preventive drug benefit programisosorbide dinitrate ext-release isosorbide dinitrate sublingual...

81222.1014 Western Refining PPO A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

PREVENTIVE DRUG BENEFIT PROGRAM

Employee GuideEffective January 1, 2015

PREVENTIVE DRUG BENEFIT PROGRAM

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INTRODUCTIONBlue Cross and Blue Shield of New Mexico (BCBSNM) administers the preventive drug benefit for your group’s health plan. The preventive drug benefit program includes categories of prescription drugs that are substantially used for preventive purposes. Coverage for these medications is subject to your prescription drug benefit plan.

Below and on the following pages is a list of the specific prescription drugs included within each of the preventive drug categories. This list will be reviewed periodically and is subject to change. Coverage of all medications is still subject to your plan limitations, exclusions and out-of-pocket requirements (for example, your prescription drug payment levels).

81222.1014 Western Refining PPO

The preventive drug program currently includes prescription drugs in the following categories:

• Anti-angina• Anti-arrhythmics• Anti-coagulants/anti-platelets• Anti-malarial• Breast cancer prevention• Contraceptives• Diabetes Rx – hypoglycemic agents• Diabetes Rx – insulin and oral• Diabetic supplies• Fluoride supplements

• Heparins/low molecular weight heparin• High blood pressure• High cholesterol• Infant eye ointment (for newborns)• Osteoporosis• Prenatal vitamins• Respiratory• Tobacco cessation• Vaccines

The drugs in each category are listed alphabetically below.

• Generic drugs are listed in bold.• Brand drugs are listed in all CAPITAL letters.* Generic equivalent available

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ANTI-ANGINA DILATRATE SR IMDUR * ISORDIL TITRADOSE 5 MG * ISORDIL TITRADOSE 40 MG isosorbide dinitrate ext-release ISOSORBIDE DINITRATE SUBLINGUAL isosorbide dinitrate tabs, 5 mg, 10 mg, 20 mg ISOSORBIDE DINITRATE 30 MG isosorbide mononitrate isosorbide mononitrate ext-release NITRO-BID NITRO-DUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR * NITRO-DUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin ext-release nitroglycerin lingual pumpspray nitroglycerin patches NITROLINGUAL PUMPSPRAY * NITROMIST NITROSTAT RANEXA

ANTI-ARRHYTHMICS amiodarone BETAPACE * BETAPACE AF * CORDARONE * DIGOXIN SOLN digoxin tabs disopyramide flecainide LANOXIN * mexiletine MULTAQ NORPACE * NORPACE CR propafenone propafenone ext-release quinidine gluconate ext-release quinidine sulfate 300 mg QUINIDINE SULFATE 200 MG QUINIDINE SULFATE EXT-RELEASE RYTHMOL * RYTHMOL SR * sotalol sotalol AF TAMBOCOR * TIKOSYN

ANTI-COAGULANTS/ ANTI-PLATELETS AGGRENOX AGRYLIN * anagrelide BRILINTA cilostazol clopidogrel COUMADIN * dipyridamole EFFIENT ELIQUIS PERSANTINE * PLAVIX * PLETAL * PRADAXA warfarin XARELTO ZONTIVITY

ANTI-MALARIAL ARALEN * atovaquone/proguanil chloroquine phosphate hydroxychloroquine MALARONE mefloquine PLAQUENIL * PRIMAQUINE

BREAST CANCER PREVENTION EVISTA * raloxifene SOLTAMOX tamoxifen

CONTRACEPTIVESCervical CapsFEMCAPPRENTIF CAVITY-RIM CERVICAL CAPPRENTIF FITTING SET

DiaphragmsOMNIFLEX DIAPHRAGMORTHO DIAPHRAGM ALL-FLEXORTHO DIAPHRAGM COIL SPRING KITORTHO DIAPHRAGM FLAT SPRING KITWIDE-SEAL SILICONE DIAPHRAGM KIT

Emergency Progestinlevonorgestrel My WayNext Choice/One DosePLAN B/ONE-STEP *

Emergency EllaELLA

Implants ProgestinIMPLANONNEXPLANON

Injectable ProgestinDEPO-PROVERA CONTRACEPTIVE *DEPO-SUBQ PROVERA 104medroxyprogesterone acetate

IUD ProgestinMIRENA SKYLA

Oral CombinedAltaveraAlyacenApriAranelle AubraAvianeAzuretteBalzivaBEYAZBREVICON *BriellynCaziantCesia ChatealCryselleCyclafemCYCLESSA *Dasetta DelylaDESOGEN * desogestrel/ethinyl estradiol drospirenone/ethinyl estradiol ElinestEmoquetteEnpresse EnskyceEstaryllaESTROSTEP FE * FALESSA FalminaFEMCON FE *

2015 COMMON PREVENTIVE DRUG LIST


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GENERESS FEGianvi GildagiaGildessGildess FeJunelJunel FeKarivaKelnor KurveloLarinLarin Fe LeenaLessina Levonest levonorgestrel/ethinyl estradiolLevoraLO LOESTRIN FELO MINASTRIN FELOESTRIN *LOESTRIN 24 FELOESTRIN FE * LOMEDIA 24 FELorynaLow-OgestrelLuteraMarlissaMicrogestinMicrogestin Fe MINASTRIN 24 FEMIRCETTE *MODICON * Mono-LinyahMononessa MyzilraNATAZIANecon 0.5/35, 1/35, 7/7/7NECON 1/50, 10/11 NikkiNORDETTE *norethindrone/ethinyl estradiolnorethindrone/ethinyl estradiol fe norgestimate/ethinyl estradiolnorgestrel/ethinyl estradiolNORINYL 1+35 *NORINYL 1+50NortrelOcellaOGESTRELOrsythia

ORTHO TRI-CYCLEN * ORTHO TRI-CYCLEN LOORTHO-CEPT *ORTHO-CYCLEN *ORTHO-NOVUMOVCON-35 *Philith Pimtrea PirmellaPortiaPrevifemReclipsenSAFYRALSoliaSprintecSronyxSyedaTilia Fe Tri-EstaryllaTri-Legest Fe Tri-LinyahTRI-NORINYL *Tri-PrevifemTri-SprintecTrinessaTrivoraVelivetVesturaViorele Vyfemla WeraWymzya FeYASMIN *YAZ *ZarahZenchentZenchent FeZeosaZovia 1/35EZOVIA 1/50E

Oral Extended ContinuousAmethiaAmethia LoAMETHYSTCamreseCamrese Lo DayseeIntrovaleJolessa

levonorgestrel/ethinyl estradiolLOSEASONIQUE *QUARTETTEQuasenseSEASONIQUE *

Oral ProgestinCamilaErrinHeather JencyclaJolivette LyzaNOR-QD *Nora-BEnorethindrone NorlyrocORTHO MICRONOR *

Transdermal CombinedORTHO EVRA * XulaneVaginal CombinedNUVARING

DIABETES Rx – HYPOGLYCEMIC AGENTSGLUCAGENGLUCAGEN HYPOKITGLUCAGON EMERGENCY KITPROGLYCEM

DIABETES Rx – INSULIN AND ORAL acarboseACTOPLUS MET *ACTOPLUS MET XRACTOS *AMARYL *APIDRA BYDUREONBYETTA CHLORPROPAMIDECYCLOSET DIABETA DUETACT FARXIGA FORTAMET *glimepirideglipizideglipizide ext-release



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glipizide/metformin GLUCOPHAGE *GLUCOPHAGE XR *GLUCOTROL *GLUCOTROL XL *GLUCOVANCE *GLUMETZAglyburide, generics of Micronase GLYBURIDE, distributor of DIABETAglyburide micronizedglyburide/metforminGLYNASE *GLYSETHUMALOGHUMULIN INVOKAMETINVOKANAJANUMET JANUMET XRJANUVIA JARDIANCE JENTADUETO JUVISYNC KAZANO KOMBIGLYZE XRLANTUSLEVEMIRmetformin metformin ext-releasenateglinideNESINANOVOLINNOVOLIN RELIONNOVOLOGONGLYZA OSENI pioglitazonepioglitazone/glimepiridepioglitazone/metforminPRANDIMETPRANDIN *PRECOSE *RELION R repaglinideRIOMETSTARLIX *SYMLINPEN TANZEUM tolazamide 250 mgTOLAZAMIDE 500 MG

TOLBUTAMIDE TRADJENTAVICTOZA

DIABETIC SUPPLIES ALCOHOL PREP PADS, SWABS ALL DIABETIC SUPPLIES – CALIBRATION LIQUID, INSULIN SYRINGES, LANCETS, LANCET DEVICES, PEN NEEDLES INSULIN INFUSION PUMP TUBING, IV SETS, RESERVOIRS, AND ADAPTERS TEST STRIPS (ACETONE, BLOOD AND URINE GLUCOSE, BLOOD AND URINE KETONE)

FLUORIDE SUPPLEMENTSACT TOTAL CARE DRY MOUTHCOLGATE DRY MOUTH RELIEFFLORICAL FLUOR-A-DAY CHEW TABSFLUORABONFLUORIDEX DAILY DEFENSE SENSITIVITY RELIEF GELFLURA-DROPS GEL-KAM * LISTERINE ESSENTIAL CARELISTERINE RESTORING *LISTERINE SMART RINSE *LISTERINE TOOTH DEFENSE *LISTERINE TOTAL CARE ZEROLISTERINE TOTAL CARE *LISTERINE WHITENING/RESTORING *LOZI-FLURLURIDE * MONOCALNAFRINSE OMNI GEL *PHOS FLURPREVIDENT * REACH KIDSREMBRANDTsodium fluoride chew tabs; crm; drops; gel; oral rinse; paste; soln SODIUM FLUORIDE TABS sodium fluoride/potassium nitrate stannous fluorideTHERA-FLUR-N *

HEPARINS/LOW MOLECULAR WEIGHT HEPARIN ARIXTRA * enoxaparin fondaparinux FRAGMIN heparin sodium inj, 5,000 unit/mL IPRIVASK LOVENOX *

HIGH BLOOD PRESSUREACCUPRIL *ACCURETIC *acebutolol ACEON *ACETAZOLAMIDE 125 MGacetazolamide 250 mg acetazolamide ext-releaseADALAT CC *ALDACTAZIDE 25/25 MG *ALDACTAZIDE 50/50 MGALDACTONE *ALTACE *amilorideamiloride/hydrochlorothiazideamlodipine amlodipine/atorvastatinamlodipine/benazeprilAMTURNIDE ATACAND *ATACAND HCT *atenololatenolol/chlorthalidoneAVALIDE *AVAPRO *AZORbenazeprilbenazepril/hydrochlorothiazideBENICARBENICAR HCTbetaxolol BIDILbisoprololbisoprolol/hydrochlorothiazide bumetanideBYSTOLICCADUET *CALAN *CALAN SR *



candesartan candesartan/hydrochlorothiazidecaptopril CAPTOPRIL/HYDROCHLOROTHIAZIDECARDENE SRCARDIZEM *CARDIZEM CD * CARDIZEM LA 120 MGCARDIZEM LA 180 MG, 240 MG, 300 MG, 360 MG, 420 MG *CARDURA *carvedilolCATAPRES *CATAPRES-TTS * CHLOROTHIAZIDE 250 MGchlorothiazide 500 mgCHLORTHALIDONEclonidine CLORPRESCOREG *COREG CRCORGARD *CORZIDE *COZAAR *DEMADEX *DEMSER DIAMOX *DIBENZYLINEDILACOR XR *diltiazemdiltiazem ext-releaseDIOVAN *DIOVAN HCT *DIURILdoxazosin DUTOPROLDYAZIDE *DYRENIUM EDARBI EDARBYCLOREDECRINenalaprilenalapril/hydrochlorothiazide EPANEDeplerenone eprosartanEXFORGEEXFORGE HCTfelodipine ext-releasefosinopril

fosinopril/hydrochlorothiazide FUROSEMIDE SOLN 8 MG/MLfurosemide soln 10 mg/mL; tabs guanfacine hydralazine hydrochlorothiazideHYZAAR *indapamideINDERAL LA * INDERAL XLINNOPRAN XLINSPRA *irbesartanirbesartan/hydrochlorothiazideISOPTIN SR *ISRADIPINEKERLONE *labetalol LASIX *LEVATOLlisinopril lisinopril/hydrochlorothiazideLOPRESSOR *LOPRESSOR HCT *losartanlosartan/hydrochlorothiazideLOTENSIN *LOTENSIN HCT *LOTREL *MAVIK *MAXZIDE *MAXZIDE-25 *methazolamide METHYCLOTHIAZIDEmethyldopaMETHYLDOPA/ HYDROCHLOROTHIAZIDEmetolazonemetoprolol succinate ext-releasemetoprolol tartratemetoprolol/hydrochlorothiazide MICARDIS *MICARDIS HCT *MICROZIDE *MINIPRESS *minoxidilmoexiprilmoexipril/hydrochlorothiazidenadololnadolol/bendroflumethiazide

NEPTAZANE * nicardipine nifedipinenifedipine ext-releasenimodipinenisoldipine ext-release 8.5 mg, 17 mg, 34 mg NISOLDIPINE EXT-RELEASE 20 MG, 25.5 MG, 30 MG, 40 MGNORVASC * NYMALIZEperindoprilpindololprazosinPRINIVIL *PROCARDIA *PROCARDIA XL *PROPRANOLOL SOLNpropranolol tabspropranolol ext-release PROPRANOLOL/ HYDROCHLOROTHIAZIDEquinapril quinapril/hydrochlorothiazideramiprilSECTRAL *spironolactonespironolactone/hydrochlorothiazide SULAR *TARKATEKAMLOTEKTURNATEKTURNA HCT telmisartantelmisartan/amlodipinetelmisartan/hydrochlorothiazideTENEX *TENORETIC *TENORMIN *terazosin TEVETEN 400 MG TEVETEN 600 MG *TEVETEN HCTTIAZAC *TIMOLOL TABS TOPROL XL *torsemideTRANDATE *trandolapril

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triamterene/hydrochlorothiazide caps, 37.5 / 25 mg; tabs TRIAMTERENE/ HYDROCHLOROTHIAZIDE CAPS, 50/25 MGTRIBENZORTWYNSTA *UNIRETIC *UNIVASC * valsartan valsartan/hydrochlorothiazideVASERETIC *VASOTEC * VERAPAMIL 40 MGverapamil 80 mg, 120 mg verapamil ext-releaseVERELAN *VERELAN PM *ZAROXOLYN * ZEBETA *ZESTORETIC *ZESTRIL *ZIAC *

HIGH CHOLESTEROLADVICORALTOPREV amlodipine/atorvastatinANTARA atorvastatinCADUET *cholestyraminecholestyramine lightCOLESTID *colestipol CRESTOR FENOFIBRATE CAPS 50 MG, 150 MG fenofibrate tabsfenofibrate micronizedFENOFIBRIC ACID fenofibric acid delayed-releaseFENOGLIDEFIBRICOR fluvastatingemfibrozilLESCOL *LESCOL XLLIPITOR *LIPOFEN * LIPTRUZET

LIVALOLOFIBRA *LOPID *lovastatinLOVAZA *MEVACOR * niacin ext-release NIACORNIASPAN * omega-3-acid ethyl estersPRAVACHOL *pravastatin QUESTRAN *QUESTRAN LIGHT *SIMCORsimvastatinTRICOR *TRIGLIDETRILIPIX * VASCEPA VYTORINWELCHOLZETIAZOCOR *

INFANT EYE OINTMENT (for newborns)erythromycin eye oint

OSTEOPOROSISACTONEL *alendronate 5 mg, 10 mg, 35 mg, 70 mgALENDRONATE 40 MGALENDRONATE SOLNATELVIA BINOSTO BONIVA *calcitonin-salmonDIDRONEL * ETIDRONATEEVISTA * FORTICAL FOSAMAX *FOSAMAX PLUS D ibandronateMIACALCIN NASAL * raloxifenerisedronateSKELID

PRENATAL VITAMINSALL PRESCRIPTION PRENATAL VITAMINS

RESPIRATORYACCOLATE *ACCUNEB * acetylcysteine ADVAIR DISKUSADVAIR HFA AEROSPANalbuterolalbuterol ext-releaseALVESCO ANORO ELLIPTAARCAPTA NEOHALER ASMANEXATROVENT HFA BREO ELLIPTABRONDILBROVANA budesonide inhal susp 0.25 mg/2 mL, 0.5 mg/2 mLCOMBIVENT COMBIVENT RESPIMATcromolyn sodium inhal soln DALIRESP DULERA DUONEB *ELIXOPHYLLIN FLOVENT DISKUSFLOVENT HFAFORADIL AEROLIZERipratropium inhal solnipratropium/albuterol inhal soln levalbuterol inhal solnLUFYLLINMAXAIR AUTOHALER METAPROTERENOL montelukastPERFOROMISTPROAIR HFAPROVENTIL HFAPULMICORT FLEXHALERPULMICORT RESPULES 0.25 MG/2 ML, 0.5 MG/2 ML *PULMICORT RESPULES 1 MG/2 ML QVARSEREVENT DISKUSSINGULAIR *

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SPIRIVA HANDIHALER STRIVERDI RESPIMATSYMBICORTterbutaline THEO-24 theophyllinetheophylline ext-release TUDORZA PRESSAIR VENTOLIN HFAVOSPIRE ER *XOPENEXXOPENEX CONCENTRATE *XOPENEX HFAzafirlukast

TOBACCO CESSATIONALL BRAND/GENERIC OTC NICOTINE GUM, LOZENGES, PATCHES bupropion ext-release (smoking cessation)CHANTIXCOMMIT * (OTC)NICODERM CQ * (OTC)NICORETTE * (OTC)nicotine gum, lozenges, patches NICOTINE TRANSDERMAL KIT (OTC) NICOTROL INHALERNICOTROL NSZYBAN *

VACCINESACTHIBADACELAFLURIA BOOSTRIXCERVARIXCOMVAXDAPTACELDIPHTHERIA/TETANUS TOXOID – ADSORBED ENGERIX-BFLUARIX FLUARIX QUADRIVALENT FLUBLOKFLUCELVAXFLULAVAL FLULAVAL QUADRIVALENTFLUMIST NASAL FLUMIST QUADRIVALENTFLUVIRIN FLUZONE FLUZONE QUADRIVALENTGARDASILHAVRIXHIBERIXINFANRIXINFLUENZA A (H1N1)IPOL

KINRIXM-M-R II MENACTRA MENHIBRIXMENOMUNE-A/C/Y/W-135MENVEOPEDIARIXPEDVAX HIBPENTACELPNEUMOVAX 23PREVNAR 13PROQUADRECOMBIVAX HBROTARIXROTATEQ TENIVAC TETANUS TOXOID ADSORBEDTETANUS/DIPHTHERIA TOXOIDS TRIPEDIATWINRIXVAQTAVARIVAXZOSTAVAX

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