732660.1016

Employee GuideEffective January 1, 2017

PREVENTIVE DRUG BENEFIT PROGRAMFOR GROUPS USING THE BASIC OR ENHANCED DRUG LIST

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

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INTRODUCTION

Blue Cross and Blue Shield of Texas (BCBSTX) administers the preventive drug benefit for your group’s high-deductible health plan (“HDHP”), which has been designed for use with health savings accounts (“HSAs”). The preventive drug benefit program includes categories of prescription drugs that are frequently used for preventive purposes. If your doctor has prescribed any of them to you for preventive purposes, then you and your HSA-eligible dependents may have coverage before satisfying your HDHP deductible.

Below and on the following pages is a guide listing some examples of drugs that are commonly prescribed for preventive purposes. Coverage of all medications is still subject to your HDHP limitations, exclusions and out-of-pocket requirements (for example, your prescription drug payment levels). Coverage of some medications or drug products may be covered under your medical benefit.

IMPORTANT REMINDER: These drugs could also at times be prescribed for treatment purposes. As a result, the listing of a drug in the Guide does not mean that it will be covered by your particular benefit plan before your HDHP deductible is satisfied. If your doctor has prescribed a listed drug for treatment purposes (and not preventive purposes) then your plan does not provide coverage for that drug before your HDHP deductible is satisfied.

As each individual’s medical circumstances are different, and because proper classification is necessary for you to ensure you are complying with your HDHP tax obligations, it is important for you to confirm the purpose of the prescription with your doctor. Please call the number on the back of your member ID card when your doctor confirms to you that he or she prescribed one of the listed drugs for treatment purposes so your claims can be processed correctly. Unless you provide us with this information, claims for the drugs listed in the Guide will be processed as “preventive,” and you or your doctor may be asked by us to provide medical records showing that the drug you’re taking is being used for prevention. Remember, if you improperly classify the drug, it may result in adverse tax consequences, so please be sure to take the confirming step to properly classify your claim.

REMEMBER: Just because a drug is on the list, doesn’t always mean it is covered.

FOLLOW THESE STEPS:

1. Find your drug in the Guide.

2. Talk to your doctor about whether your drug is in fact being prescribed for preventive purposes (and not treatment purposes).

3. If prescribed for treatment purposes, call the number on the back of your ID card to let us know.

4. If prescribed for preventive purposes, there is no need to call.

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This Guide lists some, but not all, examples of drugs that are commonly prescribed for preventive purposes. It is being provided to you at your employer’s request as a resource to help you in managing your prescription drug benefits under your employer’s HDHP.

This list does not include all drugs that may be prescribed as preventive. It will be reviewed periodically and is subject to change. Coverage of all medications is still subject to your HDHP limitations, exclusions and out-of pocket requirements (for example, your prescription drug payment levels). Coverage of some medications or drug products may be covered under your medical benefit.

It is important to note, for the reasons described in the Introduction to this Guide, that the listing of a drug in the Guide does not mean that it will be covered by your particular benefit plan before your HDHP deductible is satisfied. Please follow the steps outlined in the Introduction to ensure you are properly directing the processing of your claims.

The preventive drug program currently includes prescription drugs in the following categories:

• Anti-angina

• Anti-arrhythmics

• Anti-coagulants/anti-platelets

• Breast cancer primary and secondary prevention

• Contraceptives

• Diabetes medications

• Diabetic supplies

• Fluoride supplements

• Heparins/low molecular weight heparin

• High blood pressure

• High cholesterol

• Infant eye ointment (for newborns)

• Osteoporosis

• Prenatal vitamins

• Respiratory

The drugs in each category are listed alphabetically on the following pages.

Generic drugs are listed in bold.Brand drugs are listed in all CAPITAL letters.Asterisk (*) denotes generic equivalent available

Please be reminded that health savings accounts (HSAs) have tax and legal ramifications. Blue Cross and Blue Shield of Texas does not provide legal or tax advice, and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on, for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products.

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ANTI-ANGINADILATRATE SRISORDIL TITRADOSE 5 MG* ISORDIL TITRADOSE 40 MGisosorbide dinitrate 5 mg, 10 mg,

20 mgISOSORBIDE DINITRATE 30 MGISOSORBIDE DINITRATE ERisosorbide mononitrateisosorbide mononitrate ext-releaseNITRO-BIDNITRO-DUR 0.1 MG/HR, 0.2 MG/HR,

0.4 MG/HR, 0.6 MG/HR*NITRO-DUR 0.3 MG/HR, 0.8 MG/HRnitroglycerin ext-release NITROGLYCERIN LINGUALnitroglycerin lingual spraynitroglycerin patchesNITROLINGUAL PUMPSPRAY*NITROMISTNITROSTATRANEXA

ANTI-ARRHYTHMICSamiodaroneBETAPACE*BETAPACE AF*CORDARONE*DIGOXIN SOLNdigoxin tabsdisopyramidedofetilideflecainideLANOXIN 0.0625 MG, 0.1875 MGLANOXIN 0.125 MG, 0.25 MG*mexiletineMULTAQNORPACE*NORPACE CR propafenonepropafenone ext-releasequinidine gluconate ext-releaseQUINIDINE SULFATEQUINIDINE SULFATE EXT-RELEASERYTHMOL*RYTHMOL SR*sotalol

sotalol AFSOTYLIZETIKOSYN*

ANTI-COAGULANTS/ ANTI-PLATELETSAGGRENOXAGRYLIN*anagrelideASPIRIN/DIPYRIDAMOLEBRILINTAcilostazolclopidogrelCOUMADIN*dipyridamoleEFFIENTELIQUISPERSANTINE*PLAVIX*PLETAL*PRADAXASAVAYSAwarfarinXARELTOZONTIVITY

BREAST CANCER PRIMARY AND SECONDARY PREVENTIONanastrozoleARIMIDEX*AROMASIN*EVISTA*exemestaneraloxifeneSOLTAMOXtamoxifen

CONTRACEPTIVESCervical CapsFEMCAPPRENTIF CAVITY-RIM CERVICAL

CAPPRENTIF FITTING SET

DiaphragmsCAYAOMNIFLEX DIAPHRAGMORTHO DIAPHRAGM COIL SPRING

KITORTHO DIAPHRAGM FLAT SPRING

KITWIDE-SEAL SILICONE DIAPHRAGM

KIT

Emergency EllaELLA

Emergency ProgestinAfteraEcontera EZFallback SoloLEVONORGESTREL 0.75 MGlevonorgestrel 1.5 mgMy Way Next Choice One DoseOpcicon One-StepPLAN B ONE-STEP*Take Action

Injectable ProgestinDEPO-PROVERA CONTRACEPTIVE*DEPO-SUBQ-PROVERA 104medroxyprogesterone acetate

IUD ProgestinLILETTAMIRENASKYLA

Oral CombinedAltaveraAlyacenApriAranelleAubraAvianeAzuretteBalzivaBekyreeBEYAZBlisovi FeBlisovi 24 FeBREVICON*BriellynCaziant

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ChatealCryselleCyclafemCYCLESSA*CyredDasettaDelylaDESOGEN*desogestrel/ethinyl estradioldrospirenone/ethinyl estradiolElinestEmoquetteEnpresseEnskyceEstaryllaESTROSTEP FE*FALESSAFalminaFEMCON FE*GENERESS FE*GianviGildagiaGildessGildess FeGildess 24 FeJuleberJunelJunel FeJunel Fe 24Kaitlib FeKarivaKelnorKimidessKurveloLarinLarin FeLarin 24 FeLayolis FeLeenaLessinaLevonestlevonorgestrel/ethinyl estradiolLevoraLOESTRIN*LOESTRIN FE*LO LOESTRIN FELomedia 24 FeLorynaLow-Ogestrel

LuteraMarlissaMicrogestinMicrogestin FeMicrogestin 24 FeMINASTRIN 24 FEMIRCETTE*MODICON*Mono-LinyahMononessaMyzilraNATAZIANecon 0.5/35, 1/35, 7/7/7NECON 1/50, 10/11Nikkinorethindrone/ethinyl estradiolnorethindrone/ethinyl estradiol fenorgestimate/ethinyl estradiolNORINYL 1+35*NORINYL 1+50NortrelOcellaOGESTRELOrsythiaORTHO TRI-CYCLEN*ORTHO TRI-CYCLEN LO*ORTHO-CEPT*ORTHO-CYCLEN*ORTHO-NOVUM*OVCON-35*PhilithPimtreaPirmellaPortiaPrevifemReclipsenSAFYRALSprintecSronyxSyedaTarina FeTilia FeTri-EstaryllaTri-Legest FeTri-LinyahTri-Lo-EstaryllaTri-Lo-MarziaTri-Lo-SprintecTRI-NORINYL*

Tri-PrevifemTri-SprintecTrinessaTrinessa LoTrivoraVelivetVesturaVienvaVioreleVyfemlaWeraWymzya FeYASMIN*YAZ*ZarahZenchentZenchent FeZovia 1/35EZOVIA 1/50E

Oral Extended ContinuousAmethia

Amethia Lo

Amethyst

Ashlyna

Camrese

Camrese Lo

Daysee

Introvale

Jolessa

levonorgestrel/ethinyl estradiolLOSEASONIQUE*QUARTETTEQuasenseSEASONIQUE*Setlakin

Oral ProgestinCamilaDeblitaneErrinHeatherJencyclaJolivetteLyzaNOR-QD*Nora-BenorethindroneNorlyroc

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ORTHO MICRONOR*Sharobel

Transdermal CombinedORTHO EVRAXulane

Vaginal CombinedNUVARING

DIABETES MEDICATIONS

Hypoglycemic Agents GLUCAGEN HYPOKITGLUCAGON EMERGENCY KIT

Insulin Only AFREZZAAPIDRAHUMALOGHUMULINLANTUSLEVEMIRNOVOLIN RELIONNOVOLOGRELION RTOUJEO SOLOSTAR

Orals Only acarboseACTOPLUS MET*ACTOPLUS MET XRACTOS*ALOGLIPTINALOGLIPTIN/METFORMINALOGLIPTIN/PIOGLITAZONEAMARYL*CHLORPROPAMIDECYCLOSETDIABETADUETACT*FARXIGAFORTAMET*glimepirideglipizideglipizide ext-releaseglipizide/metformin GLUCOPHAGE*GLUCOPHAGE XR*GLUCOTROL*GLUCOTROL XL*

GLUCOVANCE*GLUMETZA*GLYBURIDE, distributor of Diabetaglyburide, generics of Micronaseglyburide/metforminglyburide micronizedGLYNASE*GLYSET*GLYXAMBIINVOKAMETINVOKANAJANUMETJANUMET XRJANUVIAJARDIANCEJENTADUETOJENTADUETO XRKAZANOKOMBIGLYZE XRmetformin metformin ext-releasemiglitolnateglinideNESINANOVOLINONGLYZAOSENIpioglitazonepioglitazone/glimepiridepioglitazone/metforminPRANDIMETPRANDIN*PRECOSE*repaglinideREPAGLINIDE/METFORMIN RIOMETSTARLIX*SYMLINPENSYNJARDYTOLAZAMIDETOLBUTAMIDETRADJENTATRESIBAXIGDUO XR

Other Diabetic InjectablesBYDUREONBYETTATANZEUM

TRULICITY

VICTOZA

DIABETIC SUPPLIESAlcohol prep pads, swabsCalibration liquid Insulin Infusion Pump Tubing, IV

sets, reservoirs, and adaptersInsulin syringesLancetsLancet devicesPen needlesTest strips (acetone, blood and

urine glucose, blood and urine ketone)

FLUORIDE SUPPLEMENTSACT TOTAL CARE DRY MOUTHCOLGATE DRY MOUTH RELIEFCREST COMPLETEFLORICALFLORIVAFLUOR-A-DAY CHEW TABSFLUORABONFLUORIDEX DAILY DEFENSE

SENSITIVITY RELIEF GELFLURA-DROPSGEL-KAM*LISTERINE ESSENTIAL CARELISTERINE RESTORING*LISTERINE SMART RINSE*LISTERINE TOTAL CARE*LISTERINE WHITENING/RESTORING*LOZI-FLURLURIDE*MONOCALNAFRINSEOMNI GEL*PHOS FLURPHOS-FLUR ORTHO DEFENSEPREVIDENT*REMBRANDTSENSODYNE REPAIR & PROTECT

WHITENINGsodium fluoride chew tabs; crm;

drops; gel; oral rinse; paste; solnSODIUM FLUORIDE TABS

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sodium fluoride/potassium nitratestannous fluoride gel, oral rinseSTANNOUS FLUORIDE RINSE

THERA-FLUR-N*

HEPARINS/LOW MOLECULAR WEIGHT HEPARINARIXTRA*enoxaparinfondaparinuxFRAGMINheparin sodium inj, 5,000 unit/

0.5 mL, 5,000 unit mLIPRIVASKLOVENOX*

HIGH BLOOD PRESSUREACCUPRIL*ACCURETIC*acebutolol ACEON*ADALAT CC*ALDACTAZIDE 25-25 MG*ALDACTAZIDE 50-50 MGALDACTONE*ALTACE*amilorideamiloride/hydrochlorothiazideamlodipineamlodipine/atorvastatinamlodipine/benazeprilamlodipine/valsartanamlodipine/valsartan/

hydrochlorothiazideAMTURNIDEATACAND*ATACAND HCT*atenololatenolol/chlorthalidoneAVALIDE*AVAPRO*AZORbenazeprilbenazepril/hydrochlorothiazideBENICARBENICAR HCT

betaxolol BIDILbisoprololbisoprolol/hydrochlorothiazide bumetanideBUMEX* BYSTOLICCADUET*CALAN*CALAN SR*candesartancandesartan/hydrochlorothiazidecaptoprilCAPTOPRIL/HYDROCHLOROTHIAZIDECARDIZEM*CARDIZEM CD* CARDIZEM LA 120 MGCARDIZEM LA 180 MG, 240 MG,

300 MG, 360 MG, 420 MG*CARDURA*carvedilolCATAPRES*CATAPRES-TTS*CHLOROTHIAZIDE 250 MGchlorothiazide 500 mgCHLORTHALIDONEclonidine CLORPRESCOREG*COREG CRCORGARD*CORZIDE*COZAAR*DEMADEX*DEMSERDIBENZYLINE*diltiazemdiltiazem ext-releaseDIOVAN*DIOVAN HCT*DIURILdoxazosinDUTOPROLDYAZIDE*DYRENIUMEDARBIEDARBYCLORenalaprilenalapril/hydrochlorothiazide

EPANEDeplerenoneEPROSARTAN EXFORGE*EXFORGE HCT*felodipine ext-releasefosinoprilfosinopril/hydrochlorothiazide FUROSEMIDE SOLN 8 MG/MLfurosemide soln 10 mg/mL; tabs guanfacine hydralazine hydrochlorothiazideHYZAAR*indapamideINDERAL LA*INDERAL XLINNOPRAN XLINSPRA*irbesartanirbesartan/hydrochlorothiazideisradipineKERLONE*labetalol LASIX*LEVATOLlisinoprillisinopril/hydrochlorothiazideLOPRESSOR*LOPRESSOR HCT*losartanlosartan/hydrochlorothiazideLOTENSIN*LOTENSIN HCT*LOTREL*MAVIK*MAXZIDE*MAXZIDE-25*METHYCLOTHIAZIDEmethyldopaMETHYLDOPA/

HYDROCHLOROTHIAZIDEmetolazonemetoprolol succinate ext-releasemetoprolol tartrate 25 mg, 50 mg,

100 mgMETOPROLOL TARTRATE 37.5 MG,

75 MGmetoprolol/hydrochlorothiazide

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MICARDIS*MICARDIS HCT*MICROZIDE*MINIPRESS*minoxidilmoexiprilmoexipril/hydrochlorothiazidenadololnadolol/bendroflumethiazidenicardipine nifedipinenifedipine ext-releasenisoldipine ext-release 8.5 mg,

17 mg, 34 mgNISOLDIPINE EXT-RELEASE 20 MG,

25.5 MG, 30 MG, 40 MGNORVASC*perindoprilphenoxybenzaminepindololprazosinPRESTALIAPRINIVIL*PROCARDIA*PROCARDIA XL*PROPRANOLOL SOLNpropranolol tabspropranolol ext-releasePROPRANOLOL/

HYDROCHLOROTHIAZIDEquinapril quinapril/hydrochlorothiazideramiprilSECTRAL*spironolactonespironolactone/hydrochlorothiazideSULAR*TARKA*TEKAMLOTEKTURNATEKTURNA HCTtelmisartantelmisartan/amlodipinetelmisartan/hydrochlorothiazideTENEX*TENORETIC*TENORMIN*terazosin TEVETEN 600 MG

TEVETEN HCTTIAZAC*TIMOLOL TABS TOPROL XL*torsemide trandolapriltrandolapril/verapamil ext-releasetriamterene/hydrochlorothiazide

caps, 37.5-25 mg; tabsTRIAMTERENE/

HYDROCHLOROTHIAZIDE CAPS, 50-25 MG

TRIBENZORTWYNSTA*valsartanvalsartan/hydrochlorothiazideVASERETIC*VASOTEC*verapamilverapamil ext-releaseVERELAN*VERELAN PM*ZEBETA*ZESTORETIC*ZESTRIL*ZIAC*

HIGH CHOLESTEROLALTOPREVamlodipine/atorvastatinANTARAatorvastatinCADUET*cholestyraminecholestyramine lightCOLESTID*colestipol CRESTOR*EQUAPAX/ATORVASTATIN/COQ10FENOFIBRATE CAPS fenofibrate micronizedfenofibrate tabsFENOFIBRIC ACIDfenofibric acid delayed-releaseFENOGLIDE*FIBRICORfluvastatinfluvastatin ext-release

gemfibrozilLESCOL*LESCOL XL*LIPITOR*LIPOFENLIVALOLOFIBRA*LOPID*lovastatinLOVAZA*MEVACOR*niacin ext-releaseNIACORNIASPAN*omega-3-acid ethyl estersPRAVACHOL*pravastatin QUESTRAN*QUESTRAN LIGHT*rosuvastatin simvastatinTRICOR*TRIGLIDETRILIPIX*VASCEPA VYTORINWELCHOLZETIA

ZOCOR*

INFANT EYE OINTMENT (for newborns)erythromycin eye ointment

OSTEOPOROSISACTONEL*alendronate 5 mg, 10 mg, 35 mg, 70 mgALENDRONATE 40 MGALENDRONATE SOLNATELVIA*BINOSTOBONIVA*calcitonin-salmonEVISTA*FORTICALFOSAMAX*FOSAMAX PLUS D

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ibandronateMIACALCIN NASAL*raloxifenerisedronaterisedronate delayed-release

PRENATAL VITAMINSALL PRESCRIPTION PRENATAL

VITAMINS

RESPIRATORYACCOLATE*acetylcysteineADVAIR DISKUSADVAIR HFAAEROSPANalbuterolalbuterol ext-releaseALVESCOANORO ELLIPTAARCAPTA NEOHALERARNUITY ELLIPTAASMANEX HFAASMANEX TWISTHALERATROVENT HFABEVESPI AEROSPHEREBREO ELLIPTABROVANA budesonide inhal susp COMBIVENT RESPIMATCROMOLYN SODIUM INHAL SOLNDALIRESPDULERAdyphylline/guaifenesinELIXOPHYLLIN FLOVENT DISKUSFLOVENT HFAFORADIL AEROLIZERINCRUSE ELLIPTAipratropium inhal solnipratropium/albuterol inhal soln levalbuterol inhal solnLUFYLLINMETAPROTERENOLmontelukastPERFOROMISTPROAIR HFA

PROAIR RESPICLICKPROVENTIL HFAPULMICORT FLEXHALERPULMICORT RESPULESQVARSEREVENT DISKUSSINGULAIR*SPIRIVA HANDIHALERSPIRIVA RESPIMATSTIOLTO RESPIMATSTRIVERDI RESPIMATSYMBICORTterbutaline THEO-24theophyllinetheophylline ext-releaseTUDORZA PRESSAIRUTIBRON NEOHALERVENTOLIN HFAVOSPIRE ER*XOPENEX*XOPENEX CONCENTRATE*XOPENEX HFAzafirlukast

2017 STANDARD HSA COMMON PREVENTIVE DRUG LIST FOR A.H. BELO CORPORATION

Third-party brand names are the property of their respective owners.