Preventive Drug List - Marshfield Clinic

Preventive Drug List2020

IntroductionIn addition to a healthy lifestyle, preventive prescription drugs are important in helping peopleavoid many types of illnesses and complications from illnesses. This book contains a list of the mostcommonly prescribed preventive prescription drugs. It does not include all conditions that may beprevented with prescription drugs. The prescription drugs listed serve to maintain a person’s healthstatus and to 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 on 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 andSupplies category is further divided into two subcategories labeled “Diabetic List” and “Insulin andInsulin Supply List.” Drugs are considered preventive by Security Health Plan when taken by a personwho has developed risk factors for a disease that has not yet become clinically apparent (e.g., bloodpressure or cholesterol drugs to prevent heart attack or stroke). Taking these medications as directedby your prescriber can help avoid serious health problems.Note: Some plans do not include this preventive drug list and some plans cover the entire preventivedrug list, while other plans will only cover select categories within the list. Please refer to your plandocuments for information specific to your preventive coverage.

Preventive Drug ListAsthma and chronic obstructive pulmonary disease (COPD) drugsPrevention of an asthma or COPD episodeAlbuterol nebulesAlbuterol Sulfate ER tabletAlbuterol Sulfate tabletAlbuterol syrupAnoro Ellipta inhalerArnuity Ellipta inhalerBudesonide suspensionCombivent Respimat inhalerCromolyn nebulesFlovent DiskusFlovent HFA inhalerFluticasone‐Salmeterol inhalation powderIncruse ElliptaIpratroprium‐Albuterol nebulesIpratropium 0.02% solutionLevalbuterol nebulesMetaproterenol tabletMetaproterenol syrupMontelukast granulesMontelukast tabletMontelukast tablet chewQVAR RediHalerSerevent DiskusSpiriva HandihalerSpiriva Respimat inhalerStiolto Respimat inhalerTerbutaline tabletTheophylline elixirTheophylline ER tabletTheophylline tabletTrelegy Ellipta inhalerVentolin HFA inhalerWixela Inhub inhalation powderZafirlukast tabletBlood thinnersPrevention of stroke, blood clot or repeat heart attackBrilinta tabletClopidogrel tabletCoumadin tabletDipyridamole tabletDipyridamole capsuleEliquis tabletJantoven tabletPrasugrel tabletWarfarin tabletXarelto tabletDiabetes drugs and suppliesPrevention of complications related to high blood sugarDiabetic List:Acarbose tabletAlogliptin tabletAlogliptin‐Metformin tabletAlogliptin‐Pioglitazone tabletGlimepiride tabletGlipizide tabletGlipizide ER tabletGlipizide XL tabletGlipizide‐Metformin tabletGlyxambi Invokamet tabletInvokamet XR tabletInvokana tabletJanumet tabletJanumet XR tabletJanuvia tabletJardiance tabletJentadueto tabletJentadueto XR tabletMetformin tabletMetformin ER tabletNateglinide tabletInsulin and Insulin Supply List:Alcohol prep padsBatteriesChemstripsDexcom (if over age 18, prior authorization is required)Diastix (urine glucose test strips)Fiasp FreeStyle control solutionFreeStyle Freedom Lite meterFreeStyle InsuLinx Plus meterFreeStyle InsuLinx test stripsFreeStyle Libre readerFreeStyle Libre sensorsFreeStyle Lite MeterFreeStyle Lite test stripsFreeStyle Optium ketone stripsFreeStyle test stripsFreeStyle lancetsGlucagon emergency kitInsulin needlesInsulin syringesKeto‐Diastix (urine glucose‐acet test strip)Lancets

Diabetes drugs and supplies (continued)Prevention of complications related to high blood sugarDiabetic List:Ozempic injectionPioglitazone‐Glimepiride tabletPioglitazone tabletRepaglinide tabletRepaglinide‐Metformin tabletSynjardy tabletSynjardy XR tabletTolazamide tabletTolbutamide tabletTradjenta tabletTrulicity injectionVictoza injectionInsulin and Insulin Supply List:Lantus Novolin 70‐30Novolin NNovolin RNovolog Novolog Mix 70‐30Precision Neo test stripsPrecision Xtra beta ketone test stripsPrecision Xtra meterPrecision Xtra test stripsPrecision Xtra control solutionToujeo Trueplus Ketone test stripsHeart disease drugsPrevention of heart diseaseAmiodarone tabletDigoxin tabletDigoxin oral solutionDisopyramide capsuleDofetilide capsuleFlecainide tabletIsosorbide Dinitrate tabletIsosorbide mononitrate tabletMexilitine capsuleNitroglycerin sublingual tabletPropafenone tabletQuinidine tabletSotalol AF tabletSotalol tabletHigh blood pressure drugsPrevention of stroke, complications due to high blood pressure and reoccurrence of heart attackAcetazolamide tabletAcebutolol capsuleAfeditab CR tabletAmiloride tabletAmiloride‐HCTZ tabletAmlodipine tabletAmlodipine ‐Valsartan tabletAmlodipine ‐Valsartan‐HCTZ tabletAmlodipine‐Benazepril tabletAtenolol tabletAtenolol‐Chlorthalidone tabletBenazepril tabletBenazepril‐HCTZ tabletBetaxolol tabletBisoprolol tabletBisoprolol‐HCTZ tabletBumetanide tabletCandesartan tabletCandesartan‐HCTZ tabletCaptopril tabletCaptopril‐HCTZ tabletCartia XT capsuleCarvedilol tabletChlorothiazide tabletChlorthalidone tabletClonidine tabletClonidine Transderm PatchDilt XR capsuleDiltiazem tabletIrbesartan‐HCTZ tabletIsradipine capsuleLabetalol tabletLisinopril tabletLisinopril‐HCTZ tabletLosartan tabletLosartan‐HCTZ tabletMethyclothiazide tabletMethyldopa tabletMetolazone tabletMetoprolol Succinate ER tabletMetoprolol Tartrate tabletMetoprolol‐HCTZ tabletMinoxidil tabletMoexipril tabletNadolol tabletNifedipine ER tabletOlmesartan tabletOlmesartan/HCTZ tabletPerindopril tabletPindolol tabletPrazosin capsulePropranolol tablet

High blood pressure drugs (continued)Prevention of stroke, complications due to high blood pressure and reoccurrence of heart attackDiltiazem 12Hr ER capsuleDiltiazem 24Hr CD capsuleDiltiazem 24Hr ER capsuleDiltiazem 24Hr ER tabletDiltiazem ER capsuleDoxazosin capsuleEnalapril tabletEnalapril‐HCTZ tabletEpaned oral solutionEplerenone tabletEprosartan tabletEthacrynic Acid tabletFelodipine ER tabletFosinopril tabletFosinopril‐HCTZ tabletFurosemide solutionFurosemide tabletGuanfacine tabletHydralazine tabletHydrochlorothiazide capsuleHydrochlorothiazide tabletIndapamide tabletIrbesartan tabletPropranolol ER capsulePropranolol‐HCTZ tabletQuinapril tabletQuinapril‐HCTZ tabletRamipril capsuleSpironolactone tabletSpironolactone‐HCTZ tabletTelmisartan tabletTelmisartan‐HCTZ tabletTerazosin capsuleTimolol tabletTorsemide tabletTrandolapril tabletTrandolapril ‐Verapamil ER tabletTriamterene‐HCTZ capsuleTriamterene‐HCTZ tabletValsartan tabletValsartan‐HCTZ tabletVerapamil tabletVerapamil ER tabletHigh cholesterol drugsHigh cholesterol drugs (prevention of heart disease)Atorvastatin tabletCholestyramine for oral suspensionCholestyramine Light for oral suspensionColestipol tabletColestipol granulesColestipol tabletEzetimibe tabletFenofibrate (54mg, 160mg) tabletFenofibric Acid tabletFenofibric Acid DR capsuleFluvastatin capsuleGemfibrozil tabletLovastatin tabletNiacin ER tabletPravastatin tabletRosuvastatin tabletSimvastatin tabletMental health drugsPrevention of symptoms of anxiety, depression or other mood disordersCitalopram tabletCitalopram solutionEscitalopram tabletEscitalopram solutionFluoxetine capsule (10, 20, 40 mg)Fluoxetine solutionParoxetine tables (10, 20, 30 40 mg)Sertraline tabletSertraline solutionOsteoporosis (bone disease) drugsPrevention of bone fracturesAlendronate tabletCalcitonin (Salmon) Nasal sprayIbandronate tabletPrenatal vitaminsPrevention of birth defectsPrenatal vitamin tablets (generic versions only)Raloxifene tabletRisedronate tablet

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