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Mybenefits.trinity-health.org

High Deductible Health Plan (HDHP) - Health Savings Account (HSA)
Preventive Therapy Drug List
(02/01/14)
ANTICONVULSANTS

ACE INHIBITOR/CALCIUM CHANNEL

COMBINATION ANTIHYPERLIPIDEMICS
BLOCKER COMBINATIONS
lamotrigine ext-rel levetiracetam
BETA-BLOCKERS
DIABETES
ORAL DIABETES AGENTS
CARDIOVASCULAR CONDITIONS -
metoprolol/hydrochlorothiazide nadolol metformin metformin ext-rel ANTIARRHYTHMIC AGENTS
CALCIUM CHANNEL BLOCKERS
HYPERTENSION
ACE INHIBITORS/
ORAL ANTIANGINAL AGENTS
ANGIOTENSIN II RECEPTOR ANTAGONISTS
SL and chewable formulations are not included TRANSDERMAL/TOPICAL ANTIANGINAL
CORONARY ARTERY DISEASE
ANTIHYPERLIPIDEMICS
DIURETICS
Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue System (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications. This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894b 012014 DENTAL CARIES PREVENTION
IMMUNOSUPPRESSIVE AGENTS
spironolactone/hydrochlorothiazide OSTEOPOROSIS
OTHER ANTIHYPERTENSIVE AGENTS
WOMEN'S HEALTH
PREVENTIVE CARE SERVICES
ANTIESTROGENS
AGENTS FOR CHEMICAL DEPENDENCY
AROMATASE INHIBITORS
buprenorphine/naloxone sublingual CONTRACEPTIVES
MENTAL HEALTH
ANTI-OBESITY AGENTS
ANTIDEPRESSANTS
LOW-DOSE MONOPHASIC PILLS
SMOKING DETERRENTS
levonorgestrel/EE 0.1/20 and EE 10 norethindrone acetate/EE 1/20 and iron Over-the-Counter (OTC) products require a prescription. norethindrone acetate/EE 1.5/30 and RESPIRATORY DISORDERS
HIGH-DOSE MONOPHASIC PILLS
ANTICOAGULANTS
BIPHASIC PILLS
ANTICOAGULANTS/
PLATELET AGGREGATION INHIBITORS
TRIPHASIC PILLS
ANTIPSYCHOTICS
VARIOUS CONDITIONS
ANTI-MALARIAL AGENTS
olanzapine orally disintegrating tabs norgestimate/EE 0.18-35/0.215-35/ Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue System (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications. This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894b 012014 CONTINUOUS-CYCLE PILLS
levonorgestrel - Next Choice One Dose EXTENDED-CYCLE PILLS
MISCELLANEOUS CONTRACEPTIVES
PROGESTIN-ONLY PILLS
levonorgestrel/EE 0.15/30 and EE 10 EMERGENCY CONTRACEPTION
Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Some strengths or dosage forms may not be included in the Preventive Therapy Drug List and certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider should you have any questions about coverage. Additional medications may be included in this list from time to time in compliance with Affordable Care Act requirements and/or U.S. Internal Revenue System (IRS) guidance. This list includes medications considered preventive by the IRS; it may not include all preventive medications. This Preventive Therapy Drug List has been adopted by the referenced health plan. CVS Caremark makes no representations regarding its compliance with applicable legal requirements. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. 106-1038894b 012014

Source: http://mybenefits.trinity-health.org/documents/Trinity%20Health%20HDHP%20HSA%20Preventive%20DL_070113.pdf

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