Benefits.na.sage.com

High Deductible Health Plan (HDHP) - Health Savings Account (HSA)
Preventive Therapy Drug List
(07/01/13)
ANTICONVULSANTS
CARDIOVASCULAR CONDITIONS -
ANTIARRHYTHMIC AGENTS
ORAL ANTIANGINAL AGENTS
COMBINATION ANTIHYPERLIPIDEMICS
SL and chewable formulations are not included TRANSDERMAL/TOPICAL ANTIANGINAL
DIABETES
DIAGNOSTIC AGENTS AND SUPPLIES
CORONARY ARTERY DISEASE
ANTIHYPERLIPIDEMICS
INJECTABLE DIABETES AGENTS
Some strengths or dosage forms may not be included in the HDHP - HSA Preventive Therapy Drug List. Certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider. Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This HDHP - HSA Preventive Therapy Drug List is provided as a courtesy and CVS Caremark makes no representations regarding the suitability for your particular plan. The HDHP - HSA Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor with the advice of counsel, if appropriate. 106-1038894b 062413 Over-the-Counter (OTC) products require a prescription. ORAL DIABETES AGENTS
ACE INHIBITOR/CALCIUM CHANNEL
BLOCKER COMBINATIONS
HYPERTENSION
ACE INHIBITORS/ANGIOTENSIN II RECEPTOR
ANTAGONISTS
BETA-BLOCKERS
CALCIUM CHANNEL BLOCKERS
HEMATOLOGIC AGENTS
Some strengths or dosage forms may not be included in the HDHP - HSA Preventive Therapy Drug List. Certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider. Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This HDHP - HSA Preventive Therapy Drug List is provided as a courtesy and CVS Caremark makes no representations regarding the suitability for your particular plan. The HDHP - HSA Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor with the advice of counsel, if appropriate. 106-1038894b 062413 IMMUNIZING AGENTS
DIURETICS
spironolactone/hydrochlorothiazide OTHER ANTIHYPERTENSIVE AGENTS
ANTIPSYCHOTICS
MENTAL HEALTH
ANTIDEPRESSANTS
olanzapine orally disintegrating tabs Some strengths or dosage forms may not be included in the HDHP - HSA Preventive Therapy Drug List. Certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider. Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This HDHP - HSA Preventive Therapy Drug List is provided as a courtesy and CVS Caremark makes no representations regarding the suitability for your particular plan. The HDHP - HSA Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor with the advice of counsel, if appropriate. 106-1038894b 062413 VARIOUS CONDITIONS
ANTI-MALARIAL AGENTS
Over-the-Counter (OTC) products require a prescription. DENTAL CARIES PREVENTION
RESPIRATORY DISORDERS
HEREDITARY ANGIOEDEMA AGENTS
OSTEOPOROSIS
IMMUNOSUPPRESSIVE AGENTS
MULTIPLE SCLEROSIS AGENTS
ANTICOAGULANTS
PREVENTIVE CARE SERVICES
AGENTS FOR CHEMICAL DEPENDENCY
ANTICOAGULANTS/PLATELET AGGREGATION
INHIBITORS
WOMEN'S HEALTH
ANTIESTROGENS
ANTI-OBESITY AGENTS
AROMATASE INHIBITORS
CONTRACEPTIVES
SMOKING DETERRENTS
LOW-DOSE MONOPHASIC PILLS
Some strengths or dosage forms may not be included in the HDHP - HSA Preventive Therapy Drug List. Certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider. Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This HDHP - HSA Preventive Therapy Drug List is provided as a courtesy and CVS Caremark makes no representations regarding the suitability for your particular plan. The HDHP - HSA Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor with the advice of counsel, if appropriate. 106-1038894b 062413 EMERGENCY CONTRACEPTION
levonorgestrel/EE 0.1/20 and EE 10 levonorgestrel - Next Choice One Dose norethindrone acetate/EE 1/20 and iron norethindrone acetate/EE 1.5/30 and norgestimate/EE 0.18-35/0.215-35/ TRANSDERMAL PATCH
MISCELLANEOUS CONTRACEPTIVES
FOUR-PHASIC
EXTENDED-CYCLE PILLS
HIGH-DOSE MONOPHASIC PILLS
levonorgestrel/EE 0.15/30 and EE 10 BIPHASIC PILLS
PRENATAL VITAMINS
TRIPHASIC PILLS
CONTINUOUS-CYCLE PILLS
PROGESTIN-ONLY PILLS
Some strengths or dosage forms may not be included in the HDHP - HSA Preventive Therapy Drug List. Certain products or categories may not be covered, regardless of their appearance in this document. Please check with your plan provider. Please note: This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This HDHP - HSA Preventive Therapy Drug List is provided as a courtesy and CVS Caremark makes no representations regarding the suitability for your particular plan. The HDHP - HSA Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor with the advice of counsel, if appropriate. 106-1038894b 062413

Source: http://benefits.na.sage.com/GuidesForms/Preventive%20DL%200713.pdf

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