2018 Preventive Medication List

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1 2018 Preventive Medication List

2 Introduction In addition to a healthy lifestyle, preventive medications are important in helping people avoid many types of illnesses and complications from illnesses. This book contains a list of the most commonly prescribed preventive medications. It does not include all conditions that may be prevented with medications. The medications listed serve to maintain a person s health status and to avoid acute complications. This list is not all-inclusive and is subject to change. Important facts about this benefit This benefit is for use with a qualified health savings account plan. Please refer to your plan documents for coverage on the selected products. Quantity limits, step therapy, prior authorizations and other coverage limitations may apply. Quantities are limited to a maximum 3-month supply per fill. Tier 3 medications listed on the Security Health Plan Formulary will not be routinely covered. If a generic equivalent product is available, the originator brand medication will not be covered (Example: simvastatin is covered, ZOCOR is not). The covered preventive medications are divided into medication categories. The listed medications in the medication categories include those which are always prescribed for prevention and those which are sometimes prescribed for prevention. Medications used for treatment of an existing condition are typically not covered under the preventive prescription drug benefit. Note: Benefits vary by plan. Please refer to your Plan documents for information specific to your coverage.

3 Notice of nondiscrimination Discrimination is against the law Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Security Health Plan of Wisconsin, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Security Health Plan of Wisconsin, Inc.: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service. If you believe that Security Health Plan of Wisconsin, Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Security Health Plan Member Advocate 1515 North Saint Joseph Avenue Marshfield, WI Phone: (TTY: 711) Fax: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Security Health Plan s Member Advocate is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC Phone: or (TDD) Complaint forms are available at

4 Language assistance services ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY 711). Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). (Arabic) (c) ال عرب ية ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: (. 117 Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните ( телетайп: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 전화해 (TTY: 711) 주십시오번으로. 전화해주십시오. Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Deitsch (Pennsylvania Dutch) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: (TTY: 711). ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫອດ ານພາສາ, ໂດຍບເສ ຽຄ າ, ແມ ນມພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 711). Français (French) ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ह द द ((Hindi) ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711).

5 Anti-asthmatic agents Preventive Medication List Prevention of an asthma episode Albuterol Solution Montelukast Granules Albuterol Sulfate Tablet Montelukast Tablet Chew Albuterol Sulfate ER Tablet Proair HFA Inhaler Anoro Ellipta Inhaler Pulmicort Respule Breo Ellipta Inhaler Pulmicort Flexhaler Budesonide Suspension Serevent Diskus Combivent Respimat Inhal Spray Spiriva Handihaler Flovent Diskus Spiriva Respimat Inhaler Flovent HFA Inhaler Stiolto Respimat Inhal Spray Fluticasone-Salmeterol Inhalation powder Symbicort Inhaler Ipratroprium-Albuterol nebules Terbutaline Tablet Ipratropium 0.02% Solution Theochron ER Tablet Levalbuterol nebules Theophylline 80 Mg/15 Ml Solution Metaproterenol Tablet Theophylline ER Tablet Metaproterenol 10 Mg/5 Ml Syrup Ventolin HFA Inhaler Montelukast Tablet Zafirlukast Tablet Anticoagulants Prevention of stroke, blood clot or repeat heart attack Clopidogrel Tablet Prasugrel Tablet Coumadin Tablet Warfarin Tablet Dipyridamole Tablet Warfarin Powder Eliquis Tablet Xarelto Tablet Jantoven Tablet Anti-diabetic agents Prevention of complications related to high blood sugar Acarbose Tablet Januvia Tablet Accu-Chek Aviva Plus Meter Jardiance Tablet Accu-Chek Aviva Plus Test Strp Lantus Accu-Chek Aviva Control Solution Levemir Accu-Chek Compact Plus Meter Metformin Hcl Tablet Accu-Chek Compact Plus Control Solution Metformin Hcl ER Tablet Accu-Chek Compact Plus Strips Nateglinide Accu-Chek Fastclix Lancets Novolin Accu-Chek Multiclix Lancets Novolin N Accu-Chek Nano Smartview Meter Novolin R Accu-Chek Rapid D Novolog Accu-Chek Smartview Control Solution Novolog Mix Accu-Chek Smartview Test Strip Onetouch Delica Lancing Device Accu-Chek Softclix Lancets Onetouch Ultra Control Solution Alogliptin Tablet Onetouch Ultra Test Strips Alogliptin -Metformin Tablet Onetouch Ultramini Meter Alogliptin -Pioglitazone Tablet Onetouch Ultrasoft Lancets Chlorpropamide Tablet Onetouch Verio Meter Glimepiride Tablet Onetouch Verio Test Strips Glipizide Tablet Pioglitazone Hcl Tablet Glipizide ER Tablet Pioglitazone-Glimepiride Tablet Glipizide XL Tablet Repaglinide Tablet Glipizide-Metformin Tablet Repaglinide-Metformin Tablet Glucagon 1 Mg Vial Synjardy Tablet

6 Anti-diabetic agents (continued) Prevention of complications related to high blood sugar Glyburide Micro Tablet Glyburide-Metformin Tablet Invokamet Tablet Invokana Tablet Janumet Tablet Janumet XR Tablet Anti-hyperlipidemics High cholesterol medications (prevention of heart disease) Atorvastatin Tablet Cholestyramine Cholestyramine Light Colestipol Tablet Colestipol Granules Colestipol Micronized Tablet Ezetimibe Tablet Fenofibrate Capsule Fenofibrate Tablet Fenofibric Acid Tablet repeat of a second heart attack Acetazolamide Tablet Afeditab CR Tablet Amiloride Tablet Amiloride-Hctz Tablet Amlodipine Tablet Amlodipine -Valsartan Tablet Amlodipine -Valsartan-Hydrochlorothiazide Tablet Amlodipine-Benazepril Tablet Atenolol Tablet Atenolol-Chlorthalidone Tablet Benazepril Tablet Benazepril-Hctz Tablet Betaxolol Tablet Bisoprolol Tablet Bisoprolol-Hctz Tablet Bumetanide Tablet Candesartan Tablet Candesartan-Hctz Tablet Captopril Tablet Captopril-Hctz Tablet Cartia XT Capsule Carvedilol Tablet Chlorothiazide Tablet Chlorthalidone Tablet Clonidine Hcl Tablet Dilt XR Capsule Diltiazem Tablet Diltiazem 12Hr ER Capsule Diltiazem 24Hr CD Capule Diltiazem 24Hr ER Capsule Diltiazem 24Hr ER Tablet Diltiazem ER Capsule Tolazamide Tablet Tolbutamide Tablet Toujeo Tresiba Trulicity Victoza Fenofibric Acid DR Capsule Fluvastatin Capsule Gemfibrozil Tablet Lovastatin Tablet Niacin ER Tablet Pravastatin Tablet Prevalite Packet Prevalite Powder Rosuvastatin Tablet Simvastatin Tablet Anti-hypertensive agents Prevention of stroke and other complications due to elevated blood pressure and complications following heart attack or Isradipine Capsule Labetalol Tablet Lisinopril Tablet Lisinopril-Hctz Tablet Losartan Tablet Losartan-Hctz Tablet Matzim LA Tablet Methyclothiazide Tablet Methyldopa Tablet Metolazone Tablet Metoprolol Succ ER Tablet Metoprolol Tartrate Tablet Metoprolol-Hctz Tablet Minoxidil Tablet Moexipril Tablet Moexipril-Hctz Tablet Nadolol Tablet Nifedipine Capsule Nifedipine ER Tablet Nimodipine Capsule Nisoldipine ER Tablet Perindopril Tablet Pindolol Tablet Prazosin Capsule Propranolol Tablet Propranolol ER Capsule Propranolol-Hctz Tablet Quinapril Tablet Quinapril-Hctz Tablet Ramipril Capsule Spironolactone Tablet Spironolactone-Hctz Tablet

7 Anti-hypertensive agents (continued) Prevention of stroke and other complications due to elevated blood pressure and complications following heart attack or repeat of a second heart attack Enalapril Tablet Enalapril-Hctz Tablet Epaned 1 Mg/Ml Oral Solution Eplerenone Tablet Eprosartan Tablet Ethacrynic Acid Tablet Felodipine ER Tablet Fosinopril Tablet Fosinopril-Hctz Tablet Furosemide Tablet Guanfacine Tablet Hydralazine Tablet Hydrochlorothiazide Capsule Hydrochlorothiazide Tablet Indapamide Tablet Irbesartan Tablet Irbesartan-Hctz Tablet Cardiovascular disease agents Prevention of heart disease Aspirin-Dipyridamole ER Capsule Digoxin Tablet Digoxin 50 Mcg/Ml Oral Solution Isosorbide Dinitrate Tablet Osteoporosis medications Prevention of bone fractures Alendronate Tablet Calcitonin (Salmon) Nasal Spray Etidronate Tablet Ibandronate Tablet Telmisartan Tablet Telmisartan-Hctz Tablet Terazosin Capsule Timolol Tablet Torsemide Tablet Trandolapril Tablet Trandolapril -Verapamil ER Tablet Triamterene-Hctz Capsule Triamterene-Hctz Tablet Valsartan Tablet Valsartan-Hctz Tablet Verapamil Tablet Verapamil ER Capsule Verapamil ER PM Capsule Verapamil ER Tablet Verapamil SR Capsule Isosorbide Mononitrate Tablet Nitroglycerin Sublingual Tablet Sotalol AF Tablet Sotalol Tablet Raloxifene Tablet Risedronate DR Tablet Risedronate Tablet

8 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, Wisconsin Fax HP (10/17) Security Health Plan of Wisconsin, Inc. HP M-10-17

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