Preventive Drug List2021

COMMERCIAL

In addition to a healthy lifestyle, preventive prescription drugs are important in helping people avoid many types of illnesses and complications from illnesses. This book contains a list of the most commonly prescribed preventive prescription drugs. It does not include all conditions that may be pre-vented with prescription drugs. The prescription drugs listed here serve to maintain a person’s health status and help them avoid acute complications. This list is not all-inclusive and is subject to change.

Important facts about this benefit

• Please refer to your plan documents for coverage on the selected products. Quantity limits, steptherapy, prior authorizations and other coverage limitations may apply.

• Quantities are limited to a maximum 3-month supply per fill.

• Tier 3 medications listed in the Security Health Plan Formulary are not routinely placed on thepreventive list.

• If a generic equivalent product is available, the originator brand medication will not be covered(Example: simvastatin is covered, ZOCOR is not).

• This list is updated annually on a calendar year basis.

The covered preventive drugs are divided into medication categories. The Diabetic Drugs and Supplies category is further divided into three subcategories labeled “Diabetic List,” “Diabetic Supply List” and “Insulin List.” Drugs are considered preventive by Security Health Plan when taken by a person who has developed risk factors for a disease that has not yet become clinically apparent (e.g., blood pressure or cholesterol drugs to prevent heart attack or stroke). Taking these medications as directed by your prescriber can help avoid serious health problems.

Note: Some plans do not include this preventive drug list and some plans cover the entire preventive drug list, while other plans will only cover select categories within the list. Please refer to your plan documents for information specific to your preventive coverage.

You can view your Summary of Benefits and Certificate of Coverage or Policy online when you log into your My Security Health Plan account. If you don’t have an account go to

www.securityhealth.org/registration.

Advair® Diskus Ipratropium 0.02% solutionAlbuterol HFA inhaler Levalbuterol nebulesAlbuterol nebules Metaproterenol syrupAlbuterol Sulfate ER tablet Montelukast granulesAlbuterol Sulfate tablet Montelukast tablet Albuterol syrup Montelukast tablet chewAnoro® Ellipta inhaler QVAR® RediHalerArnuity® Ellipta inhaler Serevent® DiskusBudesonide suspension Spiriva® HandihalerBudesonide/Salmeterol HFA inhaler Spiriva® Respimat inhalerCombivent® Respimat inhaler Stiolto® Respimat inhalerCromolyn nebules Terbutaline tabletFlovent® Diskus Theophylline elixirFlovent® HFA inhaler Theophylline ER tabletFluticasone-Salmeterol inhaler (generic Airduo®) Theophylline tabletIncruse® Ellipta Trelegy® Ellipta inhalerIpratroprium-Albuterol nebules Zafirlukast tablet

Aspirin-Dipyridamole ER capsule Eliquis® tabletBrilinta® tablet Jantoven® tabletClopidogrel tablet Prasugrel tabletDipyridamole tablet Warfarin tablet

Xarelto® tablet

Diabetic List:Acarbose tablet Jentadueto® XR tabletGlimepiride tablet Metformin tabletGlipizide tablet Metformin ER tabletGlipizide ER tablet Nateglinide tabletGlipizide XL tablet Ozempic® injectionGlipizide-Metformin tablet Pioglitazone-Glimepiride tabletGlyxambi® Pioglitazone tabletInvokamet® tablet Repaglinide tabletInvokamet® XR tablet Repaglinide-Metformin tabletInvokana® tablet Synjardy® tabletJanumet® tablet Synjardy® XR tabletJanumet® XR tablet Tolbutamide tablet Januvia® tablet Tradjenta® tablet Jardiance® tablet Trulicity® injection Jentadueto® tablet Victoza® injection

Diabetes drugs and suppliesPrevention of complications related to high blood sugar

Preventive Drug ListAsthma and chronic obstructive pulmonary disease (COPD) drugsPrevention of an asthma or COPD episode

Blood thinnersPrevention of stroke, blood clot or repeat heart attack

Diabetic Supply ListAlcohol prep pads FreeStyle® lancetsBatteries Glucagon® emergency kit Baqsimi Nasal Spray Gvoke® HypopenChemstrips Gvoke® SyringeDexcom® G6 Insulin needlesDiastix® (urine glucose test strips) Insulin syringesFreeStyle® control solution Keto-Diastix® (urine glucose-acet test strip)FreeStyle® Freedom Lite meter LancetsFreeStyle® InsuLinx Plus meter Novopen® EchoFreeStyle® InsuLinx test strips Pen NeedlesFreeStyle® Libre reader Precision® Neo meterFreeStyle® Libre sensors Precision® Neo test strips Freestyle® Libre 2 reader Precision® Xtra beta ketone test stripsFreestyle® Libre 2 sensors Precision® Xtra meterFreeStyle® Lite Meter Precision® Xtra test stripsFreeStyle® Lite test strips Medisense Glucose & Ketone Control SolutionFreeStyle® Optium ketone strips Trueplus® Ketone test strips FreeStyle® test strips Insulin ListFiasp® Novolin® RLantus® Novolin® R FlexpenLantus® Solostar Novolog®Novolin® 70-30 Novolog® FlexpenNovolin® 70-30 Flexpen Novolog® Mix 70-30Novolin® N Novolog® Mix 70-30 FlexpenNovolin® N Flexpen Toujeo®

Amiodarone tablet Isosorbide mononitrate tabletDigoxin tablet Mexilitine capsuleDigoxin oral solution Nitroglycerin sublingual tabletDisopyramide capsule Propafenone tabletDofetilide capsule Quinidine tabletFlecainide tablet Sotalol AF tabletIsosorbide Dinitrate tablet Sotalol tablet

Acetazolamide tablet Hydrochlorothiazide capsuleAcebutolol capsule Hydrochlorothiazide tabletAmiloride tablet Indapamide tabletAmiloride-HCTZ tablet Irbesartan-HCTZ tabletAmlodipine tablet Isradipine capsuleAmlodipine -Valsartan tablet Labetalol tabletAmlodipine -Valsartan-HCTZ tablet Lisinopril tabletAmlodipine-Benazepril tablet Lisinopril-HCTZ tabletAtenolol tablet Losartan tabletAtenolol-Chlorthalidone tablet Losartan-HCTZ tabletBenazepril tablet Methyclothiazide tablet

High blood pressure drugsPrevention of stroke, complications due to high blood pressure and reoccurrence of heart attack

Heart disease drugsPrevention of heart disease

Diabetes drugs and supplies (continued)Prevention of complications related to high blood sugar

Benazepril-HCTZ tablet Methyldopa tabletBetaxolol tablet Metolazone tabletBisoprolol tablet Metoprolol Succinate ER tabletBisoprolol-HCTZ tablet Metoprolol Tartrate tabletBumetanide tablet Metoprolol-HCTZ tabletCandesartan tablet Minoxidil tabletCandesartan-HCTZ tablet Moexipril tabletCaptopril tablet Nadolol tabletCaptopril-HCTZ tablet Nifedipine ER tabletCartia® XT capsule Olmesartan tabletCarvedilol tablet Olmesartan/HCTZ tabletChlorothiazide tablet Perindopril tabletChlorthalidone tablet Pindolol tabletClonidine tablet Prazosin capsuleClonidine Transderm Patch Propranolol tabletDilt® XR capsule Irbesartan tabletDiltiazem 12Hr ER capsule Propranolol ER capsuleDiltiazem 24Hr CD capsule Propranolol-HCTZ tabletDiltiazem 24Hr ER capsule Quinapril tabletDiltiazem ER capsule Quinapril-HCTZ tabletDiltiazem tablet Ramipril capsuleDoxazosin capsule Spironolactone tabletEnalapril tablet Spironolactone-HCTZ tabletEnalapril-HCTZ tablet Telmisartan tabletEpaned oral solution Telmisartan-HCTZ tabletEplerenone tablet Terazosin capsuleEprosartan tablet Timolol tabletEthacrynic Acid tablet Torsemide tabletFelodipine ER tablet Trandolapril tabletFosinopril tablet Trandolapril -Verapamil ER tabletFosinopril-HCTZ tablet Triamterene-HCTZ capsuleFurosemide solution Triamterene-HCTZ tabletFurosemide tablet Valsartan tabletGuanfacine tablet Valsartan-HCTZ tabletHydralazine tablet Verapamil tablet

Verapamil ER tablet

Atorvastatin tablet Fenofibric Acid tabletCholestyramine for oral suspension Fenofibric Acid DR capsuleCholestyramine Light for oral suspension Fluvastatin capsuleColestipol tablet Gemfibrozil tabletColestipol packet Lovastatin tabletColestipol granules Niacin ER tabletColestipol tablet Pravastatin tabletEzetimibe tablet Rosuvastatin tabletFenofibrate (54mg, 160mg) tablet Simvastatin tablet

High cholesterol drugs High cholesterol drugs (prevention of heart disease)

High blood pressure drugs (continued)Prevention of stroke, complications due to high blood pressure and reoccurrence of heart attack

Citalopram tablet Fluoxetine solutionCitalopram solution Paroxetine tablet (10, 20, 30 40 mg)Escitalopram tablet Sertraline tabletEscitalopram solution Sertraline solution Fluoxetine capsule (10, 20, 40 mg)

Alendronate tablet Raloxifene tabletCalcitonin (Salmon) Nasal spray Risedronate tabletIbandronate tablet

Prenatal vitamin tablets (generic versions only)

Prenatal vitamins Prevention of birth defects

Osteoporosis (bone disease) drugsPrevention of bone fractures

Mental health drugsPrevention of symptoms of anxiety, depression or other mood disorders

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