5/8/17
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, please click here. 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.
Some medications are available at a retail copay but will still require specialty distribution limited to a maximum of a 30 day supply. BCBSAZ has
selected Briova Specialty Pharmacy as the exclusive Specialty Pharmacy. The medications followed by “SP” must be obtained through Briova. Please
contact Briova directly at (866) 618-6741 to establish service with them. If you are currently obtaining a Specialty Medication from a Specialty Pharmacy
and need to receive that medication from a retail pharmacy instead, please contact the Pharmacy Benefit Customer Service number listed on your
BCBSAZ identification card. BCBSAZ and/or the PBM will decide whether you are eligible to receive the Specialty Medication from a retail pharmacy
instead of a Specialty Pharmacy. 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, please click here.
ANTINEOPLASTIC
HORMONAL ONCOLOGICS
Level 1
anastrozole (PL)
(generic for Arimidex)
tablet: 1mg
Arimidex (PL)
Fareston
Soltamox (PL)
OTHER GYNECOLOGICS, HORMONAL
ONCOLOGICS
Level 1
megestrol acetate
(generic for Megace)
tablet: 20mg, 40mg
CARDIOVASCULAR/HEART
ANGIOTENSIN-CONVERTING ENZYME
INHIBITORS (ACEI)
Level 1
benazepril
(generic for Lotensin)
tablet: 5mg, 10mg, 20mg, 40mg
captopril
(generic for Capoten)
tablet: 12.5mg, 25mg, 50mg, 100mg
enalapril
(generic for Vasotec)
tablet: 2.5mg, 5mg, 10mg, 20mg
enalapril/HCTZ
(generic for Vasoretic
tablet: 10-25mg, 5-12.5mg
fosinopril
(generic for Monopril)
tablet: 10mg, 20mg, 40mg
fosinopril/hctz
(generic for Monopril HCT)
tablet: 10mg-12,5mg, 20-12,5mg
lisinopril
(generic for Prinivil/Zestril)
tablet: 2.5mg, 5mg, 10mg, 20mg, 30mg,
40mg
quinapril HCL
(generic for Accupril)
tablet: 5mg, 10mg, 20mg, 40mg
quinapril-hctz
(generic for Accuretic)
tablet: 10-12.5mg, 20-12.5mg, 20-25mg
ramipril
(generic for Altace)
capsules: 1.25, 2.5mg, 5mg, 10mg
trandolapril
(generic for Mavik)
tablet: 1mg, 2mg, 4mg
moexipril/hctz
(generic for Uniretic)
tablet: 12,5/7.5mg, 12.5/15mg, 25/15mg
moexipril
(generic for Univasc)
tablet: 7.5mg, 15mg
lisinopril/hctz
(generic for Prinzide, Zestoretic)
tablet: 10-12.5mg, 20-12.5mg, 20-25mgmg
Level 3
Accupril
Accuretic
Aceon
Altace capsules
Capoten
Lotensin
Mavik
Monopril
Monopril HCT
Prinivil
Prinzide
Qbrelis
Quinapril
Quinaretic
Uniretic
Univasc
Vasotec
Zestril
Zestoretic
Level 4
Prestalia (PL)
ANGIOTENSIN RECEPTOR BLOCKERS (ARB)
Level 1
eprosart mesylate
(generic for Teveten) (PL)
tablet: 600mg
Hydral/hctz
(generic for Apresazide)
tablet: 25/25mg, 50/50mg
Irbesartan (PL)
(generic for Avapro)
tablet: 75mg, 150mg, 300mg
Irbesartan-HCTZ (PL)
(generic for Avalide)
tablet: 150-12.5mg, 300-12.5mg
The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about
Prescription Limitations, please click here.
losartan (generic for Cozaar)
tablet: 25mg, 50mg, 100mg
losartan/hydrochlorothiazide
(generic for Hyzaar)
tablet: 50/12.5mg, 100/12.5mg, 100/25mg
Candesartan (PL)
(generic for Atacand)
Tablets: 4mg, 8mg, 16mg, 32mg
Level 3
Atacand (PL)
Avalide (PL)
Avapro (PL)
Benicar (PL)
Cozaar
Hyzaar
Olmesartan Medoxomil (PL)
Teveten (PL) Teveten HCT ANGIOTENSIN II RECEPTOR BLOCKERS
(A2RB)
Level 1
amlodipine/besylate/valsartan (PL)
(generic for Exforge)
tablet: 5-160mg, 10-160mg, 5-320mg, 10320mg
amlodipine/valsartan/hydrochlorothiazide (PL)
(generic for Exforge HCT)
tablet: 5-160-12.5mg, 10-160mg-25mg,10160-12.5mg, 10-160-25mg, 10-320-25mg
candesa/cilexetil/hctz (PL)
(generic for Atacand HCT)
Tablets: 16-12.5 mg, 32-12.5 mg, 32-25mg,
16-12.5 mg, 32-12.5 mg
losartan
(generic for Cozaar)
tablet: 25mg, 50mg, 100mg
losartan/hydrochlorothiazide
(generic for Hyzaar)
tablet: 50/12.5mg, 100/12.5mg, 100/25mg
telmisartan-hydrochlorothiazide
(generic for Micardis HCT) (PL)
tablet: 80-12.5mg, 80-25mg, 40-12.5mg
telmisartan
(generic for Micardis)
tablet: 20mg, 40mg, 80mg
valsartan-Hydrochlorothiazide (PL)
(generic for Diovan HCT)
tablet: 80-12,5mg, 160-12mg, 160-25mg, 320-12,5mg, 320-25mg
valsartan (PL)
(generic for Diovan)
tablet: 40mg, 80mg, 160mg, 320mg
ANTI-PLATELETS
Level 1
anagrelide HCL
(generic for Agrylin)
tablet: 0.5mg, 1mg
aspirin/dipyridamole SR
(generic for Aggrenox)
capsules: 25-200mg
cilostazol (PL)
(generic for Pletal)
tablet: 50mg, 100mg
clopidogrel bisulfate
(generic for Plavix) (PL)
tablet: 75mg, 300mg
dipyridamole
(generic for Persantine)
tablet: 25mg, 50mg, 75mg
pentoxifyllin ER, pentoxil CR
(generic for Trental)
tablet: 400mg
ticlopidine
(generic for Ticlid)
tablet: 250mg
Level 2
Aggrenox
Brilinta
Effient (PL)
Zontivity (PL)
Level 3
Agrylin
Persantine
Pletal (PL)
Ticlid
Trental
Yosprala (PL)
Level 4
Plavix (PL)
BETA BLOCKERS
Level 1
acebutolol
(generic for Sectral)
capsule: 200mg, 400mg
atenolol
(generic for Tenormin)
tablet: 25mg. 50mg, 100mg
betaxolol
(generic for Kerlone) (PL)
tablet: 10mg, 20mg
bisoprolol
(generic for Zebeta)
tablet: 5mg, 10mg
Level 3
carvedilol
Atacand HCT (PL)
(generic for Coreg)
Benicar HCT (PL)
tablet: 3.125mg,6.25mg,12.5mg,25mg
Olmesartan/Medoxomil-Hydrochlorothiazide (PL)
labetalol
Olmesartan/Amlodipine/Hydrochlorothiazide (generic for Trandate)
Micardis tablet: 100mg, 200mg, 300mg
Micardis HCT (PL)
metoprolol tartrate
Tribenzor
(generic for Lopressor)
Byvalson (PL) tablet: 25mg, 50mg, 100mg, 200mg
metoprolol succinate ER/SR
Level 4
(generic for Toprol XL)
Diovan (PL)
tablet: 25mg, 50mg, 100mg
Diovan HCT (PL)
nadlol
Exforge (PL)
(generic for Corgard
Exforge HCT (PL)
13885 0403
tablet: 20mg, 40mg, 80mg
pindolol
(generic for Visken)
tablet: 5mg, 10mg
propranolol
(generic for Inderal)
tablet: 10mg, 20mg, 40mg, 60mg, 80mg
oral solution: 20mg/5ml, 40mg/5ml
propranolol ER/SR
(generic for Inderal LA)
tablet: 60mg, 80mg, 120mg, 160mg
sotalol, sorine
(generic for Betapace)
tablet: 80mg, 120mg, 160mg, 240mg
sotalol AF
(generic for Betapace AF)
tablet: 80mg, 120mg, 160mg
Level 2
Bystolic
Level 3
Betapace
Coreg
Corgard
Hemangeol
Kerlone (PL)
Levatol
Lopressor
Metoprolol Tartrate 37.5mg, 75mg
Sectral
Sotylize
Tenormin
Timolol tab
Toprol XL
Trandate
Zebeta
Level 4
Coreg CR
Betapace AF
Inderal LA
Inderal XL
Innopran XL (PL)
BETA BLOCKERS, COMBOS
Level 1
Dutoprol
atenolol/chlorthalidone
(generic for Tenoretic)
tablet: 50-25mg, 100-25mg
tablet: 40mg/25mg, 80mg/25mg
nadolol/bendroflumethiazide
(generic for Corzide)
tablet: 40-5mg, 80-5mg
metoprolol/HCTZ
(generic for Lopress HCT)
tablet: 50-25mg, 100-25mg, 100-50mg
bisoprolol/HCTZ
(generic for Ziac)
Tablet: 2.5/6.25mg, 5-6.25mg,10-6.25mg
Level 3
Corzide
Lopress HCT
Tenoretic
Ziac
Level 4
Dutoprol Tabs
Metoprolol/HCTZ Tabs
2
The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about
Prescription Limitations, please click here.
BENIGN PROSTATIC HYPERTROPHY (BPH)
Level 1
doxazosin
(generic for Cardura)
tablet: 1mg, 2mg, 4mg, 8mg
terazosin
(generic for Hytrin)
capsule: 1mg, 2mg, 5mg, 10mg
Level 3
Cardura
CALCIUM CHANNEL BLOCKER (CCB)
Level 1
amlodipine
(generic for Norvasc)
Tablet: 2.5mg, 5mg, 10mg
amlodipine besylate-benazepril
(generic for Lotrel)
tablet: 2.5/0mg, 5/10mg. 5/20mg. 5/40mg,
10/20mg, 10/40mg
diltiazem
(generic for Cardizem)
tablet: 30mg, 60mg, 90mg, 120mg
diltiazem ER/SR,CD, dilt-CD, dilt-XR, diltzac,
cartia-XT, Taztia XT
(generic for Cardizem CD, Dilacor XR, Tiazac)
tablet: 120mg, 180mg, 240mg, 300mg,
360mg
felodipine ER
(generic for Plendil)
tablet: 2.5mg, 5mg, 10mg
Isradipine
matzim LA
(generic for Cardizem LA)
tablet: 180mg, 240mg, 300mg, 360mg,
420mg
nifedipine ER, afeditab, nifediac CC)
(generic for Atalat CCl)
tablet: 30mg, 60mg, 90mg
nicardipine
(generic for Cardene)
tablet: 20mg, 30mg
nifedical XL, nifedipine ER
(generic for Procardia XL)
tablet: 30mg, 60mg, 90mg
nifedipine
(generic for Procardia)
capsule:10, 20mg
nimodipine (PL)
(generic for Nimotop))
capsule:30mg
nidoldipine
(generic for Sular))
tablet: 8.5mg, 17mg, 34mg
verapamil
(generic for Calan)
Tablet: 80mg, 120mg
verapamil ER/SR
(generic for Calan SR, Isoptin SR, Covera HS,
Verelan, Veralan PM)
tablet: 120mg, 180mg, 240mg
capsule: 100mg,120mg, 180mg, 200mg,
240mg, 300mg, 360mg
Level 2
Cardene SR
Sular 10, 20, 30 & 40mg (PL)
13885 0403
Level 3
Adalat CC
Amlodipine Besylate-Olmesartan Medoxomil (PL)
Azor (PL)
Bendroflumethiazide/Rauwolfia
Calan
Calan SR
Cardizem
Cardizem CD
Cardizem LA (PL)
Dilacor XR
Isoptin SR
Lotrel
Nisolidipine SR 20, 25.5, 30mg tab
Nimotop (PL)
Nymalize
Norvasc
Procardia
Procardia X
Sular 8.5, 17 & 34mg
Tarka
Tiazac
Twynsta
Vecamyl
Verelan
Verelan PM
CHOLESTEROL LOWERING
Level 1
atorvastatin (PL)
(generic for Lipitor
tablet: 10mg, 20mg, 40mg, 80mg
cholestyramine, prevalite
(generic for Questran, Questran Lite)
Can: 4gm, bulk can only
colestipol
(generic for Colestid)
tablet: 1gm
granules & packets: 5gm
ezetimibe
(generic for Zetia) (PL)
tablets: 10mg
ezetimibe-Simvastatin
(generic for Vytorin) (PL)
tablets: 10-10mg,10-20mg, 10-40mg, 1080mg
fenofibrate (PL)
(generic for Lofibra, Triglide, Tricor)
tablet: 48mg, 54mg, 148mg, 160mg
capsules: 67mg, 134mg, 200mg
fluvastatin (PL)
(generic for Lescol)
capsules: 20mg, 40mg
gemfibrozil
(generic for Lopid)
tablet: 600mg
lovastatin (PL)
(generic for Mevacor)
tablet: 10mg, 20mg,
tablet: 40mg
pravastatin (PL)
(generic for Pravachol)
tablet: 10mg, 20mg,
tablet: 40mg
rosuvastatin (PL)
(generic for Crestor)
tablet: 5gm. 10mg, 20mg,
40mg
simvastatin (PL)
(generic for Zocor)
tablet: 5mg, 10mg, 20mg, 40mg & 80mg
omega 3 acid ethyl esters
(generic for Lovaza)
tablet: 1 gram (PL)
Level 2
Niacin ER (PL)
Vytorin (PL)
Welchol (PL)
Level 3
Advicor (PL)
Altoprev
Antara (PL)
Colestid
Edarbi (PL)
Edarbyclor
Fenofibric Acid (PL)
Fenoglide
Fibricor (PL)
Fluvastatin ER/SR (PL)
Lescol (PL)
Lescol XL (PL)
Lipofen
Livalo
Lofibra (PL)
Lopid
Lovaza (PL)
Mevacor (PL)
Niaspan (PL)
Pravachol (PL)
Questran
Simcor (PL)
Tricor(PL)
Triglide (PL)
Trilipix (PL)
Vascepa (PL)
Level 4
Crestor (PL)
Lipitor (PL)
Liptruzet
Zetia (PL)
Zocor (PL)
DIRECT RENIN INHIBITORS
Level 2
Amturnide
Tekamlo
Tekturna (PL)
Tekturna HCT (PL)
Valturna
DIURETICS 1, LOOP
Level 1
furosemide
(generic for Lasix)
tablet: 20mg, 40mg, 80mg
oral solution: 8mg/ml, 10mg/ml
torsemide
(generic for Demadex)
tablet: 5mg, 10mg, 20mg, 100mg
Level 3
Demadex
Edecrin
Lasix
DIURETICS 2, THIAZIDE
Level 1
amiloride/hydrochlorothiazide
(generic for Moduretic)
3
The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about
Prescription Limitations, please click here.
tablets: 5-50mg
benazepril/HCTZ
(generic for Lotensin HCT)
tablet: 5mg/6.25mg, 10mg/12.5mg,
20mg/12.5mg, 20mg/25mg
enalapril/HCTZ
(generic for Vaseretic)
tablet: 5mg/12.5mg, 10mg/25mg
hydrochlorothiazide
(generic for Microzide, Esidrix)
capsule: 12.5mg
tablets: 12.5mg, 25mg, 50mg
indapamide
(generic for Lozol)
tablets: 1.25mg, 2.5mg
methyclothiazide
(generic for Enduron)
tablets: 1.25mg, 2.5mg
metiolazone
(generic for Zaroxolyn)
tablets: 2.5mg, 5mg, 10mg
Level 3
Capozide
Captopril-hctz
Chlorthalidone
Clorpres
Lotensin HCT
Microzide
Propranolol-hctz 40-25mg, 80-25mg
Vaseretic
Zaroxolyn
DIURETICS 3, OTHERS
Level 1
methyldopa/HCTZ
(generic for Aldoril)
tablet: 250-15mg
spironolactone
(generic for Aldactone)
tablet: 25mg, 50mg, 100mg
spironolactone/HCTZ
(generic for Aldactazide)
tablet: 25/25mg, 50/59mg
triamterene/HCTZ
(generic for Dyazide)
capsule: 37.5-25mg
triamterene/HCTZ
(generic for Maxzide)
tablet: 37.5-25mg, 75-50mg
Level 3
Aldactone
Aldactazide
Dyazide
Maxzide
OTHER ANTI-HYPERTENSION
Level 1
clonidine
(generic for Catapres)
tablet: 0.1mg, 0.2mg, 0.3mg
transdermal: 0,1mg, 0,2mg, 0.3mg
hydralazine
(generic for Apresoline)
tablet: 10mg, 25mg, 50mg, 100mg
eplerenone (PL)
(generic for Inspra)
tablet: 25mg, 50mg
methyldopa
(generic for Aldomet)
13885 0403
capsule: 250mg, 500mg
prazosin
(generic for Minipress)
capsule: 1mg, 2mg, 5mg
guanfacine
(generic for Tenex)
capsule: 1mg, 2mg
Level 3
Catapres
Catapres-TTS Dis
Dibenzyline
Guanabenz Acetate
Inspra (PL)
Minipress
Nexiclon XR
Reserpine
Tenex
Methyldopa/HCTZ 250-25mg
NITRATES
Level 1
minoxidil
(generic for Loniten)
tablet: 2.5mg, 10mg
ENDOCRINE/ METABOLIC
CALCIUM METABOLISM
Level 1
alendronate (PL)
(generic for Fosamax)
tablet: 5mg, 10mg,35mg, 70mg
calcitonin, fortical
(generic for Miacalcin)
spray: 200mg
raloxifene (PL)
(generic for Evista)
tablet: 60mg
risedronate (PL)
(generic for Actonel)
tablet: 5mg, 30mg, 35mg 150mg
risedronate delayed release (PL)
(generic for Atelvia)
tablet: 35mg
Level 3
Actonel 150mg (PL)
Alendronate tab 40mg (PL)
Alendronate oral soln 70mg/75ml (PL)
Boniva (PL)
Didronel Evista (PL)
Fosamax (PL)
Levobunolol Miacalcin (PL) Risedronate 35mg (PL)
Skelid Level 4
Atelvia (PL)
Actonel 5mg, 30mg, 35mg (PL)
Binosto (PL) Fosamax Plus D (PL)
Osphena
DIABETES MELLITUS
Level 1
acarbose
(generic for Precose)
tablet:25mg, 50mg, 100mg
glimepiride (PL)
(generic for Amaryl)
tablet: 1mg, 2mg, 4mg
glipizide
(generic for Glucotrol)
tablet: 5mg, 10mg
glipizide ER/
(generic for Glucotrol XL)
extended-release tablet: 2.5mg, 5mg, 10mg
glipizide-metformin (PL)
(generic for Metaglip)
Tablet: 2.5-250mg, 2.5-500mg, 5mg-500mg
glyburide-metformin (PL)
(generic for Glucovance)
tablet: 1.25/250mg, 2.5/500mg. 5/500mg
glyburide, glycron
(generic for Diabeta, Micronase, Glynase)
tablet: 1.25mg, 2.5mg, 5mg
prestab: 1.5mg, 3mg, 6mg
insulin Injection, vials (PL)
metformin
(generic for Glucophage)
tablet: 500mg, 850mg, 1000mg
metformin ER/SR
(generic for Glucophage XR)
extended-release tablet: 500mg, 750mg
metformin ER/SR Osmotic (PL)
(generic for Fortamet)
sustained release tablet: 500mg, 1000mg
nateglinide (PL)
(generic for Starlix)
tablet: 60mg, 120mg
pioglitazone (PL)
(generic for Actos)
tablet: 15mg, 30mg, 45mg
pioglitazone-metformin (PL)
(generic for Actoplus Met)
tablet: 15-500mg, 15-850mg
pioglitazone-glimepiride(PL)
(generic for Duetact)
tablet: 30-2mg, 30-4mg
repaglinide
(generic for Prandin)
tablet: 1 mg, 2mg
Level 2
Actoplus Met XR
Apidra Solostar
Avandia (PL)
Avandamet (PL)
Avandaryl (PL)
Byetta (PL)
Bydureon (PL)
Bydureon Pen (PL)
Farxiga (PL)
Glyset
Humalog Pen
Humalog Kwikpen 100, 200 U
Humalog Mix Kwikpen
Humalog Mix Pen
Humulin Kwikpen
Humulin N Kwikpen
Humulin R U-500 (PL)
Invokana
Invokamet
Invokamet XR
Janumet (PL)
Janumet XR
Januvia (PL)
Kombiglyze XR
Lantus Opticlick
4
The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about
Prescription Limitations, please click here.
Lantus Solostar
Levemir Flexpen
Levemir Flextouch
Novolog Flexpen
Novolog Mix Flexpen
Novolog Penfill
Onglyza
Prandin 0.5mg
Repaglinide-Metformin
Symlin pen (PL)
Toujeo Solostar Pen
Xigduo XR
Xultophy (PL)
Level 3
Adlyxin (PL)
Amaryl (PL)
Chlorpropamide
Cycloset
Duetact (PL)
Diabinese
Glucophage (PL)
Glucovance (PL)
Glucotrol
Glucotrol XL
Glynase
Jardiance
Jentadueto
Jentadueto XR (PL)
Kazano
Korlym (PL)
Nesina
Oseni
Precose
Riomet
Starlix (PL)
Soliqua (PL)
Tanzeum (PL)
Tolbutamide
Tradjenta
Tresiba Flexpen (PL)
Trulicity (PL)
Victoza (PL)
Level 4
Actoplus Met (PL) Actos (PL) Afrezza (PL)
Alogliptin Basaglar Kwikpen (PL)
Diabeta Fortamet (PL)
Glucophage XL (PL)
Glumetza (PL)
Glyxambi (PL)
Metaglip (PL) Metformin modified release ER/SR (PL)
Nesina Prandimet Synjardy
Synjardy XR
OTHER ENDOCRINE/METABOLIC
Level 2
Glucagen
Glucagon
Level 3
Proglycem
13885 0403
NUTRIENTS & BLOOD
MODIFIERS
ANTICOAGULANTS/THROMBOLYTICS
Level 1
warfarin, jantoven
(generic for Coumadin)
tablet: 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg,
6mg, 7.5mg, 10mg
Level 2
Coumadin
Level 3
Brilinta
RESPIRATORY ANAPHYLAXIS
Level 1
Epinephrine
(generic for Adrenalin)
Injection: 1mg/ml
Level 2
Mylan Epinephrine Pen (PL)
Level 3
Adrenalin vial
Level 4
Adrenaclick pen (PL)
Auvi-Q pen by Sanofi (PL)
Epi-Pen (PL)
Epi-Pen JR (PL)
Non Mylan Epinephrine Pens (PL)
BRONCHODILATORS
Level 1
albuterol
(generic for Proventil/Ventolin)
nebulizer: 0.05%, 0.083%
tablet: 2mg, 4mg
syrup: 2mg/5ml
albuterol er
(generic for Vospire ER)
tablet: 4mg, 8mg
albuterol
(generic for Accuneb)
nebulizer: 0.63mg/3ml,1.25mg/3ml
(generic for Accuneb)
nebulizer: 0.63mg/3ml,1.25mg/3ml
ipratropium bromide inhal sol
(generic for Atrovent)
Solution: 0.02%, 0.03%, 0.06%
levalbuterol
(generic for Xopenex)
concentrated nebulizer: 1.25mg/0.5ml
nebulizer: 0.31mg, 0.63mg, 1.25mg
Level 2
Atrovent HFA (PL)
Serevent Diskus (PL)
Ventolin HFA
Level 3
Accuneb
Adrenalin
Bevespi Aerosphere (PL)
Levabuterol HFA (PL)
Brovana (PL)
Perforomist (PL)
Spiriva Handihaler (PL)
Spiriva Respimat (PL)
Vospire ER Xopenex Concentrate Nebulizer Xopenex HFA (PL)
Level 4
ProAir HFA
ProAir Respiclick
Proventil HFA
BRONCHODILATORS, INHALED STEROIDS
Level 1
Fluticasone propionate/salmeterol
(generic for Airduo)
Inhaler: 113-14mcg/act, 232-14mcg/act, 5514mcg/act
Level 2
Advair (PL)
Advair HFA (PL)
Level 3
Airduo Respiclick
ASTHMA, OTHER
Level 1
dyphyllin-gg, DG 200, COPD, dyflex G
(generic for Lufyllin GG)
Elixir: 100-100mg tablet: 200-200mg difil-g fort liquid 100-100
difil g 400 tablet
dilex-g liquid 100-100
dy-G liquid 100-100
dyphylline tab gg es
(generic for Difil G)
tablets: 200-300mg
Ipratropium/albuterol
(generic for Duoneb)
nebulizer solution: 0.5-2.5mg/3ml (generic for Intal) Nebulizer: 20mg/2ml
montelukast (PL)
(generic for Singulair)
tablet: 4mg, 5mg, 10mg
zafirlukast
(generic for Accolate) (PL)
tablet: 10mg, 20mg
budesonide suspension
(generic for Pulmicort Respules) (PL)
tablet: 0.25mg, 0.5mg
theophylline solution
(generic for Slo-phyllin)
Solution: 80mg/15ml
Level 2
Alvesco (PL)
Arnuity Ellipta
Asmanex
Asmanex HFA
Flovent Diskus
Flovent HFA
Pulmicort respules 1MG (PL)
Pulmicort flexhaler (PL)
Qvar (PL)
Theo-24
5
The medications followed by "PL" have Prescription Limitations as stated in your benefit plan booklet. To learn more about
Prescription Limitations, please click here.
sustained-release tablet:400mg, 600mg
Level 3
Accolate (PL)
Aerobid M
Aerospan
Alvesco (PL)
Aminophyllin tab
Arcapta
Broncap
Broncodur Sol
Broncomar 1 Elx
Brondil Liquid
Combivent
Combivent Respimat
Cromolyn sodium nebulizer
Difil G 200-300
Dilex G
Dylix Elizir
Ed-Bron G syp
Elixohyllin Elixir
Jay-Phyl
Lufyllin
Lufyllin GG
Quibron
Seebri Neohaler
Singulair (PL)
Theophylline Eixir
Utibron Neohaler
Zileuton SR
Zyflo
Zyflo CR
PRENATAL PRESCRIPTION
VITAMINS
Level 3 (PL)
Prescription Brands
Level 4
Dulera (PL)
Duoneb
Symbicort (PL)
OTHER PULMONARY
Level 1
terbutaline
(generic for Brethine)
Tablet: 2.5mg, 5mg
Injection: 1mg/ml
metaproteren
(generic for Metaprel)
Tablet: 10mg, 20mg
Level 2
Anoro Ellipta
Breo Ellipta
Incruse Ellipta
Pulmozyme (PL)
Level 3
Maxair autohaler
Metaproferen syrup
Tudorza Pressair
Stiolto Respimat (PL)
Level 4
Striverdi Respimat
THEOPHYLLINES
Level 1
theophylline SR 12 HR
(generic for Theo-Dur)
sustained-release tablet:100mg, 200mg,
300mg, 450mg
theophylline SR 24 HR
(generic for Uniphyl)
13885 0403
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