BlueSaver Generic Preventive Care Drug Program List

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1 An independent licensee of the Blue Cross and Blue Shield Association. BlueSaver Generic Preventive Care Drug Program List Preventive care drugs are drugs that can help keep you from developing a health condition or related complications of a health condition. The Generic Preventive Care Drug Program includes certain generic preventive care drugs used for the following conditions: Cardiovascular Disease, Osteoporosis, Prenatal Care, Diabetes, and Asthma. For applicable BlueSaver plans, the generic preventive care drugs included on this list are available at 100% coverage, with the deductible waived. All generic drugs listed below are subject to the quantity and day supply limits included with your benefit plan (typically a 90-day supply). Please refer to your benefit plan for a complete list of benefits, including specific exclusions. GENERIC NAME ACARBOSE ACEBUTOLOL HCL ADRENALIN CHLORIDE AFEDITAB CR ALBUTEROL SULFATE ALENDRONATE SODIUM AMILORIDE HCL AMILORIDE HCL-HCTZ AMINOPHYLLINE AMLODIPINE BESYLATE AMLODIPINE BESYLATE-BENAZEPRIL AMLODIPINE-ATORVASTATIN ATENOLOL ATENOLOL-CHLORTHALIDONE ATORVASTATIN CALCIUM BENAZEPRIL HCL BENAZEPRIL-HYDROCHLOROTHIAZIDE BETAXOLOL HCL BISOPROLOL FUMARATE BISOPROLOL-HYDROCHLOROTHIAZIDE BUDESONIDE CALCITONIN-SALMON CALNA CAPTOPRIL CAPTOPRIL-HYDROCHLOROTHIAZIDE CARTIA XT CARVEDILOL CAVAN ONE OMEGA CAVAN-ALPHA KIT DRUG CLASSIFICATION 04HQ1121 R01/13

2 CAVAN-EC SOD DHA CAVAN-HEME OB CHLOROTHIAZIDE CHLOROTHIAZIDE SODIUM CHLORPROPAMIDE CHLORTHALIDONE CHOLESTYRAMINE CHOLESTYRAMINE LIGHT CLONIDINE CLONIDINE HCL CLOPIDOGREL CLORPRES COLESTIPOL HCL COMPLETE NATAL DHA COMPLETENATE CO-NATAL FA COPD CROMOLYN SODIUM DAILY PRENATAL DIFIL-G FORTE DILT-CD DILTIA XT DILTIAZEM 24HR CD DILTIAZEM 24HR ER DILTIAZEM ER DILTIAZEM HCL DILT-XR DILTZAC ER DIPYRIDAMOLE ED-BRON G ELITE OB DHA ELITE-OB ENALAPRIL MALEATE ENALAPRIL-HYDROCHLOROTHIAZIDE EPHEDRINE SULFATE EPINEPHRINE EPROSARTAN MESYLATE ETIDRONATE DISODIUM EZFE FORTE FELODIPINE ER FENOFIBRATE FENOFIBRIC ACID FLUVASTATIN SODIUM FOLBECAL Page 2 of 7

3 FOLCAL DHA FOLCAPS OMEGA-3 FOLIC ACID FOLINATAL PLUS B FOLIVANE-EC CALCIUM DHA NF FOLIVANE-OB FOLIVANE-PRX DHA NF FORTICAL FOSINOPRIL SODIUM FOSINOPRIL-HYDROCHLOROTHIAZIDE GEMFIBROZIL GENTEX ADE GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER GLIPIZIDE XL GLIPIZIDE-METFORMIN GLYBURIDE GLYBURIDE MICRONIZED GLYBURIDE-METFORMIN HCL GUANFACINE HCL HEMENATAL OB HEMENATAL OB + DHA HYDROCHLOROTHIAZIDE IBANDRONATE SODIUM INATAL ADVANCE INATAL GT INATAL ULTRA INDAPAMIDE IPRATROPIUM BROMIDE IPRATROPIUM-ALBUTEROL IRBESARTAN IRBESARTAN-HYDROCHLOROTHIAZIDE ISRADIPINE JANTOVEN KPN LABETALOL HCL LEVALBUTEROL HCL LISINOPRIL LISINOPRIL-HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM LOSARTAN-HYDROCHLOROTHIAZIDE LOVASTATIN MACNATAL CN DHA Page 3 of 7

4 MATZIM LA METAPROTERENOL SULFATE METFORMIN HCL METFORMIN HCL ER METHYCLOTHIAZIDE METHYLDOPA METHYLDOPA-HYDROCHLOROTHIAZIDE METOLAZONE METOPROLOL SUCCINATE METOPROLOL TARTRATE METOPROLOL-HYDROCHLOROTHIAZIDE MOEXIPRIL HCL MOEXIPRIL-HYDROCHLOROTHIAZIDE MONTELUKAST SODIUM MYNATAL MYNATAL ADVANCE MYNATAL PLUS MYNATAL-Z MYNATE 90 PLUS NADOLOL NADOLOL-BENDROFLUMETHIAZIDE NATEGLINIDE NICARDIPINE HCL NIFEDIAC CC NIFEDICAL XL NIFEDIPINE ER NISOLDIPINE NUTRI-TAB OB NUTRI-TAB OB + DHA OB-NATAL ONE OBSTETRIX DHA PERINDOPRIL ERBUMINE PERRY PRENATAL PINDOLOL PIOGLITAZONE PIOGLITAZONE-METFORMIN PNV OB+DHA PNV-DHA PNV-DHA + DOCUSATE PNV-OMEGA PNV-SELECT PNV-TOTAL PR NATAL 400 PR NATAL 400 EC Page 4 of 7

5 PR NATAL 430 PR NATAL 430 EC PRAVASTATIN SODIUM PRENA1 PRENA1 CHEW PRENA1 PLUS PRENAFIRST PRENAISSANCE PRENAISSANCE BALANCE PRENAISSANCE NEXT PRENAISSANCE PLUS PRENAPLUS PRENATABS FA PRENATABS RX PRENATAL 19 PRENATAL AD PRENATAL COMPLETE PRENATAL FORMULA PRENATAL LOW IRON PRENATAL MULTI + DHA PRENATAL PLUS PRENATAL PLUS DHA PRENATAL VITAMINS PRENATAL-U PRENAVITE PREVALITE PROPRANOLOL HCL PROPRANOLOL-HYDROCHLOROTHIAZIDE QUINAPRIL HCL QUINAPRIL-HYDROCHLOROTHIAZIDE RAMIPRIL RELNATE DHA SE-CARE SE-CARE CONCEIVE SE-CARE GESTURE SE-NATAL 19 SE-NATAL 90 SE-NATAL ONE SE-PLETE DHA SE-TAN DHA SETONET SETONET-EC SIMVASTATIN SPIRONOLACTONE Page 5 of 7

6 SPIRONOLACTONE-HCTZ TARON A PRENATAL TARON EC CALCIUM TARON-BC TARON-C DHA TARON-DUO EC TARON-EC CAL TARON-PREX PRENATAL TAZTIA XT TERBUTALINE SULFATE THEOCHRON THEOPHYLLINE THEOPHYLLINE ANHYDROUS TIAZAC TICLOPIDINE HCL TIMOLOL MALEATE TL-SELECT TOLAZAMIDE TOLBUTAMIDE TRANDOLAPRIL TRI RX TRIADVANCE TRIAMTERENE-HCTZ TRIMESIS RX TRINATAL GT TRINATAL RX 1 TRINATAL ULTRA TRINATE TRIVEEN-DUO DHA TRIVEEN-ONE TRIVEEN-PRX RNF TRIVEEN-TEN TRIVEEN-U ULTIMATE OB DHA ULTIMATECARE ADVANTAGE ULTIMATECARE ONE ULTIMATECARE ONE NF VALSARTAN-HYDROCHLOROTHIAZIDE VEMAVITE-PRX 2 VENA-BAL DHA VENATAL COMPLETE DHA VENATAL-FA VERAPAMIL ER VERAPAMIL ER PM Page 6 of 7

7 VERAPAMIL HCL VINACAL VINATE AZ VINATE AZ EXTRA VINATE C VINATE CALCIUM VINATE CARE VINATE GT VINATE IC VINATE II VINATE ONE VINATE PN CARE VINATE ULTRA VINATE-M VIRT-BAL DHA VIRT-BAL DHA PLUS VIRT-PN VIRT-PN DHA VITAFOL-OB VITAFOL-PN VITASPIRE V-NATAL V-NATAL DHA VOL-NATE VOL-PLUS VOL-TAB RX VP-CH-PNV VP-ERA OB PLUS VP-GGR-B6 WARFARIN SODIUM ZAFIRLUKAST ZATEAN-CH ZATEAN-PN ZATEAN-PN DHA ZATEAN-PN PLUS ZINGIBER Page 7 of 7

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