Health Savings Plan tip sheet Benefits Preventive drug list Prescription drugs The following drugs are considered preventive care and are covered at 100% by the plan without being subject to the deductible. This list represents certain common single-source brand and generic preventive medications that are covered in full for HSA-qualified plans and is subject to change without prior notification. Some drugs may need a prior authorization. Brand name medications that have a generic equivalent are not covered under this HSP Preventive Drug List. If you have questions about your pharmacy benefit, please call Premera Customer Service at (800) 676-1411. Heart disease prevention Examples include prevention of stroke, heart attack and heart failure. ACE inhibitors (hypertension) Beta-blockers (hypertension) All single-source brand and generic medications in this category. Examples include: All single-source brand and generic medications in this category. Examples include: benazepril acebutolol atenolol betaxolol bisoprolol Bystolic benazepril/amlodipine benazepril/HCTZ captopril captopril/HCTZ enalapril fosinopril lisinopril moexipril quinapril ramipril trandolapril Adrenergic agents (hypertension) All single-source brand and generic medications in this category. Examples include: doxazosin methyldopa methyldopa/HCTZ prazosin terazosin ARBs (Angiotensin II Receptor Blockers)* (hypertension) carvedilol labetalol metoprolol succinate metoprolol tartrate Blood thinning agents All single-source brand and generic medications in this category. Examples include: cilostazol clopidogrel dipyridamole enoxaparin ticlopidine warfarin Calcium channel blockers (hypertension) All single-source brand and generic medications in this category. Examples include: All single-source brand and generic medications in this category. Examples include: irbesartan losartan amlodipine diltiazem diltiazem ER telmisartan valsartan Antiarrhythmic agents All single-source brand and generic medications in this category. Examples include: amiodarone digoxin disopyramide flecainide mexiletine procainamide propafenone sotalol Antihyperlipidemics (high cholesterol) All single-source brand and generic medications in this category. Examples include: atorvastatin cholestyramine light cholestyramine colestipol Crestor fenofibrate lovastatin Simcor simvastatin Vytorin WelChol Zetia felodipine isradipine * Some drugs in this category may need a prior authorization. nicardipine nifedipine Diuretics (hypertension) All single-source brand and generic medications in this category. Examples include: amiloride bumetanide chlorthalidone chlorothiazide eplerenone furosemide hydrochlorothiazide (HCTZ) indapamide metolazone Miscellaneous blood pressure drugs hydralazine hydralazine/HCTZ Tekturna Vasodilators (chest pain) All single-source brand and generic medications in this category. Examples include: isosorbide dinitrate isosorbide mononitrate 022506 (11-2014) nadolol pindolol propranolol timolol nitroglycerin nitroglycerin transdermal patch Benefits Health Savings Plan tip sheet Preventive drug list Asthma attack prevention* Advair Aerospan Alvesco aminophylline Asmanex budesonide respules Dulera Flovent Foradil montelukast Perforomist Pulmicort Gout attack prevention QVAR Serevent Symbicort theophylline zafirlukast Zyflo CR Bone disease and fracture prevention* All single-source brand and generic medications in this category. Examples include: Actonel alendronate Atelvia calcitonin ibandronate medroxyprogesterone norethindrone progesterone raloxifene All single-source brand and generic medications in this category. Examples include: allopurinol Colcrys Uloric HIV prevention for PrEP and PMTCT For HIV prevention, please call Customer Service at (800) 676-1411 to ensure these medications are covered in full for PrEP and PMTCT. Atripla Epzicom Isentress Norvir Prezista Reyataz Stribild Tivicay Truvada Infection prevention An example includes malaria. Breast cancer recurrence anastrozole exemestane letrozole raloxifene tamoxifen Soltamox acyclovir famciclovir pentamidine amantadine hydroxychloroquine primaquine atovaquone mefloquine valacyclovir atovaquone/proguanil Colonoscopy preparations Kidney disease — prevention of high phosphate levels All single-source brand and generic medications in this category. Examples include: All single-source brand and generic medications in this category. Examples include: polyethylene glycol Fosrenol sodium phosphate salts trilyte Examples include prevention of blindness and kidney failure. All covered diabetic supplies, for example: needles, syringes, test strips, lancets, monitors, pumps and related supplies. Apidra Humalog Humulin Non-Insulin acarbose Byetta chlorpropamide glimepiride glipizide & combinations Renvela Nausea and dizziness prevention Diabetes* Insulin Renagel Lantus Levemir glyburide & combinations Januvia & combinations metformin metformin ER Novolin Novolog nateglinide Onglyza pioglitazone repaglinide tolazamide tolbutamide Victoza All single-source brand and generic medications in this category. Examples include: Emend dronabinol meclizine scopolamine Pregnancy prevention All single-source brand and generic medications in this category. Examples include: Aviane Gianvi Jolivette Junel Fe 1.5/30 Microgestin NuvaRing Sprintec-28 Trinessa Ulcer disease prevention All single-source brand and generic medications in this category. Examples include: esomeprazole lansoprazole * Some drugs in this category may need a prior authorization. ondansetron prochlorperazine promethazine pantoprazole rabeprazole ranitidine sucralfate Benefits Health Savings Plan tip sheet Preventive medications, supplements and devices The following qualify as preventive drugs covered at 100%. To receive the preventive drug benefit, you will need a written prescription. This benefit is only available for these drugs/devices when they meet the indicated requirements and strength. Drug Requirements Strength Aspirin Over-the-counter, oral form only. 75 – 325 mg Coverage is for individuals who are ages 45–79 and are considered “at-risk” due to cardiology (heart conditions). Aspirin only (like Bayer Aspirin) products. Does not include Excedrin-type products. Fluoride By prescription, generic only. All formulations Coverage is for children up to 18 years old. Folic Acid Generic over-the-counter only. 0.4 – 0.8 mg Coverage is for females only who are pregnant or are considering pregnancy. Prenatal vitamins with folic acid will continue to be paid or denied according to the standard benefit of your plan and are subject to the cost shares and limits of that plan. Iron Supplements Over-the-counter. Coverage is for children up to 1 year old. Generic liquid form only If over-the-counter iron is covered on your plan for added age or tablet form, it will continue to be paid according to the standard benefit of your plan and will be subject to the cost shares and limits of that plan. Tobacco Cessation Prescription only for the following drugs: ▪▪ Bupropion (generic Zyban only) ▪▪ Chantix ▪▪ NRT (Nicotine replacement therapy) nasal spray ▪▪ NRT inhaler All formulations of these listed drugs Coverage is available for generic, over-the-counter patches, lozenges and gum. Vitamin D Supplements For ages 65 and over. 500 – 1,000 mg Vitamin D2, D3 and combination products containing calcium with vitamin D of ≤ 1,000 IU per dosage. 400 – 1,000 IU Women’s Birth Control Coverage is for females only for generic oral contraceptives, cervical caps, patches, diaphragm, IUD, contraceptive implants and over-the-counter birth control (i.e., female condoms, sponges). If you have questions about your preventive drug coverage, call Premera at (800) 676-1411.
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