Enhanced - High Deductible Health Plan Preventive Drug List

Enhanced - High Deductible Health Plan Preventive Drug List

A drug is considered to be used for preventive purposes if it is being prescribed primarily (1) to prevent the symptomatic onset of a condition in a person who has developed risk factors for a disease that has not yet become clinically apparent or (2) to prevent recurrence of a disease or condition from which the patient has recovered. A drug is not considered preventive if it is being prescribed to treat an existing symptomatic illness, injury or condition.

This list is specific to HDHP Enhanced formulary benefit plans; not Affordable Care Act (ACA) mandated preventive benefits. To verify if you are eligible for these benefits, use our secure website (mybcbsnc.com) that details the specific benefits for your plan, review your benefit booklet or call the Customer Service number listed on your BCBSNC ID card. This drug list does not apply to the NetResults 5 Tier C formulary. This list is subject to change. 

Anti-Abuse

DISULFIRAM

Anti-Estrogen

ANASTROZOLE

EXEMESTANE 

LETROZOLE

RALOXIFENE

TAMOXIFEN

Anti-Coagulants/Anti-Platelets 

CLOPIDROGREL

DIPYRIDAMOLE

JANTOVEN

WARFARIN SODIUM

High Blood Pressure

ACEBUTOLOL

AFEDITAB CR

AMILORIDE 

AMILORIDE/HYDROCHLOROTHIAZIDE

AMLODIPINE

AMLODIPINE/BENAZEPRIL

AMLODIPINE/OLMESARTAN*

AMLODIPINE/VALSARTAN

ATENOLOL

ATENOLOL/CHLORTHALIDONE

BENAZEPRIL

BENAZEPRIL/HYDROCHLOROTHIAZIDE

BETAXOLOL

BISOPROLOL

BISOPROLOL/HYDROCHLOROTHIAZIDE 

BUMETANIDE TAB

CAPTOPRIL* 

CARTIA XT 

CARVEDILOL 

CHLOROTHIAZIDE TABLETS 

CHLORTHALIDONE 

CLONIDINE TABLETS 

DILTIAZEM CAPSULES and TABLETS (EXTENDED RELEASE) 

DILTIAZEM TABLETS (IMMEDIATE RELEASE)

DILT-XR 

DOXAZOSIN* 

ENALAPRIL TABLETS 

ENALAPRIL/HYDROCHLOROTHIAZIDE 

FELODIPINE (EXTENDED RELEASE)

FOSINOPRIL 

FOSINOPRIL/HYDROCHLOROTHIAZIDE 

FUROSEMIDE TABLETS 

GUANFACINE* 

HYDRALAZINE

HYDROCHLOROTHIAZIDE

INDAPAMIDE 

IRBESARTAN 

IRBESARTAN/HY DROCHLOROTHIAZIDE 

LABETALOL

LISINOPRIL TABLETS

LISINOPRIL/HYDROCHLOROTHIAZIDE

LOSARTAN

LOSARTAN/HYDROCHLOROTHIAZIDE 

METHYCLOTHIAZIDE

METHYLDOPA 

METOPROLOL SUCCINATE (EXTENDED RELEASE) 

METOPROLOL TARTRATE (IMMEDIATE RELEASE) 

METOPROLOL/HYDROCHLOROTHIAZIDE 

MINOXIDIL (2.5MG & 10MG)* 

MOEXIPRIL 

MOEXIPRIL/HYDROCHLOROTHIAZIDE 

NADALOL* 

NIFEDICAL XL 

NIFEDIPINE TABLETS (EXTENDED RELEASE) 

OLMESARTAN MEDOXOMIL* 

OLMESARTAN MEDOXOMIL/HY DROCHLOROTHIAZIDE* 

PERINDOPRIL

PINDOLOL 

PRAZOSIN*

PROPRANOLOL TABLETS (IMMEDIATE RELEASE)

PROPRANOLOL CAPSULES (EXTENDED RELEASE)

QUINAPRIL

QUINAPRIL/HYDROCHLOROTHIAZIDE

RAMIPRIL 

SOTALOL TABLETS 

SPIRONOLACTONE 

SPIRONOLACTONE/HYDROCHLOROT HIAZIDE TABLET 25/25 

TAZTIA XT 

TELMISARTAN 

TRANDOLAPRIL 

TRANDOLAPRIL/VERAPAMIL 

TRIAMTERENE/HY DROCHLOROTHIAZIDE

TERAZOSIN*

TORSEMIDE

VALSARTAN

VALSARTAN/HYDROCHLOROTHIAZIDE 

VERAPAMIL CAPSULES (EXTENDED RELEASE)

VERAPAMIL TABLETS (IMMEDIATE RELEASE AND EXTENDED RELEASE)

High Cholesterol 

ATORVASTATIN

FENOFIBRATE MICRONIZED CAPSULES (43mg, 67mg, 130mg, 134mg, 200mg)

FENOFIBRATE TABLETS (48mg, 54mg, 145mg, 160mg)

GEMFIBROZIL

LOVASTATIN

PRAVASTATIN

SIMVASTATIN

CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE

PREVALITE POWDER 4 GM/DOSE 

ROSUVASTATIN

Diabetes

ACARBOSE*

GLIMEPIRIDE 

GLIPIZIDE (IMMEDIATE RELEASE)

GLIPIZIDE (EXTENDED RELEASE)

GLIPIZIDE XL

GLIPIZIDE/METFORMIN*

GLYBURIDE (IMMEDIATE RELEASE)

GLYBURIDE MICRONIZED

GLYBURIDE/METFORMIN

HUMULIN R U-500*

LANTUS

LANTUS SOLOSTAR

LEVEMIR

LEVEMIR FLEXTOUCH

METFORMIN TABLETS (EXTENDED RELEASE; GENERIC EQUIVALENT TO GLUCOPHAGE XR ONLY)

METFORMIN TABLETS (IMMEDIATE RELEASE)

NOVOLIN 70/30 

NOVOLIN 70/30 RELION

NOVOLIN N

NOVOLIN R

NOVOLIN N RELION

NOVOLIN R RELION 

NOVOLOG

NOVOLOG FLEXPEN

NOVOLOG MIX 70/30

NOVOLOG MIX 70/30 PREFILLED FLEXPEN

NOVOLOG PENFILL

PIOGLITAZONE

TOUJEO SOLOSTAR

TRESIBA FLEXPEN*

Diabetic Supplies

INSULIN PEN NEEDLES

INSULIN SYRINGES

Osteoporosis

ALENDRONATE SODIUM

IBANDRONATE SODIUM

Prenatal Vitamins

PRENATAL VITAMINS

Respiratory

ADVAIR DISKUS

ADVAIR HFA

AIRDUO RESPICLICK

ANORO ELLIPTA*

ARNUITY ELLIPTA*

ASMANEX HFA*

ASMANEX TWISTHALER

BREO ELLIPTA*

BUDESONIDE SUSPENSION*

COMBIVENT*

DULERA

FLOVENT DISKUS

FLOVENT HFA

FLUTICASONE-SALMETEROL AER POWDER

INCRUSE ELLIPTA* 

IPRATROPIUM/ALBUTEROL SOLUTION*

MONTELUKAST TABLETS AND CHEWS*

QVAR

SEREVENT*

SPIRIVA*

STIOLTO*

SYMBICORT

TERBUTALINE*

TRELEGY ELLIPTA*

Tobacco Cessation

BUPROBAN

BUPROPION SR