The medications listed below have been identified as those most likely to qualify as preventive, based on U.S. Treasury Department guidance.

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7/3/18 Guidance regarding Waiver of Deductible for Preventive Medications Covered Under High Deductible Health Plans Designed for Use With a Health Savings Account.

1 7/3/18 Guidance regarding Waiver of Deductible for Preventive Medications Covered Under High Deductible Health Plans Designed for Use With a Health Savings Account. This guide applies only to certain high deductible health plans designed for use with a health savings account. It applies only for specific large groups that have elected this preventive medication benefit. If you are not certain whether your group has this benefit option, please contact BCBSAZ. The laws governing HSA-compatible, high deductible health plans generally require members to satisfy a deductible before the plan begins to pay for any benefits. The only permitted exception to that rule is for preventive care. The plan can pay for covered preventive care benefits before the member has met the high deductible. The medications listed below have been identified as those most likely to qualify as preventive, based on U.S. Treasury Department guidance. If your plan covers BCBSAZ designated prevention medications as a preventive benefit and you have your prescription filled at an in-network pharmacy, your plan will treat these designated medications as preventive. This means you will pay only your applicable copay or coinsurance amount, regardless of whether you have met your deductible. The BCBSAZ prevention medication benefit applies only at in-network pharmacies. If you obtain BCBSAZ designated preventative medications from an out of network pharmacy, your standard prescription benefits, with applicable deductible, coinsurance and copays, will apply. Your cost share payments for preventive medications will count towards your deductible. Neither BCBSAZ nor your plan sponsor can guarantee that the U.S. Treasury Department will agree that all of these medications qualify as preventative, particularly when applied to a member s specific medical circumstances. You or your provider may be asked to demonstrate that you are taking a specific medication for purposes regarded as preventive under Treasury Department guidance. This list does not include every medication that might possibly be considered preventive or every condition for which a preventive drug may be prescribed. The list is subject to change at any time, without prior notice. If you want any of these listed medications to process under your standard pharmacy benefit instead of your preventive care benefit, please click here. If your medications process under your standard prescription benefit, your costs for applicable coverage will apply. Placement on this list is not a guarantee that the listed drug is a covered benefit under any specific benefit plan. Some medications are available at a retail copay but will still require specialty distribution limited to a maximum of a 30 day supply. BCBSAZ has selected Briova Specialty Pharmacy as the exclusive Specialty Pharmacy. The medications followed by SP must be obtained through Briova. Please contact Briova directly at (866) to establish service with them. If you are currently obtaining a Specialty Medication from a Specialty Pharmacy and need to receive that medication from a retail pharmacy instead, please contact the Pharmacy Benefit Customer Service number listed on your BCBSAZ identification card. BCBSAZ and/or the PBM will decide whether you are eligible to receive the Specialty Medication from a retail pharmacy ANTINEOPLASTIC HORMONAL ONCOLOGICS Fareston Soltamox (PL) OTHER GYNECOLOGICS, HORMONAL ONCOLOGICS megestrol acetate (generic for Megace) tablet: 20mg, 40mg CARDIOVASCULAR/HEART ANGIOTENSIN-CONVERTING ENZYME INHIBITORS (ACEI) benazepril (generic for Lotensin) tablet: 5mg, 10mg, 20mg, 40mg captopril (generic for Capoten) tablet: 12.5mg, 25mg, 50mg, 100mg enalapril (generic for Vasotec) tablet: 2.5mg, 5mg, 10mg, 20mg enalapril/hctz (generic for Vasoretic tablet: 10-25mg, mg fosinopril (generic for Monopril) tablet: 10mg, 20mg, 40mg fosinopril/hctz (generic for Monopril HCT) tablet: 10mg-12,5mg, 20-12,5mg lisinopril (generic for Prinivil/Zestril) tablet: 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg quinapril HCL (generic for Accupril) tablet: 5mg, 10mg, 20mg, 40mg quinapril-hctz (generic for Accuretic) tablet: mg, mg, 20-25mg ramipril (generic for Altace) capsules: 1.25, 2.5mg, 5mg, 10mg trandolapril (generic for Mavik) tablet: 1mg, 2mg, 4mg moexipril/hctz (generic for Uniretic) tablet: 12,5/7.5mg, 12.5/15mg, 25/15mg moexipril (generic for Univasc) tablet: 7.5mg, 15mg lisinopril/hctz (generic for Prinzide, Zestoretic) tablet: mg, mg, 20-25mgmg Accupril Accuretic Aceon Altace capsules Capoten Lotensin Mavik Monopril Monopril HCT Prinivil Prinzide Qbrelis Quinapril Quinaretic Uniretic Univasc Vasotec Zestril Zestoretic Prestalia (PL) ANGIOTENSIN RECEPTOR BLOCKERS (ARB) eprosart mesylate (generic for Teveten) (PL) tablet: 600mg Hydral/hctz (generic for Apresazide) tablet: 25/25mg, 50/50mg Irbesartan (PL) (generic for Avapro) tablet: 75mg, 150mg, 300mg Irbesartan-HCTZ (PL)

2 (generic for Avalide) tablet: mg, mg losartan (generic for Cozaar) tablet: 25mg, 50mg, 100mg losartan/hydrochlorothiazide (generic for Hyzaar) tablet: 50/12.5mg, 100/12.5mg, 100/25mg Candesartan (PL) (generic for Atacand) Tablets: 4mg, 8mg, 16mg, 32mg Atacand (PL) Avalide (PL) Avapro (PL) Benicar (PL) Cozaar Hyzaar Olmesartan Medoxomil (PL) Teveten (PL) Teveten HCT ANGIOTENSIN II RECEPTOR BLOCKERS (A2RB) amlodipine/besylate/valsartan (PL) (generic for Exforge) tablet: 5-160mg, mg, 5-320mg, mg amlodipine/valsartan/hydrochlorothiazide (PL) (generic for Exforge HCT) tablet: mg, mg-25mg, mg, mg, mg candesa/cilexetil/hctz (PL) (generic for Atacand HCT) Tablets: mg, mg, 32-25mg, mg, mg losartan (generic for Cozaar) tablet: 25mg, 50mg, 100mg losartan/hydrochlorothiazide (generic for Hyzaar) tablet: 50/12.5mg, 100/12.5mg, 100/25mg telmisartan-hydrochlorothiazide (generic for Micardis HCT) (PL) tablet: mg, 80-25mg, mg telmisartan (generic for Micardis) tablet: 20mg, 40mg, 80mg valsartan-hydrochlorothiazide (PL) (generic for Diovan HCT) tablet: 80-12,5mg, mg, mg, ,5mg, mg valsartan (PL) (generic for Diovan) tablet: 40mg, 80mg, 160mg, 320mg Atacand HCT (PL) Benicar HCT (PL) Olmesartan/Medoxomil-Hydrochlorothiazide (PL) Olmesartan/Amlodipine/Hydrochlorothiazide Micardis Micardis HCT (PL) Tribenzor Byvalson (PL) Diovan (PL) Diovan HCT (PL) Exforge (PL) Exforge HCT (PL) ANTI-PLATELETS anagrelide HCL (generic for Agrylin) tablet: 0.5mg, 1mg aspirin/dipyridamole SR (generic for Aggrenox) capsules: mg cilostazol (PL) (generic for Pletal) tablet: 50mg, 100mg clopidogrel bisulfate (generic for Plavix) (PL) tablet: 75mg, 300mg dipyridamole (generic for Persantine) tablet: 25mg, 50mg, 75mg pentoxifyllin ER, pentoxil CR (generic for Trental) tablet: 400mg prasugrel (generic for Effient) (PL) tablet: 5mg, 10mg ticlopidine (generic for Ticlid) tablet: 250mg Aggrenox Brilinta Prasugrel (PL) Zontivity (PL) Agrylin Effient (PL) Persantine Pletal (PL) Ticlid Trental Plavix (PL) Yosprala (PL) * BETA BLOCKERS acebutolol (generic for Sectral) capsule: 200mg, 400mg atenolol (generic for Tenormin) tablet: 25mg. 50mg, 100mg betaxolol (generic for Kerlone) (PL) tablet: 10mg, 20mg bisoprolol (generic for Zebeta) tablet: 5mg, 10mg carvedilol (generic for Coreg) tablet: 3.125mg,6.25mg,12.5mg,25mg labetalol (generic for Trandate) tablet: 100mg, 200mg, 300mg metoprolol tartrate (generic for Lopressor) tablet: 25mg, 50mg, 100mg, 200mg metoprolol succinate ER/SR (generic for Toprol XL) tablet: 25mg, 50mg, 100mg nadlol (generic for Corgard tablet: 20mg, 40mg, 80mg pindolol (generic for Visken) tablet: 5mg, 10mg propranolol (generic for Inderal) tablet: 10mg, 20mg, 40mg, 60mg, 80mg oral solution: 20mg/5ml, 40mg/5ml propranolol ER/SR (generic for Inderal LA) tablet: 60mg, 80mg, 120mg, 160mg sotalol, sorine (generic for Betapace) tablet: 80mg, 120mg, 160mg, 240mg sotalol AF (generic for Betapace AF) tablet: 80mg, 120mg, 160mg Bystolic Betapace Coreg Corgard Hemangeol Kerlone (PL) Levatol Lopressor Metoprolol Tartrate 37.5mg, 75mg Sectral Sotylize Tenormin Timolol tab Toprol XL Trandate Zebeta Coreg CR Betapace AF Inderal LA * Inderal XL * Innopran XL (PL) * BETA BLOCKERS, COMBOS Dutoprol atenolol/chlorthalidone (generic for Tenoretic) tablet: 50-25mg, mg tablet: 40mg/25mg, 80mg/25mg nadolol/bendroflumethiazide (generic for Corzide) tablet: 40-5mg, 80-5mg metoprolol/hctz (generic for Lopress HCT) tablet: 50-25mg, mg, mg bisoprolol/hctz (generic for Ziac) Tablet: 2.5/6.25mg, mg, mg 2

3 Corzide Lopress HCT Tenoretic Ziac Dutoprol Tabs Metoprolol/HCTZ Tabs BENIGN PROSTATIC HYPERTROPHY (BPH) doxazosin (generic for Cardura) tablet: 1mg, 2mg, 4mg, 8mg terazosin (generic for Hytrin) capsule: 1mg, 2mg, 5mg, 10mg Cardura CALCIUM CHANNEL BLOCKER (CCB) amlodipine (generic for Norvasc) Tablet: 2.5mg, 5mg, 10mg amlodipine besylate-benazepril (generic for Lotrel) tablet: 2.5/0mg, 5/10mg. 5/20mg. 5/40mg, 10/20mg, 10/40mg diltiazem (generic for Cardizem) tablet: 30mg, 60mg, 90mg, 120mg diltiazem ER/SR,CD, dilt-cd, dilt-xr, diltzac, cartia-xt, Taztia XT (generic for Cardizem CD, Dilacor XR, Tiazac) tablet: 120mg, 180mg, 240mg, 300mg, 360mg felodipine ER (generic for Plendil) tablet: 2.5mg, 5mg, 10mg Isradipine matzim LA (generic for Cardizem LA) tablet: 180mg, 240mg, 300mg, 360mg, 420mg nifedipine ER, afeditab, nifediac CC) (generic for Atalat CCl) tablet: 30mg, 60mg, 90mg nicardipine (generic for Cardene) tablet: 20mg, 30mg nifedical XL, nifedipine ER (generic for Procardia XL) tablet: 30mg, 60mg, 90mg nifedipine (generic for Procardia) capsule:10, 20mg nimodipine (PL) (generic for Nimotop)) capsule:30mg nidoldipine (generic for Sular)) tablet: 8.5mg, 17mg, 34mg verapamil (generic for Calan) Tablet: 80mg, 120mg verapamil ER/SR (generic for Calan SR, Isoptin SR, Covera HS, Verelan, Veralan PM) tablet: 120mg, 180mg, 240mg capsule: 100mg,120mg, 180mg, 200mg, 240mg, 300mg, 360mg Cardene SR Sular 10, 20, 30 & 40mg (PL) Adalat CC Amlodipine Besylate-Olmesartan Medoxomil (PL) Azor (PL) Bendroflumethiazide/Rauwolfia Calan Calan SR Cardizem Cardizem CD Cardizem LA (PL) Dilacor XR Isoptin SR Lotrel Nisolidipine SR 20, 25.5, 30mg tab Nimotop (PL) Nymalize Norvasc Procardia Procardia X Sular 8.5, 17 & 34mg Tarka Tiazac Twynsta Vecamyl Verelan Verelan PM CHOLESTEROL LOWERING atorvastatin (PL) (generic for Lipitor tablet: 10mg, 20mg, 40mg, 80mg cholestyramine, prevalite (generic for Questran, Questran Lite) Can: 4gm, bulk can only colestipol (generic for Colestid) tablet: 1gm granules & packets: 5gm ezetimibe (generic for Zetia) (PL) tablets: 10mg ezetimibe-simvastatin (generic for Vytorin) (PL) tablets: 10-10mg,10-20mg, 10-40mg, 10-80mg fenofibrate (PL) (generic for Lofibra, Triglide, Tricor) tablet: 48mg, 54mg, 148mg, 160mg capsules: 67mg, 134mg, 200mg fluvastatin (PL) (generic for Lescol) capsules: 20mg, 40mg gemfibrozil (generic for Lopid) tablet: 600mg lovastatin (PL) (generic for Mevacor) tablet: 10mg, 20mg, tablet: 40mg pravastatin (PL) (generic for Pravachol) tablet: 10mg, 20mg, tablet: 40mg rosuvastatin (PL) (generic for Crestor) tablet: 5gm. 10mg, 20mg, 40mg simvastatin (PL) (generic for Zocor) tablet: 5mg, 10mg, 20mg, 40mg & 80mg omega 3 acid ethyl esters (generic for Lovaza) tablet: 1 gram (PL) Colesevelam tab 625mg (PL) Niacin ER (PL) Vytorin (PL) Welchol (PL) Advicor (PL) Altoprev Antara (PL) Colestid Edarbi (PL) Edarbyclor Fenofibric Acid (PL) Fenoglide Fibricor (PL) Fluvastatin ER/SR (PL) Lescol (PL) Lescol XL (PL) Lipofen Livalo Lofibra (PL) Lopid Lovaza (PL) Mevacor (PL) Niaspan (PL) Pravachol (PL) Questran Simcor (PL) Tricor(PL) Triglide (PL) Trilipix (PL) Vascepa (PL) Zypitamag (9) Crestor (PL) Lipitor (PL) Liptruzet Zetia (PL) Zocor (PL) DIRECT RENIN INHIBITORS Amturnide Tekamlo Tekturna (PL) Tekturna HCT (PL) Valturna DIURETICS 1, LOOP furosemide (generic for Lasix) 3

4 tablet: 20mg, 40mg, 80mg oral solution: 8mg/ml, 10mg/ml torsemide (generic for Demadex) tablet: 5mg, 10mg, 20mg, 100mg Demadex Edecrin Lasix DIURETICS 2, THIAZIDE benazepril/hctz (generic for Lotensin HCT) tablet: 5mg/6.25mg, 10mg/12.5mg, 20mg/12.5mg, 20mg/25mg enalapril/hctz (generic for Vaseretic) tablet: 5mg/12.5mg, 10mg/25mg hydrochlorothiazide (generic for Microzide, Esidrix) capsule: 12.5mg tablets: 12.5mg, 25mg, 50mg indapamide (generic for Lozol) tablets: 1.25mg, 2.5mg methyclothiazide (generic for Enduron) tablets: 1.25mg, 2.5mg metiolazone (generic for Zaroxolyn) tablets: 2.5mg, 5mg, 10mg Capozide Captopril-hctz Chlorthalidone Clorpres Lotensin HCT Microzide Propranolol-hctz 40-25mg, 80-25mg Vaseretic Zaroxolyn DIURETICS 3, OTHERS methyldopa/hctz (generic for Aldoril) tablet: mg spironolactone (generic for Aldactone) tablet: 25mg, 50mg, 100mg spironolactone/hctz (generic for Aldactazide) tablet: 25/25mg, 50/59mg triamterene/hctz (generic for Dyazide) capsule: mg triamterene/hctz (generic for Maxzide) tablet: mg, 75-50mg Aldactone Aldactazide Dyazide Maxzide OTHER ANTI-HYPERTENSION clonidine (generic for Catapres) tablet: 0.1mg, 0.2mg, 0.3mg transdermal: 0,1mg, 0,2mg, 0.3mg hydralazine (generic for Apresoline) tablet: 10mg, 25mg, 50mg, 100mg eplerenone (PL) (generic for Inspra) tablet: 25mg, 50mg methyldopa (generic for Aldomet) capsule: 250mg, 500mg metoprolol hydrochlorothiazide tablet: mg prazosin (generic for Minipress) capsule: 1mg, 2mg, 5mg guanfacine (generic for Tenex) capsule: 1mg, 2mg Catapres Catapres-TTS Dis Dibenzyline Guanabenz Acetate Inspra (PL) Minipress Nexiclon XR Reserpine Tenex Methyldopa/HCTZ mg NITRATES minoxidil (generic for Loniten) tablet: 2.5mg, 10mg ENDOCRINE/ METABOLIC CALCIUM METABOLISM alendronate (PL) (generic for Fosamax) tablet: 5mg, 10mg,35mg, 70mg calcitonin, fortical (generic for Miacalcin) spray: 200mg raloxifene (PL) (generic for Evista) tablet: 60mg risedronate (PL) (generic for Actonel) tablet: 5mg, 30mg, 35mg 150mg risedronate delayed release (PL) * (generic for Atelvia) tablet: 35mg Actonel 150mg (PL) Alendronate tab 40mg (PL) Alendronate oral soln 70mg/75ml (PL) Boniva (PL) Didronel Evista (PL) Fosamax (PL) Levobunolol Miacalcin (PL) Risedronate 35mg (PL) Skelid Atelvia (PL) * Actonel 5mg, 30mg, 35mg (PL) Binosto (PL) * Fosamax Plus D (PL) Osphena DIABETES MELLITUS acarbose (generic for Precose) tablet:25mg, 50mg, 100mg glimepiride (PL) (generic for Amaryl) tablet: 1mg, 2mg, 4mg glipizide (generic for Glucotrol) tablet: 5mg, 10mg glipizide ER/ (generic for Glucotrol XL) extended-release tablet: 2.5mg, 5mg, 10mg glipizide-metformin (PL) (generic for Metaglip) Tablet: mg, mg, 5mg-500mg glyburide-metformin (PL) (generic for Glucovance) tablet: 1.25/250mg, 2.5/500mg. 5/500mg glyburide, glycron (generic for Diabeta, Micronase, Glynase) tablet: 1.25mg, 2.5mg, 5mg prestab: 1.5mg, 3mg, 6mg Humalog Mix Vial (PL) Humalog vial (PL) Humalin vial (PL) Humulin R vial (PL) Humulin N vial Humulin 70/30 vial (PL) Lantus insulin vial (PL) metformin (generic for Glucophage) tablet: 500mg, 850mg, 1000mg metformin ER/SR (generic for Glucophage XR) extended-release tablet: 500mg, 750mg metformin ER/SR Osmotic (PL) (generic for Fortamet) sustained release tablet: 500mg, 1000mg nateglinide (PL) (generic for Starlix) tablet: 60mg, 120mg pioglitazone (PL) (generic for Actos) tablet: 15mg, 30mg, 45mg pioglitazone-metformin (PL) (generic for Actoplus Met) tablet: mg, mg pioglitazone-glimepiride(pl) (generic for Duetact) tablet: 30-2mg, 30-4mg repaglinide (generic for Prandin) tablet: 1 mg, 2mg Actoplus Met XR 4

5 Avandia (PL) Avandamet (PL) Avandaryl (PL) Byetta (PL) Bydureon (PL) Bydureon Pen (PL) Bydureon Bcise Farxiga (PL) Glyset Humalog Cartridge Humalog Junior Kwikpen Humalog Mix Kwikpen Humulin Kwikpen Humulin N Kwikpen Humulin R U-500 concentrated vial (PL) Humulin R U-500 Kwikpen Humulin 70/30 Kwikpen Invokana Invokamet Invokamet XR Janumet (PL) Janumet XR Januvia (PL) Kombiglyze XR Lantus Solostar pen Onglyza Prandin 0.5mg Repaglinide-Metformin Soliqua (PL) Symlin pen (PL) Toujeo Solostar Pen Trulicity (PL) Victoza (PL) Xigduo XR Xultophy (PL) Adlyxin (PL) Admelog vial (PL) Admelog Solostar (PL) Amaryl (PL) Apidra Solostar (PL) Apidra Vial (PL) Chlorpropamide Cycloset Duetact (PL) Diabinese Fiasp vial (PL) Fiasp Flextouch (PL) Freestyle Libre (PL) Glucophage (PL) Glucovance (PL) Glucotrol Glucotrol XL Glynase Jardiance Jentadueto Jentadueto XR (PL) Kazano Korlym (PL) Levemir vial (PL) Levemir Flextouch (PL) Nesina Novolin N vial (PL) Novolin N Relion vial (PL) Novolin R vial (PL) Novolin R Relion vial (PL) Novolin 70/30 vial (PL) Novolin 70/30 Relion vial (PL) Novolog Flexpen (PL) Novolog Mix Flexpen (PL) Novolog Penfill (PL) Novolog Mix Vial (PL) Novolog Vial (PL) Oseni Ozempic (PL) Precose Relion N Innolet syringe (PL) Relion vial (PL) Riomet Starlix (PL) Tanzeum (PL) Tolbutamide Tradjenta Tresiba Flexpen (PL) Actoplus Met (PL) Actos (PL) Afrezza (PL) Alogliptin Basaglar Kwikpen (PL) Diabeta Fortamet (PL) Glucophage XL (PL) Glumetza (PL) Glyxambi (PL) Metaglip (PL) Metformin modified release ER/SR (PL) Nesina Prandimet Qtern (PL) Synjardy Synjardy XR OTHER ENDOCRINE/METABOLIC Glucagen Glucagon Proglycem NUTRIENTS & BLOOD MODIFIERS ANTICOAGULANTS/THROMBOLYTICS warfarin, jantoven (generic for Coumadin) tablet: 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg Coumadin Brilinta RESPIRATORY ANAPHYLAXIS Epinephrine (generic for Adrenalin) Injection: 1mg/ml Mylan Epinephrine Pen (PL) Adrenalin vial Adrenaclick pen (PL) Auvi-Q pen by Sanofi (PL) Epi-Pen (PL) Epi-Pen JR (PL) Non Mylan Epinephrine Pens (PL) BRONCHODILATORS albuterol (generic for Proventil/Ventolin) nebulizer: 0.05%, 0.083% tablet: 2mg, 4mg syrup: 2mg/5ml albuterol (generic for Accuneb) nebulizer: 0.63mg/3ml,1.25mg/3ml (generic for Accuneb) nebulizer: 0.63mg/3ml,1.25mg/3ml ipratropium bromide inhal sol (generic for Atrovent) Solution: 0.02%, 0.03%, 0.06% levalbuterol (generic for Xopenex) concentrated nebulizer: 1.25mg/0.5ml nebulizer: 0.31mg, 0.63mg, 1.25mg Atrovent HFA (PL) ProAir HFA ProAir Respiclick Serevent Diskus (PL) Ventolin HFA Accuneb Adrenalin Albuterol ER Bevespi Aerosphere (PL) Levabuterol HFA (PL) Brovana (PL) Perforomist (PL) Spiriva Handihaler (PL) Spiriva Respimat (PL) Vospire ER Xopenex Concentrate Nebulizer Proventil HFA (PL) Xopenex HFA (PL) BRONCHODILATORS, INHALED STEROIDS Fluticasone propionate/salmeterol (generic for Airduo) Inhaler: mcg/act, mcg/act, 55-14mcg/act Advair (PL) Advair HFA (PL) 5

6 Airduo Respiclick (PL) ASTHMA, OTHER dyphyllin-gg, DG 200, COPD, dyflex G (generic for Lufyllin GG) Elixir: mg tablet: mg difil-g fort liquid difil g 400 tablet dilex-g liquid dy-g liquid dyphylline tab gg es (generic for Difil G) tablets: mg Ipratropium/albuterol (generic for Duoneb) nebulizer solution: mg/3ml (generic for Intal) Nebulizer: 20mg/2ml montelukast (PL) (generic for Singulair) tablet: 4mg, 5mg, 10mg zafirlukast (generic for Accolate) (PL) tablet: 10mg, 20mg budesonide suspension (generic for Pulmicort Respules) (PL) tablet: 0.25mg, 0.5mg theophylline solution (generic for Slo-phyllin) Solution: 80mg/15ml Alvesco (PL) Arnuity Ellipta Asmanex Asmanex HFA Flovent Diskus Flovent HFA Pulmicort respules 1MG (PL) Pulmicort flexhaler (PL) Qvar (PL) Qvar Redihaler Symbicort Theo-24 Accolate (PL) Aerobid M Aerospan Alvesco (PL) Aminophyllin tab Arcapta Broncap Broncodur Sol Broncomar 1 Elx Brondil Liquid Combivent Combivent Respimat Cromolyn sodium nebulizer Difil G Dilex G Dylix Elizir Ed-Bron G syp Elixohyllin Elixir Jay-Phyl Lonhala Magnair Kit (PL) Lufyllin Lufyllin GG Quibron Seebri Neohaler Singulair (PL) Theophylline Eixir Trelelgy Ellipta (PL) Utibron Neohaler Zileuton SR Zileuton ER Zyflo Zyflo CR Dulera (PL) Duoneb OTHER PULMONARY terbutaline (generic for Brethine) Tablet: 2.5mg, 5mg Injection: 1mg/ml metaproteren (generic for Metaprel) Tablet: 10mg, 20mg Anoro Ellipta Breo Ellipta Incruse Ellipta Pulmozyme (PL) Maxair autohaler Metaproferen syrup Tudorza Pressair Stiolto Respimat (PL) Striverdi Respimat THEOPHYLLINES theophylline SR 12 HR (generic for Theo-Dur) sustained-release tablet:100mg, 200mg, 300mg, 450mg theophylline SR 24 HR (generic for Uniphyl) sustained-release tablet:400mg, 600mg PRENATAL PRESCRIPTION VITAMINS (PL) Prescription Brands 6

7 Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call for Spanish and for all other languages and other aids and services. If you believe that BCBSAZ 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: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ , , TTY/TDD , crc@azblue.com. You can file a grievance in person or by mail or . If you need help filing a grievance BCBSAZ s Civil Rights Coordinator 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 or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at

8 Multi-language Interpreter Services

Value-Based Drug List for ABCs of Diabetes

Effective January 1, 2019 Value-Based Drug List for ABCs of Diabetes PCPS provides a Value-Based Benefit Design (VBD) to qualified participants in the ABCs of Diabetes. This means you will have lower out-of-pocket