Your Preventive Drug Coverage

Transcription

1 Your Preventive Drug Coverage Your benefits include coverage for preventive prescription drugs with no out-ofpocket payments by you.* Deductibles and out-of-pocket maximums do not have to be met prior to these drugs being covered at 100 percent. This coverage makes it easy for you to receive medication to help you lead a healthier lifestyle. This benefit includes drugs that help you stop smoking, lose weight, lower your cholesterol, lower your blood pressure and other drugs that address other common conditions. The standard preventive drug categories include: Alcohol dependence Cholesterol-lowering agents Fluoride preparations High blood pressure-lowering agents (Hypertension) Prenatal vitamins Weight loss For a list of preventive drugs, see the following pages. If you wish to use a drug on the preventive list but your prescription coverage has a closed formulary or exclusion and the preventive drug isn t covered, you will have to pay the full price of the drug. Formulary and coverage rules overrule the preventive list. For more information, please call the customer service number on the back of your Blues ID card. * Please check your specific prescription drug benefits for any limitations or maximums for this preventive drug coverage benefit.

2 Alcohol Dependence Antabuse Campral Disulfiram Choleseterol-Lowering Advicor Altoprev Amlodipine/Atovastatin Antara Atovastatin Caduet Cholestyramine Cholestyramine Light Colestid Colestipol HCL Crestor Epanova Fenofibrate Fenofibric Acid Fenoglide Fibricor Fluvastatin Gemfibrozil Juvisync Lescol Lescol XL Lipitor Lipofen Liptruzet Livalo Locholest Locholest Light Lofibra Lopid Lovastatin Lovaza Mevacor Niacor Niaspan Omtryg Pravachol Pravastatin Sodium Prevalite Questran BCBSM Standard Preventive Drug List

3 Questran Light Rosuvastatin Simcor Simvastatin Tricor Triglide Trilipix Vascepa Vytorin Welchol Zetia Zocor Fluoride Preparations Clinpro 5000 Denta 5000 Plus Dentagel Fluoride Gel-Kam Karigel Karigel/N Phos-Flur Prevident Prevident 5000 Prevident 5000 Enamel Prevident 5000 Plus Prevident 5000 Sensitive SF SF 5000 Plus Sodium Fluoride Stannous Fluoride Thera-Flur-N Hypertension Accupril Accuretic Acebutolol HCL Aceon Adalat Adalat CC Afeditab CR Aldactazide Aldactone Altace Amiloride HCL Amiloride HCL w. HCTZ Amlodipine Besylate Amlodipine - Benazepril

4 Atacand Atacand HCT Atenolol Atenolol w. Chlorthalidone Avalide Avapro Azor Benazepril HCL Benazepril HCL-HCTZ Benicar Benicar HCT Betapace Betapace AF Betaxolol HCL Bisoprolol Fumarate Bisoprolol Fumarate/HCTZ Bumetanide Bystolic Byvalson Calan Calan SR Candesartan/HCTZ Capoten Capozide Captopril Captopril/Hydrochlorothiazide Cardene SR Cardizem Cardizem CD Cardizem LA Cardura Cardura XL Cartia XT Carvedilol Catapres Catapres-TTS Chlorothiazide Chlorothalidone Clonidine HCL Clorpres Coreg Coreg CR Corgard Cozaar Demadex Demser Dibenzyline Dilacor XR

5 Dilt-CD Diltiazem 24 ER Diltiazem ER Diltiazem HCL Dilt-XR Diltzac ER Diovan Diovan HCT Diuril Doxazosin Mesylate Dyazide Dyrenium Edarbi Edarbyclor Edecrin Enalapril Maleate Enalapril Maleate/HCTZ Epaned Eplerenone Eprosartan Esidrix Exforge Exforge HCT Felodipine ER Fosinopril Sodium Fosinopril/Hydrochlorothiazide Furosemide Guanfacine HCL Hydralazine HCL Hydrochlorothiazide Hydrodiuril Hyzaar Ibesartan Ibesartan/HCTZ Indapamide Inderal LA Innopran XL Inspra Isoptin S.R. Isradipine Kerlone Labetalol HCL Lasix Levatol Lisinopril Lisinopril-HCTZ Lopressor Lopressor HCT

6 Losartan Losartan HCT Lotensin Lotensin HCT Lotrel Matzim LA Mavik Maxzide Methyclothiazide Methyldopa Methyldopa/Hydrochlorothiazide Metolazone Metoprolol Succinate Metoprolol Tartrate Metoprolol- Hydrochlorothiazide Micardis Micardis HCT Microzide Minipress Minoxidil Moexipril HCL Moexipril - Hydrochlorothiazide Nadolol Nadolol-Bendroflumethiazide Nicardipine HCL Nifediac CC Nifedical XL Nifedipine Nifedipine ER Nimodipine Nimotop Nisoldipine Norvasc Perindolpril Erbumine Pindolol Prazosin HCL Prestalia Prinivil Prinzide Procardia Procardia XL Propranolol HCL Propranolol HCL-HCTZ Quinapril Quinapril-HCTZ Quinaretic Ramipril Reserpine Sectral

7 Sorine Sotalol Sotalol AF Spironolactone Spironolactone with HCTZ Sular Tarka Taztia XT Tekturna Tekturna HCT Tenex Tenoretic Tenormin Terazosin HCL Teveten Teveten HCT Thalitone Tiazac Timolol Maleate Toprol XL Torsemide Trandate Trandolapril Trandolapril-verapamil Triamterene with HCTZ Twynsta Uniretic Univasc Valsartan/HCTZ Vaseretic Vasotec Verapamil ER Verapamil HCL Verelan Verelan PM Zaroxolyn Zebeta Zestoretic Zestril Ziac Prenatal Vitamins Atabex Cal-Nate Citranatal 90 DHA Citranatal Assure Citranatal DHA

8 Citranatal Rx Complete Natal DHA Completenate Complete-RF Prenatal Concept DHA Concept OB Duet DHA Duet DHA EC Edge OB Elite-OB Folbecal Folcaps Care One Folinatal Plus B Foltabs Gentex Ade Gesticare DHA ICAR-C plus SR Inatal Advance Inatal Ultra Marnatal-F Plus M-Vit Mynatal Plus Natachew Natafort Natalcare Plus Natelle One Natelle-EZ Nestabs Nexa Select Nestabs Rx Nutrinate OB Complete OB Complete 400 OB Complete DHA OB Complete One OB-Natal One Obtrex Obtrex DHA O-Cal FA O-Cal Prenatal Optinate Paire OB Plus DHA PNV DHA PNV DHA + Docusate PNV DHA Plus PNV-Iron PNV-Omega PNV-Select

9 PNV-Total Precare Premier Prefera-OB Prefera OB One Prefera-OB plus DHA Prenaplus Prenatabs FA Prenatabs Rx Prenatal 19 Prenatal AD Prenatal Low Iron Prenatal Multivitamin W-Iron Prenatal Plus Prenatal RX 1 Prenatal U Prenate DHA Prenate Elite Prenate Essential Prenexa Preque 10 PR Natal 400 PR Natal 400 EC PR Natal 430 PR Natal 430 EC Select-OB Select-OB + DHA SE-Natal 19 Setonet Setonet-EC Taron BC Taron C DHA Taron Prex Prenatal Tri Rx Triadvance Trimesis Rx Trinatal Rx 1 Trinate Triveen Duo DHA Triveen 1 Triveen-PRX RNF Triveen Ten Ultimatecare One Ultimatecare One NF Ultra Natalcare Venatal-FA Vinate AZ Vinate Calcium Vinate Care

10 Vinate GT Vinate IC Vinate II Vinate One Vinate PN Care Vinate Ultra Vinate-M Vitafol-OB Vitafol-OB+DHA Vitaspire Vol-nate Vol-Plus Vol-Tab-RX Zatean CH Zatean PN Zatean PN DHA Zatean PN - Plus Weight Loss Products Adipex-P Belviq Belviq XR Benzphetamine HCL Bontril PDM Contrave Didrex Diethylpropion HCL Ionamin Melfiat-105 Phendimetrazine Tartrate Phentermine HCL Prelu-2 Qsymia Saxenda Suprenza Xenical Please note: This list is not all-inclusive and is subject to change. Many of these drugs are available as generics and are listed by the brand and generic names.

11 If a brand is available as a generic equivalent, then the brand is usually not covered or requires a higher copay depending on your plan design. Preventive drugs must be covered under your Prescription Drug Program to be payable. Formulary rules override the preventive drug list. Drugs that are not covered under the Closed Formulary will be denied as not covered under the Preventive drug program. Your BCBSM preventive drug list may differ from the standard program. Contact the BCBSM customer service number on the back of your ID card to check if a particular drug is included in your preventive drug program. BCBSM believes that these compounds likely satisfy the safe harbor for preventive care. However, BCBSM cannot guarantee or provide any legal advice on the manner in which these products are prescribed for preventive purposes or that the Treasury Department would agree that all satisfy the definition of preventive care.