PREVENTIVE DRUG
BENEFIT PROGRAM
Employee Guide
Effective January 1, 2015
21009.1014
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
PREVENTIVE DRUG BENEFIT PROGRAM
INTRODUCTION
Blue Cross and Blue Shield of Illinois (BCBSIL) administers the preventive drug benefit for your group’s high
deductible health plan (“HDHP”), which has been designed for use with Health Savings Accounts (“HSAs”). The
preventive drug benefit program includes categories of prescription drugs that are frequently used for preventive
purposes. If your doctor has prescribed any of them to you for preventive purposes, then you and your HSA-eligible
dependents may have coverage before satisfying your HDHP deductible.
Below and on the following pages is a Guide listing some examples of drugs that are commonly prescribed for
preventive purposes. Coverage of all medications is still subject to your HDHP limitations, exclusions and out-ofpocket requirements (for example, your prescription drug payment levels).
IMPORTANT REMINDER: These drugs could also at times be prescribed for treatment purposes. As a
result, the listing of a drug in the Guide does not mean that it will be covered by your particular benefit plan
before your HDHP deductible is satisfied. If your doctor has prescribed a listed drug for treatment purposes
(and not preventive purposes) then your plan does not provide coverage for that drug before your HDHP
deductible is satisfied.
As each individual’s medical circumstances are different, and because proper classification is necessary for you
to ensure you are complying with your HDHP tax obligations, it is important for you to confirm the purpose of
the prescription with your doctor. Please call the number on the back of your member ID card when your doctor
confirms to you that he or she prescribed one of the listed drugs for treatment purposes so your claims can be
processed correctly. Unless you provide us with this information, claims for the drugs listed in the Guide will
be processed as “preventive,” and you or your doctor may be asked by us to provide medical records showing
that the drug you’re taking is being used for prevention. Remember, if you improperly classify the drug, it may
result in adverse tax consequences so please be sure to take the confirming step to properly classify your claim.
REMEMBER: Just because a drug is on the list, doesn’t always mean it is covered.
FOLLOW THESE STEPS:
1. Find your drug in the Guide.
2. Talk to your doctor about whether your drug is in fact being prescribed for you for preventive purposes
(and not treatment purposes).
3. If prescribed for treatment purposes, call the number on the back of your ID card to let us know.
4. If prescribed for preventive purposes, there is no need to call.
21009.1014
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(Continued)
2015 STANDARD HSA COMMON PREVENTIVE DRUG LIST
This Guide lists some, but not all, examples of drugs that are commonly prescribed for preventive purposes. It
is being provided to you at your employer’s request as a resource to help you in managing your prescription drug
benefits under your employer’s HDHP.
This list does not include all drugs that may be prescribed as preventive. It will be reviewed periodically and is
subject to change. Coverage of all medications is still subject to your HDHP limitations, exclusions and out-of
pocket requirements (for example, your prescription drug payment levels).
It is important to note, for the reasons described in the Introduction to this Guide, that the listing of a drug in
the Guide does not mean that it will be covered by your particular benefit plan before your HDHP deductible
is satisfied. Please follow the steps outlined in the Introduction to ensure you are properly directing the
processing of your claims.
The preventive drug program currently includes prescription drugs in the following categories:
• Anti-angina
• Anti-arrhythmics
• Anti-coagulants/anti-platelets
• Anti-malarial
• Breast cancer prevention
• Contraceptives
• Diabetes Rx – hypoglycemic agents
• Diabetes Rx – insulin and oral
• Diabetic supplies
• Fluoride supplements
• Heparins/low molecular weight heparin
• High blood pressure
• High cholesterol
• Infant eye ointment (for newborns)
• Osteoporosis
• Prenatal vitamins
• Respiratory
• Tobacco cessation
• Vaccines
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 Illinois 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.
21009.1014
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(Continued)
2015 STANDARD HSA COMMON PREVENTIVE DRUG LIST
ANTI-ANGINA
DILATRATE SR
IMDUR *
ISORDIL TITRADOSE 5 MG *
ISORDIL TITRADOSE 40 MG
isosorbide dinitrate ext-release
ISOSORBIDE DINITRATE SUBLINGUAL
isosorbide dinitrate tabs,
5 mg, 10 mg, 20 mg
ISOSORBIDE DINITRATE 30 MG
isosorbide mononitrate
isosorbide mononitrate ext-release
NITRO-BID
NITRO-DUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR *
NITRO-DUR 0.3 MG/HR, 0.8 MG/HR
nitroglycerin ext-release
nitroglycerin lingual pumpspray
nitroglycerin patches
NITROLINGUAL PUMPSPRAY *
NITROMIST
NITROSTAT
RANEXA
ANTI-ARRHYTHMICS
amiodarone
BETAPACE *
BETAPACE AF *
CORDARONE *
DIGOXIN SOLN
digoxin tabs
disopyramide
flecainide
LANOXIN *
mexiletine
MULTAQ
NORPACE *
NORPACE CR
propafenone
propafenone ext-release
quinidine gluconate ext-release
quinidine sulfate 300 mg
QUINIDINE SULFATE 200 MG
QUINIDINE SULFATE EXT-RELEASE
RYTHMOL *
RYTHMOL SR *
sotalol
sotalol AF
TAMBOCOR *
TIKOSYN
21009.1014
ANTI-COAGULANTS/
ANTI-PLATELETS
AGGRENOX
AGRYLIN *
anagrelide
BRILINTA
cilostazol
clopidogrel
COUMADIN *
dipyridamole
EFFIENT
ELIQUIS
PERSANTINE *
PLAVIX *
PLETAL *
PRADAXA
warfarin
XARELTO
ZONTIVITY
ANTI-MALARIAL
ARALEN *
atovaquone/proguanil
chloroquine phosphate
hydroxychloroquine
MALARONE
mefloquine
PLAQUENIL *
PRIMAQUINE
BREAST CANCER PREVENTION
EVISTA *
raloxifene
SOLTAMOX
tamoxifen
CONTRACEPTIVES
Cervical Caps
FEMCAP
PRENTIF CAVITY-RIM CERVICAL CAP
PRENTIF FITTING SET
Diaphragms
OMNIFLEX DIAPHRAGM
ORTHO DIAPHRAGM ALL-FLEX
ORTHO DIAPHRAGM COIL SPRING KIT
ORTHO DIAPHRAGM FLAT SPRING KIT
WIDE-SEAL SILICONE DIAPHRAGM KIT
Emergency Progestin
levonorgestrel
My Way
Next Choice/One Dose
PLAN B/ONE-STEP *
Emergency Ella
ELLA
Implants Progestin
IMPLANON
NEXPLANON
Injectable Progestin
DEPO-PROVERA CONTRACEPTIVE *
DEPO-SUBQ PROVERA 104
medroxyprogesterone acetate
IUD Progestin
MIRENA
SKYLA
Oral Combined
Altavera
Alyacen
Apri
Aranelle
Aubra
Aviane
Azurette
Balziva
BEYAZ
BREVICON *
Briellyn
Caziant
Cesia
Chateal
Cryselle
Cyclafem
CYCLESSA *
Dasetta
Delyla
DESOGEN *
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
Elinest
Emoquette
Enpresse
Enskyce
Estarylla
ESTROSTEP FE *
FALESSA
Falmina
FEMCON FE *
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(Continued)
2015 STANDARD HSA COMMON PREVENTIVE DRUG LIST
GENERESS FE
Gianvi
Gildagia
Gildess
Gildess Fe
Junel
Junel Fe
Kariva
Kelnor
Kurvelo
Larin
Larin Fe
Leena
Lessina
Levonest
levonorgestrel/ethinyl estradiol
Levora
LO LOESTRIN FE
LO MINASTRIN FE
LOESTRIN *
LOESTRIN 24 FE
LOESTRIN FE *
LOMEDIA 24 FE
Loryna
Low-Ogestrel
Lutera
Marlissa
Microgestin
Microgestin Fe
MINASTRIN 24 FE
MIRCETTE *
MODICON *
Mono-Linyah
Mononessa
Myzilra
NATAZIA
Necon 0.5/35, 1/35, 7/7/7
NECON 1/50, 10/11
Nikki
NORDETTE *
norethindrone/ethinyl estradiol
norethindrone/ethinyl estradiol fe
norgestimate/ethinyl estradiol
norgestrel/ethinyl estradiol
NORINYL 1+35 *
NORINYL 1+50
Nortrel
Ocella
OGESTREL
Orsythia
21009.1014
ORTHO TRI-CYCLEN *
ORTHO TRI-CYCLEN LO
ORTHO-CEPT *
ORTHO-CYCLEN *
ORTHO-NOVUM
OVCON-35 *
Philith
Pimtrea
Pirmella
Portia
Previfem
Reclipsen
SAFYRAL
Solia
Sprintec
Sronyx
Syeda
Tilia Fe
Tri-Estarylla
Tri-Legest Fe
Tri-Linyah
TRI-NORINYL *
Tri-Previfem
Tri-Sprintec
Trinessa
Trivora
Velivet
Vestura
Viorele
Vyfemla
Wera
Wymzya Fe
YASMIN *
YAZ *
Zarah
Zenchent
Zenchent Fe
Zeosa
Zovia 1/35E
ZOVIA 1/50E
Oral Extended Continuous
Amethia
Amethia Lo
AMETHYST
Camrese
Camrese Lo
Daysee
Introvale
Jolessa
levonorgestrel/ethinyl estradiol
LOSEASONIQUE *
QUARTETTE
Quasense
SEASONIQUE *
Oral Progestin
Camila
Errin
Heather
Jencycla
Jolivette
Lyza
NOR-QD *
Nora-BE
norethindrone
Norlyroc
ORTHO MICRONOR *
Transdermal Combined
ORTHO EVRA *
Xulane
Vaginal Combined
NUVARING
DIABETES Rx –
HYPOGLYCEMIC AGENTS
GLUCAGEN
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM
DIABETES Rx – INSULIN AND
ORAL
acarbose
ACTOPLUS MET *
ACTOPLUS MET XR
ACTOS *
AMARYL *
APIDRA
BYDUREON
BYETTA
CHLORPROPAMIDE
CYCLOSET
DIABETA
DUETACT
FARXIGA
FORTAMET *
glimepiride
glipizide
glipizide ext-release
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2015 STANDARD HSA COMMON PREVENTIVE DRUG LIST
glipizide/metformin
GLUCOPHAGE *
GLUCOPHAGE XR *
GLUCOTROL *
GLUCOTROL XL *
GLUCOVANCE *
GLUMETZA
glyburide, generics of Micronase
GLYBURIDE, distributor of DIABETA
glyburide micronized
glyburide/metformin
GLYNASE *
GLYSET
HUMALOG
HUMULIN
INVOKAMET
INVOKANA
JANUMET
JANUMET XR
JANUVIA
JARDIANCE
JENTADUETO
JUVISYNC
KAZANO
KOMBIGLYZE XR
LANTUS
LEVEMIR
metformin
metformin ext-release
nateglinide
NESINA
NOVOLIN
NOVOLIN RELION
NOVOLOG
ONGLYZA
OSENI
pioglitazone
pioglitazone/glimepiride
pioglitazone/metformin
PRANDIMET
PRANDIN *
PRECOSE *
RELION R
repaglinide
RIOMET
STARLIX *
SYMLINPEN
TANZEUM
tolazamide 250 mg
TOLAZAMIDE 500 MG
21009.1014
TOLBUTAMIDE
TRADJENTA
VICTOZA
DIABETIC SUPPLIES
ALCOHOL PREP PADS, SWABS
ALL DIABETIC SUPPLIES –
CALIBRATION LIQUID, INSULIN SYRINGES, LANCETS,
LANCET DEVICES, PEN NEEDLES
INSULIN INFUSION PUMP TUBING,
IV SETS, RESERVOIRS,
AND ADAPTERS
TEST STRIPS (ACETONE, BLOOD
AND URINE GLUCOSE, BLOOD
AND URINE KETONE)
FLUORIDE SUPPLEMENTS
ACT TOTAL CARE DRY MOUTH
COLGATE DRY MOUTH RELIEF
FLORICAL
FLUOR-A-DAY CHEW TABS
FLUORABON
FLUORIDEX DAILY DEFENSE SENSITIVITY RELIEF GEL
FLURA-DROPS
GEL-KAM *
LISTERINE ESSENTIAL CARE
LISTERINE RESTORING *
LISTERINE SMART RINSE *
LISTERINE TOOTH DEFENSE *
LISTERINE TOTAL CARE ZERO
LISTERINE TOTAL CARE *
LISTERINE WHITENING/RESTORING *
LOZI-FLUR
LURIDE *
MONOCAL
NAFRINSE
OMNI GEL *
PHOS FLUR
PREVIDENT *
REACH KIDS
REMBRANDT
sodium fluoride chew tabs; crm; drops;
gel; oral rinse; paste; soln
SODIUM FLUORIDE TABS
sodium fluoride/potassium nitrate
stannous fluoride
THERA-FLUR-N *
HEPARINS/LOW MOLECULAR
WEIGHT HEPARIN
ARIXTRA *
enoxaparin
fondaparinux
FRAGMIN
heparin sodium inj, 5,000 unit/mL
IPRIVASK
LOVENOX *
HIGH BLOOD PRESSURE
ACCUPRIL *
ACCURETIC *
acebutolol
ACEON *
ACETAZOLAMIDE 125 MG
acetazolamide 250 mg
acetazolamide ext-release
ADALAT CC *
ALDACTAZIDE 25/25 MG *
ALDACTAZIDE 50/50 MG
ALDACTONE *
ALTACE *
amiloride
amiloride/hydrochlorothiazide
amlodipine
amlodipine/atorvastatin
amlodipine/benazepril
AMTURNIDE
ATACAND *
ATACAND HCT *
atenolol
atenolol/chlorthalidone
AVALIDE *
AVAPRO *
AZOR
benazepril
benazepril/hydrochlorothiazide
BENICAR
BENICAR HCT
betaxolol
BIDIL
bisoprolol
bisoprolol/hydrochlorothiazide
bumetanide
BYSTOLIC
CADUET *
CALAN *
CALAN SR *
Page 6 of 9
(Continued)
2015 STANDARD HSA COMMON PREVENTIVE DRUG LIST
candesartan
candesartan/hydrochlorothiazide
captopril
CAPTOPRIL/HYDROCHLOROTHIAZIDE
CARDENE SR
CARDIZEM *
CARDIZEM CD *
CARDIZEM LA 120 MG
CARDIZEM LA 180 MG, 240 MG,
300 MG, 360 MG, 420 MG *
CARDURA *
carvedilol
CATAPRES *
CATAPRES-TTS *
CHLOROTHIAZIDE 250 MG
chlorothiazide 500 mg
CHLORTHALIDONE
clonidine
CLORPRES
COREG *
COREG CR
CORGARD *
CORZIDE *
COZAAR *
DEMADEX *
DEMSER
DIAMOX *
DIBENZYLINE
DILACOR XR *
diltiazem
diltiazem ext-release
DIOVAN *
DIOVAN HCT *
DIURIL
doxazosin
DUTOPROL
DYAZIDE *
DYRENIUM
EDARBI
EDARBYCLOR
EDECRIN
enalapril
enalapril/hydrochlorothiazide
EPANED
eplerenone
eprosartan
EXFORGE
EXFORGE HCT
felodipine ext-release
fosinopril
21009.1014
fosinopril/hydrochlorothiazide
NEPTAZANE *
FUROSEMIDE SOLN 8 MG/ML
nicardipine
furosemide soln 10 mg/mL; tabs
nifedipine
guanfacine
nifedipine ext-release
hydralazine
nimodipine
hydrochlorothiazide
nisoldipine ext-release 8.5 mg,
HYZAAR *
17 mg, 34 mg
indapamide
NISOLDIPINE EXT-RELEASE 20 MG, INDERAL LA *
25.5 MG, 30 MG, 40 MG
INDERAL XL
NORVASC *
INNOPRAN XL
NYMALIZE
INSPRA *
perindopril
irbesartan
pindolol
irbesartan/hydrochlorothiazide
prazosin
ISOPTIN SR *
PRINIVIL *
ISRADIPINE
PROCARDIA *
KERLONE *
PROCARDIA XL *
labetalol
PROPRANOLOL SOLN
LASIX *
propranolol tabs
LEVATOL
propranolol ext-release
lisinopril
PROPRANOLOL/
lisinopril/hydrochlorothiazide
HYDROCHLOROTHIAZIDE
LOPRESSOR *
quinapril
LOPRESSOR HCT *
quinapril/hydrochlorothiazide
losartan
ramipril
losartan/hydrochlorothiazide
SECTRAL *
LOTENSIN *
spironolactone
LOTENSIN HCT *
spironolactone/hydrochlorothiazide LOTREL *
SULAR *
MAVIK *
TARKA
MAXZIDE *
TEKAMLO
MAXZIDE-25 *
TEKTURNA
methazolamide
TEKTURNA HCT
METHYCLOTHIAZIDE
telmisartan
methyldopa
telmisartan/amlodipine
METHYLDOPA/telmisartan/hydrochlorothiazide
HYDROCHLOROTHIAZIDE
TENEX *
metolazone
TENORETIC *
metoprolol succinate ext-release
TENORMIN *
metoprolol tartrate
terazosin
metoprolol/hydrochlorothiazide
TEVETEN 400 MG
MICARDIS *
TEVETEN 600 MG *
MICARDIS HCT *
TEVETEN HCT
MICROZIDE *
TIAZAC *
MINIPRESS *
TIMOLOL TABS
minoxidil
TOPROL XL *
moexipril
torsemide
moexipril/hydrochlorothiazide
TRANDATE *
nadolol
trandolapril
nadolol/bendroflumethiazide
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2015 STANDARD HSA COMMON PREVENTIVE DRUG LIST
LIVALO
triamterene/hydrochlorothiazide
LOFIBRA *
caps, 37.5 / 25 mg; tabs
TRIAMTERENE/ LOPID *
lovastatin
HYDROCHLOROTHIAZIDE CAPS, LOVAZA *
50/25 MG
MEVACOR *
TRIBENZOR
niacin ext-release
TWYNSTA *
NIACOR
UNIRETIC *
NIASPAN *
UNIVASC *
omega-3-acid ethyl esters
valsartan
PRAVACHOL *
valsartan/hydrochlorothiazide
pravastatin
VASERETIC *
QUESTRAN *
VASOTEC *
QUESTRAN LIGHT *
VERAPAMIL 40 MG
SIMCOR
verapamil 80 mg, 120 mg
simvastatin
verapamil ext-release
TRICOR *
VERELAN *
TRIGLIDE
VERELAN PM *
TRILIPIX *
ZAROXOLYN *
VASCEPA
ZEBETA *
VYTORIN
ZESTORETIC *
WELCHOL
ZESTRIL *
ZETIA
ZIAC *
ZOCOR *
HIGH CHOLESTEROL
ADVICOR
ALTOPREV
amlodipine/atorvastatin
ANTARA
atorvastatin
CADUET *
cholestyramine
cholestyramine light
COLESTID *
colestipol
CRESTOR
FENOFIBRATE CAPS 50 MG, 150 MG
fenofibrate tabs
fenofibrate micronized
FENOFIBRIC ACID
fenofibric acid delayed-release
FENOGLIDE
FIBRICOR
fluvastatin
gemfibrozil
LESCOL *
LESCOL XL
LIPITOR *
LIPOFEN *
LIPTRUZET
21009.1014
INFANT EYE OINTMENT
(for newborns)
erythromycin eye oint
OSTEOPOROSIS
ACTONEL *
alendronate 5 mg, 10 mg, 35 mg,
70 mg
ALENDRONATE 40 MG
ALENDRONATE SOLN
ATELVIA
BINOSTO
BONIVA *
calcitonin-salmon
DIDRONEL *
ETIDRONATE
EVISTA *
FORTICAL
FOSAMAX *
FOSAMAX PLUS D
ibandronate
MIACALCIN NASAL *
raloxifene
risedronate
SKELID
PRENATAL VITAMINS
ALL PRESCRIPTION PRENATAL VITAMINS
RESPIRATORY
ACCOLATE *
ACCUNEB *
acetylcysteine
ADVAIR DISKUS
ADVAIR HFA
AEROSPAN
albuterol
albuterol ext-release
ALVESCO
ANORO ELLIPTA
ARCAPTA NEOHALER
ASMANEX
ATROVENT HFA
BREO ELLIPTA
BRONDIL
BROVANA
budesonide inhal susp 0.25 mg/2 mL, 0.5 mg/2 mL
COMBIVENT
COMBIVENT RESPIMAT
cromolyn sodium inhal soln
DALIRESP
DULERA
DUONEB *
ELIXOPHYLLIN
FLOVENT DISKUS
FLOVENT HFA
FORADIL AEROLIZER
ipratropium inhal soln
ipratropium/albuterol inhal soln
levalbuterol inhal soln
LUFYLLIN
MAXAIR AUTOHALER
METAPROTERENOL
montelukast
PERFOROMIST
PROAIR HFA
PROVENTIL HFA
PULMICORT FLEXHALER
PULMICORT RESPULES 0.25 MG/2 ML, 0.5 MG/2 ML *
PULMICORT RESPULES 1 MG/2 ML
QVAR
SEREVENT DISKUS
SINGULAIR *
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2015 STANDARD HSA COMMON PREVENTIVE DRUG LIST
SPIRIVA HANDIHALER
STRIVERDI RESPIMAT
SYMBICORT
terbutaline
THEO-24
theophylline
theophylline ext-release
TUDORZA PRESSAIR
VENTOLIN HFA
VOSPIRE ER *
XOPENEX
XOPENEX CONCENTRATE *
XOPENEX HFA
zafirlukast
VACCINES
ACTHIB
ADACEL
AFLURIA
BOOSTRIX
CERVARIX
COMVAX
DAPTACEL
DIPHTHERIA/TETANUS TOXOID – ADSORBED
ENGERIX-B
FLUARIX
FLUARIX QUADRIVALENT
FLUBLOK
TOBACCO CESSATION
ALL BRAND/GENERIC OTC NICOTINE GUM, LOZENGES, PATCHES
bupropion ext-release (smoking cessation)
CHANTIX
COMMIT * (OTC)
NICODERM CQ * (OTC)
NICORETTE * (OTC)
nicotine gum, lozenges, patches
NICOTINE TRANSDERMAL KIT (OTC)
NICOTROL INHALER
NICOTROL NS
ZYBAN *
21009.1014
FLUCELVAX
FLULAVAL
FLULAVAL QUADRIVALENT
FLUMIST NASAL
FLUMIST QUADRIVALENT
FLUVIRIN
FLUZONE
FLUZONE QUADRIVALENT
GARDASIL
HAVRIX
HIBERIX
INFANRIX
INFLUENZA A (H1N1)
IPOL
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB
PENTACEL
PNEUMOVAX 23
PREVNAR 13
PROQUAD
RECOMBIVAX HB
ROTARIX
ROTATEQ
TENIVAC
TETANUS TOXOID ADSORBED
TETANUS/DIPHTHERIA TOXOIDS
TRIPEDIA
TWINRIX
VAQTA
VARIVAX
ZOSTAVAX
Third-party brand names are the property of their respective owners.
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