2015 Preventive Drug List
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1 2015 Preventive Drug List If your health plan includes the Preventive Drug List option, you just pay a copay for preventive care medications instead of having to meet your plan s deductible for certain prescription drugs. Prescription drugs on the Preventive Drug List will be covered as if you already met your deductible, so you are only responsible for paying the appropriate copay. This enhanced benefit to your health plan makes it easier for you to purchase the medications you and your family need to stay healthy today and tomorrow. Medications on the Preventive Drug List help prevent and manage several health concerns. Some of these conditions, if not prevented or managed, can lead to serious illnesses and complications. Following your doctor s treatment plan, including taking prescribed medications as directed, can help you live a healthier life today, and avoid a serious illness and high health care costs in the future. This list contains some of the most commonly prescribed preventive care drugs and is not all-inclusive. This list does not guarantee coverage for preventive care drugs that are not listed. Covered Generics Asthma and Other Respiratory Conditions albuterol soln Advair Diskus Pulmicort Flexhaler budesonide nebulizer soln Advair HFA cromolyn sodium Anoro Ellipta ipratropium bromide inhaler Arcapta Neohaler ipratropium-albuterol Asmanex Asmanex HFA levalbuterol Breo Ellipta metaproterenol sulfate Brovana montelukast Combivent Respimat terbutaline sulfate Dulera zafirlukast Flovent Diskus Flovent HFA Foradil Perforomist ProAir HFA QVAR Serevent Diskus Spiriva Spiriva Respimat Symbicort Tudorza Pressair Conditions Related to Blood Clots anagrelide Brilinta Aggrenox
2 cilostazol Effient Coumadin clopidogrel Eliquis Fragmin QL dipyridamole enoxaparin QL fondaparinux QL Jantoven pentoxifylline ticlopidine warfarin sodium Altavera Alyacen Amethia Amethia Lo Amethyst Apri Aranelle Ashlyna Aubra Aviane Azurette Balziva Briellyn Camila Camrese Camrese Lo Caziant Chateal Cryselle Cyclafem Cyclafem 7/7/7 Dasetta Daysee Deblitane Delyla desogestrel-ethinyl estradiol drospirenone-ethyinyl estradiol Elinest Emoquette Enskyce Enpresse Errin Estarylla Falmina Gianvi Pradaxa Xarelto Contraception
3 Gildagia Gildess Gildess FE Gildess 24 FE Heather Introvale Jencycla Jolessa Jolivette Junel 1.5/30 Junel 1/20 Junel FE 1.5/30 Junel FE 1/20 Kariva Kelnor 1/35 Kimidess Kurvelo Larin Larin FE Layolis Leena Lessina Levonest levonorgestrel-est estradiol Levora Lomedia 24 Fe Loryna Low-Ogestrel Lutera Lyza Marlissa medroxyprogesterone acetate Microgestin 1.5/30 Microgestin 1/20 Microgestin FE 1.5/30 Microgestin FE 1/20 Mono-Linyah Mononessa Myzilra Necon 0.5/35 Necon 1/35 Necon 1/50 Necon 7/7/7 Nikki Nora-Be
4 norethindrone acetate 0.35 norgestimate-ethinyl estradiol Norlyroc Nortrel 0.5/35 Nortrel 1/35 Nortrel 7/7/7 Ocella Ogestrel Orsythia Philith Pimtrea Pirmella Portia Previfem Quasense Reclipsen Sharobel Sprintec Sronyx Syeda Tarina FE Tilia FE Tri-Estarylla Tri-Legest FE Tri-Linyah Trinessa Tri-Previfem Tri-Sprintec Trivora Velivet Vestura Viorele Vyfemia Wera Wymzya FE Xulane Zarah Zenchent Zenchent FE Zeosa Zovia 1/35 Zovia 1/50 Diabetes acarbose Bydureon (pens & vials) Actoplus Met XR chlorpropamide Byetta Apidra ST
5 glimepiride Farxiga Apidra SoloSTAR ST glipizide Invokana Avandamet glipizide ext-rel Janumet Avandaryl glipizide-metformin Janumet XR Avandia glyburide Januvia Glumetza glyburide micronized Jentadueto Glyset glyburide-metformin Lantus SoloSTAR Humalog (pens & vials) ST Lantus (vials)* Levemir (pens) Humulin (pens & vials) ST Levemir (vials)* Novolin (pens) Prandimet metformin Novolog (pens) Riomet metformin ext-rel Tradjenta SymlinPen nateglinide Novolin (vials)* Novolog (vials)* pioglitazone pioglitazone-glimepiride pioglitazone-metformin repaglinide tolazamide tolbutamide Victoza Diabetic Supplies Bayer Contour/Breeze2 diabetic products* QL alcohol preps and lancets QL Lifescan One Touch diabetic products* QL BD insulin syringes QL *Under your plan, this brand-name product is available at the lowest copay level. Emotional Health amitriptyline amitriptyline-chlordiazepoxide amitriptyline-perphenazine amoxapine aripiprazole bupropion bupropion ext-rel chlorpromazine citalopram clomipramine clozapine PA desipramine doxepin duloxetine escitalopram fluoxetine fluphenazine Abilify PA Latuda PA Seroquel XR PA
6 fluvoxamine haloperidol imipramine loxapine maprotiline mirtazapine nefazodone nortriptyline olanzapine PA olanzapine-fluoxetine PA paroxetine paroxetine ext-rel perphenazine phenelzine protriptyline quetiapine PA risperidone PA sertraline thioridazine thiothixene tranylcypromine trazodone trifluoperazine venlafaxine venlafaxine ext-rel ziprasidone PA acebutolol acetazolamide Afeditab CR amiloride amiloride-hctz amiodarone amlodipine amlodipine-atorvastatin amlodipine-benazepril atenolol atenolol-chlorthalidone benazepril benazepril-hctz betaxolol bisoprolol fumarate bisoprolol-hctz bumetanide candesartan High Blood Pressure & Other Heart Conditions Azor Benicar Benicar HCT Bystolic Coreg CR Lanoxin Tribenzor
7 candesartan-hctz captopril captopril-hctz Cartia XT carvedilol chlorothiazide chlorthalidone clonidine tablets Clorpres digoxin diltiazem diltiazem 24 HR CD diltiazem ext-rel Dilt-XR disopyramide phosphate doxazosin enalapril enalapril-hctz eplerenone eprosartan felodipine ext-rel flecainide acetate fosinopril fosinopril-hctz furosemide guanfacine hydralazine hydrochlorothiazide indapamide irbesartan irbesartan-hctz isosorbide dinitrate/mononitrate isradipine K-effervescent Klor-Con EF Klor-Con M Klor-Con 8mEq Klor-Con 10mEq Klor-Con 20mEq labetalol lisinopril lisinopril-hctz losartan losartan-hctz Matzim LA
8 methazolamide methyclothiazide methyldopa methyldopa-hctz metolazone metoprolol succinate ext-rel metoprolol tartrate metoprolol-hctz mexiletine minoxidil moexipril moexipril-hctz nadolol nadolol-bendroflumethiazide nicardipine Nifediac CC Nifedical XL nifedipine ext-rel nimodipine nisoldipine ext-rel NitroBid nitroglycerin Nitro-Time Pacerone perindopril pindolol potassium bicarbonate potassium chloride prazosin propafenone propranolol propranolol ext-rel propranolol-hctz quinapril quinapril-hctz quinidine gluconate quinidine sulfate ramipril reserpine Sorine sotalol sotalol AF spironolactone spironolactone-hctz Taztia XT
9 telmisartan telmisartan-amlodipine telmisartan-hctz terazosin timolol maleate torsemide trandolapril trandolapril-verapamil ext-rel triamterene-hctz valsartan valsartan-hctz verapamil verapamil ER PM verapamil ext-rel atorvastatin cholestyramine colestipol fenofibrate fenofibric acid fluvastatin gemfibrozil lovastatin niacin niacin ext-rel pravastatin Prevalite simvastatin Glatopa SPRx Crestor Liptruzet Simcor Vytorin Zetia Ampyra PA SPRx Avonex SPRx Copaxone SPRx Gilenya PA SPRX Rebif SPRx Rebif Rebidose SPRx High Cholesterol Multiple Sclerosis Tecfidera PA SPRx Osteoporosis (a done disease) alendronate Actonel Fosamax Plus D calcitonin-salmon nasal spray Fortical ibandronate raloxifene risedronate Atelvia Miacalcin injection Prenatal Care (Vitamins)
10 all generic vitamins Seizure Conditions carbamazepine Dilantin Banzel carbamazepine ER Oxtellar XR Celontin clonazepam Vimpat Diastat divalproex delayed-rel divalproex ext-rel Epitol ethosuximide felbamate gabapentin lamotrigine lamotrigine ext-rel lamotrigine ODT levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin sodium extended primidone tiagabine Topiragen topiramate valproic acid zonisamide levothyroxine Levoxyl liothyronine methimazole Nature-Thyroid NP Thyroid propylthiouracil Unithroid Westhroid Legend Thyroid Modifiers Onfi Peganone Potiga Sabril SPRx Stavzor PA This drug requires prior authorization ST Requires other selected drugs to be tried first QL This drug has quantity limits on amount covered SPRx Specialty drug. Many plans require you to get this type of drug from a Specialty Pharmacy. This list is subject to change throughout the year. Please call Member Service at the phone number listed on your BlueCross BlueShield of Tennessee member ID card or visit our website at bcbst.com for the most up-to-date information.
11 Tagalog: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese: 如果需要中文的帮助, 请拨打这个号码 Navajo: Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' BlueCross does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN bcbst.com BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association 14PHM3592 (07/15) Preventive List Flier
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