Preferred Covered Brands (may have a reduced copay)
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1 Preventive Drug List For High-Deductible Health Plans Only effective 1/1/12 For your better health, your employer has added an enhanced benefit to your High-Deductible Health Plan for preventive care drugs. Instead of having to meet your plan s deductible for certain prescription drugs, you just pay a copay for medications on the Preventive Drug List. 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 High-Deductible 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, treat 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 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. This list is subject to change throughout the year. Check bcbst.com for the current list. Non- Asthma and Other Respiratory Conditions albuterol Advair Diskus Accuneb budesonide nebulizer soln Asmanex Alvesco cromolyn sodium Combivent Duoneb flunisolide Dulera Flonase fluticasone propionate Flovent Diskus Foradil ipratropium bromide Flovent HFA Maxair Autohaler ipratropium-albuterol ProAir HFA Pulmicort Flexhaler metaproterenol sulfate QVAR Singulair terbutaline sulfate Serevent Diskus Spiriva triamcinolone Symbicort Xopenex zafirlukast Ventolin HFA Veramyst Conditions Related to Blood Clots anagrelide Xarelto (QL) Aggrenox cilostazol Arixtra (QL) dipyridamole Coumadin enoxaparin (QL) Effient fondaparinux (QL) Fragmin (QL) Jantoven Lovenox (QL) ticlopidine Plavix warfarin sodium (PA, QL) Pradaxa Amethyst Apri Aranelle Aviane Azurette Balziva Camila Caziant Cesia Cryselle Cyclafem Cyclafem 7/7/7 Enpresse Errin Gianvi Gildess FE Jolessa Jolivette Junel 1.5/30 Junel 1/20 Junel FE 1.5/30 Junel FE 1/20 Kariva Kelnor 1/35 Leena Lessina Levora Low-Ogestrel Contraception
2 Contraception (cont.) Non- Lutera Microgestin 1.5/30 Microgestin 1/20 Microgestin FE 1.5/30 Microgestin FE 1/20 Mononessa Necon 0.5/35 Necon 1/35 Necon 1/50 Necon 7/7/7 Nortrel 0.5/35 Nortrel 1/35 Nortrel 7/7/7 Ocella Portia Previfem Quasense Reclipsen Solia Sprintec Sronyx Tilia FE Tri-Legest FE Trinessa Tri-Previfem Tri-Sprintec Trivora Velivet Zenchent Zovia 1/50 Diabetes acarbose Byetta Actoplus Met glimepiride Humulin (pens) (QL) Actoplus Met XR glipizide Janumet Actos glipizide ext-rel Januvia Apidra glipizide-metformin Novolin (pens) (QL) Avandamet glyburide Novolog (pens) (QL) Avandaryl glyburide-metformin Victoza Avandia Humulin (vials)* (QL) Duetact Levemir (vials)* (QL) Humalog (QL, ST) (pens & vials) metformin Lantus SoloSTAR (QL) metformin ext-rel Lantus vials (QL) nateglinide Levemir (pens) (QL) Novolin (vials)* (QL) Prandimet Novolog (vials)* (QL) Prandin Symlin Diabetic Supplies Bayer Contour/Breeze2 diabetic products* (QL) alcohol preps and lancets (QL) Roche Accu-Chek products* (QL) BD insulin syringes (QL) *Under your plan, this brand-name product is available at the lowest copay level. Emotional Health amitriptyline Lexapro Abilify (PA<18) bupropion Fanapt bupropion ext-rel Geodon citalopram Invega clomipramine Latuda clozapine Saphris desipramine Seroquel (PA<18) doxepin Seroquel XR fluoxetine fluphenazine fluvoxamine haloperidol imipramine
3 Non- Emotional Health (cont.) maprotiline mirtazapine nefazodone nortriptyline olanzapine (PA<18) paroxetine paroxetine ext-rel risperidone (PA<18) sertraline thiothixene tranylcypromine trazodone venlafaxine venlafaxine ext-rel Hepatitis C ribavirin (PA) Pegasys (PA) Copegus (PA) Incivek (PA) PegIntron (PA) Rebetol (PA) Victrelis (PA) High Blood Pressure & Other Heart Conditions acebutolol Azor acetazolamide Benicar amiloride Benicar HCT amiloride-hctz Bystolic amlodipine Coreg CR amlodipine-benazepril Lanoxin atenolol Micardis atenolol-chlorthalidone Micardis HCT benazepril Tribenzor (ST) benazepril-hctz Twynsta (ST) betaxolol bisoprolol fumarate bisoprolol-hctz bumetanide captopril captopril-hctz Cartia XT carvedilol chlorthalidone clonidine digoxin diltiazem ext-rel doxazosin enalapril enalapril-hctz eplerenone felodipine ext-rel fosinopril fosinopril-hctz furosemide guanfacine hydralazine hydrochlorothiazide indapamide isosorbide dinitrate/mononitrate labetalol lisinopril lisinopril-hctz losartan
4 losartan-hctz methazolamide methyldopa methyldopa-hctz metolazone metoprolol succinate ext-rel metoprolol tartrate metoprolol-hctz minoxidil moexipril-hctz nadolol nifedipine ext-rel nisoldipine ext-rel nitroglycerin perindopril prazosin propranolol propranolol ext-rel propranolol-hctz quinapril quinapril-hctz ramipril reserpine sotalol spironolactone spironolactone-hctz Taztia XT terazosin timolol maleate torsemide trandolapril trandolapril-verapamil ext-rel triamterene-hctz verapamil ext-rel cholestyramine fenofibrate gemfibrozil lovastatin niacin pravastatin simvastatin alendronate calcitonin-salmon nasal spray Non- High Blood Pressure & Other Heart Conditions (cont.) Crestor Niaspan Simcor Vytorin High Cholesterol Multiple Sclerosis Osteoporosis (a bone disease) Actonel Boniva Miacalcin injection Ampyra Avonex Betaseron Copaxone Extavia Rebif Prenatal Care (Vitamins) all generic vitamins all brand vitamins Seizure Conditions carbamazepine Dilantin Carbatrol divalproex delayed-rel Depakene divalproex ext-rel Depakote gabapentin Depakote ER
5 lamotrigine levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin sodium extended primidone topiramate valproic acid zonisamide Levothroid levothyroxine Levoxyl liothyronine methimazole propylthiouracil Unithroid Seizure Conditions (cont.) Thyroid Modifiers Non- Depakote Sprinkle Keppra Keppra XR Lamictal Lamictal XR Phenytek Sabril Tegretol Topamax Trileptal
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CARDIOVASCULAR ACE INHIBITORS fosinopril lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC COMBINATIONS fosinoprilhydrochlorothiazide
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VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
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