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The following drugs are considered preventive care and are covered at 100% by the plan without being subject to the deductible. Note: Multi-source brand preventive medications are
not covered at 100% (for example, Lipitor is not covered at 100% but its generic equivalent—
atorvastatin—is covered at 100%).
Ace inhibitors (hypertension)
Anti-hyperlipidemics (high cholesterol)
All single-source brand and generic medications in this All single-source brand and generic medications in this category. Examples include:
category. Examples include:
ARBs (Angiotensin Receptor Blockers)
(hypertension)
All single-source brand and generic medications in this category. Examples include:
Adrenergic antagonists & related drugs
Beta-blockers (hypertension)
All single-source brand and generic medications in this All single-source brand and generic medications in this category. Examples include:
category. Examples include:
Antianginal agents
All single-source brand and generic medications in this category. Examples include:
Birth control
All single-source brand and generic medications in this category. Examples include:
Anti-arrhythmic agents
All single-source brand and generic medications in this category. Examples include:
Blood thinning agents
All single-source brand and generic medications in this category. Examples include:
cilostazol
Bone disease and fractures
All single-source brand and generic medications in this All single-source brand and generic medications in this category. Examples include:
category. Examples include:
Infection
Breast cancer recurrence
Calcium channel blockers (hypertension)
All single-source brand and generic medications in this category. Examples include:
Kidney disease
All single-source brand and generic medications in this category. Examples include:
Colonoscopy preparations
All single-source brand and generic medications in this Low level hormones
category. Examples include:
polyetheylene glycol sodium phosphate salts trilyte All single-source brand and generic medications in this Diabetes
category. Examples include:
medroxyprogesterone
All covered diabetic supplies, for example: needles, syringes, test strips, lancets, monitors, pumps and Miscellaneous blood pressure drugs
Insulin:
Nausea and dizziness
Non-Insulin:
All single-source brand and generic medications in this category. Examples include:
Ulcer disease
All single-source brand and generic medications in this category. Examples include:
Diuretics (hypertension)
This list represents certain common single-source brand and All single-source brand and generic medications in this generic preventive medications that are covered in full for category. Examples include:
HSA-qualified plans and is subject to change without prior notification. Brand name medications that have a generic equivalent are not covered under this HSP Preventive Drug List. If you have questions about your pharmacy benefit, please call Premera Customer Service at (800) 676-1411.
The following over-the-counter drugs also qualify as preventive drugs covered at 100%.
To receive the preventive drug benefit on over-the-counter drugs, submit a prescription claim reimbursement form. Make sure you include the national drug code (NDC) on the claim form or your claim will be denied. The NDC number can be found underneath the bar code on the outside of the drug’s box.
Requirements
Strength
Coverage is for individuals who are considered “at-risk” due to cardiology (heart conditions).
Aspirin only (like Bayer Aspirin) products. Does not include Excedrin-type products.
Folic Acid
Coverage is for females only who are pregnant or are considering pregnancy.
Prenatal vitamins with folic acid will continue to be paid or denied according to the standard benefit of your plan and are subject to the cost shares and limits of that plan.
Supplements
Coverage is for children up to 1 year old.
If over-the-counter iron is covered on your plan for added age or tablet form, it will continue to be paid according to the standard benefit of your plan and will be subject to the cost shares and limits of that plan.
Fluoride
Prescription only, all formulations.
Coverage is for children up to 18 years old.
Prescription only for the following drugs: Cessation
▪ NRT (Nicotine replacement therapy) nasal spray▪ NRT inhaler No over-the-counter patches or lozenges are covered, unless your plan already covers these. In these cases, the plan’s prescription benefit cost share applies.
Women’s
Over-the-counter birth control (i.e.,female condoms, sponges) Birth Control
Vitamin D
For ages 65 and over with written prescription Supplements
If you have questions about your preventive drug coverage, call Premera at (800) 676-1411.

Source: http://msbdguide.blob.core.windows.net/2013/pdfs/2013-MSFTPreventiveDrugCoverage.pdf