NF-641: Preventive Medication List for Health Savings Account

NF-641: Preventive Medication List for Health Savings Account

HEALTH SAVINGS
ACCOUNT
Preventive Medication List
(by Therapy Class)
Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association
Preventive medications are an important
element in keeping members healthy.
Your Health Savings Account (HSA) qualified health plan is designed to promote
smarter spending on prescription drugs while improving your overall health.
Prescription drugs that can help keep you from developing a health condition are
called preventive medications.
With the HSA preventive medication option, no deductible is applied to preventive
prescription drugs, allowing health care dollars to go further. Members can
purchase these prescription medications with lower out-of-pocket costs.
The HSA preventive medication listing includes four tiers* of medications: generic
preferred (tier 1), generic nonpreferred (tier 2), brand preferred (tier 3), and brand
nonpreferred (tier 4) drugs. Your cost share for prescription medications is based
on which tier your drug falls into.
Generic drugs are typically the most affordable and offer you a lower cost share
than brand-name drugs. The active ingredient in a generic drug is chemically
identical to the active ingredient of the corresponding brand-name drug. To help
lower your out-of-pocket cost, we encourage you to choose a generic medication
whenever possible.
•• Generic preferred drugs (tier 1) usually have the lowest cost share.
•• Generic nonpreferred drugs (tier 2) usually have a slightly higher cost
share than generic preferred drugs and a lower cost share than brand
name drugs.
Please note that not all strengths and formulations of generic drugs have the
same tier status. For example, metformin er 500mg is generic preferred (tier 1)
and metformin er 750mg is generic nonpreferred (tier 2).
Brand-name drugs are marketed under a specific trade name and are protected
by a patent. Brand-name drugs can be either preferred or nonpreferred.
*All plans do not include a
two-tier generic benefit. For
plans that do not have a twotier generic benefit, the generic
copayment will be applied to both
generic preferred and generic
nonpreferred drugs. Refer to
your Certificate of Coverage for
specific information about your
prescription benefit.
PAGE 2
•• Brand preferred drugs (tier 3) are usually available at a slightly higher cost
share than generic drugs. These drugs are designated preferred brand
because they are more cost effective compared to other brand drugs that
treat the same condition.
•• Brand nonpreferred drugs (tier 4) usually have the highest cost share.
These drugs are listed as nonpreferred because they have not been found
to be any more cost effective than available generics, preferred brands, or
over-the-counter drugs. Nonpreferred brand medications are not covered
under a closed formulary benefit plan.
Generic Substitution Program
Generic substitution programs help to reduce out-of-pocket expenses and help to contain the rising
costs of providing prescription drug benefits. Capital BlueCross offers two types of generic substitution
programs* — mandatory and restrictive:
•• Mandatory Generic Substitution Program is when a generic drug is substituted for a brand-name
product. If a generic drug is available and you obtain a brand-name drug, even if your doctor has
requested brand necessary, you will be charged the brand-name cost share plus the cost difference
between the generic and brand-name medication.
•• Restrictive Generic Substitution Program allows your doctor to specify that a brand-name drug
be dispensed by indicating “No Generic Substitution Permissible” on the written prescription. In this
case, you will only be charged the brand-name cost share. But, if you request a brand-name drug
when a generic is available, you will be charged the brand-name cost share plus the cost difference
between the generic and brand-name medication.
*
Please refer to your Certificate of Coverage for specific information about your prescription benefit.
Prior Authorization
Some medications are subject to prior authorization and may require approval prior to filling. You can easily
identify these medications as they will have a PAR symbol next to them. The prior authorization process helps
to ensure that certain drugs are prescribed appropriately and in keeping with FDA guidelines.
To help prevent delays in filling these prescriptions, you, your physician, or your authorized representative
should request an authorization before your prescriptions are filled. Medications that require authorization will
not be covered if authorization is not obtained prior to dispensing. (You can initiate a prior authorization request
from our website or by calling the Rx Member Services number on the back of your ID card.)
Enhanced Prior Authorization (step therapy)
Certain medications are subject to enhanced prior authorization (or step therapy) due to health care concerns
and/or safety reasons. In order to have these medications covered under your prescription drug benefit, you
may be required to first try a formulary alternative or complete the authorization process. These medications
appear on the Preventive Medication List with an EPA symbol next to them.
Quantity Level Limits
Quantity level limits help to promote appropriate use of selected medications and enhance patient safety.
If your prescription is written for more than the allowed quantity, your prescription will be filled up to the
allowed quantity unless authorization has been obtained for a higher quantity. These medications appear on the
preventive medication list with a QLL symbol next to them.
To obtain authorization, your physician can call or fax a request with supporting clinical information to our
pharmacy benefit manager at:
CVS/caremark™
Prior Authorization Department
Phone: 800.294.5979
Fax: 888.836.0730
If you have questions about your prescription drug benefit, contact
CVS/caremark customer service at 800.585.5794 (TTY: 866.236.1069).
CVS/caremark pharmacists and customer service representatives are
available any time of the day, seven days a week. You may also visit
capbluecross.com for other helpful pharmacy information.
PAGE 3
Preventive Medication List*
Medications for Diabetes (continued)
Medications for Diabetes
Drug Name
Alternatives
(please discuss with your physician)
Drug Name
Alternatives
(please discuss with your physician)
acarbose
GNP
ACTOPLUS MET, -XR
BNP pioglitazone/metformin
JANUVIA
BP
ACTOS
BNP pioglitazone
JANUMET, -XR
BP
AFREZZA (PAR)
BNP metformin or NOVOLOG
JARDIANCE
BP
AMARYL
BNP glimepiride
JENTADUETO
APIDRA
BNP HUMALOG, NOVOLOG
KAZANO (PAR)
BNP JENTADUETO, JANUMET
BNP JENTADUETO, JANUMET
INVOKANA (PAR)
BNP FARXIGA
BP
AVANDAMET
BP
KOMBIGLYZE XR (PAR)
AVANDARYL
BP
LANTUS
BP
AVANDIA
BP
LANTUS SOLOSTAR
BP
BYDUREON (PAR)
BNP VICTOZA
LEVEMIR
BYETTA (PAR)
BNP VICTOZA
METAGLIP
metformin, metformin er
500mg
chlorpropamide
GNP
CYCLOSET
BNP metformin
DIABETA
BNP glyburide
DUETACT
BNP glimepiride/pioglitazone
BP
FARXIGA
BNP metformin er
FORTAMET (PAR)
GP
glimepiride
glimepiride/pioglitazone
GNP
glipizide
GP
glipizide er 5mg
GP
glipizide er 10mg
BP
BNP glipizide/metformin
GP
metformin er 750mg
GNP
metformin osmotic er
GNP
MICRONASE
BNP glyburide
nateglinide
GNP
NESINA (PAR)
BNP JANUVIA, TRADJENTA
NOVOLIN products
BP
NOVOLOG PRODUCTS
BP
ONGLYZA (PAR)
BNP JANUVIA, TRADJENTA
GNP
OSENI (PAR)
BNP
glipizide/metformin
GNP
pioglitazone
GNP
GLUCOPHAGE XR (PAR)
BNP metformin er
PRANDIMET
BNP repaglinide + metformin
GLUCOTROL, -XL
BNP glipizide, -er
PRANDIN
GLUCOVANCE
BNP glyburide/metformin
PRECOSE
BNP acarbose
GLUMETZA (PAR)
BNP metformin er
RIOMET (PAR)
BNP metformin
glyburide 5mg
GNP
STARLIX
BNP nateglinide, repaglinide
glyburide 1.25mg, 1.5mg,
2.5mg, 3mg, 6mg
GP
glyburide/metformin
1.25/250mg
GP
glyburide/metformin
2.5/500mg, 5/500mg
GNP
BP
GLYSET
GLYXAMBI
BNP JANUMET
HUMALOG products (PAR)
BNP NOVOLOG
HUMULIN products (PAR)
BNP NOVOLIN
INVOKAMET (PAR)
BNP XIGDUO XR
JANUVIA, TRADJENTA,
pioglitazone
BP
SYNJARDY
BP
SYMLIN, -PEN (EPA)
BP
TANZEUM (PAR)
BNP TRULICITY
tolazamide
GNP
tolbutamide
GNP
TOUJEO
BP
TRADJENTA
BP
TRULICITY
BP
VICTOZA
BP
XIGDUO XR
BP
GP = Generic Preferred GNP = Generic Nonpreferred BP = Brand Preferred BNP = Brand Nonpreferred
PAR = Prior Authorization Required EPA = Enhanced Prior Authorization QLL = Quantity Level Limit
PAGE 4
Medications to Prevent and
Treat Osteoporosis
Medications for Arrhythmia or Angina
(continued)
Drug Name
Drug Name
Alternatives
(please discuss with your physician)
BNP risedronate (QLL)
ACTONEL (EPA)
alendronate 5mg, 35mg, 70mg
(QLL)
GP
alendronate 10mg, 40mg
GNP
ATELVIA (EPA, QLL)
BNP alendronate (QLL)
BINOSTO (EPA, QLL)
BNP alendronate (QLL)
BONIVA (EPA, QLL)
BNP ibrandronate (QLL)
calcitonin nasal spray
GNP
DIDRONEL
BNP etidronate
etidronate
GNP
BNP raloxifene
EVISTA
BP
FORTEO (PAR)
FORTICAL NASAL SPRAY
BNP calitonin nasal spray
FOSAMAX (EPA, QLL)
BNP alendronate (QLL)
FOSAMAX-D (EPA, QLL)
GNP
MIACALCIN NASAL SPRAY
BNP calitonin nasal spray
GNP
risedronate (QLL)
GNP
Medications for Arrhythmia or Angina
Drug Name
GP
isosorbide mononitrate er
60mg, 120mg
GNP
mexiletine
GNP
MINITRAN
BNP nitroglycerin
MULTAQ
BNP amiodarone
NITRO-DUR
BNP nitroglycerin
nitroglycerin
GNP
NITROMIST
BNP nitroglycerin
NORPACE, -CR
BNP disopyramide
PACERONE
BNP amiodarone
propafenone
GNP
quinidine
GNP
RYTHMOL, -SR
ibrandronate (QLL)
raloxifene
isosorbide mononitrate er
30mg
RANEXA (PAR)
BP
Alternatives
(please discuss with your physician)
Alternatives
(please discuss with your physician)
sotalol 80mg, 160mg
BP
BNP propafenone
GP
sotalol 120mg, 240mg; -af
GNP
TAMBOCOR
BNP flecainide
TIKOSYN
BNP
Medications for High Blood Pressure and
Other Cardiovascular Conditions
Drug Name
Alternatives
(please discuss with your physician)
GP
amiodarone 200mg
amiodarone 100mg, 400mg
GNP
ACCUPRIL (PAR)
BNP quinapril
BETAPACE, -AF
BNP sotalol, -af
ACCURETIC (PAR)
BNP quinapril/hctz
CORDARONE
BNP amiodarone
acebutolol
CORLANOR
BNP RANEXA (PAR)
ACEON (PAR)
BNP perindopril
disopyramide
GNP
acetazolamide
GNP
flecainide
GNP
ADALAT CC
BNP nifedipine er
IMDUR
BNP isosorbide mononitrate
ALDACTAZIDE
BNP spironolactone/hctz
ISORDIL
BNP isosorbide dinitrate
ALDACTONE
BNP spironolactone
isosorbide dinitrate
GNP
ALTACE (PAR)
BNP ramipril
isosorbide dinitrate er 40mg
GNP
isosorbide mononitrate 10mg,
20mg
GP
amiloride/hctz
amiloride
amlodipine
GP
GP
GNP
GP
GP = Generic Preferred GNP = Generic Nonpreferred BP = Brand Preferred BNP = Brand Nonpreferred
PAR = Prior Authorization Required EPA = Enhanced Prior Authorization QLL = Quantity Level Limit
PAGE 5
Preventive Medication List* (continued)
Medications for High Blood Pressure and
Other Cardiovascular Conditions (continued)
Medications for High Blood Pressure and
Other Cardiovascular Conditions (continued)
Drug Name
Drug Name
Alternatives
(please discuss with your physician)
Alternatives
(please discuss with your physician)
amlodipine/benazepril
GNP
COREG
BNP carvedilol
amlodipine/valsartan
GNP
COREG CR
BNP carvedilol
amlodipine-valsartanhydrochlorothiazide
GNP
CORGARD
BNP nadolol
ATACAND (PAR)
BNP candesartan
CORZIDE
BNP nadolol/bendroflumethiazide
ATACAND HCT (PAR)
BNP candesartan/hctz
COZAAR (PAR)
BNP losartan
DEMADEX
BNP torsemide
atenolol/ -chlorthalidone
GP
AVALIDE (PAR)
BNP irbesartan/hctz, losartan/hctz
AVAPRO (PAR)
BNP irbesartan, losartan
BP
AZOR
benazepril/ -hctz
GNP
bendroflumethiazide/
-rauwolfia
GNP
BP
BENICAR/ -HCT
DEMSER
BNP
DIAMOX
BNP acetazolamide
dibenzyline
GNP
diltiazem 30mg, 60mg, 120mg
GP
diltiazem 90mg
GNP
diltiazem -er, -sr, -cd
GNP
DIOVAN HCT (PAR)
BNP valsartan/hctz
BNP valsartan
betaxolol
GNP
DIOVAN (PAR)
bisoprolol
GNP
DIURIL
BNP chlorothiazide
bisoprolol/hctz 2.5/6.25mg
GNP
doxazosin
GNP
bisoprolol/hctz 5/6.25mg,
10/6.25mg
GP
DYAZIDE
BNP triamterene/hctz
DYRENIUM
BNP amiloride, spironolactone
EDARBI (PAR)
BNP irbesartan, losartan
EDARBYCLOR (PAR)
BNP irbesartan/hctz, losartan/hctz
EDECRIN
BNP
bumetanide
GNP
BUMEX
BNP bumetanide
BP
BYSTOLIC
CALAN, -SR
BNP verapamil, -sr
candesartan
GNP
enalapril/ -hctz
captopril
GNP
eprosartan
captopril/hctz
GNP
CARDENE SR
BNP nicardipine
CARDIZEM, -SR, -CD, -LA
BNP diltiazem, -er, -sr, -cd
CARDURA
BNP doxazosin
carvedilol
CATAPRES
GP
BNP clonidine
chlorothiazide
GP
chlorthalidone
GNP
clonidine tab
GP
EXFORGE/ -HCT (PAR)
felodipine er
fosinopril
fosinopril/hctz
GP
GNP
BP
GNP
GP
GNP
furosemide
GP
guanabenz
GNP
guanfacine 1mg
GP
guanfacine 2mg
GNP
hydralazine 10mg
clonidine patch
GNP
hydralazine 25mg, 50mg,
100mg
CLORPRES
BNP clonidine + chlorthalidone
hydrochlorothiazide cap
bumetanide, furosemide,
torsemide
GP
GNP
GP
GP = Generic Preferred GNP = Generic Nonpreferred BP = Brand Preferred BNP = Brand Nonpreferred
PAR = Prior Authorization Required EPA = Enhanced Prior Authorization QLL = Quantity Level Limit
PAGE 6
Medications for High Blood Pressure and
Other Cardiovascular Conditions (continued)
Medications for High Blood Pressure and
Other Cardiovascular Conditions (continued)
Drug Name
Drug Name
Alternatives
(please discuss with your physician)
hydrochlorothiazide 25mg,
50mg tab
GP
hydrochlorothiazide 12.5mg tab
GNP
HYZAAR (PAR)
BNP losartan/hctz
GP
indapamide
INDERAL
BNP propranolol
INDERAL LA
BNP propranolol er
INNOPRAN XL
BNP propranolol er
INSPRA
BNP eplerenone
irbesartan/ -hctz
GNP
ISOPTIN SR
BNP verapamil
isradipine
GNP
KERLONE
BNP betaxolol
labetalol
GNP
LASIX
BNP furosemide
LEVATOL
BNP acebutolol, pindolol
GP
lisinopril/ -hctz
Alternatives
(please discuss with your physician)
MICARDIS HCT (PAR)
BNP telmisartan/hctz
MICROZIDE
BNP hydrochlorothiazide
MINIPRESS
BNP prazosin
minoxidil tab
GNP
moexipril/ -hctz
GNP
nadolol
GNP
nadolol/bendroflumethiazide
GNP
NEPTAZANE
BNP methazolamide
nicardipine
GNP
nifedipine, -er
GNP
nimodipine
GNP
nisoldipine er
GNP
NORVASC
BNP amlodipine
perindopril
GNP
pindolol
GNP
prazosin 1mg
GP
prazosin 2mg, 5mg
GNP
PRINIVIL (PAR)
BNP lisinopril
PRINZIDE (PAR)
BNP lisinopril/hctz
PROCARDIA, -XL
BNP nifedipine, -er
LOPRESSOR
BNP metoprolol
LOPRESSOR HCT
BNP metoprolol/hctz
losartan/ -hctz
GNP
LOTENSIN (PAR)
BNP benazepril
LOTENSIN HCT
BNP benazepril/hctz
propranolol 10mg, 20mg, 40mg,
80mg tab
LOTREL (PAR)
BNP amlodipine/benazepril
propranolol 60mg tab
GNP
MAVIK (PAR)
BNP trandolapril
propranolol er
GNP
MAXZIDE
BNP triamterene/hctz
propranolol/hctz
GNP
methazolamide
GNP
quinapril
methyclothiazide
GNP
quinapril/hctz
GP
GP
GNP
methyldopa 250mg
GP
methyldopa 500mg
GNP
reserpine
GNP
methyldopa/hctz
GNP
SAVAYSA
BNP XARELTO
GP
SECTRAL
BNP acebutolol
GNP
SOTYLIZE
BNP sotolol
metolazone 10mg
metolazone 2.5mg, 5mg
metoprolol
GP
ramipril
spironolactone 25mg
GP
GP
metoprolol er
GNP
spironolactone 50mg, 100mg
GNP
metoprolol/hctz
GNP
spironolactone/hctz
GNP
MICARDIS (PAR)
BNP telmisartan
SULAR
BNP nisoldipine er
GP = Generic Preferred GNP = Generic Nonpreferred BP = Brand Preferred BNP = Brand Nonpreferred
PAR = Prior Authorization Required EPA = Enhanced Prior Authorization QLL = Quantity Level Limit
PAGE 7
Preventive Medication List* (continued)
Medications for High Blood Pressure and
Other Cardiovascular Conditions (continued)
Drug Name
Alternatives
(please discuss with your physician)
BNP trandolapril + verapamil
TARKA (PAR)
TEKAMLO
BP
TEKTURNA/ -HCT
BP
telmisartan/-hctz
GNP
telmisartan/amlodipine
GNP
TENEX
BNP guanfacine
TENORETIC
BNP atenolol/chlorthalidone
TENORMIN
BNP atenolol
GP
terazosin
irbesartan/hctz, losartan/
hctz, eprosartan
Medications for High Cholesterol
Drug Name
ADVICOR (EPA)
Alternatives
(please discuss with your physician)
BNP SIMCOR (QLL)
ALTOPREV (PAR)
BNP lovastatin (QLL)
atorvastatin (QLL)
GNP
atorvastatin/amlodipine
GNP
CADUET
BNP atorvastatin/amlodipine
cholestyramine
GNP
colestipol
GNP
CRESTOR (QLL)
BP
fenofibrate
GNP
fluvastatin
GNP
TEVETEN/ -HCT (PAR)
BNP
gemfibrozil
GNP
THALITONE
BNP chlorthalidone
LESCOL (PAR, QLL)
BNP fluvastatin, pravastatin (QLL)
timolol tab
GNP
LESCOL XL (PAR, QLL)
BNP fluvastatin, pravastatin (QLL)
TOPROL XL
BNP metoprolol er
LIPITOR (PAR, QLL)
BNP atorvastatin (QLL)
LIVALO (PAR, QLL)
BNP
torsemide 5mg, 10mg
GP
torsemide 20mg, 100mg
GNP
TRANDATE
BNP labetolol
trandolapril
GNP
trandolapril-verapamil hcl
GNP
triamterene/hctz tablets
GP
TRIBENZOR
BP
lovastatin (QLL)
atorvastatin (QLL),
simvastatin (QLL)
GP
LOVAZA
BNP omega-3 acids ER
MEVACOR (PAR, QLL)
BNP lovastatin (QLL)
niacin er
GNP
NIASPAN
BNP niacin er
omega-3 acids ER
GNP
TWYNSTA (PAR)
BNP telmisartan/amlodipine
UNIRETIC (PAR)
BNP moexipril/hctz
UNIVASC (PAR)
BNP moexipril
valsartan
GNP
VASERETIC (PAR)
BNP enalapril/hctz
simvastatin (QLL)
BNP enalapril
TRILIPIX
BNP fenofibrate
VASCEPA
BNP omega-3 acids ER
VASOTEC (PAR)
GP
verapamil
PRAVACHOL (PAR, QLL)
BNP pravastatin (QLL)
pravastatin (QLL)
GNP
SIMCOR (QLL)
BP
GP
GNP
VYTORIN (QLL)
BP
VERELAN
BNP verapamil, -cr, -sr
WELCHOL
BP
ZAROXOLYN
BNP metolazone
ZETIA
ZEBETA
BNP bisoprolol
ZOCOR (PAR, QLL)
ZESTORETIC (PAR)
BNP lisinopril/hctz
ZESTRIL (PAR)
BNP lisinopril
ZIAC
BNP bisoprolol/hctz
verapamil-cr, -sr
BP
BNP simvastatin (QLL)
GP = Generic Preferred GNP = Generic Nonpreferred BP = Brand Preferred BNP = Brand Nonpreferred
PAR = Prior Authorization Required EPA = Enhanced Prior Authorization QLL = Quantity Level Limit
PAGE 8
Maintenance Medications for Asthma
and COPD
Medications for Mental Health (continued)
Drug Name
Drug Name
Alternatives
(please discuss with your physician)
BP
ADVAIR / -HFA (QLL)
chlorpromazine
ASMANEX (QLL), FLOVENT HFA
BNP
(QLL)
ALVESCO (QLL)
citalopram tab (QLL)
Alternatives
(please discuss with your physician)
GNP
GP
ANORO ELLIPTA
BP
citalopram suspension
GNP
ASMANEX (QLL)
BP
clomipramine
GNP
ATROVENT HFA
BP
clozapine
GNP
BREO ELLIPTA
BP
CLOZARIL
BNP clozapine
COMPAZINE
BNP prochlorperazine
CYMBALTA (PAR)
BNP venlafaxine, -er
desipramine
GNP
BP
desvenlafaxine SR 24 HR (QLL)
GNP
FLOVENT DISKUS (QLL)
BP
doxepin 10mg; solution
FLOVENT HFA (QLL)
BP
doxepin 25mg, 50mg, 75mg,
100mg, 150mg, cream
GNP
EFFEXOR (PAR)
BNP venlafaxine
EFFEXOR XR (PAR, QLL)
BNP venlafaxine er (QLL)
EMSAM PATCH (PAR)
BNP
escitalopram (QLL)
GNP
ESKALITH
BNP lithium
FANAPT (PAR)
BNP
FAZACLO
BNP clozapine
FETZIMA (PAR, QLL)
BNP
fluvoxamine
GNP
GNP
budesonide respules
BP
COMBIVENT
BNP
DALIRESP
DULERA (QLL)
INCRUSE ELLIPTA (PAR)
BNP SPIRIVA
PULMICORT FLEXHALER (QLL)
BNP ASMANEX (QLL)
PULMICORT respules
BNP budesonide respules
QVAR (QLL)
ASMANEX (QLL), FLOVENT HFA
BNP
(QLL)
BP
SPIRIVA
STRIVERDI RESPIMAT
BNP FORADIL, SEREVENT
SYMBICORT (PAR, QLL)
BNP ADVAIR/ -HFA (QLL)
BP
TUDORZA (PAR)
SPIRIVA
Medications for Mental Health
Drug Name
Alternatives
(please discuss with your physician)
fluoxetine capsules 10mg,
20mg (QLL)
GP
BNP
quetiapine, risperidone,
ziprasidone
fluoxetine tablets 10mg (QLL)
GP
fluoxetine tablets 20mg (QLL)
GNP
ABILIFY DISCMELT (PAR)
BNP quetiapine, risperidone
fluoxetine 40mg tab; solution
GNP
amitriptyline 100mg
GNP
fluoxetine (PMDD)
GNP
fluoxetine weekly (QLL)
GNP
GP
amoxapine
GNP
ANAFRANIL
BNP
BRINTELLIX (PAR, QLL)
BNP
bupropion
bupropion, -sr, -xl
CELEXA (PAR, QLL)
fluphenazine 1mg
quetiapine, risperidone,
ziprasidone
fluoxetine (QLL), paroxetine
(QLL)
GP
ABILIFY (PAR)
amitriptyline 10mg, 25mg,
50mg, 75mg, 150mg
citalopram (QLL), paroxetine
(QLL)
GP
fluphenazine 2.5mg, 5mg, 10mg GNP
GEODON (PAR)
BNP ziprasidone
haloperidol tablets
GNP
GNP
imipramine 10mg
GP
GNP
imipramine 25mg, 50mg
GNP
BNP citalopram (QLL)
imipramine pamoate
GNP
fluoxetine (QLL), paroxetine
(QLL)
GP = Generic Preferred GNP = Generic Nonpreferred BP = Brand Preferred BNP = Brand Nonpreferred
PAR = Prior Authorization Required EPA = Enhanced Prior Authorization QLL = Quantity Level Limit
PAGE 9
Preventive Medication List* (continued)
Medications for Mental Health (continued)
Medications for Mental Health (continued)
Drug Name
Drug Name
Alternatives
(please discuss with your physician)
Alternatives
(please discuss with your physician)
IRENKA (PAR)
BNP duloxetine
RAPIFLUX (PAR)
BNP fluoxetine
INVEGA ER (QLL)
BNP risperidone
REMERON
BNP mirtazapine
KHEDEZLA (PAR)
BNP escitalopram
RISPERDAL (PAR)
BNP risperidone
LATUDA
BNP
RISPERDAL M-TAB (PAR)
BNP risperidone, -m
risperidone tablets 0.25mg,
0.5mg, 2mg, 3mg, 4mg; ODT
GNP
BNP
LEXAPRO (EPA, QLL)
quetiapine, risperidone,
ziprasidone
escitalopram (QLL),
citalopram (QLL)
GP
lithium
risperidone tablets 1mg
GP
SARAFEM (PAR)
BNP fluoxetine
BNP lithium
SAPHRIS (PAR)
BNP
loxapine
GNP
SEROQUEL (PAR)
BNP quetiapine
LOXITANE
BNP loxapine
SEROQUEL XR (PAR, QLL)
BNP quetiapine
LUVOX CR
BNP fluvoxamine
sertraline tab
maprotiline
GNP
sertraline suspension
GNP
SERZONE
BNP nefazodone
SURMONTIL
BNP trimipramine
thioridazine 10mg, 25mg,
100mg
GNP
lithium cr
GNP
LITHOBID
GP
mirtazapine 15mg
mirtazapine 7.5mg, 30mg, 45mg GNP
mirtazapine ODT
GNP
NAVANE
BNP thiothixene
nefazodone
GNP
NORPRAMIN
BNP desipramine
GP
nortriptyline cap
GP
thioridazine 50mg
GP
thiothixene 1mg, 2mg
GP
thiothixene 5mg, 10mg
GNP
TOFRANIL
BNP imipramine
tranylcypromine
GNP
nortriptyline suspension
GNP
olanzapine (QLL)
GNP
OLEPTRO ER (PAR)
BNP trazodone
trazodone 50mg, 100mg,
150mg
PAMELOR
BNP nortriptyline
trazodone 300mg
GNP
PARNATE
BNP tranylcypromine
trifluoperazine
GNP
trimipramine
GNP
GP
paroxetine (QLL)
quetiapine, risperidone,
ziprasidone
GP
paroxetine cr (QLL)
GNP
venlafaxine
GNP
PAXIL (PAR, QLL)
BNP paroxetine (QLL)
venlafaxine er (QLL)
GNP
PAXIL CR (PAR, QLL)
BNP paroxetine cr (QLL)
VIIBRYD (PAR)
BNP fluoxetine (QLL), sertraline
perphenazine
GNP
VIVACTIL
PEXEVA (PAR, QLL)
BNP paroxetine (QLL)
WELLBUTRIN (PAR)
PRISTIQ (PAR, QLL)
BNP venlafaxine er (QLL)
WELLBUTRIN, -SR, -XL (PAR)
BNP bupropion, -sr, -xl
prochlorperazine
GNP
ziprasidone
GNP
BP
BNP bupropion
PROZAC (PAR, QLL)
BNP fluoxetine (QLL)
ZOLOFT (PAR)
BNP sertraline
PROZAC WEEKLY (PAR, QLL)
BNP fluoxetine weekly (QLL)
ZYPREXA (PAR, QLL)
BNP olanzapine (QLL)
quetiapine
GNP
ZYPREXA ZYDIS (PAR, QLL)
BNP olanzapine (QLL)
GP = Generic Preferred GNP = Generic Nonpreferred BP = Brand Preferred BNP = Brand Nonpreferred
PAR = Prior Authorization Required EPA = Enhanced Prior Authorization QLL = Quantity Level Limit
PAGE 10
Prenatal Vitamins (examples)
Medications for Anticoagulation
Drug Name
Drug Name
Alternatives
(please discuss with your physician)
Alternatives
(please discuss with your physician)
BP
advanced natalcare
GNP
AGGRENOX
CITRACAL PRENATAL
BNP generics
BRILINTA
BNP clopidogrel
CITRANATAL
BNP generics
cilostazol
GNP
DUET DHA
BNP generics
clopidogrel
GNP
BNP generics
COUMADIN
BNP warfarin
dipyridamole
GNP
ENBRACE HR
NATALCARE RX
BNP generics
PRECARE CONCEIVE
BNP generics
PREFERAOB MIS +DHA
BNP generics
PREMESIS RX
BNP generics
prenatal
GNP
PRIMACARE ONE, -COMBO
BNP generics
PROVIDA DHA
BNP generics
TANDEM DHA
BNP generics
EFFIENT
BP
ELIQUIS
BNP
PERSANTINE
BNP dipyridamole
PLAVIX
BNP clopidogrel
PRADAXA
BNP warfarin
TICLID
BNP ticlopidine
ticlopidine
GNP
warfarin
XARELTO 15mg, 20mg
ZONTIVITY
GP
BP
BNP clopidogrel
The information contained in this document was current at the time
of printing and is subject to change. It is not intended to substitute
for your physician’s independent medical judgment based on your
specific needs. Current as of January 2016.
*This list does not indicate coverage and is not all-inclusive. The coverage of these services depends on the terms of your benefit plan.
Please refer to your Certificate of Coverage for specific details, or call the customer service number listed on your ID/membership card.
This list does not include all conditions that may be prevented with preventive prescription drugs or all preventive drugs available. Capital
BlueCross believes that these drugs satisfy the requirements for preventive care as outlined by the U.S. Treasury Department (see IRS
notice 2004-50 Comprehensive HSA Guidance and IRS notice 2004-23 Health Savings Accounts – Preventive Care) but cannot guarantee
that the Treasury Department would agree that all of these drugs satisfy the definition of preventive care.
GP = Generic Preferred GNP = Generic Nonpreferred BP = Brand Preferred BNP = Brand Nonpreferred
PAR = Prior Authorization Required EPA = Enhanced Prior Authorization QLL = Quantity Level Limit
PAGE 11
If you have questions about your prescription
drug benefit, contact CVS/caremark customer
service at 800.585.5794 (TTY: 866.236.1069).
You may also visit capbluecross.com for other
helpful pharmacy information.
capbluecross.com | capitalbluestore.com
The information contained in this document was current at the time of printing and is subject to change. It is not intended to substitute for your
physician’s independent medical judgement based on your specific needs. Please call the customer service number on your ID card for the most current
preventive medication information and your expected out-of-pocket expenses.
On behalf of Capital BlueCross, CVS/caremark™ assists in the administration of our prescription drug program. CVS/caremark is an independent
pharmacy benefit manager.
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company,® Capital
Advantage Assurance Company ® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association. Communications
issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
NF-641 (12/22/15)