2009 Qualified Preventive Prescription Drugs

Preventive Drug
Benefit Program
Employee Guide
Effective January 1, 2009
46683.1008
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
• Asthma/COPD
• Contraceptives
• Diabetes
• Lipid-lowering agents
• Osteoporosis drugs
• Pediatric vitamins with fluoride
• Prenatal vitamins
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).
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
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.
BETAPACE AF
ANTIHYPERTENSIVES
ACCUPRIL
*
*
chlorothiazide
betaxolol
chlorthalidone
BIDIL
clonidine
bisoprolol
CLORPRES
acebutolol
bumetanide
COREG
ACEON
BUMEX
*
COREG CR
acetazolamide
BYSTOLIC
CORGARD
CADUET
CORZIDE
ACCURETIC
ADALAT CC
*
*
*
*
COVERA-HS
*
afeditab cr
CALAN
*
ALDACTONE *
ALTACE *
CALAN SR
amiloride/hydrochlorothiazide
CARDENE I.V.
amlodipine
CARDENE SR
ATACAND
CARDIZEM
ATACAND HCT
CARDIZEM CD
ALDACTAZIDE
*
*
CAPOTEN *
COZAAR
captopril
DEMSER
DEMADEX
*
*
DIAMOX
DIAZOXIDE
DIBENZYLINE
*
*
DILACOR XR
*
dilt-cd
atenolol
CARDIZEM LA
AVALIDE
CARDURA
AVAPRO
cartia xt
diltiazem cd
AZOR
CARTROL
diltiazem er
benazepril
carvedilol
diltiazem xr
BENDROFLUMETHIAZIDE
CATAPRES
BENICAR
CATAPRES-TTS-1
DIOVAN
BENICAR HCT
CATAPRES-TTS-2
DIOVAN HCT
CATAPRES-TTS-3
DIURIL
BETAPACE
*
*
*
diltiazem
dilt-xr
Page 1 of 5
(Continued)
DYAZIDE
THALITONE
MICARDIS HCT
doxazosin
*
*
*
*
MICROZIDE
TIAZAC
DYNACIRC CR
MINIPRESS
TIMOLIDE 10/25
DYRENIUM
minoxidil
TIMOLOL
EDECRIN
moexipril
TOPROL XL
*
*
enalapril
MONOPRIL
eplerenone
MONOPRIL HCT
EXFORGE
nadolol
TRANDATE IV
felodipine er
nicardipine
trandolapril
fosinopril
nifediac cc
triamterene/hydrochlorothiazide
furosemide
nifedical xl
UNIRETIC
GUANABENZ ACETATE
nifedipine
guanfacine
nifedipine er
torsemide
*
*
TRANDATE
*
UNIVASC *
VASERETIC *
VASOTEC *
hydralazine
nimodipine
hydrochlorothiazide
NIMOTOP
HYPERTENSOLOL
NISOLDIPINE
verapamil er
*
verapamil sr
HYTRIN
*
NORVASC
HYZAAR
PINDOLOL
indapamide
PLENDIL
*
prazosin
INNOPRAN XL
PRINIVIL
INDERAL LA
INSPRA
*
verapamil
VERELAN
*
*
PROCARDIA
*
PROCARDIA XL
INVERSINE
ISOPTIN SR
*
*
*
ZAROXOLYN *
ZEBETA *
ZESTORETIC *
ZESTRIL *
ZIAC *
VERELAN PM
*
PRINZIDE *
INTROL
*
*
propranolol
isradipine
propranolol cr
propranolol er
ASTHMA/COPD
quinapril
ACCOLATE
quinaretic
ACCUNEB
LEVATOL
ramipril
ADRENALIN
lisinopril
RAUWOLFIA/BENDROFLUMETHIAZIDE
ADVAIR DISKUS
RESERPINE
ADVAIR HFA
*
KERLONE
labetalol
LASIX
*
LOPRESSOR
*
LOPRESSOR HCT
LOTENSIN
*
*
SECTRAL
*
*
*
AEROBID
sorine
AEROBID-M
sotalol
albuterol
sotalol (Af)
albuterol er
spironolactone
ALUPENT
LYTENSOPRIL-90
SULAR
ALVESCO
*
TARKA
aminophylline
taztia xt
ASMANEX
TEKTURNA HCT
ATROVENT HFA
LOTENSIN HCT
LOTREL
*
*
LYTENSOPRIL
MAVIK
MAXZIDE
*
MAXZIDE-25
*
*
methazolamide
TENEX
METHYCLOTHIAZIDE
TENORETIC 50
BRETHINE
*
BRONCAP
metolazone
*
TENORETIC 100 *
TENORMIN *
metoprolol
terazosin
BRONDIL
metoprolol er
TEVETEN
BROVANA
MICARDIS
TEVETEN HCT
CLENBUTEROL
methyldopa
BRONCODUR
BRONCOMAR-1
Page 2 of 5
(Continued)
COMBIVENT
UNIPHYL
copd
VENTOLIN HFA
NECON 10/11-28
*
nora-be
cromolyn
VOSPIRE ER
dg 200
XOPENEX
difil-g forte
XOPENEX CONCENTRATE
dilex-g
XOPENEX HFA
*
NORINYL 1+35 *
NORINYL 1+50 *
NOR-QD *
ZYFLO
nortrel
DUONEB
*
dyflex-g
NORDETTE-28
*
NUVARING
ZYFLO CR
dy-g
ocella
DYLIX
OGESTREL
dyphylline gg
CONTRACEPTIVES
ORTHO EVRA
ED-BRON G
*
*
apri
ORTHO MICRONOR
ELIXOPHYLLIN
aranelle
ORTHO TRI-CYCLEN
EPHEDRINE
aviane
ORTHO TRI-CYCLEN LO
epinephrine
balziva
ORTHO-CEPT-28
FLOVENT DISKUS
BREVICON-28
FLOVENT HFA
camila
FLUNISOLIDE
cesia
FORADIL AEROLIZER
cryselle
INTAL INHALER
CYCLESSA
ORTHO-CYCLEN-28
*
*
ORTHO-NOVUM 7/7/7-28 *
OVCON 35 *
ORTHO-NOVUM 1/35-28
*
DESOGEN *
OVCON 50
ipratropium
PLAN B
ISOPROTERENOL
enpresse
portia
ISUPREL
errin
previfem
JAY-PHYL
ESTROSTEP FE
LUFYLLIN
FEMCON FE
*
*
quasense
reclipsen
*
jolessa
SEASONALE
MAXAIR AUTOHALER
jolivette
SEASONIQUE
metaproterenol
junel
solia
PERFOROMIST
kariva
sprintec
PROAIR HFA
LUFYLLIN-GG
*
kelnor
sronyx
PROVENTIL HFA
leena
tilia fe
PULMICORT
lessina
tri-legest fe
PULMICORT FLEXHALER
levora
trinessa
PULMOPHYLLINE
LO/OVRAL-28
TRI-NORINYL 28
*
QUIBRON 300
LOESTRIN 1/20-21
QVAR
LOESTRIN 1.5/30-21
SENOPHYLLINE
LOESTRIN 24
SEREVENT DISKUS
LOESTRIN FE 1/20
SINGULAIR
LOESTRIN FE 1.5/30
*
*
tri-sprintec
trivora
*
velivet
*
YASMIN 28
SPIRIVA HANDIHALER
low-ogestrel
YAZ
SYMBICORT
lutera
zenchent
zovia
terbutaline
LYBREL
THEO-24
microgestin
theochron
microgestin fe
THEOMAR GG
MIRCETTE
*
*
tri-previfem
*
DIABETES
theophylline cr
MODICON-28
ACTOPLUS MET
theophylline er
mononessa
AMARYL
theophylline td
necon
APIDRA
*
Page 3 of 5
(Continued)
APPFORMIN
NOVOLIN 70/30
MEVACOR
APPFORMIN-D
NOVOLIN 70/30 INNOLET
NIASPAN
AVANDAMET
NOVOLIN 70/30 PENFILL
PRAVACHOL
AVANDARYL
NOVOLIN N
pravastatin
BYETTA
NOVOLIN N INNOLET
prevalite
chlorpropamide
NOVOLIN N U-100 PENFILL
PROBUCOL
DIABETA
NOVOLIN R
QUESTRAN
DUETACT
NOVOLIN R INNOLET
QUESTRAN LIGHT
FORTAMET
NOVOLIN R U-100 PENFILL
SIMCOR
glimepiride
NOVOLOG
simvastatin
glipizide
NOVOLOG FLEXPEN
TRICOR
glipizide er
NOVOLOG MIX 70/30
TRIGLIDE
glipizide xl
NOVOLOG MIX 70/30 PREFILLED
VYTORIN
glipizide/metformin
GLUCOPHAGE
*
GLUCOPHAGE XR
GLUCOTROL
*
*
GLUCOTROL XL
FLEXPEN
*
*
*
*
WELCHOL
NOVOLOG PENFILL
ZETIA
PRANDIN
ZOCOR
*
RELION 70/30
*
*
RELION N
RELION R
OSTEOPOROSIS
GLUMETZA
RIOMET
ACTONEL
glyburide
STARLIX
alendronate
GLYCRON
SYMLIN
BONIVA
GLUCOVANCE
GLYNASE
*
SYMLINPEN 60
DIDRONEL
HUMALOG
SYMLINPEN 120
etidronate di
HUMALOG KWIKPEN
tolazamide
EVISTA
HUMALOG MIX 50/50
TOLBUTAMIDE
fortical
*
HUMALOG MIX 50/50 KWIKPEN
FOSAMAX
HUMALOG MIX 50/50 PEN
MIACALCIN
*
*
HUMALOG MIX 75/25
LIPID – LOWERING
HUMALOG MIX 75/25 KWIKPEN
ADVICOR
HUMALOG MIX 75/25 PEN
ALTOPREV
HUMALOG PEN
ANTARA
HUMULIN 50/50
cholestyramine
PEDIATRIC VITAMINS WITH
FLUORIDE
HUMULIN 70/30 PEN
cholestyramine light
chewable multivitamins/flouride/iron
HUMULIN N
COLESTID
HUMULIN N U-100 PEN
colestipol
multi vita-bets/fluoride
HUMULIN R
CRESTOR
multivitamin drops/fluoride
HUMULIN R U-500
fenofibrate
multivitamin drops/fluoride/iron
JANUMET
FENOGLIDE
multivitamins/fluoride
LANTUS
gemfibrozil
multivitamins/fluoride/iron
LANTUS OPTICLIK
LESCOL
poly-vitamin/fluoride
LANTUS SOLOSTAR
LESCOL XL
poly-vitamin/fluoride/iron
LEVEMIR
LIPITOR
tri-vit/fluoride
LEVEMIR FLEXPEN
LIPOFEN
METAGLIP
*
LOFIBRA
tri-vitamin/fluoride
*
LOPID
metformin er
lovastatin
*
chewable multivite w/fl
*
metformin
MICRONASE
*
SKELID
LOVAZA
Page 4 of 5
(Continued)
natalcare glosstabs
prenatal mr 90 fe
natalcare pic
prenatal mtr/selenium
natalcare pic forte
prenatal plus
advanced natalcare
natalcare plus
prenatal plus/iron
advanced-rf natalcare
natalcare rx
prenatal rx
aminate fe-90
natalcare three
prenatal z
ATABEX PRENATAL
NATALVIT
prenatal-h
BRIGHT BEGINNINGS PRENATAL
natamar rx
prenatal-u
cal-nate
natatab fa
PRENATE DHA
natatab Rx
PRENATE ELITE
PRENATAL VITAMINS
CARENATAL DHA
CENOGEN ULTRA
*
CITRANATAL 90 DHA
CITRANATAL DHA
*
*
*
NATELLE
NATELLE C
PRIMACARE
*
PRIMACARE ADVANTAGE
NATELLE EZ
PRIMACARE ONE
*
NATELLE PLUS W/DHA
PRUET DHA
combi rx
NATELLE PREFER
pruet dhaec
co-natal fa
NEEVO
re dualvit ob
CRNATAL
NESTABS CBF
*
NESTABS FA *
NESTABS RX *
NOVANATAL *
NOVASTART *
renate
CITRANATAL RX
docosavit
DUET
*
DUET DHA
DUET DHA EC
*
renate dha
renate dha extra
SELECT-OB
TANDEM DHA
ELITE OB WITH DHA
nu-natal advanced
TANDEM OB
elite-Ob
nutrinate
ternamar
*
*
tricare
EMBREX 600
nutrispire
folbecal
OB COMPLETE
foltabs
OB COMPLETE WITH DHA
ultra natal
foltabs prenatal plus dha
obstetrix ec
ultra natalcare
*
trinate
GESTICARE
OBTREX
*
ultra tabs
GESTICARE DHA
O-CAL PRENATAL
ultra-natal
ICAR PRENATAL COMBO PACK
OPTINATE
vinatal forte
inatal advance
poly iron pn
vinate az
inatal gt
poly iron pn forte
VINATE AZ EXTRA
inatal ultra
PRECARE
VINATE CALCIUM
*
PRECARE CONCEIVE
vinate gt
MARNATAL-F
PRECARE PREMIER
vinate ic
maternity
PREFERA OB
vinate ii
MAXINATE
PREMESIS RX
multifol plus
prenafirst
vinate ultra
m-vit
prenatabs cbf
VITAFOL-OB
LACTOCAL-F
*
*
vinate m
prenatabs fa
VITAFOL-OB+DHA
mynatal advance
prenatabs obn
VITAFOL-PN
MYNATAL
mynatal plus
prenatabs Rx
vita-natal
mynatal ultracaplet
prenatal 1 plus 1
VITAPHIL
mynatal-z
prenatal 19
vitaphil aide
mynate 90 plus
prenatal ad
vitaphil one
natacaps
prenatal advantage
VITA-PREN
*
NATAFORT *
prenatal formula
VIVA DHA
NATACHEW
prenatal low iron
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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