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Ppo 2500 preventive drug list

High Deductible Health Plan Preventive Drug List
Effective January 1, 2013
The medications that qualify for the preventive drug list are outlined below by
drug classification.
Wellmark Drug
CARDIOVASCULAR MEDICATIONS
List Tier
Generic name
Brand Name*
CALCIUM ANTAGONISTS
nifedipine extended-release – ADALAT CC diltiazem – CARDIZEM/LA/CD, DILACOR XR nifedipine extended-release – PROCARDIA XL diltiazem – TIAZAC, DILTZAC, TAZTIA XL verapamil extended-release – VERELAN-PM, VERELAN SR DIURETICS
methyclothiazide – AQUATENSEN, ENDURON hctz/triamterene – DYAZIDE, MAXZIDE, MAXZIDE-25 hydrochlorothiazide – ESIDRIX, HYDRODIURIL BETA-ADRENERGIC ANTAGONIST DRUGS & BETA-BLOCKER/DIURETIC
COMBINATIONS
ACE INHIBITORS & ACE/DIURETIC COMBINATIONS
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) & ARB/DIURETIC
COMBINATIONS
irbesartan/hctz – AVALIDE 150/12.5mg & 300/12.5mg only ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS
benazepril/amlodipine besylate – LOTREL OTHER ANTIHYPERTENSIVE
clonidine hcl/chlorthalidone – CLORPRES VASODILATING DRUGS
ISODITRATE ER NITROSTAT, NITRO-BID, NITRO-DUR, ANTILIPIDEMIC DRUGS
cholestyramine/aspartame – QUESTRAN LIGHT HMG-COA REDUCTASE INHIBITORS & COMBINATIONS
ENDOCRINE MEDICATIONS
Generic name
Brand Name*
ANTIDIABETIC AGENTS - ALPHA-GLUCOSIDASE INHIBITORS
ANTIDIABETIC AGENTS - SULFONYLUREAS
glyburide – DIABETA, GLYNASE, MICRONASE ANTIDIABETIC AGENTS - THIAZOLIDINEDIONES (TZDs)
ANTIDIABETIC AGENTS - OTHER
pioglitazone/metformin xr – ACTOPLUS MET XR rosiglitazone maleate/metformin – AVANDAMET rosiglitazone maleate / glimepriride – AVANDARYL insulin, human – HUMULIN, HUMULIN PEN, RELION insulin, human – NOVOLIN, NOVOLIN INNOLET, RELION insulin, human aspart & prot – NOVOLOG MIX, NOVOLOG MIX PENFILL insulin, human aspart – NOVOLOG, NOVOLOG PENFILL DRUGS TO TREAT OSTEOPOROSIS
NUTRITION, BLOOD MODIFIERS,ELECTROLYTES
Generic name
Brand Name*
DRUGS AND VITAMINS AFFECTING COAGULATION
RESPIRATORY MEDICATIONS
Generic name
Brand Name*
BRONCHODILATORS - BETA AGONISTS, LONG ACTING
BRONCHODILATORS - BETA AGONISTS, SHORT ACTING
BRONCHODILATORS - COMBINATIONS
albuterol sulfate/ipratropium – DUONEB mometasone furoate/formoterol – DULERA BRONCHODILATORS - OTHER
tiotropium bromide – SPIRIVA HANDIHALER PULMONARY CORTICOSTEROIDS
LEUKOTRIENE MODIFIERS
*For Tier 1 medications, the Brand Name provided is for reference only. In these cases,
only the Tier 1 product is exempt from the deductible. Products that are Tier 2 have no
generic and are exempt from the deductible.

DISCLAIMER:
This list is being provided for illustrative purposes only. For purposes of your qualified
high deductible health plan, these drugs have been identified as being “preventive”.
When you purchase a “preventive” drug using your high deductible health plan, you do
not have to meet your health plan deductible. However, your regular drug cost sharing
does apply and may be based upon whether the drug is a generic (Tier One), preferred
brand (Tier Two), or non-preferred brand drug (Tier Three). Your cost-sharing is defined
in your member materials. If you have questions, please call Wellmark customer
service; the number is on your Wellmark ID card. Please note, this list may change as
new drugs enter the market, drugs become obsolete, or as the definition of “preventive”
evolves over time. Changes may occur throughout the year and plan exclusions may
override this list.
Updated November 2012

Source: http://www.ruan.com/filesimages/pdfs/Benefit%20Plans/Preventive%20Drug%20List.pdf

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