2018 Preventive Drug List
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1 2018 Preventive Drug List
2 Introduction In addition to a healthy lifestyle, preventive prescription drugs 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 prescription drugs. It does not include all conditions that may be prevented with prescription drugs. The prescription drugs 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. The Preventive Drug List is updated annually on a calendar year basis (effective Jan. 1 of each year). Please note, this may be different than the plan year start date for some employer plans and any changes made to this list would be effective midyear for these members. Important facts about this benefit 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 drug is available, the originator brand drug will not be covered (Example: simvastatin is covered, ZOCOR is not). The covered preventive drugs are divided into categories. The listed drugs in the categories include those which are always prescribed for prevention and those which are sometimes prescribed for prevention. Drugs 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, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Security Health Plan does not exclude people or treat them differently because of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status. Security Health Plan: 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 at (TTY: 711). If you believe that Security Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status, you can file a grievance with: Security Health Plan Attn: Grievances 1515 North Saint Joseph Avenue Marshfield, WI Phone: (TTY: 711) Fax: shp.appeals.grievance@securityhealth.org You can file a grievance in person or by mail, fax or . If you need help filing a grievance, Security Health Plan can 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 Phone: or (TDD) Complaint forms are available at
4 Language Assistance Services 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) ةيبرعلا ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف 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 (TTY: 711) 번으로전화해주십시오. 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 (TTY: 711). າພາສາ ລາວ, ການບ ລການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ 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
5 ह द (Hindi) ध य न द : य द आप ह द ब लत ह त आपक लए 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). Oroomiffa (Oromo/Somalia) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). Large print If you require materials in large print, please call (TTY: 711). 2
6 Asthma drugs 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 Flexhaler Breo Ellipta inhaler Serevent Diskus Budesonide suspension Spiriva Handihaler Combivent Respimat inhal spray Spiriva Respimat inhaler Flovent Diskus Stiolto Respimat inhal spray Flovent HFA inhaler Symbicort inhaler Fluticasone-Salmeterol inhalation powder Terbutaline tablet Ipratroprium-Albuterol nebules Theochron ER tablet Ipratropium 0.02% solution Theophylline 80 Mg/15 Ml solution Levalbuterol nebules Theophylline ER tablet Metaproterenol tablet Ventolin HFA inhaler Metaproterenol Ml syrup Zafirlukast tablet Montelukast tablet Blood thinners 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 Diabetes drugs and supplies Preventive Drug List Prevention of complications related to high blood sugar Acarbose tablet Januvia tablet Accu-Chek Aviva Plus meter Jardiance tablet Accu-Chek Aviva Plus test strip 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 tablet 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 vial Synjardy tablet
7 Diabetes drugs and supplies (continued) Prevention of complications related to high blood sugar Glyburide Micro tablet Tolazamide tablet Glyburide-Metformin tablet Tolbutamide tablet Invokamet tablet Toujeo Invokana tablet Tresiba Janumet tablet Trulicity Janumet XR tablet Victoza Heart disease drugs Prevention of heart disease Aspirin-Dipyridamole Er tablet Isosorbide Mn tablet Amiodarone tablet Mexilitine capsule Digoxin tablet Nitroglycerin Sublingual tablet Digoxin oral solution Propafenone capsule Disopyramide capsule Quinidine tablet Dofetilide capsule Sotalol AF tablet Flecainide tablet Sotalol tablet Isosorbide Dn tablet High blood pressure drugs Prevention of stroke, complications due to high blood pressure and reoccurence of heart attack Acetazolamide tablet Isradipine capsule Afeditab CR tablet Labetalol tablet Amiloride tablet Lisinopril tablet Amiloride-Hctz tablet Lisinopril-Hctz tablet Amlodipine tablet Losartan tablet Amlodipine -Valsartan tablet Losartan-Hctz tablet Amlodipine -Valsartan-Hydrochlorothiazide tablet Matzim LA tablet Amlodipine-Benazepril tablet Methyclothiazide tablet Atenolol tablet Methyldopa tablet Atenolol-Chlorthalidone tablet Metolazone tablet Benazepril tablet Metoprolol Succ ER tablet Benazepril-Hctz tablet Metoprolol Tartrate tablet Betaxolol tablet Metoprolol-Hctz tablet Bisoprolol tablet Minoxidil tablet Bisoprolol-Hctz tablet Moexipril tablet Bumetanide tablet Moexipril-Hctz tablet Candesartan tablet Nadolol tablet Candesartan-Hctz tablet Nifedipine capsule Captopril tablet Nifedipine ER tablet Captopril-Hctz tablet Nimodipine capsule Cartia XT capsule Nisoldipine ER tablet Carvedilol tablet Perindopril tablet Chlorothiazide tablet Pindolol tablet Chlorthalidone tablet Prazosin capsule Clonidine Hcl tablet Propranolol tablet Dilt XR capsule Propranolol ER capsule Diltiazem tablet Propranolol-Hctz tablet Diltiazem 12Hr ER capsule Quinapril tablet Diltiazem 24Hr CD Capule Quinapril-Hctz tablet Diltiazem 24Hr ER capsule Ramipril capsule Diltiazem 24Hr ER tablet Spironolactone tablet Diltiazem ER capsule Spironolactone-Hctz tablet Enalapril tablet Telmisartan tablet Enalapril-Hctz tablet Telmisartan-Hctz tablet Epaned oral solution Terazosin capsule Eplerenone tablet Timolol tablet
8 High blood pressure drugs (continued) Prevention of stroke, complications due to high blood pressure and reoccurence of heart attack Eprosartan tablet Torsemide tablet Ethacrynic Acid tablet Trandolapril tablet Felodipine ER tablet Trandolapril -Verapamil ER tablet Fosinopril tablet Triamterene-Hctz capsule Fosinopril-Hctz tablet Triamterene-Hctz tablet Furosemide tablet Valsartan tablet Guanfacine tablet Valsartan-Hctz tablet Hydralazine tablet Verapamil tablet Hydrochlorothiazide capsule Verapamil ER capsule Hydrochlorothiazide tablet Verapamil ER PM capsule Indapamide tablet Verapamil ER tablet Irbesartan tablet Verapamil SR capsule Irbesartan-Hctz tablet High cholesterol drugs High cholesterol drugs (prevention of heart disease) Atorvastatin tablet Fenofibric Acid DR capsule Cholestyramine Fluvastatin capsule Cholestyramine Light Gemfibrozil tablet Colestipol tablet Lovastatin tablet Colestipol granules Niacin ER tablet Colestipol Micronized tablet Pravastatin tablet Ezetimibe tablet Prevalite Packet Fenofibrate capsule Prevalite Powder Fenofibrate tablet Rosuvastatin tablet Fenofibric Acid tablet Simvastatin tablet Osteoporosis (bone disease) drugs Prevention of bone fractures Alendronate tablet Raloxifene tablet Calcitonin (Salmon) Nasal spray Risedronate DR tablet Etidronate tablet Risedronate tablet Ibandronate tablet
9 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, Wisconsin Fax HP (04/18) Security Health Plan of Wisconsin, Inc
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