Intel Connected Care with Providence 2015 Preventive Drug List

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1 Intel Connected Care with Providence 2015 Preventive Drug List Formulary drugs listed below are covered at 100%, not subject to the deductible for the High Deductible Health Plan (HDHP) and Primary Care Plus Plan. Changes to the Formulary Our Pharmacy & Therapeutics Committee continue to review the latest evidence to identify opportunity to promote safe, effective and affordable drug therapy. The formulary is updated every two months. Generally, formulary status for a formulary drug you are taking with Providence Health Plans pharmacy benefit coverage will not change during the year unless: The same drug is now available in generic form, or Safety or effectiveness concerns are raised about the prescription drug, or The Pharmacy & Therapeutics Committee determines that changes to the formulary would overall be in the best interest of PHP s health plan members. In such cases, impacted individuals are notified in writing if the formulary change results in a reduction of benefits or an increase in copayment. The Preventive Drug List Based on the interpretation of the regulations and guidance provided by the IRS at the current time, not all classes of drugs can be offered at no cost to plan participants and still be compliant with HSA rules. At the present time, the preventive drug list used for the Health Reimbursement and Health Savings Medical Plans provides 100% coverage for generic and brand prescriptions for the following classes of drugs used to treat asthma, cardiovascular conditions, diabetes, and other chronic conditions based on guidance relating to Internal Revenue Service Notice and (Q.27). The list is reviewed periodically and may be updated to ensure the drugs comply with the guidance and with Pharmacy & Therapeutics Committee formulary decisions.. Drug Name ACARBOSE ACEBUTOLOL HCL ACTONEL (5,30,35 MG) PA ACTOPLUS MET XR ADVAIR DISKUS ADVAIR HFA AFEDITAB CR AGGRENOX ALBUTEROL SULFATE NEBULIZER SOLUTION ALENDRONATE SODIUM ALVESCO AMETHYST AMILORIDE HCL AMILORIDE HCL-HCTZ AMLODIPINE BESYLATE AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE-ATORVASTATIN ANAGRELIDE HCL APRI ARANELLE ASMANEX ATENOLOL ATENOLOL-CHLORTHALIDONE ATORVASTATIN AVIANE BALZIVA BENAZEPRIL HCL BENAZEPRIL-HYDROCHLOROTHIAZIDE BETAXOLOL HCL BISOPROLOL FUMARATE BREVICON BRILINTA BUDESONIDE NEB SUSPENSION Blood Formation Modifiers BUMETANIDE BYDUREON PA BYETTA PA CANDESARTAN CILEXETIL CAPTOPRIL CAPTOPRIL-HYDROCHLOROTHIAZIDE CARTIA XT

2 CARVEDILOL CHANTIX CHLOROTHIAZIDE CHLORPROPAMIDE CHLORTHALIDONE CHOLESTYRAMINE CHOLESTYRAMINE LIGHT CILOSTAZOL CLONIDINE HCL CLONIDINE TRANSDERMAL PATCH CLOPIDOGREL 75MG COLESTIPOL HCL COMPRO COREG CR CRYSELLE DEPO-SUBQ PROVERA 104 DILTIAZEM ER CAPSULES DILTIAZEM ER TABLETS DILTIAZEM HCL DIPYRIDAMOLE DUETACT DYRENIUM EDECRIN EFFIENT Smoking Cessation Agents Progestins ELIQUIS EMEND TRIFOLD PACK QL (1 PACK PER 15 DAYS) EMEND 80MG QL (4 CAPSULES PER 28 DAYS) ENALAPRIL MALEATE ENALAPRIL-HYDROCHLOROTHIAZIDE ENOXAPARIN SODIUM INJECTABLE ENPRESSE EPLERENONE EPROSARTAN MESYLATE ETIDRONATE DISODIUM FELODIPINE ER FENOFIBRATE FENOFIBRIC ACID FLOVENT HFA FLOVENT DISKUS FLUORABON FLUVASTATIN FOLIC ACID FONDAPARINUX Vitamins - Prescription FORTEO PA FOSAMAX 70 MG ORAL SOLUTION FOSINOPRIL SODIUM FOSINOPRIL-HYDROCHLOROTHIAZIDE FRAGMIN FUROSEMIDE GEMFIBROZIL GIANVI GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER GLIPIZIDE-METFORMIN GLYBURIDE GLYBURIDE MICRONIZED GLYBURIDE-METFORMIN HCL Cardiovascular Agents, Combos

3 GRANISETRON GUANABENZ ACETATE GUANFACINE HCL HUMALOG MIX HUMALOG MIX HUMALOG HUMULIN HUMULIN MIX HUMULIN N HUMULIN R HYDROCHLOROTHIAZIDE IBANDRONATE SODIUM 150 MG TABLET INDAPAMIDE IRBESARTAN IRBESARTAN-HYDROCHLOROTHIAZIDE ISRADIPINE JANTOVEN JANUMET XR PA JANUMET PA JANUVIA PA JENTADUETO PA JOLESSA JUNEL FE JUNEL KARIVA KAZANO PA KELNOR KOMBIGLYZE XR PA LABETALOL HCL LANTUS SOLOSTAR LANTUS LEENA LEVALBUTEROL 1.25 MG/0.5 ML LEVATOL LEVEMIR LEVORA LISINOPRIL LISINOPRIL-HYDROCHLOROTHIAZIDE LOSARTAN LOSARTAN-HYDROCHLOROTHIAZIDE LOVASTATIN LOW-OGESTREL LUTERA MEDROXYPROGESTERONE INJECTION Progestins METFORMIN HCL METFORMIN HCL ER 500MG AND 750MG METHYLDOPA METHYLDOPA-HCTZ METOLAZONE METOPROLOL SUCCINATE ER METOPROLOL TARTRATE METOPROLOL-HYDROCHLOROTHIAZIDE MICROGESTIN FE MICROGESTIN MOEXIPRIL HCL MOEXIPRIL-HYDROCHLOROTHIAZIDE MONONESSA MONTELUKAST SODIUM Antileukotrienes PA,QL (8 TABLETS PER 30 DAYS, 30ML PER 30 DAYS)

4 MULTIVIT-FLUORIDE MULTIVIT-IRON-FL NADOLOL NADOLOL-BENDROFLUMETHIAZIDE NATEGLINIDE NECON NESINA PA NICARDIPINE HCL NICOTROL NIFEDIAC CC NIFEDICAL XL NIFEDIPINE ER NIMODIPINE NISOLDIPINE NORINYL NORTREL NOVOLIN MIX INNOLET NOVOLIN N INNOLET NOVOLIN N NOVOLIN R NOVOLIN NOVOLOG MIX NOVOLOG NUVARING OCELLA OGESTREL ONDANSETRON HCL (24 MG) TABS ONDANSETRON HCL (4 OR 8MG) TABS ONDANSETRON HCL SOLUTION Smoking Cessation Agents ONDANSETRON ODT (4 OR 8 MG) TABS ONGLYZA PA ORTHO TRI-CYCLEN LO OSENI PA PENTOXIFYLLINE PENTOXIFYLLINE SA PERINDOPRIL ERBUMINE PINDOLOL PIOGLITAZONE HCL PIOGLITAZONE HCL/METFORMIN HCL POLY-IRON-FL PORTIA PRADAXA PRAVASTATIN SODIUM PRAZOSIN HCL PRENATABS RX PRENATAL 19 PRENATAL PLUS Cardiovascular Agents, Other Cardiovascular Agents, Other Alpha-adrenergic Blocking Agents PREVALITE PROAIR HFA QL (2 INHALERS PER 30 DAYS) PROCHLORPERAZINE EDISYLATE PROCHLORPERAZINE MALEATE PROMETHEGAN PROPRANOLOL PROPRANOLOL ER PROPRANOLOL-HCTZ QUASENSE QUINAPRIL HCL QUINAPRIL-HYDROCHLOROTHIAZIDE QVAR

5 RAMIPRIL RECLIPSEN RIOMET SEREVENT DISKUS SIMVASTATIN 20MG AND LOWER SIMVASTATIN 40MG QL (30 TABLETS PER 30 DAYS) SOTALOL SOTALOL AF SPIRONOLACTONE SPIRONOLACTONE-HCTZ Antiarrhythmics Antiarrhythmics SYMBICORT SYMLIN PA SYMLINPEN PA TAZTIA XT TERAZOSIN HCL TERBUTALINE SULFATE Alpha-adrenergic Blocking Agents Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE ANHYDROUS (Xanthines) Bronchodilators, Phosphodiesterase Inhibitors THEOPHYLLINE ER (Xanthines) TICLOPIDINE TIMOLOL MALEATE TABS TORSEMIDE TRADJENTA PA TRANDOLAPRIL TRANSDERM-SCOP TRIAMTERENE-HCTZ TRICOR TRI-LEGEST TRIMETHOBENZAMIDE TRINESSA TRI-PREVIFEM TRI-SPRINTEC TRI-VIT-FLUOR TRI-VIT-FLUOR-IRON VALSARTAN VALSARTAN-HYDROCHLOROTHIAZIDE ST (LOOKS FOR TRIAL OF LOSARTAN OR LOSARTAN- HCTZ) VENTOLIN HFA QL (2 INHALERS PER 30 DAYS) VERAPAMIL ER VERAPAMIL ER PM VERAPAMIL HCL VICTOZA PA VINATE ONE VINATE-M WARFARIN SODIUM XARELTO XOPENEX HFA (EXCEPT 1.25 MG/0.5 ML) XOPENEX XULANE PATCH ZAFIRLUKAST Antileukotrienes QL (60 TABLETS PER 30 DAYS) ZOVIA