PV3 Preventive Drug List These drugs are covered in full for HSA qualifying plans.
Ace Inhibitors Antihyperlipidemics Calcium Channel Blockers Oral Antidiabetic Agents (hypertension) (high cholesterol) (hypertension) (diabetes) benazepril atorvastatin amlodipine acarbose benazepril / amlodipine cholestyramine amlodipine / benazepril chlorpropamide captopril cholestyramine light diltiazem glimepiride enalapril colestipol diltiazem ER glipizide fosinopril fenofibrate diltiazem CR glipizide ER lisinopril fluvastatin felodipine glipizide XL moexipril gemfibrozil isradipine glipizide / metformin quinapril lovastatin nicardipine glyburide ramipril pravastatin nifedipine glyburide micronized trandolapril simvastatin nifedipine ER glyburide / metformin benazepril / HCTZ nisoldipine metformin captopril / HCTZ Beta-Blockers nimodipine metformin ER enalapril / HCTZ (hypertension) verapamil tolazamide fosinopril / HCTZ acebutolol verapamil CR tolbutamide lisinopril / HCTZ atenolol Diuretics (hypertension) Angiotensin II Receptor moexipril / HCTZ atenolol / chlorthalidone quinapril / HCTZ betaxolol amiloride Blockers (ARBs) bisoprolol bumetanide candesartan Adrenergic Agents carvedilol chlorothiazide eprosartan (hypertension) labetalol chlorthalidone irbesartan clonidine metoprolol succinate eplerenone losartan doxazosin metoprolol tartrate furosemide candesartan / HCTZ guanabenz nadolol hydrochlorothiazide (HCTZ) eprosartan / HCTZ guanfacine immediate release nadolol / bendroflumethiazide indapamide irbesartan / HCTZ methyldopa pindolol methyclothiazide losartan / HCTZ prazosin propranolol metolazone valsartan / HCTZ reserpine timolol spironolactone terazosin atenolol / HCTZ torsemide Generic Thyroid Hormones methyldopa / HCTZ bisoprolol / HCTZ amiloride / HCTZ levothyroxine metoprolol / HCTZ spironolactone / HCTZ liothyronine Vasodilators (chest pain) propranolol / HCTZ triamterene / HCTZ hydralazine continued » isosorbide dintrate Blood Thinning Agents isosorbide mononitrate warfarin nitroglycerin cilostazol nitroglycerin transdermal patch clopidogrel hydralazine / HCTZ dipyridamole ticlopidine Antiarrhythmic Agents amiodarone disopyramide flecainide This is not a complete list of medications covered under your plan. This mexiletine list represents certain common generic medications that are covered in full for HSA-qualified plans and is subject to change without prior propafenone notification. Select brand name medications are only covered under quinidine gluconate CR Human Insulin and Asthma categories. If you have questions about quinidine sulfate your pharmacy benefit, please visitpremera.com/MyPharmacyPlus . If quinidine sulfate CR you don’t have access to our web site, please call the customer service sotalol number listed on the back of your ID card.
An Independent Licensee of the Blue Cross Blue Shield Association 028061 (12-2013) PV3 Preventive Drug List, continued These drugs are covered in full for HSA qualifying plans.
Generic 2nd Generation Generic Osteoporosis Asthma (selected Antidepressants Therapy drugs only) citalopram alendronate Asmanex (120, 14, 30, 60, 7) escitalopram ibandronate inhalers fluoxetine aminophylline fluvoxamine Human Insulin (selected budesonide inhaler paroxetine drugs only) cromolyn sertraline Humulin R Flovent diskus venlafaxine Humulin N Flovent HFA mirtazapine Humulin 70/30 Intal bupropion Novolin R monteleukast Novolin N pulmicort flexhaler Novolin 70/30 theophylline zafirleukast
Miscellaneous pentoxifylline CR digoxin