Preventive Drug List

Effective January 1, 2012, for those enrolled in the IBM High Deductible with Health Savings Account plan option under the IBM Managed Pharmacy Program, you will pay your usual coinsurance for preventive medications (those used to prevent a condition from occurring), even if you have not reached your deductible. Medications covered as part of the preventive drug benefit follow the guidelines set by the US Preventive Services Task Force.

Drug Category Examples of Products Antimalarials Limited to these specific drugs: • atovaquone/proguanil (Malarone) • chloroquine (Aralen) • hydroxychloroquine (Plaquenil) • mefloquine (Lariam) • primaquine Anti-influenza • oseltamivir (Tamiflu) • zanamivir (Relenza) Bowel evacuant products • polyethylene glycol 3350 combination products (Colyte, Golytely, HalfLytely, Nulytely, Trilyte, Moviprep) • phosphate salts (Visicol, Osmoprep) replacement products • calcium acetate (PhosLo) • • • • • • Calcium gluceptate • • Calcium orotate • Calcium pangamate • Calcium phosphate

Contraceptives • Apri • medroxyprogesterone (DepoProvera) • Estrostep Fe • Lybrel • NuvaRing • Ortho Evra • Ortho Tri-Cyclen • Ortho Tri-Cyclen Lo • Ovcon • Seasonale • TriNessa • Trivora • Yasmin • Seasonique • YAZ Miscellaneous agents Limited to this specific drug: • hepatitis B immune globulin (HepaGam B) Prenatal vitamins • Nata chew • Nata fort • Natelle • PreCare • Prenatal Plus, Prenatal Rx • Prima Care • Vita fol-OB

If you have any questions, please call our dedicated IBM support team at CVS Caremark Customer Care toll-free at 855-465-0030 (TTY: 1-800-863-5488), If you have questions about your prescriptions or benefits, you can contact Customer Care 24 hours a day, seven days a week.

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