2007 Qualified Preventive Prescription Drugs

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2007 Qualified Preventive Prescription Drugs
Preventive Drug
Benefit Program
Employee Guide
46683.0107
Temple-Inland
PREVENTIVE DRUG BENEFIT PROGRAM
Blue Cross and Blue Shield of Texas administers the
preventive drug benefit for your group’s high deductible
health plan (“HDHP”), which has been designed for use
with Health Savings Accounts. The preventive drug benefit
program includes categories of prescription drugs that are
substantially used for preventive purposes, thus allowing you
and your dependents coverage before satisfying your HDHP
deductible. Coverage for these medications is subject to your
prescription drug benefit plan.
The preventive drug program currently includes prescription
drugs in the following categories:
• Antihypertensives
• Contraceptives
• Lipid-lowering agents
• Osteoporosis drugs
• Pediatric vitamins with fluoride
• Prenatal vitamins
The drugs in each category are listed alphabetically below.
• Generic drugs are listed in bold.
• Brand drugs are listed in all CAPITAL letters.
* Generic equivalent available
Below and on the following pages is a list of the specific
prescription drugs included within each of the preventive
drug categories. This list will be reviewed periodically and
is subject to change. Coverage of all medications is still
subject to your HDHP limitations, exclusions and out-ofpocket requirements (for example, your prescription drug
payment levels).
Please be reminded that Health Savings Accounts (HSAs) have tax and legal ramifications. Blue Cross and Blue Shield of
Texas does not provide legal or tax advice, and nothing herein should be construed as legal or tax advice. These materials,
and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on, for the
purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or
marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular
circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products.
ANTIHYPERTENSIVES
*
BETAPACE AF
CARTROL
*
betaxolol
CATAPRES
BIDIL
CATAPRES-TTS
acebutolol
bisoprolol
chlorothiazide
ACEON
bisoprolol/hydrochlorothiazide
chlorthalidone
ACCUPRIL
*
*
ACCURETIC
ADALAT CC
*
BLOCADREN
*
ALDACTONE *
ALDORIL *
bumetanide
ALTACE
CALAN
amiloride/hydrochlorothiazide
CALAN SR
ALDACTAZIDE
BUMEX
*
clonidine
CLORPRES
COREG
*
*
CORGARD
CADUET
CORZIDE
*
*
COVERA-HS
ATACAND HCT
*
CAPOTEN *
CAPOZIDE *
atenolol
captopril
DILACOR XR
atenolol/chlorthalidone
captopril/hydrochlorothiazide
Diltia XT
AVALIDE
CARDENE
AVAPRO
CARDENE SR
benazepril
CARDIZEM
benazepril/hydrochlorothiazide
CARDIZEM CD
BENICAR
CARDIZEM LA
BENICAR HCT
CARDURA
ATACAND
BETAPACE
*
Cartia XT
COZAAR
*
diltiazem
diltiazem ER
*
*
*
DEMADEX
Dilt-XR
*
DIOVAN
DIOVAN HCT
doxazosin
DYAZIDE
*
Page 1 of 4
(Continued)
DYNACIRC CR
metoprolol
TENORMIN
DYRENIUM
metoprolol/hydrochlorothiazide
terazosin
EDECRIN
MICARDIS
TEVETEN
enalapril
MICARDIS HCT
TEVETEN HCT
enalapril/hydrochlorothiazide
MICROZIDE
THALITONE
felodipine ER
*
MINIPRESS *
fosinopril
MINIZIDE
TIMOLIDE 10/25
fosinopril/hydrochlorothiazide
minoxidil
timolol
furosemide
MODURETIC
TOPROL XL
GUANABENZ
MONOPRIL
guanfacine
MONOPRIL HCT
hydralazine
nadolol
triamterene/hydrochlorothiazide
HYDRALAZINE/HYDROCHLOROTHIAZIDE
nicardipine
UNIRETIC
hydrochlorothiazide
Nifediac CC
UNIVASC
*
Nifedical XL
VASERETIC
TIAZAC
*
*
*
torsemide
*
TRANDATE
HYZAAR
nifedipine
*
VASOTEC *
indapamide
nifedipine ER
verapamil
*
NIMOTOP
verapamil ER
INDERAL LA
NORVASC
VERELAN
INDERIDE
pindolol
VERELAN PM
INNOPRAN XL
PLENDIL
*
prazosin *
PRINIVIL *
PRINZIDE *
ZAROXOLYN
HYTRIN
INDERAL
INSPRA
INVERSINE
*
ISOPTIN SR
PROCARDIA
isradipine
KERLONE
*
ZESTRIL
*
ZIAC
*
*
*
*
ZESTORETIC
PROCARDIA XL
*
*
SKELID
propranolol
labetalol
LASIX
ZEBETA
*
*
propranolol/hydrochlorothiazide
LEVATOL
quinapril
CONTRACEPTIVES
LEXXEL
quinapril/hydrochlorothiazide
ALESSE
lisinopril
Quinaretic
Apri
RAUWOLFIA/BENDROFLUMETHIAZIDE
Aranelle
RESERPINE
Aviane
lisinopril/hydrochlorothiazide
*
LOPRESSOR HCT
*
LOTENSIN
SECTRAL
LOTENSIN HCT
*
LOTREL
LOZOL
*
MAVIK
BREVICON
Sorine
Camila
sotalol
Cesia
sotalol (AF)
Cryselle
spironolactone
CYCLESSA
spironolactone/hydrochlorothiazide
DEMULEN
*
SULAR
*
DESOGEN *
METHYCLOTHIAZIDE
TARKA
Enpresse
methyldopa
Taztia XT
Errin
methyldopa/hydrochlorothiazide
TENEX
metolazone
TENORETIC
MAXZIDE
*
*
*
MAXZIDE-25
*
*
ESTROSTEP FE
*
Jolivette
Page 2 of 4
(Continued)
Junel
ORTHO TRI-CYCLEN
Kariva
ORTHO TRI-CYCLEN LO
Kelnor
ORTHO-CEPT
Leena
ORTHO-CYCLEN
*
*
LIPID-LOWERING
ADVICOR
ALTOPREV
*
ORTHO-NOVUM *
ANTARA
OVCON-50
cholestyramine light
Levora
PLAN-B
COLESTID
*
LOESTRIN *
Portia
CRESTOR
Previfem
fenofibrate
Reclipsen
gemfibrozil
Low-Ogestrel
SEASONALE
LESCOL
Lutera
SEASONIQUE
LESCOL XL
Microgestin
Solia
LIPITOR
Microgestin Fe
Sprintec
*
MODICON *
TRI-LEVLEN
Mononessa
TRI-NORINYL
Necon
TRIPHASIL
Nora-BE
Tri-Previfem
OMACOR
Tri-Sprintec
PRAVACHOL
*
NOR-QD *
Trivora
pravastatin
Velivet
Prevalite
Nortrel
YASMIN
QUESTRAN
NUVARING
YAZ
QUESTRAN LIGHT
OGESTREL
Zovia
simvastatin
Lessina
LEVLITE
*
LO/OVRAL
LOESTRIN FE
*
MIRCETTE
NORDETTE
NORINYL
ORTHO EVRA
ORTHO MICRONOR
*
*
LOFIBRA
*
LOPID
Trinessa
*
cholestyramine
lovastatin
*
*
MEVACOR
*
NIASPAN
*
*
*
TRICOR
*
TRIGLIDE
VYTORIN
WELCHOL
ZETIA
ZOCOR
*
Page 3 of 4
(Continued)
OSTEOPOROSIS
PRENATAL VITAMINS
ACTONEL
Advanced Natalcare
ACTONEL WITH CALCIUM
Advanced-RF Natalcare
BONIVA
Cal-nate
DIDRONEL
*
CENOGEN ULTRA
*
*
etidronate
CITRACAL PRENATAL RX
EVISTA
Duet tabs
FORTEO
DUET DHA
fortical
ICAR PRENATAL COMBO PACK
FOSAMAX
NataCaps
FOSAMAX PLUS D
MIACALCIN
NataFort
*
NatalCare GlossTabs
NatalCare Plus
NataTab FA
PEDIATRIC VITAMINS
W/FLUORIDE
NataTab Rx
chewable multivitamins/fluoride/iron
NATELLE PREFER
chewable multivite w/fluoride
NOVANATAL
multiple vitamins/fluoride
NutriNate
multivitamin drops/fluoride
NutriSpire
multivitamin drops/fluoride/iron
OPTINATE
multivitamins/fluoride/iron
PRECARE
*
POLY-VI-FLOR
POLY-VI-FLOR/IRON
TRI-VI-FLOR
NATELLE
*
PRECARE CONCEIVE
*
*
vitamins a/d/c/fluoride
PRECARE PRENATAL
PREMESIS RX
Prenatal Formula 3
Prenatal MR 90 Fe
Prenatal MTR/selenium
Prenatal Plus
Prenatal Rx 1
Prenatal-H
Prenatal-U
PRENATE ELITE
PRIMACARE
PRIMACARE ONE
Ultra NatalCare
Vinate GT
Vinate II
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 4 of 4

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