KETONE TEST STRIP KETOSTIX REAGENT KOMBIGLYZE XR KOSHER PRENATAL PLUS IRON kpn LANCETS LANCETS THIN LANCETS ULTRA THIN LANTUS LANTUS SOLOSTAR LESCOL LESCOL XL levalbuterol concentrate levalbuterol hcl LEVALBUTEROL TARTRATE HFA LEVEMIR LEVEMIR FLEXTOUCH LIPITOR LIPOFEN lisinopril

12 lisinopril hydrochlorothiazide LITE TOUCH LITETOUCH INSULIN SYRINGE LIVALO LONHALA MAGNAIR REFILL LONHALA MAGNAIR STARTER LOPID LOPRESSOR LOPRESSOR HCT losartan potassium losartan hydrochlorothiazide LOTENSIN LOTENSIN HCT LOTREL lovastatin LUER LOK SYRINGE MAGELLAN INSULIN SAFETY SYRNG MAGELLAN INSULIN SYRINGE MALARONE MARNATAL F matzim la MAXI COMFORT MEDISENSE THIN LANCETS MEDLANCE PLUS medlance plus MEDLANCE PLUS SPECIAL BLADE mefloquine hcl metaproterenol sulfate METFORMIN HCL metformin hcl metformin hcl er methyclothiazide metolazone metoprolol succinate METOPROLOL SUCCINATE ER HCTZ metoprolol tartrate metoprolol hydrochlorothiazide MICARDIS MICARDIS HCT MICRO Prevention of Malaria Prevention of Malaria

13 MICRO THIN LANCETS MICRODOT MICROLET MICROTAINER LANCETS MICROZIDE miglitol MINI ULTRA THIN II moexipril hcl moexipril hydrochlorothiazide MONOJECT MONOJECT INSULIN SAFETY SYRNG MONOJECT INSULIN SYRINGE MONOLET LANCETS MONOLET THIN LANCETS montelukast sodium MYGLUCOHEALTH MYGLUCOHEALTH LANCETS mynatal mynatal advance mynatal plus mynatal z mynate 90 plus nadolol nadolol bendroflumethiazide NATACHEW nateglinide NEEDLES NESINA NESTABS NESTABS ABC NESTABS DHA NESTABS ONE NEUTEK 2TEK TEST STRIPS newgen NEXA PLUS niacin er NIACOR NIASPAN nicardipine hcl nifedipine

14 nifedipine er nisoldipine NORVASC NOVA MAX GLUCOSE TEST STRIPS NOVA SAFETY LANCETS NOVA SUREFLEX NOVAMAX PLUS NOVOFINE 32 NOVOFINE AUTOCOVER NOVOFINE PLUS NOVOLIN NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOTWIST OB COMPLETE GOLD OB COMPLETE ONE OB COMPLETE PETITE OB COMPLETE PREMIER OB COMPLETE WITH DHA obstetrix dha OBSTETRIX ONE OBTREX DHA O CAL PRENATAL olmesartan medoxomil olmesartan amlodipine hctz olmesartan hydrochlorothiazide ON CALL EXPRESS TEST STRIP ON CALL LANCET ON CALL PLUS LANCET ON CALL PLUS TEST STRIP ON CALL VIVID TEST STRIP ONETOUCH DELICA ONETOUCH LANCETS ONETOUCH SURESOFT ONETOUCH ULTRA BLUE TEST STRP ONETOUCH VERIO

15 ONGLYZA ON THE GO OPTIUM OPTIUM EZ OPTUMRX OSENI OZEMPIC PEN NEEDLE PEN NEEDLES PENTIPS PERFOROMIST perindopril erbumine PHARMACIST CHOICE pindolol pioglitazone hcl pioglitazone glimepiride pioglitazone metformin PLAVIX pnv 29 1 pnv dha pnv dha + docusate pnv ferrous fumarate docu fa pnv omega pnv select pnv vp u pr natal 400 pr natal 400 ec pr natal 430 pr natal 430 ec PRADAXA PRANDIN prasugrel hcl PRAVACHOL PRECISION PCX PRECISION PCX PLUS PRECISION POINT OF CARE PRECISION Q I D PRECISION XTRA PRECOSE PREFERA OB

16 PREFERA OB ONE PREFERA OB PLUS DHA PREMIER TEST STRIP PREMIUM BLOOD GLUCOSE TEST PREMIUM V10 prena1 chew prena1 pearl prena1 true prenaissance prenaissance plus PRENATA prenatabs fa prenatabs rx PRENATAL 19 prenatal low iron prenatal multi dha prenatal plus PRENATAL PLUS DHA prenatal vitamin plus low iron prenatal u PRENATE AM PRENATE CHEWABLE PRENATE DHA PRENATE ELITE PRENATE ENHANCE PRENATE ESSENTIAL PRENATE MINI PRENATE PIXIE PRENATE RESTORE PRENATE STAR preplus PRESSURE ACTIVATED LANCETS PRESTALIA pretab prevalite PREVNAR 13 PREVYMIS PRIMACARE PRIMAQUINE PRINIVIL Prevention of Infections Prevention of Infections Prevention of Malaria

17 PRO COMFORT INSULIN SYRINGE PRO COMFORT LANCET PRO COMFORT LANCETS PRO COMFORT PEN NEEDLE PRO VOICE V8 V9 TEST STRIP PROAIR HFA PROAIR RESPICLICK PROCARDIA PROCARDIA XL PRODIGY INSULIN SYRINGE PRODIGY LANCETS PRODIGY NO CODING PRODIGY TWIST TOP LANCET PROGLYCEM propranolol hcl propranolol hcl er propranolol hydrochlorothiazid PROVENTIL HFA PROVIDA DHA PROVIDA OB PULMICORT PULMICORT FLEXHALER PUREFE OB PLUS PUSH BUTTON SAFETY LANCETS QBRELIS QTERN QUESTRAN QUESTRAN LIGHT quinapril hcl quinapril hydrochlorothiazide QUINTET AC QVAR REDIHALER ramipril READYLANCE SAFETY LANCETS REFUAH PLUS RELIAMED RELIAMED SAFETY SEAL LANCETS RELION CONFIRM MICRO RELION PEN NEEDLES RELION PRIME TEST STRIPS

18 RELION THIN repaglinide repaglinide metformin hcl REVEAL TEST STRIP RIGHTEST GL300 LANCETS RIGHTEST GS100 TEST STRIPS RIGHTEST GS300 TEST STRIPS RIGHTEST GS550 TEST STRIPS RIOMET risedronate sodium risedronate sodium dr R NATAL OB rosuvastatin calcium SAFESNAP INSULIN SYRINGE SAFETY LANCETS SAFETY SEAL LANCETS SAFETYGLIDE INSULIN SYRINGE SAFETYGLIDE SYRINGE SAFETY LET SAVAYSA SEEBRI NEOHALER SEGLUROMET SELECT OB SELECT OB SELECT OB + DHA se natal 19 SEREVENT DISKUS simvastatin SINGLE LET SINGULAIR SMART SENSE SMART SENSE LANCETS SMART SENSE TEST STRIPS SMARTEST LANCET SMARTEST TEST SOFT TOUCH SOLIQUA SOLUS V2 SOLUS V2 LANCETS SOLUS V2 TEST STRIPS Prevention of Osteoporosis Prevention of Osteoporosis

19 SPIRIVA SPIRIVA RESPIMAT STARLIX STEGLATRO STEGLUJAN STERILANCE TL STIOLTO RESPIMAT STRIVERDI RESPIMAT SULAR SUPER THIN LANCETS SURE COMFORT SURE COMFORT INSULIN SYRINGE SURE COMFORT LANCETS SURE FINE PEN NEEDLES SURE JECT INSULIN SYRINGE SURE LANCE SURE TEST EASYPLUS MINI SURE TOUCH SYMBICORT SYMLINPEN 120 SYMLINPEN 60 SYNJARDY SYNJARDY XR TARKA taron c dha taron prex prenatal taztia xt TECHLITE INSULIN SYRINGE TECHLITE LANCETS TECHLITE PEN NEEDLE TELCARE telmisartan telmisartan amlodipine telmisartan hydrochlorothiazid TENORETIC 100 TENORETIC 50 TENORMIN terbutaline sulfate TERUMO INSULIN SYRINGE terumo insulin syringe

20 TEST N'GO TEST STRIPS THEO 24 theochron theophylline theophylline anhydrous THIN LANCETS THINPRO INSULIN SYRINGE thinpro insulin syringe THRIVITE RX TIAZAC timolol maleate tolazamide tolbutamide TOPCARE CLICKFINE TOPCARE ULTRA COMFORT TOPCARE UNIVERSAL1 LANCET TOPCARE UNIVERSAL1 THIN LANCET TOPROL XL TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR TRADJENTA trandolapril trandolapril verapamil er TRELEGY ELLIPTA TRESIBA FLEXTOUCH U 100 TRESIBA FLEXTOUCH U 200 TRIBENZOR TRICARE TRICOR TRIGLIDE TRILIPIX trinatal rx 1 trinate TRISTART DHA triveen duo dha TRUE METRIX GLUCOSE TEST STRIP TRUEPLUS INSULIN SYRINGE TRUEPLUS KETONE TEST STRIP TRUEPLUS LANCETS

21 TRUEPLUS PEN NEEDLE TRUETEST TEST STRIPS TRUETRACK TEST STRIP TRULICITY trust natal dha TUDORZA PRESSAIR TWIST LANCETS TWYNSTA ULTICARE ulticare ULTICARE INSULIN SYRINGE ULTICARE PEN NEEDLE ULTILET BASIC ULTILET CLASSIC ULTILET INSULIN SYRINGE ULTILET LANCETS ULTILET PEN NEEDLE ULTILET SAFETY ULTIMA ULTRA COMFORT ultra comfort ULTRA THIN LANCETS ULTRA THIN PLUS ULTRA THIN PLUS LANCETS ULTRA CARE LANCETS ULTRA FINE MICRO PEN NEEDLE ULTRA FINE MINI PEN NEEDLE ULTRA FINE NANO PEN NEEDLE ULTRA FINE ORIGINAL PEN NEEDLE ULTRA FINE SHORT PEN NEEDLE ULTRALANCE ULTRA THIN II ULTRATLC LANCETS ULTRATRAK ULTRATRAK ULTIMATE UNIFINE PENTIPS UNIFINE PENTIPS PLUS UNILET COMFORTOUCH UNILET EXCELITE UNILET EXCELITE II

22 UNILET GP LANCET UNILET LANCET UNILET LANCETS UNISTIK 3 UNISTIK 3 EXTRA UNISTIK CZT UNISTIK PRO UNISTIK SAFETY UNISTIK TOUCH UNISTRIP1 UNIVERSAL 1 UTIBRON NEOHALER valsartan valsartan hydrochlorothiazide VANISHPOINT VASERETIC VASOTEC VENTOLIN HFA VEO INSULIN SYRINGE verapamil er verapamil er pm verapamil hcl verapamil sr VERASENS TEST STRIP VERELAN VERELAN PM VICTOZA 2 PAK VICTOZA 3 PAK vinate care vinate ii vinate one virt advance virt c dha virt nate dha virt pn virt pn dha virt pn plus virt select virt vite gt VITAFOL GUMMIES

23 VITAFOL NANO VITAFOL ULTRA VITAFOL OB VITAFOL OB+DHA VITAFOL ONE VITAMEDMD ONE RX VITAMEDMD REDICHEW RX VITAPEARL VITATRUE vp ch plus vp ch pnv VP PNV DHA VYTORIN warfarin sodium WAVESENSE JAZZ WAVESENSE PRESTO WELCHOL XARELTO XIGDUO XR XOPENEX XOPENEX CONCENTRATE XOPENEX HFA XULTOPHY zafirlukast zatean pn dha zatean pn plus ZESTORETIC ZESTRIL ZETIA ZIAC zileuton er zingiber ZOCOR ZONTIVITY ZYFLO ZYFLO CR ZYPITAMAG