Preventive Drug List
Preventive Drug List
Preventive Drug List
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<strong>Preventive</strong> <strong>Drug</strong> <strong>List</strong><br />
Effective October 1, 2009<br />
Your high-deductible health plan offers a special benefit for certain prescription medications that can help keep you healthy. By<br />
managing your health before it becomes a problem, you may feel better and save money.<br />
About the <strong>Preventive</strong> Medication Benefit<br />
Coverage for most medications under your high-deductible<br />
health plan, like coverage for other medical services, does not<br />
start until you have met your deductible. But your plan offers<br />
a special benefit for certain prescription medications that may<br />
be recommended by your healthcare provider to prevent an<br />
illness or medical condition. The <strong>Preventive</strong> <strong>Drug</strong> <strong>List</strong> (PDL)<br />
includes all the preventive medications that are covered by<br />
your plan, but does not include medications prescribed to<br />
treat an illness, injury, or condition that you already have.<br />
Medications covered may be used for the following purposes:<br />
• Help smokers quit<br />
• Help prevent medical conditions such as blood clots,<br />
glaucoma, osteoporosis, and stomach ulcers<br />
• Provide prenatal and well-child care<br />
• Help prevent heart disease and reduce the risk of stroke<br />
• Provide immunizations<br />
• Help problem drinkers avoid alcohol<br />
• Help people lose weight<br />
This PDL was developed by Walgreens Health Initiatives,<br />
your health plan’s pharmacy benefit manager. It was<br />
created under the direction of a committee of doctors and<br />
pharmacists in accordance with federal regulations that<br />
specify the types of medications your plan can cover without<br />
a deductible.<br />
How to Use Your <strong>Preventive</strong> Medication Benefit<br />
If your doctor prescribes a medication on the PDL, your<br />
copay will be [$x for generics or brand-name generics, $y for<br />
brand-name medications]. The copay will be applied to your<br />
deductible and may be paid with funds from your health<br />
savings account.<br />
How to Find Medications on the PDL<br />
• Generic medications are listed in lowercase letters below<br />
the word generic. Not all generic medications available<br />
are listed.<br />
• Brand-name generic medications use a brand name instead<br />
of a chemical name. They are listed with the first letter<br />
in Uppercase.<br />
• Brand-name medications are listed in UPPERCASE letters<br />
below the word BRAND. Brand-name medications with<br />
an available generic may not be listed.<br />
• Check different categories for your medication.<br />
All medications on this list have been approved by the Food and<br />
<strong>Drug</strong> Administration.<br />
Additional Information<br />
Not all medications are listed in this PDL. For information<br />
specific to your plan, register on the Walgreens Health<br />
Initiatives web site, MyWHI.com, and click on<br />
<strong>Drug</strong> costs & coverage.<br />
For assistance, please call the Walgreens Customer Care<br />
Center toll-free at 800-207-2568. For information about<br />
your health savings account balance, contact your benefits<br />
plan administrator.<br />
Please note: The PDL is subject to change without notice.<br />
Continued<br />
CS10531A-0909
Walgreens Health Initiatives 2009 <strong>Preventive</strong> <strong>Drug</strong> <strong>List</strong>—Effective October 1, 2009 Page 2<br />
ANTICOAGULATION<br />
Angiotensin Receptor Blockers (ARBs)<br />
Potassium Sparing Diuretics<br />
Anticoagulants<br />
generic BRAND<br />
generic BRAND<br />
generic<br />
Jantoven<br />
warfarin<br />
Platelet Inhibitors<br />
generic<br />
cilostazol<br />
dipyridamole<br />
ticlopidine<br />
BRAND<br />
COUMADIN<br />
BRAND<br />
AGGRASTAT<br />
AGGRENOX<br />
INTEGRILIN<br />
ATACAND<br />
AVAPRO<br />
BENICAR<br />
—<br />
COZAAR<br />
DIOVAN<br />
MICARDIS<br />
TEVETEN<br />
Angiotensin Receptor Blockers (ARBs)<br />
Combinations<br />
amiloride<br />
eplerenone<br />
spironolactone<br />
Renin Inhibitors<br />
generic<br />
Thiazide Diuretics<br />
DYRENIUM<br />
MIDAMOR<br />
BRAND<br />
TEKTURNA<br />
TEKTURNA-HCT<br />
REOPRO<br />
PLAVIX<br />
ASTHMA<br />
Inhaled Corticosteroid Agents<br />
generic BRAND<br />
generic<br />
—<br />
BRAND<br />
ATACAND HCT<br />
AVALIDE<br />
AZOR<br />
BENICAR HCT<br />
DIOVAN HCT<br />
HYZAAR<br />
MICARDIS HCT<br />
generic<br />
chlorothiazide<br />
chlorthalidone<br />
hydrochlorothiazide<br />
indapamide<br />
methyclothiazide<br />
metolazone<br />
BRAND<br />
DIURIL<br />
THALITONE<br />
ADVAIR<br />
AEROBID<br />
AEROBID-M<br />
ASMANEX<br />
—<br />
AZMACORT<br />
FLOVENT<br />
PULMICORT<br />
FLEXHALER<br />
PULMICORT<br />
RESPULES<br />
QVAR<br />
SYMBICORT<br />
BLOOD PRESSURE LOWERING<br />
ACE Inhibitors<br />
generic BRAND<br />
benazepril<br />
ACEON<br />
captopril<br />
enalaprilat<br />
enalapril<br />
fosinopril<br />
lisinopril<br />
moexipril<br />
quinapril<br />
ramipril<br />
trandolapril<br />
TEVETEN HCT<br />
Beta Blockers<br />
generic BRAND<br />
acebutolol<br />
BREVIBLOC<br />
atenolol<br />
BYSTOLIC<br />
bisoprolol<br />
COREG CR<br />
carvedilol<br />
INNOPRAN XL<br />
esmolol<br />
LEVATOL<br />
labetalol<br />
metoprolol<br />
metoprolol ER<br />
nadolol<br />
pindolol<br />
propranolol<br />
propranolol LA<br />
Sorine<br />
sotalol<br />
sotalol AF<br />
Calcium Channel Blockers<br />
generic BRAND<br />
Afeditab CR<br />
CARDENE I.V.<br />
amlodipine<br />
CARDENE SR<br />
Cartia XT<br />
CARDIZEM CD<br />
Dilt-CD<br />
CARDIZEM LA<br />
Dilt XR<br />
CLEVIPREX<br />
Diltia XT<br />
COVERA-HS<br />
CHOLESTEROL REDUCING<br />
Cholesterol Binding Agents<br />
generic BRAND<br />
cholestyramine COLESTID<br />
cholestyramine light WELCHOL<br />
colestipol<br />
Prevalite<br />
Cholesterol Reducing Agents—<br />
Combination<br />
generic BRAND<br />
— ADVICOR<br />
SIMCOR<br />
VYTORIN<br />
Cholesterol Reducing Agents—<br />
Miscellaneous<br />
generic BRAND<br />
fenofibrate<br />
ANTARA<br />
gemfibrozil<br />
FENOGLIDE<br />
lofibra<br />
LIPOFEN<br />
triglide<br />
LOVAZA<br />
NIACOR<br />
NIASPAN<br />
PRAVIGARD PAC<br />
TRICOR<br />
TRILIPIX<br />
ACE Inhibitor Combinations<br />
diltiazem ER<br />
DYNACIRC CR<br />
ZETIA<br />
generic BRAND<br />
benazepril/hctz<br />
captopril/hctz<br />
enalapril/hctz<br />
fosinopril/hctz<br />
—<br />
lisinopril/hctz<br />
moexipril/hctz<br />
Prinzide<br />
quinapril/hctz<br />
Quinaretic<br />
ACE Inhibitor/Calcium Channel Blocker<br />
Combination<br />
diltiazem<br />
diltiazem XR<br />
Diltzac ER<br />
felodipine ER<br />
isradipine<br />
nicardipine<br />
Nifediac CC<br />
Nifedical XL<br />
nifedipine<br />
nifedipine ER<br />
nisoldipine<br />
nisoldipine ER<br />
Taztia XT<br />
NIMOTOP<br />
SULAR<br />
Cholesterol Reducing Agents—Statins<br />
generic BRAND<br />
lovastatin<br />
ALTOPREV<br />
pravastatin<br />
CRESTOR<br />
simvastatin<br />
LESCOL<br />
LESCOL XL<br />
LIPITOR<br />
Cholesterol Reducing Miscellaneous<br />
generic BRAND<br />
— CADUET<br />
LIPOCHOL PLUS<br />
generic BRAND<br />
verapamil<br />
OMACOR<br />
amlodipine/benazepril LEXXEL<br />
TARKA<br />
verapamil ER
Walgreens Health Initiatives 2009 <strong>Preventive</strong> <strong>Drug</strong> <strong>List</strong>—Effective October 1, 2009 Page 3<br />
GASTRIC ULCER PREVENTION<br />
Gastric Acid Secretion Reducer and Ulcer<br />
Therapy<br />
generic BRAND<br />
PREVACID<br />
—<br />
NAPRAPAC<br />
PYLERA<br />
GLAUCOMA<br />
Glaucoma Agents<br />
generic BRAND<br />
betaxolol<br />
ALPHAGAN P<br />
brimonidine<br />
AZOPT<br />
carbastat<br />
BETIMOL<br />
carboptic<br />
BETOPTIC S<br />
carteolol<br />
COMBIGAN<br />
dorzolamide<br />
HUMORSOL<br />
dorzolamide/timolol IOPIDINE<br />
levobunolol<br />
ISOPTO<br />
metipranolol<br />
CARBACHOL<br />
pilocarpine<br />
ISOPTO<br />
timolol<br />
CARPINE 1%<br />
ISOPTO<br />
CARPINE 2%<br />
ISOPTO<br />
CARPINE 4%<br />
ISTALOL<br />
LUMIGAN<br />
MIOCHOL-E<br />
MIOSTAT<br />
PHOSPHOLINE<br />
IODIDE<br />
PILOPINE HS<br />
TIMOPTIC<br />
TRAVATAN<br />
TRAVATAN Z<br />
XALATAN<br />
IMMUNIZATIONS<br />
Vaccines<br />
INFANRIX PF<br />
IPOL<br />
JE-VAX<br />
KINRIX<br />
LYMERIX<br />
MENACTRA<br />
MENOMUNE-A/C/Y/W-<br />
135<br />
MERUVAX II<br />
M-M-R II<br />
M-R-VAX II<br />
MUMPSVAX<br />
ORIMUNE DISPETTE<br />
PEDIARIX<br />
PEDVAXHIB<br />
PENTACEL<br />
PNEUMOVAX 23<br />
PNU-IMUNE 23<br />
PREVNAR<br />
PROQUAD<br />
RABAVERT<br />
RECOMBIVAX HB<br />
ROTARIX<br />
ROTATEQ<br />
STAPHAGE LYSATE<br />
(SPL)<br />
TE ANATOXAL BERNA<br />
TETANUS DIPHTHERIA<br />
TOXOIDS<br />
TETANUS- DIPHTERIA-<br />
DECAVAC<br />
TETANUS TOXOID<br />
ADSORBED<br />
TRIHIBIT<br />
TRIPEDIA<br />
TWINRIX<br />
TYPHIM VI<br />
VAQTA<br />
VARIVAX<br />
VIVOTIF BERNA<br />
YF-VAX<br />
ZOSTAVAX<br />
OSTEOPOROSIS<br />
Osteoporosis Agents<br />
generic BRAND<br />
alendronate<br />
ACTONEL<br />
calcitonin/salmon BONIVA TABLET<br />
etidronate<br />
EVISTA<br />
pamidronate<br />
FORTEO<br />
FORTICAL<br />
FOSAMAX PLUS D<br />
MIACALCIN<br />
RECLAST<br />
ZOMETA<br />
PRENATAL CARE<br />
Prenatal Vitamin Preparations<br />
All generic and brand-name prenatal vitamins<br />
PROBLEM DRINKING<br />
Anti-Alcoholic Preparations<br />
generic BRAND<br />
naltrexone ANTABUSE<br />
CAMPRAL<br />
VIVITROL<br />
SMOKING CESSATION<br />
Smoking Deterrents<br />
generic BRAND<br />
Buproban<br />
NICOTROL<br />
bupropion ER<br />
INHALER<br />
bupropion SR NICOTROL NS<br />
ZYBAN<br />
WELL-CHILD PRODUCTS<br />
Pediatric Vitamin Preparations<br />
All generic and brand-name pediatric<br />
multivitamins and minerals<br />
generic BRAND<br />
OBESITY/WEIGHT LOSS<br />
ACTHIB<br />
Appetite Suppressants<br />
ADACEL<br />
AFLURIA<br />
ATTENUVAX<br />
BOOSTRIX<br />
COMVAX<br />
DAPTACEL<br />
DIPHTHERIA-TETANUS<br />
TOXOID<br />
ENGERIX-B<br />
FLUARIX<br />
FLULAVAL<br />
FLUMIST<br />
FLUOGEN<br />
FLUSHIELD<br />
generic BRAND<br />
benzphetamine ADIPEX-P<br />
diethylpropion BONTRIL PDM<br />
melfiat-105<br />
BONTRIL SR<br />
phendimetrazine DIDREX<br />
phentermine<br />
FASTIN<br />
IONAMIN<br />
MERIDIA<br />
PRO-FAST HS<br />
PRO-FAST SA<br />
PRO-FAST SR<br />
TENUATE<br />
Fat Absorption Decreasing Agents<br />
—<br />
FLUVIRIN<br />
FLUZONE<br />
GARDASIL<br />
HAVRIX<br />
HIBTITER<br />
IMOVAX RABIES<br />
INFANRIX<br />
generic<br />
—<br />
BRAND<br />
XENICAL
Walgreens Health Initiatives 2009 <strong>Preventive</strong> <strong>Drug</strong> <strong>List</strong>—Effective October 1, 2009 Page 4<br />
MISCELLANEOUS<br />
Bone Resorption Inhibitors<br />
generic BRAND<br />
SKELID<br />
Calcium Channel Blockers<br />
generic BRAND<br />
nimodipine<br />
Electrolyte Stabilizers<br />
generic BRAND<br />
GANITE<br />
Iron Replacement<br />
generic BRAND<br />
FE C<br />
Multivitamin Preparations<br />
generic BRAND<br />
VITAMAX<br />
<strong>Drug</strong> names are the property of their respective owners.
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