Microsoft word - hsa preventive list 2.19.14

2/19/14 Guidance regarding Waiver of Deductible for Preventive Medications Covered Under High Deductible Health Plans Designed for Use With a Health Savings Account. This guide applies only to certain high deductible health plans designed for use with a health savings account. It applies only for specific large groups that have elected this preventive medication benefit. If you are not certain whether your group has this benefit option, please contact BCBSAZ. The laws governing HSA-compatible, high deductible health plans generally require members to satisfy a deductible before the plan begins to pay for any benefits. The only permitted exception to that rule is for preventive care. The plan can pay for covered preventive care benefits before the member has met the high deductible. The medications listed below have been identified as those most likely to qualify as preventive, based on U.S. Treasury Department guidance. If your plan covers BCBSAZ designated prevention medications as a preventive benefit and you have your prescription filled at an in-network pharmacy, your plan will treat these designated medications as preventive. This means you will pay only your applicable copay or coinsurance amount, regardless of whether you have met your deductible. The BCBSAZ prevention medication benefit applies only at in-network pharmacies. If you obtain BCBSAZ designated preventative medications from an out of network pharmacy, your standard prescription benefits, with applicable deductible, coinsurance and copays, will apply. Your cost share payments for preventive medications will count towards your deductible. Neither BCBSAZ nor your plan sponsor can guarantee that the U.S. Treasury Department will agree that all of these medications qualify as preventative, particularly when applied to a member’s specific medical circumstances. You or your provider may be asked to demonstrate that you are taking a specific medication for purposes regarded as preventive under Treasury Department guidance. This list does not include every medication that might possibly be considered preventive or every condition for which a preventive drug may be prescribed. The list is subject to change at any time, without prior notice. If you want any of these listed medications to process under your standard pharmacy benefit instead of your preventive care benefit, If your medications process under your standard prescription benefit, your costs for applicable coverage will apply. Placement on this list is not a guarantee that the listed drug is a covered benefit under any specific benefit plan. The medications followed by “PL” have Prescription Limitations or Precertification as stated in your benefit plan booklet. To learn more about Prescription Limitations and Precertification, pleas ANTINEOPLASTIC
tablet: 12,5/7.5mg, 12.5/15mg, 25/15mg HORMONAL ONCOLOGICS
tablet: 12.5mg, 25mg, 50mg, 100mg Level 1
tablet: 10-12.5mg, 20-12.5mg, 20-25mgmg Level 3
Level 2
Level 3
Arimidex (PL)
Soltamox (PL)
tablet: 2.5mg, 5mg, 10mg, 20mg, 30mg, OTHER GYNECOLOGICS, HORMONAL
ONCOLOGICS
Level 1
tablet: 10-12.5mg, 20-12.5mg, 20-25mg CARDIOVASCULAR/HEART
capsules: 1.25, 2.5mg, 5mg, 10mg ANGIOTENSIN-CONVERTING ENZYME
INHIBITORS (ACEI)
Level 1
ANGIOTENSIN RECEPTOR BLOCKERS (ARB)
Level 1

The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about
Prescription Limitations, please
(generic for Teveten) (PL)
(generic for Plavix) (PL)
Level 2
Irbesartan (PL)
Bystolic (PL)
Level 3
Irbesartan-HCTZ (PL)
Innopran (PL)
Level 2
Kerlone (PL)
tablet: 50/12.5mg, 100/12.5mg, 100/25mg Effient (PL)
Candesartan (PL)
Level 3
Effiient (PL)
Level 3
Atacand (PL)
Pletal (PL)
Avalide (PL)
Level 4
Avapro (PL)
Benicar (PL)
Level 4
Plavix (PL)
BETA BLOCKERS, COMBOS
Teveten (PL)
Level 1
BETA BLOCKERS
Level 1
ANGIOTENSIN II RECEPTOR BLOCKERS
Level 1
Diovan (PL)
candesa/cilexetil/hctz (PL)
Tablets: 16-12.5 mg, 32-12.5 mg, 32-25mg, (generic for Kerlone) (PL)
valsartan-Hydrochlorothiazide(PL)
tablet: 50-25mg, 100-25mg, 100-50mg Tablet: 2.5/6.25mg, 5-6.25mg,10-6.25mg Level 2
Level 3
Exforge (PL)
tablet: 3.125mg,6.25mg,12.5mg,25mg Exforge HCT (PL)
Level 3
Atacand HCT (PL)
BENIGN PROSTATIC HYPERTROPHY (BPH)
Benicar HCT (PL)
Level 1
Micardis HCT (PL)
Level 4
Diovan HCT (PL)
Valsartan (PL)
Level 3
ANTI-PLATELETS
tablet: 10mg, 20mg, 40mg, 60mg, 80mg CALCIUM CHANNEL BLOCKER (CCB)
Level 1
oral solution: 20mg/5ml, 40mg/5ml Level 1
cilostazol (PL)
tablet: 80mg, 120mg, 160mg, 240mg
The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about
Prescription Limitations, pl
tablet: 2.5/0mg, 5/10mg. 5/20mg. 5/40mg, Zetia (PL)
Level 4
Lipitor (PL)
diltiazem ER/SR,CD, dilt-CD, dilt-XR, diltzac, CHOLESTEROL LOWERING
Level 1
Zocor (PL)
(generic for Cardizem CD, Dilacor XR, Tiazac) Niacin ER (PL)
tablet: 120mg, 180mg, 240mg, 300mg, (generic for Lipitor (PL)
DIRECT RENIN INHIBITORS
Level 2
Tekturna (PL)
Tekturna HCT (PL)
tablet: 180mg, 240mg, 300mg, 360mg, fenofibrate (PL)
DIURETICS 1, LOOP
tablet: 48mg, 54mg, 148mg, 160mg capsules: 20mg, 40mg (PL)
Level 3
nimodipine (PL)
tablet: 40mg (PL)
DIURETICS 2, THIAZIDE
tablet: 40mg (PL)
simvastatin (PL)
tablet: 5mg, 10mg, 20mg, 40mg & 80mg (generic for Calan SR, Isoptin SR, Covera HS, Level 2
Crestor (PL)
Lovaza (PL)
Niaspan (PL)
Welchol (PL)
Level 2
Level 3
Advicor (PL)
Sular 10, 20, 30 & 40mg (PL)
Antara (PL)
Level 3
Edarbi (PL)
Azor (PL)
Fenofibric Acid (PL)
Fibricor (PL)
Fluvastatin ER/SR (PL)
Lescol (PL)
Cardizem LA (PL)
Lescol XL (PL)
Level 3
Lofibra (PL)
Mevacor (PL)
Nimotop (PL)
Pravachol (PL)
Simcor (PL)
Tricor(PL)
Triglide (PL)
Trilipix (PL)
DIURETICS 3, OTHERS
Vytorin (PL)
Level 1

The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about
Prescription Limitations, please
methyldopa/HCTZ
Level 2
Actonel (PL)
Level 2
Atelvia (PL)
Evista (PL)
Avandia (PL)
Avandamet (PL)
Level 3
Avandaryl (PL)
Alendronate tab 40mg (PL)
Byetta (PL)
Alendronate oral soln 70mg/75ml (PL)
Bydureon (PL)
Boniva (PL)
Fosamax (PL)
Level 3
Miacalcin (PL)
Janumet (PL)
Januvia (PL)
Level 4
Juvisync (PL)
Actonel with Calcium (PL)
OTHER ANTI-HYPERTENSION
Binosto (PL)
Level 1
Fosamax Plus D (PL)
DIABETES MELLITUS
Level 1
glimepiride (PL)
Symlin (PL)
Vuctoza (PL)
Level 3
Amaryl (PL)
Bydureon (PL)
extended-release tablet: 2.5mg, 5mg, 10mg glipizide-metformin (PL)
Duetact (PL)
glyburide-metformin (PL)
tablet: 1.25/250mg, 2.5/500mg. 5/500mg Fortamet (PL)
Glucophage (PL)
(generic for Diabeta, Micronase, Glynase) Glucovance (PL)
insulin Injection, vials (PL)
Korlym (PL)
NITRATES
extended-release tablet: 500mg, 750mg Level 1
metformin SR Osmotic (PL)
Starlix (PL)
Victoza (PL)
pioglitazone (PL)
ENDOCRINE/ METABOLIC
Level 4
Actoplus Met (PL)
CALCIUM METABOLISM
pioglitazone-metformin (PL)
Actos (PL)
Level 1
Glucophage XL (PL)
alendronate (PL)
Invokana (PL)
pioglitazone-glimepiride(PL)
Metaglip (PL)

The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about
Prescription Limitations, pl
Glumetza (PL)
nebulizer: 0.31mg, 0.63mg, 1.25mg Alvesco (PL)
OTHER ENDOCRINE/METABOLIC
Level 2
Level 2
Atrovent HFA (PL)
Foradil aerolizer (PL)
Level 3
Serevent Diskus (PL)
Xopenex HFA (PL)
NUTRIENTS & BLOOD
MODIFIERS
Dulera (PL)
ANTICOAGULANTS/THROMBOLYTICS
Brovana (PL)
Level 1
Perforomist (PL)
tablet: 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, BRONCHODILATORS, INHALED STEROIDS
Level 2
Singulair (PL)
Level 2
Advair (PL)
Advair HFA (PL)
ASTHMA, OTHER
Level 3
Level 1
Level 4
RESPIRATORY
OTHER PULMONARY
Level 1
ANAPHYLAXIS
Level 1
Level 2
Epipen (PL)
Level 2
Epipen JR (PL)
nebulizer solution: 0.5-2.5mg/3ml Pulmozyme (PL)
Level 3
Level 3
montelukast (PL)
Level 4
Level 4
Adrenaclick (PL)
Auvi-Q (PL)
(generic for Accolate) (PL)
Epinephrine Pen (PL)
THEOPHYLLINES
Level 1
BRONCHODILATORS
(generic for Pulmicort Respules) (PL)
Level 1
sustained-release tablet:100mg, 200mg, Level 2
sustained-release tablet:400mg, 600mg Alvesco (PL)
Level 2
Spiriva (PL)
Pulmicort respules 1MG (PL)
Pulmicort flexhaler (PL)
PRENATAL PRESCRIPTION
Qvar (PL)
VITAMINS
Symbicort (PL)
Level 1 (PL)
Level 3
Accolate (PL)
Level 3 (PL)
concentrated nebulizer: 1.25mg/0.5ml

Source: https://www.azblue.com/~/media/azblue/files/pharmacy%20forms%20mastery%20directory/all%20other/other%20forms%20and%20resources/hsa%20standard%20preventive%20drug%20list.pdf