OGB Pelican HSA 775 CDHP Maintenance/ Preventive Care Drug List

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1 OGB Pelican HSA 775 CDHP Maintenance/ Preventive Care Drug List Preventive care medications are drugs that can help you prevent health problems or problems caused by a health condition. The OGB Pelican HSA 775 CDHP (consumer-driven health plan) Maintenance/Preventive Care Drug List shows certain brand and generic preventive drugs covered by your plan. Drugs on this list are covered with no deductible, when you fill them at a network pharmacy, though they may require you or your doctor to follow some rules based on your plan. Please see your benefit plan for a full list of these rules, which are listed as benefits, limitations and exclusions. DRUG NAME 1ST CHOICE LANCETS 1ST TIER UNIFINE PENTIPS 1ST TIER UNILET COMFORTOUCH ACARBOSE ACCU-CHEK ACCU-CHEK AVIVA PLUS ACCU-CHEK COMPACT ACCU-CHEK FASTCLIX SOFT TOUCH ACCU-CHEK SMARTVIEW ACCU-CHEK SOFTCLIX ACCUPRIL ACCURETIC ACCUTREND GLUCOSE ACEBUTOLOL HCL ACTI-LANCE ACTONEL ACTOPLUS MET ACTOPLUS MET XR ACTOS ADACEL ADALAT CC ADVAIR DISKUS ADVAIR HFA ADVANCED GLUCOSE TEST STRIPS ADVANCED TRAVEL LANCETS ADVOCATE LANCET ADVOCATE PEN NEEDLES ADVOCATE REDI-CODE ADVOCATE SYRINGES ADVOCATE TEST STRIP DRUG CLASSIFICATION

2 AFEDITAB CR AFLURIA AFLURIA QUAD AGAMATRIX AMP AGGRENOX ALBUTEROL SULFATE ALDACTAZIDE ALDACTAZIDE ALDACTONE ALENDRONATE SODIUM ALOGLIPTIN ALOGLIPTIN-METFORMIN ALOGLIPTIN-PIOGLITAZONE ALTACE ALTOPREV ALVESCO AMARYL AMILORIDE HCL AMILORIDE HCL W/HCTZ AMLODIPINE BESYLATE AMLODIPINE-ATORVASTATIN AMLODIPINE-VALSARTAN AMLODIPINE-VALSARTAN-HCTZ ANTARA APIDRA APIDRA SOLOSTAR ARCAPTA NEOHALER ARNUITY ELLIPTA ASMANEX ASMANEX HFA ASPIRIN-DIPYRIDAMOLE ER ASSURE 4 ASSURE HAEMOLANCE PLUS ASSURE ID INSULIN SAFETY ASSURE LANCE ASSURE LANCE PLUS ASSURE PLATINUM ASSURE PRISM MULTI ATABEX EC ATACAND ATACAND HCT ATELVIA ATENOLOL Page 2 of 21

3 ATENOLOL W/CHLORTHALIDONE ATORVASTATIN CALCIUM ATOVAQUONE-PROGUANIL HCL ATROVENT HFA PEN- NEEDLE BD AUTOSHIELD PEN NEEDLE AVALIDE AZOR BAL-CARE DHA BAL-CARE DHA ESSENTIAL BD MICROTAINER LANCET B-D ULTRA FINE LANCETS BD INSULIN PEN NEEDLE UF MINI BD NANO PEN NEEDLE BENAZEPRIL HCL BENAZEPRIL HCL-HCTZ BENICAR BENICAR HCT BETAXOLOL HCL BEVESPI AEROSPHERE BEXSERO BINOSTO BISOPROLOL FUMARATE BISOPROLOL FUMARATE/HCTZ BLOOD GLUCOSE TEST BLOOD GLUCOSE STRIPS BLOOD LANCETS BONIVA BOOSTRIX ASCENSIA BREEZE 2 BREO ELLIPTA BRILINTA BROVANA BUDESONIDE BULLSEYE MINI SAFETY LANCETS BYDUREON PEN C-NATE DHA CADUET CALAN CALAN SR CALCITONIN-SALMON CALCIUM PNV CANDESARTAN CILEXETIL Prevention of Malaria Page 3 of 21

4 CANDESARTAN-HYDROCHLOROTHIAZID CAPTOPRIL CARDIZEM CARDIZEM CD CAREFINE PEN NEEDLE CAREONE CARESENS N CARTIA XT CARVEDILOL CATAPRES CATAPRES-TTS CERVARIX CHEMSTRIP K CHEMSTRIP UGK CHLOROQUINE PHOSPHATE CHLOROTHIAZIDE CHLORPROPAMIDE CHLORTHALIDONE CHOLESTYRAMINE CHOLESTYRAMINE LIGHT CITRANATAL 90 DHA CITRANATAL B-CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX PRENAVITE CLEVER CHEK LANCETS CLEVER CHOICE MICRO TEST STRIP CLEVER CHOICE PRO CLEVER CHOICE TEST STRIPS CLEVER CHEK TEST STRIPS CLICKFINE CLONIDINE HCL CLOPIDOGREL CLORPRES CLORPRES COAGUCHEK COLESTID COLESTID COLESTIPOL HCL COLOR LANCETS COMBIVENT RESPIMAT COMFORT EZ Prevention of Malaria Page 4 of 21

5 COMFORT LANCETS COMPLETE NATAL DHA COMPLETENATE CONCEPT DHA CONCEPT OB CONTOUR CONTOUR NEXT EZ CONTROL COOL GLUCOSE TEST STRIP COREG COREG CR CORZIDE COUMADIN COZAAR CRESTOR CROMOLYN SODIUM CYCLOSET DAPTACEL DIASTIX REAGENT DIATRUE PLUS DILT-XR DILTIAZEM ER DILTIAZEM 24HR CD DILTIAZEM HCL DIOVAN DIOVAN HCT DIPHTHERIA-TETANUS TOXOIDS-PED DIPYRIDAMOLE DIURIL DOTHELLE DHA DROPLET LANCETS DROPLET PEN NEEDLE DUET DHA DUET DHA BALANCED DUETACT DULERA DYAZIDE E-Z JECT LANCETS LANCET EASY COMFORT EASY COMFORT INSULIN SYRINGE EASY COMFORT PEN NEEDLES EASY PLUS II Page 5 of 21

6 EASY STEP EASY TALK EASY TOUCH EASY TOUCH FLIPLOCK INSULIN EASY TOUCH INSULIN SAFETY EASY TOUCH LUER LOCK INSULIN EASY TOUCH SHEATHLOCK INSULIN EASY TOUCH UNI-SLIP EASY TRAK EASYGLUCO PLUS EASYGLUCO EASYMAX N BD ECLIPSE EDARBI EDARBYCLOR EFFIENT ELEMENT COMPACT ELEMENT TEST STRIPS ELIQUIS ELITE-OB ELIXOPHYLLIN EMBRACE EMBRACE EVO EMBRACE PRO ENALAPRIL MALEATE ENBRACE HR ENGERIX-B EPANED EPLERENONE EPROSARTAN MESYLATE ETIDRONATE DISODIUM EVENCARE G2 EVENCARE G3 EVENCARE MINI GLUCOSE TEST STR EVISTA EVOLUTION TEST STRIPS EXFORGE EXPECTA PRENATAL EXTRA-VIRT PLUS DHA EZ SMART EZ SMART LANCETS EZ SMART PLUS FA-8 Page 6 of 21

7 FELODIPINE ER FENOFIBRATE FENOFIBRIC ACID FENOGLIDE FIFTY50 SAFETY SEAL LANCETS FIFTY50 TEST STRIP FINE 30 UNIVERSAL LANCETS FINGERSTIX FLOVENT DISKUS FLOVENT HFA FLUAD FLUARIX FLUBLOK FLUCELVAX QUAD FLULAVAL FLUOR-A-DAY FLUORIDE FLUORITAB FLUVASTATIN ER FLUVASTATIN SODIUM FLUVIRIN FLUZONE HIGH-DOSE FLUZONE QUAD FLUZONE QUAD PEDI FOCALGIN 90 DHA FOCALGIN CA FOLBECAL FOLET ONE FOLIC ACID FOLIVANE-OB FORA D10 FORA D15G FORA D20 FORA D40-G31 TEST STRIPS FORA G20 FORA G30A FORA GD50 TEST STRIPS FORA LANCETS FORA V30A FORA TN'G VOICE TEST STRIPS FORA V10 FORA V10-V12-D10-D20 FORA V12 Page 7 of 21

8 FORA V20 FORACARE GD20 FORACARE GD40 FORADIL FORTAMET FORTEO FORTISCARE GLUCOSE TEST STRIPS FOSAMAX FOSAMAX PLUS D FOSINOPRIL SODIUM FOSINOPRIL-HYDROCHLOROTHIAZIDE FREESTYLE INSULINX FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE PRECISION FREESTYLE PRECISION NEO FREESTYLE TEST STRIPS FREESTYLE UNISTIK 2 GARDASIL GARDASIL 9 GE100 BLOOD GLUCOSE TEST STRIP GENSTRIP GLIPIZIDE ER GLIPIZIDE XL GLIPIZIDE-METFORMIN GLUCAGEN GLUCAGON EMERGENCY KIT GLUCO NAVII GLUCOCARD 01 SENSOR GLUCOCARD EXPRESSION GLUCOCARD SHINE GLUCOCARD VITAL GLUCOCARD VITAL SENSOR GLUCOCOM GLUCOCOM GLUCOSE GLUCOCOM LANCETS GLUCOPHAGE GLUCOPHAGE XR GLUCOSE TEST STRIP GLUCOTROL GLUCOTROL XL GLUCOVANCE GLUMETZA Page 8 of 21

9 GLYBURIDE GLYBURIDE MICRONIZED GLYBURIDE-METFORMIN HCL GLYNASE GLYSET GLYXAMBI GMATE GMATE TEST STRIPS GUANFACINE HCL HAVRIX HEALTHPRO TEST STRIPS HEALTHY ACCENTS UNIFINE PENTIP HEALTHY ACCENTS UNILET LANCET HEMANGEOL HEMENATAL OB HEMENATAL OB + DHA HUMALOG HUMALOG MIX HUMALOG MIX HUMULIN 70/30 KWIKPEN HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 KWIKPEN HYDROCHLOROTHIAZIDE HYZAAR INATAL ADVANCE INATAL ULTRA IN CONTROL PEN NEEDLE INCONTROL SUPER THIN LANCETS INCONTROL ULTRA THIN LANCETS INDAPAMIDE INDERAL LA INDERAL XL INFANRIX INFINITY TEST STRIPS INJECT EASE LANCETS INSPRA INSUFLON INSULIN PEN NEEDLE INSULIN- SYRINGE B-D INSULIN SYRINGE BD INSULIN SYRINGE MF INSUPEN Page 9 of 21

10 BD INTEGRA SYRINGE INVACARE LANCETS INVOKAMET INVOKAMET XR INVOKANA IPOL ISRADIPINE JANTOVEN JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR KAZANO KETO-DIASTIX REAGENT KETONE KETOSTIX REAGENT KINRIX KOSHER PRENATAL PLUS IRON KPN LABETALOL HCL LANTUS LANTUS SOLOSTAR LESCOL XL LEVALBUTEROL HCL LEVALBUTEROL TARTRATE HFA LEVATOL LEVEMIR LEVEMIR FLEXTOUCH LIBERTY TEST STRIP LIPITOR LIPOFEN LISINOPRIL-HCTZ LITE TOUCH LIVALO LOFIBRA LOPID LOPRESSOR LOPRESSOR HCT LOSARTAN POTASSIUM LOTENSIN LOTENSIN HCT Page 10 of 21

11 LOTREL LOVASTATIN LUDENT FLUORIDE LUER-LOK SYRINGE M-M-R II VACCINE W/DILUENT M-VIT MACNATAL CN DHA MAGELLAN INSULIN SAFETY SYRNG MAGELLAN INSULIN SYRINGE MALARONE MARNATAL-F MATZIM LA MAVIK MAXI-COMFORT MAXINATE MAXZIDE MEDISENSE THIN LANCETS MEDLANCE PLUS MEDLANCE PLUS MEDLANCE PLUS SPECIAL BLADE MENACTRA MENHIBRIX MENOMUNE-A-C-Y-W-135 MENVEO A-C-Y-W-135-DIP METAPROTERENOL SULFATE METFORMIN HCL METFORMIN HCL ER METHYCLOTHIAZIDE METHYLDOPA METHYLDOPA/HYDROCHLOROTHIAZIDE METOLAZONE METOPROLOL SUCCINATE METOPROLOL TARTRATE METOPROLOL-HYDROCHLOROTHIAZIDE MIACALCIN MICARDIS MICARDIS HCT MICRO MICRO THIN LANCETS MICRODOT MICROLET MICROZIDE MIGLITOL Prevention of Malaria Page 11 of 21

12 MINI ULTRA-THIN II MOEXIPRIL HCL MOEXIPRIL-HYDROCHLOROTHIAZIDE MONOJECT MONOJECT INSULIN SYRINGE MONOLET LANCETS MONOLET THIN LANCETS MONTELUKAST SODIUM MULTIVITAMIN WITH FLUORIDE MVC-FLUORIDE MYGLUCOHEALTH MYGLUCOHEALTH LANCETS MYNATAL MYNATAL ADVANCE MYNATAL PLUS MYNATAL-Z MYNATE 90 PLUS NADOLOL NADOLOL-BENDROFLUMETHIAZIDE NATACHEW NATEGLINIDE NEEDLES NESINA NESTABS NESTABS ABC NESTABS DHA NEUTEK 2TEK TEST STRIPS NEWGEN NIACIN ER NIACOR NIASPAN NICARDIPINE HCL NIFEDICAL XL NIFEDIPINE NIFEDIPINE ER NISOLDIPINE NORVASC MAX GLUCOSE TEST STRIPS NOVA SAFETY LANCETS NOVA SUREFLEX NOVAMAX PLUS NOVOFINE NOVOFINE AUTOCOVER Page 12 of 21

13 NOVOFINE PLUS NOVOLIN NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOTWIST O-CAL FA O-CAL PRENATAL OB COMPLETE OB COMPLETE GOLD OB COMPLETE ONE OB COMPLETE PETITE OB COMPLETE PREMIER OB COMPLETE DHA OBSTETRIX DHA OBSTETRIX EC OBSTETRIX ONE OBTREX DHA OMEGA-3 ACID ETHYL ESTERS ON CALL EXPRESS TEST STRIP ON CALL LANCET ON CALL PLUS LANCET ON CALL PLUS TEST STRIP ON CALL VIVID TEST STRIP ON-THE-GO ONE-A-DAY WOMEN'S PRENATAL DHA DAILY PRENATAL ONE TOUCH DELICA ONE TOUCH LANCETS ONE TOUCH SURESOFT ONE TOUCH ULTRA TEST STRIPS ONE TOUCH VERIO OPTIUM OPTIUM EZ OPTUMRX OSENI PAIRE OB PLUS DHA PEDIARIX PEDVAXHIB PENTACEL PENTIPS Page 13 of 21

14 PERFOROMIST PERINDOPRIL ERBUMINE PERRY PRENATAL TABLET PHARMACIST CHOICE PINDOLOL PIOGLITAZONE-GLIMEPIRIDE PIOGLITAZONE-METFORMIN PLAVIX PNEUMOVAX 23 PNV-DHA PNV-DHA + DOCUSATE PNV-OMEGA PNV-SELECT PNV-VP-U PR NATAL 400 PR NATAL 400 EC PR NATAL 430 PR NATAL 430 EC PRADAXA PRANDIN PRAVACHOL PRAVASTATIN SODIUM PRECISION POINT OF CARE PRECISION Q-I-D PRECISION XTRA PRECOSE PREFERA-OB PLUS DHA PREMIUM BLOOD GLUCOSE TEST PREMIUM V10 PRENA1 CHEW PRENA1 PEARL PRENA1 TRUE PRENAISSANCE PRENAISSANCE NEXT PRENAISSANCE PLUS PRENATA PRENATABS FA PRENATABS RX PRENATAL PRENATAL 19 PRENATAL COMPLETE PRENATAL FORMULA PRENATAL PLUS Page 14 of 21

15 PRENATAL PLUS DHA PRENATAL-U PRENATE AM PRENATE PRENATE DHA PRENATE ELITE PRENATE ENHANCE PRENATE ESSENTIAL PRENATE MINI PRENATE PIXIE PRENATE RESTORE PRENATE STAR PREPLUS PREQUE 10 PRESSURE ACTIVATED LANCETS PRESTALIA PREVALITE PREVNAR 13 PRIMAQUINE PRINIVIL PRO COMFORT LANCETS PROAIR HFA PROAIR RESPICLICK PROCARDIA PROCARDIA XL PRODIGY INSULIN SYRINGE PRODIGY LANCETS PRODIGY NO CODING PRODIGY TWIST TOP LANCET PROGLYCEM PROPRANOLOL HCL PROPRANOLOL HCL ER PROPRANOLOL HCL-HCTZ PROQUAD PROVENTIL HFA PROVIDA DHA PROVIDA OB PULMICORT PULMICORT FLEXHALER PUREFE OB PLUS PUREFE PLUS QBRELIS QUADRACEL DTAP-IPV Prevention of Malaria Page 15 of 21

16 QUESTRAN QUINAPRIL QUINAPRIL-HYDROCHLOROTHIAZIDE QUINTET R-NATAL OB RALOXIFENE HCL RAMIPRIL RECOMBIVAX HB REFUAH PLUS RELIAMED RELIAMED SAFETY SEAL LANCETS RELION CONFIRM-MICRO RELION PEN NEEDLES RELION PRIME RELION THIN RELNATE DHA REPAGLINIDE REPAGLINIDE-METFORMIN HCL RESERPINE REVEAL TEST STRIP RIGHT STEP PRENATAL VITAMINS RIGHTEST GL300 LANCETS RIGHTEST GS100 TEST STRIPS RIGHTEST GS300 TEST STRIPS RIGHTEST GS550 TEST STRIPS RIMANTADINE HCL RIOMET RISEDRONATE SODIUM RISEDRONATE SODIUM DR ROSUVASTATIN CALCIUM ROTARIX ROTATEQ RULAVITE DHA SAFESNAP INSULIN SYRINGE SAFETY LANCETS SAFETY-LET B-D SAFETYGLIDE SAVAYSA SE-NATAL 19 SE-TAN DHA SECTRAL SELECT-OB SELECT-OB + DHA Page 16 of 21

17 SIDEKICK SINGLE-LET SINGULAIR SMART SENSE SMART SENSE LANCETS SMART SENSE TEST STRIPS SMARTEST LANCET SMARTEST TEST SODIUM FLUORIDE SOFTCLIX SOLUS V2 SOLO V2 LANCETS SOLO V2 TEST STRIPS SPIRIVA SPIRIVA RESPIMAT SPIRONOLACTONE SPIRONOLACTONE W/HCTZ STARLIX STERILANCE TL STIOLTO RESPIMAT STRIVERDI RESPIMAT SULAR SUPER THIN LANCETS SURE COMFORT SURE COMFORT INSULIN SYRINGE SURE COMFORT LANCETS SURE-FINE PEN NEEDLES SURE-JECT INSULIN SYRINGE SURE-LANCE SURE-TEST EASYPLUS MINI SURE-TOUCH SYMBICORT SYNJARDY TANZEUM TARKA TARON-C DHA TARON PRENATAL TAZTIA XT TECHLITE BLOOD LANCET TECHLITE PEN NEEDLE TEKTURNA TEKTURNA HCT TELCARE Page 17 of 21

18 TELMISARTAN-AMLODIPINE TENEX TENIVAC TERBUTALINE SULFATE TERUMO INSULIN SYRINGE TERUMO INSULIN SYRINGE TEST N'GO TEST STRIPS THEOPHYLLINE ANHYDROUS LANCETS,THIN THIN LANCETS THINPRO INSULIN SYRINGE THINPRO INSULIN SYRINGE THRIVITE 19 THRIVITE RX TIAZAC TIMOLOL MALEATE TOLAZAMIDE TOLBUTAMIDE TOPCARE ULTRA COMFORT TOPCARE UNIVERSAL1 THIN LANCET TOPROL XL TOUJEO SOLOSTAR TRADJENTA TRANDOLAPRIL-VERAPAMIL TRESIBA FLEXTOUCH U-100 TRESIBA FLEXTOUCH U-200 TRI-TABS DHA TRI-VITAMIN WITH FLUORIDE TRIAMTERENE W/HCTZ TRIBENZOR TRICARE TRICARE PRENATAL TRICARE PRENATAL DHA ONE TRICARE PRENATAL WITH DHA TRIGLIDE TRILIPIX TRINATAL GT TRINATAL RX 1 TRINATE TRISTART DHA TRIVEEN-DUO DHA TRUE METRIX GLUCOSE TEST STRIP Page 18 of 21

19 TRUEPLUS INSULIN SYRINGE TRUEPLUS LANCETS TRUETEST TEST STRIPS TRUETRACK TRULICITY TRUMENBA TRUST NATAL DHA TWINRIX TWYNSTA ULTICARE ULTICARE ULTICARE INSULIN SYRINGE ULTILET BASIC ULTILET CLASSIC ULTILET INSULIN SYRINGE ULTILET LANCETS ULTILET PEN NEEDLE ULTILET SAFETY ULTIMA ULTIMATECARE ONE ULTIMATECARE ONE NF ULTRA COMFORT ULTRATHIN LANCETS ULTRA THIN LANCETS RELION ULTRA THIN PLUS ULTRA THIN PLUS LANCETS ULTRA-THIN II ULTRALANCE ULTRATLC LANCETS ULTRATRAK PRO ULTRATRAK ULTIMATE UNIFINE PENTIPS UNIFINE PENTIPS PLUS UNILET COMFORTOUCH UNILET EXCELITE UNILET EXCELITE II UNILET GP LANCET UNILET LANCETS UNISTIK 3 UNISTIK 3 EXTRA UNISTIK CZT UNISTIK SAFETY UNISTIK TOUCH Page 19 of 21

20 UNISTRIP1 UNIVERSAL 1 VALSARTAN VANISHPOINT VARIVAX VACCINE VASERETIC VASOTEC VEMAVITE-PRX 2 VENTOLIN HFA VERAPAMIL ER VERAPAMIL ER PM VERAPAMIL HCL VICTOZA VINATE VINATE II VINATE ONE VINATE ULTRA VINATE-M VIRT-ADVANCE VIRT NATE VIRT-NATE DHA VIRT-SELECT VIRT-VITE GT VITAFOL VITAFOL NANO VITAFOL ULTRA VITAFOL-OB VITAFOL-OB+DHA VITAFOL-ONE VITAMED MD ONE RX VITAMED MD PLUS RX VITAMEDMD REDICHEW RX VITAMINS A,C,D & FLUORIDE VITAPEARL VITATRUE VIVA DHA VOL-NATE VOL-TAB RX VOSPIRE ER VP-CH PLUS VP-GGR-B6 VYTORIN WARFARIN SODIUM Page 20 of 21

21 WAVESENSE JAZZ WAVESENSE PRESTO WELCHOL XARELTO XIGDUO XR XOPENEX HFA ZAFIRLUKAST ZATEAN-CH ZATEAN-PN DHA ZATEAN-PN PLUS ZEBETA ZETIA ZIAC ZINGIBER ZOCOR ZOSTAVAX ZYFLO ZYFLO CR Page 21 of 21