ACCOUNT HEALTH SAVINGS. Preventive Medication List (by Therapy Class)

Transcription

1 HEALTH SAVINGS ACCOUNT Preventive Medication List (by Therapy Class) Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association

2 Preventive medications are an important element in keeping members healthy. Your Health Savings Account (HSA) qualified health plan is designed to promote smarter spending on prescription drugs while improving your overall health. Prescription drugs that can help keep you from developing a health condition are called preventive medications. With the HSA preventive medication option, no deductible is applied to preventive prescription drugs, allowing health care dollars to go further. Members can purchase these prescription medications with lower out-of-pocket costs. The HSA preventive medication listing includes four tiers* of medications: generic preferred (tier 1), generic non-preferred (tier 2), brand preferred (tier 3), and brand non-preferred (tier 4) drugs. Your cost share for prescription medications is based on which tier your drug falls into. Generic drugs are typically the most affordable and offer you a lower cost share than brand-name drugs. The active ingredient in a generic drug is chemically identical to the active ingredient of the corresponding brand-name drug. To help lower your out-of-pocket cost, we encourage you to choose a generic medication whenever possible. Generic preferred drugs (tier 1) usually have the lowest cost share. Generic non-preferred drugs (tier 2) usually have a slightly higher cost share than generic preferred drugs and a lower cost share than brand name drugs. Please note that not all strengths and formulations of generic drugs have the same tier status. For example, metformin er 500mg is generic preferred (tier 1) and metformin er 750mg is generic non-preferred (tier 2). Brand-name drugs are marketed under a specific trade name and are protected by a patent. Brand-name drugs can be either preferred or non-preferred. *All plans do not include a two-tier generic benefit. For plans that do not have a twotier generic benefit, the generic copayment will be applied to both generic preferred and generic non-preferred drugs. Refer to your Certificate of Coverage for specific information about your prescription benefit. Brand preferred drugs (tier 3) are usually available at a slightly higher cost share than generic drugs. These drugs are designated preferred brand because they are more cost effective compared to other brand drugs that treat the same condition. Brand non-preferred drugs (tier 4) usually have the highest cost share. These drugs are listed as non-preferred because they have not been found to be any more cost effective than available generics, preferred brands, or over-the-counter drugs. Non-preferred brand medications are not covered under a closed formulary benefit plan. PAGE 2

3 Prior Authorization Some medications are subject to prior authorization and may require approval prior to filling. You can easily identify these medications as they will have a PAR symbol next to them. The prior authorization process helps to ensure that certain drugs are prescribed appropriately and in keeping with FDA guidelines. To help prevent delays in filling these prescriptions, you, your physician, or your authorized representative should request an authorization before your prescriptions are filled. Medications that require authorization will not be covered if authorization is not obtained prior to dispensing. (You can initiate a prior authorization request from our website or by calling the Rx Member Services number on the back of your ID card.) Enhanced Prior Authorization (step therapy) Certain medications are subject to enhanced prior authorization (or step therapy) due to health care concerns and/or safety reasons. In order to have these medications covered under your prescription drug benefit, you may be required to first try a formulary alternative or complete the authorization process. These medications appear on the Preventive Medication List with an EPA symbol next to them. Quantity Level Limits Quantity level limits help to promote appropriate use of selected medications and enhance patient safety. If your prescription is written for more than the allowed quantity, your prescription will be filled up to the allowed quantity unless authorization has been obtained for a higher quantity. These medications appear on the preventive medication list with a QLL symbol next to them. To obtain authorization, your physician can call or fax a request with supporting clinical information to our pharmacy benefit manager at: CVS Caremark Prior Authorization Department Phone: Fax: If you have questions about your prescription drug benefit, contact CVS Caremark customer service at (TTY: ). CVS Caremark pharmacists and customer service representatives are available any time of the day, seven days a week. You may also visit capbluecross.com for other helpful pharmacy information. PAGE 3

4 Preventive Medication List* Medications for Diabetes Medications for Diabetes (continued) acarbose ACTOPLUS MET, -XR BNP pioglitazone/metformin ACTOS BNP pioglitazone AMARYL BNP glimepiride APIDRA BNP HUMALOG, NOVOLOG AVANDAMET AVANDARYL AVANDIA BYDUREON (EPA) BNP BYETTA (EPA) BYETTA (EPA) chlorpropamide CYCLOSET BNP metformin DIABETA BNP glyburide DIABINESE BNP chlorpropamide DUETACT BNP glimepiride/pioglitazone FARXIGA BNP JANUVIA glimepiride glimepiride/pioglitazone glipizide glipizide er 5mg glipizide er 10mg glipizide/metformin GLUCOPHAGE XR BNP metformin er GLUCOTROL, -XL BNP glipizide, -er GLUCOVANCE BNP glyburide/metformin glyburide 5mg glyburide 1.25mg, 1.5mg, 2.5mg, 3mg, 6mg glyburide/metformin 1.25/250mg glyburide/metformin 2.5/500mg, 5/500mg GLYSET HUMALOG products HUMULIN products INVOKANA BNP JANUVIA JANUVIA JANUMET, -XR JENTADUETO JUVISYNC KAZANO (PAR) BNP JENTADUETO, JANUMET KOMBIGLYZE XR (PAR) BNP JENTADUETO, JANUMET LANTUS LANTUS SOLOSTAR BNP LANTUS LEVEMIR METAGLIP BNP glipizide/metformin metformin, metformin er 500mg metformin er 750mg metformin osmotic er MICRONASE BNP glyburide nateglinide NESINA (PAR) BNP JANUVIA, TRADJENTA NOVOLIN products NOVOLOG PRODUCTS ONGLYZA (PAR) BNP JANUVIA, TRADJENTA OSENI (PAR) BNP pioglitazone JANUVIA, TRADJENTA, pioglitazone PRANDIMET BNP PRANDIN + metformin PRANDIN PRECOSE BNP acarbose STARLIX BNP nateglinide, PRANDIN SYMLIN, -PEN (EPA) tolazamide tolbutamide TRADJENTA VICTOZA (EPA) BNP BYETTA (EPA) Medications to Prevent and Treat Osteoporosis ACTONEL (EPA, QLL) BNP alendronate (QLL) alendronate 35mg, 70mg (QLL) = Generic Preferred = Generic Non-preferred = Brand Preferred BNP = Brand Non-Preferred PAGE 4

5 Medications to Prevent and Treat Osteoporosis (continued) alendronate 5mg, 10mg, 40mg ATELVIA (EPA, QLL) BNP alendronate (QLL) BINOSTO (EPA, QLL) BNP alendronate (QLL) BONIVA (EPA, QLL) BNP ibrandronate (QLL) calcitonin nasal spray DIDRONEL BNP etidronate etidronate EVISTA BNP raloxifene FORTEO (PAR) FORTICAL NASAL SPRAY BNP calitonin nasal spray FOSAMAX (EPA, QLL) BNP alendronate (QLL) FOSAMAX-D (EPA, QLL) ibrandronate (QLL) MIACALCIN NASAL SPRAY BNP calitonin nasal spray raloxifene Medications for Arrhythmia or Angina amiodarone BETAPACE, -AF BNP sotalol, -af CORDARONE BNP amiodarone disopyramide flecainide IMDUR BNP isosorbide mononitrate ISMO BNP isosorbide mononitrate ISORDIL BNP isosorbide dinitrate isosorbide dinitrate isosorbide dinitrate er 40mg isosorbide mononitrate 10mg isosorbide mononitrate 20mg isosorbide mononitrate er 30mg isosorbide mononitrate er 60mg, 120mg mexiletine Medications for Arrhythmia or Angina (continued) MEXITIL BNP mexiletine MINITRAN BNP nitroglycerin MONOKET BNP isosorbide mononitrate MULTAQ BNP amiodarone NITRO-DUR BNP nitroglycerin nitroglycerin 0.3mg nitroglycerin 0.4mg, 2.5mg, 6.5mg nitroglycerin patch, spray NITROMIST BNP nitroglycerin NORPACE, -CR BNP disopyramide PACERONE BNP amiodarone propafenone quinidine 200mg quinidine 300mg, 324mg RANEXA (PAR) RYTHMOL, -SR BNP propafenone sotalol 80mg, 160mg sotalol 120mg, 240mg; -af TAMBOCOR BNP flecainide TIKOSYN BNP Medications for High Blood Pressure and Other Cardiovascular Conditions ACCUPRIL (EPA) BNP quinapril ACCURETIC BNP quinapril/hctz acebutolol ACEON (EPA) BNP perindopril acetazolamide ADALAT CC BNP nifedipine er ALDACTAZIDE BNP spironolactone/hctz ALDACTONE BNP spironolactone ALTACE (EPA) BNP ramipril = Generic Preferred = Generic Non-preferred = Brand Preferred BNP = Brand Non-Preferred PAGE 5

6 Preventive Medication List* (continued) Medications for High Blood Pressure and Other Cardiovascular Conditions (continued) amiloride/hctz amiloride amlodipine amlodipine/benazepril ATACAND (EPA) BNP candesartan ATACAND HCT (EPA) BNP candesartan/hctz atenolol/ -chlorthalidone AVALIDE (EPA) BNP irbesartan/hctz, losartan/hctz AVAPRO (EPA) BNP irbesartan, losartan AZOR benazepril/ -hctz bendroflumethiazide/ -rauwolfia BENICAR/ -HCT betaxolol bisoprolol bisoprolol/hctz bumetanide 0.5mg, 1mg bumetanide 2mg BUMEX BNP bumetanide BYSTOLIC (EPA) CALAN, -SR BNP verapamil, -sr candesartan CAPOZIDE BNP captopril/hctz captopril captopril/hctz CARDENE SR BNP nicardipine CARDIZEM, -SR, -CD, -LA BNP diltiazem, -er, -sr, -cd CARDURA BNP doxazosin carvedilol CATAPRES BNP clonidine chlorothiazide chlorthalidone 25mg chlorthalidone 50mg, 100mg clonidine tab Medications for High Blood Pressure and Other Cardiovascular Conditions (continued) clonidine patch CLORPRES BNP clonidine + chlorthalidone COREG BNP carvedilol COREG CR BNP carvedilol CORGARD BNP nadolol CORZIDE BNP nadolol/bendroflumethiazide COVERA-HS BNP verapamil sr COZAAR (EPA) BNP losartan DEMADEX BNP torsemide DEMSER BNP DIAMOX BNP acetazolamide dibenzyline diltiazem diltiazem -er, -sr, -cd DIOVAN HCT BNP valsartan/hctz DIOVAN DIURIL BNP chlorothiazide doxazosin doxazosin SR DYAZIDE BNP triamterene/hctz DYNACIRC CR BNP isradipine DYRENIUM BNP amiloride, spironolactone EDARBI (EPA) BNP irbesartan, losartan EDARBYCLOR (EPA) BNP irbesartan/hctz, losartan/hctz EDECRIN BNP enalapril/ -hctz bumetanide, furosemide, torsemide ENDURON BNP methyclothiazide eprosartan EXFORGE/ -HCT felodipine er fosinopril fosinopril/hctz furosemide guanabenz guanfacine 1mg = Generic Preferred = Generic Non-preferred = Brand Preferred BNP = Brand Non-Preferred PAGE 6

7 Medications for High Blood Pressure and Other Cardiovascular Conditions (continued) guanfacine 2mg hydralazine 25mg hydralazine 10mg, 50mg, 100mg hydrochlorothiazide cap hydrochlorothiazide 25mg, 50mg tab hydrochlorothiazide 12.5mg tab HYZAAR (EPA) BNP losartan/hctz indapamide INDERAL BNP propranolol INDERAL LA BNP propranolol er INNOPRAN XL BNP propranolol er INSPRA BNP eplerenone INVERSINE irbesartan/ -hctz BNP ISOPTIN SR BNP verapamil isradipine KERLONE BNP betaxolol labetalol LASIX BNP furosemide LEVATOL BNP acebutolol, pindolol lisinopril/ -hctz LOPRESSOR BNP metoprolol LOPRESSOR HCT BNP metoprolol/hctz losartan/ -hctz LOTENSIN BNP benazepril LOTENSIN HCT BNP benazepril/hctz LOTREL BNP amlodipine/benazepril MAVIK (EPA) BNP trandolapril MAXZIDE BNP triamterene/hctz methazolamide methyclothiazide methyldopa 250mg methyldopa 500mg methyldopa/hctz metolazone Medications for High Blood Pressure and Other Cardiovascular Conditions (continued) metoprolol metoprolol er metoprolol/hctz MICARDIS (EPA) BNP telmisartan MICARDIS HCT (EPA) BNP telmisartan/hctz MICROZIDE BNP hydrochlorothiazide MINIPRESS BNP prazosin minoxidil tab moexipril/ -hctz nadolol nadolol/bendroflumethiazide NEPTAZANE BNP methazolamide nicardipine nifedipine, -er nimodipine NIMOTOP BNP nimodipine nisoldipine er NORVASC BNP amlodipine perindopril pindolol prazosin PRINIVIL (EPA) BNP lisinopril PRINZIDE (EPA) BNP lisinopril/hctz PROCARDIA, -XL BNP nifedipine, -er propranolol 10mg, 20mg, 40mg, 80mg tab propranolol 60mg tab propranolol er propranolol/hctz quinapril quinapril/hctz ramipril 1.25mg, 2.5mg, 5mg ramipril 10mg reserpine SECTRAL BNP acebutolol spironolactone 25mg = Generic Preferred = Generic Non-preferred = Brand Preferred BNP = Brand Non-Preferred PAGE 7

8 Preventive Medication List* (continued) Medications for High Blood Pressure and Other Cardiovascular Conditions (continued) spironolactone 50mg, 100mg spironolactone/hctz SULAR BNP nisoldipine er TARKA BNP trandolapril/verapamil TEKAMLO TEKTURNA/ -HCT telmisartan/-hctz telmisartan/amlodipine TENEX BNP guanfacine TENORETIC BNP atenolol/chlorthalidone TENORMIN BNP atenolol terazosin TEVETEN/ -HCT (EPA) BNP irbesartan/hctz, losartan/ hctz, eprosartan THALITONE BNP chlorthalidone timolol tab TOPROL XL BNP metoprolol er torsemide 5mg, 10mg torsemide 20mg, 100mg TRANDATE BNP labetolol trandolapril/-verapamil triamterene/hctz TRIBENZOR TWYNSTA (EPA) BNP telmisartan/amlodipine UNIRETIC (EPA) BNP moexipril/hctz UNIVASC (EPA) BNP moexipril VALTURNA VASERETIC (EPA) BNP enalapril/hctz VASOTEC (EPA) BNP enalapril verapamil verapamil-cr, -sr VERELAN BNP verapamil, -cr, -sr ZAROXOLYN BNP metolazone ZEBETA BNP bisoprolol ZESTORETIC (EPA) BNP lisinopril/hctz ZESTRIL (EPA) BNP lisinopril ZIAC BNP bisoprolol/hctz Medications for High Cholesterol ADVICOR BNP SIMCOR (EPA, QLL) ALTOPREV (EPA) BNP lovastatin (QLL) atorvastatin (QLL) atorvastatin/amlodipine CADUET BNP atorvastatin/amlodipine cholestyramine colestipol CRESTOR (QLL) fenofibrate fluvastatin gemfibrozil LESCOL (EPA) BNP fluvastatin, pravastatin (QLL) LESCOL XL (EPA, QLL) BNP fluvastatin, pravastatin (QLL) LIPITOR (EPA, QLL) BNP atorvastatin (QLL) LIVALO (EPA, QLL) BNP lovastatin (QLL) atorvastatin (QLL), simvastatin (QLL) LOVAZA BNP omega-3 acids ER MEVACOR (EPA, QLL) BNP lovastatin (QLL) niacin er NIASPAN BNP niacin er omega-3 acids ER PRAVACHOL (EPA, QLL) BNP pravastatin (QLL) pravastatin 10mg, 20mg, 40mg (QLL) pravastatin 80mg (QLL) SIMCOR (QLL) simvastatin (QLL) TRILIPIX BNP fenofibrate VASCEPA BNP LOVAZA VYTORIN (QLL) WELCHOL ZETIA ZOCOR (EPA, QLL) BNP simvastatin (QLL) = Generic Preferred = Generic Non-preferred = Brand Preferred BNP = Brand Non-Preferred PAGE 8

9 Maintenance Medications for Asthma and COPD ADVAIR / -HFA (QLL) ALVESCO (QLL) BNP ASMANEX (QLL), FLOVENT HFA (QLL) ANORO ELLIPTA BNP SPIRIVA, TUDORZA ASMANEX (QLL) ATROVENT HFA BREO ELLIPTA budesonide (PAR) COMBIVENT DALIRESP DULERA (QLL) FLOVENT DISKUS (QLL) FLOVENT HFA (QLL) BNP PULMICORT (PAR, QLL) BNP budesonide QVAR (QLL) BNP SPIRIVA ASMANEX (QLL), FLOVENT HFA (QLL) SYMBICORT (QLL) BNP ADVAIR/ -HFA (QLL) TUDORZA Medications for Mental Health ABILIFY BNP quetiapine, risperidone, ziprasidone ABILIFY DISCMELT BNP quetiapine, risperidone amitriptyline amoxapine ANAFRANIL BNP BRINTELLIX (EPA, QLL) BNP bupropion bupropion, -sr, -xl fluoxetine (QLL), paroxetine (QLL) CELEXA (EPA, QLL) BNP citalopram (QLL) chlorpromazine citalopram tab (QLL) Medications for Mental Health (continued) citalopram suspension CLOMIPRAMINE clozapine BNP CLOZARIL BNP clozapine COMPAZINE BNP prochlorperazine CYMBALTA (EPA) BNP venlafaxine, -er desipramine DESYREL BNP trazodone doxepin 10mg; solution doxepin 25mg, 50mg, 75mg, 100mg, 150mg, cream EFFEXOR BNP venlafaxine EFFEXOR XR (EPA, QLL) BNP venlafaxine er (QLL) EMSAM PATCH (EPA) BNP escitalopram (QLL) ESKALITH BNP lithium FANAPT BNP FAZACLO BNP clozapine FETZIMA (EPA, QLL) BNP fluvoxamine fluoxetine 10mg, 20mg (QLL) fluoxetine 40mg tab; solution fluoxetine (PMDD) fluoxetine weekly (QLL) fluphenazine 1mg fluphenazine 2.5mg, 5mg, 10mg GEODON BNP ziprasidone haloperidol 0.5mg, 1mg, 2mg, 5mg haloperidol 10mg, 20mg, suspension imipramine INVEGA ER (QLL) BNP risperidone LATUDA BNP citalopram (QLL), paroxetine (QLL) quetiapine, risperidone, ziprasidone fluoxetine (QLL), paroxetine (QLL) quetiapine, risperidone, ziprasidone = Generic Preferred = Generic Non-preferred = Brand Preferred BNP = Brand Non-Preferred PAGE 9

10 Preventive Medication List* (continued) Medications for Mental Health (continued) Medications for Mental Health (continued) LEXAPRO (QLL) BNP lithium 150mg, 300mg lithium 600mg lithium cr LITHOBID BNP lithium loxapine 5mg loxapine 50mg LOXITANE BNP loxapine escitalopram (QLL), citalopram (QLL) LUVOX CR BNP fluvoxamine maprotiline mirtazapine 15mg mirtazapine 7.5mg, 30mg, 45mg mirtazapine ODT NAVANE BNP thiothixene nefazodone NORPRAMIN BNP desipramine nortriptyline cap nortriptyline suspension olanzapine (QLL) OLEPTRO ER BNP trazodone PAMELOR BNP nortriptyline PARNATE BNP tranylcypromine paroxetine (QLL) paroxetine cr (QLL) PAXIL (EPA, QLL) BNP paroxetine (QLL) PAXIL CR (EPA, QLL) BNP paroxetine cr (QLL) perphenazine PEXEVA (EPA, QLL) BNP paroxetine (QLL) PRISTIQ (EPA, QLL) BNP venlafaxine er (QLL) prochlorperazine PROZAC (EPA, QLL) BNP fluoxetine (QLL) PROZAC WEEKLY (EPA, QLL) BNP fluoxetine weekly (QLL) quetiapine REMERON BNP mirtazapine RISPERDAL BNP risperidone RISPERDAL M-TAB BNP risperidone, -m risperidone SAPHRIS BNP SEROQUEL BNP quetiapine SEROQUEL XR (QLL) BNP quetiapine sertraline tab sertraline suspension quetiapine, risperidone, ziprasidone SERZONE BNP nefazodone SURMONTIL BNP trimipramine thioridazine thiothixene 1mg, 2mg thiothixene 5mg, 10mg TOFRANIL BNP imipramine tranylcypromine trazodone 50mg, 100mg, 150mg trazodone 300mg trifluoperazine 1mg, 2mg trifluoperazine 5mg, 10mg trimipramine venlafaxine venlafaxine er (QLL) VIIBRYD (EPA) BNP fluoxetine (QLL), sertraline VIVACTIL WELLBUTRIN (EPA) BNP bupropion WELLBUTRIN, -SR, -XL (EPA) BNP bupropion, -sr, -xl ziprasidone ZOLOFT (EPA) BNP sertraline ZYPREXA (QLL) BNP olanzapine (QLL) ZYPREXA ZYDIS (QLL) BNP olanzapine (QLL) = Generic Preferred = Generic Non-preferred = Brand Preferred BNP = Brand Non-Preferred PAGE 10

11 Prenatal Vitamins (examples) Medications for Anticoagulation advanced natalcare CITRACAL PRENATAL BNP generics CITRANATAL BNP generics DUET DHA BNP generics NATALCARE RX BNP generics PRECARE CONCEIVE BNP generics PREMESIS RX BNP generics prenatal PRIMACARE ONE, -COMBO BNP generics TANDEM DHA BNP generics AGGRENOX BRILINTA cilostazol clopidogrel COUMADIN dipyridamole EFFIENT ELIQUIS (PAR) PERSANTINE PLAVIX PRADAXA (PAR) TICLID ticlopidine warfarin XARELTO 15mg, 20mg BNP clopidogrel BNP warfarin BNP warfarin BNP dipyridamole BNP clopidogrel BNP warfarin BNP ticlopidine *This list does not indicate coverage and is not all-inclusive. The coverage of these services depends on the terms of your benefit plan. Please refer to your Certificate of Coverage for specific details, or call the customer service number listed on your ID/membership card. This list does not include all conditions that may be prevented with preventive prescription drugs or all preventive drugs available. Capital BlueCross believes that these drugs satisfy the requirements for preventive care as outlined by the U.S. Treasury Department (see IRS notice Comprehensive HSA Guidance and IRS notice Health Savings Accounts Preventive Care) but cannot guarantee that the Treasury Department would agree that all of these drugs satisfy the definition of preventive care. = Generic Preferred = Generic Non-preferred = Brand Preferred BNP = Brand Non-Preferred PAGE 11

12 If you have questions about your prescription drug benefit, contact CVS Caremark customer service at (TTY: ). You may also visit capbluecross.com for other helpful pharmacy information. capbluecross.com capitalbluestore.com/blog The information contained in this document was current at the time of printing and is subject to change. It is not intended to substitute for your physician s independent medical judgement based on your specific needs. Please call the customer service number on your ID card for the most current preventive medication information and your expected out-of-pocket expenses. On behalf of Capital BlueCross, CVS Caremark assists in the administration of our prescription drug program. CVS Caremark is an independent pharmacy benefit manager. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. NF-641 (7/2014)