High Deductible Health Plan (HDHP) - Health Savings Account (HSA) Preventive Therapy Drug List
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- Frank Owens
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1 (12/01/15) High Deductible Health Plan (HDHP) - Health Savings Account (HSA) ANTICOAGULANTS/ ANTIPLATELETS ANTICOAGULANTS enoxaparin fondaparinux warfarin Jantoven ARIXTRA COUMADIN COUMADIN INJECTION DURLAZA ELIQUIS FRAGMIN IPRIVASK LOVENOX PRADAXA SAVAYSA XARELTO PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole dipyridamole ext-rel/aspirin ticlopidine AGGRENOX BRILINTA EFFIENT PERSANTINE PLAVIX ZONTIVITY ANTICONVULSANTS carbamazepine carbamazepine ext-rel clonazepam divalproex sodium delayed-rel divalproex sodium ext-rel ethosuximide felbamate lamotrigine lamotrigine ext-rel levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin phenytoin sodium extended primidone tiagabine topiramate topiramate ext-rel valproic acid zonisamide Epitol APTIOM Preventive Therapy Drug List BANZEL CARBATROL CELONTIN DEPAKENE DEPAKOTE DEPAKOTE ER DILANTIN FELBATOL FYCOMPA GABITRIL KEPPRA KEPPRA XR KLONOPIN LAMICTAL LAMICTAL XR LAMICTAL XR KIT MYSOLINE ONFI OXTELLAR XR PEGANONE PHENYTEK POTIGA QUDEXY XR SABRIL STAVZOR TEGRETOL TEGRETOL-XR TOPAMAX TOPIRAMATE ER TRILEPTAL TROKENDI XR VIMPAT ZARONTIN ZONEGRAN BOWEL PREPARATIONS peg 3350/electrolytes Gavilyte COLYTE GOLYTELY MOVIPREP NULYTELY OSMOPREP PREPOPIK SUPREP CARDIOVASCULAR CONDITIONS - OTHER ANTIARRHYTHMIC AGENTS amiodarone disopyramide flecainide propafenone propafenone ext-rel sotalol sotalol AF Pacerone BETAPACE BETAPACE AF CORDARONE NORPACE NORPACE CR RYTHMOL RYTHMOL SR SOTYLIZE TIKOSYN NEPRILYSIN/ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ENTRESTO ORAL ANTIANGINAL AGENTS isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate ext-rel nitroglycerin nitroglycerin lingual spray nitroglycerin sublingual aerosol DILATRATE-SR ISORDIL NITROLINGUAL NITROMIST SL and chewable formulations are not included on this list. TRANSDERMAL/TOPICAL ANTIANGINAL AGENTS nitroglycerin transdermal Minitran NITRO-BID NITRO-DUR CORONARY ARTERY DISEASE ANTIHYPERLIPIDEMICS atorvastatin cholestyramine colestipol fenofibrate fenofibric acid fenofibric acid delayed-rel fluvastatin fluvastatin ext-rel gemfibrozil lovastatin niacin ext-rel omega-3 acid ethyl esters pravastatin simvastatin Niacor Prevalite
2 ALTOPREV ANTARA COLESTID CRESTOR FENOGLIDE FIBRICOR JUXTAPID LESCOL XL LIPITOR LIPOFEN LIVALO LOCHOLEST/LOCHOLEST LIGHT LOFIBRA LOPID LOVAZA MEVACOR NIASPAN PRAVACHOL QUESTRAN/QUESTRAN LIGHT TRICOR TRIGLIDE TRILIPIX VASCEPA WELCHOL ZETIA ZOCOR COMBINATION ANTIHYPERLIPIDEMICS amlodipine/atorvastatin ADVICOR CADUET LIPTRUZET SIMCOR VYTORIN DIABETES DIAGNOSTIC AGENTS AND SUPPLIES BLOOD GLUCOSE MONITORS - ALL BLOOD GLUCOSE STRIPS - ALL CONTROL SOLUTIONS INSULIN SYRINGES AND NEEDLES - ALL KETONE BLOOD TEST STRIPS - ALL LANCETS, LANCET DEVICES URINE TESTING STRIPS - ALL INHALED DIABETES AGENTS AFREZZA INJECTABLE DIABETES AGENTS APIDRA BYDUREON BYETTA HUMALOG HUMULIN LANTUS LEVEMIR NOVOLIN NOVOLOG SYMLINPEN TANZEUM TOUJEO TRESIBA TRULICITY VICTOZA Over-the-Counter (OTC) products require a prescription. Coverage may vary by plan. ORAL DIABETES AGENTS acarbose chlorpropamide glimepiride glipizide glipizide ext-rel glipizide/metformin glyburide glyburide, micronized glyburide/metformin metformin metformin ext-rel nateglinide pioglitazone pioglitazone/glimepiride pioglitazone/metformin repaglinide tolbutamide ACTOPLUS MET ACTOPLUS MET XR ACTOS AMARYL DIABETA DUETACT FARXIGA FORTAMET GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVANCE GLUMETZA GLYNASE GLYSET GLYXAMBI INVOKAMET INVOKANA JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO KAZANO KOMBIGLYZE XR METAGLIP NESINA ONGLYZA OSENI PRANDIMET PRANDIN PRECOSE RIOMET STARLIX SYNJARDY TRADJENTA XIGDUO XR HEMATOLOGIC AGENTS ADVATE ALPHANATE ALPHANINE SD ALPROLIX BEBULIN BENEFIX CORIFACT ELOCTATE HELIXATE FS HEMOFIL M HUMATE-P IXINITY KOATE-DVI KOGENATE KOGENATE FS MONOCLATE-P MONONINE NOVOEIGHT PROFILNINE SD RECOMBINATE RIXUBIS TRETTEN XYNTHA HYPERTENSION ACE INHIBITORS/ANGIOTENSIN II RECEPTOR ANTAGONISTS AND COMBINATION AGENTS amlodipine/benazepril benazepril benazepril/hydrochlorothiazide candesartan candesartan/hydrochlorothiazide captopril captopril/hydrochlorothiazide enalapril enalapril/hydrochlorothiazide eprosartan fosinopril fosinopril/hydrochlorothiazide irbesartan irbesartan/hydrochlorothiazide lisinopril lisinopril/hydrochlorothiazide losartan losartan/hydrochlorothiazide moexipril moexipril/hydrochlorothiazide perindopril quinapril quinapril/hydrochlorothiazide ramipril telmisartan telmisartan/hydrochlorothiazide trandolapril trandolapril/verapamil ext-rel valsartan valsartan/hydrochlorothiazide
3 ACCUPRIL ACCURETIC ACEON ALTACE ATACAND ATACAND HCT AVALIDE AVAPRO BENICAR BENICAR HCT COZAAR DIOVAN DIOVAN HCT EDARBI EDARBYCLOR EPANED HYZAAR LOTENSIN LOTENSIN HCT LOTREL MAVIK MICARDIS MICARDIS HCT PRESTALIA PRINIVIL TARKA TEVETEN TEVETEN HCT VASERETIC VASOTEC ZESTORETIC ZESTRIL BETA-BLOCKERS AND COMBINATION AGENTS acebutolol atenolol atenolol/chlorthalidone betaxolol bisoprolol bisoprolol/hydrochlorothiazide carvedilol labetalol metoprolol metoprolol succinate ext-rel metoprolol/hydrochlorothiazide nadolol nadolol/bendroflumethiazide pindolol propranolol propranolol ext-rel propranolol/hydrochlorothiazide timolol maleate BYSTOLIC COREG COREG CR CORGARD CORZIDE DUTOPROL INDERAL LA KERLONE LEVATOL LOPRESSOR LOPRESSOR HCT SECTRAL TENORETIC TENORMIN TOPROL-XL TRANDATE ZEBETA ZIAC CALCIUM CHANNEL BLOCKERS AND COMBINATION AGENTS amlodipine diltiazem diltiazem ext-rel diltiazem XR felodipine ext-rel isradipine nicardipine nifedipine nifedipine ext-rel nisoldipine ext-rel verapamil verapamil ext-rel Afeditab CR Cartia XT Dilt-XR Matzim LA Nifediac CC Nifedical XL Taztia XT ADALAT CC CALAN CALAN SR CARDIZEM CARDIZEM CD CARDIZEM LA ISOPTIN SR NORVASC PROCARDIA PROCARDIA XL SULAR TIAZAC VERELAN VERELAN PM DIURETICS amiloride/hydrochlorothiazide chlorothiazide chlorthalidone hydrochlorothiazide indapamide methyclothiazide spironolactone/hydrochlorothiazide triamterene/hydrochlorothiazide ALDACTAZIDE DIURIL DYAZIDE MAXZIDE MICROZIDE OTHER ANTIHYPERTENSIVE AGENTS amlodipine/telmisartan amlodipine/valsartan/ hydrochlorothiazide clonidine clonidine transdermal guanabenz guanfacine hydralazine methyldopa methyldopa/hydrochlorothiazide minoxidil reserpine Clorpres AZOR CATAPRES CATAPRES-TTS EXFORGE EXFORGE HCT TEKTURNA TEKTURNA HCT TENEX TRIBENZOR TWYNSTA IMMUNIZING AGENTS ALLERGENIC EXTRACTS CERVARIX CHOLERA VACCINE COMBINATION VACCINES CYTOMEGALOVIRUS IMMUNE GLOBULIN DPT VACCINE DT VACCINE DTaP VACCINE GARDASIL GARDASIL 9 GRASTEK HEPATITIS A VACCINE HEPATITIS B IMMUNE GLOBULIN HEPATITIS B VACCINE HIB VACCINE INFLUENZA VACCINE JAPANESE ENCEPHALITIS VACCINE MEASLES VACCINE MENINGOCOCCAL VACCINE MUMPS VACCINE ORALAIR PNEUMOCOCCAL VACCINE POLIO VACCINE PREVNAR 13 RABIES IMMUNE GLOBULIN RABIES VACCINE RAGWITEK RHO (D) IMMUNE GLOBULIN ROTARIX ROTATEQ RSV VACCINE RUBELLA VACCINE TETANUS IMMUNE GLOBULIN TYPHOID VACCINE VARICELLA VACCINE
4 VARICELLA-ZOSTER IMMUNE GLOBULIN YELLOW FEVER VACCINE ZOSTAVAX MENTAL HEALTH ANTIDEPRESSANTS amitriptyline amoxapine bupropion bupropion ext-rel citalopram clomipramine desipramine doxepin duloxetine delayed-rel escitalopram fluoxetine fluoxetine delayed-rel fluvoxamine imipramine HCl imipramine pamoate maprotiline mirtazapine nortriptyline paroxetine HCl paroxetine HCl ext-rel phenelzine protriptyline sertraline tranylcypromine trazodone venlafaxine venlafaxine ext-rel ANAFRANIL APLENZIN BRINTELLIX CELEXA CYMBALTA EFFEXOR XR EMSAM FETZIMA FORFIVO XL IRENKA KHEDEZLA LEXAPRO MARPLAN NARDIL NORPRAMIN OLEPTRO PAMELOR PARNATE PAXIL PAXIL CR PEXEVA PRISTIQ PROZAC PROZAC WEEKLY REMERON SURMONTIL TOFRANIL TOFRANIL-PM VIIBRYD WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL ZOLOFT ANTIPSYCHOTICS aripiprazole chlorpromazine clozapine fluphenazine fluphenazine decanoate haloperidol loxapine olanzapine olanzapine orally disintegrating tabs paliperidone perphenazine quetiapine risperidone thioridazine thiothixene trifluoperazine ziprasidone ABILIFY ABILIFY MAINTENA ARISTADA CLOZARIL EQUETRO FANAPT FAZACLO GEODON HALDOL HALDOL DECANOATE INVEGA INVEGA SUSTENNA INVEGA TRINZA LATUDA REXULTI RISPERDAL RISPERDAL CONSTA SAPHRIS SEROQUEL SEROQUEL XR VERSACLOZ ZYPREXA ZYPREXA ZYDIS OBSESSIVE COMPULSIVE DISORDER fluvoxamine ext-rel OSTEOPOROSIS alendronate calcitonin calcitonin/salmon ibandronate raloxifene risedronate ACTONEL ATELVIA BINOSTO BONIVA BONIVA INJECTION EVISTA FORTICAL FOSAMAX FOSAMAX PLUS D MIACALCIN NASAL SPRAY PROLIA RECLAST PREVENTIVE CARE SERVICES AGENTS FOR CHEMICAL DEPENDENCY acamprosate calcium buprenorphine sublingual buprenorphine/naloxone sublingual disulfiram naltrexone Depade ANTABUSE BUNAVAIL REVIA SUBOXONE FILM ZUBSOLV ANTI-OBESITY AGENTS benzphetamine diethylpropion diethylpropion ext-rel phendimetrazine phendimetrazine ext-rel phentermine ADIPEX-P BELVIQ BONTRIL CONTRAVE QSYMIA REGIMEX SAXENDA SUPRENZA XENICAL SMOKING DETERRENTS bupropion ext-rel nicotine polacrilex nicotine transdermal Buproban CHANTIX NICODERM CQ NICORETTE GUM NICORETTE LOZENGE NICOTROL INHALER NICOTROL NS ZYBAN Over-the-Counter (OTC) products require a prescription. Coverage may vary by plan. RESPIRATORY DISORDERS RESPIRATORY AGENTS budesonide suspension cromolyn sodium montelukast zafirlukast
5 ACCOLATE ADVAIR ADVAIR HFA AEROSPAN ALVESCO ARNUITY ELLIPTA ASMANEX BREO ELLIPTA DULERA FLOVENT DISKUS FLOVENT HFA PULMICORT QVAR SINGULAIR SYMBICORT SYNAGIS XOLAIR ZYFLO ZYFLO CR SUPPLIES SPACER DEVICES SPACER SUPPLIES VARIOUS CONDITIONS ANTI-MALARIAL AGENTS atovaquone/proguanil chloroquine mefloquine ARALEN MALARONE PRIMAQUINE DENTAL CARIES PREVENTION sodium fluoride PEDIATRIC MULTIVITAMINS WITH FLUORIDE - ALL MARKETED PRODUCTS HEREDITARY ANGIOEDEMA AGENTS CINRYZE IMMUNOSUPPRESSIVE AGENTS cyclosporine caps mycophenolate mofetil mycophenolate sodium delayed-rel sirolimus tacrolimus Gengraf ASTAGRAF XL CELLCEPT ENVARSUS XR MYFORTIC NEORAL NULOJIX PROGRAF RAPAMUNE SANDIMMUNE ZORTRESS MULTIPLE SCLEROSIS AGENTS glatiramer AUBAGIO AVONEX BETASERON COPAXONE EXTAVIA GILENYA LEMTRADA PLEGRIDY REBIF TECFIDERA TYSABRI WOMEN'S HEALTH ANTIESTROGENS tamoxifen SOLTAMOX AROMATASE INHIBITORS anastrozole exemestane letrozole ARIMIDEX AROMASIN FEMARA CONTRACEPTIVES EE = ethinyl estradiol ME = mestranol LOW-DOSE MONOPHASIC PILLS desogestrel/ee 0.15/30 drospirenone/ee 3/30 ethynodiol diacetate/ee 1/35 levonorgestrel/ee 0.1/20 and EE 10 levonorgestrel/ee 0.15/30 norethindrone acetate/ee 1/20 norethindrone acetate/ee 1/20 and iron norethindrone acetate/ee 1.5/30 norethindrone acetate/ee 1.5/30 and iron norethindrone/ee 0.4/35 norethindrone/ee 0.5/35 norethindrone/ee 0.8/25 chewable norethindrone/ee 1/35 norethindrone/ee 1/50 norethindrone/me 1/50 norgestimate/ee 0.25/35 norgestrel/ee 0.3/30 MINASTRIN 24 FE HIGH-DOSE MONOPHASIC PILLS ethynodiol diacetate/ee 1/50 norgestrel/ee 0.5/50 BIPHASIC PILLS desogestrel/ee 0.15/20 TRIPHASIC PILLS desogestrel/ee / / mg-mg levonorgestrel/ee / / mg-mcg norethindrone/ee / / 1-35 mg-mcg norethindrone/ee /1-35/ mg-mcg norethindrone/ee 1-20/1-30/ 1-35 mg-mcg norgestimate/ee / / mg-mcg ORTHO TRI-CYCLEN LO FOUR-PHASIC NATAZIA EXTENDED-CYCLE PILLS drospirenone/ee 3/20 drospirenone/ee 3/30 levonorgestrel/ee 0.1/20 levonorgestrel/ee 0.15/30 levonorgestrel/ee 0.15/30 and EE 10 BEYAZ LO LOESTRIN FE LOESTRIN 24 QUARTETTE SAFYRAL CONTINUOUS-CYCLE PILLS levonorgestrel/ee 0.09/20 PROGESTIN-ONLY PILLS norethindrone 0.35 mg EMERGENCY CONTRACEPTION levonorgestrel levonorgestrel - Next Choice One Dose ELLA PLAN B ONE-STEP TRANSDERMAL PATCH norelgestromin/ee ORTHO EVRA MISCELLANEOUS CONTRACEPTIVES medroxyprogesterone acetate 150 mg/ml DEPO-SUBQ PROVERA 104 DIAPHRAGM FEMCAP IMPLANON LILETTA MIRENA NEXPLANON NUVARING PARAGARD T380A SKYLA PRENATAL VITAMINS PRENATAL VITAMINS - ALL PRESCRIPTION
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