IBM Preventive Drug List – Proposed

IBM Preventive Drug List – Proposed

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) • sodium phosphate salts (Visicol, Osmoprep) Calcium replacement products • calcium acetate (PhosLo) • calcium carbonate • calcium citrate • calcium gluconate • Calcium chloride • Calcium glubionate • Calcium gluceptate • Calcium lactate • 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. All rights in the product names, trade names, or logos of all third-party products appearing in italics in this document, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. .

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